Thursday, October 17, 2013

Skinny Bitch and Bulimic Vegetarians

Introduction
In 2007, few people would have expected a "no-nonsense" book of "tough-love" for American females to become one of the most successful vegetarian advocacy publications in the Western hemisphere. This book, Skinny Bitch, spawned a whole slew of products including a cookbook, an instructional book on pregnancy, a journal, and now three work out videos. Already, the original book has become an international bestseller, hung onto the New York Times bestseller list (including a brief spot at the top), has sold two million copies, and has been translated into 20 languages.

While many vegetarian and AR activists have welcomed this book with open arms, too few people have heeded to the criticisms that this book preys on female body insecurities. Below, I will discuss why disguising a vegetarian message within a frame about weight-loss/management is not only detrimental to the health of adolescent females and young women but also trivializes the radical political orientation of veganism by conflating it with a self-interested, faddish diet. In light of continuous research that links the adoption of vegetarian diets by teens to disguise and/or justify their eating disorders, the sizist discourse that shames and blames "fat" people, and the vogue-ing of vegetarianism for the mainstream, I suggest that vegans ally instead with feminist and radical social justice groups to promote body acceptance and HEALTH rather than societal acceptance and "health."

"I am a vegetarian: I don't eat meat... or anything for that matter."
For a while there has been some discussion over whether many young female vegetarians choose their diets as a way to manage their weight by having a socially acceptable reason to decline eating a large percentage of the food available to them; however, not until recent years have researchers ever had substantial evidence to conclude whether this was true or false. Just several weeks ago, a paper published in the Journal of the American Dietetic Association proved such fears true. The authors of the study conclude that

[a]dolescent and young adult vegetarians may experience the health benefits associated with increased fruit and vegetable intake and young adults may experience the added benefit of decreased risk for overweight and obesity. However, current vegetarians may be at increased risk for binge eating with loss of control, while former vegetarians may be at increased risk for extreme unhealthful weight-control behaviors. It would be beneficial for clinicians to inquire about current and former vegetarian status when assessing risk for disordered eating behaviors.
Though there may be health benefits from adopting a vegetarian diet, many who choose such diets do so as a guise to manage their weight in the most unhealthy ways.

John Cloud from The Times recentlyreported on this latest study:


Although most teens in Robinson-O'Brien's study claimed to embark on vegetarianism to be healthier or to save the environment and the world's animals, the research suggests they may be more interested in losing weight than protecting cattle or swine...in a 2001 study in the Journal of Adolescent Health, researchers found that the most common reason teens gave for vegetarianism was to lose weight or keep from gaining it. Adolescent vegetarians are far more likely than other teens to diet... [and] teens with eating disorders are more likely to practice vegetarianism than any other age group.
So while the public and socially acceptable answer many teenage vegetarian girls for their vegetarian may be "to save the animals/environment," at least one out of five (and potentially over half) really adopted the diet primarily out of concern for the health and/or image of their body.

Cloud continues, summarizing the results of the study:


approximately 20% of the [teen] vegetarians turned out to be binge eaters [and had engaged in extreme weight-control measures], compared with only 5% of those who had always eaten meat...This disparity in extreme behavior disappeared between [the]... ages 19 to 23, with about 15% in each group reporting such weight-control tactics. But among former vegetarians, that number jumped to 27%. The findings suggest that age matters when it comes to vegetarianism
Interestingly, teen vegetarians were four times as likely to be binge eaters than omnivores, but young adult vegetarians were no more likely, suggesting that many teen vegetarians started extreme dieting prior to their omnivorous counterparts. Most concerning is that over one of four those who had once been vegetarians as teens, but quit, were extreme dieters. That's twice the rate of eating disorders as among young adults who had never been or who still were vegetarian! The moral: the adoption of a vegetarian diet as a teenager for the primary purpose of body-management sets one up for serious risk of eating disorders in the future.

I Love them Bitches: Don't Have a Cow, You Fat Pig, LOL!
The authors and publishers of Skinny Bitch are not naive to the "self-loathing" young (and old) women feel as a product of modern capitalist patriarchal culture. The official Skinny Bitch website gives a concise description of the book, or at least why someone should be interested and pick the thing up:


If you can't take one more day of self-loathing, you're ready to hear the truth: You cannot keep shoveling the same crap into your mouth every day and expect to lose weight.
The answer to self-loathing, the book suggests, is not to accept and love one's body, but to stop eating crap and lose weight--never mind that many of the readers of the book are probably already at a healthy weight. In fact, if you didn't already know, "fat" does not always = unhealthy.

As one blogger writes, "[t]hough Skinny Bitch is meant to be dramatic, its overall message, inspiring self-loathing complete with the names to call yourself was over the top." The blogger cites a quote from chapter 12 that particularly disgusted her. In it, the authors explain how they, as "skinny bitches," empathize with their audience of "fat bitches:" "we have some fat, gross body parts, too. We’re women." In other words, the authors agree with mainstream misogynism that, yes, women are just kinda disgusting; no matter how much you alter and manage your body, it'll always be just a little "gross," a tad "fat."

Of course, the point of the book is not to make girls into "skinny bitches" but into veg*ns with jarring editorializations of meat processing and propaganda. The title is just a diversion to get people to pick up what Julie Klausner, in a scathing review of the book at Salon described as "a PETA pamphlet in chick-lit clothing and an innovative fusion of animal rights with punitive dieting tactics that prey on women's insecurities about their bodies." According to a previous review in the New York Times


[o]ne South Cal botique has sold more than 2,000 copies of Skinny Bitch because "[customers] just like the title." Likewise, one fashion publicist said that she "would never have read 'The Omnivore’s Dilemma.' I’m not even sure I know what an omnivore is. But I know what a skinny bitch is, and I know I want to be one."
To put it simply, the Skinny Bitch franchise is so popular largely due to the clever marketing that went into it. As the fashion publicist said, women know skinny bitches, and they know they want to be them; they don't necessarily know (or care) what an omnivore or a vegan is. With a title like Skinny Bitch, the book drew on a much larger, mainstream audience, like a magnet for body-insecure women. But is this more of a success for vegetarianism or perpetuating body-image anxiety?

Klausner would probably agree with he latter: Skinny Bitch is more likely to perpetuate eating disorders than to nurture a sustainable compassion for animal others. For instance, the book exploits metaphors that are both misogynistic and speciesist as part of its "in your face" coaching:


The relentless bullying peppered throughout the authors' advice accounts for much of the book's humor, including quips like "you need to exercise, you lazy shit," "coffee is for pussies" and "don't be a fat pig anymore." It was a formerly anorexic friend of mine who nailed it when she read excerpts from the book. "When you have an eating disorder," she told me, "that's the voice you hear in your head all the time."
Likewise, Joanna at Vegans of Color believes the book is being marketed as a tool to shame women into a vegetarian diet so they ca be skinny. She adds

I feel like the idea behind the book, & certainly how it’s being talked about, definitely plays the shame game. And competition & jealousy — I mean, women who don’t care about animal rights are picking this up because they want to be skinny
The authors of the book, understand that bullying voice internalized in women from all races, classes, and regions of America that drives them toward unhealthy eating, and they are not afraid of exploiting it to humorously shaming/motivating people into eating "better" food.

Angie at Voice of Dissent further notes that the tag line, "Stop being a moron and start getting skinny," "is playing directly into the stereotype that all overweight people are stupid, ignorant and lazy." Not only the readers being shamed for being "fat," but all the bad stereotypes associated with it: fatness is something that could be overcome if you weren't too stupid not to be disgusted by your body and too lazy to exercise and cook healthy food. How ever tongue-in-cheek the humor of their tough-love style is, it trivializes that oppressive voice within women's heads and further validates false associations between fat/stupid/lazy/bad and thin/smart/agency/good. In many ways, the humor actually is apologetic for that oppressive voice as well as misogynism and sizism.

Nonetheless, some counter the criticism by noting that the authors admit at the end of the book that they tricked the reader into reading this pro-vegan book, that they really don't care about being skinny. Johanna, however, is not so convinced that such jest makes any difference. Johanna writes: "Well, I flipped through the book yesterday at a store, & this epilogue is about 3 paragraphs long. Not only that, I almost missed it — & I knew it was there & was looking for it!" The discreetness of the true intent of the book, whether the authors' decision or the publishers', ultimately betrays the good intentions. Consequentially, most readers will read/skim through the book without ever realizing the political agenda behind the text; and if they do, they probably won't even care since the agenda--the "real" values behind the text--are such a marginal theme.

Klausner continues by noting the irony that the L.A. boutique cited in the NYT article which has already sold 2,000 copies, is a place where purchasers of the book are "only to be blindsided with accounts of live cows skinned alive on the assembly line." Will people change their minds about animals used for clothing after reading the book--now feeling disturbed and disgusted at skins wrapped around their bodies--or will these readers celebrate the sizes they've dropped by purchasing a whole new wardrobe of "sexy" leather pants and wool sweaters? Johanna, again, is skeptical.


from my own experiences, & from what I’ve heard other folks talking about, those who convert to veg*nism for health reasons... are less likely to stick with it, unless they also have a strong ethical reason for eating the way they do
Most vegans I know will also agree that the reason for one choosing to become veg*n is important in determining whether one will maintain their lifestyle or trade it in for an old or a new one.

If one goes veg because they value justice and compassion for animal others, they are more likely to commit to veg*nism than someone who prioritises their self-interest or external opinion. If one cares about animal "rights," veg*nism is essential to putting their values in practice, but veg*nism is only contingent if they care more about body-image, which can not only be attained a number of ways, but is also something that cannot be guaranteed by a strict vegetarian regime. Certainly one can be "vegan" and eat unhealthy foods and not exorcise, but some people are not naturally disposed to being "thin" as others--making the pursuit of thinness a futile journey. In the end, those people striving for thinness on a veg*n diet may be unhappy with the lax results and move on to "the next big thing" to lose weight so that they can achieve their "ideal" body size.

PETA: People Encouraging Teen Anorectics?
The title of this section may be hyperbole, but I also don't believe it is totally out-of-hand or false. On the contrary, the success of the Skinny Bitch franchise comes after almost two decades of PETA "selling" vegetarianism and sex in the form of attaining a more beautiful and virile body, which is almost always abnormally thin and fit and often (though this is less and less the case) white. It is not surprising then that Ingrid Newkirk endorsed Skinny Bitch, saying that "If I had it in my power, I’d provide a free copy to every young woman in the developed world; we could then become, instead of the fattest next generation in history, the healthiest." [Note that she wrongly equates fatness with both veg*nism and health. I'll touch on this in a future post ("The Fat, the Thin, and the Hungry")]

Skiny Bitch, in fact, has successfully done what PETA could only dream of doing, tapping into millions of young, impressionable female minds and promoting vegetarianism. The book has even increased the number of requests for vegetarian starter kits. According to Gina Anderson of the Colorado Daily


The New York Times bestseller "Skinny Bitch" is creating a new wave of vegetarians and vegans -- especially on college campuses..."'Skinny Bitch' has helped to introduce millions of mainstream Americans to veganism," said Ryan Huling, the College Campaign Coordinator for PETA2, the youth division of People for the Ethical Treatment of Animals..."For example, we have been distributing our free 'Vegetarian Starter Kit' for years, but by some estimates as many as 25 percent of those requests in 2008 were as a result of the requester reading 'Skinny Bitch,'" Huling said. "That is thousands of new vegetarians and vegans."
Certainly, it is good to hear that some people who picked up the book are interested enough in requesting a veg starter kit from an animal welfare organization. But again, the question is not how many "new" vegetarians are there today, but how many 5-year-long vegetarians will there be in five years.

Yet, PETA, which unlike Skinny Bitch, does not garb its political agenda in weight-management discourse, is no less the culprit of perpetuating body-image anxiety. The organization often utilizes fat phobia and sizism to shame/motivate people to adopt a veg*n diet. For instance, Vegan Kid notes that, according to PETA's video"Chew on This: 30 Reasons to Go Vegetarian," the #3 reason to go vegetarian is because "meat and dairy make you fat." Of course, many other things "make you fat," and meat and dairy need not be any of these things. They prioritize this "fact" because they know that most people are already insecure if not ashamed of their weight and size, and as such, it may be more compelling than reason 11 "because it is violence that you can stop."

Another example of the "fat" phobia/shaming done by PETA is in a response to Jessica Simpson's "Real Girls Eat Meat" shirt on the official PETA blog. According to this PETA employee, the #4 reason that "Only Stupid Girls Brag about Eating Meat" is that


Meat will make you fat. All the saturated fat and cholesterol in chicken wings, pork chops, and steak eventually leads to flabby thighs and love handles. I hope the upcoming "Jessica Simpson's Intimates" line comes in plus sizes! Going vegetarian is the best way to get slim and stay that way.
Here again, just like we saw with Skinny Bitch, is the perpetuation of the stereotype linking size to stupidity--something that has been common at least since the pseudo-science of physiognomy. The reasoning goes as such: only a "stupid" person would eat meat because they'll get cancer and fat; just think how ashamed of herself she'll be then when she gets caught shopping in the 'plus size' section, gasp! Even worse, is that this fat phobic response is neither logical nor scientific: saturated fat and cholesterol intake are no more connected with weight-gain than carbohydrates and protein.

Worse of all is that PETA even has the audacity to distribute "Chicken Chump Cards"--which are still available at their online store and Petakids.com--to kids, of which one shames fat children. On the front of the card is a sad, morbidly-obese child entitled "Tubby Tammy;" on the back it explains "how" chicken makes you so fat you'll have to wear a bungee cord for a belt. Also, since this card is part of a series of other cards including "Cruel Kyle," "Sickly Sally,' and "Feathered Friends," there is an implicit position that being "tubby" is analogous to being "sickly" and "cruel," not something conducive of friendship. Fatness is thus framed as a mix between a social disease (i.e. cruelty) and a biological one (i.e. sickness).

Again, these three cases of fat phobia/shaming are in no way trivial. Each is part of a highly calculated marketing tactic to "sell" vegetarianism as a social panacea. The discourse in the blurbs and visuals has little to do with enhancing and sustaining health (or even a healthy body weight), but about looking your best for society which will reject you as a big fat, stupid person who is probably less compassionate and more self-indulgent than the other kids.

Unfortunate for the well-intentioned female animal advocates of PETA, those who do not conform to the mainstream's socially acceptable standard of beauty for women, the very standards PETA perpetuates, will be harassed and shunned. Take for instance the reactions at Perez Hilton to a publicity stunt in which a pregnant woman posed in a mock-gestation crate to protest hog farms. Comments included:


Yikes, I get the picture, but hmm... saggy boobs= kinda gross!!!! What's a tubby naked bitch in a cage got to do with eating pork?? She needs to go on a diet wtf is this about ewwwwwwwww Moo cow..UGLY Why couldn't they have chosen an attractive female?
Of course, no one deserves to be called such horrible, misogynistic and speciesist names; but it would not be surprising if PETA, or some animal advocates in general, used the same rhetoric to attack a woman who was promoting pork. As is suggested in their anti-fur ads, "Be Comfortable in Your Own Skin," one blogger comments, PETA "is basically saying that yes, you should let animals keep their fur because you should be comfortable in your own skin–as long as you’re a size 2 and conventionally beautiful."

In a devastating critique of "fascist" beauty standards established by many ARAs to promote vegetarianism as a "healthier" and "sexier" diet, Sabayon at Vegans Against PETA examines how certain advocates alienate and ostracize vegans who do not look "as good as they should." According to Sabayon:


so much of the animal rights movement, thanks mostly to PETA, has built itself around the idea that vegans, particularly vegan women, are hot...They try to convince people that being vegan will automatically make you hot if you're a woman, and if you're a dude you'll suddenly have all these hot women flocking to you...And what does this emphasis on looks mean for us vegans who don't measure up, for vegans who are fat or have acne or, like me, have thin hair...It means we're a failure.
She cites one blogger (and believe me, I've heard these comments from several animal advocates in person) as an example of some of the fat-hate ARAs have to deal with, particularly women:

Fat vegans, however, have failed one important animal: themselves...their audiences of meat-eaters and animal-abusers may be so distracted by their appearance that they cannot hear the vital issues of animal rights
So not only do "fat" vegans have to deal with fatphobia in the mainstream world, but also among their supposed allies. Yet, so much of this is borderline hypocritical since people's agency is not necessarily to "blame" for their "fatness." The result: body-insecure vegans rushing out to buy body products that have been likely tested on animals in order to look "good" and "sexy" to promote the cause.

It is thus ironic that, after all the fat phobic media PETA has produced and distributed, in a press release, PETA's Vice President Daphna Nachminovitch would be cited saying


The AKC's fetish for body image causes dogs health problems that mutts don't usually have...The AKC is directly responsible for the promotion of purebreds, which means money for breeders but creates sick dogs and vet bills for their guardians--and leaves pound pups homeless.
Of course, one could also argue PETA has a "fetish for body image" since they not only publicize fat phobia, but also advertise themselves through images that capitalize off the bodies of conventional beautiful women which "means money for [them] but creates sick [girls] and [hospital] bills for their [parents]." As Angie notes,


[t]he majority of PETA’s messages include promoting a certain type of body. All of their models tend to be thin, young and fit contemporary society’s definition of beautiful. They have ads blatantly telling women that body hair is unattractive and comparative to wearing animal skins. They [even] have ads making fun of overweight people.
In face of the constant letters they receive pleading them to stop objectifying women and using only abnormally thin women in their ads, PETA has yet to end its tactics that more than likely to some degree create sick teen females with the dominant "fetish for body image."

Lettuce Entertain You: Vegetarianism is the New Black
In contrast to past anti-fur ads that are occupied by naked and nearly naked small-sized women, PETA's recent ad campaign, "Let vegetarianism grow on you" features women in more graceful than haughty clothing. However, even these ads have raised some concerns. Take the new ad featuring long-time film actress, Cloris leachman. Ophilia at Feminocracy


highly doubt[s] Peta would have run the ad if Cloris had wanted to be naked. Placing Cloris in a lettuce dress reaffirms the sentiment behind their previous ads–that the female body is meant for consumption, and when that body begins to show age, it must be covered to protect our sensibilities (however, it is worth note that the dress conforms to her figure–so they’ve got to have their sexy factor in there somewhere).
The accusation of ageism may seem trite to many people, especially since Alysa Milano, who certainly isn't particularly an "old" woman, has also been a part of the "Let Vegetarianism grow on you" ad campaign and thus also robed in a lettuce dress instead of the typical lettuce bikini of Pamela Anderson and others. Another blogger notes that she "doubt[s] they would dress Carmen Electra in a cabbage gown" because she both wants to and is "supposed to" be seen as a sex object. Those without the proper body, as was the case above in the mock-gestation crate, are publicly ridiculed for not hiding theirs beneath clothing.

The following blogger brings up another excellent point: Ms. Leachman may be older than typical PETA poster girls, but she isn't exactly "fat" or "overweight." Is it solely a coinicidence that Elizabeth Berkley, the original Lettuce Lady,


started the trend by sending a postcard with her ad and a note to every restaurant in the U.S.' 10 fattest cities urging them to do their part to help diners slim down by beefing up on vegetarian selections[?]
PETA's official Lettuce Ladies website further validates this suspicion by listing the reasons lettuce ladies choose vegetarianism: "vegetarian celebs are hot!," "vegans make better lovers," "a vegan diet gives you a lean sexy body," and "eating meat causes impotence." None of these reasons actually have to do with being veg*n; they are all contingent--equally true of someone on a Mediterranean diet who works out and reads Cosmo. Yet, all of them praise sexually virile bodies (see their "Sexiest Vegetarian Next Door" competition) and shun those that do not "perform" in socially acceptable ways. [Note: the website does also feature a small "amateur photo gallery" reserved for people wearing custom-made lettuce bikinis, many of whom are non-conventional sizes.]

If PETA wants to get people to eat more vegetables and less meat, Chris L. astutely wonders whether "it make more sense to show celebrity advocates, you know, EATING vegetables, instead of wearing them?" To this I have a couple responses. First, as I will argue in a future post ("The Sexual Politics of Vegetarianism"), PETA knows much of its mainstream audience will not consume veggies without also consuming "meat." In this metaphoric sense, PETA "serves" up the "meat" (i.e. erotic women) to their audience, garnished--or rather "dressed"--in lettuce and other vegetables. Rather than challenging the entire system of privilege which requires the subordination of Others, PETA perpetuates it by downplaying the subjectivity of one marginalized group (women) for another (animals). Lettuce ladies wear vegetables to be looked at, as they ought to be "consumed" just like the vegetables they wear. Both "food" and women ought to be "consumed" by the arrogant eye, or male gaze, and be denied their independence from the observer. With these ads, however, "the animal" is what Carol Adams has called the "absent referent"--the subject that is being referenced, but not directly. Thus, veg*nism can be promoted through the dominant means of denying the subjectivity of another without ever mentioning the real reason people should adopt the lifestyle: by acknowledging Others' subjectivities.

Second, and perhaps more relevant to the topic at hand, nearly all of PETA's ad campaigns utilizes not just any woman (or man), but celebrities, and not just any celebrities, but particularly physically attractive ones who are actors and musicians. These celebrities, thus, are visual icons. There are few, if any ads of famous (and beautiful) female scientists, photographers, authors, scholars, etc. suggesting the organization values (or at least values the people who value) "entertainment" over "art," science, and literature. Such famous people may not be "cool" enough for PETA's campaign targeting youth. Vegetarianism and AR is being "sold" as the "in" thing, and as is evident with anti-fur slogans in the movement that publicly shame (cisexual) women for wearing fur (as well as trans people for just being "rediculous") (i.e. "worse dressed," "the Trollsen Twins," "Fur is worn by beautiful animals and ugly people," "Fur is a Drag," etc.), women who do not conform are not only morally but physically ridiculed.

Toward Radical Vegan Outreach: Out with Mainstream Advocacy, in with Alliance Politics
Let me emphasize that the use of such visual celebrities is very deliberate, and, as I believe, very misguided. The use of these celebrities over others emphasizes not any moral, political, artistic, or intellectual of the particular person being associated with vegetarianism and AR, but an image. One should go veg because vegetarians are pretty, hot, bad ass, or funny, not because they are social/political radicals healing injustices everywhere or writing/discovering something that will change the world. (Unfortunately, television, cinema, and the internet have made the former celebrities' images much more prominent and at the expense of the great works of scholars, scientists, artists, and social entrepreneurs).

To return to Chris' point, PETA dresses-up celebrities in vegetables instead of showing them eating vegetables because PETA doesn't really care what people eat so long as their "food" does not come from animals. For all they care, vegans could just eat a Boca burger, potato chips, and a soft drink--not exactly a nutritional powerhouse. The ads are not intended to promote HEALTH, but to promote an image. By dressing up celebrities in vegetables, PETA is marketing the vegetarian diet as either sexy and/or graceful. Vegetarianism, in a sense, is the latest fashion, "the color" of the 21st Century.

However, note that by framing vegetarianism and AR as an image, as an "in" thing, it easily can become an "out" thing. Many of these ads and campaigns which target younger audiences may influence thousands of people to try out vegetarianism and AR, but the question becomes "for how long?" If vegetarianism is a matter or being like a particular "cool" or "hot" celebrity, especially one whom may be obsolete in two years or turns out not to actually be vegetaraian, as soon as another "cool" celebrity comes around who eats animals or people realize how potentially challenging a vegetarian diet can be (all the social and emotional maintenance that is involved) they may shrug it off; it's just not worth it, just as those irksome designer heels are just not worth it.

On the other hand, if vegetarianism is advocated as a political-ideological-intellectual orientation and commitment, it becomes a part of one's values, and hence one's more permanent identity until those values change, if they change. Instead of going for numbers, if non-profits and other organizations went for outstanding citizens, we may have much stronger and longer-term advocates on our hands. So much of these attempts take the "shotgun" approach by trying to hit any and everyone in a mass audience.

In contrast, rather than appealing to the masses through ads that cater to juvenile longings to be like a superficial and scandalous celebrity, organizations can target more radical and politically active social agents committed to multiple social justice causes by demonstrating how vegetarianism fits into their world view (rather than the typical self-interest/altruist trichotomy of health, environment, animals). Tragically, many of these politically active and radical people are being "turned-off" to the vegetarian message and thousands of dollars are being wasted because these ads and discourses more than likely alienate and offend potential ARAs who are not "thin" like the women in these ads, and more generally, unjustly contribute to the anxiety of girls outside the movement about their own body image.

A Healthy Conclusion
This is why I advocate HEALTH and not "health." As I will more thoroughly describe in the future ("What is Health?"), HEALTH cannot be achieved by individuals alone; true health is the consequent of an entire community flourishing mutually together. Modern reductionist approaches to health, define "health" as something that can be achieved independent of Others and often at the expense of them (i.e. (over)fishing to consume more fish oil, enslaving people to pick tomatoes, wiping out wildlife to grow organic leafy greens, "curing" diseases by giving them fist to millions of "animals," etc.). Within this outlook, veg*n outreach that promotes veg*nism as good for "one's health" is playing into the liberal, antagonistic discourse of self-interest. Instead, promoting veganism itself--an anti-oppression philosophy--does not allow for the appropriation of "health" (the privilege accorded to "self-interest") discourse. Since Health must be achieved together it ought not, as much as possible, come at the expense of the health of Others.

In this sense, appropriating mainstream means of advertising (i.e. using the promise of becoming a conventionally sexy and beautiful women) so as to exploit common insecurities over body-image (o)pressed into the minds of young women is not healthy. Exploiting, and thus perpetuating, oppression as a means to a "good" end can never be healthy, even if it promotes "health," because it ultimately subordinates the health of Others. Since it is more than likely true that these ads and discourses prey upon insecurities over one's own body, of which often lead to extreme and even fatal weight-management, they are not morally justifiable.

If as the recent study suggests, that young women who become vegetarian for body-management issues (and later give it up) are twice as likely to practice extreme dieting, we ought neither promote nor celebrate books such as Skinny Bitch and organizations like PETA if they continue to prey on unjust insecurities. If the Skinny Bitch franchise and PETA wish to redeem themselves, they ought to empower young women and other marginalized groups (including those that have been marginalized by them in the past) rather than appropriating their oppression to "sell" an agenda, no matter how benevolent it may be. Though I doubt they will change any time soon, by doing so, they will be more authentically applying the principles of veganism and augmenting a very powerful task-force for the cause of not only "animals" but everyone on the planet.

Favorite Human - Animal Relation Quotes

Thought I'd share some quotes I've encountered  researching Human-Animal relations, ethics, and subjectivity as I pull together a post on the moral psychology of animal encounters. Enjoy!
Stories with animals are older than history and better than philosophy.
--Paul Sheppard

The more I spoke about animals, the less possible it became to speak to them.
--David Abram

Man becomes aware of himself returning the [animal’s] look… [Today] animals are always the observed. The fact that they can observe us has lost all significance... The more we know, the further away we are.
--John Berger

The most matter of fact person could not help thinking of the hogs they were so innocent they came so very trustingly and they were so very human in their protests and so perfectly within their rights... It was like some crime committed in a dungeon all unseen and buried out of sight and of memory... Relentless remorseless it was all his protests... his screams were nothing it it did its cruel will with him as if his wishes feelings had simply no existence at all it cut his and watched him gasp out his life

He had stood and watched the hog-killing, and thought how cruel and savage it was, and come away congratulating himself that he was not a hog; now his new acquaintance showed him that a hog was just what he had been--one of the packer's hogs!...What they wanted from a hog was all the profits that could be got out of him; and that's what they wanted form the working man... What the hogs thought of it, and what he suffered, was not considered; and no more was it with the working man... That was true everywhere under capitalism.
--Upton Sinclair

How many of my ancestors
Were treated like today’s farm animals?
How many of us look the other way?
When I hear of calves
Being taken from their mothers
To be sold as veal
I can hear the wailing voices of mothers
Crying for their babies
As the slave master takes them away
The mother cow breastfeeds the human race
My ancestors breastfed the white race
So when I looked into those stunned eyes today,
No one could have said to me,
‘What’s the big deal?’ ‘ It’s only an animal.’
I could have remembered a time
When someone might have said the same thing about me
--Mary Spears

The possibility of the pogrom is decided in the moment when the gaze of a fatally-wounded animal falls on a human being. The defiance with which he repels this gaze—‘after all, it’s only an animal’—reappears irresistibly in cruelties done to human beings, the perpetrators having again and again to reassure themselves that it is ‘only an animal,’ because they could never fully believe this even of animals
--Theodore Adorno

Men do all they can in order to dissimulate this cruelty or to hide it from themselves, in order to organize on a global scale the forgetting or misunderstanding of this violence that some would compare to the worst cases of genocide (there are also animal genocides)… conditions that previous generations would have judged monstrous, outside of every supposed norm of a life proper to animals that are thus exterminated by means of their continued existence or even their overpopulation.

No one can deny the suffering, fear or panic, the terror or fright that humans witness in certain animals… the response to the question "can they suffer?" leaves no doubt… War is waged over the matter of pity… To think the war we find ourselves waging is not only a duty, a responsibility, an obligation, it is also a necessity … I say "to think" this war, because I believe it concerns what we call "thinking."
--Jacques Derrida

There were seventy of us in a forestry commando unit for Jewish prisoners of War in Nazi Germany… halfway through our long captivity, for a few short weeks before the sentinels chased him away, a wandering dog entered our lives... we called him Bobby, an exotic name, as one does with a cherished dog. He would appear at morning assembly and was waiting for us as we returned, jumping up and down and barking in delight. For him, there was no doubt that we were men... This dog was the last Kantian in Nazi Germany, without the brain needed to universalize maxims and drives
--Emmanuel Levinas

However, even vegetarianism in your hands, would make a capital article... its connection with modern socialism, atheism, nihilism, anarchy and other political creeds... Brussels sprouts seem to make people bloodthirsty, and those who live on lentils and artichokes are always calling for the gore of the aristocracy and for the severed heads of kings... in the political sphere a diet of green beans seems dangerous.
--Oscar Wilde

Connecting the Meditech Hospitals in Massachusetts

Yesterday I joined several Massachusetts CIOs at a Meditech healthcare information exchange kickoff meeting.  

Here are the slides we used.

Meditech has chosen to do the right thing - support the Direct protocol without requiring a vendor specific HISP, an interoperability "subscription" or transaction fees.    Nationwide, any of Meditech's Meaningful Use Stage 2 certified platforms - Magic 5.66, Client/Server 5.66, or  6.07  can support the Direct implementation guide (SMTP/SMIME) and the SOAP/XDR addendum.

The Massachusetts HIE, the Mass HIWay, has been live since October 2012 and now transports thousands of transactions per day among providers, payers, patients, and government.  Our goal in 2013 is to add more organizations and more use cases.    Meditech provides about 70% of the hospital information systems in the Commonwealth, so it is critically important that Meditech integrates well into the state's cloud-based HISP.

Over the next few months, a diverse array of hospitals will work closely with Meditech and state government to implement production HIE transactions.

Earlier adopters will include Jordan Hospital, Holyoke Hospital, Winchester Hospital, Berkshire Health Systems, Harrington Hospital, and Exeter Health (New Hampshire)

Use cases include transition of care summary exchange, public health reporting. lab results reporting, admission notification, and ED arrival notification.

Once these pilots are complete, we'll spread Meditech connectivity through the Commonwealth.

With other EHR vendors, which are requiring vendor specific HISPs, we're still working through the trust issues (authentication is easy, authorization is harder) that enable HISP to HISP communications among those clinicians who have agreed to all our privacy policies.    Once this work is done the number of clinicians with HIE connectivity will accelerate as network effects incentivize data exchange for care coordination, care management, and population health.

Meaningful Use Stage 2 Certification Strategy

Two weeks ago, ONC created a very helpful Certification Guide for EHR technology developers 
Many people in the industry have told me that the most challenging scripts are the demonstration of CCDA generation/display/Direct transmission (45 CFR §170.314(b)(1) and 45 CFR §170.314(b)(2)), the Clinical Quality Measures (45 CFR §170.314©(1)-(3)), and Patient View/Download/Transmit (45 CFR §170.314(e)(1)).

Although some stakeholders have suggested that these criteria are too aspirational, using standards that are still maturing, I think it is unlikely that rule making will alter their intent.   I also think it unlikely that the test scripts will be significantly revised to reduce the complexity of certification.

As I wrote recently in my post about What Keeps Me Up at Night, the only way to pass an impossible test is to change the rules.

Our approach has been to leverage the modularity of Meaningful Use Stage 2 to divide up the work among vendors, the State government, and our own developers.

Here's how we're doing it.

The State HIE, MassHIWay, fully implements the Direct protocol including certificate validation - everything required by §170.314(b)(2).   Unfortunately, modular certification does not enable the splitting of a script, so in order to use the MassHIWay for all of §170.314(b), we also need to demonstrate its ability to generate and display a CCDA.   Luckily, the MassHIWay received an innovation grant to create the Surrogate EHR Environment (SEE) application for LTAC/SNF/stakeholders without an EHR.   This application can generate and display CCDAs.   We'll leverage the MassHIWay capabilities and demonstrate its Direct functionality as part of the BIDMC self-certification efforts.   Then, we'll help all the other users in the Commonwealth by getting it certified as a §170.314(b) compliant module so that anyone in Massachusetts can include it in their attestation.

The Clinical Quality Measures require demonstration of QRDA Category I (Patient-level) and
QRDA Category III (Aggregate-level) capabilities.  They also require stratification by several demographic data elements to support disparities of care reporting.   The test script results in a QRDA that is over a megabyte because 21 test patients with 29 measures are stratified 3 ways.   Rather than apply significant resources to QRDA programming, we chose to outsource our quality reporting to the Massachusetts eHealth Collaborative Quality Data Center (QDC), as described in my earlier blog about our ACO strategy.   The QDC takes CCDAs from each of our EHRs and produces all the reports needed for ACO, Meaningful Use and PQRS reporting.    Last week, MAeHC achieved modular certification for all its CQM reporting.

The Patient View/Download/Transmit (VDT) scripts are tough because the ecosystem of products supporting patient transmit workflows is still very immature.   We are implementing VDT in two ways.   The MassHIWay will connect to a PHR and thus we'll likely include the MassHIWay VDT features in our self certification.   We'll also augment our Automated Blue Button (ABBI) functionality so that a patient can initiate an ABBI transmission instead of relying on a transition of care event, as is now the case.   Our ABBI code is open source from the Direct project.

Thus, by building our core EHR functionality and certifying it supplemented with modular certification of  the state HIE, the Quality Data Center, and Automated Blue Button, we can get to a full "shopping cart" of functionality to support hospital and professional attestation.

It took us half a day to achieve Meaningful Use Stage 1 certification.   We estimate that 3 full days of demonstrations will be required for Meaningful Use Stage 2 certification.

The division of labor described above will make it possible to us to certify all our software in time for early 2014 reporting periods and attestation.

Advice to the Next National Coordinator

Over the next few months, Jacob Reider will serve as the interim National Coordinator for Healthcare IT while the search continues for Farzad Mostashari's permanent replacement.

What advice would I give to the next national coordinator?

David Blumenthal led ONC during a period of remarkable regulatory change and expanding budgets.  He was the right person for the "regulatory era"

Farzad Mostashari led ONC during a period of implementation when resources peaked, grants were spent, and the industry ran marathons every day to keep up with the pace of change.   He was the right person for the "implementation era"

The next coordinator will preside over the "consolidate our gains" era.   Grants largely run out in January 2014. Budgets are likely to shrink because of sequestration and the impact of fiscal pressures (when the Federal government starts operating again).    Many regulatory deadlines converge in the next coordinator's term.  The right person for this next phase must listen to stakeholder challenges, adjust timelines, polish existing regulations, ensure the combined burden of regulations from many agencies in HHS do not break the camel's back, and keep Congress informed every step of the way.    I did not include parting the Red Sea, so maybe there is a mere human who could do this.

What tools does the coordinator have in an era of shrinking budgets?

At present, Meaningful Use Stage 2, ICD-10, the Affordable Care Act, HIPAA Omnibus Rule, and numerous CMS imperatives have overlapping timelines, making it nearly impossible for provider organizations to maintain operations while complying with all the new requirements.

Can resources be expanded? Given that Medicare/Medicaid reimbursements are falling, private insurance payments are nearly flat, and costs continue to escalate, the pie of resources is a fixed size and very challenging for anyone to expand.  

The new coordinator has only two levers - reduce scope or extend time.

Changing the scope of initiatives already in progress may be very challenging i.e. require acts of Congress, realignment of powerful stakeholders, or compromise of the important interoperability goals we've worked so hard to craft.

That leaves "time" as the one lever under the coordinator's control.  However, even revising schedules will be challenging because of competing stakeholder demands.  

a.  ICD-10 - although some large organizations have significant sunk costs and want the deadline to remain as October 1, 2014, smaller organizations will not be ready.   Some payers (including government payers) may not be ready.    It's clear we need to extend the deadline at least 6 months.    Maybe encourage voluntary ICD10 transactions on October 1, 2014  but allow a 6 month grace period without regulatory enforcement for the industry to catchup with the software, training, and process change needed for ICD-10 success?

b.  Meaningful Use stage 2 - Software products are still being certified, so many hospitals and professionals have not yet upgraded to Meaningful Use Stage 2 certified applications, making a 2014 reporting period/attestation somewhat challenging.   Meaningful Use Stage 2 reporting periods have already begun for hospitals, so no delay is possible, but the reporting period timeframe could be extended.   Maybe provide an 18 month window for Stage 2 attestation?  I realize this could delay future stages of Meaningful Use, but the industry needs a breather to consolidate our gains.

c.  ACA - the Affordable Care Act has motivated many organizations to focus on continuous wellness rather than episodic sickness.   ACOs are building private data exchanges and outcomes registries.  Progress is accelerating because every dollar spent on IT has the potential to reduce costs in risk-based contracts.  ACA and private insurer equivalent programs (such as the Blue Cross Alternative Quality contract) include many quality measures.  Unfortunately, these measures are not optimized for the EHR era and are retooled from a time when quality measurement was done by abstractors in health information management.    Rather than escalate already burdensome quality reporting requirements (BDMC produces over 1000 measures per year for various regulatory agencies), shouldn't we step back and ask what measures are truly important and urgent in a fully electronic era?   Reducing reporting burdens temporarily while s a consolidated set of new electronic measures is developed would be very helpful.

d.  HIPAA Omnibus Rule - audits require at least 10 operational hours for every auditor hour.  While hospitals and practices are in the midst of enhancing policies, revising infrastructure, and learning about the operational implications of the Omnibus Rule, it would be prudent to slow the pace of audits, just temporarily.  We all want to protect privacy and reduce risk but there is a fixed rate at which organizations can integrate change.   We need to focus on the long term and build a robust multi-layered defense.   At times in the past, we've moved faster with regulations/enforcement than standards and technology maturity could support.

e.  Some have suggested that if industry does move fast enough, more regulations will cause stakeholders to move faster.   I really believe that more regulations will be a case of haste makes waste.   Let's integrate existing regulations into the fabric of our operations, using the market forces created by the accountable care act to align incentives, and only consider new regulations when we have enough information about the impact of prior regulations.    Although challenging, maybe the coordinator could even consider polishing existing regulations to reduce the artificially burdensome aspects which are not necessary to achieve policy objectives.  I'd start with taking testimony about the certification scripts for view/download/transmit, transitions of care, quality measurement, automated numerator/denominator, and clinical decision support.

Jacob Reider will do a great job over the next few months and could become the permanent coordinator.   I will do everything in my power as co-chair of the Standards Committee to support whatever scope and timing revisions the coordinator considers.

Dispatch From a Mysterious Island

Whenever I travel on business, I try to take a few hours to explore the road less traveled.   Whether that's climbing Mt. Fuji, hiking the Aonach Eagach ridge in Scotland, or crossing the Baltic Sea in a kayak, there's always an adventure to be found.
During my current Asia trip, I sought the help of several friends in Japan to arrange the trains, planes, and boats that would bring me to the shores of Yakushima, Japan's first World Heritage site, to explore the island's cloud forest and volcanoes.   Some of my colleagues who've heard about Yakushima, call it The Mysterious Island after the Jules Verne novel of the same name.

If I were to design the perfect Mysterious Island, here are the characteristics it would have:

1.   The approach should be difficult and ideally involve a small plane flying through miles of cloud cover with no visibility.    Check, did that.


2.   Ideally, crossing an active volcano should be involved.   Check, did that.

3.   The forest should be ancient, filled with giant trees over 5000 years old.   Check, Yakushima is filled with Yaku-sugi, cedar trees that are thousands of years old with circumferences exceeding 30 feet

Mysterious Island

4.   Make it wet so that the entire forest is covered with moss and waterfalls.   Check, Yakushima has the highest rainfall in the world, over 30 feet per year.

Mysterious Island
Mysterious Island

5.  Put it in the track of many typhoons to make staying there exciting.  I just flew from the island into Typhoon Wipha - the photo below shows the swirling vortex of the storm creating a strange split level sky.  My hiking clothes are saturated despite total body Gore-tex.


6.  Make it dark and misty with 6000 foot cloud-covered peaks topped with snow in the winter.   Check, here are a few shots of the cloud forest I hiked.

Mysterious Island
Mysterious Island
7.   Fill it with unusual animals, insects, and birds that are found nowhere else in the world, including miniature deer and walking sticks that look like a cross between a centipede and spider.  Check.   It also has leeches, giant hornets, enormous spiders, venomous centipedes and poisonous snakes

Mysterious Island

8.  Add monkeys, it must have monkeys.  Check.  Yakushima has its own species of Macaque Monkey


9.  Give the plants an almost human look with long finger-like roots. Add vines and exotic flowers.  Check.


10.  Add forest spirits.   Admittedly, that only happened in the movie inspired by Yakushima, the Miyazaki anime called Princess Mononoke.   Almost check.


My visit to the Mysterious Island included 20 miles of hiking/climbing with a 6000 foot elevation gain including scrambling over moss-covered rocks during a typhoon.  I stayed in a wonderful place called  Wa no Cottage Sen-no-ie  handcrafted of cedar.  I highly recommend staying there if you visit.  The people who run it are remarkable and speak English.

Attestation VS Certification for HISPs

Of all the Meaningful Use Stage 2 questions I'm asked by vendors, HISPs, and providers, many involve confusion between certification and attestation.

As I've written about several times, the certification criteria are so extensive, often in unnecessary and confusing ways, that few vendors have been able to get through them.   Certification criteria exceed attestation criteria in many scripts.

I was recently asked about transition of care data exchange using Direct and the need for message delivery notification (MDN).   Micky Tripathi wrote the following excellent analysis, the bottom-line of which is that MDN is a narrow certification criteria, not an attestation requirement.   In the future, I think certification must be simplified to include the bare minimum necessary to support attestation.     Many people on the Standards Committee feel the same way and we'll support whatever polishing strategy ONC deems appropriate.

Micky wrote:

"1)  Organizations with self-developed systems may depend on a HISP as part of their certification, but organizations with vendor-based EHRs will not
a.   Although organizations with self-developed systems may chose to use the HISP as part of their alternative certification, most organizations will rely on their EHR vendor's complete certification
b.   For example, for Beth Israel Deaconess Medical Center certification, the HISP, acting as modular certified technology, needs to generate MDNs in response to incoming messages.
c.   For everyone else, the HISP does NOT need to generate any type of MDNs.  Sending providers only need to have reasonable assurance that messages sent via the HISP have been delivered to the intended recipients.

2)      There are three requirements that are relevant here:  the transitions of care attestation requirement, the technology certification for receiving messages, and the technology certification for creating/transmitting messages:
a.       The Meaningful Use Stage 2 transitions of care attestation requirement is that “the summary of care record must be received by the provider to whom the sending provider is referring or transferring the patient” (see page 4 of the measure)
b.      2014 Edition certification requires that an EHR be able to receive a Direct-compliant message and send an MDN for successfully received message (see page 5 of the NIST test script)
c.       2014 Edition certification requires that an EHR be able to transmit a Direct-compliant message to a Direct address recipient.  There is no MDN requirement on the transmission certification.  (NIST test script).

3)      The MDN requirement is SOLELY a certification requirement (it is NOT an attestation requirement) and it applies only to the requirements regarding receiving messages.  There is no certification requirement for MDN in transmission transactions.  There is no attestation requirement for MDNs (or any other technical means) to demonstrate assurance of receipt of transmitted transitions of care.
a.     While attestation does require that the intended recipient actually receive the message, there are no requirements on what type of assurance the sending provider must have in order to meet the Meaningful Use transitions of care measure.  Indeed, the ONC commissioned white paper on the topic of assurance states that:  “It is up to the Certified EHR Technology vendor to determine how to assist its customers and provide them with assurance that transmissions have reached their intended recipients.  This assurance could include a presumption of success on the provider’s part of subsequent transmissions if they have reasonable certainty that initial transmissions were successful.”  (see page 2 of the white paper)

4)      The MDN issue thus applies only to organizations that are using alternative certification and using the HISP as relied upon software because they need to be able to meet the “receive” and “create/transmit” criteria.  It does NOT apply to users who are using off-the-shelf Certified EHR Technology to transmit Direct messages over the HISP.
a.      Any other organization with off-the-shelf Certified EHR Technology which wants to use the HISP for transitions of care transmission does NOT need the HISP to be certified
b.      Their own Certified EHR Technology will generate a Direct-compliant message and pass it to the HISP for delivery
c.       The sender will have met their transitions of care requirement at this point as long as they have reasonable assurance that the HISP delivered the message to its intended recipient
d.      This assurance could be provided by MDNs delivered back from the receiving EHRs, but it does not have to be, and indeed, since recipients are not required to be Meaningful Use compliant, many recipients won’t be able to generate an MDN anyway
e.      In any case, it is NOT a HISP responsibility to generate and transmit MDNs back to the sending EHRs (except in the case where the HISP is acting as relied upon software for alternative certification)

5)      Some organizations may want the HISP to be certified for their attestation purposes.  For the purposes of attestation, the HISP will be certified ONLY for “generate/transmit” and NOT for “receive”, and thus it has no obligation to create MDNs
a.       In order for the HISP to receive modular certification for “receive”, it would have to be able to display CCDA documents, accurately match patients, and consume structured information for medication, problems, and medication allergies.  That would require that the HISP to include EHR features beyond the scope of HISP operations.
b.      Any organization that would like to attest with the HISP could thus only use the HISP for the “generate/transmit” requirement.

6)      Regardless of whether the HISP is used as just a conduit (#4) or as a certified module for transmission (#5), the HISP does need to provide some type of assurance of delivery back to the senders
a.       The current plan for the Massachusetts State HISP is to send back MDNs to provide assurance of delivery, which is ideal – however, it is NOT required
b.      The HISP could assure delivery by contract such as a service level agreement
c.      And/or the HISP could make available transaction audit records back to senders periodically or on-demand"

Wednesday, October 16, 2013

National Health IT Projects Seems To Be Too Hard For Almost Everyone! Witness The Current Mess in The US.

The US has - as of October 1, 2013 - implemented a major change in in its health system. Termed the Affordable Care Act (ACA) - or Obamacare - it has been causing vast political ructions. Underlying the ACA are what are called Health Insurance Exchanges which permit the user to find subsidised health care cover (insurance) if they are eligible. This is said to move some 30 million people into the insured population - but of course it is not cheap - hence US Conservatives hate it and US Democrats love it! As I type we now have a good part of the US Government shut down as the Conservatives try to block a law that has passed, been approved by the Supreme Court, seen Obama re-elected and has now started - go figure how that works.
The implementation of these HIX’s has been pretty messy. The website is www.healthcare.gov.  Here is some of the commentary.

Some say health-care site’s problems highlight flawed federal IT policies

By Craig Timberg and Lena H. Sun, E-mail the writers

Problems with the federal government’s new health-care Web site have attracted legions of armchair analysts who speak of its problems with “virtualization” and “load testing.” Yet increasingly, they are saying the root cause is not simply a matter of flawed computer code but rather the government’s habit of buying outdated, costly and buggy technology.
The U.S. government spends more than $80 billion a year for information-technology services, yet the resulting systems typically take years to build and often are cumbersome when they launch. While the error messages, long waits and other problems with www.healthcare.gov have been spotlighted by the high-profile nature of its launch and unexpectedly heavy demands on the system, such glitches are common, say those who argue for a nimbler procurement system.
They say most government agencies have a shortage of technical staff and long have outsourced most jobs to big contractors that, while skilled in navigating a byzantine procurement system, are not on the cutting edge of developing user-friendly Web sites.
These companies also sometimes fail to communicate effectively with each other as a major project moves ahead. Dozens of private firms had a role in developing the online insurance exchanges at the core of the health-care program and its Web site, working on contracts that collectively were worth hundreds of millions of dollars, according to a Government Accountability Office report in June.
The result has been particularly stark when compared with the slick, powerful computer systems built for Barack Obama’s presidential campaigns, which in 2008 harnessed the emerging power of social networking and in 2012 relied on aggressive data-mining efforts to identify and turn out voters. For those, the campaign recruited motivated young programmers, often from tech start-ups.
“The wizards from the campaign have no desire to contract with the federal government because it’s a pain in the butt,” said Clay Johnson, a veteran technologist for Democratic campaigns who pushes for procurement reform through his whimsically named start-up, the Department of Better Technology. “Is it possible to be good? Is it possible to do right by the taxpayer in this space? I’m not sure that it is.”
He is one of many Obama supporters hoping to help fix the Web site by drawing on the collective wisdom of software developers, a mostly left-leaning group that have been analyzing healthcare.gov and sharing their thoughts in e-mails, blog posts and exchanges on Reddit.
Among their conclusions: Requiring all users to sign in before surfing choked the system, as did insufficient server capacity. They also noted that the Web site stalls if a single step in the process — such as verifying a user’s identity — is not quickly completed.
Industry officials note that new software often is buggy, even when it is produced by respected tech firms such as Apple and Google. It’s one reason that private companies prefer gradual launches and long periods of testing before starting major marketing pushes. Although it is possible to conduct “load testing” on a site in hopes of determining how it will respond to heavy demand, there is no substitute for the crush of traffic experienced by a popular system on its official launch date.
Despite warnings of looming problems from the GAO and others, federal officials expressed surprise when the Web site failed almost immediately, with millions of people receiving puzzling, frustrating error messages.
Federal officials have blamed the problems mainly on site usage far beyond what was anticipated, with more than 8 million people trying to use healthcare.gov in the first three days after the site was fully activated on Oct. 1.
Lots more here:
Another set of interesting comments are here:

Why US government IT fails so hard, so often

One hint: Windows Server 2003 is still good enough for government work.

by Sean Gallagher - Oct 11 2013, 1:15am AUSEST
The rocky launch of the Department of Health and Human Services' HealthCare.gov is the most visible evidence at the moment of how hard it is for the federal government to execute major technology projects. But the troubled "Obamacare" IT system—which uses systems that aren't connected in any way to the federal IT infrastructure—is just the tip of the iceberg when it comes to the government's IT problems.
Despite efforts to make government IT systems more modern and efficient, many agencies are stuck in a technology time warp that affects how projects like the healthcare exchange portal are built. Long procurement cycles for even minor government technology projects, the slow speed of approval to operate new technologies, and the vast installed base of systems that government IT managers have to deal with all contribute to the glacial adoption of new technology. With the faces at the top of agency IT organizations changing every few years, each bringing some marquee project to burnish their résumés, it can take a decade to effect changes that last.
That inertia shows on agency networks. The government lags far behind current technology outside the islands of modernization created by high-profile projects. In 2012, according to documents obtained by MuckRock, the Drug Enforcement Agency's standard server platform was still Windows Server 2003.
Magnifying the problem is the government's decades-long increase in dependency on contractors to provide even the most basic technical capabilities. While the Obama administration has talked of insourcing more IT work, it has been mostly talk, and agencies' internal IT management and procurement workforce has continued to get older and smaller.
Over 50 percent of the federal workforce is over 48 years old—and nearly a quarter is within five years of retirement age. And the move to reliance on contractors for much of IT has drained the government of a younger generation of internal IT talent that might have a fresher eye toward what works in IT.
But even the most fresh and creative minds might go numb at the scale, scope, and structure forced on government IT projects by the way the government buys and builds things in accordance with "the FAR"—Federal Acquisition Regulations. If it isn't a "program of record," government culture dictates, it seems it's not worth doing.
Lots more here:
The second article especially tells it like it is. Little retained skill in government, lots of contractors, political deadlines, older technology, serious cost constraints, wrong metrics and so it goes.
Remind you of anything here is OZ - and I am not talking about the NBN!
David.