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The insurance newswires have buzzed with trade association statements decrying congressional proposals to repeal the McCarran-Ferguson Act and defending the act with sophomoric arguments. As a commentator who believes in the McCarran-Ferguson Act, when I read these knowledgeable pronouncements from insurance leaders I have to ask: Do they really believe this stuff?

One statement after another ties together strings of keywords and catchphrases that communicate one clear message: Very few people in the insurance industry have even read the McCarran-Ferguson Act.

From the Wards of New Orleans to the hearing rooms of the U.S. Capitol, a consensus is building that the states are unable or unwilling to regulate insurance. Now, influential members of Congress have proposed a different kind of deregulation: recall the states’ borrowed authority to regulate insurance and in return apply federal antitrust law and Federal Trade Commission oversight.

When the National Conference of Insurance Legislators (NCOIL) convenes in Seattle, July 19-22, discussion regarding an effort in Congress to repeal the McCarran-Ferguson Act is likely to top the agenda. Over the past six months, NCOIL officers have conducted an intense lobbying effort in defense of the 62-year-old act.

The effort kicked off with the initiation of a study of state authority over insurance. The study will be conducted under the auspices of the NCOIL-sponsored/industry-funded Insurance Legislative Foundation. The Request for Proposal for the study included seven points that the final report should include:

1. The nature and history of regulation over the business of insurance

2. Laws, rules, and procedures that enumerate the jurisdictional responsibilities of officials in governing insurance policy and related consumer protections, including issues regarding the authority that may be due nonprofit corporations and similar entities

3. Case studies that help explain the evolution leading to the current insurance regulatory environment, including the growth of assets and of information utilization and security

4. The extent and effectiveness of intragovernmental communication and cooperation regarding insurance law

5. The impact that functional regulation, as established by the Gramm-Leach-Bliley Act (GLBA) of 1999, has had on insurance oversight and responsibility

6. The consequences of federal preemptive measures on insurance policymaking

7. The role that organizations such as NCOIL and other state legislative groups, the National Association of Insurance Commissioners (NAIC), the National Governors Association (NGA), and the National Association of Attorneys General (NAAG), among others, play in insurance public policy

The sudden and abiding interest in just what the McCarran-Ferguson Act means is in direct response to S. 618, The Insurance Industry Competition Act of 2007. The legislation is the most recent of a series of bills drafted in response to a spike in medical malpractice insurance rates in the early years of this decade. Senator Patrick Leahy (D-Vt.), who chairs the Senate Judiciary Committee, sponsored the bill, which has the support of the committee’s ranking Republican, Senator Arlen Specter (R-Pa.).

On June 20, 2006, during a hearing of the Judiciary Committee, Senator Leahy observed, “Among the 15 best-rated medical malpractice insurance providers, premiums rose dramatically between 2000 and 2005, while the cost of claims paid out remained flat. If claims are not driving premiums, but insurance costs among competing companies are rising in lockstep with each other, it is time to admit that there are other causes of this problem.”

Senator Leahy continued, “If insurers around the country are operating in an honest and appropriate way, they should not object to being answerable under the same federal antitrust laws as virtually all other businesses. American consumers, from sophisticated multi-national businesses to individuals shopping for personal insurance, have the right to be confident that the cost of their insurance reflects competitive market conditions, not collusive behavior.”

To a lesser but still material extent, congressional support for McCarran-Ferguson repeal has grown in response to reports of slow, incomplete and combative claims settlement practices following Hurricanes Katrina, Rita and Wilma. Take a trip to the devastated areas of the Gulf Coast, and you will hear a consensus opinion that there is no state insurance regulation.

One of those disgruntled Gulf Coast policyholders is U.S. Senator Trent Lott (R-Miss.), who has battled with his insurance company since losing a coastal home to Katrina. Lott, the Republican Whip, has expressed support for Senator Leahy’s repeal bill. He also supports the creation of a federal backstop for catastrophe losses.

In addition to trouble in Congress, the insurance sector received a body blow from a federal commission charged with conducting a review of antitrust oversight and enforcement. The Antitrust Modernization Commission reported to Congress and the President on April 2, 2007. The report called on the Congress to repeal the McCarran-Ferguson Act.

DISCUSSIONS about hermeneutics–the theories and practices of interpretation–are ubiquitous. We all read texts–whether these be histories, novels, musical scores, paintings, playscripts or anything else humans produce that has meaning–and we are all interpreters of texts who argue over their meaning and over our interpretations. The question of our time is: Is there anything beyond our various interpretations?

Paul Ricoeur, the leading hermeneutic philosopher of the 20th century, “disappeared” (as the French say) in May at the age of 92. Of what special significance is his passing to pastors and theologians? Why should we care? We should care about Ricoeur because his philosophy enables us, jaded denizens of a post-Christian world, to care–to believe, to hope, to love–again, and this without sacrificing our intellect. He is the hermeneutical equivalent of John the Baptist, preparing the way for a new hearing of hopeful words.

Ricoeur’s central insight is that understanding depends on interpreting texts that mediate the meaning of and nourish our existence–especially poetic and religious texts that foster memory, faith and hope. Understanding comes from situating ourselves “in front of” texts that display the full range of human possibilities and capacities.

“The symbol gives rise to thought” (Symbolism of Evil). Ricoeur never tired of insisting that creative language gives to thought something that reason cannot discover on its own. Thus the whole style and substance of Ricoeur’s philosophy concerns faith and is colored with a distinctly Christian hue. In contrast to that of Jean-Paul Sartre, his contemporary in postwar France, who described being human as “a useless passion,” Ricoeur’s philosophy is positively charged: “Man is the Joy of Yes in the sadness of the finite” (Fallible Man).

His conviction of the primordial goodness of things also accounts for his charity toward other thinkers. He went out of his way to include others in a conversation oriented to something bigger than any one disciplinary aim or agenda. In Memory, History, and Forgetting, he brought the historian’s work of remembering into dialogue with different forms of forgetting: repressed memories (psychology), amnesty (politics) and repentance (religion). He even dealt with what the neurosciences contribute to the discussion, though here too he refused to reduce the rich conversation to one discourse only (the biochemical).

Ricoeur’s texts display a conspicuous lack of vitriol; his typical response to attack was: “Thank you for contributing to my self-understanding.” He even hoped that those with whom he disagreed were somehow in the truth: “Each time we sense deep affinities between realities, points of view, or disparate personages, we are happy” (History and Truth). His instinct was not to dilute differences but creatively to mediate them. This was, perhaps, his special talent. While the rest of us line up on either side–modern vs. postmodern; analytic philosophy vs. continental philosophy; religion vs. atheism; red vs. blue–Ricoeur displayed an astounding ability to discern helpful points from all sides and hence to attain higher ground.

Ricoeur’s mediating method also informs the three-part structure in his most important works, as well as his famous “hermeneutical arc.” The arc begins with a precritical moment of “naive” understanding. The second moment involves testing that understanding (testing memory by historical investigation, or testing reading by methods of critical exegesis). The crucial third phase of appropriation culminates in a “second naivete.” This is the moment of truth, of grasping not factuality (the literal truth of things) but existence (the metaphorical truth about human possibilities).

These three parts form a single project. To use a Ricoeurian metaphor: they are three masts that carry distinct but interlocking sails that belong to the same ship setting off on a single itinerary. To set sail on Ricoeur’s three-masted ship is to embark on a heady philosophical project: a voyage to new worlds–refigurations of human existence–projected by poetic texts.

Ricoeur is an excellent guide through the present cultural and intellectual inferno, and engages major intellectual figures across a host of disciplines. He confronts critical approaches–Freudian, structuralist and Marxist–by maintaining that there is something in language that survives our critical suspicion.

For years, Ricoeur has inspired and challenged the way I do theology, both my overall method and some of my material concerns. This despite his stated preference to take the exegete, not the dogmatician, as his dialogue partner. (He meant it: he coauthored Thinking Biblically with his longtime friend, Andre LaCocque, an Old Testament scholar.) Systematic theologians, he felt, moved from sacra pagina to sacra doctrina too fast, reducing the rich feast of biblical literature to a mess of conceptual pottage.

An article on cardiopulmonary resuscitation reports that in one Minneapolis, Minn, hospital only one person survived with use of the open method of cardiac massage between 1950 and 1959. Since then, 33 have survived with use of the closed method. * An author states that pinning back large ears for cosmetic reasons may be detrimental to hearing.

* “News in ORbit, report, that in Krakow, Poland, patients with respiratory disorders are being treated in underground salt mines at a depth of 700 feet. The value of the treatment is attributed to steady temperature and humidity and minimal air movement. * An article on OR staffing says 68.8% of nursing schools are hospital diploma schools, and they graduated 27,645 diploma nurses in 1965.

I COULDN’T BELIEVE what I was hearing. The woman in front of me was a woman of integrity, deep faith and sincere commitment to the church. She had been hired to be a pastoral assistant, and in that role she had contributed substantial time and amazing gifts to the congregation. She had asked for a meeting with me only after trying to speak with her supervisor, the administrative pastor.

As she worked with the congregation, her roots in the faith grew, as well as her knowledge and experience. Her voice gained clarity and authority. So when she noticed a problem, in this case the pastor’s misuse of power, she confronted the situation and challenged him. The senior pastor tried to silence her and ignore her. Reluctantly, she asked the executive council to hear her concern, but council members refused. The pastor had told them that the discussion must remain between the two of them. He quoted Matthew 18 in support of this decision: “If another member of the church sins against you, go and point out the fault when the two of you are alone.” By complying with the pastor and his use of a biblical directive, the council members allowed him to protect himself and them from the truth.

Matthew 18:15-20 is one of many scripture texts that have been used to harm others. These six verses are not meant to be a declaration of power, nor do these verses mean that if two or three people agree on something, then they can ignore others and do whatever they want. These six verses are about listening and accountability and about a larger vision of God’s kingdom.

If one looks at these verses in the context of chapter 18, one notices the hyperbole Jesus uses in a series of brief teachings. Some of these teachings we choose to take literally, and some we don’t. For example, we don’t drown others for being “stumbling blocks.” And we don’t encourage people to pluck out their eyes or cut off body parts because they’ve sinned. And most shepherds would not abandon 99 sheep to go looking for one sheep. Jesus’ exaggerated response to Peter’s question about forgiveness in verse 21 shows that he knows we want forgiveness to be a quick and simple answer although it’s not.

What is the kernel of truth that is embedded in each of these teachings, especially in verses 15-20? What is Jesus trying to teach the disciples by using such exaggeration?

Chapter 18 begins with the disciples coming to Jesus with the question, “Who is the greatest in the kingdom of heaven?” I imagine Jesus being wide-eyed at what he was hearing. Were they seriously asking this of Jesus, whose ministry had always focused on the least?

Yet he doesn’t dismiss their self-centered and self-righteous question. He takes them seriously, listens carefully and then responds, not with a direct or literal answer, but with several teachings and with exaggeration. Jesus pushes the disciples to think, to listen and to be accountable to others for the power they hold. The exaggeration allows the disciples the opportunity to learn without being embarrassed and to listen without becoming defensive. Jesus points them back to the “children,” the “little ones,” “the one that went astray,” “the one not listened to” and “the fellow slave.” The kingdom of God is not concerned with “who’s the greatest,” Jesus teaches; the kingdom of God is about using power to care for the least and most vulnerable.

Matthew 18:15-20 can be used to set up a vulnerable person to be even more vulnerable, as in the opening story. By the power of his role and by his misuse of scripture, the pastor disempowered the woman, denied her the process of being heard, protected himself and silenced the truth. Hiding behind their reading of this text, the pastor and the executive council avoided listening, stopped conversation and the possibility of healing, and joined their voices with the disciples in asking, “Who’s the greatest?” Is that what Jesus is pointing us to in this text? Or is that what we point to when we think we’re the greatest?

We must listen to and read texts like these carefully and honor the questions and tensions they raise for us. If we listen with “new ears” we always will hear something different from what we expect. That’s why Jesus uses hyperbole: to help the disciples hear the gospel of God’s love in different ways, through different experiences, with different language and images. If the Bible is a closed word and merely an answer book, then we’re in trouble. We’ll continue to use scripture to attack others and thus perpetuate violence against one another and justify such harm in God’s name. In this, we will limit God. That’s not an exaggeration.

Jesus could have used his power to tell the disciples exactly what he thought of their question, but he chose to listen, to open up conversation and to teach. The Bible invites us to enter into an ongoing conversation of Christians who struggle with what it means to live faithfully in relationship and to look beyond ourselves.

Background & objectives : Hearing impairment is one of the associated problems seen particularly in children with cleft palate rather than cleft lip alone. This has received very little attention in the area of cleft care although research shows that hearing impairment affects language development The present study was carried not to find out the type and pattern of audiogram in cases attending a speech camp, average degree of hearing loss and its relation to the side of cleft, and the acoustic immittance findings and its relation to the otológica! evaluation. The parental awareness about the hearing problem was also assessed.

Methods : The study was conducted on cleft palate patients attending a speech camp. In all, there were 43 patients (19 males and 24 females) in the age range of 3-22 yr. All had undergone audiological assessment, speech and language evaluation, and otológica! evaluation using standard procedures.

Results : Hearing loss was seen in 38 (88.38%) patients. It was the first audiological assessments they ever had. The average pure tone Thresholds revealed a reverse-ski pattern with a wide air-bone gap. The degree of hearing loss ranged from 25 to 68 dB indicating that untreated otitis media resulted in moderate to moderately severe degree of hearing loss. The immittance findings supported the extent of extracranial complications identified on otoscopie examination. There were more patients with unilateral cleft of the left side with greater hearing loss in the ear alongside the cleft.

Interpretation & conclusion : Hearing loss is prevalent in more than three - forth of the patients attending the speech camp. There is a need for early identification and intervention of middle ear effusion for all cleft palate cases.

Key words Audiogram - cleft palate - hearing impairment - immittance - pure - tone threshold - speech camp

Cleft lip and palate is one of the common referred to a speech and hearing clinic. Cleft of the palate or both has a birth prevalence rate ranging 1/1000 to 2.69/1000 amongst different parts of world1. Asians are at highest risk than Caucasians blacks. The sex distribution shows a tendency of males being more affected than females. The ratio of primary and secondary cleft to bilateral clefts is Among unilateral clefts, left side cleft is reported to more common than right side cleft1″3. It is a congenital condition and is said to occur during the first 12 wk of gestation. Hearing impairment is one of the associated problems seen particularly in children with cleft palate rather than cleft lip alone,

The part of the ear, which is usually, affected in a child with cleft palate is the middle ear. Ingenerai, 100 per cent of the children by age seven must have suffered from atleast one episode of otitis media/middle ear effusion4. Usually by age 6 or 7 yr, as anatomical development of the face takes place superior-inferiorly, the Eustachian tube assumes a diagonal shape from its horizontal shape, observed in infancy. With change in shape, infection from the throat does not have a direct access. Thus the problem of middle ear infection and blocked Eustachian tube tends to decrease with age. Cleft palate is one of the high risk factors for otitis media. The incidence in such children is as high as 100 per cent5·6. This condition, known as middle ear effusion continues to exist for several years if left untreated.

Common complications associated with otitis media are more insidious in nature. The complications may be extracranial/intracranial. The degree of hearing loss is directly proportional to the amount of fluid present. The average hearing loss ranges from 15 to 45 decibel hearing level (dB HL). Sensori-neural hearing loss may also result due to inflammatory toxins diffusing through the round and oval window membranes resulting in serous labyrinthitis/organ of corti damage7.

Little attention has been paid to the implication of otologic histories in individuals with cleft palate, although hearing impairment affects the overall development of a child. We therefore undertook this study to find out or investigate the type and pattern of audiogram in cleft lip and palate subjects attending a speech camp, the average degree of hearing loss and its relation to the side of cleft and to assess the acoustic immitance findings and compare its relation to the otological evaluation. The parents were also assessed for their awareness about hearing problem in their children.

Material & Methods

Subjects: The subjects included in this study were children and adults who attended the speech camp “Cleft Palate to Clear Speech” organized at Ali Yavar Jung National Institute for the Hearing Handicapped, Southern Regional Centre (AYJNIHH, SRC), Secunderabad, in collaboration with the Department of Plastic Surgery, Nizam’s Institute of Medical Sciences (NIMS), Hyderabad, and Reconstructive Surgery Foundation - Earthspeak, U.S.A. In this camp, pre- and post-operative assessment of speech, the surgical intervention and need for second surgery were decided for these subjects. The children who could benefit from speech therapy were trained using the corrective babbling approach8 for a period of one week.

Thanks for the Center Stage on Connie Briscoe (May 2005). Instead of giving in to her handicap, she let it become the fuel for her writing drive. Don’t succumb to “giving up,” instead, tell yourself to get up and do something. God bless!
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Travis Barbee

El Paso, Texas

Thank you, Ebony, for the inspiring article on Connie Briscoe. I also grew up with impaired hearing. My mother would take me once a year for a hearing test.

It wasn’t until my granddaughter was tested at 5 years of age that I found out my hearing loss was genetic. She is 12 years old now and is doing well in school with aids in both ears.

Though I have had two unsuccessful surgeries, I too have been able to work as a communication operator for more than 30 years. I have worn aids in both ears for 10 years now. Without them, my world is muffled, and when I’m alone there is total silence.

When I was six or seven I went up to London with my father in his car. As we passed through Whitechapel in the East End, he pointed out a pub called the Blind Beggar. ‘That’s where Ronald Kray shot George Cornell, ‘ he said. There was an element of something approaching pride in his voice, as if the grim-looking pub set back from the road was a significant cultural landmark of which I ought to take note.

I did take note (I was an obedient and faithful child), and later, when I became a reader, I tried to find out everything I could about Ron and Reg and their criminal ‘firm’. This wasn’t difficult because, on the back of the insatiable public interest in the Krays, virtually every member of their gang turned their hand to literature afterwards and published a memoir. I developed an unhealthy taste for these paperbacks and have read the lot. (The one I’d most like to read, and the only one that never got written, oddly enough, was that of ‘Mad’ Teddy Smith, a Kray associate of unimpeachable psychopathic credentials, whose stated occupation was that of ‘writer’, but who disappeared in mysterious circumstances as the net closed in. ) Later, in my early twenties, I lived for a while in a cottage on an Essex farm owned by an associate of the Krays. The farm mainly produced reinvented stolen cars, I think. But to give the place some kind of credibility there were six calves in a shed, which I looked after in return for a rent reduction. Around the farm I wore overalls, and on the rare occasions he saw me dressed up to go out, he would politely inquire whether I was ‘goin’ whorin’ ‘. And from time to time men with broad shoulders and enormous hands resting on the steering wheels of Cadillacs would roll up and ask me if Fred was in. Although they seemed to take me in with unusually perceptive eyes and were very down to earth and unjudgmental, I wouldn’t have guessed that any of them were writers.

What happened at the Blind Beggar was this. It came to the ears of Ronald Kray that a freelance villain called George Cornell had characterised him in conversation, and with some justification by all accounts, as ‘that fat poof’. When Ron heard that Cornell, a south London man, was drinking alone in the Blind Beggar, the firm’s local, he walked into the saloon bar, shot Cornell in the head, and walked out again. Whatever one says about Ron Kray, he was no Hamlet.

The only barmaid working that day told the police she hadn’t seen or heard a thing — in spite of which she, too, later wrote a memoir of the event — and Ron wasn’t charged with the murder until he was eventually brought to trial at the Old Bailey and had the book thrown at him.

Why the shooting should have acquired the central place in local mythology that it still has is difficult to say. Perhaps it’s because everyone enjoys a good western.

But I still can’t drive past the Blind Beggar without hearing in my imagination my father drawing my attention to it and experiencing a frisson of nostalgia for a vanished past.

But at the weekend I was made to think again. At a 50th birthday barbecue for an old schoolfriend, I got chatting to a chap I’ve met several times over the years but haven’t really got to know well. We were all drinking small bottles of imported French lager called ‘33′ — an apt name because you had to drink about 33 of them to get anywhere. In spite of this and the rain it was an afternoon of unrestrained laughter, and ours was the only remotely serious conversation I was involved in all evening. Jimmy has an impressive stillness about him. We got on to the Krays somehow and he told me a very remarkable thing. When Ron Kray walked into the Blind Beggar and shot George Cornell, he said, he was upstairs in bed. He was seven years old at the time. His father was the landlord of the Blind Beggar. He remembers hearing the shots.

I nearly fell backwards. He’d obviously had that star-struck reaction a great many times and looked pityingly at me, as if I were a romantic fool. Take it from him, he said, in spite of the folklore, and the slew of ghost-written memoirs, the bottom line is that the Krays were simply nasty pieces of work. If they’d been black, for example, we wouldn’t even have heard of them.

That’s what people forget, he said. After that I felt slightly ashamed of my naivety and we let the subject drop. What really interested him these days, he said, was good English prose. Graham Greene he particularly liked. And away we went for a while on the subject of writers; those whom we liked and those whom we didn’t like.

Hearing loss caused by exposure to recreational and occupational noise results in devastating disability that is virtually 100 percent preventable. Noise-induced hearing loss is the second most common form of sensorineural hearing deficit, after presbycusis (age-related hearing loss). Shearing forces caused by any sound have an impact on the stereocilia of the hair cells of the basilar membrane of the cochlea; when excessive, these forces can cause cell death. Avoiding noise exposure stops further progression of the damage. Noise-induced hearing loss can be prevented by avoiding excessive noise and using hearing protection such as earplugs and earmuffs. Patients who have been exposed to excessive noise should be screened. When hearing loss is suspected, a thorough history, physical examination and audiometry should be performed. If these examinations disclose evidence of hearing loss, referral for full audiologic evaluation is recommended.

Noise-induced hearing loss is a sensorineural hearing deficit that begins at the higher frequencies (3,000 to 6,000 Hz) and develops gradually as a result of chronic exposure to excessive sound levels.[1] Although the loss is typically symmetric, noise from such sources as firearms or sirens may produce an asymmetric loss. Acoustic trauma, a related condition, results from an acute exposure to short-term impulsive noise.

Noise is perhaps the most common occupational and environmental hazard. As many as 30 million Americans are exposed to potentially harmful sound levels in their workplaces.[3] Outside of work, many persons pursue recreational activities that can produce harmful noise. Sixty million Americans own firearms, and many use them without adequate hearing protection.[4] Other nonoccupational sources of noise include chain saws and other power tools, amplified music,[5] and recreational vehicles such as snowmobiles and motorcycles. Some types of toys for children can produce sounds capable of causing permanent hearing damage.[6]

Noise can be described in terms of intensity (perceived as loudness) and frequency (perceived as pitch). Both the intensity and the duration of noise exposure determine the potential for damage to the hair cells of the inner ear. Even sounds perceived as “comfortably” loud can be harmful.

Sound intensity is measured as sound pressure level (SPL) in a logarithmic decibel (dB) scale (Table 1). Noise exposure measurements are often expressed as dB(A), a scale weighted toward sounds at higher frequencies, to which the human ear is more sensitive. Noise can cause permanent hearing loss at chronic exposures equal to an average SPL of 85 dB(A) or higher for an eight-hour period.[7] Based on the logarithmic scale, a 3-dB increase in SPL represents a doubling of the sound intensity. Therefore, four hours of noise exposure at 88 dB(A) is considered to provide the same noise “dose” as eight hours at 85 dB(A), and a single gunshot, which is approximately 140 to 170 dB(A), has the same sound energy as 40 hours of 90-dB(A) noise.[8]

Epidemiology

Noise-induced hearing loss is the second most common sensorineural hearing loss, after age-related hearing loss (presbycusis). Of the more than 28 million Americans with some degree of hearing impairment, as many as 10 million have hearing loss caused in part by excessive noise exposure in the workplace or during recreational activities.[9] The economic costs of occupational hearing loss have been estimated to be in the billions of dollars.[10] Noise-induced hearing loss has been well recognized since the industrial revolution. An early term for the condition was “boilermakers’ disease,” because so many workers who made steam boilers developed hearing loss.[11] In today’s noisy society, even children and young adults are at risk. A recent study found evidence of high-frequency hearing loss in nearly one third of a cohort of college students.[12]

Pathophysiology

To be perceived, sounds must exert a shearing force on the stereocilia of the hair cells lining the basilar membrane of the cochlea. When excessive, this force can lead to cellular metabolic overload, cell damage and cell death. Noise-induced hearing loss therefore represents excessive “wear and tear” on the delicate inner ear structures. Concurrent exposure to ototoxic substances, such as solvents and heavy metals, may increase the damage potential of noise.7 Once exposure to damaging noise levels is discontinued, further significant progression of hearing loss stops. Individual susceptibility to noise-induced hearing loss varies greatly, but the reason that some persons are more resistant to it while others are more susceptible is not well understood.[13]

Recent animal experiments suggest that free oxygen radicals may mediate noise damage to hair cells.[14] In the future, use of chemoprotective agents such as antioxidants as well as identification of host risk factors for susceptibility to noise-induced hearing loss, may enhance prevention and treatment efforts.

In my April 2007 Rough Notes column, I provided an overview of some of the differences in expectations, communication styles, and use of technology among various age groups. The more you start to realize that “age matters,” the more successful you will be in catering to the wants and needs of different generations. In this column I will focus on how your marketing approach should be customized based on the age group you are targeting. I believe that you need to create at least four different marketing approaches.

The first lesson learned in Marketing 101 is to get to know and understand your intended customers. Following are some ideas on how you can begin to understand how generations see “marketing” differently.

When you create marketing programs for seniors, it is important to understand several characteristics. For those who reached their 60s in the 1980s, retirement typically meant a relatively passive period of’life. By contrast, many of today’s retirees see their retirement years in a different light. They see retirement as a time of exploration and reinvention. They’re traveling, volunteering, spending more time with family and friends, and taking up new hobbies. Some even enjoy their work so much that, in part, they view it as another form of recreation; others remain active in the workforce for intellectual stimulation. Because this generation accounts for 70% of financial assets there is opportunity for agents. Seniors are living longer and thus are concerned about security and stability.

Physical changes that occur with age are universal, however. Seniors and Boomers experience changes in eyesight, hearing, mobility, and strength, and these changes should be taken into consideration when communicating with them.

Take the design of marketing material, for example. For most people, the eye begins to change during the 40s. This can alter ease-of-readability. The eye’s retina begins to yellow, making it harder for older persons to distinguish between blues, greens, and purples, and easier to see reds and oranges. Glare also becomes a problem, causing Boomers and Seniors to have difficulty reading a message on a high-gloss paper. Whether using paper-based or online marketing materials, remember to keep the design and content simple.

It’s an erroneous notion that these consumers are completely clueless when it comes to technology. The reality is much different. Half of all Americans over age 60 use the Internet. The comfort level with using the Internet for purchasing decisions or using Web or phone self-service varies from consumer to consumer. But to assume that older consumers dislike technology can substantially stifle an agency’s ability to connect with these clients. They will use the Internet to research products and services.

Baby Boomers

More than half of the almost

76 million Boomers (born between 1946 and 1964) are 50 years old or older, while the rest crest the hill at the rate of 10,000 a week. Like Seniors, one mistake companies often make about this cohort is to assume that it is less technically savvy than younger generations. Having grown up during the tech revolution, most Boomers are well versed in many of the different communication channels.

Boomers will contact you using the channels they’re most comfortable with because that’s the channel they’ve been using for years. If a Boomer is contacting you via e-mail, make a note and make sure that subsequent contacts are sent via e-mail. It’s a simple concept, but one that agencies fail to pick up on. This group’s knowledge and adoption of technology comes primarily from what they learned at work.

Baby Boomers have high expectations concerning the marketing and sales pitches that companies use to acquire their business. With this group, your post-purchase customer service levels had better live up to the promises made during the sales process or they will take their business to someone else.

Many marketers believe that a consumer’s brand preferences are fixed by age 50. While this may be true of the Seniors, Boomers appear just as likely to switch brands as younger generations. Baby Boomers are also smart consumers. Don’t use vague, mass-marketing advertising with generic messages. Communicate the clear-cut benefits and values of the product and/or service you’re selling.

Generation X

This generation (born between 1964 and 1978) often gets left out primarily because of size. Gen X is only about 49 million strong, and as a result, many marketers have realized this group’s spending power will never reach that of Gen Y and the Boomers. Boldness, youthful rebellion, and benign anarchy remain the hallmarks of the generation, even as it begins to have families and start businesses. Many in this generation think of themselves as disloyal to brands and skeptical of big business.

Xers are very sensitive when companies try to “sell” them or when they suspect that they are being exploited. They’d rather believe that they are part of a dialogue with the company. Use a straightforward approach. Today there is so much marketing noise that this generation has learned to ignore it as not interesting or relevant to them. Thus, mass marketing and selling can fall on deaf ears, and fake personalization can hurt rather than help.

The incidence of vestibular and audiologic injury related to blast injury remains underreported. The primary objective of this study was to document self-reported otovestibular impairment in blast-injured amputees. Secondary objectives include a description of the Walter Reed Army Medical Center Blast Injury Questionnaire and other aspects of the audiology service and amputee physical therapy section standards of care for blast injury management. A case study illustrates the application of these standards of care. Thirty-three patients were evaluated by audiologists and physical therapists using the Walter Reed Army Medical Center Blast Injury Questionnaire, followed by audiologic and vestibular screening; 24% of patients reported symptoms of vertigo or oscillopsia following blast trauma, and 51% reported subjective hearing loss. The case study subject reported an increase in function after vestibular rehabilitation therapy. Thorough screening by audiologists and physical therapists can facilitate appropriate diagnosis and management for blast-injured patients.

In the global war on terror, blast injuries frequently cause traumatic injuries and amputations. In particular, a service member’s head and limbs are naturally susceptible to these explosions, resulting in traumatic brain injuries, otologic involvement (e.g., ruptured tympanic membranes, hearing loss, and vestibular pathology), soft tissue injuries, and complex orthopedic trauma.

The primary blast wave from an explosion causes most otologic injuries. Blast waves are characterized by an initial intense overpressurization, followed by an underpressurization.1 These intense changes in atmospheric pressure cause primary blast injuries, which lead to pathologic pressure changes in air- and fluid-filled organs, such as the middle ear and inner ear. Other effects of otologic blast injuries include centrally or peripherally mediated disequilibrium, vertigo, benign paroxysmal positional vertigo (BPPV)1 post-traumatic Ménière’s disease, sensorineural hearing loss, tympanic membrane perforation, and perilymphatic flstulae.2 Traumatic brain injury as a result of the primary overpressure wave or a subsequent blow to the head may lead to central vestibular pathology, peripheral dysfunction, or both. The effects of central nervous system trauma may include dizziness secondary to postconcussive syndrome or resulting from cerebral or brainstem injuries.3″5

For patients with blast injuries, otovestibular pathology must be considered. Patients may be unaware of the aural injury, particularly if comorbidity occurred. Auditory complaints may be assigned a lower priority by the patient or medical staff members in comparison with more severe injuries, such as a loss of limb(s). Providers and patients may also be unaware of clinical services that manage these otovestibular impairments, such as hearing loss or balance difficulties. Even after 6 months, some blast injury survivors report only limited recovery from complaints such as aural fullness, tinnitus, hearing loss, and dizziness.6 Even when otologic pathology is diagnosed, the management of such conditions is not always clear.

Much of the literature on the incidence and severity of blast injury sequelae describes case studies or case series with limited sample sizes.6″9 Additional reports and studies are necessary to improve and to standardize care for blast-injured patients and to share lessons learned among providers assisting survivors with recovery from their injuries.

Many potential benefits exist with early diagnosis and treatment of vestibular pathology in the blast-injured population. Extensive evidence in the rehabilitation literature documents the efficacy of specific vestibular rehabilitation in treating individuals with vestibular pathology, Horak et al.10 found decreases in patient symptoms of dizziness and sway with vestibular rehabilitation. Shepard and Telian” found improvements in static and dynamic posturographic findings and decreases in motion sensitivity with vestibular rehabilitation. Herdman et al.12 documented improvements in visual acuity in patients with diminished unilateral vestibular functioning with adaptation exercises. If such interventions shorten recovery time from complaints of dizziness, decreased postural stability, increased motion sensitivity, or difficulty viewing with head movement, then early diagnosis and appropriate otovestibular management can improve the overall quality of life and help the patient resume normal (symptomfree) functioning.

This retrospective review documents the incidence of selfreported otovestibular impairment in blast injury survivors with concomitant limb loss, using the Walter Reed Army Medical Center (WRAMC) Blast Injury Questionnaire (BIQ) (Fig. 1). Measures include patient-reported symptoms of otovestibular dysfunction, visual impairments, postural instability, and affective changes. This review also describes the WRAMC BIQ and discusses its use as a component of audiology and physical therapy standards of care for screening blast-injured amputees. Finally, a case study of a Marine injured in Operation Iraqi Freedom I illustrates the application of this standard of care.