19 January 2018

Dear Interested Readers,

This is no way to live. I am like one of Pavlov’s dogs. I am conditioned to check the news feeds first thing in the morning to see what has happened in Washington since I turned off Stephen Colbert long after midnight. I like reading history. I do not like living my life waiting for history to unfold before me. That said, things change so fast I am now afraid to write these letters until a few hours before they go out for fear that they will be talking about issues that have passed between the time I write and the time you get them. On more than one occasion during the unfolding ACA drama, I had to edit what was already set because things changed between my writing and your reading. I feel that I am in the same situation now as the drama over whether or not to fund the government continues to occupy the Internet, newsprint, TV’s talking heads, and talk radio.

As you might remember, this week’s drama was guaranteed in December when the Democrats agreed to a one month extension of 2017 levels of government spending in return for an extension of the CHIP program until March and a few other concessions. That agreement just kicked the can down the road until midnight on January 19. The choices now are between nothing, compromise that produces a budget for the remainder of the fiscal year, or another one month patch. The biggest issue of contention for Democrats is whether or how to connect the Deferred Action for Childhood Arrivals (DACA) program renewal to the spending bill. This is a huge issue when you consider that it involves over 700,000 Dreamers. That is many more people than live in Washington, DC, Vermont, or Wyoming. There are just a few more people in both of the Dakotas, Alaska, and Delaware. This problem touches many more people when you consider the families of the dreamers. The DACA conversations have been the reason for some memorable moments. As Vox reported on January 9:

Legislators convened in the White House to see if they could make any headway on a legislative fix for the now-sunsetting Deferred Action for Childhood Arrivals program — what many Democrats say is a prerequisite for averting a government shutdown on January 19. The meeting, by all accounts, was a doozy.

In the extended bipartisan meeting, which was televised and mostly open to the press, Trump appeared to agree to almost everything presented to him — even if it came from Democrats.
He said he would “like” to pass a “clean” DACA bill, that would restore protections for upwards of 700,000 undocumented immigrants against deportation, and would “take the heat” politically for comprehensive immigration reform. In the past, that’s meant policy with a path to citizenship — a stark break the views espoused by his immigration hardliner advisers and supporters. “We are going to do DACA, and then we then we can start immediately on the Phase 2 which would be comprehensive immigration — I would like that,” Trump said. “I think a lot of people would like to do DACA first.”

The dazed, confused, and transient optimism following the statements by the president did not last long. What he was promising was antithetical to the position of hardliners in Congress, so when Senators Dick Durbin and Lindsey Graham showed up less than 48 hours later to review their compromise bill on DACA and “the wall” in what they thought was a meeting just between them and the president, they were surprised to discover that others were waiting. The Washington Post described the scene.

The scene played out hurriedly in the morning. Graham and Durbin thought they would be meeting with Trump alone and were surprised to find immigration hard-liners such as Rep. Bob Goodlatte (R-Va.) and Sen. Tom Cotton (R-Ark.) at the meeting. White House and Capitol Hill aides say Stephen Miller, the president’s top immigration official, was concerned there could be a deal proposed that was too liberal and made sure conservative lawmakers were present.

What quickly followed was the now famous s-hole or s-house versus “strong language” controversy. It’s been downhill toward an apparently unresolvable dilemma since whatever was said in the heat of the debate in that meeting. The looming deadline heightens the tension. Associated issues like the wall, as well as attempts by some to make CHIP a real bargaining chip in the debate, have just made it all even more confusing. To add fuel to the fire and controversy over DACA, the administration has recently announced an end to TPS (Temporary Protected Status) for people from El Salvador and Haiti. Whatever the president really said there is no disagreement over his position that he wants no more Haitians. Again, the Post explains with a rough quote and analysis:

“Why are we having all these people from s---hole countries come here?” Trump said, according to these people, referring to countries mentioned by the lawmakers.

It seems that the president has an uncanny knack for finding, and using destructively, all the cleavage planes in our society:

Perhaps by the time you read this letter the whole discussion will be a closed chapter, and has become settled history, not speculation. What I am most sure about is that whatever happens to DACA and the “dreamers” who depend upon it, there will be continuing tensions over immigration, access to healthcare, race, and economic inequity, that will create other “showdowns.” The main subject of this week’s letter is one man’s attempt to see all of these inflammatory issues and their impact on health in a unified way. I think they may not be separate issues, but rather different manifestations of the same larger issue, and the continuing discussion of them in their various legislative silos perpetuates the confusion and delays, and prevents resolution. As we continue to wallow in the confusion, real people suffer. 

Sunday morning after church and participation in a vigorous discussion of neo orthodoxy and the social gospel with some references to Reinhold Niebuhr and Karl Barth, I sat down with my wife to listen to all the Sunday morning news programs that we had recorded. The week before, topic number one had been Michael Wolff’s, Fire and Fury: Inside the Trump White House. Listening for a few minutes to the reports on the s*house/hole vs. strong language debate, I became disillusioned and lost interest quickly. I asked my wife if perhaps for relief we might watch David Letterman’s Netflix conversation with Barack Obama. Whether you have plans to watch the show or not, you must read Ian Crouch’s New Yorker article about the show. Here is a quote from the article.

My guess is that the show will mean different things to different Americans. I am sure that there are those who would rather drink castor oil or have a root canal than to listen to our former president demonstrate what we have lost, and they never wanted or appreciated. For me it was a moment of nostalgia for a man and a moment in history when it felt like something amazing might happen. Those eight years set the bar of my expectation for anyone who might ever ask for my vote. Crouch thinks Obama should become a talk show host. I wondered if Letterman, as a former host, might be available to run for president if Oprah decides that she doesn’t want it. It is clear that over the last year the world has changed. Many of us desperately want to see the nation turn to a leader who is comfortable with ideas, and can express her/himself forcefully without demeaning others or making us want to cover our ears in disbelief. In the interim we are subsisting on a diet of Colbert, Kimmel, Oliver, Meyers, Bee, and Silverman. Or as Crouch says:

A lack of leadership puts us all at risk and complicates our conversations with one another, as an exchange that I had with an Interested Reader after last week’s letter demonstrates. The reader wrote me within an hour of the posting to say: 

I took the word “Disgraceful” personally (which says something about my insecurities) and thought that I needed to explain myself quickly. As usual, I got long winded:

She did respond, and all's well that ends well. I leave it to you to explain just why I thought her expresion “Disgraceful” was directed at me. I agree with the point she made that the hospital and perhaps some of its staff demonstrated disgraceful behavior. I will not reveal her identity, but will assert that as an experienced hospital based healthcare administrator, her opinion is based on years of experience and an understanding of what a hospital owes the patients who come seeking care. I am also educated to the fact that I have a responsibility to make sure that you understand what is behind my words. Her response was:

A small group of people in my community has been meeting recently to examine together how we may be more effective in our charitable activities for our community. Our definition of community is not confined to the limits of New London, but is defined more as a region that surrounds Mount Kearsarge. It extends westward toward the Vermont border. Northward we look toward Lebanon and Hanover where our major medical resource is the Dartmouth Hitchcock Medical Center with which our local critical access hospital and its outpatient affiliates are connected. To the east, away from Interstate 89, the population thins and the boundry is nebulous, but the level of poverty increases until you get to I 93 with its ski resorts and access to Lake Winnipausake. Southward we bump up against the economy of Concord. 

Within this area there are food pantries, non profit social service agencies, and ecumenical groups all intent on alleviating poverty and improving the health and welfare of the community. Each town has a welfare office, there are a few state and federally funded programs, and many of the local businesses try to accommodate the periodic inability of some customers to pay for services and utilities. There is tremendous economic variability in this small region. Homes vary from dilapidated trailers to multimillion dollar mansions on Lake Sunapee. The tax base of the towns vary greatly, but the school system is consolidated for efficiency and for some that supports a sense of a larger community. Despite the full range of economic and educational diversity that exists across the region, there is virtually no racial diversity. Almost everyone who can work, is working. Many of the poorest members of the community travel long distances in dilapidated cars and trucks between multiple minimum wage jobs, and off the record activities as they struggle as exhausted single parents or couples in many different kinds of relationship to care for multiple children. In the freezing temps of the winter, pipes burst, cars break down, and people fall on ice and break bones, as the misery index for the poor shoots through the ceiling.

What I have have learned so far is that good intentions do not assure success. Despite many years of focused effort by well meaning people, pockets of heartbreaking poverty, and human misery exist within a community with deep pockets of wealth. I can only assume that there is also a huge variation in the health of members of this community. Perhaps, compared to many other places some might say, “What’s your problem? Compared to our community you should be happy!” I look at our situation and reason that if we, with all of our resources and efforts, are having problems in an attempt to meaningfully improving the lives of people, we must be doing something wrong. Furthermore, if we, with relatively abundant assets and probably a smaller population ratio of disadvantaged people are having trouble, how in the world are communities without our resources and much larger disadvantaged populations doing it?

As I consider the experience in my community, and reflect on what I learned in the practice of medicine and my years in organizational leadership, I observe that we have a lot of uncoordinated efforts vying for attention and resources. I have come to believe that our inability to make progress in lifting people out of poverty and improve health is not a function of a lack of desire, a lack of knowledge, or a paucity of potential resources. I think other issues are at the root of our failure to make lasting change. To borrow from Atul Gawande, our failure may arise from “ineptitude,” or how we attempt to make a difference.

We are not very good at coordinated activities. We lack a proven methodology, and we have been reluctant to do the sort of critical thinking and process management that we know can yield results. We solve many little problems over and over again, but never establish the connections that could produce effective processes or lead to unified efforts for continuous improvement. It is frustrating to realize that for cultural, political, religious, economic, or some other reason, or combination of reasons, our efforts are very siloed, as is our analysis of the root cause problems we face. In the old debate over “lumping and splitting,” we have come down on the side of “splitting.” My father always advised me that it was impossible to make progress if I mounted my horse and rode off in all directions. 

I have been reading and thinking a lot about health equity over the last few years. The longer I look and think, the more I realize the connectedness of the effort to establish health equity to the need to promote all forms of equity. In the recent review of health outcomes versus money spent by other nations of similar wealth, we saw that the healthiest nations directed much of their investment to social issues that we ignore or under fund. I have come to believe that health equity is dependent upon improving racism, improving gender equity, and bringing minorities like the LGBT community into full and equal participation in society. We can’t have “food deserts,” poor housing, and people working for less than a living wage and ever imagine improving the health of the nation in an economically sustainable way. In that context Bryan Stevenson’s statement that the opposite of poverty is not wealth but justice, makes sense. The search for answers should also draw upon the wisdom of Paul Batalden who famously taught us that every system is “perfectly designed to get the results that it produces.”

The IHI is a great respecter of the principles and power of continuous improvement, and has spent decades trying to apply the wisdom of Batalden to the resolution of large problems in healthcare. I was delighted to recently discover that in December the IHI published a white paper, Achieving Health Equity: A Guide for Health Care Organizations, that could be useful to me and my colleagues in our little corner of the world, as well as for you, and healthcare organizations across the country. I fear that many hospitals, large multispecialty practices, and health systems look inward to their own institutional issues more than outward into the communities they serve. We sometimes forget that we are as dependent on our communities as they are on us. 

In his introduction to the white paper, Derek Feeley, the CEO of IHI writes:

I hope that you will download the paper, and add it to your resources as you consider how you can be an advocate for health equity and address all forms of inequity. The concepts in the paper support the idea that racism, poverty, the social determinants of health, housing, employment, education, and the sense of fear that we have from the presence of crime, as well as the heart breaking realities of addiction, are all connected.

I wish it were true that we could make the world a better place with random acts of kindness, and occasional contributions to our favorite charities, but I do not believe it. These good things are beneficial to people in the moment, but insufficient to make a lasting dent in the long term issues that face us. Inequality is a corrosive force. I believe that beyond recognizing it as a source of pain for others, it is really the greatest risk to our collective happiness and the future of the world most of us would choose.

I am not a “Jeremiah,” but I do believe that walls, quotas, prisons, and an attitude of being “tough on crime” has never been, nor will ever be, successful in producing the security and opportunity for joy that we all want. We have the tools. We have the experience. We have had the leadership and may have it again someday. In the interim, and for the long haul, I believe the most effective road forward is to recognize that the Triple Aim, and much that we hold dear depends on expanding opportunity for everyone and pledging to one another a more effective effort to address the unified issues of inequity and injustice that limit our ability to improve the performance of our system of care. 

This time of the year I do most of my walking on the roads around my home. I have a half dozen or so directions that I follow on a whim, depending on my mood, my energy, and the weather. Some have hills. Some run by the lake. Some encounter cows and horses. The only impediments are ice patches which I anticipate by attaching little metal studs to my sneakers. When it’s really treacherous, I walk with a hiking pole that has a spike on it.

Every few weeks, this time of year my friend, Steve Allenby, calls and challenges me to something that is a little more exertional. Steve likes getting into the woods. Even better for Steve is hiking up a hill in the woods through snow and ice. When I am scrambling to keep up with him, I frequently remind him that he is almost ten years younger than I am. The last ten years have not been all that kind to my carcass.

On Monday night Steve emailed me with another challenge. He always promises that the hike will be “almost all on flat land.” The conversation is a little like the debate between Charlie Brown and Lucy. Charlie doesn’t trust Lucy but then goes along only to end up on his back, once again. Steve’s concept of flat and my concept are separated by several degrees of tilt, but I have developed a sense of how to translate the difference in perception into a reasonable scale that allows me to consider the proposition. Mostly, I just go along while hoping that I will not end up testing the emergency medical system in our community. The final question is usually, “Do I need microspikes or snowshoes.” The answer he almost always gives is, “I think microspikes will be all that we need.” Once we get into the climb on “virtually flat land” and I’m trudging through a foot of snow it dawns on me that Steve must not like the hassle of snow shoes. Walking in more than six inches of snow is like walking in deep sand. I have decided that on future adventures I will just carry my snowshoes in a pack on my back for “just in case use.”

The waterfall on Mountain Brook was our destination. Mountain Brook cascades down the hills above Andover, New Hampshire and passes through Elbow Pond before eventually joining the Blackwater River, a tributary of the Contoocook River which is a tributary of the Merrimack. The hike follows the brook as it rushes down the hill over rocks and drops. With the recent warm weather and rain the “brook” looked more like a rushing torrent with chunks of ice along the banks and in eddys of slower water, here and there. I kept saying to myself, “There’s got to be fish in there!”

Tuesday was a little overcast and a veteran observer could have sensed the new snow that was coming on Wednesday. Despite a temp in the high teens, it was not long until I had shed my coat and was hiking in a vest only, and I was still sweating. Mountain Brook has many tributaries and crossing each one presented the challenge of finding stepping stones or trusting the ice. One of the first things that goes once you clear seventy is your mobility on slippery rocks. One false step and you are up to your knees in freezing water, or worse yet, flat on your back in rushing water.

Our destination is pictured in the header for this letter. Frozen waterfalls aren’t that spectacular. The wall of white just under “Healthcare and Musings” is the falls. It is a frozen drop of twenty to twenty five feet. My guess is that in the summer it’s a different destination. Steve says that you can swim in the pool under the falls. I plan to return with my fly rod. I just have to believe there will be brook trout rising in the pool under those falls this summer. 

 
I hate wasting Sunday afternoons watching football. Mercifully the Patriots/Jaguar game is not on until 3 on Sunday afternoon. That gives you plenty of time for a walk before the game. I will be walking in South Florida while on a visit to watch my granddaughter play basketball and volleyball. The weatherman is predicting that this Sunday in New England will be a relatively warm day for the game. I hope that you will be out and about on a pregame walk wherever you are.