1 December 2017

Dear Interested Readers,


The Chatter In My Head

If I was a Buddhist or at least an effective practitioner of mindfulness meditation as Robert Wright describes in his recent book, Why Buddhism is True: The Science and Philosophy of Meditation and Enlightenment, I would be able to “turn off” the chatter in my head that is a daily disability that has gone on now for a year since the election. I never have been able to meditate, and I am not very good at praying either. I have tried repeating the “Lord’s prayer” and Psalm 23 as a sort of mantra. I’ve tried using Annie Lamont’s simple guide to prayer, Help, Thanks, Wow: The Three Essential Prayers. These things work for some people, but don’t do much for me. I always end up feeling somewhat defective because I am no better at meditation or prayer than I am at playing the piano or guitar, despite years of trying.

Exercise has always effectively turned down the “chatter in my head,” or as it is sometimes called “my monkey mind.” The truth is that unless it gets too intense, I like listening to the chatter and sharing it with others. Over the years there was nothing better than an intense conversation with a good friend on a long run. Now that my septuagenarian knees will not allow a long run, I get almost exactly the same relief with an intense conversation on a long walk. If a companion is not available, an audiobook or podcast is almost as good. The other thing that helps is trying to put the “chatter” into writing.

For the last several weeks the chatter has been all about the negative effect that the current administration has had on the efforts to overcome the social determinants of health, the barriers to the Triple Aim, poverty, racism, social injustice, and economic inequality. The falsehoods that are spouted by Republicans in an attempt to pass an absolutely awful tax bill or deny millions of people the slim benefits of the ACA, and their other attacks on trade, climate, and anything positive that has happened over the last few decades, have kept the chatter going. I am incensed on an almost daily basis as I read a puerile tweet or watch the president turn what should be a meaningful experience, like the recognition of the “code whisperers,” into a name calling reminder of his personality disorder. We are in desperate need of leadership in the complex international arena where the world’s two most bizarre heads of state have the unchecked ability to hurl nuclear weapons like stones on a playground.

All this “chatter” about these issues seems to move toward of point of convergence or consilience. In the era of Trump the concept of consilience as described by E.O. Wilson in Consilience: The Unity of Knowledge, seems to be an organizing principle. The issues seem to come down to a discussion of dualism, inequity, and the manipulation of large portions of the population with fear and unfulfilled promises.

It’s all about who is in, and who is out of the conversation. It’s all about who is benefitted and who is damaged by any proposal. It’s all about who should cause fear and who should be a source of reassurance. It’s about what is real and what is fake. It’s about whose point of view is the focus of what is good, and whose views are the road to what is bad. It’s all about who wins and who loses. It is a world where everything is a zero sum situation. Non zero solutions seem impossible in the shadow of such overbearing ignorance and narcissism. It’s never about shared interests. It’s always about power and the maintenance of power. The planet, world peace, the health of the nation, the inheritance of future generations, and ultimately the future of all humankind and the planet which is our damaged home seem to be vulnerable to the immediate gratification of a few. The large majority of us seem frozen without clarity about how to respond to the threat. That’s how the chatter goes.

I probably misused the concept of consilience but it does seem like every conversation becomes the same conversation, whether we are talking about cabinet appointments like Betsy DeVos as Secretary of Education or Rick Perry as the Secretary of Energy, or talking about major pieces of legislation like the attempt to “repeal and replace” the ACA, or to destroy entitlements by further enriching the rich with “tax reform.”

Years ago I learned that it was very easy to stir the pot with negativity and anger directed at a faltering leadership. When our medical group finally succeeded in departing from the control of the insurance company, I suddenly realized that it was much harder to generate consensus about the solution to problems and how to find success than it was to resist and undermine the efforts of others.

Congressional Republicans seem to have discovered the same thing. It is very easy to shape an indictment against a piece of social legislation like the ACA that was designed to try to win their support. It is extremely hard to come up with a workable alternative when your real objective is to undermine entitlements and reduce the federal budget to enable tax cuts. It is easy to resist programs for education, health, and housing by agitating the middle class about taxes. It is hard to give the middle class anything but the illusion of a tax cut without shamefully increasing the deficit, destroying the social safety net, and denying healthcare to millions if your real objective is to give trillions of dollars to the wealthy while vastly increasing spending on weapons and walls. The second worst possible motivation for any legislation is to do something just to do something. I have said it before, primum non nocere should apply to legislators as well as doctors. An even more reprehensible reason for doing something is to prove to your donors that you are willing to perpetuate and increase inequity to insure the steady flow of their river of campaign dollars.

Facts and experience seem no longer to make a difference in a world where the objective is to maximize the return on campaign contributions. In his column entitled “The Biggest Tax Scam in History” in the New York Times this week Paul Krugman’s latest indictment of the tax bill includes a reference to the University of Chicago survey of 42 of our most prestigious economists from around the country. The survey asked two questions.

Question A: If the US enacts a tax bill similar to those currently moving through the House and Senate — and assuming no other changes in tax or spending policy — US GDP will be substantially higher a decade from now than under the status quo.

Some economist were uncertain, but only one economist out of 42, Professor Darrell Duffie of Stanford, said yes. That is amazing since the whole theory of the tax bill is to grow jobs and the economy by having the tax break for the wealthy trickle down to create jobs and grow the economy. The second question, Question B, asks whether the economists think that the debt to GDP ratio will get worse over the next decade.

Question B: If the US enacts a tax bill similar to those currently moving through the House and Senate — and assuming no other changes in tax or spending policy — the US debt-to-GDP ratio will be substantially higher a decade from now than under the status quo.

All economist either thought the ratio would be higher (worse) or were uncertain. On this question Professor Duffie was in agreement with those economists who saw debt rising faster than GDP because of the bill. All economists were either unsure or agreed. If the economists are right that would be like doing major surgery with less than a 3% chance for success. I have known some crazy surgeons, but I don’t believe I have ever met one who would be enthusiastic about going forward with those odds. The only conclusion one can draw is the one Krugman draws. The tax bill is a scam that sets most of us, and particularly the poor and lower middle class members of our nation, as the marks. As the president might say in one of his tweets, ...sad!

Last week’s letter and Tuesday’s Strategy Healthcare posting were an introduction to a discussion of leadership. This week I planned to continue the discussion of leadership with a focus on leadership development. As I began to write, I noticed an email had just arrived from an Interested Reader. Reading her letter led me to realize that she had presented me with a leadership opportunity. I wrote back and asked her permission to share her comment and my response to her with you. I hope that like her, you will join in the conversation either by responding directly to this letter about the rant above or what is to follow about the effort to end racism in our time as part of the work that is necessary if we are ever going to achieve the Triple Aim. Another option is to post your comments on the Strategy Healthcare site. No matter what you chose, or whether or not you share my point of view or violently disagree, I promise you a response.


Leadership and Issues of Race While Pursuing the Triple Aim

In the November 17th letter the second paragraph was biographical.

I first began to worry about race as a small child. My family was progressive on issues of race in comparison to other families in the South between the late forties and mid sixties, but like most white Southerners we usually held our own council and did not say anything at all. We had many warm relationships with people of other races, but we were silent on the big issues. I was present when my university was integrated, but I looked the other way. I felt uncomfortable when injustice was obvious. I minded my own business. I smiled when appropriate. I never called out injustice, and I got out of town as soon as I could. Coming North to Boston, I discovered that I was in the midst of just as much discrimination, and almost as much injustice as I had seen at home. Again, I minded my own business. I went to work on my studies. I shed my Southern accent, and adopted the posture of a “liberal.”

From there I went on to describe observations and thoughts that I had while visiting my father at the rehab facility where he was getting care in North Carolina. The letter was an attempt to connect veiled racism, economic inequality, and injustice to the healthcare disparities and much of the poverty that we tolerate as a society. The gaps in opportunity, income and health status between white America and Black America still exist 54 years after Martin Luther King, Jr's “I Have A Dream Speech,” 64 years after Brown v. The Board of Education of Topeka Kansas that deemed “separate but equal” to be unconstitutional, and 53 years after the Civil Rights Act of 1964 that theoretically ended the JIm Crow era of exploitation, organized terror, and de facto slavery that was common in the states of the old Confederacy. I tried to make the case that the Triple Aim would never be achieved unless we more effectively addressed the web of connected issues that include racism, economic inequality, and injustice. The conclusion was that the current state, if it persists, will ultimately harm us all. I ended the piece by quoting from Bryan Stevenson’s Just Mercy.

We are all implicated when we allow other people to be mistreated. An absence of compassion can corrupt the decency of a community, a state, a nation. Fear and anger can make us vindictive and abusive, unjust and unfair, until we all suffer from the absence of mercy and we condemn ourselves as much as we victimize others.

Yesterday as I was beginning to write this letter I noticed an email from an Interested Reader who I originally met a couple of years ago when I visited the large health system in the Southwest where she has a significant system wide administrative responsibility. She is one of those people who “light up the room.” It was obvious to me that she was an authentic leader. The people who worked with her were enabled by her coaching, mentoring and teaching. Her customers were “delighted.” I hoped that the executives to whom she reported really understood how fortunate they were that she was part of their team. From what I heard them say, I got a sense that they realized that their lives would not be the same without her. In her first note she did not say much, but she did not need to, because I knew who she was and any confirmation from her had deep meaning for me. She wrote:

Good Morning,

Thanks for your honesty and transparency in your letter [Her letter was a response to the letter of November 17]. I long for the day, the time and the energy that you have so that I too can help in my own little way promote equality of benefits and opportunity across all Americans. This was personally touching to me and I’m thankful for folks like you Gene who continue to help shed light and make a difference.

My response to this comment was essentially a repeat of some of the things I had said in the letter of November 17:

One of the advantages of retirement is the time to read and write. Over the last few months as I have been reading about health care disparities it has become increasingly clear that inequality is often a function of racism. As you know, I grew up in the Jim Crow, segregated South. My parents did not think of themselves as racist, but except when things were obviously and unavoidably wrong my family was content to “go along” or be silently complicit. We were a very typical family. Like all other white families of our social circle, we did not directly oppress anyone, we just did nothing to change what was happening, and we were silent beneficiaries of the status quo. There is no question that over the last few years this country’s heritage of more overt attitudes of white supremacy, for which it has never apologized or really even honestly admitted, is again rearing its ugly head.

Years ago I read The Autobiography of Malcolm X and Eldridge Cleaver’s book, Soul on Ice, and realized that they were experiencing an America that I was shielded from even needing to think about. I was profoundly affected by Dr. King’s assassination, and after his death I have come to realize how generous his philosophy is. Despite those experiences I have remained relatively quiet thinking that my role was just to model acceptance of all people based on their humanity. I bought Dr. King’s dream that someday in America we would all be judged on the merit of our character and not by the color of our skin. Over fifty years have passed and there has been only marginal and very spotty improvement in the economic status and the opportunities for black Americans and most minorities. The data shows, that in relative terms, black Americans may be worse off now than in 1965.

Recently, as I have been thinking about the differential health experience in America by race and zip code, I now see that all along I have been part of the problem. Just voting for a black president did not end racism and all forms of inequality and injustice. I am beginning to get the point now of the Black Lives Matter movement. I can better hear the “dog whistles" in our political conversations. I am ashamed and disgusted with myself and other do-gooder white Americans who really haven’t done much to change the structural inequities that exist. We have blinded ourselves to the reality of the experience of most black Americans while consoling ourselves with the sense that things are good because there is a small minority of black Americans like yourself who are exceptionally talented and have had some success. I feel it is a numerator phenomena. You are the successful numerator of a very large denominator of people who still lack the opportunity and help they deserve.

As I have followed the thread of current events and have been reading black writers like Bryan Stevenson and Ta-Nehisi Coates, I have realized that I have been a passive acceptor of persistent racial injustice that should have gone away years ago. I have begun to hope that I might become part of a new growing population of formerly silent white privileged Americans who realize that we have been part of the persistent problem. I think that there are others who like me, incorrectly think that just because we salute the accomplishments of Dr. King and voted for Barack Obama, we have done our job. What reading Stevenson and Coates convinces me of is that we all will eventually suffer from the inequity that we tolerate in our midst. Stevenson says that the opposite of poverty is not wealth; it is justice. Poverty will persist as long as injustice, in all its various forms, persists.

My grandmother always told me, “Gene, mind out! You can’t do wrong and get by!” What I now realize is that when it comes to issues of race, looking the other way is wrong. What is much harder is to know what you can do that might really make a difference. If I look at where I think I can make a difference, it is by continuing to raise the subject, especially as it relates to the injustice of the inequities that exist in healthcare. I believe that if we eliminate the injustices that add to the social determinants of poor health and remove the structural barriers to good care, specifically for black Americans and other minorities, we will simultaneously improve the lot of all Americans of all races.

If I was an educator I would be working on educational inequality. If I were a lawyer, I would be seeking to make a difference for minorities in the criminal justice system. If I was a banker I would try to see how I might help stimulate black entrepreneurial opportunities or home ownership. I think that we all must do more than just demand that politicians put an end to what have should have gone away over 150 years ago. We can also demand that those politicians do not make the problems worse, as they will do if they pass the unjust tax legislation that is working its way through Congress. I believe that to make racism in all forms end, we must admit that we still have a huge problem with inequality along lines determined by race. I do not think we will ever achieve the Triple Aim unless we more effectively resolve our issues of race. It is hard to admit, but in 2117 when historians look back on America in 2017, they will likely say that we were fooling ourselves. We could not see that we were still a society deeply divided by racism and collectively suffering from the consequences of racial injustice.

I added a postscript to my letter asking if I could share her comment with you. Her response was gold and underlined and confirmed much of what I had perceived about her as well as being a personal story of unfair burdens that her family carried while white Americans like me were having a very different experience. She gives specifics about her personal experience as a black woman in America in a gracious way that emanates from a deep personal belief in the power of love. She is candid about what she observes today in healthcare around her. As one might expect she is filled with hope.

Gene,

Please feel free to use my comment. I’m as equally touched by your reply. It makes me feel extra thankful of my upbringing, which unlike yours was very different economically, but I was blessed abundantly with the wealth of love and shielded at home from the inequalities that existed around me. My father was orphaned as a baby. He grew up as a discarded black man in the south who suffered great injustices. Ironically, despite his lack of upbringing and challenges, he went to college and obtained his doctorate in theology. My father has been a Minister for nearly 60 years now and he and my mother taught us that racial lines, barriers or limitations did not exist and despite everything, love wins in the end. I only know how to love everyone equally. My first real experience with hatred and racism was actually experienced as a mother [in a northern state] and not in the South where I grew up. I do however see daily in healthcare the inequalities and huge disparities of services and access to care for the poor and underprivileged. I have an employee who just lost her sister earlier this year to liver disease that could have more than likely been managed differently and her life spared had she had access to better care, better medication and better insurance. I sure hope we wake up before it’s written that we were foolish people. I have a lot of hope in this next generation. My two young adults are now already more connected to the social and economic injustices and far less tolerant of the foolishness than my generation.

I am awed and inspired by her and the many people like her that I see and talk with as I have opportunities to visit hospitals, practices, neighborhood health centers, and social service programs in various communities. These people give meaning to President Obama’s message of audacious hope, but I fear they are swimming against a raging current that is an increasing threat and could sweep us all away.

Where do you stand? Who knows what you think? In areas like the debate about social justice and healthcare equity most of the leaders are self appointed and hone their skill by activities that give voice to their concerns.


The Leaves Are Brown and Down, But It’s Still a Good Time For a Walk in the Woods!

There are literally hundreds of different trails in my neck of the woods. You can go up a hill or mountain, follow a mountain brook, or skirt a bog looking for interesting flora and fauna. There is so much variety that I usually solve the problem by just repeating three or four old favorites on lightly traveled paved roads as my most common walks. The footing on pavement is more secure and the hills are not as steep.

One of my socially active buddies who has gotten me involved in community service activities eschews the roads for exploring trials. I love it that he calls and says, “Let’s take a hike.” He then describes the adventure and asks me if I have ever done it before. The answer is almost always, “No, unless you took me.” This buddy really likes to do his hiking in cold weather. He loves wearing “microspikes” or snowshoes. His call woke me up on Tuesday. It is almost impossible to decline the invitation unless I am out of town. I did get a reprieve that allowed me the time it takes to work out the kinks in my joints that occur overnight, but before noon we were walking up a steep incline through an area where there had been a light snow the day before. The bare trees and the granite boulders dropped by the glaciers that covered the area only 15,000 year ago have their own special beauty.

This land has a history. 200 hundred years ago it was clear cut as farm land. Farming gave way to small mills driven by the hydropower of the rocky streams that cascade down the hills. I am not sure what the huge stone wall next to the brook in the picture which is today’s header was once all about. I can’t ask the people who built that huge wall what was going on because now are they gone. I am amazed at their accomplishment. It is hard to imagine how they did it with the rudimentary tools that they had.

One can only imagine what life must have been like as you walk through woods divided by stone walls. You can only sigh with amazement with the surprise of discovering a huge wall while walking along a partially frozen stream. It is amazing to me that on a walk in the woods you can discover beautiful evidence that change and gravity are two certainties in an otherwise uncertain word.