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December 30, 2007

Op-Ed Contributor

A Lifesaving Checklist

By ATUL GAWANDE

Boston

IN Bethesda, Md., in a squat building off a suburban parkway, sits a small federal agency called the Office for Human Research Protections. Its aim is to protect people. But lately you have to wonder. Consider this recent case.

A year ago, researchers at Johns Hopkins University published the results of a program that instituted in nearly every intensive care unit in Michigan a simple five-step checklist designed to prevent certain hospital infections. It reminds doctors to make sure, for example, that before putting large intravenous lines into patients, they actually wash their hands and don a sterile gown and gloves.

The results were stunning. Within three months, the rate of bloodstream infections from these I.V. lines fell by two-thirds. The average I.C.U. cut its infection rate from 4 percent to zero. Over 18 months, the program saved more than 1,500 lives and nearly $200 million.

Yet this past month, the Office for Human Research Protections shut the program down. The agency issued notice to the researchers and the Michigan Health and Hospital Association that, by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations. Johns Hopkins had to halt not only the program in Michigan but also its plans to extend it to hospitals in New Jersey and Rhode Island.

The government?s decision was bizarre and dangerous. But there was a certain blinkered logic to it, which went like this: A checklist is an alteration in medical care no less than an experimental drug is. Studying an experimental drug in people without federal monitoring and explicit written permission from each patient is unethical and illegal. Therefore it is no less unethical and illegal to do the same with a checklist. Indeed, a checklist may require even more stringent oversight, the administration ruled, because the data gathered in testing it could put not only the patients but also the doctors at risk ? by exposing how poorly some of them follow basic infection-prevention procedures.

The need for safeguards in medical experimentation has been evident since before the Nazi physician trials at Nuremberg. Testing a checklist for infection prevention, however, is not the same as testing an experimental drug ? and neither are like-minded efforts now under way to reduce pneumonia in hospitals, improve the consistency of stroke and heart attack treatment and increase flu vaccination rates. Such organizational research work, new to medicine, aims to cement minimum standards and ensure they are followed, not to discover new therapies. This work is different from drug testing not merely because it poses lower risks, but because a failure to carry it out poses a vastly greater risk to people?s lives.

A large body of evidence gathered in recent years has revealed a profound failure by health-care professionals to follow basic steps proven to stop infection and other major complications. We now know that hundreds of thousands of Americans suffer serious complications or die as a result. It?s not for lack of effort. People in health care work long, hard hours. They are struggling, however, to provide increasingly complex care in the absence of effective systematization.

Excellent clinical care is no longer possible without doctors and nurses routinely using checklists and other organizational strategies and studying their results. There need to be as few barriers to such efforts as possible. Instead, the endeavor itself is treated as the danger.

If the government?s ruling were applied more widely, whole swaths of critical work to ensure safe and effective care would either halt or shrink: efforts by the Centers for Disease Control and Prevention to examine responses to outbreaks of infectious disease; the military?s program to track the care of wounded soldiers; the Five Million Lives campaign, by the nonprofit Institute for Healthcare Improvement, to reduce avoidable complications in 3,700 hospitals nationwide.

I work with the World Health Organization on a new effort to introduce surgical safety checklists worldwide. It aims to ensure that a dozen basic safety steps are actually followed in operating rooms here and abroad ? that the operating team gives an antibiotic before making an incision, for example, and reviews how much blood loss to prepare for. A critical component of the program involves tracking successes and failures and learning from them. If each of the hundreds of hospitals we?re trying to draw into the program were required to obtain permissions for this, even just from research regulators, few could join.

Scientific research regulations had previously exempted efforts to improve medical quality and public health ? because they hadn?t been scientific. Now that the work is becoming more systematic (and effective), the authorities have stepped in. And they?re in danger of putting ethics bureaucracy in the way of actual ethical medical care. The agency should allow this research to continue unencumbered. If it won?t, then Congress will have to.

Atul Gawande, a surgeon at Brigham and Women?s Hospital in Boston and a New Yorker staff writer, is the author of ?Better.?

Grand Master

ATGC

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May 31, 2007

Guest Columnist

The Obama Health Plan

By ATUL GAWANDE

As a surgeon, I?ve worked with the veterans? health system, Medicare, Medicaid and private insurance companies. I?ve seen health care in Canada, Britain, Switzerland and the Netherlands. And I was in the Clinton administration when our plan for universal coverage failed. So, with a new health reform debate under way, what I want to tell you in my last guest column is this:

First, there is not a place in this world that is not struggling to control health costs while providing high-quality, easily accessible care. No one ? no one ? has a great solution.

But second, whether as a doctor or as a citizen, I would take almost any system ? from Medicare-for-all to a private insurance voucher system ? over the one we now have. Job-based insurance is bleeding away the viability of American businesses ? even doctors complain about the cost of insuring employees. And it has left large numbers of patients without adequate coverage when they need it. In the last two years, for example, 51 percent of Americans surveyed did not fill a prescription or visit a doctor for a known medical issue because of cost.

My worry is less about what happens if we change than what happens if we don?t.

This week, Barack Obama released his health reform plan. It?s a puzzle how you are supposed to regard presidential candidates? proposals. They are treated, by campaigns and media alike, as some kind of political G.P.S. device ? gadgets primarily for political positioning. So this was how Mr. Obama?s plan was reported: it is a lot like John Edwards?s plan and the Massachusetts plan signed into law by Mitt Romney last year; and it has elements of John Kerry?s proposal from four years ago. In other words ? ho hum ? another centrist plan. No one except policy wonks will tell the proposals apart from one another.

Well, all this may be true. And if what you care about is which candidate can one-up the others, it is rather disappointing. But if what you care about is whether, after the 2008 election, we?ll be in a position to finally stop the health systems? downward spiral, the similarity of the emerging proposals is exactly what?s interesting. I don?t think you can call it a consensus, but there is nonetheless a road forward being paved and a growing number of people from across the political spectrum are on it ? not just presidential candidates, but governors from California to Pennsylvania, unions and businesses like Safeway, ATT and Pepsi.

This is what that road looks like. It is not single-payer. It instead follows the lead of European countries ranging from the Netherlands to Switzerland to Germany that provide universal coverage (and more doctors, hospitals and access to primary care) through multiple private insurers while spending less money than we do. The proposals all define basic benefits that insurers must offer without penalty for pre-existing conditions. They cover not just expensive sickness care, but also preventive care and cost-saving programs to give patients better control of chronic illnesses like diabetes and asthma.

We?d have a choice of competing private plans, and, with Edwards and Obama, a Medicare-like public option, too. An income-related federal subsidy or voucher would help individuals pay for that coverage. And the proposals also embrace what?s been called shared responsibility ? requiring that individuals buy health insurance (at minimum for their children) and that employers bigger than 10 or 15 employees either provide health benefits or pay into a subsidy fund.

It is a coherent approach. And it seems to be our one politically viable approach, too. No question, proponents have crucial differences ? like what the individual versus employer payments should be. And attacks are certain to label this as tax-and-spend liberalism and government-controlled health care. But these are not what will sabotage success.

Instead, the crucial matter is our reaction as a country when the attacks come. If we as consumers, health professionals and business leaders sit on our hands, unwilling to compromise and defend change, we will be doomed to our sliding global competitiveness and self-defeating system. Avoiding this will take extraordinary political leadership. So we should not even consider a candidate without a plan capable of producing agreement.

The ultimate measure of leadership, however, is not the plan. It is the capacity to take that plan and persuade people to find common ground in it. The politician who can is the one we want.

Atul Gawande, a surgeon at Brigham and Women?s Hospital in Boston and a New Yorker staff writer, is the author of the new book ?Better.? He has been a guest columnist this month.

Doctors, Drugs and the Poor

By ATUL GAWANDE

It?s one of those questions no one tells you about when you enter medical practice. What do you do when patients come who can?t pay? Some doctors decline to see them. I have expenses to pay and a family to feed, they?ll argue.

But I grew up in a rural part of Ohio where an inordinate number of poor people live. My mother is a pediatrician there, and from the start, she could not imagine turning children away. Up to 20 percent of her patients have been without insurance, and more than half were on Medicaid, which paid terribly and was refused by other doctors. Some patients were not very grateful. Some were not as poor as they claimed. But we could count on my father?s better-paying urology practice to cross-subsidize. So that?s what she did.

The message from my parents was straightforward: We are in medicine and that comes with certain moral obligations. So I?ve understood that part of my job is to see those who can?t pay ? even if sometimes it hurts.

I?ve been thinking about this as I?ve watched the arguments unfold about what pharmaceutical companies should charge in the developing world. The history of H.I.V. drugs has not been pretty. First, for almost a decade, we in the West ignored the possibility that antiretroviral drugs could be used in the developing world. (Remember the 2001 claim of U.S. government officials that Africans couldn?t learn to take the drugs on time because they didn?t have watches?) Then, under international pressure, drug companies made some discounts, but they were not deep enough. (A year?s supply was still more than $1,000 per patient.) Only when an Indian generic manufacturer provided a copycat three-drug regimen for $150 per year and major donors stepped forward did distribution effectively reach poor countries.

We?re now in the throes of another round of H.I.V. drug battles, this time over advanced, but even more expensive drug regimens from Merck and Abbott Laboratories. Last week, the Clinton Foundation endorsed decisions by Thailand and Brazil to break the companies? patents and purchase cheaper, copycat versions of the drugs. Abbott retaliated by withholding seven new drugs from Thailand, including an antibiotic, a painkiller, and a medication for high-blood pressure. The fight has become vicious.

In a way, it?s hard to see how the confrontation could be avoided. The cost of developing a new drug now approaches $1 billion, and companies do need profit margins to recoup that cost and encourage new innovation. Yet, once a life-saving discovery is made, it is clearly grotesque to make millions suffer or die while waiting for a 20-year patent to expire.

The experience with H.I.V. drugs is oddly heartening, though. There is, in fact, a spectrum of behavior among pharmaceutical companies ? just like with doctors. Gilead Sciences has granted licenses to generic manufacturers to supply its blockbuster H.I.V. drug, Viread, to the world?s hundred poorest countries at the reasonable royalty rate of 5 percent of sales. Bristol-Meyers Squibb licensed its second-line drug, Reyataz, completely free of royalties to generic manufacturers for India and southern Africa. And through the World Health Organization?s bulk vaccine purchasing arrangements, manufacturers have been able to make significant profits selling vaccines at low cost but large volumes. This is the progress we want to build upon.

Pressure to broaden these efforts will grow, and it should. Agreement on regional pricing tiers and distribution networks for H.I.V. drugs show likelihood of solidifying in ways that make drugs available and support innovation, but we have nothing like it for drugs for heart disease, lung disease, or cancer. Meanwhile, the world is changing. The No. 1 cause of death in India, China, and Vietnam is not H.I.V. It?s heart disease. Cancer is in the top 10. Their people need clot-busting drugs, chemotherapies, and EKG machines just like everyone else. Manufacturers need to show the same willingness to make these life-saving technologies available to the poor.

Some will argue, hey, companies just invent this stuff; it isn?t their job to make sure every country gets some. But that?s not right. As Arthur Caplan, the bioethicist, points out, ?You aren?t manufacturing pantyhose when you?re in health care. There are special moral duties attached.?

And one of them is: If you?re building a lifeboat, you have to think about how many you can get inside.

Atul Gawande, a surgeon at Brigham and Women?s Hospital in Boston and a New Yorker staff writer, is the author of the new book ?Better.? He is a guest columnist this month.

Grand Master

ATGC

Posted
Posted

Doctors, Drugs and the Poor

By ATUL GAWANDE

It?s one of those questions no one tells you about when you enter medical practice. What do you do when patients come who can?t pay? Some doctors decline to see them. I have expenses to pay and a family to feed, they?ll argue.

But I grew up in a rural part of Ohio where an inordinate number of poor people live. My mother is a pediatrician there, and from the start, she could not imagine turning children away. Up to 20 percent of her patients have been without insurance, and more than half were on Medicaid, which paid terribly and was refused by other doctors. Some patients were not very grateful. Some were not as poor as they claimed. But we could count on my father?s better-paying urology practice to cross-subsidize. So that?s what she did.

The message from my parents was straightforward: We are in medicine and that comes with certain moral obligations. So I?ve understood that part of my job is to see those who can?t pay ? even if sometimes it hurts.

I?ve been thinking about this as I?ve watched the arguments unfold about what pharmaceutical companies should charge in the developing world. The history of H.I.V. drugs has not been pretty. First, for almost a decade, we in the West ignored the possibility that antiretroviral drugs could be used in the developing world. (Remember the 2001 claim of U.S. government officials that Africans couldn?t learn to take the drugs on time because they didn?t have watches?) Then, under international pressure, drug companies made some discounts, but they were not deep enough. (A year?s supply was still more than $1,000 per patient.) Only when an Indian generic manufacturer provided a copycat three-drug regimen for $150 per year and major donors stepped forward did distribution effectively reach poor countries.

We?re now in the throes of another round of H.I.V. drug battles, this time over advanced, but even more expensive drug regimens from Merck and Abbott Laboratories. Last week, the Clinton Foundation endorsed decisions by Thailand and Brazil to break the companies? patents and purchase cheaper, copycat versions of the drugs. Abbott retaliated by withholding seven new drugs from Thailand, including an antibiotic, a painkiller, and a medication for high-blood pressure. The fight has become vicious.

In a way, it?s hard to see how the confrontation could be avoided. The cost of developing a new drug now approaches $1 billion, and companies do need profit margins to recoup that cost and encourage new innovation. Yet, once a life-saving discovery is made, it is clearly grotesque to make millions suffer or die while waiting for a 20-year patent to expire.

The experience with H.I.V. drugs is oddly heartening, though. There is, in fact, a spectrum of behavior among pharmaceutical companies ? just like with doctors. Gilead Sciences has granted licenses to generic manufacturers to supply its blockbuster H.I.V. drug, Viread, to the world?s hundred poorest countries at the reasonable royalty rate of 5 percent of sales. Bristol-Meyers Squibb licensed its second-line drug, Reyataz, completely free of royalties to generic manufacturers for India and southern Africa. And through the World Health Organization?s bulk vaccine purchasing arrangements, manufacturers have been able to make significant profits selling vaccines at low cost but large volumes. This is the progress we want to build upon.

Pressure to broaden these efforts will grow, and it should. Agreement on regional pricing tiers and distribution networks for H.I.V. drugs show likelihood of solidifying in ways that make drugs available and support innovation, but we have nothing like it for drugs for heart disease, lung disease, or cancer. Meanwhile, the world is changing. The No. 1 cause of death in India, China, and Vietnam is not H.I.V. It?s heart disease. Cancer is in the top 10. Their people need clot-busting drugs, chemotherapies, and EKG machines just like everyone else. Manufacturers need to show the same willingness to make these life-saving technologies available to the poor.

Some will argue, hey, companies just invent this stuff; it isn?t their job to make sure every country gets some. But that?s not right. As Arthur Caplan, the bioethicist, points out, ?You aren?t manufacturing pantyhose when you?re in health care. There are special moral duties attached.?

And one of them is: If you?re building a lifeboat, you have to think about how many you can get inside.

Atul Gawande, a surgeon at Brigham and Women?s Hospital in Boston and a New Yorker staff writer, is the author of the new book ?Better.? He is a guest columnist this month.

Grand Master

ATGC

Posted
Posted

US rivals spar in first TV debate

Please turn on JavaScript. Media requires JavaScript to play.

Senators Barack Obama and John McCain in their first presidential debate

US presidential rivals Republican John McCain and Democrat Barack Obama have attacked each other over foreign policy and the economy, in their first debate.

Mr Obama said a $700bn (?380bn) plan to rescue the US economy was the "final verdict" on years of Republican rule.

He said Mr McCain had been "wrong" on Iraq and tried to link him to President Bush. The Republican senator described his rival as too inexperienced to lead.

Neither landed a knockout blow but polls suggested Mr Obama did better.

An immediate telephone poll by CNN and Opinion Research Corp found 51% said Mr Obama had won, to 38% for Mr McCain.

A poll of uncommitted voters by CBS News found that 39% gave Mr Obama victory, 25% thought John McCain had won, and 36% thought it was a draw.

Both campaigns claimed victory, with Mr McCain's team saying their candidate had shown a "mastery on national security issues" while Mr Obama's aides said he had passed the commander-in-chief test "with flying colours".

All things considered, it's about a draw

Matthew Yglesias, Think Progress

Tens of millions of Americans were expected to watch the debate on TV, with only about five weeks to go before the 4 November elections.

Senator McCain said he did not need "any on-the-job training".

"I'm ready to go at it right now," he added.

But Senator Obama said Mr McCain had been "wrong" about invading Iraq and that the war had led the US to take its eye off the ball in Afghanistan, where it should have been pursuing al-Qaeda.

Mr McCain argued that as a result of the "surge" - which involved sending some 30,000 extra US troops to Iraq - US military strategy was succeeding.

"We are winning in Iraq and we will come home with victory and with honour," he said.

The televised debate in Oxford, Mississippi, focused largely on foreign policy but began with discussion of the economic crisis gripping the US.

Speaking about the financial bail-out plan under discussion by the US Congress, Mr Obama said: "We have to move swiftly and we have to move wisely."

NEXT DEBATES

2 Oct - vice-presidential rivals. Topic: Domestic and foreign policy

7 Oct - presidential contenders. Topic: Any issues raised by members of the audience

15 Oct - presidential contenders. Topic: Domestic and economic policy

The BBC has full and extensive coverage of the debates

Mr McCain said he believed it would be a long time before the situation was resolved.

"This isn't the beginning of the end of this crisis," he said. "This is the end of the beginning if we come out with a package that will keep these institutions stable and we've got a lot of work to do."

Mr McCain attacked Mr Obama over his record on finance, saying he had asked for millions of dollars in so-called "earmarks" - money for pet projects - as an Illinois senator.

The Republican also suggested a spending freeze in many areas apart from defence, but Mr Obama likened the proposal to using a hatchet when a scalpel was needed.

Both candidates agreed that the bail-out plan would put massive pressure on the budget of the next president and mean cuts in government spending.

'Serious threat'

Asked about Iran, Mr McCain stressed that Tehran was a threat to the region and, through its interference in Iraq, to US troops deployed there.

Please turn on JavaScript. Media requires JavaScript to play.

John McCain and Barack Obama on dealing with Iran

He outlined a proposal for a "league of democracies" to push through painful sanctions against Tehran that were presently being blocked in bodies like the United Nations because of opposition from Russia.

He criticised Mr Obama for his previously stated willingness to hold talks with the leaders of Iran without preconditions.

Mr Obama rejected that criticism, saying he would reserve the right as president "to meet with anybody at a time and place of my choosing if I think it's going to keep America safe".

However, he said he agreed with his Republican rival that "we cannot tolerate a nuclear Iran" and the threat that that would pose to Israel, a staunch US ally.

'Safer today'

Mr McCain accused Mr Obama of "a little bit of naivete" in his initial response to the conflict between Georgia and Russia.

"Russia has now become a nation fuelled by petro-dollars that has basically become a KGB [former secret services name] apparatchik-run government. I looked in [Russian Prime Minister Vladimir] Mr Putin's eyes and I saw three letters - a K, a G and B," McCain said.

Speaking about the so-called war on terror, Mr McCain said he believed the nation was safer than it had been the day after the 11 September 2001 terror attacks but there was still a long way to go.

Mr Obama pointed to the spread of al-Qaeda to some 60 countries and said that the US had to do more to combat that, including improving its own image as a "beacon of light" on rights.

"One of the things I intend to do as president is restore America's standing in the world," Mr Obama said.

Mr McCain sought to distance himself from President George W Bush's administration, which has very low public approval ratings.

"I have opposed the president on spending, on climate change, on torture of prisoners, on Guantanamo Bay, on the way that the Iraq war was conducted," he said.

"I have a long record and the American people know me very well... a maverick of the Senate."

Mr McCain had earlier vowed not to attend the forum in Mississippi until Congress approved the economic bail-out plan, but he reversed his decision after some progress was made towards a deal.

Story from BBC NEWS:

http://news.bbc.co.uk/go/pr/fr/-/2/hi/americas/7638435.stm

Published: 2008/09/27 07:35:44 GMT

? BBC MMVIII

Grand Master

+Gary7 Subscriber²

Posted
  • Subscriber²
Posted

US rivals spar in first TV debate

Please turn on JavaScript. Media requires JavaScript to play.

Senators Barack Obama and John McCain in their first presidential debate

US presidential rivals Republican John McCain and Democrat Barack Obama have attacked each other over foreign policy and the economy, in their first debate.

Mr Obama said a $700bn (?380bn) plan to rescue the US economy was the "final verdict" on years of Republican rule.

He said Mr McCain had been "wrong" on Iraq and tried to link him to President Bush. The Republican senator described his rival as too inexperienced to lead.

Neither landed a knockout blow but polls suggested Mr Obama did better.

An immediate telephone poll by CNN and Opinion Research Corp found 51% said Mr Obama had won, to 38% for Mr McCain.

A poll of uncommitted voters by CBS News found that 39% gave Mr Obama victory, 25% thought John McCain had won, and 36% thought it was a draw.

Both campaigns claimed victory, with Mr McCain's team saying their candidate had shown a "mastery on national security issues" while Mr Obama's aides said he had passed the commander-in-chief test "with flying colours".

All things considered, it's about a draw

Matthew Yglesias, Think Progress

Tens of millions of Americans were expected to watch the debate on TV, with only about five weeks to go before the 4 November elections.

Senator McCain said he did not need "any on-the-job training".

"I'm ready to go at it right now," he added.

But Senator Obama said Mr McCain had been "wrong" about invading Iraq and that the war had led the US to take its eye off the ball in Afghanistan, where it should have been pursuing al-Qaeda.

Mr McCain argued that as a result of the "surge" - which involved sending some 30,000 extra US troops to Iraq - US military strategy was succeeding.

"We are winning in Iraq and we will come home with victory and with honour," he said.

The televised debate in Oxford, Mississippi, focused largely on foreign policy but began with discussion of the economic crisis gripping the US.

Speaking about the financial bail-out plan under discussion by the US Congress, Mr Obama said: "We have to move swiftly and we have to move wisely."

NEXT DEBATES

2 Oct - vice-presidential rivals. Topic: Domestic and foreign policy

7 Oct - presidential contenders. Topic: Any issues raised by members of the audience

15 Oct - presidential contenders. Topic: Domestic and economic policy

The BBC has full and extensive coverage of the debates

Mr McCain said he believed it would be a long time before the situation was resolved.

"This isn't the beginning of the end of this crisis," he said. "This is the end of the beginning if we come out with a package that will keep these institutions stable and we've got a lot of work to do."

Mr McCain attacked Mr Obama over his record on finance, saying he had asked for millions of dollars in so-called "earmarks" - money for pet projects - as an Illinois senator.

The Republican also suggested a spending freeze in many areas apart from defence, but Mr Obama likened the proposal to using a hatchet when a scalpel was needed.

Both candidates agreed that the bail-out plan would put massive pressure on the budget of the next president and mean cuts in government spending.

'Serious threat'

Asked about Iran, Mr McCain stressed that Tehran was a threat to the region and, through its interference in Iraq, to US troops deployed there.

Please turn on JavaScript. Media requires JavaScript to play.

John McCain and Barack Obama on dealing with Iran

He outlined a proposal for a "league of democracies" to push through painful sanctions against Tehran that were presently being blocked in bodies like the United Nations because of opposition from Russia.

He criticised Mr Obama for his previously stated willingness to hold talks with the leaders of Iran without preconditions.

Mr Obama rejected that criticism, saying he would reserve the right as president "to meet with anybody at a time and place of my choosing if I think it's going to keep America safe".

However, he said he agreed with his Republican rival that "we cannot tolerate a nuclear Iran" and the threat that that would pose to Israel, a staunch US ally.

'Safer today'

Mr McCain accused Mr Obama of "a little bit of naivete" in his initial response to the conflict between Georgia and Russia.

"Russia has now become a nation fuelled by petro-dollars that has basically become a KGB [former secret services name] apparatchik-run government. I looked in [Russian Prime Minister Vladimir] Mr Putin's eyes and I saw three letters - a K, a G and B," McCain said.

Speaking about the so-called war on terror, Mr McCain said he believed the nation was safer than it had been the day after the 11 September 2001 terror attacks but there was still a long way to go.

Mr Obama pointed to the spread of al-Qaeda to some 60 countries and said that the US had to do more to combat that, including improving its own image as a "beacon of light" on rights.

"One of the things I intend to do as president is restore America's standing in the world," Mr Obama said.

Mr McCain sought to distance himself from President George W Bush's administration, which has very low public approval ratings.

"I have opposed the president on spending, on climate change, on torture of prisoners, on Guantanamo Bay, on the way that the Iraq war was conducted," he said.

"I have a long record and the American people know me very well... a maverick of the Senate."

Mr McCain had earlier vowed not to attend the forum in Mississippi until Congress approved the economic bail-out plan, but he reversed his decision after some progress was made towards a deal.

Story from BBC NEWS:

http://news.bbc.co.uk/go/pr/fr/-/2/hi/americas/7638435.stm

Published: 2008/09/27 07:35:44 GMT

? BBC MMVIII

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