20 April 2018

Dear Interested Readers,


The Challenge to Stay Focused on Healthcare While Watching the Washington Circus

I have tried not to look or listen, but I can’t help myself from taking several daily immersions into the controversies in Washington. I cannot break the habit of beginning my day with a cup of coffee and the opinion pieces in the New York Times. Almost every weeknight I go to bed after listening to Stephen Colbert poke fun at the president at 11:30 PM. On Saturday I stay up to see how “Saturday Night Live” handles the latest presidential gaffs. My wife and I retire late on Sunday evenings chuckling after watching the predictable outrage about the president expressed by John Oliver on his Emmy winning show, “Last Week Tonight.” On Sunday after I return from church I watch as many of the Sunday morning news programs that I have recorded as time allows before I have to go for a walk to cool off.

During the week I am texted as frequently as I was onced paged with the issues related to my patients, but now the texting is done by the news services of the New York Times, The Washington Post, The Wall Street Journal, and NPR. These wonderful sources of “fake news” don’t want me to miss anything, and it is a rare day that I don’t continuously respond to the “dings” they initiate from my phone that announce the arrival of yet another report of an inane presidential tweet. These sources of news have my confidence and my attention. In between all of these news feeds I check out podcasts from Vox and look through my emails for what I can find out from the Kaiser News Service, Axios, The Brookings Institute, and The Commonwealth Fund. This is the price I pay every day for the failure of others that allowed the president’s election.

I was one of the 10 million viewers who watched George Stephanopoulos’ interview with James Comey that ABC broadcasted at ten o’clock last Sunday night. It should be no surprise to you that I accept Comey’s opinion that the president is “morally unfit for office” even though I share the opinion of many others that Comey made some serious errors of judgement in his handling of the investigation of Hillary Clinton’s misuse of classified information through use of a personal email server. Secretary Clinton is convinced that Comey’s errors cost her the presidency. I agree with Comey that the best way to resolve the question of what to do about President Trump is to settle the question on Election Day and not through an impeachment trial in the Senate.

I purchased Comey’s book on Tuesday, the first day it was available. I watched his predictable interview Tuesday evening with Stephen Colbert. Before seeing Comey on Colbert’s show I had already heard and read the transcript of the interview with Steve Inskeep of Morning Edition on NPR, and listened to Comey’s interview with Terry Gross on “Fresh Air.” I will read the book and it will take me a few more days of reading before I accept or reject the idea expressed by Julie Hirschfeld Davis and Jonathan Martin in Tuesday’s NYT that Comey’s book has diminished his stature and that he and the book will become insignificant as Robert Mueller’s investigation continues, and as the president’s supporters continue to undermine Comey’s reputation.

One of my favorite news commentators is John Dickerson. He is a second generation newsperson. His mother was the famous Nancy Dickerson. There must be some truth in genetics and some reality in the concept of inherited advantage. Dickerson was on Colbert’s show on Monday. There was a funny moment as they pondered Colbert’s advantage over Dickerson. Colbert can pick and choose what he wants to lampoon. He expressed “real sympathy” that Dickerson had to report everything, and reasoned that he must be exhausted by the deluge of reportable events. Colbert thought that it must require an enormous amount of energy to keep up with all the stuff that no one would ever be able to invent that keeps rolling out of Trump’s administration. They then speculated on the latest revelation of that day, that Sean Hannity was Michael Cohen’s “secret client.” What might that mean? They agreed that at a minimum most reputable journalists would reveal their connection to a person they are defending with “facts” on a program that theoretically tries to report the news.

The behavior that journalists are saying should have determined the way Hannity managed his relationship with Cohen is the way the world once was. They want to hold Hannity to a standard that is defined by basic norms that seem to be on the way out. We have moved on. We do not live in the world that existed before November 8, 2016. As Comey’s book and his personal struggle reveals, none of us are quite sure how to live in and react to the world in which we now find ourselves. The interviews suggest that Comey thinks those “old norms” should still apply. The president’s behavior suggests that he believes that “old norms” are inconvenient. He acts as if they have been destroyed or revealed to be the mindset of “suckers.” To appreciate the transition from the “old norms” to current operating principles one need only to think back to the Republican presidential primary process of 2015-2016 when Trump made 16 earnest candidates look like “chumps” as he invented and effectively used nicknames based on physical features and their points of view to demean them and successfully promote himself. I had disagreed to some degree with most of the political positions of those flabbergasted Republican presidential wannabes, some more than others; but I recognized them as people who saw themselves as moral beings and all of them were still playing by a set of norms and rules that they assumed should still be applied to the office that they were all seeking. Only Trump recognized that “old norms” like honesty and respect for the rights and feeling of others no longer applied.

Now it seems that we all share the experience of the 16 ill fated presidential candidates. Like them, all of us seem to be on a new learning curve in a world that is not only volatile, uncertain, complex and ambiguous, but is also made even more confusing because it no longer has the “old norms” to act as sidelines to control the field of play. It is a “whole new game” and that is why I can’t look away. That is also why I must remind myself every day to stay focused on the objective of trying in some small way to support ideas that might lead to the improvement of health or the preservation of “what is” in an era where many of the recent gains in social justice seem to be reversed on a regular basis. That is why I am constantly asking myself questions about the future of healthcare:

• How is the future of healthcare being compromised by the Trump administration? 
  

• How are the states responding to the changing posture in Washington that shifts more and more of the responsibility for managing the future of the access and quality of care from Washington to them? 
  

• What are big businesses doing to better position themselves to protect the care of their employees and block further increases in the medical bills that they cover?
  

• What can we do to improve our efforts to better manage the quest to improve the social determinants of health?
  

• What can we do to block efforts to reduce entitlements as we try to defend Medicaid and the other programs that are now under attack?
  

• What could/should healthcare providers be doing to make care better for everyone?
  

• Will innovation rescue us from the looming twin threats of unsustainable finance and workforce shortages?
  

• Is continued consolidation the answer?
  

• Will we really make the transition from volume to value?
  

There are surely other important questions that concern healthcare that may occur to you, but evade me, but all of our questions are at risk of being neglected in the cacophony of Washington’s struggle with Trumpism. What is equally important to the uncertain future of healthcare is the stalled attention to education, all forms of critical infrastructure, housing, the environment, and so many other concerns. Complex problems like immigration policy and the epidemics of death from misuse of opioids and guns are equally begging for resolution and there is more and more concern about the lack of effective attention given to these issues as well as our international posture on the environment, human rights and fair trade. Let’s not forget Iran and North Korea.

All these subjects bombard me as I try to decide where to place my emphasis each week. Sometimes I feel I should say something about everything, like John Dickerson must do. But, I have come down on the side of talking more about fewer things, like Colbert does. Recently I have not been able to get the issues of inequality out of my head. The subject of inequality is more complex than advocating for a “living wage” or guaranteed income for everyone. The term “inequality” sounds like an economic subject when it is really a complicated problem of public health. “Toxic Inequality” is a better way to name the problem and is a better description of the danger that inequality holds for all of us. The objective of the centerpiece of this letter is to increase your awareness of our changing view of how toxic inequality is an issue that threatens the health of every American and is not just a problem of managing “freeloaders” who are experiencing the justice of their bad karma and are poor because they are lazy.


Poverty, Race and Poor Healthcare: The Toxic Combination that Threatens Us All

Over the last year the consideration of the social determinants of health has become my greatest professional interest. This shift in my thinking has not been because I have lost interest in or am less committed to the noble ideals and objectives of the Triple Aim, but rather because I have come to believe that the Triple Aim can never be achieved, or even much lasting progress made toward those lofty objectives, without and until we realistically deal with the social determinants of health. Once that reality is accepted then the world looks different and the next question must be why is there so much variation in the social determinants of health in a country that has the economic resources that our country has. We all have heard that countries with wealth that is comparable to ours are much closer to the objectives of the Triple Aim than we are. One possibility that explains the success of other advanced economies is that they more effectively address the issues that have a direct negative effect on the social determinants of health.

I among others have accepted the idea, based on data we have understood for a decade and that has been emphasized by many authorities such as Steven Schroeder in his Shattuck lecture entitled “We Can Do Better---Improving the Health of the American People” published in the NEJM in 2007, that medical care is a minority contributor, albeit important, to overall health. It is disappointing to admit that though Schroder pointed out the problem more than a decade ago, we have not made much progress in fixing what a collective effort should allow us to fix. I have inserted bolding to emphasize Schroder’s points:

...people with lower socioeconomic status die earlier and have more disability than those with higher socioeconomic status, and this pattern holds true in a stepwise fashion from the lowest to the highest classes. In this context, class is a composite construct of income, total wealth, education, employment, and residential neighborhood. One reason for the class gradient in health is that people in lower classes are more likely to have unhealthy behaviors, in part because of inadequate local food choices and recreational opportunities. Yet even when behavior is held constant, people in lower classes are less healthy and die earlier than others. It is likely that the deleterious influence of class on health reflects both absolute and relative material deprivation at the lower end of the spectrum and psychosocial stress along the entire continuum. Unlike the factors of health care and behavior, class has been an “ignored determinant” of the nation's health. Disparities in health care are of concern to some policymakers and researchers, but because the United States uses race and ethnic group rather than class as the filter through which social differences are analyzed, studies often highlight disparities in the receipt of health care that are based on race and ethnic group rather than on class.

If going back a decade does not impress you of the fact that we in health care are ignoring both a moral responsibility as well as the opportunity to change to do a better job, let me refer you to a speech given in October 1967 by Robert Ebert, Dean of Harvard Medical School, about a month after I enrolled. [You really should click on the link and read the speech] Here are a series of quotes that make my point that we have been talking about these problems for a long time:

There is no lack of problems to preoccupy the physicians who wish satisfaction from personal involvement in the health field. In my opinion the social problems are of greater magnitude than those which are strictly medical. Not only is there a place for the physician in the approach to these problems but he must be involved if they are to be solved....

Closely linked to the evolution of the modern hospital is the problem of the distribution of medical care. There are two groups who have suffered from the changing pattern of medical practice: the rural population and the urban population occupying the central city. Both groups present special problems, and both require new approaches to solutions…

The city or county hospital or large urban voluntary hospital provides most of the care for the urban poor. Often the actual medical care is good, particularly for the acutely ill patient, but too often it is care without dignity.

...the health problems of the urban poor are intimately linked with their socio-economic problems, and they cannot be solved by imitating the care given in the suburbs.

Chronic illness is increasingly common and it cannot be handled effectively if it is thought of as an exclusively medical problem. The social, emotional and economic impacts of chronic disease must be understood and intelligently dealt with…

Dr Ebert ended his speech on a high note and with an expression of hope.

He [the medical student] must be made as aware of the social problems of medicine as he is of the biological problems.

I think that this will happen, and one reason for my optimism is the attitude of many medical students today. These students come to medical school dissatisfied with the manner in which society has handled the problems of the poor and of the Negro. They are concerned about social problems abroad as well as at home, and above all they wish to become actively involved in seeking solutions. I predict that they will provide the necessary prod to a conservative profession and to a conservative educational process.

I was among those medical students to whom he referred who came to medical school with a sense of social responsibility. Considering that we were his primary source of optimism, I feel guilty. He described the problem and issued a challenge and now looking back fifty years at the lack of real progress we have made I am left with the sense that we could have done better. But, it is not over for any of us. We still have the opportunity to translate the wisdom of fifty years ago and of a decade ago into progress toward the ideals of the Triple Aim.

One of the strategic advantages of conceptualizing shifting our central vision from the end objective to barriers between us and that objective is that “next steps” become more efficient. Whenever I am hiking up a mountain or walking up one of the steep hills in my neighborhood I frequently look up to see where I am going. It is always good to “keep your eye on the prize.” I have also learned that the best way to never achieve the mountain top is to stumble and fall on my next step or take the wrong path. So I always make sure I can take the next step without stumbling. I think in our pursuit of the Triple Aim we have stumbled many times on the next step and frequently taken the wrong or more circuitous path.

Another derivative benefit in a change in focus is that I have discovered a community of others who are drawn to the very proximate issues of the poor, racial minorities, the underserved, and the disadvantaged. They see the benefit of both short term and long term objectives. Just as my awareness of these issues was heightened by a speech given by my friend Patty Gabow, the retired CEO of Denver Health, others are contacting me as they come to understand that I share their concerns. One such articulate activist is Joe Knowles. Beyond being an “Interested Reader” Joe is the CEO of the Institute for Health Metrics, and a serial social entrepreneur. Joe and I met at his request several weeks ago to discuss a fabulous idea that he has been developing.

Going back to his days at the Harvard School of Public Health Joe has had a deep concern for impoverished families and children. He recognizes that poverty is the repugnant foundation upon which the negative aspects of the social determinants rest. He also realizes that poverty is a self perpetuating manifestation of economic inequity that is so poisonous to the future of individuals, communities, and the nation that it must be called “toxic inequality.” At the time Joe and I first met to discuss his idea about how to mitigate the toxic effects of inequality and poverty on children and families I was finishing Thomas Shapiro’s 2017 book, Toxic Inequality: How America’s Wealth Gap Destroys Mobility, Deepens The Racial Divide, and Threatens Our Future.

Shapiro’s book was one of many recent books that I have read and have mentioned in these notes that all come to the same public health conclusions that Dr. Ebert announced in 1967 and that Steven Schroder emphasized in 2007 and that remain largely unaddressed today despite many years of research and pilots: you can’t really improve the health of the nation until you fix the social determinants of health which result from “toxic inequality.” Shapiro emphasizes that as bad as “toxic inequality” is for all of our poor, it has been and remains most devastating for African Americans.

Perhaps one of the best books to read as an introduction to the matrix of issues that create and sustain toxic inequality is Matthew Desmond’s 2017 Pulitzer Prize winning beautiful example of narrative nonfiction, Evicted: Poverty and Profit in the American City. Just this week Desmond was interviewed by Terry Gross on “Fresh Air,” her NPR show. Desmond’s view of our housing policy and practices allows us to see how poor housing reinforces poverty and leads to poor health in ways that perhaps Ebert and Schroder could only sense but did not have a searchable database to prove. Few Americans understand that even though the Fair Housing Act was passed in 1968, many of the outcomes and practices of discriminatory markets to “protect” white neighborhoods and the lending practices of banks that unnecessarily block home ownership by African Americans such as “redlining” still exist or their impact still exists long after they were technically “against the law.” A New York Times editorial this week, “Blacks Still Face a Red Line on Housing,” outlines this shameful reality and supports the ideas of Desmond, Schapiro and so many other social scientists.

Joe Knowles knows that desired outcomes require an effective PDSA (Plan, Do, Study, Act) cycle that leads to scalable solutions. He presented me a fabulous 10,000 word white paper with 93 references documenting the life long toxic effects on children of growing up in poverty. Living in a daily bath of excessive catecholamines that are driven by the continuous stress of poverty on their families and neighborhoods, many children are literally doomed before birth. That fact has been emphasized again this week in an opinion piece in the NYT, “The Cost of Keeping Children Poor” by Mark Rank, a professor of sociology at Washington University.

Professor Rank brings big data analysis and economics to support many of the points Joe Knowles makes. The conclusion that we must draw from the facts is that in many many ways none of us are shielded from the damage that the poor suffer. Rank puts it in economic terms. There is a huge ROI in addressing poverty. It is easy to define the benefit in terms of public safety because no one doubts the idea that poverty breeds crime just as it breeds disease and disability. If empathy for the poor is not your thing, and it is easy for you to write off those that suffer from poverty as drug users, free loaders, and people who breed like feral cats to harvest the rewards of welfare, then you are just as delusional as Paul Ryan who is retiring to Southern Wisconsin, at least for a while, with his point of view, based more on his exposure to Ayn Rand in college than any exposure that he might have gotten to the Sermon on the Mount in his Catholic upbringing. Perhaps a focus on the damage and threat of toxic inequality to the middle and upper classes is a better strategy than trying to motivate improvements based on those who suffer most acutely at the point of insertion of poor public policy.

Rank’s article points to a need for significant political cooperation. If you list the president’s cabinet and look at each department as you ask yourself whether this individual’s actions in office mitigates or exacerbates the issues of poverty or toxic inequality, you can depress yourself. [There is such a revolving door on the cabinet that I can’t find an accurate updated roster, but click here and you can see where things were last year.] Now ask yourself what you expect from Betsy DeVos, Ben Carson, Steven Mnuchin, Wilbur Ross, Jeff Sessions, or Scott Pruitt all of whom can use their positions to improve or exacerbate the issues of toxic inequality, poverty, and the health of the nation. You might notice that I am holding off making a pronouncement about Alex Azar at HHS although his predecessor, Tom Price was a disaster and so far the damage he did continues to reap dividends. If there was ever a reason to consider a change in government, it would be to limit the damage, and to address the collective harm and generalized unfairness that we all will suffer from administrative actions directed by this president and his cabinet to undermine programs for social improvement, which they call “entitlements” with the same affect that we once reserved for “communism,” while directing tax breaks to the rich.

The poverty of anyone should be a concern for all of us, but not everyone realizes that the poverty experienced by our neighbor is a threat to all of us, but Joe Knowles does. I love the way his paper begins. It is right out of Lean thinking. It has a straightforward “reason for action” that calls us to focus our attention on what we can begin do today even as we are swimming against a very strong current coming from Washington.

Children living in poverty have lower scores on standardized tests of academic achievement, poorer grades in school, and lower educational attainment overall, a situation referred to as the “income-achievement gap” in the United States.

This gap, better understood in the context of the developing brain’s response to stress, has significant economic and societal costs if not addressed through active intervention, ideally beginning before birth. While there are existing programs to effect this valuable intervention, they suffer from a dated service model, heavy personnel expense associated with high-skill professional staffing, and constrained ability to scale for a variety of reasons. This paper reviews current thinking on the causality and amelioration of the income-achievement gap phenomenon and the effectiveness of current programs to address it. We propose a new, more cost-effective, and scalable approach to this intractable issue that harnesses existing technology to lower the skills and education threshold required of field personnel to deliver timely service in conjunction with a data-rich collection process to manage service and track outcomes.

The paper is a beautiful piece of work that leads to plausible action now that is not a jump to conclusion; but rather after considering the “current state,” and the “ideal or improved state,” and the barriers to improvement, it offers a model of care to test that contains an innovation that involves and strengthens communities. If you would like to know more let me know.

Barbara Bush

Barbara Bush’s passing this week really touched me. I think that the best short piece giving us a perspective on who she was and what she meant to our country that I have seen so far was written by Jon Meacham who authored a well know biography of her husband, our 41st president, George H.W. Bush. He called her a lady without apologies, “the first lady of the greatest generation.”

Perhaps it was her white hair or her pearls, but she always reminded me of my own mother. My mother held similar conservative political views with which I often disagreed. She always voted for Barbara’s sons. Barbara,like my mother, thought one of her most important activities was reading to her children. Both women were from a time when it was a high calling for a woman to support her husband. I got a little chuckle from Meacham’s report that her popularity eclipsed that of her husband so that during the 1992 campaign there was a campaign pin suggestion that one should “Vote for Barbara’s husband.” My father was strong willed and was often in conflict with his deacons over changes, usually the building of a building, that he thought the congregation should consider. I do not know if it is true, but the story is that at one time a frustrated opponent of my father announced that he would favor firing my Dad but “he would not want to offend Margaret Jane,” my mother.

No doubt Barbara Bush was a woman who could connect, who made a positive difference, and was always respectful of others in politics no matter their opinion, well maybe before Donald Trump attacked her son. I never knew her, as I have never known any first lady or president, but I honor her life and hope that we will always have the good sense to listen to and honor the wisdom of people like Barbara Bush even if we might see the way forward from a different perspective.


An Aquatic Marathon and The Winter That Tried Harder

Marathon Monday has been a big deal for me since 1976. It’s hard to believe that I lived in Boston for almost 9 years before I paid the marathon any attention. I sort of remember Amby Burfoot’s surprise win in 1968. I read about it in the newspapers just as I read about Bill Rodger’s first win and step from obscurity in 1975. I knew about both Kelly the older and Kelley the younger, but it was not until I accidentally stumbled on the 1976 marathon that I was hooked on marathon running.

I have told the story before, but I will tell it again. In 1976 I was no longer an intern, resident or fellow. I had been working at Harvard Community Health Plan for almost a year, and like all employees except for the few who were on call, I had Patriot’s Day as a holiday. I chose to use my day off to get some dental work done. My dentist’s office was in Cleveland Circle at about mile 22 of the Marathon where the runners turn sharply left onto Beacon Street. 1976 was one of the warmest Boston Marathons ever, averaging more than 96 degrees along the route. It is fondly called “the run for the hoses” because spectators sprayed the runners who would raise their arms as a signal to be sprayed with garden hoses.

As chance would have it my dental appointment began before noon when the traffic in Cleveland Circle was “normal.” When I came out sometime around 3PM I was met by a river of humanity coming at me down Chestnut Hill Avenue and turning onto Beacon Street. I was trapped and had to watch. Everyone looked determined. Everyone looked like me. I was inspired. I got up early the next morning, pulled on an old pair of tennis shoes, and tried to jog a mile. I have been at it ever since.

Every marathon is different. This year it was run in a monsoon with the temp in the thirties. Even on the TV you could see the runners leaning into a headwind and sheets of rain. They were often plodding through ankle deep puddles. It is hard enough to cover the distance on a “perfect day.” For me the rare perfect day was 50 degrees, overcast, with a gentle tailwind. That was what it was like two years later when I was part of the river of humanity making the turn onto Beacon Street in Cleveland Circle.

This year soon after I watched Desiree Linden become the first American woman to win since Lisa Rainsberger in 1985, I headed across town through wind, snow and sleet to get in five miles of a brisk walk on the indoor track at Colby Sawyer College. I will walk in cold weather, in snow and on ice, but when you put both together as a wet cold with a sleet that stings your skin, and a wind that can knock you down causing a fall that is likely to lead to a hip nailing, I think twice about where to get my exercise. My judgment is still good enough to send me to the gym to walk around in circles.

Today’s header reveals the latest cord of wood that I did not get stacked in the woodshed before the storm. It’s been a long winter that outlasted the wood I had stacked in the fall. The other half of the picture is my attempt to capture the beauty of persistent winter as draped over the First Baptist Church in downtown New London.The church sits on Main Street next to the college. I was struck by the beauty of the scene as I drove by on my way to the track at the college gym.

This winter has been a challenge on many levels. It’s like an old friend who came to dinner and was still hanging around long after you feel that it is time to go to bed. You know that sooner or later your friend will leave, but there just isn’t any way you can make it happen.

Since my theory of the seasons states that winter starts as soon as it wants to start and lasts as long as it wants while making many false starts at leaving, there is nothing to do but be patient and celebrate all of those hearty folks who braved the weather and completed the marathon. What they did inspires me once again to keep going. What about you?