April 25, 2025
Dear Interested Readers,
One Hundred Days of Damage to the Nation and the Future of Its Health
In his column yesterday, Thomas Friedman quoted David Brooks. Brooks has said that Donald Trump is the wrong answer to the right question. Trump is leading us back to a country fueled by coal and gas with an isolationist trade and foreign policy that failed over ninety years ago. He advocates a return to a culture that disdains diversity and seeks to trade personal freedoms for the “protections” of a strongman who claims to have all the answers, but can only deliver chaos. The question that we need to answer is how to lift up those who live in poverty or fear that the harder they try, the farther behind they get. Many of those who voted for Trump are “sick and tired of being sick and tired.” He convinced them that he had all the answers to our problems when in fact he is a problem for which there is no immediate answer. He was right that we have many things that need improvement. He was wrong to think that, given enough power, he could do the job.
For the past seventeen years, I have used these Friday letters to present the need for improvement in our care delivery. I have quoted Dr. Robert Ebert, the Dean of Harvard Medical School, when I attended in the late sixties. Dr. Ebert said that our system of care needed changes in finance and operations, not more money and facilities, if we were to improve the health of the nation. Dr. Ebert then launched a practice to test his ideas. I spent an entire professional career in that practice where we were working to find the solution to his premise that our delivery of care failed to serve many, was too expensive, and was mostly centered in the wrong environment–the hospital. To use Brooks’ concept, the question of how to improve our system of healthcare has been unanswered for my entire professional career, and decades before and more than another decade since I retired. How to fix healthcare is an important question. Donald Trump is not the answer.
Trump’s answers to our problems include giving important responsibilities to a host of marginally qualified administrators who share unquestioned loyalty, right or wrong, to the man with all the answers. The job of leading the search for the solutions to our healthcare problems has been entrusted to a fanatic with the mindset of a charlatan practitioner who seems to disdain the scientific method. He is on a crusade to replace science with biases and access to care with strategies to fund tax cuts for people who have too much already. There will be long-term losses from research that won’t be done. Medical education will be undermined as academic freedom is restricted and the training of a diverse workforce of needed professionals to optimally serve a very diverse population is crippled by the attack on issues of diversity, equity, and inclusion.
If the question was how do we set access to care back to the mid-sixties, substantially increase the cost of marginal care to a smaller fraction of the population, continue to expose every one to the greater dangers of a warming, more polluted planet, while promoting the process of zooinosis with the emergence of more virulent viruses, then Trump is the answer. Not only can he deliver the dismantling of the most effective system yet for fostering medical research, but he can also do that and threaten the economy of the whole world simultaneously! He is indeed talented.
There is no question that progress toward the Triple Aim has been frustratingly slow. Healthcare finance is a Gordian Knot of problems, but using a chainsaw to cut the knot and lose the progress that has been the product of slow but effective continuous improvement over decades has never been the answer. It has not been the research community or our universities that have slowed our progress. Progress toward better care for everyone from compassionate healthcare providers at a sustainable cost has been mostly thwarted by political forces that are self-serving and reluctant to extend the benefit of better care to everyone. There is a reluctance to continue to invest in improvements in access to care delivery, even when a healthier nation would be a benefit for everyone.
Even our richest citizens would benefit from improvements in healthcare finance, safety, patient-centeredness, and continuing research. Ironically, in a reverse of “the rain falls on the just and unjust” (Matthew 5:45), those who seek to delay progress toward a fairer and more efficient system of care likely will be harmed in the end by their resistance to progress in their effort to perpetuate their advantages from the current self-serving status quo from which they handsomely profit at costs to everyone’s future health. Eventually, even the president, who seeks to preserve the past and the personal advantages of his wealthier supporters, may also experience the ultimate harm that his destructive policies will produce.
You may not think that disagreeing with Trump’s chaotic foreign policy and his outrageous tariffs are healthcare issues, but they are. The potential damage to the global environment, to the global economy, and the individual benefits of human rights worldwide probably exceed our current imagination. Who would have accurately imagined where we are now, back on election day last November? I must admit that I thought we were at risk, but my doom-predicting skills were nascent. I had bad feelings that made me sad and nervous, but I was hoping that things during Trump II would be more like they had been during Trump I, when there were a few experienced handlers who succeeded in blocking many of his more destructive tendencies. Now, with the empowerment of Vance, Kennedy, Hegseth, Noem, McMahon, Bondi, Gabbard, Lutnick, Rubio, Bessent, and others of unquestioned loyalty to ignorance, hope for reprieve is greatly diminished and replaced by the expectation that it will get even worse before it gets better in the distant future.
What has disturbed me as much as the economic, scientific, and disease threats to our nation is the decline in collective character and virtue that Trump’s words and actions in office foster. I have described the Dunning-Krueger effect, which Wikipedia describes as:
The Dunning–Kruger effect is a cognitive bias in which people with limited competence in a particular domain overestimate their abilities. It was first described by the psychologists David Dunning and Justin Kruger in 1999. Some researchers also include the opposite effect for high performers: their tendency to underestimate their skills. In popular culture, the Dunning–Kruger effect is often misunderstood as a claim about general overconfidence of people with low intelligence instead of specific overconfidence of people unskilled at a particular task.
I would posit that a person who is simultaneously a sociopathic narcissist and demonstrates the biases incorporated in the Dunning-Kruger effect is a danger to himself and others. Beyond Trump’s lack of skills as a statesman or a manager of complex systems is his apparent pleasure in shocking us with his defiance of norms and his world-class ability to be crass. He demonstrated that he could be an amazing bully in his now-famous tag-team attack with J.D. Vance when Volodymyr Zelenskyy came calling to the Oval Office in February to sign a deal that in itself seemed like an exercise in extortion. It was hard for me to imagine a more repugnant demonstration of his flawed character, but on Easter, he exceeded my expectations with his Easter greeting to the American people published on his own commercial venture, “Truth Social.” He wrote:
Happy Easter to all, including the Radical Left Lunatics who are fighting and scheming so hard to bring Murderers, Drug Lords, Dangerous Prisoners, the Mentally Insane, and well known MS-13 Gang Members and Wife Beaters, back into our Country. Happy Easter also to the WEAK and INEFFECTIVE Judges and Law Enforcement Officials who are allowing this sinister attack on our Nation to continue, an attack so violent that it will never be forgotten! Sleepy Joe Biden purposefully allowed Millions of CRIMINALS to enter our Country, totally unvetted and unchecked, through an Open Borders Policy that will go down in history as the single most calamitous act ever perpetrated upon America. He was, by far, our WORST and most Incompetent President, a man who had absolutely no idea what he was doing — But to him, and to the person that ran and manipulated the Auto Pen (perhaps our REAL President!), and to all of the people who CHEATED in the 2020 Presidential Election in order to get this highly destructive Moron Elected, I wish you, with great love, sincerity, and affection, a very Happy Easter!!!
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What kind of leader would write that as an Easter message to the nation? I wonder how Pope Francis would have responded to such a greeting.
An honest appraisal of Trump and where we are in our history should include all of our moments of confusion and “backsliding” away from human rights, democracy, and our failed attempts to live up to the declaration that we believe that all are equal. Historians like Jill Lapore in her book THESE TRUTHS: A History of the United States give us a stark presentation of the fact that the arc of history toward justice is not only very long, but it is also a journey with reversals, dead-end turns, and self-induced disasters. We say that we desire liberty for all, but at times during our history, we have lapsed into illiberalism out of fear, self-interest, or economic instability.
In his podcast on Tuesday of this week, Ezra Klein interviewed NYU historian Steven Hahn, who published a book in 2024, Illiberal America: A History, that may provide some hope that as we are led by Trump deeper and deeper into an illiberal moment, we may turn things around once again over time. We have been in illiberal moments before, and liberal democracy has survived. Hahn also wrote a guest essay in the New York Times in May 2024. He began his piece with a few prescient sentences. He wrote:
In a recent interview with Time, Donald Trump promised a second term of authoritarian power grabs, administrative cronyism, mass deportations of the undocumented, harassment of women over abortion, trade wars and vengeance brought upon his rivals and enemies, including President Biden…
Further on, he writes:
While it’s true that Mr. Trump was the first president to lose an election and attempt to stay in power, observers have come to recognize the need for a lengthier view of Trumpism. Even so, they are prone to imagining that there was a time not all that long ago when political “normalcy” prevailed. What they have failed to grasp is that American illiberalism is deeply rooted in our past and fed by practices, relationships and sensibilities that have been close to the surface, even when they haven’t exploded into view.
Hahn and Lepore look into a mirror or view a family album of disturbing pictures that most of us prefer to avoid or never bothered to view. That doesn’t mean that those metaphors are inaccurate or that the moment they refer to never existed.
This illiberalism celebrates hierarchies of gender, race and nationality; cultural homogeneity; Christian religious faith; the marking of internal as well as external enemies; patriarchal families; heterosexuality; the will of the community over the rule of law; and the use of political violence to achieve or maintain power. This illiberalism sank roots from the time of European settlement and spread out from villages and towns to the highest levels of government. In one form or another, it has shaped much of our history. Illiberalism has frequently been a stalking horse, if not in the winner’s circle. Hardly ever has it been roundly defeated.
After discussing many of our illiberal moments going back to the beginning, Hahn offers us a little hope that in time things can get better. Remember that this piece was written in May 2024 long before Trump’s election, and even before Kamala Harris took over from Joe Biden. What Hahn wrote last May was a warning and perhaps a prediction.
Only by recognizing what we’re up against can we mount an effective campaign to protect our democracy, leaning on the important political struggles — abolitionism, antimonopoly, social democracy, human rights, civil rights, feminism — that have challenged illiberalism in the past and offer the vision and political pathways to guide us in the future.
Our biggest mistake would be to believe that we’re watching an exceptional departure in the country’s history. Because from the first, Mr. Trump has tapped into deep and ever-expanding illiberal roots. Illiberalism’s history is America’s history.
Well, we know what happened in November, and we realize that short of a miracle or divine intervention, it will be at least 2026 before we have a partial reprieve from this most recent entrenchment of illiberism. There is little solace in the reality that we have frequently sung an illiberal song. It is also a bit hopeful that in the past, we have decided to eventually change the song to a more hopeful melody.
A better future for healthcare and improvements in the social determinants of health are on hold waiting for the moment when a majority of Americans move beyond complaining about Trump’s illiberalism and begin to remember that we are all better off when we seek to accept that our true strength has been in our progress toward being a pleuralistic nation where all are invited to contribute and to partake of our collective opportunities. That better moment in our future depends on slowly moving along that long arc toward justice for all.
Ah, It Is Spring, At Least For the Moment
I was so delighted by the surprise of seeing our first daffodil that I took its picture so that I could share it with you in today’s header. In the shaded areas of our property, there are still some rudimentary piles of dirty snow. Nevertheless, this brave little flower represents the promise that we may soon consistently reach the seventies. Today may be the first time in the seventies for us in 2025.
This week, a brave crew in wetsuits installed our dock for the coming season. The water temperature is still in the low to mid-fifties, but it has been great to sit on the dock over the past few evenings and just survey the scene. We hear and see the loons. Perhaps this year the loons will overcome their marital problems and produce one or two loon chicks to entertain us for the summer.
My weekend plans include my first fishing efforts for the season. Last year was a bust because of my multiple medical issues. I am hoping for more time on the water fishing, sailing, and swimming, this year. I am excited by the fact that my wife is deep into developing plans for a big event to celebrate my eightieth birthday in early July. This should be a great summer.
I hope that you are developing your expectations for the summer of ‘25. It is time to get started because it is just a month until Memorial Day, and there are only nineteen weekends until Labor Day. Time flies!
Be well,
Gene
