| 11 May 2018 Dear Interested Readers, What Happened to Truth? Is There Anything But Chaos Without It?One of the greatest joys of my retirement has been getting to know the many interesting people who live in and around New London, New Hampshire. I have not met Steven Tyler of Arrowsmith, but my wife has run into him at the local grocery store. He delighted a group of young shoppers by posing for pictures at the deli counter. People frequently report Tyler sightings in the same way that they report seeing bears at their birdfeeders. Ken Burns isn’t quite so obvious since he does not wear a headband and tight pants, but if you are a PBS fan and know what he looks like you might also spot him at the grocery store or the hardware store. There are many people in the arts including children’s author Tomie dePaola and former poet laureate, Donald Hall. A very common way to start a conversation in our town is to say, “Tell me how you came to live in New London.” One of the most interesting people that I have met in town is John Taylor. John and I met working for the Democratic Party during the fall of 2016. As chance would have it we became a team within a large number of volunteers that would gather on weekends that fall to swoop through our neighborhoods knocking on doors and earnestly requesting that our neighbors show up on November 8 to vote for our candidates. The effort must have been pretty effective because Hillary carried our little town by about 500 votes. It was roughly 1700 to 1200. She carried New Hampshire by about 2500 votes. I like to think that John and I made a difference. The measurable benefit of our effort as part of the larger team was the election of Maggie Hassan as a Democratic senator over the Republican incumbent Kelly Ayotte. Hassan won with even a smaller margin, 0.1 % or less than 2000 votes. Getting to know John who is a retired architect and an active painter of impressionistic landscapes was my greatest reward for the invested effort. Since the election we have meet from time to time for lunch. Over soup and sandwiches we exchange ideas, notify each other of good books to read, and generally share ideas and enjoy the company of one another. It was John who introduced me to Thomas Shapiro’s Toxic Inequality: How America's Wealth Gap Destroys Mobility, Deepens the Racial Divide, and Threatens Our Future and Keith Payne’s The Broken Ladder: How Inequality Affects the Way We Think, Live, and Die. We were having lunch this last week, and as usual most of our conversation was about current events and politics. Somehow the conversation shifted slightly to the abstract and “truth” or Trump’s lack of truth. I can’t remember exactly what presidential pronouncement triggered the exchange. Perhaps we were discussing Rudy Giuliani and the president’s comment that Giuliani was a new member of his legal team and implied that it would take awhile to “coordinate stories.” There was a time when truth was not a slippery process that required a learning curve, but we are into a new reality now. It could have been that what was on my mind as we began to talk about truth was that the president had recently joined the 3,000 hit club along with Albert Pujols of the LA Angels. There have only been 32 other hitters to get to 3000 hits. It usually takes a minimum of 15 years, and more often longer for a player to get to 3000 hits (200 hits/year x 15 years). It only took the president 466 days to hit the 3000 plateau, lies not hits. That’s more than six a day. Recently, he appears to have upped his game and is averaging over nine! And those are only the ones recorded by the purveyors of fake news. Who knows what goes on behind closed doors? The president likes to be known for impressive feats that no one else can match. I am rooting for him to remain the all time leader on this one. I hope that no other president ever breaks this record. I am trying not to tell a lie. I guess I can’t be sure just what it was that got John and me talking about truth and a post truth world. I do remember having a thought that flashed across my mind as we talked that I do not think that I shared with John. What I thought about then and have continued to ponder since has been observed by others; the similarity of the idea of the “death of truth” to the existential concept of the “death of God”. I well remember my shock back in 1966 when I saw bold type on the cover of Time magazine that asked the question, “ Is God Dead?” It was the first time that Time had ever published an issue without a picture on its cover. There were just bold red letters on a black background. Perhaps the linkage between the death of truth and the death of God had been planted in my mind by the current editors of Time. Time had published an issue on truth last year and copied the format of their 1966 “Is God Dead?” issue. |
| | I was shocked back in 1966 when I read the article that followed the bombshell cover. I had just begun to think a little bit about existential concepts. As a premed student most of my classes were science related, but I had taken as many literature courses as I could squeeze into my schedule. It was hard to read the literature of the twentieth century and avoid “existential angst.” As a premed student I was being presented concepts that needed to be integrated with the teaching that had come to me with mother’s milk.
God’s death felt like a bridge too far and an abandonment of the effort to find common ground between theology and science. It was a real challenge for me. I was vaguely aware that the concept had been like a festering boil since Friedrich Nietzsche had said “Gott ist tot” in the 1880s. It was an idea that I rejected emotionally and then was spending a lot of time trying to find a rational defense for my gut reaction. I was well into Christian apologetics before I knew the term. I believed in science and was a fan of all that we had learned from science, but I was not ready to accept that science had done away with a need for God.
The editors of Time chose to published their bold type cover as a stark indicator of the gravity of the story that they published during the Easter season of 1966. It worked for them in 1966. I guess that's reason enough to explain their use of the same mechanism last year to bring attention to their issue that considered whether we were living in a post truth world, and that was part of the reason we had awakened on November 9, 2016 to discover that Donald Trump was the president elect. Well into the article that goes with the cover Michael Scherer writes of the strategic impact of the president’s fabrications:
"These big falsehoods are different," explains Bill Adair, who created PolitiFact, the fact-checking journalistic site that won a Pulitzer Prize. "They are like a neutron bomb. They just take over the discussion and obliterate a lot of other things that we should be discussing."
The “truth” issue of Time is now over a year in the past but things haven’t changed much. In the same edition Scherer published an interview with Trump where he gives him a chance to respond to many of the specifics that come up in the article. The president defends himself with a word salad that is sometimes hard to follow.
I guess that I am old school. I was horrified by the idea of a world with a dead God. I am equally traumatized by the idea that we are now trying to make progress while living with the challenge of being lead by someone who has his own special relationship with truth and has gained power because he is a world class prevaricator.
John and I moved on to other subjects pretty quickly. What else could we say? The thought of trying to conceptualize how order and progress occurs in a world where we don’t even play like truth matters is so disorienting that it is a conversation stopper. I have made my share of attempts at humor as a mechanism for dealing with President Trump’s systematic disregard of the norms of his office and the generally accepted mechanisms of civility, but we all know that humor requires some truth to “work.” As we see truth die, and I propose the corollary that “facts” are collateral damage, it must follow that humor will die also. Bullies and autocrats don’t like facts, truth, or humor. They prefer to determine what is real and what is funny. Bullies and despots expect us to accept their “alternative facts” and force a grin when they tell a joke or make fun of someone who is clearly a loser because they cling to the idea that “the truth will make you free” (John 8:32).
The “God is dead” concept was an natural extension of at least two realities. First, we were increasingly distressed by our explanation of how a merciful God could allow things like the Holocaust or World Wars that viciously took millions of lives. Second, we were impressed with our growing ability to explain the world with our scientific knowledge. It was not a big leap to say that if we understood the origin of our world and how things work why can’t we make it better ourselves? Why do we need God anymore? Even if I was willing to sign up for that idea, it’s been true so far that something always destabilizes utopia. Perhaps what Atul Gawande says about healthcare also applies to everything. He points out that the problem with creating better healthcare is not that we are ignorant. We are just inept.
Maybe if we could just be a little smarter we would no longer need God and we could just “retire” our latest concept of what/who/he/she is and move on to making the world a better and safer place to live that would allow us all to grant one another the opportunity to pursue life, liberty, and happiness. Even if God persists, more and more people are getting by without the concept. It is a scary thought to realize that it is probably easier to have a working society without a working concept of God than it is to imagine a better world without truth or facts.
Science requires facts and truth. If God is just an antiquated concept that helps keep the masses happy and in line and we are putting God out to pasture, can we also afford to discard truth? If truth is also a dying concept, perhaps truth and God are related. Theologians like Paul Tillich did describe God as “the ground of our being.” He rejected the personification of evil as a devil and the naming of a list of “don'ts” as sin. He defined sin as anything that separated us from each other and from God. No one seems concerned about discussing whether the Devil has died. Tillich’s concept makes the Devil an unnecessary character, but it seems to me that Tillich’s theology does suggest that falsehoods do separate us and are frequently the origin of injustice and therefore are the origin of much of human misery.
Even if we are able to make a good argument that we don’t need God to pursue life, liberty and happiness, only a fool would suggest that we can ever “Make America Great Again” by discarding truth. Without God we are left with existential angst. Without truth we have certain chaos or some veneer of order through manipulation, bribery, oppression and exclusion.
Bringing the discussion back to healthcare, truth is absolutely necessary if we are ever going to approach the ideal of the Triple Aim. How can we have better health for everyone without building from some database of a few shared facts that allow agreement on some mutual objectives. The president was famously amazed to discover that “healthcare is so complicated.” The most effective way to manage complicated problems is to begin by gathering reliable information that allows the creation of understanding that enables strategic thinking.
Truth and facts are necessary for trust and for productive discussion, compromise, and the search for solutions. Trust is one of the most fragile human characteristics. Trust dies with falsehoods, reversals of pledges, and the failure to accept clearly established facts. Without trust and the participation in process that trust enables the only way to avoid confusion and chaos is to use oppressive tools to demand compliance despite the lack of truth. I think that is what Daniel Patrick Moynihan had in mind when he said:
“You are entitled to your opinion. But you are not entitled to your own facts.”
To move forward with the construction of a program of universal healthcare we need to accept as truth or fact some of the things we have learned from experience over the last fifty years. We have a huge amount of “truth” that should be considered a community asset. If we can define a commonly accepted data set then we can use personal preferences and opinions to negotiate some common objectives. With accepted facts and shared objectives we can then debate various strategies to achieve those objectives. The Triple Aim is not a truth. It is a proposed objective. It was built on facts, but it also contains opinions. It does represent an objective that we can reach working together if we can share truth and regain norms of civility. Unless the president chooses to speak the truth we will never be able to make progress on the sustainability we need in healthcare and every other shared concern. He has gained most of what he has by disregarding truth and civility. Change is always possible, but it is more likely that we must contemplate a minimum of another 30 months without much truth. I hope that truth will then rise from the grave or emerge from hibernation.
Slip Slidin' Away
Paul Simon is one of our most insightful poets/singers/ and songwriters. His song “Slip Slidin' Away” has always felt like it had a special message for me. Near the end of the song he sings:
Slip slidin' away
You know the nearer your destination
The more you're slip slidin' away
God only knows, God makes his plan
The information's unavailable to the mortal man
We're working our jobs, collect our pay
Believe we're gliding down the highway
When in fact we're slip slidin' away
Slip slidin' away
Slip slidin' away
You know the nearer your destination
The more you're slip slidin' away
Over the last twenty five years we have made much progress in the journey toward true quality in the care we provide to patients. Over the last twelve years beginning with the 2006 passage of “Chapter 58,” or if you prefer “Romneycare,” in Massachusetts and continuing with the passage of the ACA in 2010 we have achieved a patchwork of some coverage for 90% of the population. Despite these victories the events of the last eighteen months leave me feeling that our gains may be “slip sliding away.” As Paul Simon says,
You know the nearer your destination
The more you're slip slidin' away
In their fabulous little book Buy-In: Saving Your Good Idea from Getting Shot Down, John Kotter and Lorne Whitehead suggest that a simple majority in favor of a change is a metastable situation that is likely to deteriorate. They advise shooting for much larger pluralities. They assume that majorities are not made up of people with similar profiles of commitment. Of those who vote yes there are some who are solidly sold and are committed to the idea. They are willing to sacrifice to make it work. When the going gets tough they will still be there.
There are others who are sort of for the idea as long as it goes as planned, but will begin to waver and question the idea and may even withdraw support as problems arise or conditions change. They are not the biggest concern for the leader of change or the proposer of a new order. The biggest concern is that percent of the “yes” votes in the majority that come from those who were skeptical or sensed some conflict between the proposed change and their own best interest. They went along for political reasons or for reasons of convenience and will be the first to bail.
I had a coach once that liked to say, “When the going gets tough, the tough get going!” Sometimes I would mutter to myself that everyone else beside “the tough” either went home or got lost going in some other direction. There is no question in my mind that among those who have supported the ACA and the remarkable accomplishments of the last twenty five years there are many advocates, but perhaps not a rock solid majority who are forever committed to the Triple Aim. I fear that there are many who are fair weather advocates. They think that it would be nice as long as what is required of them is not too demanding. Finally there are some who barely signed on to the idea. They went along with the concept, and did not vigorously oppose it, but there were other things that they deemed more important. Perhaps they figured it was another passing phase or empty platitude that was best ignored because it would eventually die of its own defects or from the resistance of others.
In eight years the ACA has taken some big blows and is still standing. Getting the exchanges up and running was a managerial challenge and gave naysayers a lot of ammunition. The concept of the exchanges was difficult for many clients to understand and the technical glitches in the software were enough alone to create a near death experience for the new law. Perhaps the biggest disappointment was the decision by the Supreme Court to allow states not to accept the medicaid expansion, but before the election many of the resistant states were coming around.
I will always admire the courage, patriotism, and humanity of John McCain, even though on many issues I have vigorously disagreed with him. Perhaps the greatest measure of his character, even greater than his vote of conscience that saved the ACA, was the famous encounter with a woman who wanted to pass on defamatory remarks about Barack Obama during the last month of the 2008 presidential campaign. He cut her off and in no uncertain terms told her that Obama was an honest man who loved his country and would make a good president. He did not agree with Obama’s position on many questions, but he would not attack him with lies. John McCain saved the ACA for another day, but the attack continued. The tax law cancelled the mandate. The attack on Medicaid continues and Medicare is vulnerable to crippling changes.
I know many people who believe that things will turn around with the election this fall. They are already anticipating regaining control of the House and are dreaming about a miracle in the Senate. Those are ambitious objectives from a party that doesn’t even appear as organized as a flock of geese. Simultaneously, the world is turbulent and hopefully the president will successfully negotiate a peaceful resolution of the nearly seventy year problems in Korea. The downside of that good act will be to strengthen his position on other issues and improve his favorability.
The Republican control of a majority of state legislatures that control redistricting is likely to continue the advantages of gerrymandered districts and repressive state voter laws made possible by the decision written by Justice Roberts in 2013 that undermined the Voting Rights Act of 1965. The Koch brothers and the Mercers are still in business and are greatly empowered by the Citizens United decision of the Supreme Court.
President Trump could be gone tomorrow and the House and Senate could become controlled by Democrats and the concept of universal coverage could be still challenged by an increasingly conservative court. Ruth Bader Ginsburg is in her mid eighties and has had colon cancer and pancreatic cancer. She hangs on for dear life for women, the poor, and for healthcare. Her mind is strong still, but there is a high likelihood that before the next presidential election she will be replaced by a very young and very conservative justice.
Perhaps the two greatest risks to what has been gained have nothing to do with elections. Those people who have healthcare are paying more and more for the care they get. They see the cost of providing care to the underserved as a burden that threatens their own economic security. The economy only looks strong because the market is high. Why is the market high? It is not because of new and expanding manufacturing. Much of the apparent market strength may be coming from companies buying back their own stock rather than investing in new products and paying workers more. Our capacity to expand the economy may be limited by the inability of companies to find the talent they need. The ability to play a video game on a smart phone is not the same as the ability it takes to manage the production of a new product. Our dream of better healthcare for all may be vulnerable to issues far beyond attacks on the ACA.
Beyond, but connected to a poor economy and the concerns of many for “what about me,” is the complexity of the creation and distribution of care to those in our society deemed as “other.” We have great diversity and amazing superficial civility in many of our largest cities. Our television shows and movies are trying to teach the potential benefits of a post racial society, but the road to the eradication of racial and economic inequality seems longer, steeper, and fraught with more danger than the road to the Triple Aim. All of these forces will impact the future of the ACA and the hopes that we have invested in that vision.
What can we do? As individuals we can speak out and vote. We can wisely focus on what can bring us together and tolerate much of what can so easily divide us. We can demand truth and members of Congress that respect and participate in a return to civility. At home and at work we can practice Gandhi's suggestion that we be the change we want to see. I fear that perhaps the biggest risk to the future of healthcare is healthcare’s concern for itself rather than those it was created to serve. Finally, we can expect further attacks and perhaps future losses that we will need to process and resolve to survive.
Some more “slipping” may be impossible to avoid, but “slidin' away” is something that we must be willing to work hard to prevent. The best way to defend against the reality of failure is to recognize it as a possibility. If there is nothing else that we learn from the practice of medicine or the election of 2016, it is that the unexpected can occur to the unaware.
Big Apple Adventures and the Rivalry Continues
Throughout my life I have done everything I could to avoid New York City. I have driven hundreds of miles out of the way just to avoid the George Washington Bridge. Despite doing everything possible to avoid the city even when I had children living there, some of my most memorable moments have been adventures in the city. I had a great time there in 1956 when my parents took me there to get a quick look at the city. In one day we went to the top of the Empire State Building, circled Manhattan on the Circle Line cruise, and finished the amazing day at Coney Island.
I finished my first marathon in Central Park in 1977 and then ran the New York Marathon four more times after that. I also bombed one year in the Bronx and rode the subway back to my midtown hotel. The temperature that day was in the eighties. It was too hot for me, but I still tried to do a qualifying time for Boston and lost.
Our youngest son has been in Brooklyn now for about five years. He did a Master’s Degree at NYU, married, and now has settled into a great job. It’s Donald Trump’s fault that I will be traveling to New York for at least another three years. My daughter in law has a commitment to refugees and migrants. She worked for several years for the UN in places like Iraq, Jordan and Tunisia. Since marrying my son she has worked stateside resettling immigrants through a non profit in Manhattan that is largely supported by grants from the State Department. Now that we are building walls and cleansing the population by deporting people who by some standard do not belong here, funds for her work have dried up. With the reductions in immigration there is not much work to be done. Her response is that now is the time to get a law degree with the idea of a career of continued service helping immigrants with all the legal issues that challenge them.
My son and daughter in law are aware of my apprehensions about the city that they love. Each time we visit they go out of their way to demonstrate once again that despite all the congestion and expense, it is an interesting place to visit and even a better place to live. They celebrate the diversity of their neighborhood, and smile as they spend many hours a week hanging from straps on the subway as they travel to and from work.
On this trip we decided to visit the old World’s Fair site in Flushing Meadows. There is still a lot to see and learn more than fifty years after it closed. Before being the New York pavilion for the fair the building in front of the giant globe was the home of the United Nations from 1946 until the early 50s. Who knew? Now it is a great museum with a “must see” exhibit of a scale model of all of New York in a room the size of a basketball court.
The highlight of the weekend for me was DUMBO. For most of my life Dumbo was a cute little elephant invented by Walt Disney. Now it stands for Down Under the Manhattan Bridge Overpass. Perhaps the acronym is a stretch, but it is an interesting area and a great place to walk before enjoying a meal at an excellent restaurant. The bridge in the picture that is this week’s header is the Brooklyn Bridge. The area features both bridges but I guess DUMBO is more creative than DUBBO.
Surviving New York can be a challenge. Just ask the Red Sox. The Red Sox showed up in the Bronx this week and promptly lost two exciting games, and came close to blowing a four run lead in the final game. It took a homerun in the eighth inning that barely cleared the fence to regain the lead and preserve the win. The result of the difficult trip is that they now share their division leading position in the standings with the hated Yankees.
I hope that your Mother’s Day weekend plans will bring you joy as you celebrate all that she did for you. If you live in New York and if you are lucky enough to still have your mother, I would suggest that you take her for a walk in DUMBO and then enjoy lunch or dinner with her. |
| Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
Dr. Gene Lindsey
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| | The Healthcare Musings Archive
Previous editions of the "Healthcare Musings" newsletter, by Dr. Gene Lindsey are now archived and available to you at:
www.getresponse.com/archive/strategy_healthcare
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