What’s Inside Plus It Just Goes On and OnThis week I finished one of the most remarkable, informative, challenging and thought provoking books I have ever read.
Behave:The Biology of Humans at Our Best and Worse by Stanford professor of biology and neurology, Robert Sapolsky is a remarkable accomplishment. Reading it was somewhat like going back to medical school because the author spends a lot of time bringing the reader up to date on the vast accomplishments of the last hundred plus years in genetics, molecular biology, and the neurosciences. This year it is exactly fifty years since my first medical school courses in neuroanatomy and neurophysiology, and trust me, much has been learned in the last fifty years. There was a lot of refreshing and catching up to do.
To look at the book as a scientific work or as a foundation to a better understanding of normal or abnormal neurological and psychological processes does not come close to doing it justice. You might have noticed that I have already used Sapolsky’s book twice to support my letters. Last week I wrote about reciprocal altruism. The week before last my subject was individualistic and collectivist facets of the healthcare debate. Both subjects were right out of the book. My sense is that if you left the pure anatomy, genetics, and chemistry out of the book you would still have a landmark work of philosophy that is a resource for survival of your soul in times of great conflict, change, and uncertainty.
If you clicked on the link above you would have seen a review from
The Guardian by Steven Poole. If you did not click, here is a paragraph that I do not want you to miss.
This book is a miraculous synthesis of scholarly domains, and at the same time laudably careful in its determination to point out at every step the limits of our knowledge. Sapolsky offers a vivid account of a standard view before lining up complications or objections to it from other research, particularly in brain science. (Testosterone, for example, does not cause aggression but amplifies pre-existing tendencies for or against it. The actions of such molecules in general “depend dramatically on context”). In a phrase that has unfortunately become associated with the dishonest attempts to smuggle creationism into American schools, he is adept at “teaching the controversy”, often providing anecdotes of scientists with battling views from decades ago. Throughout, he insists on how much individual variability there is hidden beneath the statistical averages of studies, and how the explanation of nearly every human phenomenon is going to be “multifactorial”: dependent on many causes. The literature on one scientific question, he notes comfortingly, is “majorly messy”.As the paragraph implies Sapolsky bends over backwards to present all views and is meticulous in considering all facts and respecting all views and opinions where the issues are unsettled. That alone is worth emulating in our world of “alternative facts” and “fake news.” In the last few chapters of the book Sapolsky takes us back to the thorny question of “free will.” I have previously related in these notes how I was shaken to the core of my being by my first encounter with “determinism” or a challenge to the concept of “free will” which occurred at the end of a very interesting lecture given to my class in the spring of 1968 by a young professor who looked like he could have been a rock star, and whom I believe is the now famous
Harvard Professor Jonathan Beckwith. At that time and to this day, I emotionally rejected
determinism and clung to the concepts of
free will that my culture had installed in me. I did formulate an argument that satisfied me, but I did not have the confidence in my reasoning to present it to others. That task still remains beyond my capacity. For me, free will is a necessity in a world that demands accountability, but its existence is still more a matter of faith than provable fact. Sapolsky deals nicely with this conundrum and advances an argument and mechanism that I can accept.
At the end of the day Sapolsky is a determinist, but I appreciated the gentle process by which he meets me part way with his case for a “mitigated free will” that considers our evolving culture and our personal ability to learn and change the vector of determinism. This working model or practical form of free will balanced by determinism can form a basis for collective and personal responsibility. That’s all I need. I need to feel that our actions are more than a complex sum of action potentials triggered by events in our external environment. That may sound like a whimpering and pathetic response from a sentimental old man, but I want to have a share in the responsibility for the mess we are in.
In times like these I also want to believe that I can demand compassion and reason from others in the search for the answers to the complex questions that face us individually and collectively. I greatly appreciate the sense from Sapolsky that I also got from Robert Wright, that whether or not there is a God calling us to be better we are slowly making progress toward a more ideal state where we accept the rationality that better relations with one another is a good strategy for a small planet. In a ten steps forward and nine steps backward sort of hobble, we are slowly moving forward. There is always something happening that can call forth our “better angels.” In a Trumpian Era that is a reassuring rationalization.
Let me indulge your patience for a quote from the last few paragraphs of the book. Sapolsky writes:
If you had to boil this book down to a single phrase, it would be, “It's complicated.” Nothing seems to cause anything; instead everything just modulates something else. Scientists keep saying, “We used to think X, but now we realize that…” Fixing one thing often messes up 10 more, as the law of unintended consequence reigns. On any big, important issue it seems like 51% of the scientific studies conclude one thing, and 49% conclude the opposite. And so on. Eventually it can seem hopeless that you can actually fix something, can make things better. But we have no choice but to try. And if you are reading this, you are probably ideally suited to do so. You've amply proven you have intellectual tenacity. You probably also have running water, a home, adequate calories, and low odds of festering with a bad parasitic disease. You probably don't have to worry about Ebola virus, warlords, or being invisible in your world. And you've been educated. In other words, you are one of the lucky humans. So try. Finally you don't have to choose between being scientific and being compassionate. On Tuesday, about the time I was finishing the book, the Senate was beginning its debate or whatever it is doing this week to try to “fix healthcare.”
John McCain had made his brave and dramatic arrival and had made his speech. He had cast his deciding vote to begin another exercise that could either by design, or as an unintended consequence, kill many while denying better care to who knows how many millions. I would have preferred him to show the courage of voting with Susan Collins and Lisa Murkowski against starting the debate.
Had McCain voted no, then all of his words about returning the Senate to its bipartisan glory days would have made sense as the initiation of a truly bipartisan process rather than the series of votes that followed his speech. As the Senate progresses through its long list of votes, each subsequent vote will require an even more focused effort by the defenders of the ACA to avoid an outcome that does not protect the underserved. McCain was simultaneously eloquent and infuriating and the weakness of his case was underlined by his own statement that he would not vote for an outcome that he did not like. I would have preferred that he use his dramatic moment and personal influence to start a process that had a greater likelihood of a positive bipartisan outcome.
A good bill will be hard to produce and will take more time and a broader base of participation than the process that McCain has enabled. No less authority than the president has deemed healthcare more complicated than anyone knew, but even that momentary expression of wisdom from the president does not provide us with direction because on any subject, and with any crowd, as he demonstrated once again this week with
his speech before the Boy Scouts, the president is all over the map with only one orienting point of reference, himself.
While I was delighted that in the late hours of Tuesday evening the Better Care and Reconciliation Act of 2017 was defeated, I was miffed to see that
McCain played it safe and voted for what he had said a few hours earlier he could not support. His office later reported that
his vote was “procedural.” John looks like one slippery guy! Susan Collins, Bob Corker, Tom Cotton, Lindsey Graham, Dean Heller, Mike Lee, Jerry Moran, Lisa Murkowski, and Rand Paul voted with the Democrats to defeat the heinous bill 43 to 57. Shelley Moore Capito seemed to have capitulated from her position stated last week that she did not come to Washington to hurt people. She was missing in action on both votes although she did return to the fold on the vote to “repeal without replacement.” It is sad to say that many of the Republicans lead by the vocal Ron Paul voted against the bill because it did not go far enough to regain the pre ACA neglect of the underserved.
It’s been a tight timeline this week. Tuesday the vote to start debate passed by one vote, thanks to John McCain and Mike Pence. Wednesday the Senate voted again on whether to repeal without replacement and as I mentioned above, this time John McCain and Shelley Moore Capito used their vote to define that they want to repeal the ACA, but only if there is a replacement that fits a formula that does not hurt those dependent on the ACA in their state. Listening to McCain’s speech I had the idea that he had a broader view of the picture and was genuinely concerned about what might be good for all Americans.
The next vote will be on the “
Skinny Repeal.” The suspense continues and it appears that several Senators are going back and forth between yes and no votes. Wednesday the score was 45-55 as several senators like Lamar Alexander and Rob Portman who had voted yes for the BCRA and then voted no for the bill that called for repeal effective in two years, but with no replacement known now.
You can see the full score card with all of the twists and switches. I am impressed with Collins and Murkowski. They have been consistent right down the line. Mitch McConnell is probably not surprised by all that has happened. His strategy is just to keep on hammering until something passes so that the Senate and House can use the House bill in conference to come up with
what a majority of Americans dread, and an exhausted group of fifty Republican senators might allow Mike Pence to pass.
That’s McConnell’s “Hail Mary” pass. He has enough of a chance to have that pass caught that I remain quite apprehensive and concerned. Maybe by the time you read this far we all will know what happened. Will it be over because the “skinny repeal” was rejected, or will we be even more worried because what could come out of conference? With the House it is anybody’s guess.
While I was pondering these things I decided to paraphrase Sapolsky:
If you had to boil healthcare reform and finance down to a single phrase, it would be, “It's complicated.” Nothing seems to cause anything; instead everything just modulates something else. Politicians keep saying, “We used to think X, but now we realize that…” Fixing one thing often messes up 10 more, as the law of unintended consequence reigns. On any big, important issue it seems like 51% of politicians conclude one thing, and 49% conclude the opposite. And so on. Eventually it can seem hopeless that you can actually fix something, can make things better. But we have no choice but to try. And if you are reading this, you are probably ideally suited to do so. You've amply proven you have intellectual tenacity. You’re probably a caring healthcare professional who also has a job and colleagues you love, patients that you worry about, a home, adequate calories, and low odds of ever losing your own healthcare coverage. You probably don't have to worry about getting thrown off Medicaid, the uncertainties of your job in a world of globalization, or being invisible in your world. And you've been educated. In other words, you are one of the lucky humans. So try.
Finally you don't have to choose between being politically active and being compassionate. Perhaps when all the voting ends and if all the pointless and contradictory amendments have been considered and rejected, our leaders will start all over trying to find a way toward
...Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time,…in settings that support caregiver wellness… and they will realize that until they come up with something that is really better, and not just a con of the American people, the wisest thing to do is to leave the ACA and Medicaid alone for the good that they do for millions of Americans.
“Us/Them-ing”: A Barrier to The Way Forward For Healthcare Recently, I was excited to hear that
Senator Al Franken was going to be the guest on Tom Ashbrook’s daily program on NPR, “On Point.”
Franken was there to talk about his new book,
Al Franken: Giant of the Senate. These days Franken still can’t keep himself from being a humorist, but he is also a serious and effective member of the Senate. Some folks are beginning to ask themselves if a reality TV show star is qualified to be president, why not a really intelligent writer and former cast member of “Saturday Night Live?”
Early in the program the conversation turned to healthcare. Franken started talking about a public option for counties that no longer had insurance companies that would offer them products on the exchanges. He made comments about the importance of Congress
guaranteeing to insurers that the CSR (cost sharing reductions) would continue. That is needed because forgetting the CSR and not enforcing the mandate are great ways for the president to effect his prediction that the
ACA is in a “death spiral.” Franken said good things about Senator Lamar Alexander and said that he was willing to work with Republicans in a bipartisan way to repair and strengthen the ACA. He was certain that if Republicans would work with them, he and many other Democrats were willing to go work to in a bipartisan way to repair the ACA.
He said that comedy was about “brutal honesty.” In that vein he said that he liked Ted Cruz, but that Cruz was an “outlier” and a “toxic coworker.” His contention was that among the other ninety nine Senators there were plenty of Republicans and Democrats who had warmer feelings for their colleagues across the aisle. He thinks that those relationships could be foundational for good bipartisan work. Franken offered a hopeful resistance to Ashbrook’s recurrent contention that things are a mess. You can hear the show for yourself if you click on the link above. After the opening comments they went to the phones.
The first caller was a woman named Darla from Florida who said she appreciated what she and others had gained from the ACA, but she was frustrated by her inability to contact her senator, Marco Rubio. She wanted to let Rubio know how important it was that he protect the gains that so many people had appreciated. She felt that there was no effective way to get her concerns through to Rubio. Franken tried to offer suggestions that she could try, and Ashbrook focused on how ineffective and patronizing his suggestions sounded for citizens who were estranged from the process.
Then came Nancy, a self described independent conservative from Kentucky. She introduced herself as a member of the middle class, and said she was getting the life sucked out of her by Obamacare. She bought healthcare on the exchange because she was forced to do so, but did not use it. She launched into a diatribe against Congress and those not trying to work with the president. She characterized Medicare recipients as freeloaders “sitting at home on the dole” who did not deserve what the ACA gave them. Franken went into an explanatory mode trying to give each of Nancy’s many concerns a respectful answer, but he did not accept her generalization of Medicaid recipients as people who were unfairly pulling her down and costing her money. He pointed out that many of the recipients were disabled, many were the working poor, others were children, or the frail elderly in nursing homes. He talked about his own visits to the poor rural communities of Minnesota where without the current Medicaid supports the healthcare system was likely to collapse.
Franken’s answer referenced
Atul Gawande’s recent article about the ACA in the New England Journal of Medicine [If you have not read the article, perhaps a better use of your time is to read it now and forget this letter.] It seemed to me that Franken’s reference to Gawande in his response to Nancy launched Ashbrook on an attack of Franken, even though Franken’s long response to her blamed Democrats in part for failing to educate voters like her. Ashbrook passionately dressed Franken down for ineffectively “lecturing” Nancy in a way that did not recognized her anger, and predicted that his lecture had little likelihood of changing her mind.
Under fire from Ashbrook’s generalized frustration with the ineptitude of Democrats, Franken maintained his humility, his civility, and his reliance on facts. Ashbrook contended that Franken’s answer was emblematic of why the Democrats had lost the House, the Senate and the presidency. Democrats, per Ashbrook, seem to be essentially “tone deaf” to the feeling of the typical Trump voter, the disaffected white, blue collar voters of middle America who have many fears.
There was an unusual tension that perhaps was manufactured by Ashbrook to get Franken to be more interesting by getting him out of his pre scripted automatic mode. If that was his intent, I think he succeeded. He also got me thinking. Ashbrook’s stance made me think about how much of the explanation of this moment in our history is an extension of “us/them-ing.” I was set up to have those thoughts because I had recently read Robert Sapolsky’s chapter on “Us Versus Them” in his magnificent new book,
Behave: The Biology of Humans at Our Best and Worst.
Us versus them is our species at its best and its worst. Sapolsky presents the neurophysiology of categorizing others as a “them” or recognizing others as an “us” as a process that occurs in a few milliseconds. Nancy’s collective characterization of the homogeneity of Medicaid recipients is right out of the basic playbook of “us/them-ing” behavior. The technical term for seeing the “out group” of them as composed of people who have a “cookie cutter” similarity is called essentialism. I am just as guilty of the same “lumping” of the thems when I think about people, especially politicians, who do not see the benefits of the ACA.
"Us versus them" is at the core of our most negative politics, just as the unity of “us” has given us the ability to work together to defend our way of life and to work with allies as we did in World War II against threats from authoritarian foreign enemies who were willing to push us versus them to the level of genocide. As I listened to Nancy, I realized that what she imagined to be true about recipients of Medicaid was not thematically much different than Hillary Clinton’s comments about half of Trump’s supporters being in what she called a “
basket of deplorables,” nor is it much different from Donald Trump's favorite campaign exercise of “theming”
Mexican immigrants who were rapists and “bad hombres” who need to be fenced out. It is helpful to imagine the recent discussions of the 1% Occupy Movement or the Black Lives Matter conversation as examples of the tensions and misunderstandings enlightened by thinking about the significance of “us/them-ing.”
Sapolsky’s discussion of how easily we fall into groups, and the reality that we each are in many groups, is beyond the limits of this letter. But as shorthand for that discussion, I know that it is true that when I discover that someone lived in the South, I immediately feel closer to them. My wife grew up in a Catholic family and attended parochial schools. She instantly affiliates with someone she discovers has experienced the same childhood. I have been in distant places like South Africa and suddenly seen a guy wearing a Red Sox hat and realized in an instant that we were affiliated. Most of us are constantly dividing the world into two groups. In fact most of us are constantly aware of the groups we are in that are defined by our profession, gender, economic status, physical features, race, sexual orientation, and yes, even favorite teams. We are comfortable and usually supportive of those in our “us groups” and confused, or fearful, or disdainful, or dismissive of the “thems” who are not. It’s hard to trust someone who is not in our group, and we probably trust people that we should avoid just because they are part of one of our “us” groups. Almost all religions have their dualist or “us/them-ing” characteristics and even do internal subdivisions of us/ them. Think Catholic/Protestant or
Sunni/Shiite.
Hierarchy and economics further complicate “us/them-ing.” Within your “us” group you see virtue. Within the “thems” you often see evil and ignorance. Thems or out groups are the butts of our jokes. Just as the same “out groups” use humor as a way of tolerating their disadvantaged state in relationship to those in control. I eagerly await Stephen Colbert’s nightly lampooning of the president and his underlings, just as the president has no problem gathering a crowd of committed followers who still gleefully chant “lock her up.”
I have barely scratched the surface of “us/them-ing.” My goal has been to convince you that if we are to ever get beyond the growing sense of division in our society that disables us from solving our healthcare problems, we must think creatively about how to manage what divides us. Patty Gabow has correctly diagnosed our most potentially threatening national maladie as a “lack of social solidarity.” More and more we fail fail to see all who live in our country as an “us.” It is even more dramatically true that not thinking of all humankind as an “us” precludes solving problems as complex as climate change.
Historically a lot of “us/them-ing” leads to intergroup or even intragroup strife, loss, war and death. I have been struggling over the past month through Philip Jenkin’s book,
Jesus Wars: How Four Patriarchs, Three Queens, and Two Emperors Decided What Christians Would Believe For the Next 1,500 Years. It’s not about The Crusades, it’s about how it was as much politics and military power that determined Christian orthodoxy rather than the Sermon on the Mount or the other teachings and parables of Jesus. “Us/them-ing has determined much of our current world, and if we want a better world we will need to manage ourselves within the realities of our natural tendencies.
Sapolsky not only describes the problem, but he offers some solutions supported by experimental evidence. The answers are complex and a full discussion is again beyond the scope of this letter and gets into managing biases, and the things that create them, like priming and framing. A lot of our distress from “us/them-ing” comes from the “thinking fast” automatic responses of
Kahneman’s “thinking fast and thinking slow.” At a simpler level more of us need to be self monitoring and self questioning. We need to foster empathy for the “thems” as Arlie Russell Hochschild did to write her book
Strangers in Their Own Land: Anger and Mourning on the American Right. She instinctively realized that to make progress we must not do what Nancy, the caller to “On Point,” did. We can’t lump the “thems.” We must see them as individuals. We must also look for the ways in which the “us/them-ing” obscures our similarities, our shared humanity with its vulnerability to uncertainty, fear, and disease. We must listen to one another with less bias and preconceived concepts that characterize the “thems.” Sapolsky specifically advises:
Thus, in order to lessen the adverse effects of Us-Them-ing, a shopping list would include emphasizing individualism and shared attributes, perspective taking, more benign dichotomies, lessening hierarchical differences, and bringing people together on equal terms with shared goals. I think that is good advice. It will be hard to do that against a background of mutual distrust in an environment that is more tit for tat, as is our current political environment. It will take leadership with courage to occupy a space where initially you likely will be misunderstood or ignored. We need a small “guiding coalition” that can courageously start a bipartisan process. Is it too much to hope that Lisa Murkowski, Susan Collins, and one or two other Republican “thems” like a Rob Portman, a Shelley Moore Capito, a Lamar Alexander or even a John McCain might bravely start a process that Democrats like Al Franken might join. I heard Franken say that such a process is what he is hoping for. Me too.
The Garden and Other Joys of Summer One of my greatest pleasures in the summer is to just sit quietly on the deck looking out across the garden that is one of my wife’s greatest joys and where she gets much of her exercise while I watch all the changes that I can observe on and around the lake. Sometimes loons swim by. Sometimes I can see an eagle high above, just riding updrafts. Occasionally I see a blue heron along a distant shoreline. This summer has been a summer of butterflies as you can see in today’s header. A picture taken by my wife in one of her gardens near the lake. There have been more than I remember in years past. Recently I was surprised to see a bat at twilight. The last decade has been tough on bats. They have been more than decimated by “
white nose fungus.” I hope that it will not be long until I see more.
One of my greatest challenges is walking the fine line between putting just enough birdseed and suet out to keep a steady parade of woodpeckers, finches, chickadees, nuthatches and hummingbirds visiting our garden, with a few jays and other feathery friends coming by, but not enough seed and suet to attract a bear who might be passing through the neighborhood. Along with the birds I feed a lot of squirrels. Recently, to my utter surprise I was visited by a
white squirrel! It was in and out too fast for me to get a picture, but it has definitely moved into the neighborhood. I have seen the white flash several times now. Twice on walks I have seen my new friend as far as a mile away as I walk along the shore road. This white flash is usually with more than one normally pigmented squirrel, but looks quicker or maybe that’s just my imagination. You can be sure that if I ever do succeed in capturing my new friend in a picture, you will see it as the header for the next week. Until then the best I can do is to tell you that it looks just like the ones you can see if you click on the link. I have not been able to see its eyes. If it is an albino, the eyes will be red. If you read the link you will learn that there are other mutations that can also be the explanation and that there are places in the Eastern states and Canada where white squirrels are common. I am beginning to feel like Thoreau and want to say, “
I traveled much in New London.”
