Health Care Rationing or Just Common Sense?

The media continues to produce bombastic reports regarding health care reform full of scare tactics from both sides. One of the buzz words used to scare people is the word – RATIONING.  This word has been used to describe negative aspects of the UK National Health System (NHS) system (or the proposed “public” system in the US); and the word implies the perils of such a system–as if a health care czar sits in the coliseum giving a thumbs up or a thumbs down on medical procedures based on what side of the bed he got out of.  I have a one word retort which the British might use to refute such allegations: BOLLOCKS.

You might call it rationing, but I call it common sense and logical decision making based on costs and benefits for health care procedures.  And I have a perfect example of a person who has experienced rationing in the UK and lived to tell about it – Me.

My Personal Health Care Story

As I have noted in my four previous articles at Demockracy.com, my view on this subject is based on my direct experience with the health systems both in the US and Europe. Unlike most pundits on this subject, I have worked and lived in the UK and the US and experienced both health care systems first hand, as an employee, as an executive,  as a corporate board member, as an owner, and, most importantly, as a patient.  Four years ago, I was diagnosed with cancer while living in the UK and received treatment and advice from both the US and UK systems.  The differences in the way these two systems treated my disease were telling – and at the end of the day the UK’s “rationing” system appeared to do everything the US plan offered at a fraction of the cost. Let me explain the detail.

In 2005, I was diagnosed with tonsil cancer while living in the UK. After my initial diagnoses and shock, I sat down with my UK doctors and discussed the treatment plan offered by the NHS. The proposed plan essentially consisted of the following:

1. A surgery procedure to cut the from my tonsil area and  a major neck dissection that would cut tumor surrounding tissue from the tumor and lymph nodes from my neck and shoulder area.

2.  Four weeks of rest to recuperate from the surgery.

3. Then, I would undergo seven weeks of focused radiotherapy to further eradicate pesky cancer cells in my neck and throat region.

4. And finally, in concert with the radiotherapy, I would receive several doses of chemotherapy over the same seven-week period to further blast away any cancer cells that had invaded my body.

All of that seemed perfectly reasonable to me; but to make doubly sure I was getting the correct treatment, I flew to the US to get a second opinion from a highly respected leading specialty hospital in New York. I was somewhat intrigued that this second opinion and treatment of the cancer were essentially the same as the NHS program.  Intrigued, because I was still under the impression that US health care was better–different, and that I would be offered a different option, perhaps more expensive, but perhaps with better outcomes.  But, no, the diagnosis and treatment plan were almost identical.

I followed the treatment plan in the UK – surgery, chemo, radio, all provided free of charge by the NHS. I have dual citizenship in the UK and the US and had lived in the UK for six years, so this was all perfectly within the rules of the NHS. And after 12 weeks of treatment, I was weakened and tired but satisfied that my doctors and I had done all that I could do to combat the cancer. So up to this point, there was essentially zero difference in the way a US or UK doctor would have treated me.

Now came the aftercare plan. I was told by both US and UK doctors that the tumor had a 50% chance of reappearing – a percentage high enough to cause me and my family many, many sleepless nights. Doctors on both sides of the Atlantic agreed that vigorous aftercare monitoring was needed to check to see if the cancer was to reappear. In the US, the doctors suggested that the best way to monitor a reappearance of the cancer was a series of PET /CT scans; they would use the latest and greatest technology to peer inside my body to see if the cancer had returned. They suggested a PET/CT scan once every six months for two years and then perhaps once per year until year 5.  In all, this would mean 7-8 PET/CT scans, which at about $4,000 per scan would mean a total cost of about $30,000.  That sounded like a lot of money, but, hey, – it was my life we are talking about, and there was a 50% chance of the tumor coming back so it sounded like a no-brainer to spend the money and get my ticket out of Camp Cancer.

I then met with my UK doctor and explained the proposed US treatment plan for aftercare. I still remember my doctor giving a wry smile that suggested there was a simpler way – (the smile also of someone who does not have a bottomless pit of money and funding).  She agreed with the need for close monitoring to see if the cancer reappeared, but then explained her treatment plan to me, which was decidedly low tech.  For the first year, she would have me back in her office every 60 days to perform a thorough physical examination. She explained that if indeed the tumor did recur, that 99 times out of 100 the tumor would reappear in the neck or throat area.  Since this area is relatively exposed and easy to see (down the throat with a scope) or feel (through touching and feeling the neck area), she would be able to see or feel the tumor before it gets to the size of one centimeter (maybe even a bit less, depending on its location) – which is about the same size by which a PET/CT scan can detect a tumor.  Furthermore, she explained, that although the PET/CT scans can be a very useful tool, they often can show false positives (white spots on the scan that turn out not to be malignant tumors), and these false positives will just lead to more aggravation and stress for both the patient and the doctor (and also more costs as the health system has to perform more tests to determine that a false positive is indeed false). Not totally convinced, I asked more questions about PET/CT scans and their use; my UK doctor then told me that if the initial tumor had been on an internal organ (the lung or pancreas for example), then the PET /CT scan would be a very useful tool, because if the tumor reappeared, it would be internal and not be in a place where a doctor’s visual or tactile examination could reveal its presence.

Upon further questioning regarding the benefits of the PET/CT scan, the UK doctor did accept that if in the 1 out of 100 chance that the tumor did reappear in another part of the body (not the neck or throat, but an organ such as the liver, the lung, or the pancreas), her physical inspection of the neck and throat area would not likely find the tumor and the PET / CT would give the patient an earlier indication that trouble had returned.  However, she also noted that if the tumor reappeared via PET/CT scan in the liver or the pancreas, that this early detection does not usually lead to a better outcome for the patient. Unfortunately, if the cancer is found in another organ in the body, this would probably mean the cancer had metastasized and was spreading throughout the body. The sad reality of this situation is that one can run all the tests and scans in the world, but in all probability the patient has terminal cancer, and now the question becomes not if but when – a sad conclusion, but medicine and health care do not always have happy endings.

Now I am generally a skeptic on such matters; and I was still operating under the mindset that the US health care is better than UK health care. But I listened to what the UK doctor said, and I believed her. After all, the UK’s public system had not skimped one bit when it came to the surgery, chemo, and radiotherapy – these are expensive procedures, but the benefit they provide is very demonstrable and intuitive.  But intuitively, the expensive aftercare offered by the US seemed to be a lot of work, effort, and technology for little result.  Indeed, I had “found” the initial tumor when I felt a “lump” on my neck about the size of a pea and it was relatively easy to feel once you knew what you were looking for.

The Costs of Health Care

And, being the accountant that I am, I did the math on the treatment plans.  The US and UK aftercare plans were similar in terms of trips to the doctors. However, to recap,the US plan included 7-8 PET/CT scans which would cost about $30,000. My UK doctor said that 99 times out of 100 a doctor’s visual/physical inspection would find the tumor as soon as the PET/CT scan.  But one time out of 100 the scan would find the tumor that had reappeared at some different part of the body – but even then, in most cases, the likely outcome for the patient was terminal cancer, and the doctors could prolong life for a bit, but the patient would be left with a similar outcome – terminal cancer and death. So for our sample of 100 patients in the US who opt for regular PET/CT scans in their aftercare treatment plan, they and their doctors will certainly feel better about all the money and technology that is being spent to combat the disease. However, these 100 patients in the US will cost the system about $3 million ($30,000 times the 100 patient sample = $3 million); and this extra $3 million will provide little or no benefit when compared with the low tech, low cost approach.

Now let’s go back to the US doctor who is presented with this argument; let’s say he or she agrees with the argument and uses the British, low-tech and low-cost method. Two years later, 50 of his or her 100 patients have cancer (50% recurrence rate in both populations) – of those 50 maybe 2 or 3 or 4 think they have been treated wrongly and decide to sue for malpractice. They engage a lawyer and spend a lot of money on courts and legal proceedings.  And ultimately the doctor has to stand in front of 12 jurors while a litigation lawyer – highly practiced in creating courtroom drama – will try to make the doctor look like a villain.  Undoubtedly, during testimony, the lawyer will pointedly ask the doctor this question: “So you decided not to use the PET/CT, a technologically advanced procedure designed to identify cancer at early stages, and you chose not to perform this test to save the company $3,000 – and because of your penny pinching treatment plan, the patient did not get all the tests available to medical science, and now my client is dying of cancer because you would not allow the PET/CT scan?” These words may not be exactly true, but the lawyer is very good at bending and stating the facts in such a way to garner sympathy for his client. (And who really can blame him; he is simply doing his job.)

So the US doctor contemplates the legal scenario above … and guess what – he or she decides to order the PET/CT scan, and by the way, when he/she orders the scan he/she also gets to charge $500 to the patient to read and interpret the scan report – just another little incentive to do more not less. But who can blame him/her: he/she correctly justifies decisions as helping to save lives, reducing threats of litigation, making patients happier, and making a bit more money.

Back in the UK, the doctor has little or no liability from litigation, for a whole series of reasons. The most relevant is that the NHS has done the cost/benefit analysis and clearly sets treatment protocol based on this logical cost/benefit analysis. The doctor did it by the book, so there is little chance of liability.

And, finally, let’s look at is from the patients point of view. I imagine many may accept the logic of this argument. However, when it comes down to individual decisions on whether to do the PET/CT scans, many will still opt for doing the tests – nothing wrong with that – it’s a  free country.  But what the patient should decide is whether he or she is prepared to spend $30,000 of his or her own money to do these tests. I personally do not want to spend my tax dollars on a government run system that spends this kind of money for tests or programs with little or no benefit.  So the patient can bankroll this $30,000 option by either dipping into his or her savings or opting into a fancy, pay-all, private insurance plan with all the bells and whistles that will pay for such luxuries.  The cost of such an insurance plan will undoubtedly cost several thousand dollars more per year, but you get what you pay for.

Now back to the math and the big picture of US health care. In our little sample of 100 throat cancer patients, the US system spends approximately $3 million more than the low-tech approach. Across the country, in the US, about 30,000 people per year are diagnosed with tonsil/throat cancer. So expanding our sample from 100 to 30,000 means the US spends perhaps $900 million on PET/CT scans for throat and neck cancer patients per year, and this extra money provides little if any benefit in patient outcomes. $900 million is therefore largely unnecessarily spent in the US for this one little disease category. The American doctor often opts for the more expensive, more technical solution, not so much for the welfare of the patient, but so he or she is seen as doing as much as he/she can do when dealing with patients who are ill. This makes the patient happy, the doctor happy, the health care companies rich, and feeds into the common misperception in US medicine that more invasive care equates to better care.

$900 million – almost $1 billion spent with no recognizable benefit for one condition.  And as the saying goes, “a billion here and a billion there–pretty soon we are talking real money.” And this one economic example, repeated over and over for other disease categories is certainly one of the major reasons that the US spends twice as much per capita on health care as most other developed countries with no demonstrable benefit to the population.

Rationing of health care services – bring it on.  Let’s stop spending money on health care treatments which do not provide a real benefit.  More money does not always mean better care.

You might call it rationing, but I call it common sense–making logical , informed decisions about health care procedures is an achievable goal that can make health care affordable to all Americans.  So let’s look behind the scare tactics and buzz words and do what is right and allow for Affordable Health Care for all Americans.

Review of Freedom’s Orator

Freedom’s Orator: Mario Savio and the Radical Legacy of the 1960s.

by Robert Cohen Oxford University Press, 532 pages, $34.95

It probably wasn’t until seven years after his death that a Mario Savio speech would reach its largest audience – albeit in altered form.  Anyone of a certain age who detected an echo of Savio’s 1964 “gears of the machine” speech in the 2003 season finale of Battlestar Galactica was not having one of those legendary acid flashbacks.  The show’s producer had been looking at a copy of the speech hanging on his wall for five years and it was with the permission Savio’s widow that the character known as “The Chief” delivered a paraphrase of the words that led into the famous Free Speech Movement (FSM) sit-in at the University of California, Berkeley’s Sproul Hall.

Probably more of Savio’s peers saw the clip of his original speech in another television show, though, Martin Scorsese’s 2005 Bob Dylan documentary, “No Direction Home.”  Only fitting in that, as FSM principal Jack Weinberg told Robert Cohen, author of the Savio biography, “Freedom’s Orator,” back then “If you named … young people who were famous, all the rest were rock musicians … [the] Beatles and Bob Dylan–and Mario Savio was a celebrity of that caliber.” Since it was Weinberg’s arrest that set off the thirty-two hour blockade of a police car that created FSM, he may lack sufficient distance to make such a judgement, but then it is a fact that, upon finishing his speech that day, Savio turned the mike over to Joan Baez for a rendition of her friend Bob Dylan’s “The Times They Are A Changin.”

When Mario Savio enrolled at UC Berkeley in 1963, it was his third college in three years.  Berkeley already had a free thinking reputation when he arrived.  That fact was the better part of why he was there: There was a serious student political party of several years standing called SLATE; Cal students had participated in major San Francisco demonstrations in 1960 at a House Un-American Activities Committee hearing at City Hall and outside the 1964 Republican National Convention at the Cow Palace; and the Civil Rights movement was a campus presence – Savio would be one of 167 arrested at a sit-in protesting the discriminatory hiring policies of the San Francisco Sheraton Palace hotel.  By the time Savio left, the campus had a free speech reputation as well – the man and the institution each having become a nationwide symbol of a new wave of student activism.

A ban on political advocacy on the Berkeley campus dated back to the 1930s, apparently a result of a West Coast Red scare that followed the San Francisco general strike.  There was, however, a twenty-six-foot-strip of sidewalk on Bancroft and Telegraph Avenues where such activity went on because it was believed to be city, not university property.  But in September of 1964, university administrators decided otherwise and shut the free speech area down.  A couple of brief sit-ins protesting the ban at administration offices followed over the next few days.  Then, at a Sproul Plaza rally called in defiance of the ban, administrators decided to arrest the above mentioned Jack Weinberg because he was not currently a Cal student, having dropped out of graduate math studies to concentrate on civil rights activities through a campus chapter of the Congress of Racial Equality.

Cohen writes: “The method used to arrest Weinberg could not have been more provocative … he had been dragged into a police car in the center of Sproul Plaza.  It was the most crowded spot on campus and shortly before noon, the busiest time of day.” A “fairly major level of stupidity,” Savio later observed.  At that moment, the Berkeley sit-in moved to a new level: “Before the officer could start his engine students were sitting in around the car.” Savio, who had already emerged as the leader of protests against the free speech ban, had been sitting on the car’s hood and, he recalled, later, “Sometimes you’re just … gripped by the moment and you have a feel for what’s poetically right.” Then “I took my shoes off.  I didn’t want to hurt the car,” (although he would later bite a cop’s leg – and subsequently apologize profusely), stepped up into history and gave the first speech of the protest that would block the police car for the next day.

The American campus had never seen anything like this before.  And it grew – 6,000 came to a December 2 protest at which Savio gave “the speech” about blocking the machine with your body that swelled the numbers ultimately deciding to sit in at the Administration office building to over a thousand.  Jackie Goldberg, later an LA City Councilor and member of the California Assembly, remembered the people “who walked into that building who had come to the rally not intending to sit in,” but did “because Mario had given that speech that just lifted us four or five inches off the ground.”

But as a speaker at the Sproul Hall memorial service following Savio’s death recalled, it wasn’t just that speech, but the fact that so many students had already heard Savio many times articulate their growing sense that right was on their side over the preceding months.  Literary critic Wendy Lesser considered him “the only political figure of my era for whom language truly mattered … the last American perhaps who believed that civil, expressive, precisely worded, emotionally truthful exhortation could bring about significant change … The sentences he spoke were complicated and detailed, with clauses and metaphors and little byways of digression that together added up to a coherent grammatical whole.” Well, maybe there were a few more besides Savio, but he was definitely a carryover from a pre-sound bite era of detailed argument.

At least a bit of his style can be traced back to Savio’s experience a few months earlier with the Student Nonviolent Coordinating Committee (SNCC) in Freedom Summer which he considered “the event which more than any other created the white student movement” by bringing together “privileged upper- and middle-class youths from northern campuses with the disenfranchised black community of Mississippi.” As Cohen writes, “Having defied the Klan in Mississippi, he was not going to be intimidated by campus officials in Berkeley.” And if there is another figure that Savio resembles, both in his plain spoken but powerful speaking style and his reticence regarding the limelight, it would likely be Robert Moses of SNCC.

The Berkeley free speech advocates ultimately carried the day, although not before Savio was hauled off stage by campus police in front of a crowd of 15,000 at Berkeley’s Greek Theater, another disastrous episode in a series of administration blunders.  His arch adversary, UC Chancellor Clark Kerr later acknowledged that he “was obviously a genius at understanding crowds, appealing to them, and handling situations like that – quite beyond the capacity of any of us in the administration.”

There was a down side to all this, Cohen notes – the “rift between the Left and liberalism [that] would benefit the Right and contribute to the rise of Ronald Reagan” who would win the governorship two years later promising to “clean up the mess” in Berkeley.  Savio was expelled from the university for his actions and would not complete his undergraduate degree for nearly two decades.  In the immediate aftermath of the FSM he was a sought after speaker, participating in the 36-hour 1966 Berkeley Vietnam War teach-in but, as he would say many years later, “ I had trouble during the anti-Vietnam days because it was hard for me to talk about something I had not seen.” He ran a desultory 1968 state Senate campaign as a Peace and Freedom Party candidate, but never showed any inclination to stay in the limelight just because he could.  On the balance celebrity was a burden to him and he retired from public view (although FBI files show that the agency followed his activities for the next decade.)

Jackie Goldberg certainly surprised a few of us at the memorial service who did not personally know Savio with her mention that he was “a very troubled person.” Cohen tells us that he was hospitalized for depression in 1971 and that his eloquence was all the more striking to those who knew him, as he suffered from a severe stutter that he did not shed until the Free Speech Movement.

When he finally returned to college in the 1970s, he was again brilliant, this time in physics, to the point where a professor later included “Savio’s Theorem” in his text book Analytical Mechanics for Relativity and Quantum Mechanics.   When opponents of 1980s US Central America policy pined for a movement to rival that of the Vietnam era, it just came naturally to seek out Savio, whose subsequent seclusion had left his place in the annals of 1960s student activism untarnished.

Savio responded with speeches on a number of campuses that were every bit as thoughtful as before, particularly on the difficulties of mounting efforts against American foreign policy.  Recognizing that the anti-Vietnam War movement did not carry with it the physical dangers that pushing for civil rights did in many locations, he nonetheless defended it as, in some ways, the more difficult effort.  Compared to arguing for constitutional rights, the antiwar case was “less sweet.  I mean there is no way it could be otherwise.  It is an attack rather than a defense,” but “That’s what was needed because the war had to be stopped.” He thought “There was no way to have a decade to catch up so you could educate people so you could talk to them about these things.  In fact what was necessary was what the country got.  It got the best it could, given the time pressure.” Likewise, he thought opposing US Central America policy more difficult that opposing apartheid in South Africa.

In producing his definitive biography, Cohen has included nearly a hundred pages of Savio’s speeches and writings, starting with his 1960 valedictory speech at Martin Van Buren High School in Queens, New York, apparently delivered without hint of his then severe stammer, and ending with a pamphlet co-authored with his son Nadav, “In Defense of Affirmative Action: The Case Against Proposition 209.”   (Some of his speeches are also available at www.savio.org.)

When Savio died of a heart condition at age 53, he was heavily involved in a fight against a tuition increase at Sonoma State University where he lectured in math.   One colleague found his method of continuing to bring student voices to the fore “really wonderful.” He would get journalists to the campus “because it was Mario Savio calling,” but “he would not be there when the reporters came” – so they spoke with student activists instead.

Future of Afghanistan Complicated by Election Outcome

The Afghan presidential elections have ended. And I’m sure I’m not the only one to who finds the outcome thoroughly unsatisfying. After vehemently denying that his campaign had engaged in massive voting fraud, President Hamid Karzai essentially admitted to fraud, accepting the election commission’s revised vote tally. This revision dropped Karzai’s support from 54% to under 50%, triggering a runoff under the Afghan constitution. Karzai’s opponent in the runoff, Abdullah Abdullah, not in a position to actually win and fearing more fraud and violence with a second round of voting, dropped out of the contest, leaving Karzai the winner.

American officials act reasonably satisfied with these elections, though it’s hard to see why. They are now left with an Afghan partner in the escalating war against the Taliban that has run a shockingly corrupt and ineffective government, has garnered less than half the majority of votes cast in the election, and has committed large-scale fraud in a failed effort to win these elections. To sum up, Karzai has proven to be bad at governing Afghanistan, does not have the support of most of the Afghan people, and was caught trying to steal the election. While Karzai seems to have legitimately won a commanding plurality of the vote, his behavior indicates a blatant disregard for the electoral process and the rule of law that would be condemned by the US government had it occurred in a place such as Iran or Venezuela.

Though President Obama gave Karzai a scolding about improving his governance when he called to congratulate him on his victory, close US-Afghan cooperation is bound to continue. Indeed, if Obama has his way, it will increase (though he appears to be feeling less hawkish about Afghanistan than he was as candidate – perhaps because of this tainted election). And it should. The return of the Taliban poses a threat to Afghans, the region, and perhaps the world. After a decade of supporting violent religious fanatics (both Afghan and foreign) against the Soviets, and then walking away to let these extremists, drug kingpins, and warlords plunge the country into civil war, the US owes the Afghan people a serious commitment to rebuilding Afghanistan by providing security, promoting development, and nurturing a democratic government.

This means US military involvement is needed, but more importantly, it means overcoming the challenges of bringing things like water, electricity, roads, health care, education, and jobs to Afghans. Yet, hopes have been dashed that these elections would give Afghanistan a clear and legitimate democratic leader who was ready to work with the US and battle the Taliban with the support of the Afghan public. The muddied results will certainly make the work of the Afghan government, the US, NATO, and other foreign players more difficult. And the Taliban are already claiming victory, believing that their attacks stopped the second round of voting.

In the end, these elections give little hope for the immediate future of Afghanistan and the US mission there. By his own actions, Karzai has weakened his position vis-à-vis the Taliban, and the US will be hard-pressed to win Afghan hearts and minds while backing a largely discredited Afghan government and failing to follow through on efforts to improve the lives of Afghan people. US involvement is also becoming increasingly unpopular at home, and the longer US soldiers and aid workers are in Afghanistan, the more chances there are for casualties that may not be palatable to Americans who increasingly believe that there are unclear reasons to stay in Afghanistan.

The Obama administration is hopeful that Karzai will clean up his act and the UK is making threats that it can’t support a government that is so unapologetically corrupt. However, it is hard to imagine that the US or the UK – as heavily invested in Afghanistan as they are – will simply quit Afghanistan if Karzai continues running his government as is. The US certainly has some leverage over Karzai, but for now it has little choice but to put most of its eggs in one basket, hoping that he is the man best suited to improve life in Afghanistan and to fight the Taliban. Unrest seems sure to continue to plague Afghanistan, and US ability to win a counterinsurgency campaign in Afghanistan has been seriously compromised by this election’s outcome. How adeptly Obama’s strategy can adapt to today’s complex political situation in Afghanistan and how well US forces can work with other regional players (Pakistan, India, Russia, Iran, China) will be key to preventing Afghanistan and the entire region from becoming more dangerous and unstable than they are today.

This is the second article covering the Afghan election and the fourth in a series on major elections in Asia this year.

Prospects for Change in Burma: Too Many Wild Cards in the Deck?

From the US, Burma (more recently known as Myanmar) has appeared for the past two decades to be a global pariah, ruled by an isolated, paranoid, and  power-hungry military notorious for its suppression of human rights, government critics, and ethnic minorities. In the last few years it has made the news for all the wrong reasons – the continued imprisonment of opposition leader and Nobel Peace Prize winner Aung San Suu Kyi, the bloody crackdown on huge crowds of protesting Buddhist monks in 2007, the refusal to allow international aid agencies into the country after Cyclone Nargis killed at least 140,000 people in 2008, and holding a clearly illegitimate constitutional referendum in which 92% of Burmese supposedly supported the new constitution drafted by the ruling military junta.

US policy towards Burma under George W. Bush was to shun the military government and to stick to the strict international sanctions regime imposed on the junta. This did nothing to noticeably change Burma’s internal political situation. So now the Obama administration is trying a new tack of unconditional diplomatic engagement while continuing sanctions until the junta makes some significant concessions. The US and many Burmese would like to see three things – the release of Suu Kyi and other political prisoners, constitutional reforms, and assurances that 2010’s election will be free and fair. While committed to dialogue with General Than Shwe’s government, the US does not appear optimistic that change will happen quickly in Burma.

While this strategy alone may not bring quick or significant change to Burma, other factors are also shaking up the country’s political status quo. Aung San Suu Kyi – the incredibly popular and politically shrewd leader of the opposition National League for Democracy who has been under house arrest for most of the past 20 years after winning the 1990 elections, only to have the results ignored — has recently met with members of the junta, agreeing to help negotiate an end to sanctions on Burma by Western nations. While Suu Kyi likely believes that the sanctions have been ineffective and detrimental to the Burmese people (the standard argument for ending them), she is also making a political move.  This is based on the assumption that her favor to the junta will not go unrewarded, perhaps reminding the junta of the substantial power she still wields. Should the junta decide to release Suu Kyi, next year’s elections have a chance of being legitimate, with Suu Kyi’s NLD possibly coming to power.

In recent days, there have been hints that Suu Kyi may indeed be released by the government. This could be thanks to Suu Kyi’s recent cordial relations with the government, because of the change in US Burma policy or due to mounting international pressure. The US is leaning on other nations to put pressure on the Burmese government, and China, India, and Russia recently have joined the US and Europe in calling for Suu Kyi’s release. The calls of the three emerging powers are particularly significant given their relatively close ties and positions of influence with Burma. These new calls for Suu Kyi’s release accompany strained relations between Burma and its closest ally, China, because of border disputes and Chinese anxiety over the possibility of improved US-Burma ties.

Within Burma, politically active Buddhist monks continue to challenge the junta, pressing it to apologize for killings during 2007’s massive protests and threatening further protests if their demands go unmet. Monks inside and outside Burma have also demanded a timeline and clear benchmarks for US engagement with Than Shwe’s government.

The most likely change in the foreseeable future is the release of some political prisoners, including Suu Kyi, which could open a Pandora’s box for the junta. The more parties involved in 2010’s elections, the greater likelihood that they may, from the junta’s perspective, get out of control. Should the elections actually be held freely and fairly, countless other complicated political and constitutional issues will be raised. After this, a redrafting of the constitution could take place, which would likely deny the junta the constitutional protections that they now enjoy against prosecution for their actions while in power.

Of course, there are a host of other possible futures for Burma – the most likely being that not much will change. The junta may allow cosmetic political changes while retaining power and continuing to suppress its domestic critics, defying the international community. However, there seem to be enough wild cards in the deck now that a political shakeup in the next year is more likely than it has been for some time. Whatever happens, one hopes that life will improve for the Burmese people.