January 14, 2022
Dear Interested Readers:
Improving The Social Determinants of Health Near Home
While out for a walk this week I was delighted to be listening to a podcast from Ezra Klein who now is a fixture at the New York Times but had been away for several weeks on paternity leave. I have been a regular consumer of his podcasts and writing for several years. Klein is only thirty-seven but has already had a remarkable career in journalism. He began his career as a blogger and then moved on to writing and blogging at the American Prospect and The Washington Post, before becoming a co-founder of Vox. Along the way, he has published an insightful analysis of our political divide, Why We’re Polarized. In November 2020, he left Vox to become a regular columnist and podcaster for the New York Times. Now he works from his home in the Bay Area of his native California. His first podcast on his return from his paternity leave was a conversation with Chris Hayes of MSNBC.
If you clicked on Why We’re Polarized, you discovered that the link took you to a review of Klein’s book by Norman Ornstein of the American Enterprise Institute, which ironically, given Klein’s left-leaning politics, is a right-of-center think tank. Despite their probable political and philosophical differences, Ornstein delivers a very positive review of Klein’s book beginning with an apt description of Klein’s remarkable capacity for “explanatory journalism.” Ornstein’s description of Klein’s talent matches my own experience listening to and reading Klein:
What made Klein so prominent was his ability to absorb vast amounts of data and complex studies and provide a framework for understanding them in a clear-cut, readable fashion, accessible both to experts and to lay people. He makes clear that he is firmly on the progressive side of politics and policy, but does not tilt his analysis to fit his predispositions.
Ornstein succinctly describes the sum of Klein’s analysis which suggests that we may be doomed to a downward spiral because of our inability to escape our identities:
What Klein adds especially to our understanding of how we got here — why Trump is more a vessel for our division than the cause, and why his departure will not provide any magical cure — is represented in his overall thesis: There is a logic to our polarization. It has become a kind of loop. As the public has polarized, in part because of the behavior of political actors and institutions (including media), the actors and institutions respond by behaving in more polarized ways — which further polarizes the public, and so on and so on. Klein focuses on political identity, noting that the phrase “identity politics” has become a weapon used by one group to diminish the legitimacy of others, but that there is a better way to use the term: not as a blade, he says, but as a lens.
The last paragraph of the review is a description of where I find myself in January 2022:
In the end, he offers simply the hope that as Americans become more aware of the cancer of our current identity politics, they will make efforts to reduce their own involvement. I hope he is right. I fear that, notwithstanding his thoughtful, clear and persuasive analysis, we have a long and torturous path ahead.
It strikes me that the possibility of 2022 being a torturous path ahead is a positive statement. Any path that leads us “ahead” seems hopeful when considering the current political challenges and the flow of events that suggest that we may be on the brink of an even deeper and wider political divide if that is possible to imagine. As we move deeper into an election year, it is quite possible that events could totally negate the hope for the “brighter day” that seemed possible before the events of last January 6 demonstrated that we have lost our knack for the peaceful transfer of political power.
My hopes for progress in 2022 for legislation like the Build Back Better bill that could theoretically improve the social determinants of health for many Americans, especially children, seem more likely to be doomed as is the possibility that through some miracle the two voting rights bills before the Senate might pass. It is sad to imagine, but the barriers to voting that are emerging in so many states will constitute an even greater challenge to progress toward a more equitable America and improvements in the social determinants of health.
I was delighted as I listened to the speeches that President Biden and Vice President Harris made in Atlanta this week. It was totally appropriate that they frequently referenced Dr. Martin Luther King, Jr. and John Lewis since so much of what they worked so hard to accomplish over fifty years ago is vulnerable even as we prepare to celebrate Dr. King’s birthday.
The president used the dramatic moment to suggest that we end the filibuster, or at least modify it yet again so that we can pass the two voting rights bills that now seem destined to defeat. It is true and ironic that without some great movement in the minds of two Democrats, Kyrsten Sinema and Joe Manchin, both of the voting rights bills and the Build Back Better bill will likely die a death in the Senate. Build Back Better could be passed by the reconciliation process and its passage does not require an end to the filibuster, but passage would require the support of all fifty Democratic senators. Joe Manchin has said that he will not vote for the bill even in a very modified form. Manchin’s position is hard to understand since the bill would help many impoverished people in West Virginia which suggests that his opposition arises from issues that are more political and cultural than logical.
During Klein’s conversation with Hayes while they were talking about our tortuous learning curve and policy debacles associated with immunization, boosters, masks, the contradictory public health pronouncements during the pandemic, and the continuing controversies over what can be mandated, and what is a violation of individual rights, I heard a remarkable statement:
Health is not just what happens in the hospital. It’s what we breathe and eat.
It was such a simple statement, but it is oh so true. While I walked along thinking about the statement, I took a trip back in time to the period during my fourth year of medical school when I was making the rounds of potential sites for my internship. It was a good list: The Peter Bent Brigham, The MGH, the then existent Harvard medical service at the Boston City Hospital, U Penn, Strong Memorial, and UNC. Ultimately, I matched at The Brigham where I had a very good interview and where they knew me because I had my medicine rotation in my third year at The Brigham.
My interview at The Brigham went well because of an “error” I had made in an interview at another very prestigious institution. I had been asked a question about the management of diabetes. My response was not what the inquisitors were expecting to hear. In a rudimentary way, I was already plugged into a 1970 version of concern about the social determinants of health. In retrospect, my orientation was probably influenced by some of the discussions that I had had during my time working in the very innovative Family Health Program that was a project of Dr. Joel Alpert at Boston’s Children’s Hospital. The two years that I was a student in the Children’s program were my best experience in medical school.
My answer to the question from my inquisitors did not focus on the pathophysiology of insulin metabolism, the treatment of ketoacidosis, or the associated vascular responses to decades of diabetes, but rather I focused on the behavioral and social issues that complicated the lives of diabetics, and the chronic outpatient management of diabetes, especially the issues that challenged children with diabetes. As I talked on, I saw eyes rolling and yawns on the faces of my inquisitors. I made an attempt to get back in a grove that they cared about which tended to be more about the pathophysiology of diabetic ketoacidosis. By the end of the interview, I had pretty much marked that hospital off my list and ranked it near the bottom of my choices.
As I left the interview, I said, “Note to self. Stick to biochemistry, pathophysiology, and hospital management in future interviews.” I left the experience with the realization that most of the “deciders” weren’t interested in the social issues associated with practice and patient care that fascinated me. As I tested my theory over the rest of my interviews, I got more smiles than eye rolls.
I don’t remember much about my interview at The Brigham. I do remember that the venerable George Thorn, the Chief of Medicine, asked me something about thiamine metabolism. My memory is shakey maybe the question was about tyrosine metabolism and its importance in health since Dr. Thorn was one of the most important pioneers in endocrinology. I was loaded for both and a lot more. I can’t remember what I said, but my answer was definitely more “medical” than “social.” I left the room feeling like I was making a small compromise to play the game. I don’t regret having spent the next forty years coming and going from The Brigham.
Thinking about how resistant the Senate is to the passage of the bills that we so critically need has been difficult for me. I am trying to accept the reality that it is unlikely that the bills to protect voting rights and improve the lives of millions of Americans while improving the social determinants of health for so many Americans are unlikely to pass because of the resistance of two Democratic senators and fifty Republicans.
I am trying to deal with the realization that my only way as a simple citizen to make any positive contribution to the issues I care about is to act locally. Over the past five years, I have been active in two local non-profits, Kearsarge Regional Ecumenical Ministries (KREM) and Kearsarge Neighborhood Partners (KNP). These organizations work in different ways and together to provide material resources and emotional and developmental support for individuals and families in need in our area.
Within these organizations, my wife and I enjoy both the opportunity to guide policy and contribute financially, but what we enjoy most is the opportunity to have direct contact with the many people in our area who are in need and suffer significant economic challenges to their health and well-being. My wife manages a program that provides wood to many families that heat with wood. I am very involved directly with individuals who need financial counseling, money for car repairs, fuel, telephone bills, medications, and many of the essentials for life that most of us are privileged to never worry about but are big factors in the complexity of the social determinants of health.
I am particularly proud of the work that the two organizations have done together to provide good mechanically sound cars to people so that they can go to work, shop for themselves, and do the things that are so necessary but difficult to do in a rural area with no public transportation when you don’t own a car. Please listen to three of my friends discuss the program “Kars For Kearsarge” that is described in this YouTube link.
I am delighted to report that two of the first three recipients of cars were clients that I have been working with. Contributions to both organizations are tax-deductible, and both organizations have become critical assets in the struggle to improve the social determinants of health where I live. It feels like there will be moss on my tombstone before the political divisions and identities that threaten our democracy allow a nationwide effort to address many of the economic and social issues that challenge the health of millions of Americans.
If you are as frustrated as I am by the stalemates in our political system that are more likely to result in a worsening of the social determinants of health, I would urge you to seek out the opportunities to make a difference near where you live and work. Klein and Hayes were right:
Health is not just what happens in the hospital. It’s what we breathe and eat.
I would add that it is how we move about, how we heat our homes, how we clothe our children, and so much more that fall under the broad topic of the social determinants of health. It is clear to me that if I am disturbed by the suffering in people’s lives that I see around me, my direct action at home is much more likely to make a difference than waiting for the Senate to do its work. My hope is that in time we will realize that there is much more that should unite us than divide us, but that day seems too far away to just wait.
Baby It’s Cold Outside
These days I frequently find myself humming a well-worn song, “Baby It’s Cold Outside,” that was written back in the 1940s by Frank Loesser. You have surely heard the song as a slightly risque duet. Wikipedia documents about seventy renditions by big-name artists from Steve Lawrence and Eydie Gormé to Jimmy Fallon and Cecily Strong on “Saturday Night Live.” My favorite version of the duet is by Nora Jones and Willie Nelson although I must admit that Ray Charles and Betty Carter did a nice job with the duet back in 1961. My favorite lines are the first verse. It’s a back and forth conversation between the guy who wants her to stay the night and the very proper lady who is not so sure that staying the night is such a good idea. Give Willie and Nora a listen by clicking on their names.
I really can’t stay
Baby it’s cold outside
I gotta go away
Baby it’s cold outside
This evening has been
Been hoping that you’d dropped in
So very nice
I’ll hold your hands they’re just like ice
There’s more that I could say about “Baby It’s Cold Outside,” but you get the picture. With the exception of yesterday (Thursday), this has been an extremely cold week (a low of minus nine on Tuesday with a high of one degree), and the forecast is for more of the same this weekend with tomorrow’s low a chilly minus nine with a high of three degrees above zero. Next Monday is the only day next week for which there is any hope of the temp besting thirty-two. Baby, it is cold outside.
If the temp tops about eighteen degrees I try to walk outside with cleats and hiking poles to diminish the chance of a fall on the downslope of an icy hill. Several days this week I decided that it would be better to take a bike ride in Panama, Taiwan, or in the Canadian Rockies during the summer. I have many venues to choose from when I mount my Peloton (A gift from my oldest son.) My bike is in a large guest room on our second floor which has big windows overlooking our lake. During COVID visitors have been rare so it is also the location for the bike and a Pilates reformer. Tuesday while virtually pumping away to burn more calories in Panama, my alternative view out the window is presented in the header for today.
The arrival of the first ice house is always an event of interest to me. I figure that if the ice will support the heavy snowmobile or pickup truck necessary to get the structure out to the middle of the lake, it is safe for me to take a walk on the ice. So far there is only one little shanty on the ice, but I expect that there will be more soon. Ironically, the extreme cold that we are now experiencing after a delayed start for “real winter” may actually be a detriment to those who want to retreat to the lake for escape.
I love to fish, and I had a buddy who is now fishing in the afterlife from whom I inherited fine ice fishing gear including a pop-up shelter, but I have never had any enthusiasm for sitting by a little hole in the ice in very cold weather waiting for something to happen. My guess is the enthusiasts for the activity are looking for something other than a big fish. We all need a chance to find some escape in difficult times.
Be well,
Gene
