March 18, 2022

Dear Interested Readers,

 

Trying To Make Some Sense Of A Continuing Senseless Tragedy

 

There was a brief moment in time almost sixty years ago when I considered changing my college major from chemistry/pre-med to English. I was completely mesmerized by a young English professor who could open up the deeper meaning of the poems and books we studied, and I imagined living a life like his. One of the poems we read that immediately impressed me and has stuck in the deeper recesses of my memory over the intervening years is W.H. Auden’s “September 1, 1939.” 

 

I especially like the first verse:

 

I sit in one of the dives

On Fifty-second Street

Uncertain and afraid

As the clever hopes expire

Of a low dishonest decade:

Waves of anger and fear

Circulate over the bright

And darkened lands of the earth,

Obsessing our private lives;

The unmentionable odour of death

Offends the September night…

 

I wasn’t sitting in a dive on Fifty-second Street when Russia invaded Ukraine. I was just sitting by a frozen lake in semi-rural New Hampshire, but I think my anger matched Auden’s and I shared his sense of preceding universal dishonesty that extended back at least a decade, if not longer. Putin didn’t decide sometime in February that he was going to disrupt the world. He as much as told us last July what he was going to do and more of us should have listened to President Biden and taken Putin at his word because what he said was consistent with what he had been doing for more than a decade in Georgia, Crimea, Syria, and Chechnya. 

 

As I thought back about our collective experience with the international adventures over the course of more than a decade that have sprung from the pathological personality of Vladamir Putin and remembered all those who admired and tried to emulate his “genius,” I got even angrier. In hindsight, it should have been obvious to us as it was happening that just as there had been more than a decade of trouble with Fascism in Europe before the German tanks rolled into Poland on September 1, 1939, we had been living for at least a decade through the same song second verse with Putin. Mark Twain (Samuel Clemons) is credited by some with the line: History does not repeat itself but it often rhymes. 

 

Now, it is too late to prevent Putin’s malevolence from disrupting the world and killing thousands. Because of Putin’s distorted sense of history and some unrealistic desire to recreate a Russia that really never existed, the people of Ukraine are living through a nightmare, and most of us can’t do much more than contribute to emergency relief funds as we root for them and ask ourselves —“How did this happen?” We feel guilty as we watch in horror as missiles, bombs, and artillery shells rain down and destroy their cities and kill civilians, young and old. President Biden is right to claim that Putin’s airstrikes against homes, apartment buildings, hospitals, and venues like a theater where people desperately sought shelter makes him a war criminal. Through it all, the Ukrainians show us their bravery and demonstrate a love of freedom that gives evidence to basic values that we seem to have forgotten. 

 

We were graced with a new hero this week. The big surprise was that our new hero is a young Russian woman, Marina Ovsyannikova. I hope that you have seen the video of her moment of bravery in defiance of Putin’s abolition of free speech. Click on the link if somehow you missed it or want to see it again. Is the dropped jaw look on the news anchor’s face emblematic of the startled awareness of the average Russian watching the newscast? Is that a bleeding heart on the anchor’s white shirt? 

 

 

Just in case you missed it or have forgotten let me remind you that Putin recently had his legislature make any reference to the war or suggestion of disagreement with the invasion to be punishable with fifteen years in prison. It inspires me that despite the knowledge that her action would put her into a Russian prison until she was a much older woman, Ms. Ovsyannikova was willing to chance to suffer that extreme penalty in order to tell a large Russian TV audience that Putin is a liar who is killing innocent people. She is a mother of two small children, and one of her parents is Ukrainian. If you want to know more about her, click here.

 

There are many heroes in Ukraine. Some are captured on video while others struggle out of view from the cameras, and some die in obscurity. This week I became aware of another hero/leader, the mayor of Kyiv, Vitali Klitschko. He was less dramatic than his president, but very convincing when he was asked what was going to happen when the Russians finally get to Kyiv. He said, 

 

“Russians killed our children, destroyed our buildings, destroyed our city, we’re ready to fight … and defend our city.”

 

The president is a short former comedian. The mayor of the largest city and capital of Ukraine is a six-foot-seven-inch former boxer. He was the heavyweight champion of the world and knocked out some pretty ferocious people before he became a politician and then a source of strength and inspiration for his city and country. 

 

I keep asking myself why over the last few years I can’t stop writing about politics and now the war that Putin has brought to Ukraine. My answer to myself is that healthcare has been on hold since the first week in November 2016. There are many things that must be resolved before we can turn our full attention back to strategies that might transform healthcare in order for it to do a better job of improving health. It has been tough to conceptualize a positive transformation of healthcare toward the objectives of the Triple Aim since Donald Trump was elected. To me, it feels like healthcare improvement has been under siege for over five years. Perhaps, my justification for calling these weekly letters “Strategy Healthcare” has been that the only available strategy has been to keep alive the hope that someday we might do better, much better, in healthcare as we have weathered one insult after another.

 

Since 2016 healthcare quality has fallen like a stone. If equity has improved it is that we all share the same rapidly increasing costs, terrible access with long delays waiting for care, and often then equally experience the curtness of providers who don’t have the support they need for the work they must do. That facetious statement is wrong because I know that during the deterioration of our system of care the inequalities that we have said exist have become worse. If things have gotten worse for my family, they have become much worse for those who are poor or are members of a minority. Our healthcare leaders seem incapable of initiating improvements that aren’t mandated and are more interested in bottom lines than missions. Our politicians would rather point out each other’s inadequacies than work together to accomplish some universal benefit. On a positive note, our science is still strong, but the distribution of its benefits is inept and impaired by politically induced distrust. On an even more negative note, I fear we have run out of our ability to endure masks and social distancing just in time to accelerate the spread of the more infectious Omicron BA.2 variant. 

 

We all wonder how the war will end. It is great that many knowledgeable authorities believe that Russia may eventually capture some of the cities, perhaps even Kyiv, but that they are unlikely ever to control the country, or come close to bringing Ukraine back into Russia in the way that Putin unrealistically dreamed. The downside to that prediction is a long, protracted, and destructive process. More than $100 billion dollars of damage has already been done by Putin’s targeting of infrastructure, municipal buildings, airports, housing, hospitals, and commercial properties. In their effort to block the advance of Russian tanks and armored vehicles, the Ukrainians have destroyed many of their key bridges. The reconstruction costs would be astronomical if the fighting ended today. Who knows what the losses will be by the time some sort of cessation of action occurs. The economic losses of Europe and the rest of the free war will also be huge even if the war ended today. The loss of property and infrastructure is insignificant compared to human losses. And, for what? A crazy man’s desire that someday there will be a statue in Red Square proclaiming his greatness?

 

When the “wall” fell in 1989, we felt that freedom, democracy, and capitalism had defeated communism and the autocrats. Francis Fukuyama, a well-respected academic political scientist, and economist was so excited by the possibilities that he wrote a book entitled The End of History and the Last Man (1992). Fukuyama was an optimist and imagined that in the wake of communism liberal democracies and free-market capitalism would spread to cover the world. Fukuyama suggested that the West and its lifestyle, political structures, and values would represent the final manifestation of our collective social evolution and government. It should not surprise you that Fukuyama attracted a lot of critics.

 

I liked Fukuyama’s vision of the future. In a way, Don Berwick with his vision of the power of the pursuit of quality and safety to transform healthcare and end inequality shared some of Fukuyama’s naivete. I wish that Fukuyama’s prediction had been true, but today the list of countries without a real democracy and dominated by autocrats is growing. Turkey, Hungary, The Philippines, Brazil, Egypt, Venezuela, India, China, and Russia( an incomplete list) all fly in the face of Fukuyama’s prediction, and Trump’s behavior would suggest that he would have loved for us to join the growing list of countries where democracy is nonexistent or a sham. While we were hoping Fukuyama and Berwick were right things have been falling apart.

 

I mention Fukuyama and describe his misconception about history because I want you to know that despite the fact that his hope about the future of democracy has not panned out, I want to present his predictions about how the conflict in Ukraine will end because I think that some part, if not all of what he thinks will happen, is likely to be true. With that preparation here are the predictions about Ukraine that Fukuyama published this week in the online journal, American Purpose. Fukuyama writes:

 

I’ll stick my neck out and make several prognostications:

• Russia is heading for an outright defeat in Ukraine. Russian planning was incompetent, based on a flawed assumption that Ukrainians were favorable to Russia and that their military would collapse immediately following an invasion…Putin at this point has committed the bulk of his entire military to this operation—there are no vast reserves of forces he can call up to add to the battle. Russian troops are stuck outside various Ukrainian cities where they face huge supply problems and constant Ukrainian attacks.

• The collapse of their position could be sudden and catastrophic, rather than happening slowly through a war of attrition. The army in the field will reach a point where it can neither be supplied nor withdrawn, and morale will vaporize…

• There is no diplomatic solution to the war possible prior to this happening. There is no conceivable compromise that would be acceptable to both Russia and Ukraine given the losses they have taken at this point.

• The United Nations Security Council has proven once again to be useless. The only helpful thing was the General Assembly vote, which helps to identify the world’s bad or prevaricating actors.

• The Biden administration’s decisions not to declare a no-fly zone or help transfer Polish MiGs were both good ones; they’ve kept their heads during a very emotional time. It is much better to have the Ukrainians defeat the Russians on their own, depriving Moscow of the excuse that NATO attacked them, as well as avoiding all the obvious escalatory possibilities. The Polish MiGs in particular would not add much to Ukrainian capabilities. Much more important is a continuing supply of Javelins, Stingers, TB2s, medical supplies, comms equipment, and intel sharing. I assume that Ukrainian forces are already being vectored by NATO intelligence operating from outside Ukraine.

• The cost that Ukraine is paying is enormous, of course. But the greatest damage is being done by rockets and artillery, which neither MiGs nor a no-fly zone can do much about. The only thing that will stop the slaughter is defeat of the Russian army on the ground.

• Putin will not survive the defeat of his army. He gets support because he is perceived to be a strongman; what does he have to offer once he demonstrates incompetence and is stripped of his coercive power?

• The invasion has already done huge damage to populists all over the world, who prior to the attack uniformly expressed sympathy for Putin. That includes Matteo Salvini, Jair Bolsonaro, Éric Zemmour, Marine Le Pen, Viktor Orbán, and of course Donald Trump. The politics of the war has exposed their openly authoritarian leanings.

• The war to this point has been a good lesson for China. Like Russia, China has built up seemingly high-tech military forces in the past decade, but they have no combat experience. The miserable performance of the Russian air force would likely be replicated by the People’s Liberation Army Air Force, which similarly has no experience managing complex air operations. We may hope that the Chinese leadership will not delude itself as to its own capabilities the way the Russians did when contemplating a future move against Taiwan.

• Hopefully Taiwan itself will wake up as to the need to prepare to fight as the Ukrainians have done, and restore conscription. Let’s not be prematurely defeatist.

• Turkish drones will become bestsellers.

• A Russian defeat will make possible a “new birth of freedom,” and get us out of our funk about the declining state of global democracy. The spirit of 1989 will live on, thanks to a bunch of brave Ukrainians.

 

I hope that Fukuyama is right, but he has not included the possibility that Putin will widen the war as an alternative to defeat. Just as Fukuyama did not see the rise of autocrats coming to challenge the dominance of  democracy, he has not considered that a crazy man might resort to chemical or nuclear weapons. I hope Fukuyama is right and Putin just accepts the loss. Is there anything else to say? 

 

There is more to say if we try to learn from some of the mistakes that made the mess in Ukraine possible. Ukraine is at war because we did not defang Putin before he became a problem for himself and others. In a similar way, we have been frozen in our progress to improve our healthcare system, and the future of the health of our nation collectively and as individuals are at risk because we have a flawed democracy and because we don’t effectively regulate our brand capitalism to mitigate its tendency to evolve toward monopolies and to generate inequality. That combination of realities makes the transition toward a system of care that is patient-centric, safe, efficient, effective, timely, and above all equal or at least adequate for every American very difficult to create and even harder to maintain. 

 

For more than a dozen years I have been trying to articulate strategies that might foster the Triple Aim. In retrospect since Donald Trump was elected in November 2016, the exercise has changed from trying to describe what could be to just hoping that some of the small gains that had been made between 1990 and 2016 might survive. In retrospect, I think that I believed that healthcare could reform itself and evolve toward something better. In a way, that was as delusional as Fukuyama’s view that we had reached the final manifestation of society and that we were in a promised land where history was no longer relevant. We were both wrong. It seems clear to me now that our improvements in healthcare are closely linked to the further evolution of liberal democracy, and that the gains we have made and the health of the nation may be more vulnerable than ever to illiberal thoughts and policies. Let me give you some evidence via Dana Milbank of The Washington Post of the craziness to which we are currently still vulnerable. Milbank’s most recent column has the interesting title “How does Ron DeSantis sleep at night?”

 

The point of the column is that living in a state that is controlled by a Republican governor with a Republican legislature puts you at higher risk of getting COVID and dying from it. Wannabe Trump replacements like Ron DeSantis oversee particularly dangerous states. Milbank writes:

 

Using data from the Centers for Disease Control and Prevention, consultant Doug Haddix reported Sunday that since July 1 (when the lifesaving vaccine was widely available), the 14 states with the highest death rates were all run by Republican governors. This included Florida (at about 153 deaths per 100,000 residents), Ohio (142 deaths per 100,000), Arizona (138) and Georgia (134). Contrast that with the deep-blue District of Columbia (only 27 deaths per 100,000) and California (58 per 100,000).

 

This disturbing data was verified from the Johns Hopkins database. 

 

For verification, I checked with health-care analyst Charles Gaba, whose data on covid-19 and voting patterns has been widely cited. He ran the numbers for me using data mostly from Johns Hopkins and found similar results. The 16 states with the highest coronavirus death rates since July 1 were all run by Republicans. The worst was West Virginia (about 204 deaths per 100,000), followed closely by Oklahoma, Tennessee, Wyoming and the aforementioned Florida.

 

The flip of that fact is that the states with the lowest death rates had Democratic governors, although states with progressive Republican governors and Democratic legislatures like Maryland, Vermont, and Massachusetts did well. Milbank drives the stake in the heart of DeSantis and other Trump wannabes by comparing the death rates in their states to those states led by governors who promoted masks, social distancing, and vaccinations and asking how many people died because of their policy choices. We can continue to ask the same question in reference to our collective failure to institute a system of care on the foundations of quality that we have been talking about for the last twenty years, those were the same twenty years that we watched Putin as he prepared to move toward destroying Ukraine.

 

All is not lost. There is still time to dedicate our efforts to ensuring freedom for everyone and better health for everyone on the planet. The two objectives are inseparably linked. The future of Ukraine, the future of the planet, and the future of healthcare are uncertain. It will take determination and decisions rooted in the common good for us to avoid undesirable destinations that might lie nearer to us than we want to admit just down the road to the future.

 

Anticipating Longer And Warmer Days

 

Today’s header was taken on last Sunday. I am predicting that we had our last significant snowstorm on Saturday. I hope that prediction is true. We did get an overnight half-inch on Tuesday, and there is a little snow in the forecast for next Wednesday, but the daytime temp all week has been knocking on fifty and that trend seems steady for the next week and a half. The predicted high for today is 63! The official start of Spring comes this weekend. Despite the snow that is predicted for mid-week next week, all the high temps for each day will be in the 40s or 50s. I’ll be looking for that first crocus soon! Even if winter returns, I am enjoying that extra hour of daylight now that we have pushed our clocks forward an hour! 

 

I am always impressed by how clear and bright the sky is on the day after most storms. In the first few hours, there is still snow on the limbs of the trees. If you look closely you can see there is still snow on the limbs of the conifers in the foreground. There is a “peaceful easy feeling” after the storm has passed. I hope it will not be long before the storm in Ukraine passes, and we can start enjoying the peaceful easy feeling that will follow.

 

Be well,

Gene