3 November 2017

Dear Interested Readers,


Can Grassroots Bipartisan Conversations Foster Healing and a Healthier Country?

I have been trying to remember a song, probably an old country classic, that has the line “...there are thoughts that I ain’t thunk…” I thought it was a Kris Kristofferson line, and maybe it is. Let me know, if you know. My search came up empty, but it was fun. In the process I listened to some good songs that I had not heard for a while. Listening to Kristofferson’s “To Beat the Devil” I found other lines that say even more to me in these days when words are often not heard, especially if they come from the voice of someone with whom we disagree.

And you still can hear me singin' to the people who don't listen,
To the things that I am sayin', prayin' someone's gonna hear.
And I guess I'll die explaining how the things that they complain about,
Are things they could be changin', hopin' someone's gonna care.


It seems that everybody preaches to their own choir and no one wants to hear the music from someone else’s church. Living in a “purple state” I often meet interesting people with whom I share some possible connection that both of us choose not to explore because a little superficial exchange quickly reveals that we see the world through the lenses of different political affiliations. Our assumptions about who we are then flow quickly from the stereotypes that are attached to those ideas. In the exchange of a few polite words we can both come to the unstated conclusion that discussing more than sports and the weather is probably ill advised, and we both politely move along, never knowing what we might have learned if we had the courage or the skill of knowing how to talk to one another about the things that we see differently.

Sometimes words are not necessary to decide that there is no use to pursue a more complex conversation. We make many decisions on the basis of visual clues. My wife bought a new car a year or so ago, and I inherited the old energy efficient 2008 Toyota Highlander with 150,000 miles on the odometer that she had been driving. It is a good car to have for trips to the dump or to take to parking lots in Boston where strange things can happen to a car. At our local dump I occasionally sense that someone is judging me because of the bumper stickers that festoon the tailgate of the car. My wife is one of those people who uses bumper stickers to advertise her point of view. A quick look at the tailgate of the old Toyota makes it immediately clear just what our political preferences are. There are Obama/Biden stickers, stickers that endorse Obamacare, Elizabeth Warren stickers, and one that just proclaims, “Not a Republican,” as if anyone who looked at the collection might still wonder what our political affiliation is. There is even more information about our political history that can be gleaned from a closer analysis of the display. One sticker says “Ready for Hillary,” then there is “Bernie in 2016”, and a slightly newer sticker that says “Bernie has my heart, but Hillary has my vote.” The most recent addition to the collection simply says “Resist.”

We label ourselves in both obvious and sometimes subtle ways. John Gallagher, my good friend and Lean guru, once informed me (long before the 2016 election) that conservatives do not drive Subarus! I was skeptical, so he challenged me to send him a photo taken with my iPhone of a Subaru with a conservative bumper sticker, if I ever saw one. It was no problem finding Subarus that were festooned somewhat like my Toyota. Finally after about two years, last August, John helped me out with the quest. He texted me a picture with the title “Black Swan event” showing a Subaru Outback in a parking lot in Virginia sporting a “Cuccinelli for Governor” bumper sticker. Ken Cuccinelli, a very conservative Attorney General for Virginia, lost the 2014 election for Governor to the Democrat, Terry McAuliffe. Despite John’s refutation of his own theory that conservatives do not drive Subarus, I figure that I can always smile and wave to Subaru drivers with a secure sense of probable affiliation. Whenever my wife and I attend a social event at someone’s home in our new “home town,” I am sure to check the density of Subarus in the driveway and along the side of the road. There are usually several Subarus, some with old Hillary or Bernie stickers on their bumpers, and I enter the event eager to meet those kindred spirits.

You probably have read, and maybe remember, my admonition to ask whenever you are concerned about a problem to drop back into a reflective posture of self examination and ask, “What part of the problem am I?” Applying that line of reasoning recently to the lack of civil discourse and the widening gulf that exists in our society between those that label themselves as conservative and those that like to consider themselves progressive, I find that I am playing as big a role as anyone I know in the perpetuation of the problem. I need to follow the advice of Ghandi and be part of the change I want to see in the world.

I have been in a self examining mode since writing the centerpiece of last week’s very long letter (Please accept my apologies. I will try not to go that long again.) entitled “Dr. Gabow’s Question: Can the American Healthcare System Deliver Health For Every American?” All the facts were a recitation of things we knew. What made Dr. Gabow’s presentation unique was the rhetorical nature of it. Behind it all was the question, “Is this the way we want it to be?” If not, what are we doing that needs to change, and what are we not doing that we should begin to do?” She presented a slide with a long list of things to do if we want to use our healthcare system to deliver better health. I tried to put her ideas into a few paragraphs and misplaced her emphasis, but in the revised form of the letter in this week’s “Strategy Healthcare” posting she gave me a little help and her suggestions are summarized as:

Dr. Gabow finished her presentation talking about short term and long term efforts that begin at home. She asked the rhetorical question, “Can the healthcare system be the entity that broadens our national focus from its current narrow biomedical focus to the broader determinants of health.” She thinks that it will require changes outside the healthcare system, but the healthcare system can continue improvement efforts on access, cost, and quality. Those efforts are necessary but insufficient. We must do more to reduce waste to free up resources. We need to make the public aware of the social determinants of health and the healthcare disparities that exist and advocate for addressing the problems. We must address income inequality by ensuring that all work produces a “living wage.” We must be sure that all of our healthcare programs and institutions are adequately funded.

The end of Dr. Gabow’s presentation has stuck with me. Given our current realities she is describing a sum of actions which taken together on the up side add up to a long shot. There is some possibility that given the current climate of divisiveness in our country that what might occur won’t be positive, and health in America may decline. The status of the social determinants of health may deteriorate as spending on non value providing care rises, and access for many deteriorates. That mindset was reinforced when I listened to a podcast that my son in California gave me. During our recent visit I had been talking with him about how much I had enjoyed reading Yuval Noah Harari’s 2015 book, Sapiens: A Brief History of Humankind. I have mentioned this book in a recent post. He immediately suggested that I listen to a podcast where Ezra Klein talked with Harari about his books. Following his advice I listened to the podcast as I was out for a walk earlier this week, and about forty five minutes into the conversation Harari said:

What we are talking about in the twenty first century is the possibility that for the first time that most human beings will lose their economic and political value. They will become a kind of massive useless class. Useless, not from the viewpoint of their mother or their children, but useless from the viewpoint of the economic, military and political system. And once this happens the system also loses the incentive to invest in human beings. In the twentieth century governments all over the world, even in dictatorial regimes, invested heavily in the health, education, and welfare of masses of people because the government and the elites needed them.

Yuval Harari, author of “Sapiens” on the Vox podcast “The Ezra Klein Show” February 28, 2017

What followed was Harari’s review of the history of the last one hundred years as a majority of Americans moved from working on the farm, to working in factories, to working in the warehouses of Amazon and as cashiers at Walmart and at my local grocery store. At each step along the way the efficiencies of mechanization and the emergence of globalization made fewer and fewer people necessary. It’s sort of like the game of musical chairs.

What is next? There is a hint of the future at the grocery store where now I am learning how to check myself out at the self service counter. What will the cashier do next when I finally get proficient? The new checkout process at my grocery store is a small demonstration of how in our world of automation and emerging Augmented Intelligence fewer people are needed for everything from food production, to product creation, to distribution, to defense of the country. The jobs that are theoretically available for that cashier in our town will be limited, and to get a job with opportunity she/he must be willing to go back to school and then face substantial competition from new grads and other former retail workers. Some of them won’t be “needed” and will fall onto public assistance, or find a less desirable job for less money. It is possible that this has already happened before and that she became a cashier when she lost a job in manufacturing. Perhaps she does not live in our affluent town with its many retired executives and professionals. Perhaps she lives in one of the nearby impoverished post manufacturing towns of the Upper Valley where there are empty storefronts. A year ago there were ubiquitous signs suggesting that it was time to “Make America Great Again.”

Another event occurred this week that got me thinking. It requires a short story. My wife and I went out to dinner and to hear some live music with good friends and neighbors whom we have known since the day we bought our home in New London nine years ago. We don’t see eye to eye on everything with them politically, but we are neighbors and we have come to understand each other and laugh about our different takes on the big issues. The husband (an interested reader) is a gregarious man who loves to kid around and enjoys trying to pull off practical jokes. He has an inquiring mind and is always eager to engage in discussions of politics and business. He gets a big kick out of saying something outrageous that he hopes will pull a sensitive cord. The funniest part of some of his efforts at humor is the way they can backfire.

There was one tense moment a little over five years ago when he thought it would be funny to add a “Romney for President” banner to the rolling political commentary on the back of my wife’s car. The next day when nothing had been noticed he texted a picture of his deed to my wife who did not see the humor. Things were tense for a while as various forms of retaliation were considered and then rejected because of the more important realities of our friendship. In the aftermath of the “joke” meaningful dialog about the “real” issues has been easier and our friendship stronger.

The other couple whom we we did not know were friends of our neighbors. They were very nice and interesting people who are planning early retirement in their mid fifties. He has a responsible position with a large national insurance company where he has worked for a long time. In the small talk we got into a discussion of healthcare, and brushed up against some superficial review of the current efforts on tax reform in Congress. I was treading lightly, attempting to preserve civility, not wanting the evening to fall off the high road and into the ditch of uncomfortable and impossible to resolve tensions. The most precarious moment was when he revealed that in retirement his employer would maintain his access to his doctor who was a concierge physician. It seemed like such a great way to get care that he had a hard time understanding why that was not the solution to America’s healthcare concerns. I finished the conversation without a review of all the economic and practical reasons why his idea would not work by simply saying that I was happy that he was so happy with his care, but I doubted that we had enough doctors to extend that sort of access to every man, woman and child in America. I realized that if someone is secure and happy with their health and healthcare a simple recitation of facts like Dr. Gabow has given us is never going to change their mind. Trying to explain the vulnerabilities and inequities of our healthcare system over a good but high volume cover of “My Girl” is not a viable tactic that supports the larger strategy.

I grew up in the divided, separate, and unequal culture of the Jim Crow South. The two camps had limited interactions over which my team exercised harsh control with strict laws against the racially mixed use of schools, hospitals, buses, trains, and hotels. At my doctor’s office, caucasians entered a front door and sat on comfortable chairs in a well appointed waiting room. African American patients entered a door in the rear and sat on used church pews. Today there is no doubt in my mind that one of the emotions behind the reactionary efforts of white supremacists that find some safety under the banner of Make America Great are a misdirected effort to get relief from the larger issues that were hinted at in the Yuval Harari quote. If fewer good jobs are available, being a member of the preferred "native population" is an advantage. The world that we are moving into will be a challenge for everyone, and if opportunities will not exist for everyone, then minorities and immigrants represent a threat in the subconscious minds of a large number of our neighbors. I say subconscious because I think that most of us can explain our preferences with rationalizations that shield us from darker motivations that might be embarrassing.

“Jim Crow” realities have been theoretically gone since the mid sixties. First there was Brown v. Board of Education of Topeka in 1954, and then the passage of the Civil Rights Act of 1964 and the Voters Rights Act of 1965. But, as the controversies over Civil War statues demonstrates, the symbols of the era are still with us. Any sociologist can give you evidence that the Jim Crow laws of the South may be gone, but the basic problem persists as Jim Crow de facto realities that were always with us in both the North and the South. Underneath the data that Dr. Gabow presents there is reason to argue that persistent racial inequality in all areas of our society explains much of what makes care wasteful, overly expensive, and poorly distributed.

I realized while listening to the music across the dinner table from my new friend that if we needed to avoid the issues of healthcare and tax policy there was no way that we could ever get to the larger subject of why we all need to talk about the ideas that did make America a brave experiment, and how so far those ideas have never applied to everyone. Harari has insightfully pointed out that there are more and more people in the world whom some treat as a “not their problem or concern” at best, and sometimes as just another form of discardable surplus. We will never be able to effectively respond to Dr. Gabow’s challenges until people like “us” can listen to people like “them.” Perhaps if we listen and ask questions of those with whom we disagree, rather than preach at them and bombard them with contempt, there will begin to be some progress toward a healthier nation. The alternative is one side eventually subduing the other. History underlines the fact that totalitarian states work for a while for some, but eventually fail for all.

If we want things to get better, the first step in our development of an ability to listen to each other is to look inside ourselves and assess our own motivations with questions. More than 2400 years ago Socrates gave us advice that cost him his life when he said at his trial for corrupting the youth of Athens that the unexamined life is not worth living. Socrates also taught us that one of the best ways to help other people gain new insights is by asking questions that send them on a journey of discovery.

My songwriting son put a new song on the Internet this week, as he has every Monday for almost seven years, that talks about looking inside ourselves and asking questions. His essay and song contributed to the ideas I have tried to express in this letter to you. In his introduction he writes:

This song is about living with our memories, and the daily work of distracting ourselves from our darkest corners. Maybe it is a necessary impulse to push certain things aside, to try to be a lighter self, to play a more cheerful melody. We don’t usually want to frame our pain and put it on the wall for everyone to see. But we also have a lot to learn from the encounter with our tougher memories. I think the tension between avoidance and acceptance of the past is uniquely human. It requires the capacity to understand the linearity of experience, but also the vulnerability to which memory subjects us. The past is in the past, but we also carry it with us everywhere we go. “Us Humans” is a song that exists at the nexus of that tension.

To hear the song click on the title below or to get the point poetically by just reading the words.

Us Humans

The morning tries to break
The fabric of the night

The mist is strange today
It pulls the light apart

I can’t adjust
The finer edges of my sight


Like most,
I shun the darkest motions of my heart

Are you one of us?
Have you bowed your head into your hands
And raged the passing of your plans?

Were you here before?
Did you crack the ice and peer beneath
The blue and murky colors of the deep?

Another person struck the pavement
WIth his hand

Another person bled
And marveled at the pain

Some other person cried
The night the war began

And someone else called out
To give the war a name

Are you one of us?
Have you bowed your head into your hands
And raged the passing of your plans?

Were you here before?
Did you crack the ice and peer beneath
The blue and murky colors of the deep?

Did you whisper in your sleep?
Are you one of us?

The picture in today’s header is also a gift from my son and a reminder to all of us to enjoy what’s left of the fall foliage. Get out this weekend and get about. A walk in the woods is a great time to think about how you might make a difference participating in the conversation in your community that can bridge the divide that surely exists and threatens the health of us all.