January 5, 2024
Dear Interested Readers,
A Surprising Event At The Beginning of a Pivotal Year
I have observed presidential campaigns for a long time. I well remember watching the 1952 presidential nominating conventions on our recently acquired black and white 17-inch RCA television that received only one station, WKY-TV in Oklahoma City. In many places in those earlier days of television, one could easily estimate their neighbor’s wealth by the size of their television antennas. Some seemed to be almost as tall as today’s cell phone towers. We were able to get by with a relatively small antenna because we were only thirty-five miles east of Oklahoma City.
Over the years, there have been some surprising moments in presidential campaigns. George Romney ruined any chance that he had to become president by stating that his original support for the war in Vietnam was due to his having been “brainwashed” by generals. Senator Ed Muskie was a viable candidate for the nomination for president going into the New Hampshire presidential primary in 1972 until the Manchester Union Leader and its far-right publisher, William Loeb, participated in one of Nixon’s “dirty tricks” that accused Muskie of laughing at a derogatory term used to describe people of French Canadian heritage of which there are many in Manchester and all of New Hampshire. Things got worse when the ploy was extended to Muskie’s wife, and he chose to confront the lies in a tearful speech delivered in a snowstorm in front of the Manchester Union Leaders offices. As we know, George McGovern won the Democratic nomination and lost in a landslide victory for Nixon.
These events came to mind this week as candidate Nikki Haley stumbled over a very easy question about why the Civil War was fought in one of her many New Hampshire “Town Hall” meetings. The best description of the significance of the moment that I have read came from a piece by Sidney Blumenthal in The Guardian. There are plenty of YouTube clips of the encounter online. Click here for one that includes a little of what Blumenthal describes. In his opinion piece entitled “Nikki Haley’s comment on the US civil war was no gaffe” Blumenthal wrote:
“What was the cause of the United States civil war?” a man asked Haley at a campaign town hall in North Conway, New Hampshire. She reacted as if she were being physically threatened. Haley immediately turned her back to the questioner, breathed fast and heavy into the microphone, and walked quickly away. When she swiveled to face the crowd, she did not speak at first. Gaining her composure, she replied with an accusatory edge: “Well, don’t come with an easy question.”
Of course, the answer is an easy one for any eighth grader. But for Haley it went to the molten core of the history and politics of South Carolina, where she had been governor, to the southern strategy that realigned the Republican party, and to its hard crystallization in Trump’s party. She retreated as if struck, not because she didn’t know the obvious answer, but because she knows that it is more fraught than it has been in decades.
“I think the cause of the civil war was basically how government was going to run, the freedoms and what people could and couldn’t do,” Haley began haltingly. Then she stopped.
“What do you think the cause of the civil war was?” she asked her questioner. He replied that he was not running for president and wished to hear her thoughts. “I think it always comes down to the role of government and what the rights of the people are,” Haley continued, and continued, and continued. “And I will always stand by the fact that I think government was intended to secure the rights and freedoms of the people. It was never meant to be all things to all people. Government doesn’t need to tell you how to live your life. They don’t need to tell you what you can and can’t do. They don’t need to be a part of your life.”
I have always enjoyed reading about history. To prove that claim, let me inform you that I was the 1958 winner of the DAR medal for the best student in American History at West Junior High School in Waco, Texas. I knew as an eighth grader that the Civil War was fought to free the slaves. As a student at the University of South Carolina in the mid-sixties, I was surprised when the professor in the survey course of American History which was a requirement for all students, said that the Civil War was fought over “States’ Rights” and not slavery as everyone thought. Had I answered on the final exam that the Civil War was fought over slavery, my answer would have been marked as wrong.
Haley’s answer was not so much a gaff as it was a window into one of the subtle realities of the far-right white supremacist conservative agenda in America today. Blumenthal accurately describes her dance as she was looking for an answer that would not offend the sensibilities of many of the far-right voters that are critical for her to attract in the distorted primary process that has evolved over the 72 years since I watched my first political convention.
I find Haley to be a serious potential threat to Joe Biden’s reelection. If Donald Trump fails to win the nomination of his party through the emergence of some unexpected aversion to his lies and illiberal ways from more moderate Republicans, or some legal event, or by the development of some health issue, Haley is well positioned to be the nominee. At worst, she is lining herself up as Trump’s choice for the Vice Presidency. Despite her Civil War “gaff” Haley is attractive to many slightly right-of-center independent voters as an articulate, intelligent woman with leadership experience, and some knowledge of foreign affairs.
I doubt that on her own as president, Haley would be a threat to Democracy, but she would be a conservative foil to policies that might improve the social determinants of health for another four to eight years. I see her as a potential Bush II-like president. As a VP candidate, she could be more dangerous. She could attract voters to a ticket headed by Trump who might otherwise be leery of giving him a second term. Any benefit she offers to Trump in his effort to be reelected could make his threat of “dictator for a day” a reality that is not limited to 24 hours.
[After writing about Haley, I discovered in this morning’s (1/5/24) New York Times that Paul Krugman shares many of my concerns about Haley and what her gaff represents. I recommend that you take a look at his column entitled “Ron DeSantis, Nikki Haley and Politically Obtuse Plutocrats.”]
Is it easy for conservative, white suburban, or rural Americans who are focused on their economic uncertainty to discount the concerns of underserved minorities? I hope not, but this week there was yet another report of the ZIP code variation in health outcomes and life expectancy that can be plausibly traced to the sort of continuing discomfort with our history of slavery, Jim Crow suppression of the freedoms of African Americans, and our collective ability to avoid dealing with uncomfortable realities that would be inconvenient to acknowledge. Haley’s candidacy like the campaigns of all other Republicans can’t dare to deal with race, slavery, the long history of racial inequality, and the impact of discriminatory policies on the lives of millions of Americans. Healthcare disparities are subtly related to Haley’s double talk about the origin of the Civil War. If she gets elected to any office it is hard to imagine any significant progress in eliminating our chronic healthcare disparities.
This week The Washington Post published an article that should upset and motivate all legitimate presidential candidates who claim to care about the underserved members of our society. It was entitled “Half of Black D.C. residents lack easy access to health care, analysis shows.” The authors were Michael Brice-Saddler, Jenna Portnoy, John D. Harden, and Janice Kai Chen. The article begins:
Nearly half of Black D.C. residents live in medically underserved areas — neighborhoods with a shortage of primary care services where the rates of heart disease, hypertension and other serious chronic conditions are more prevalent than in the rest of the city, a Washington Post analysis of federal data shows.
What follows is a detailed analysis of how a lack of access to care led to substantially higher death rates from COVID, as well as the continuing misery from diabetes, cancers, heart disease, strokes, and a host of other conditions that are neglected past the time of a chance of improvement when access to care is compromised. Below are a few facts that were revealed by the reporting team:
- [COVID] had a devastating impact on Black residents, who made up more than three-quarters of D.C.’s at least 2,230 deaths but represent only half of the city’s population.
- Data analyzed by The Post shows that a large percentage of Black residents in D.C. face more challenges with health-care access than those in Maryland and Virginia. Across the region, about 21 percent of Black residents live in medically underserved areas compared to D.C.’s 49 percent.
- In 2017, residents in Ward 8 — which contains the city’s highest concentration of Black residents — lived 16 fewer years on average than residents of Ward 3, the Whitest and most affluent ward in the District, according to city data. Their plight has been further complicated by increased rates of gun violence compared with the rest of the city and fewer options for nutritious, affordable food.
- The United Medical Center, the only full-service hospital in Southeast Washington [ward 8 which has the highest density of Black Washingtonians], will soon close permanently following years of complaints related to financial mismanagement and patient care. In 2017, after regulators detected a series of dangerous mistakes, the United Medical Center shut down its obstetrics ward.
- …the District has more than 300,000 members in its Medicaid program, a little more than half the city, the 2018 study noted that 76 percent of D.C.’s Medicaid patients typically traveled outside their ward to receive primary care. Researchers found at the time that 40 percent of Medicaid enrollees did not receive any primary care in a given 12-month period.
- A 2018 health equity report from the city found that social health determinants drive 80 percent of the city’s health outcomes compared with 20 percent related to clinical care — and in a place like D.C. where poverty is largely concentrated in the easternmost neighborhoods, negative health outcomes have followed a similar pattern.
There is more. The article describes how multiple attempts to improve the plight of the underserved have failed. A new hospital in Southeast Washington is under construction, but even before it is completed there is serious concern that it will not make much of a difference in the healthcare experience of the majority of Washington’s Black population. The long article ends with a quote from an apprehensive community leader. Could it be that they are trying the wrong things?
“We can’t hide the fact that as the city has progressed, certain populations and people have been marginalized, displaced and not included in that progress. And while we’ve made some strides over the years, important investments, it’s not been enough and it’s not been consistent or sustained,” said Wellons, the community foundation’s president. “That’s why we’ve seen things worsening.”
Why do we have problems with equality, the social determinants of health, and even access to healthcare in a resource-rich area like our national capital? Even though I know the answer to the question, I continue to wonder why, or perhaps I am just amazed that in a society with as many resources as ours, immoral and enormous problems with the social determinants of health persist. Next week is our celebration of the life of Dr. Martin Luther King, Jr. In the time between the passage of the Voters Rights Act of 1965 and his death in 1968, Dr. King was confounded by the same reality. That was over fifty years ago, and we are still not able to answer the questions he asked.
I am biased by personal experience to believe that our continuing dismal picture of health equity is connected to politicians who are reluctant to offend members of their base. They are afraid to speak the truth about slavery and the Civil War and demand that the study of “critical race theory” be abandoned in our schools. It is beneficial to their political careers to cowtow to a vocal minority that demands that we not talk about anything that creates discomfort for those of us who have enjoyed disproportionate advantage and privilege. Haley is no dummy. She knows how things work. She was just caught off guard.
A Big Transition
I became the interim CEO of Harvard Vanguard and Atrius Health almost sixteen years ago in mid-February 2008. I was overwhelmed and a little bit terrified. It is a fact that there are big gaps in my memory of those early days, but I do remember the sense that many people wanted me to succeed at an endeavor that others felt I was not capable of assuming.
I was fortunate to have observed Charlie Baker as he took over Harvard Pilgrim during a difficult moment. He succeeded in part because he was straight with people. He was seen everywhere. He gave straight answers to difficult questions. He wrote to the employees frequently with the good news, the bad news, and humor that made any message easier to receive. When he delivered bad news it was always accompanied by a hopeful strategic idea that addressed the concern. Ken Paulus wasn’t a writer, but he was also a communicator, and like Charlie, he was everywhere answering questions and presenting ideas. I resolved to follow their example.
On Thursday, February 21, 2008, I sat down to write the first of 298 consecutive letters to my colleagues. Those letters were always edited by Marci Sindell who was our Chief of External Affairs, a great mentor to me, and someone I could always depend upon to be honest with me. At times we argued over what she thought was better left out, but in retrospect, I think she was usually right.
Earlier in that first week we had held a meeting with our central administrative staff at our Riverside (a suburban office park near the Route 128 beltway and the Charles River in Newton) management offices. Before the meeting, Marci had looked me in the eye and said something like, “What makes you think you are qualified for this job.” I was thinking the same thing. Perhaps the best way for me to give you the flavor of my start is to let you read that first letter. I have bolded subjects that I will return to over the next few weeks.
February 22, 2008
Dear Harvard Vanguard Team,
I would like to take this opportunity to acknowledge all the expressions of congratulations and good wishes that I have received this week. After one week serving as your interim leader, I would like to report on what I have observed.
Everywhere that I have been, I have been greeted by people who have demonstrated warmth, optimism, commitment, and devotion to the work we do together. Many of my meetings have been with nurses. They have asked me tough questions that demonstrate not only the fact that they care about job do-ability, but also about the quality of their work and the safety of the environment that we offer to our patients. They also expressed an honest concern about what the values of the organization will be going forward.
As I walked around Cambridge with Jennifer Whitworth, Braintree with Susan Robichau, Kenmore with Michael Knosp and Burlington with Donna Sevigny, I got to have conversations with people like Joe Zorn, Tom Krueger, Sarah Kelly, Diana Parks-Forbes, Steve Dong, Alona Rotkovitch, Zufan Araya, Ina Cushman and Adam Roses. Each demonstrated a pride in their units, a joy in what they do and a desire to further improve the service they provide our patients.
I have received input and discussed many topics with people this week including job do-ability, the pros and cons of the Atrius Health affiliation, optimizing the benefits of Epic, succession planning, the Atrius Experience/Lead project, the decision-making process in our practice, compensation philosophy, culture, and our vision for the future of Harvard Vanguard. These dialogues have demonstrated to me that much wisdom exists within our practice. Many of you expressed a desire to see a change in the way information flows through our practice and to be a part of the decision-making processes that affect your ability to care for patients or support those who provide care to patients.
I had a particularly enlightening discussion with the team at Riverside about the difficulties we encounter now in credentialing new physicians. They offered some insights and excellent suggestions for how we could improve this process.
I’m looking forward to seeing each of you in the very near future. If you don’t get to one of the meetings that will occur regularly – don’t worry – you will see me coming down your hallway and I will meet you where you work. I hope that you will tell me something that I need to know which I will carry back to Riverside to share with others here. I consider it my responsibility to be an effective link between the Harvard Vanguard practices and the supports for those practices in our management offices.
We possess within our staff more than enough energy, passion and expertise to achieve something truly remarkable for our patients. Don’t limit your dreams and don’t stop demanding what our patients need.
As the weeks go by I will try to use this weekly communication to help coordinate our efforts, improve the flow of information through our organization and share your questions about the details of our vision. As the conversation progresses, I hope that all of us will be able to contribute to the vision in such a fashion to have a rich image of our common goal. I hope to facilitate discussions that make you say, “I’m a part of something that is really great”. The truth is, we are pretty good now but I didn’t hear anyone say that they thought we were yet what we could be. I hope you will find great joy and enthusiasm for what you do over the next several months. I am anticipating that I will be having the time of my life.
One last word – we are beginning the process of electing a new trustee to fill the seat on the Board of Trustees from which I resigned last week. I have met many people this week who were filled with a passion to make a difference and demonstrated a knowledge of the issues that showed me expertise that could be valuable in this important position. If you are eligible, please consider giving us all the benefit of your contributions in our group’s governance. Plans are underway to update the work of the board to serve as a partner with me as I seek to serve you.
Be well,
Gene
The Holidays Were Intermittently Wet And Warm, But All Was Well
I hope that your Holiday season was satisfying and restful. Could it be these “brown” holidays have been a preview of what we will experience in years to come? I hope not.
Sledding and snowball fights were replaced by “fallish” hikes in the woods and trips to museums. The warmer weather made it comfortable to be outside when it wasn’t raining. We were very lucky that it was a balmy evening without rain when we visited the Coastal Maine Botanical Gardens in Booth Bay Harbor last weekend to see the Holiday light show with our grandsons, their parents, and their uncle and his wife. The Gardens are graced by huge statues of trolls. The header for this week shows my two grandsons standing in front of the “baby troll.”
I have never wanted to live in the Midwest, but I must admit I was a little jealous when the upper Midwest got a Christmas Day gift of snow. I think that I should be clear that my concern is not so much the loss of the joy of a “White Christmas” as it is what the loss says about what to expect in future years from global warming. I was not surprised to find that there is at least one like-minded soul in the world. In The New York Times Opinion section this Tuesday, Elizabeth Spiers posted a piece entitled “The End of Snow.”
Ms. Spiers lives in Brooklyn, New York, but she alternates her Holiday visits between Alabama and Nebraska. She does reveal at the end of her column that she was in Omaha for this year’s Holiday season and was benefited by snowfall on Christmas Day, but her points about the future are still valid. She writes:
Every Christmas my husband and I pack up ourselves and our now 8-year-old and leave Brooklyn for a visit to either Nebraska (where my in-laws live) or Alabama (where my family lives). If we’re headed to Omaha, we pack heavy layers because the weather is somewhere between Arctic tundra and what it might feel like to live inside an Icee. If it’s a year when we head to Wetumpka, we pack moderate layers but also short sleeves and maybe even shorts, since 60-to-70-degree Christmases are not unheard-of there.
This past year was an Omaha year, and we arrived on the 22nd to find that the weather was very mild — almost 50 degrees — and there was no snow. More unusually, there had been no snow for the entire month of December. Aside from some brief and very sparse flurries, it hadn’t snowed in Brooklyn, either, in November or December. I’m an incorrigible heat seeker, and the phrase “wintry mix” fills me with despair. But even so, the lack of cold and ice in 2023 felt unsettling.
Except for a couple of anemic dustings of snow at the end of November and in early December, I could say “ditto” for New Hampshire. Further along, she writes:
I was thinking about this while standing outside a science museum a couple of days ago with a friend. We were talking about the weather but not the kind of small talk when you have nothing else to say. “I’m not sure our grandkids will even know what snow is,” she said, with a wry “I’m kidding, but I’m not” laugh. She and her family were leaving for a ski trip the next week, uncertain whether there would be enough snow.
Near the end of the piece, she gets philosophical in a way that I am sure that our evangelical Speaker of the House, Mike Johnson from Louisiana, an energy-producing state with a fair share of climate deniers, would find objectionable. She continues:
We’re accustomed to viewing the world in a human-centric way that says the planet exists for us on some level, and that’s heavily reflected in our culture and religious traditions, including the one I grew up in, where a moody god “so loved the world” that he sacrificed his son to save it. It exists in the techno-optimism of Silicon Valley billionaires who believe that if the planet gets destroyed, they’ll just colonize a new one. But when the weather is doing strange things, it undermines the idea that we are the center of the universe and have potential agency over anything nature can do to us.
She finishes with what seems to be an effort to be hopeful at least for the short term.
…I believe humans can reverse some of the harm we’ve caused to the environment — we’ve done it before, which is why the state of the ozone layer is no longer a problem on the heels of the Montreal protocol — so I’m not a total pessimist. But I am worried.
It finally snowed a bit in Omaha, on Christmas Day, no less — a bit of temporary relief. I’m not worried that my grandchildren, if they ever materialize, will grow up not knowing what snow is, as my friend suggested. But I wonder if, somewhere down the line, one of my descendants will build the last snowman in Omaha.
I share Ms.Spiers’ concerns, but my greatest hope for 2024 is that the wars in Gaza and Ukraine will end, and in November, we will elect a government that is dedicated to maintaining peace and Democracy, improving the health of everyone, and making an even greater effort to ensure that Ms. Spier’s descendants, as well as yours and mine, get to enjoy making snowmen and throwing snowballs. Have a great 2024!
Be well,
Gene
