february 2016 sombrero

SombreroP i m a C o u n t y M e d i c a l S o c i e t y

Home Medical Society of the 17th United States Surgeon-General

F E B R U A R Y 2 0 1 6

A familiar PCMS president returns

Remembering Dr. Michael R. Manning

Focus on Retina Associates

2 SOMBRERO February 2016

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Official Publication of the Pima County Medical Society Vol. 49 No. 2

PrintingWest PressPhone: (520) 624-4939E-mail: [email protected]

PublisherPima County Medical Society5199 E. Farness Dr., Tucson, AZ 85712Phone: (520) 795-7985 Fax: (520) 323-9559Website: pimamedicalsociety.org

EditorStuart FaxonE-mail: [email protected] do not submit PDFs as editorial copy.

Art DirectorAlene RandklevPhone: (520) 624-4939Fax: (520) 624-2715E-mail: [email protected]

Pima County Medical Society OfficersPresident Timothy C. Fagan, MD

President-ElectMichael A. Dean, MD

Vice-PresidentSusan J. Kalota, MD

Secretary-TreasurerUnfilled / Appointment

Past-President Melissa D. Levine, MD

PCMS Board of DirectorsDavid Burgess, MDHoward Eisenberg, MDKelly Ann Favre, MD

Jason Fodeman, MDJerry Hutchinson, DORoy Loewenstein, MDKevin Moynahan, MDWayne Peate, MDDebra Polson, MDSarah Sullivan, DOSalvatore Tirrito, MDFred Van Hook, MDScott Weiss, MDLeslie Willingham, MDJaren Trost, MD (Resident)Aditya Paliwal, MD (alt. resident)Jared Brock (student)Juhyung Sun (alt. student)

Members at Large Charles Krone, MD

Clifford Martin, MD

Board of MediationThomas Griffin, MD

Evan Kligman, MD

George Makol, MD

Sheldon Marks, MD

Mark Mecikalski, MD

Arizona Medical Association OfficersMichael F. Hamant, MD Vice PresidentThomas C. Rothe, MD Outgoing Past President

At Large ArMA Board Robert M. Aaronson, MDR. Screven Farmer, MD

Pima Directors to ArMATimothy C. Fagan, MD

Delegates to AMATimothy C. Fagan, MD (alternate)Gary R. Figge, MDMichael F. Hamant, MD (alternate)Thomas H. Hicks, MD

SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson, AZ. POSTMASTER: Send address changes to Pima County Medical Society, 5199 E. Farness Drive, Tucson, Arizona 85712-2134. Opinions expressed are those of the individuals and do not necessarily repre-sent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Officers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright 2015, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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Executive DirectorBill FearneyhoughPhone: (520) 795-7985Fax: (520) 323-9559E-mail: billf [email protected]

AdvertisingPhone: (520) 795-7985Fax: (520) 323-9559E-mail: [email protected]


5 Dr. Timothy C. Fagan: What can organized medicine and you do for each other?

6 Milestones: Honors for two of our members, and a very long journey for another.

7 Membership: We focus on Retina Associates.

9 PCMS News: Feds penalize hospitals over patient safety; med school applications way up.

12 In Memoriam: Remembering Dr. Michael R. Manning.

13 Makols Call: America takes the good and bad for being the big guy on the block.

15 Perspective: Our editor looks at a certain golden anniversary this year.

17 Environment: Since theres no Arizona without water, Arizona Town Hall examined it.

26 Continuing Medical Education: Coming CMEvents.

On the Cover

This physicians photo may look familiar because its from our January 2011 cover, and so is our 2016 president, IM physician and clinical pharmacologist Timothy C. Fagan, M.D. He has long been active in organized medicine and education and has volunteered to serve as PCMS president again this year. He is vice-governor and treasurer of the Arizona Chapter of the American College of Physicians, and serves as an ArMA alternate delegate to AMA. He is a University of Arizona Professor of Medicine Emeritus (Ryan Fagan photo).

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Inside


What is organized medicine doing for me?By Dr. Timothy C. Fagan

PCMS President

There are today more challenges to physician autonomy, freedom to practice the medicine that is best for patients, reimbursement and physician mental health, than at any time in the past.

Individual physicians may have some influence on these issues, e.g. by contacting state and

federal legislators, or as members of groups dealing with a limited number of issues. However, with increasing time demands for documentation, prior authorizations, EMR requirements, etc., there is very little that physicians can do as individuals.

The AMA, in addition to its annual and interim meetings, holds a State Legislative Strategy Conference (SLSC) every year. Its purpose is to help state, local, and specialty medical associations with the major challenges facing physicians and society today.

The most recent SLSC was Jan. 7-9, in Tucson and consisted of 11 hours of formal presentations and three hours of workshops, as well as networking opportunities. It was attended by 129 representatives of state, local, and specialty medical societies, 24 nationally prominent invited speakers, 26 members of the AMA Board of Trustees, and 36 AMA staff members.

Doctors Fagan, Figge, Hicks, and Jared Brock, PCMS student board member, represented PCMS. Other Arizona representatives were Katherine Marsh, UofA medical student; Marilyn Laughead, M.D.; Chic Older, ArMA CEO; and Pele Fischer, ArMA vice-president for policy and public Affairs.

Topics included several aspects of digital technology, opioid abuse and prescription drug monitoring, AMA activity at the federal level, and various aspects of access to care. Timothy S. Jost, J.D. discussed the national health insurance landscape, including increased access through Medicaid expansion and the federal Health Insurance Exchanges, so that only 11.9% of the U.S. population remains uninsured, including 10.5% of non-elderly adults. He also discussed problems associated with these programs, including health insurance company responses to the programs.

The problem of hospital and health insurance consolidation was discussed by Thomas L. Greaney, J.D., Joshua H. Soren, J.D. and Joseph M. Miller, J.D., former counsel to Americas Health Insurance Plans, the national association of health insurance companies. Antitrust challenges to mergers ideally include proof of harm. However, antitrust law allows presumption of illegality based on market concentration.

AMA has researched health insurance company concentration in all 50 states, the District of Columbia, and 388 metropolitan service areas (MSAs) using the HHI, a legally accepted index of market concentration. This is published in Competition in

Health Insurance: A Comprehensive Study of U.S. Markets, which is available at ama-assn.org.

This study found that the proposed Anthem-Cigna merger can be legally presumed to enhance the combined companys market power in 10 states and 85 MSAs, and would raise concerns regarding increased power in one additional state and 26 additional MSAs. Fortunately, no MSA in Arizona falls into either of these categories.

The proposed Aetna-Humana merger would enhance market power in 15 MSAs in seven states, and raise concerns in 43 additional MSAs in seven additional states. Yuma is the only MSA in Arizona which falls under the raises concern category, and no Arizona MSAs are in the increased market power category.

AMA has written comprehensive letters to the U.S. Department of Justice regarding both mergers, based upon this research and other information, in order to protest the proposed mergers. AMA has also testified before the U.S. House of Representatives Judiciary Committee, and makes extensive materials available to state and specialty medical societies.

These proposed mergers create two problems. The first is monopoly, in which there is one supplier of a good, product, or service, in this case health insurance policies. The second problem is monopsony, in which there is only one purchaser of a good, product, or service, in this case health insurance company purchase of physician services. Thus with high market concentration, health insurance companies have more power to dictate how much they pay physicians and to dictate the conditions.

If individual physicians have an inside track to influencing the multiple problems which confront physicians today, they should take advantage of it, in order to deal with these problems. However, the complexity and multiplicity of problems today require us to work through local, state and specialty medical societies, by joining, becoming more aware of the problems and, if possible, by becoming active in these societies.

If you are not a PCMS member, additional information is available, and membership applications are available for Pima County Medical Society at pimamedicalsociety.org and for: Arizona Medical Association at azmed.org; Arizona Osteopathic Medical Association at az-osteo.org; American Medical Association at ama-assn.org; and American College of Physicians at acponline.org. Other specialty medical societies are easily found online.

IM physician and clinical pharmacologist Timothy C. Fagan, M.D., has long been active in organized medicine and education. He is vice-governor and treasurer of the Arizona Chapter of the American College of Physicians, and serves as an ArMA alternate delegate to AMA. He is a University of Arizona Professor of Medicine Emeritus. n


Milestones

American College of Physicians honors Dr. Fagan

Coincidental to his returning as PCMS president, Dr. Timothy C. Fagan recently received the highest honor awarded by the Arizona Chapter of the American College of Physicians at its annual chapter meeting in November 2015.

ACP says the Laureate Award is a way to recognize Fellows and Masters of the College who have demonstrated, by their example and conduct, an abiding commitment to excellence in medical care, education and research, and service to their community, their chapter, and ACP.

Dr. Iserson returns to AntarcticaMary Lou Iserson has put out the word that her husband, EM and improvised medicine specialist Dr. Ken Iserson, is globetrotting again.

I just wanted to touch base with everyone before Ken leaves for Antarctica again, she e-mailed. I will be updating everyone with news while Ken is on the ice. By the time you read this, Dr. Iserson will have left to spend the Antarctic winter at McMurdo Station, so he will be gone for several months.

It will be interesting to compare this trip with the last one, which was during the summer at McMurdo, Mary Lou said. He is going down to overlap with the summer doctor for two weeks. Because of weather, the last flight in or out was in mid-February. It takes him three days to get to New Zealand, and he spends two days there filling out paperwork and getting the extreme weather clothing he needs. Then they have a long flight to McMurdo, assuming weather is good. Last time he spent an extra four days waiting for good weather!

Dr. Jean-Paul Bierny (Chris Tanz photo, courtesy Arizona Friends of Chamber Music.)

Dr. Timothy C. Fagan, to the left with fellow PCMS member and Arizona Chapter of the American College of Physicians Gov. Robert Aaronson. M.D., and Award Chair Priya Radhakrishnan, M.D., receives the chapters Laureate Award (ACP photo).

Chamber Music America honors Dr. BiernyJean-Paul Bierny, M.D., Associate PCMS member who retired in 2008 from Radiology, Ltd., and past-president of Arizona Friends of Chamber Music, was chosen in December 2015 to receive Chamber Music Americas 2016 CMAcclaim Award.

This award recognizes extra-ordinary contributions to the field of chamber music in a particular region or locale, CMA CEO Margaret M. Lioi said, complimenting Dr. Biernys tireless work in bringing high-quality chamber music to the Tucson area, for initiating your most successful commissioning program, and for the Piano and Friends series that provides performance opportunities for young artists.

The award will be presented at a future concert, and Chamber Music magazine will feature Dr. Bierny in an upcoming issue. The Arizona Daily Stars Caliente noted that Dr. Bierny co-founded Arizona Friends of Chamber Music and served as its president for 35 years, saying he helped make chamber music central to Arizonas cultural landscape.

In 2012 AFCM won an Arts Patron Lumie award from the Tucson Pima Arts Council, the paper reported. Dr. Bierny co-founded AFCMs Tucson Winter Chamber Musical Festival, where new pieces commissioned by the Friends are on the program, and world-class musicians settle in Tucson for a week to perform staggeringly good chamber music, Caliente opined.

This years Chamber Music Festival is March 13-20. For more info on the event, please log onto arizonachamber music.org. n


Membership

Retina Associates focal pointStory and photos by Dennis Carey

Ophthalmologists at Retina Associates have a kind of tunnel vision. At their three office locations in Tucson and Green Valley, they focus only on diseases and injuries of the retina and vitreous.

The four physicians who rotate between the practices three offices have plenty of work. While the original Retina Associates opened in 1974, the current version has been in place since 2009 and includes PCMS members Cameron Javid, M.D.; April Harris, M.D.; Egbert Saavedra, M.D.; and Mark Walsh, M.D.

The main office and surgical center is at 6561 E. Carondelet Drive. The other Tucson location is at 6130 N. La Cholla Blvd., Suite 230. In Green Valey they are at 1055 N. La Canada Drive, Suite 103.

All three offices have undergone extensive renovations and improvements in the last four years, Dr. Javid said. Not only are we trying to be up to date on the current technologies and treatments, but we also try to make our patients feel comfortable. We want the visit to be as smooth and efficient as possible.

Dr. Javid graduated from med school at the University of Illinois in 1994, served his internship at the Scottsdale Mayo Clinic in 1995, and completed his ophthalmology residency in 1998. He also completed a fellowship at Massachusetts Eye and Ear Infirmary at Harvard Medical School before arriving in Tucson in 1999. He joined PCMS that year and also serves as a clinical associate professor at the University of Arizona.

Dr. Harris came to Tucson and joined PCMS in 2004. She graduated from the University of Texas at Dallas Medical School in 1995, and did her internship at Mayo Clinic in Jacksonville, Fla. She completed her OPH residency at Louisiana State University, New Orleans, in 2000. She completed a retinal fellowship at University of Texas in Dallas in 2002. After two years in private practice in Vermont, she moved to Tucson. Perhaps anyone would for the climate change!

Dr. Saavedra has been practicing in Tucson and a PCMS member since 2006. He graduated in 2006 from Virginia Commonwealth University, Richmond, Va. After an IM internship at Riverside Regional Medical Center, in Newport News, Va., in 2001, he did his OPH residency in at Cole Eye Institute in Cleveland, 2001-2004. He completed a fellowship in medical and retina surgery at Wilmer Eye Institute at The Johns Hopkins University 2004-2006.

Dr. Mark Walsh is the latest addition to Retina Associates, joining the practice and PCMS in 2009. He graduated from Washington University in St.

Louis. Mo. In 2003, and finished his IM internship at St. Francis Hospital in Evanston, Ill. in 2004. His OPH residency was at Johns Hopkins 2004-2007, and he completed a retina fellowship from William Beaumont Hospital in Royal Oak, Mich. 2007-2009.

Treating an organ as complex as the eye helps explain why there are seven OPH sub-specialties. Its also why Retina Associates does not treat other eye conditions. Conditions treated by retina specialists include diabetic retinopathy, macular degeneration, macular holes, retina tears and detachments, pediatric retina

conditions, and ocular tumors.

Ophthalmologists must renew their board certifications every 10 years. In order to stay on top of the latest advancements in diagnostics and treatments, Retina Associates physicians have continued their educations. Depending on the situation, they can turn to some recent high-tech innovations.

Fundus photography is a camera with a low-power microscope attached to take pictures of the retina. Filters and dyes can be used to enhance the cameras images. Retinal angiography helps monitor blood circulation in the eye with the help of contrasting dyes. Ophthalmologic ultrasound

Cameron Javid, M.D., senior physician at Retina Associates, shows some of the latest diagnostic tools to help in treatment of retina conditions. Images displayed are from fundus photography (top), retinal angiography (bottom left), optical coherence tomography (bottom center) and ophthalmologic ultrasound (bottom right).

Retina Associates has three offices in Tucson and Green Valley that have all been updated in the last four years. State-of-the-art workstations help physicians and medical staff provide the latest treatments for retina conditions.


uses high-frequency sound waves to detect different densities in the eye just as other ultrasound imaging methods do in other organs. Optical coherence tomography (OCT) provides a three-dimensional image of tissue morphology that is more detailed than traditional ultrasound or MRI.

Recent years have seen treatment advancements such as laser surgery, vitrectomy surgery, and injections and medications for macular degeneration. We can improve or stabilize the condition in 90 percent of the patients we see, Dr. Javid said. We do try to keep up as much as possible on anything new that can help our patients.

Patients are usually referred to Retina Associates by primary care physicians and optometrists who suspect a specific problem related to the retina. Nearly all of the treatments, including emergencies, are done at one of the offices.

Our offices are equipped to deal with retina emergencies, Dr. Javid said. Most hospitals dont have the specialized equipment we have in our surgery center to work on these kinds of emergencies.

Retina Associates is a leader in ocular oncology. The practice was part of the Collaborative Ocular Melanoma Study and has a full-time employee dedicated to coordinating care for ocular tumors.

Retina Associates further commitment to research includes its current involvement seven active treatment studies, Dr. Javid said the practice has been one of the most active in clinical trials in the Southwest. Two two full-time employees are dedicated solely to research. A list of studies can be found on the practice web site retinatucson.com.

The practice is looking to the future by providing training to UofA

A strong support staff is one reason Retina Associates says its physicians can improve or stabilize 90 percent of its patients. Silvia Neighbor, left, and Ericka Beitman, pictured here with Dr. Cameron Javid, help coordinate patient care.

OPH residents. They also employ medical scribes for updating electronic medical records.

The future of ophthalmology is important to us, Dr. Javid said. It is not just about training, but they help improve our practice. The scribes get valuable experience as they may move on to medical careers. They also free up the physicians to concentrate on patient issues and not spend lot of time updating records.

At its offices and in research, Retina Associates employs 60 staffers to support its four physicians. It isnt just about the doctors, Dr. Javid said. I dont think we would have as much success in helping our patients without the team we have put in place. n

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PCMS News

Massacre memorialized

A ceremony for hospital staff was given Jan. 8 on the lawn at Banner-University Medical CenterTucson, the organization reported. The bell-ringing ceremony was to remember the 19 people killed or wounded in a mass shooting at a Tucson shopping center five years ago.

The brief ceremony for the hospitals physicians and staff included a prayer by hospital Chaplain Joe Fitzgerald, and a reading of the names of each victim, followed by a bell-ringing by one of the shooting survivors at precisely 10:10 a.m., the moment when madman Jared Loughner opened fire at a crowded Congress On Your Corner event hosted by Rep. Gabrielle Giffords.

There were also comments by hospital CEO Tom Dickson, and an update on the proposed January 8th Memorial in downtown Tucson by Crystal Kasnoff, executive director of the January 8th Memorial Foundation. The foundation is 501(c)(3) organization with the sole mission of completing a permanent memorial to the Jan. 8, 2011 tragedy, an unforgettable day in the history of our community, our state, and our nation, the university reported. The Together We Thrive capital campaign, spearheaded by the foundation, is underway to fund the memorial project. Implementation after the public comment period is completed. Campaign honorary co-chairs are former Rep. Gabrielle Giffords and car dealer Jim Click, Jr.

After the shootings in 2011, the wounded were rushed to UMC, location of the only Level 1 trauma center in Southern Arizona. A grieving Tucson decorated the hospital lawn with thousands of flowers, candles, and messages of hope following the shootings. Every Jan. 8 since the event, the hospital has held a remembrance ceremony on the hospital lawn.

Jim Tucker, one of the Tucsonans wounded in the Jan. 8, 2011 mass shootings, rings a bell for each of 19 victims at a remembrance ceremony Jan. 8 at Banner-University Medical CenterTucson Campus. Hospital Chaplain Joe Fitzgerald led hospital staff and members of the public in a prayer on the fifth anniversary of the shootings. In the background are architect renderings for a Jan. 8th memorial garden to be built downtown.

Feds penalize hospitals over patient safetyThe federal government is penalizing 758 hospitals with higher rates of patient safety incidents, and more than half of those places had also been fined last year, Medicare records released in December 2015 show, according to this December 2015 story by Joradu Rau in Kaiser Health News.

Among the hospitals getting punished for the first time are some well-known institutions, including Stanford Health Care in Northern California, Denver Health Medical Center and two satellite hospitals run by the Mayo Clinic Health System in Minnesota, according to the federal data.

Sixteen Arizona hospitals were cited, including Tucson Medical Center, Banner- University Medical CenterTucson, and Carondelet St. Josephs Hospital. The fines are based on the governments assessment of the frequency of several kinds of infections, sepsis, hip fractures, and other complications. Medicare will lower all its payments to the penalized hospitals by 1 percent over the course of the federal fiscal year, which runs through this September. In total, Medicare estimates the penalties will cost hospitals $364 million.

The penalties, created by the 2010 health law, are the toughest sanctions Medicare has taken on hospital safety, and they remain contentious. Patient safety advocates worry the fines are not large enough to alter hospital behavior and that they only examine a small portion of the types of mistakes that take place. Medicare plans to add more types of conditions in future years.

I think the penalties are important, said Helen Haskell, a prominent patient advocate. I think its the only thing that gets peoples attention. My concern is the measures stay strong or even be strengthened.

Hospitals say the penalties are counterproductive and unfairly levied against places that have made progress in safety but have not caught up to most facilities. They are also bothered that the health law requires Medicare to punish a quarter of hospitals each year.

What bothers me the most is when people are improving and get that penalty, thats money that could be invested into better care, said Dr. Mark Jarrett, chief quality officer for the North Shore-LIJ Health System on Long Island, which had several hospitals penalized this year. Taking the money away, all youve done is to make it harder for hospitals to function.

The penalties are one prong of the health laws mandate to leverage taxpayer dollars to improve hospital quality. Each year, Medicare also docks the pay of hospitals with too many patients coming back within a month, and it doles out bonuses and penalties to hospitals based on patient satisfaction scores, death rates and other performance measures.

Nonetheless, Medicare payments to most hospitals continue to be based primarily on the number and nature of the services they conduct, a system that health care experts say encourages hospitals to perform more procedures and focus on complexand lucrativeones.


For hospitals, complications are still profitable, said Dr. Martin Makary, a pancreatic surgeon and researcher at Johns Hopkins Medicine in Baltimore who studies safety. Much of what we do in healthcare still has the incentives aligned the wrong way.

This second round of the Hospital-Acquired Condition Reduction Program was based on the governments assessment of the frequency in 2013 and 2014 of infections in patients with central lines inserted into veins, urinary catheters, and incisions from colon surgeries and hysterectomies. Those infection rates comprise 75 percent of Medicares evaluation.

The rest is based on eight other complications, such as surgical tears, collapsed lungs, broken hips and reopened wounds, between July 2012 and June 2014. Most of these complications were part of last years penalty assessments, but the infections from colon operations and hysterectomies were added to the calculations this year.

In practice, only about one in six hospitals are getting the penalty because Congress exempted veterans hospitals, childrens hospitals and critical access hospitals, which are generally the sole providers in their areas.

In releasing the numbers, Medicare said average hospital performance improved for two of the three measures that the government relied on for the penalties both last year and this year. Infections from catheters used to collect urine from patients who are not mobile increased slightly over the year.

The HAC penalties have come under criticism by the hospital industry and researchers. A paper in JAMA examined the first year of the program and found that the hospitals that were penalized were more likely to have characteristics usually associated with quality. These included accreditation by the Joint Commission, the presence of the most extensive types of trauma centers, and more nurses per patient.

Daron Cowley, a spokesman for Intermountain Healthcare in Salt Lake City, said in a statement that the penalty evaluation is flawed and there are clearly refinements and changes needed. Intermountains flagship hospital in Murray, Utah, has been penalized both years. Cowley said the penalty assessments do not properly consider the substantial variations in size and number of procedures performed by different hospitals.

Another paper published in May 2015 in the American Journal of Infection Control suggested that while health experts recommend hospitals use urinary catheters as rarely as possible to limit the chance of infections, those same hospitals may look worse because the catheters are mostly used in the sickest patients, who are more prone to infections.

A number of hospitals, such as those run by UCLA Health, have focused on decreasing the use of catheters in response to the penalty program. Both UCLA Medical Center, Santa Monica and Ronald Reagan UCLA Medical Center were penalized this year. Dr. Robert Cherry, chief medical and quality officer of UCLA Health, said in a statement that infection rates decreased this year.

Dr. Brian Whited, vice-chair of operations at Mayo, endorsed the penalties even though they were levied against Mayo hospitals in Fairmont and Albert Lea. As an organization, were not satisfied with these results and understand we have work to do to reduce

hospital-acquired conditions, Whited said in a statement. We support the objectives of the Hospital-Acquired Condition Reduction Program, and all our practices have been developing improvement strategies and other changes to reduce those conditions.

Stanford said it had reduced injuries since the end of the period examined in determining the penalties. Dr. Rajneesh Behal, chief quality officer, said in a statement: It should be noted, the HAC program lags and does not reflect our current performance.

A total of 407 hospitals were penalized in both years of the program.

Nearly 6,500 apply to med school 2020 classThe University of Arizona College of MedicineTucson reports that it is outpacing other medical schools in terms of the increasing number of applicants who aspire to become physicians. College admissions officials cite several reasons for the increased interest in the UAs Tucson medical school.

The college has received a record 6,457 applications for enrollment in the class of 2020, a nearly 14 percent increase over the 5,667 applications the college received for admission to the Class of 2019. Its more than two-and-a-half times the 2,500 applications the college received in 2009, the first year it accepted applications from students outside Arizona, said Tanisha Price-Johnson, Ph.D., UA College of MedicineTucsons executive director of admissions and financial aid. The college of medicine in Tucson limits enrollment to 115 students per year.

Medical schools across the nation are averaging a 6.2-percent increase in applications this year, compared with last year, the Association of American Medical Colleges reported in October, 2015.

Of the 6,457 applicants, 883 are Arizona residents, and 2,134 are from California, the Tucson colleges largest feeder state, Price-Johnson said. A lot of different elements influence the decision to pursue careers in medicine. Of course, these are people who want to help others. I think it also has to do with the fact that nationwide, we are facing a serious shortage of physicians. According to AAMC estimates, the U.S. faces a shortage of between 46,000 and 90,000 physicians by 2025.

Price-Johnson and Tejal Parikh, M.D., a 1990 graduate of the college and now assistant dean for admissions and financial aid, identified several reasons why the UAs Tucson medical school is seeing a much higher increase than other U.S. medical schools.

Arizona offers a lot of opportunity to learn about border health and to work with under-served and rural communities, Dr. Parikh said. Weve also been getting a lot of recognition over the past year, she said, citing the U.S. News & World Reports Best Graduate Schools issue in March 2015, which ranked the UA College of MedicineTucson 42nd in the nation for primary care training in family medicine, IM, and pediatrics. There are 145 accredited medical schools in the U.S., according to the AAMC.

The UA College of MedicineTucson also offers programs that students are unlikely to find at other medical schools, Dr. Parikh said. For example:


The college offers eight distinction tracks for medical students who want to delve into such specialized areas as global health, integrative medicine, and medical Spanish.

The colleges Rural Health Professions Program offers students opportunities to work in clinics and hospitals in communities throughout the state.

The colleges Societies Program pairs each new first-year student with a faculty mentor for all four years of medical school.

The Commitment to Under-served People (CUP) program holds clinics for refugees, abused women and children, and others who have limited access to healthcare. CUP was cited last year by the Liaison Committee on Medical Education, the accrediting organization for medical schools nationwide, as one of the colleges institutional strengths, and described by numerous medical students as a major influence in their decision to attend the college.

The college also is receiving applications from people who are interested in the University of Arizonas partnership with Banner Health, Dr. Parikh said. The college provides a warm and welcoming environment for applicants when they come for interviews, she said. After a recent interview, one prospective medical student wrote to Dr. Parikh: Going to the UA College of MedicineTucson has always been a dream of mine. But after my interview, I came to realize its more than just attending a dream school. Its about becoming part of something more: a family.

The University of Arizona College of MedicinePhoenix does not yet have a final report on numbers of applicants for the class of 2020, but last year the college, which opened in 2007, saw a 22.5-percent increase in applications over the year before; 5,088 people applied for a chance at just 80 spots in the class of 2019.

Nursing college recognized for Hispanic serviceThe UA College of Nursing is only the fourth nursing school in the U.S. to become a Hispanic-Serving Health Professions School member, joining the UA Health Sciences College of MedicineTucson, and the Mel and Enid Zuckerman College of Public Health, the university reports.

HSHPS is a member-based, nonprofit organization that consists of schools and colleges of medicine, public health, nursing, dentistry and pharmacy throughout the United States. Membership is granted to schools with a demonstrated commitment to increasing the Hispanic health workforce that will serve and promote the health of Hispanics, as

evidenced by programs, activities and student and faculty diversity.

The UA Health Sciences is committed to becoming a national leader in the training of a diverse faculty, staff, student body and health-care workforce, they reported. Substantial research underscores that minority health professionals are much more likely to treat minority patients and to serve in rural and under-served areas. These professionals bring improved understanding of cultural diversity and other issues that help better meet the needs of patients and other health service users from minority groups.

The university noted that according to the U.S. Census Bureau, in 2012, individuals from ethnic and racial minority groups accounted for more than one-third of the U.S. population, or about 37 percent. By 2043, minority populations are projected to become the majority.

According to a 2013 survey conducted by the National Council of State Boards of Nursing and the National Forum of State Nursing Workforce Centers, nurses from minority backgrounds represent 19 percent of the registered nurse workforce, and only three percent identify as Hispanic. At the UA College of Nursing, minority students represent 39.3 percent of the total student population, with 11.2 percent identifying as Hispanic.

HSHPS status allows nursing college faculty and students to apply for additional programs that advance Hispanic health research, education, and workforce development, and to access resources for identifying and securing funding for research, including grant preparation assistance and a bi-national network of potential collaborators. n


In Memoriam

Radiation oncologist Michael R. Manning, M.D., prominent Tucson physician who helped establish the Arizona Cancer Center, whose family stretches four generations in Arizona history, and who joined PCMS in 1982, died Dec. 18, 2015. He was 71.

Born here on Oct. 19, 1944, Michael graduated from Rincon High School and the University of Arizona. Upon completion of his

undergraduate degree, the family told the Arizona Daily Star, he pursued graduate studies at the UofA, later spending time as a medical technician with the 152nd Fighter Intercept Squadron of the Arizona Air National Guard. He entered the University of Arizona College of Medicine in the fall of 1969, and completed his M.D. degree in June 1973.

Dr. Manning spent time at the Cleveland Clinic and later joined the faculty, and later completed a fellowship at the University of California at San Francisco. Upon completion of residency in 1977 Dr. Manning joined the University Medical Center faculty in radiation oncology and helped establish the Arizona Cancer Center.

During his tenure Dr. Manning participated in numerous clinical research programs, most notably the use of hyperthermia as a cancer treatment. This later became the subject of two books written and edited by Dr. Manning, as well as more than 50 peer-reviewed articles. Upon leaving the University of Arizona, Dr. Manning helped develop the largest radiation oncology private practice in Southern Arizona, Southwestern Radiation Oncology, Ltd., where he practiced with doctors Eric G. Mayer, Edward E. Rogoff, Robert S. Heusinkveld, Michael J. Moore, and Silvio A. Aristizabal.

Dr. Michael R. Manning in 2007 with a portrait of his father, pioneer Tucsonan Dr. Wilkins R. Bill Manning (PCMS photo).

Dr. Michael R. Manning, 1944-2015

Dr. Mannings parents were Marjorie Sullinger Manning and Dr. Wilkins R. Bill Manning, and the younger physician enjoyed deep roots in the community, the family reported. His lineage dates back to former Tucson mayor Levi Howell Manning [known as General Manning], surveyor-general for the Arizona Territory, cotton farmer at Canoa Ranch, developer of the Santa Rita Hotel, the Owls Club, Seinfeld Mansion, and the Manning House.

Dr. W.R. Manning, born 1910 in Tucson, was the co-founding physician of the UofA College of Medicine, former Arizona Medical Association president, and former PCMS president, served on BOMEX [now AMB], and was chief of staff of both Pima County Hospital and St. Marys Hospital, the family reported. He died in 1973.

His father was a giant in this town, Dr. Manning told us in 2007.

Colleagues will remember Dr. Michael Manning as a leader, confidant, and friend, the family reported. Patients have described him as truly caring, warm, compassionate and insightful, using accolades such as encouraging, empathetic, supportive, professional, sensitive, hopeful, advocate, and father-figure.

Dr. Mannings wife, Elaine; sister Muggsy Manning Hildreth; daughter Catie Novogradac; and grandson Mason Manning Novogradac survive him. He will also be remembered by nieces Heidi Montijo and Egan Whitley, nephew Michael Hildreth, sister-in-law Clarice Mathis, and many other extended family members, colleagues, and friends.

A toast to Dr. Manning was given Dec. 30, 2015 at Tucson Country Club. Memorial donations may be made to the Arizona Oncology Foundation, 2624 N. Craycroft, Suite 100, Tucson 85712. n

Dr. Michael R. Manning in 1984 (PCMS photo).


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Makols Call

The bigand everyone elseBy Dr. George J. Makol

Theres nothing worse than having Canadian cousins. Perhaps upon further thought, it is possible there are worse things, like having amoebic dysentery, or having to listen to a 90-minute timeshare presentation with no exit door nearby.

My Canadian cousins on my mothers side, like me, are the grandchildren of Lebanese immigrants, and of course they are therefore into oil. No, not

olive oil for hummus, but as Jed Clampetts narrator said when the mountaineer was shooting at some food, ... up from the ground came a bubbling crude, oil that is, black gold, Texas tea. In central Canada its buried deep in the tar sands, and has now proven technologically extractable. Its why gasoline is so much cheaper around here lately.

Of course, that means those Canadian cousins are rich, and that in itself can be aggravating, but thats not what I find annoying. What gets my goat is that whenever I see them, they have effusive praise for their country, and tend to point out how they have universal healthcare, and how Canadians can afford to buy whatever medication is prescribed by their physicians. Some of you may have European cousins, and Im sure they sing the same tune. My answer is to quote P.J. ORourke: You take your Germany, France, and Spain, roll them together, and it wouldnt give us [Americans] room to park our cars.

You may ask, as many of my patients do, why cant America, the richest country in the world, afford to provide comprehensive medical care for everyone, and why are pharmaceuticals so darn expensive in the U.S.? As youd expect, I have a simple answer or in this case two simple answers. 1. The United States shoulders the expense for nearly the entire military defense of the Western world. As a matter of fact, among our allies the highest defense budget behind ours is one 17th of the amount we spend. Hence, they have lots of money left over to pay for healthcare, etc. 2. Drug prices are so high here because the governments in Europe, Canada, and Central and South America arbitrarily set ceilings on what their

citizens will pay for pharmaceuticals, severely elevating the cost to American consumers. In fact, we pay for basically all the drug company profits that fund research and development of new medications. The rest of the world hops on our back for a free ride.

A Dec. 15, 2015 article in The Wall Street Journal detailed a study done of the cost of the top 40 branded drugs in the U.S. compared to Norway. Prices were higher for 93 percent of these drugs in the U.S. The Norwegian Medicines Agency reviews patient data to decide whether a new drug is cost-effective. The NMA can deny a drug altogether if its not cost-effective, and also if accepted, the price the government health system will pay for that drug. Although in Norway a Big Mac costs $5.65, and a gallon of gasoline is $6, the cancer drug Routaxin costs the NMA $1,527, while the U.S. Medicare program pays $3,678.

Its kind of like the arcade game Whack a Mole in that if you hammer down the prices everywhere else in the world, one big mole is going to pop up and bust the U.S. budget. I do love my Canadian cousins, but when they start up, I merely ask them what their approximately 44-million person-country would do if Russia or China attacked it. Would they perhaps send Mountie


Dudley Do-Right and a couple of dozen other RCMP officers to face the onslaught? Or, would they ring up the American president, assuming he wasnt playing golf, and ask for assistance from our 350-million-person country?

One can of course make the argument that the United States cannot be the worlds policeman. One president who did not play much golf but actually ran the country pretty well was Harry Truman, who always thought that American prosperity at home depended on the security of our friends abroad. It was I think 1947, a year before my birth, when President Truman said, Lasting peace can never be secured if we permit our dangerous opponents to plot future wars with impunity at any mountain retreat, however distant. Pretty prescient for a working-class Democrat, no? Todays Democrats are not so good at foreign policy. Ill leave arguments about the size of our defense budget to our esteemed representatives. But it is hard to argue that the absence of a strong America for the past seven years under the leadership of a professorial dilettante has left the world a safer place.

But back to the costs of things medical and pharmaceutical. How did prices get so high? Our largest purchaser of medications is the United States government, so one would think they would be a deft bargainer, considering the clout they should have. Well, our brilliant representatives when crafting the Medicare D program outlawed any price bargaining by the government for medications provided under Medicare D. This is kind of like telling your spouse when you enter the automobile dealership, just be quiet and we will take the first price that they throw out, even if its greater than the window sticker price, so we wont hurt anyones feelings.

We do have the free market operating, but that didnt work so well for youthful Martin Shkreli, who recently bought Turing Pharmaceuticals, and raised the price of its newly acquired but generic drug for toxoplasmosis, Daraprim, from $13.50 to $750 per pill. He recently was arrested for embezzling money from a prior drug firm that he owned, called Retrofin, to pay off investors from his hedge fund, who invested millions that he promptly lost in the market.

Shkreli had previously come to the medias attention when he paid $2 million for the only copy of an album made by the group Wu-Tang Clan. I thought Wu-Tang Clan was a Chinese takeout joint, and I couldnt figure how he could be such a financial whiz after paying that much for won-ton soup.

Further evidence of his lack of brillianceor need for greedoccurred in early December 2015, when the holding company Express Scripts made arrangements with the drug compounder Imprimis Pharmaceuticals, to make a generic Daraprim for its enrollees for $1 per capsule. Its pretty hard to get $750 for a pill if its available for a buckunless youre one of our lawmakers and buying for the government! Hows that for a real bargain?

Once again, the free market beat the government at its own game.

Sombrero columnist George J. Makol, M.D., PCMS member since 1980, practices at Alvernon Allergy and Asthma, 2902 E. Grant Rd. n

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Perspecve

1966 + 50 = 2016By Stuart Faxon

Heres a solid, reliable New Year prediction. It will happen. Its based on my decades of the news business and its reflection of our obsession with 50.

Fifty is a golden wedding anniversary. Fifty is the age of a war, or a natural disaster. Fifty is the age of an assassination. Or a hit record. Fifty is the age of 25 twice. Fifty is even the age of this magazine in 2017. Is 50 really any different from 49 or 51? Nope. But it has this permanent

significant ring in our social consciousness, as if the universe cared that we earthlings think 50 is some sort of achievement.

So in summer 2013 we heard about things significant, or even trivial, that happened in 1963. In 2013 we heard about 50 years of the Kennedy assassination, and 50 years of the Beatles coming here. We even heard about 50 years of Its My Party by the late Lesley Gore. I wanted celebration of 50 years of Surfin Bird by the Trashmen, surely the greatest record ever made. But at least we got 50 years of the Ronettes.

In 2014 we heard about 50 years of everything 1964, and the same last year for 50 years of 1965. So now here comes 50 years of 1966. Could be a Baby Boomer thing, but I say its a general obsession with 50. Perhaps we Boomers are just unjustifiably amazed at ourselves, or maybe there are too many of us still in media who have not yet been ousted by its desire for attractive albeit emptyheaded youth.

Im a newsman, so the unwritten law says I have to talk about 1966 this yearbecause its 50. My 18th year was significant. Id escaped the public schools, mostly by failing, so I hadnt the record or inclination to go to college. To me public education was a form of psychological torture and I was finally free. Id gotten my first retail clerk job, in a record store. Id started playing drums and was in my first band (always musical, in younger youth Id been a choral singer with perfect pitch, then a bongo player, and later an accordionist).

I was still living at home. Its where you live on Long Island, if allowed, when you cant support yourself at 18. It was the start of my nine wilderness years, without direction, as I waited unknowingly for my front brain to finish developing. As soon as it did, it told me to go to university, which changed everything, right down to placing me here upon this page. But thats another storyperhaps for 50 years of 1975!

In the news business we like to do an advance. That means telling folks whats going to happen. This is usually preferable to coverage of something as it happens, or after the fact. So here in February Im getting the jump on those summer slow news days by doing 50 years of 1966 now.

I was a political neophyte at 18, just as are todays 18-year-olds, those undergrads whom speech so easily offends. You think you have trouble? In my time the president was Lyndon Baines Johnson, one of the two most dishonorable, despicable men to hold that office in my lifetime, a bully, a sexual predator, and a low-information war prosecutor. After he imploded over Vietnam and refused to run for a second full term in 1968, what did we do? We elected not his niceguy vice-president, but dark prince Richard Milhouse Nixon, the other of the two rats.

The so-called Selective Service Act was still in force, and Nixon tried to conscript me in 1969, and Im so glad he failed. It seems his army didnt like my hypothyroidism. I would not have made a good soldier even Id made it through basic training. I probably would have died in vain in Vietnam, as, unfortunately, all who died there did. Its amazing that Im even here, like Ishmael, to tell you. Somewhere I still have my draft card bearing 4F.

Because there was no 24th Amendment, I was age-barred from voting against Nixon, so my first presidential vote was cast for George McGovern in 1972. Nixon landslid him, though in two years hed implode, too. Nixon and Johnson. Fifty years later, even after they got their supposedly just political desserts, I still hate those guys The worst presidents weve had since cant compare to those two cases of advanced jerkism. Who ARE these people we allow to be president, anyway? Obama? G.W. Bush? People of no accomplishment? Family dynasties? I could have done a better job then either of em.

Nineteen sixty-six was also the year when, of all people. Frank Sinatra returned to the hit parade with Strangers in the Night, a song he later said he always hated, as he did My Way, though he continued to fill requests for both songs for the rest of his life. The song made the top 10 in 20 countries. But I was a rocker, and I hated it. Now I find Sinatra agreed with me! And he wasnt the most agreeable guy. That Italo-American toughguy braggadocio of his was another thing I hated about him. He seemed too like the bullies who had at me in high school.

Though one of them is as dead as Sinatra, you may hear about 50 years of the Monkees, the fake rock group created from actor-musicians for a lighthearted TV show with the general vibe of the Beatles 1964 movie A Hard Days Night. Hipsters hated them because they did not play on their own first records. But their songwriters and session musicians created for the Monkees music that still stands up today as classic pop. So I bought Monkees records, just as I bought more hip albums by Frank Zappas satiric Mothers of Invention, and the incredibly dark New Yorkers Velvet Underground.

Nineteen sixty-six was fabulous for music, as it was the year of the Beatles Revolver, the Beach Boys Pet Sounds, The Kinks Face To Face, The Byrds Fifth Dimension, the debut albums by Buffalo Springfield and Jefferson Airplane, plus Motown, and gangs of garage-rockers like Count Five, and Question Mark and the Mysterians. Just try to forget 96 Tears. You know you want to.

I was also a jazzer, so I dug all the post-bop and hard bop, but not the avant garde or New Thing, those experiments in modality and tonality that broke jazz away from its swing and chord changes. As a New Yorker I was attuned to every issue of down beat and was absorbed in the critical battles over the new forms of jazz. I hated John Coltranes cacophonous Ascension as soon as I heard it. It was so awful, it made the late Ornette Colemans 1960 Free Jazz sound good.


This movement was followed by the jazz-rock known as fusion, which I thought robbed jazz of its melody and attractive complexity, while rock only contributed volume, and too few chord changes for jazzs required virtuosity. Later in Boston, I fought for my side in the local music press, and in the eventual shakeout, I won. Avant garde never found an audience, and fusion was the stylistic dead-end Id predicted.

Of high significance to 18-year-old males, 1966 was also the year of the miniskirt. There exists no heterosexual male of any age who does not like a miniskirt unless the female it adorns is his daughter. Im told that in Swinging London, a maximum of seven inches above the knee was recorded. The miniskirt also opened up huge marketing possibilities for the hosiery trade, as miniskirt wearers adopted stockings and especially leotards. The

new colors and textures became important in the total look, Im told by the 1967 Britannica Book of the Year, a record of 1966. Yes, its from an actual set of Britannica yearbooks I now keep in my garage.

Nineteen sixty-six of course was more than fashion, music, and politics. In medicine the year was concerned with prolongation of life, accenting mouth-to-mouth artificial respiration, hospital respirators, external heat massage, the defibrillator, and the external pacemaker, most of which we now take for granted. It was the year Houston heart surgeon Michael DeBakey implanted a plastic artificial heart that sustained a woman through a three-and-a-half-hour valve-replacement operation and, six days later, enabled her to survive postoperative heart failure. The pump was removed on the 10th day after the heart had healed.

It was reported in 1966 that 62,939 cases of smallpox, with 10,324 deaths had occurred in the world in 1965. The World Health Organizations smallpox eradication program had begun in 1958, but was moving more slowly than expected. In 1966 a new 10-year program was begun, looking forward to the eradication since achieved. Fifty years later we talk mainly about preserving the dangerous viruses we have, in order to create vaccines in case the disease reasserts itself.

Also important in 1966 was the U.S. government becoming environmentally active enough to implement the amended Clean Air Act, notifying the car industry that exhaust control systems would be required on 1968 model cars.

Can you believe that so many of us once lived without integrated circuits? By the end of 1966 this quiet revolution of microelectronic components saw them well established in computers, and in military and space equipment, and they were getting underway in the consumer market. Now, we dont even not know what to do with ourselves that does not require a silicon chip to complete our circuits. We want our new cars to act like one big smart-phone.

In one way 1966 sounds like now. The most serious refugee situations were in Africa south of the Sahara, but it was because frontiers of newly independent nations cut across tribal boundaries, and political instability caused across-the-board movements of peoplesnot because Islamists set out to kill anyone not just like them.

Myriad such events and activities happened in 1966 that were far beyond, and more important than, my sheltered 18-year-old American life. But I was slowly learning. So glancing madly backward from 67-and-a-half, heres to 50 years of 1966!

Stuart Jazzackal Faxon has been Sombrero editor not for 50 years, but 18 or so. n

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Environment

The resourceWater is the resource we cannot live without. That obvious fact was the focus of the 107th Arizona Town Hall Keeping Arizonas Water Glass Full , Nov. 15-18, 2015 at the Hilton Phoenix/Mesa.

Partners included Arizona Public Service, Salt River Project, Arizona Lottery, Freeport-McMoRan Copper & Gold, Arizona Water Association, Central Arizona Project, EPCOR, Jennings Strauss Attorneys at Law, and the Nature Conservancy. The three state universities collaborated to create a background report as a factual resource for participants.

Arizona has a long-standing history of water menagement, the report said, from native people practicing sustainable forms of agriculture and building of canals to deliver water to their people, to the state leaders who took steps to protect Arizonas rights to Colorado River water that culminated in the construction of the Central Arizona Project (CAP).

Since water is essential for life, it is vital [that] Arizonans have access to clean-running water. Fifteen years of drought, increasing growth pressures, federal regulatory oversight, and growing environmental concerns, among other factors, are causing the future of Arizonas water supply to receive increasing attention. While Arizonas most populated areas do not currently face a water crisis, some rural areas are seeing more immediate problems, and there is a consensus among experts that, without action, Arizona will face a gap between demand for water and available supplies in the next 25 to 100 years.

Each of the last five decades has seen an Arizona Town Hall on water. Arizona Town Hall addressed water in 1965, 1977, 1985, 1997, and 2004. This was the sixth time a Town Hall addressed the topic. Because water issues in an arid state are never settled, there is consensus that Arizonas leaders and citizens must continue to develop and refine policies, practices, and procedures needed for Arizonas quality of life, economic prosperity and environment. Intent of the Town Hall was to discuss how best to improve the reliability and quality of existing water supplies in the face of natural and other challenges, and to identify the means to develop new or additional water supplies.

Participants considered various sources of water and unique challenges associated with

each source; projected future imbalances between water demands and supplies in various areas; access to water and usage across various sectors and geographic areas within Arizona; infrastructure needs and economic challenges; legal challenges; persistent drought and climate change; political realities; conservation efforts; and how to prioritize and finance key investments and other action items. Town Hall reported that thought not all participants agreed with each of the reports

Dr. Clavenna was born in Texas but spent most of his childhood in Baton Rouge, Louisiana. He attended Trinity University in San Antonio for his undergraduate work, receiving a B.S. in Biochemistry. Dr. Clavennas desire to personally help those with ailments, led him into the field of medicine. He earned his medical degree from Louisiana State University Medical School in Shreveport in 2009, where he was elected into Alpha Omega Alpha Honor Society. While in medical school, he was introduced to Otolaryngology (ear, nose, & throat), a wonderful field of complex anatomy, requiring surgical and medical expertise to treat those with problems of the head and neck. Dr. Clavenna completed a general surgery internship and otolaryngology surgical residency at Louisiana State University Health in Shreveport.

Following residency, Dr. Clavenna completed a Fellowship in sinus, allergy, and anterior skull base surgery at Vanderbilt University in Nashville, Tennessee. There he trained under internationally known surgeons, Drs. Rick Chandra, Paul Russell, and Justin Turner. During fellowship he focused on advanced sinus surgeries, including management of frontal sinus disease, nasal and skull base tumors, pituitary surgery approaches, ophthalmological related procedures and treatment of allergies. Many of these cases were performed in conjunction with neurosurgeons and ophthalmologists. One of his most fond memories from fellowship involved treating a patient emergently transferred to Vanderbilt for severe sinus disease encroaching on the vision of his right eye. Using his recently learned endoscopic sinus surgery techniques with the aid of image guidance, he was able to successfully treat and drain the infection and preserve the patients vision.

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conclusion and recommendations, the report reflected the consensus.

Arizona has largely avoided the water shortage crises that have plagued other states, the report said. Several factors have significantly influenced Arizonans current use of water. Arizonas municipal, agriculture, mining, forestry and ranching industries have shaped Arizonas water priorities as have tribal water settlements. Instrumental to Arizonans current use of water is Central Arizona Project, authorized by federal legislation in 1968, and developed by the Bureau of Reclamation. CAP, a system of aqueducts, tunnels, pumping plants and pipelines, is Arizonas single largest resource for renewable water supplies and is designed to bring water from the Colorado River to Central and Southern Arizona.

Along with creation of CAP, the passage of the Arizona Groundwater Management Act of 1980 has significantly influenced Arizonas current use of water. With the passage of the GMA, for the first time in our states history, all responsibilities for water planning and regulation were centralized in one state agency, the Arizona Department of Water Resources (ADWR). In addition, the judicial general stream adjudication proceedings are central to determining the extent and priority of water rights on the Gila River and Little Colorado River systems, which in turn impacts water usage.

The factors likely to have the greatest influence in shaping Arizonas future use of water are land use and ownership; expected population growth; climate change; droughts; potential shortage declarations on the Colorado River; water pricing;

lacking or deteriorating infrastructure; declining groundwater levels in some areas; legal and political challenges; tribal water settlements; and economic and agricultural vitality and sustainability. All these may influence demands on Arizonas water supply [so] Arizonans need to make tough decisions about how to manage water resources among competing considerations, such as agricultural use, metropolitan use, rural needs, mining use, power use, environmental concerns, tourism and quality of life issues.

In addition, with a decrease in federal funding for infrastructure, Arizonans will have to come up with collaborative partnerships, whether public-private, tribal, or regional, to ensure the necessary infrastructure needed to provide for current and future water use. State leaders will be required to pursue innovative ideas and to address energy issues. It will also require a willingness to seek investment from the private sector. Arizona will also have to revise its legal processes, such as the general stream adjudication process, to more efficiently and effectively define water rights in the 21st century and avoid costly litigation gridlock.

Resolution of tribal water right claims and addressing core issues of the relationship between surface and groundwater will be very important as we move forward. Lastly, Arizona needs to educate our leaders and citizens about water policy, pricing, infrastructure, delivery and other matters so as to impact the manner within which Arizonans consume water.

Successes and challenges in managing Arizona water

Arizona has managed its water resources reasonably well overall, especially relative to some other Southwest states, but

results have varied across Arizona regions. For example, management of groundwater resources has generally been better in the Active Management Areas (AMAs) and Irrigation Non-Expansion Areas (INAs) created under the GMA than in other areas of the state. Infrastructure and other water management resources also vary significantly in quality and availability among Arizonas urban, rural and tribal communities. To the extent that Arizonas management of water in its first century of statehood was largely a success story, many factors contributed. Our elected officials and other dedicated community leaders have shown vision and worked collaboratively to address Arizonas inherent water-related challenges, establishing Arizona as an early innovator in effective water management. This approach has included the GMA, CAP, SRP, irrigation districts, and investments in vital infrastructure. Without entrepreneurship, coordination, and mutual respect among stakeholders, these successes would not have been achieved.

We must confront our water management challenges, the report said, including environmental challenges such as climate

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change, drought and degradation of our forests and environment. Other challenges are in infrastructure planning, funding, and maintenance, particularly in rural and tribal communities. Legal and political factors also present challenges in various forms, including litigation and other conflicts among users of shared water resources, complex and interrelated laws and regulations, and a lack of coordinated planning in certain areas of the state (e.g., some areas not covered by AMAs or INAs). And, of course, projected population and industrial growth over the next several decades will substantially increase our demand for water, requiring both augmentation and conservation of water resources within Arizona.

We are also victims of our past successes in the sense that, because Arizona has done a relatively good job of securing a reliable water supply and is not currently facing a water crisis, many of our citizens take water delivery, quantity and quality for granted and are not as educated as they should be about the supply/demand gap.

A preeminent concern facing all Arizona communities is financial, that is, Arizonas ability to obtain the necessary funding for maintaining and updating degrading and failing infrastructure as well as building new, high-tech infrastructure. If a portion of new funding is to come from the population base, rural areas will be greatly impacted because the population base may not be sufficient to raise the necessary funding. Further, with federal funding on the decline, state funding for water and regulatory agencies, such as ADWR, the Water Supply Development Revolving Fund and ADEQ are critical. Investment from private industry will be necessary.

Funding problems are exacerbated by conflicting views and divergent water use interests among Arizonas population and special interest groups, all of whom impact the political process. Uncertainty about the effect of human, environmental, and economic factors on future water demands may deter investment in infrastructure and technology that may be required to meet those demands. The unresolved reserved rights claims of tribal communities and other federal lands further complicate the general stream adjudication.

Another challenge is access to quality water in remote areas, or the infrastructure necessary to deliver water to remote areas, especially in tribal communities. Because tribal communities control a significant percentage of current and future Arizona water supplies, these communities will likely play a significant role in meeting future water needs.

Inability to decide between competing value judgments and the best use of Arizonas water resources impedes effective and timely improvements to Arizonas water management policies. Some advocate for limited agricultural use, restricted growth in water limited areas or more astute forest land and watershed management. Further, the great debate over the impact of climate change on the environment and water in particular raises new issues. Water management techniques such as promoting close proximity between pumping and recharge or replenishment, augmentation, use of reclaimed water and desalination must be addressed. The manner and costs associated with the transportation of water to areas in need are also challenges.

Lack of education on water issues among Arizonas citizens and current leaders also presents a significant challenge. Education efforts should focus the value and importance of water to our quality of life, conservation efforts, the value of banking water, and the public perception of water quality, the relationship between water and energy and tribal water rights. Current partisan politics only add to the challenges and limit solutions. As a constituency, we must learn how to better communicate to our political leaders the importance of water management and the problems we face as well as offer potential solutions. Leadership surrounding these issues will continue to be essential moving forward with a water management system that will sustain Arizonas water resources for the next 100 years.

Innovation and technology, land use, and the economy

The two most significant Arizona water sources are groundwater, and surface water from the Colorado River, but other rivers, groundwater, and reclaimed water also provide substantial quantities of the water Arizonans use. Within each of these three principal resource categories are multiple sub-categories, such as water obtained from rain and snowfall, recharge and banked water, reclaimed water, graywater, and stormwater runoff. On a statewide basis, Arizonas existing water resources are generally adequate to meet our current needs, although both the portfolio and adequacy of water resources vary by region in the state. For example, many rural areas that do not have access to CAP water rely heavily on surface water from local rivers and streams, as well as groundwater. In some parts of Arizona, including the Navajo Nation, running water is not available to many residents. Water quality and affordability are also growing issues for some communities.

Arizona must protect its existing water portfolio, specifically its

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Colorado River supply. The structural deficit on this river must be addressed to ensure the maximum use of this vital resource. Arizona will also need to expand its portfolio of water resources to meet future needs, in light of increasing demand driven by population growth and other factors, as well as the fact that a substantial portion of the water we currently use is groundwater that is replenished slowly.

Many steps can and need to be taken to augment Arizonas existing water portfolio. Although reclaimed water is already being used for limited purposes, we should pursue strategies to expand its use, including for commercial and industrial purposes and potentially for direct potable reuse. However, using reclaimed water for human consumption will require changes in the publics perception. We should continue to enhance our use of technology to make water usage more efficient in all sectors. We should invest in water infrastructure and begin to explore the increased use of brackish water, and existing and new desalination facilities. We should address the proliferation of invasive non-native species, such as the salt cedar, that have contributed to depleted river flows and the degradation of riparian areas, as well as implement sustainable forest management programs. We should implement better flood control policies and other measures to more effectively harvest rainwater and storm water runoff.

Other short- and long-term options may include increasing storage capacity, cloud seeding, and importing water from other regions outside the state via cross-country pipelines or rail systems, which could become cost-effective in the future. While allowing the movement of existing and future water supplies from one user to another is worth exploring, it is a highly sensitive and controversial topic that has the potential to pit regions, communities and industries within Arizona against each other. There may, however, be opportunities to pursue voluntary redistribution of water resources through collaborative infrastructure planning and market-based systems in which willing buyers and sellers can buy, sell or lease their rights within the existing legal framework.

Impacts of innovation and technology have a beneficial impact

on Arizonas water use, generally allowing for a more efficient use of water. Over the years, Arizona, through ADWR and other agencies, has developed innovative policies, practices and institutions to manage its water supply. Already existing and implemented technologies that positively impact water use are automatic water readers, automated leak detection systems, improvements to nano-filtration, modernization of ditch systems, field leveling, better underground water storage capabilities and conjunctive use of aquifers. However, there are some existing technologies that are not being used statewide because they can be cost-prohibitive. For example, technologies exist for the effective recycling of waste water, but some communities cannot afford to construct the necessary facilities. In order to allow for the implementation of existing technologies in areas where such technologies are needed, more funding is needed. Future innovation may require significant financial commitments from the federal, state, and local governments as well as the private sector. Arizona should also explore different water pricing strategies, including financial incentives to those who conserve water efficiently and effectively.

Arizonans must also invest in stakeholder-driven research and development for increased water use efficiency and innovation in agricultural, mining and manufacturing industries, and Arizonas universities should play a pivotal role in advancing research in the development of water innovation and conservation. Future innovation will involve looking deeper into the pricing of water, the feasibility of the treatment of brackish water, desalination, and allowing reclaimed water to be made available as potable water. However, to implement such innovations, Arizona will need to address regulatory requirements that currently prohibit these types of innovations as well as obtain buy-in from its citizens and elected officials, through education and awareness. Lastly, Arizona needs to provide an education system that trains future water experts and provide programs of study that foster innovation and best management practices.

Water effects of land use and development

Land use, development, and population growth have widespread impact on water use. For example, increased


development in arid rural areas can affect the availability of water through wells by decreasing groundwater supplies. High-density urban residential developments typically use less water per capita than low-density developments, which has mitigated growth in water demand as Arizonas population has increased and water usage has shifted in some areas from agricultural to municipal or commercial uses.

Demographic trends associated with population growth affect water usage. Millennials have tended to seek out smaller houses and a desire to use fewer natural resources. Conversely, water availability and usage also shape our land use, development, and other policies. To the extent feasible, we should use economic incentives and other tools to encourage growth in areas where water supplies are relatively abundant, and discourage development in hydrologically sensitive areas, such as state trust lands that do not have adequate water supplies attached to them. Developing such lands creates the risk of leapfrog or checkerboard development throughout the state that places additional strain on, increases the cost of, and decreases the efficiency of our water supplies and usage.

Some communities should consider implementing assured or adequate water supply programs or net-zero approaches to water use as a condition to approving new development. We should also create appropriate incentives for conservation of water resources, even in areas where water supplies are abundant. We should explore innovative strategies to make our urban communities lower-impact and less sprawling. Local governments and property owners should be provided incentives to develop policies that link land use, economic development, and water usage in ways that advance local priorities.

Finally, we should seek to build upon the successes of existing programs, such as the AMAs and INAs implemented as part of the GMA. Development within tribal communities, which comprise nearly 28 percent of Arizonas land area, presents its own set of challenges. For example, tribal lands are held in trust by the federal government for the benefit of tribal members, but some tribal lands are leased to industrial facilities and uses that may endanger water quality and may affect availability of water. It is important to take into account the cultural traditions of tribal communities with respect to their history on the land. Mending the trust and cooperation between Native Americans and other communities is essential to good regional land development and water management decisions.

Arizonans who are not Native Americans should take into account the water needs and circumstances on tribal lands to help preserve Arizonas overall water supplies and to build a more trusting and cooperative relationship with respect to both land use and water use. The relationship between SRP and the Gila River Indian Community, which provides for the banking of tribal water in exchange for certain economic benefits to the community, may serve as a model for future collaborations between tribal and other communities.

Water as driver of economic growth and sustainable environment

Water and the economy are inextricably linked. When a particular industry is limited in its access to water, there are significant third-party impacts beyond that industry. Mis-perceptions concerning Arizonas current water supplies, i.e., that Arizona may not have adequate water to sustain industrial

development, may already discourage economic engines from investing in Arizona. Thus, Arizona must inform the public about the current stability of its water resources, successes in conservation, and existing strategic plans to secure its water supply so as to entice businesses to invest in Arizona. Arizona must also highlight groups like the Water Infrastructure Finance Authority of Arizona (WIFA) and the Statewide Water Advisory Group (SWAG) so as to assure long-term investors that Arizona is a good place to do business.

Further, to attract additional capital and move our economy forward, Arizona needs to have more definitive certainty about its water supply, which may involve streamlining the water rights adjudication process and tribal water rights settlement processes. Statewide, one of the best investments Arizona could make is to assure that ADWR is funded to accomplish its mission. Additionally, public education about water issues and conservation, uses and practices would be an excellent investment.

Arizona must also appreciate and preserve the quality of Arizonas environment, including ensuring continued use of water for recreation. For Arizonas urban economies, Arizona must provide incentives for industry and business to use less water, identify and provide incentives for multipurpose projects that can benefit multiple users and entities by providing new water supplies.

Arizona must also re-think the engineering of water deployment systems, including using non-potable sources of water for all non-drinking water uses. For rural economics, Arizona must encourage and fund alternative water sources so as to avoid further depleting groundwater through pumping. Arizona must understand and quantify the economic value of agricultural water uses.


Arizona must work with tribal communities and the federal government to ensure that any lack of water resources is addressed, and that tribal water rights are secured and efficiently used. The settlement of tribal water rights would have many benefits, including greater certainty for tribal economic development and other stakeholders, and fostering better relationships and opportunities between tribal and non-tribal communities.

Conservation and financing its role

Although it is not a panacea for Arizonas water issues, conservation has playedand will continue to playan important role in helping Arizona meet its water needs. Efficient use of water is imperative in an arid climate, and Arizona has done a good job in the past of implementing conservation measures. Agriculture has made great strides in conserving water resources, thanks to technological advances and improved farming and irrigation methods. We should expand our efforts to conserve water in the future so that, when combined with our augmentation efforts discussed elsewhere in this report, we will be able to close the projected future gap between water demand and supply.

The state and Arizonans can do a number of specific things to conserve water. Water pricing strategies, including tiered and seasonal rate structures, can be and are used to promote conservation while maintaining the financial integrity of utilities. Building codes that encourage low-impact development, installation of low-use appliances and xeriscape landscaping are effective conservation tools.

We can explore opportunities to make better use of graywater in homes and other settings, reduce evaporation, and pursue technological innovations that prevent unnecessary water overuse. Utilities can continue to empower their customers to conserve water by providing additional information about water usage, cost and conservation techniques in billing statements and through other media.

There are also opportunities for agriculture to further conserve water through better flood irrigation techniques, drip irrigation, the installation of concrete ditches and other strategies. Many renewable energy technologies consume less

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