6 July 2018
Dear Interested Readers,
Welcome to The New “Healthcare Musings” Friday Letter!
If you are reading these words you have made a transition! I talk alot about change. I know that whether I like it or not most things around me, and most of the the people and things I care about, must change, but navigating through change always makes me uneasy. Most of the time after the new reality is in place, I heave a sigh of relief and say to myself, “See, it went better than I thought it would!”
I like the sort of change that creates new options and opportunities. I hope that over the next few weeks and months I will be able to take advantage of the new creative options that will make this site available to more people. The comment process should be much easier. I will try to maintain the tone of the Friday postings and write a completely original post on Tuesdays. I plan for both posts to deliver more ideas with fewer words. I hope that you will flood me with your ideas and comments. If your comment is for me, and you would not like to see it added to the post, just say so and your comment will stay between us only. I hope that there will be plenty of comments posted that will instruct me, offer alternative points of view, and correct any misinformation that I present.
Fourth of July Ruminations: Life, Liberty, Happiness, and the Prospects for a Healthy Nation
The Fourth of July has always been a favorite holiday for me. Labor Day is OK, but it is an ending. The Fourth is a beginning. The Fourth is the real kickoff of summer. This year the Fourth sat squarely in the middle of a heat wave of unparalleled dimensions, in recent memory. The week we have just had in the Northeast should make the idea of global warming seem like an outside possibility for even the greatest deniers of the scientific evidence for climate change.
When I was a child my family often spent the Fourth at either my maternal grandparents’ home in North Carolina, or less frequently in South Carolina with my father’s people. Each summer before we had moved back to South Carolina in time for the start of the school year in the fall of 1961, we would pack up our car and spend three or four days driving across the sweltering South to spend a month “at home” in the Carolinas. My parents considered living in Oklahoma and Texas the equivalent of being a “pioneer” or a foreign missionary. My grandmother was apparently surprised to find on her first visit to see us in Oklahoma that we had electricity. Until the Interstate Highway system was completed in the seventies, driving across the South on US 80 was a cultural experience closer in reality to 1860 than 2018. It was a trek of a thousand miles of two lane highways through a land of lynchings and apartheid that we never discussed. The event that would induce the most discussion and emotion would be getting trapped for several miles behind a farmer taking his time on a tractor over a long stretch of highway with an extended “no passing zone.”
For me the annual trips offered one adventure after another. Crossing the Mississippi River was the highlight of the trip. I would brag to my playmates about how many times I had crossed the Mississippi. There were only two bridges. One was in Vicksburg, and the other one was in Memphis. Even as a child one could see why the geography had made the high bluffs of Vicksburg and Memphis key to the control of the river during the Civil War. The floodplains of the river lay to the west in Arkansas and Louisiana where for miles and miles many of the houses stood on stilts. My favorite crossings were on ferries between the two great bridges. I marveled at the sight of monster catfish that were at least six feet long and were lying In the beds of old pickup trucks in the lines of waiting cars and trucks at the ferry landings where there was always time for me to look around while we waited for the ferry to arrive.
Once we were “back home” in North Carolina or South Carolina there were picnics and outings with grandparents and a multitude of uncles, aunts, and cousins. They came in many sizes and ages. Some were old enough to be my great grandparents, and many may not have really been related at all, but earned the title of uncle or aunt for duty as a great and loyal friend. The people at the picnics, and others like them who had “passed away,” were the stars and heroes of the stories that my mother would tell us for many hours on the long trips, or at bedtime when we went back to the Southwest to await next summer’s trip.
For a brief period of time in the late forties and early fifties my father decided that he would make home movies. He recorded only five or six rolls of film before he either got too busy or decided that the hobby was too expensive. Several of the rolls were never developed. I am so grateful that he did get three rolls developed. Ironically, we never saw them. That would have required the purchase of a projector. There were two rolls of film from the forties that were black and white and varied from significantly over exposed to black. There was one roll from 1950 that was in color. I know it was from 1950 because my sister appears as a baby while my brother and I run in circles laughing with some older girls who were the daughters of the associate minister at our church in Miami, Oklahoma. I found the films in the late sixties after I had begun to film my own children. I was able to splice together fifty feet of film that is now digitally recorded.
The best clip of the fifty feet of film is about two minutes long and shows our family as it gathered in my grandmother’s backyard on July 4, 1948. My grandfather is presiding over the cutting of the watermelon. He is wearing a starched white shirt and bowtie, as he performs the function of cutting the melon like he is carving the Thanksgiving turkey. He looks a little like a high priest about to offer a sacrifice to some angry god. The camera cuts back and forth between the watermelon slicing ceremony and shots of me, aged three years minus four days, and my cousin Margaret who is six months older. “Cousin Peggy” and I are laughing and chasing each other around the yard and through a sprinkler. We are dressed only in our underpants. My brother, who was ten months old, appears in his diaper and sitting alone on the grass near the table. After he pulls himself up to a wobbly stance, he swings his arms back and forth and looks up at the adults who are waiting for their pieces of the watermelon, as if to say, “Hey, look what I can do!”
There must have been many other standout childhood Fourth events like picnics at the state park on top of Paris Mountain in South Carolina, but all those events that were not recorded have become fused together into a single positive feeling in my memory. Fireworks were never a big part of our Fourth of July celebrations, as much for the fact that they were a “waste of money” as that they were a danger. Watermelon, blackberry and peach cobblers, and hand cranked ice cream were the highlights of these summer celebrations of our nation’s birth.
Holiday events with family became less certain during my medical school years and my years as an intern, resident, and fellow. Several Fourths were spent “on call,” but forty two years ago the bicentennial weekend was a multi day celebration to end all celebrations. We were living in Newton. I was a little more than a year into practice at Harvard Community Health Plan. Behind us lived a very gregarious professor and his family. He taught marketing at Boston College School of Business. To our side lived an Australian physician with his wife and two young sons. He was doing a fellowship in radiology at the Brigham. The three families were great backyard friends. As the 200th Fourth approached we all agreed that to maximally celebrate the Fourth and the Bicentennial, and to take optimal advantage of the long weekend (the Fourth was on a Sunday in 1976), we should roast a pig and have a multi day backyard luau. Since none of us had ever roasted a suckling pig, we had a lot of research to do. The pit was dug in my backyard near where all three yards came together. As the pig was roasting we began to make merry. Our frivolities attracted curious neighbors, and in no time our three family adventure had grown into a block party that lasted three days.
I didn’t plan to read Jon Meacham’s The Soul of America: The Battle For Our Better Angels as preparation for this year’s Fourth of July, it just worked out that way. Perhaps it was the book plus the resignation of Anthony Kennedy from the Supreme Court that put me in a different frame of mind for this Fourth. I am one of many who fear that it is possible that a new court might reverse some of the issues that had seemed to be “settled law,” like a woman’s right to control her body and her reproductive choices. I am very concerned because I fear further damage to the ACA might be the ultimate outcome of Mitch McConnell’s theft of President Obama’s right to name a justice.
There is no doubt that one of the things we celebrate on the Fourth, without much thought, is our common belief that a founding principle of our nation is the protection of the rights of minorities from the oppression of a populist majority. It seems ironic that we now seem to be struggling with a situation where the non negotiable ideas of a populist minority could threaten the rights of a confused and complacent majority. A coalition of political minorities built on a collaboration of the self interested that in total still amounts to only 40% of the electorate has pursued several years of effective political strategies to gain control of all branches of government. The likely absolute control of the Supreme Court for the next few decades, at a minimum, is their crowning achievement and will allow them to block the positive social changes that are supported by a majority of citizens.
The preservation of minority rights was always the remarkable achievement of our Constitution. I doubt that the founding fathers ever imagined that the complexities of the electoral college, the lifetime tenure of Supreme Court appointees, arcane Senate rules, and extensive gerrymandering made possible through the control of state governments in a majority of states with a collective minority of citizens, would create a presidency and a Congress that had the confidence of only 40% of the electorate but the ability to change the country’s orientation to human rights and the responsibility to lead the free world while delivering money to those who have more than they can spend while denying critically needed support to those with the greatest needs. I do not think the scripture reads, “Truly I tell you, whatever you did for one of the wealthiest of these brothers and sisters of mine, you did for me.”
The compelling theme of Meacham’s review of American history, and its stuttering course toward becoming a “more perfect union” is that we have been in worse trouble in the past than we are now. We have been much more oppressive to the rights of minorities, more fearful of immigrants, more isolated from the rest of the world, more self interested and greedy, and more distrustful of the intentions of government than we are today. We have never lived up to the promise of freedom for every person in the country to enjoy life and liberty, but until now those among us who believed in the larger promise have found a way to get us back on track when we have lost our way. Our best moments and many of our most critical moments have been engineered or accomplished by flawed leaders like Lincoln, the two Roosevelts, Truman, and LBJ because they were able to rise above their own personality and intellectual flaws and inspire all of us to do better. They manage their personal flaws and shortcomings by focusing on what was best for the whole nation. As Sean Wilentz wrote in his review of The Soul of America:
Meacham returns to other moments in our history when fear and division seemed rampant. He wants to remind us that the current political turmoil is not unprecedented, that as a nation we have survived times worse than this.
Meacham’s reassurance is comforting until you begin to list all the things that had always been true until they weren’t. There is no doubt that over the past fifty years we have made some amazing advances toward extending the promises made to white land owning men at our founding toward inclusion of all people. More than just making progress on the promise of inclusion in the guarantee of participation in the rights of “freedom” and an individual’s opportunity to participate in the democracy, we have believed that the progress that we had made was essentially irreversible. For example, we had expanded voting to include all adults, and had removed poll taxes and unfair voter registration practices that were part of the foundation of laws that excluded many African American voters. The Voters Rights Act of 1965 was a huge accomplishment, but in 2013 in an opinion written by Justice Roberts undermined the 1965 Act and opened the door for moves by several states of the old South to create new barriers to voting for poor and minority voters. Just this month Roberts and four other justices decided two cases by 5-4 that will that further damage the rights of voters. One case from Ohio allows the purging of recently inactive voters from the list of voters, and in another decision it failed to uphold a lower court’s finding of gerrymandering in Texas.
Meacham describes the problem of the moment and gives “a best case” defense. He believes that history can be an important part of the moment. Those who understand what has happened in history can plot a course that avoids the mistakes that have been made by others in the past. Those that ignore the lessons of history will suffer losses that could be avoided.
On several occasions within the book Meacham excited me by including the expectations of health, education, housing, and employment in the expansion of the concept of the right to life, liberty, and the pursuit of happiness. As I ponder what I fear on yet another Fourth of July from a more conservative Supreme Court, I realize that the outcome of their decisions could be a great “undoing” of progress made toward that larger concept of life and happiness. At stake is much more than a reversal of Roe v. Wade. Recently articles have appeared that question the durability of the part of the ACA which abolishes the consideration of “preexisting” conditions.
As I look back on all the happy Fourth of July celebrations of my youth and even up to the moment, I realize that things have changed. For many of those celebrations I was protected from a full realization of all those who did not enjoy the same freedoms or potential opportunities that I took for granted. As I moved into adulthood and realized what I had and what others were denied, I took great relief in seeing a gradual improvement in circumstances. Martin Luther King, Jr. talked about the “fierce urgency of now” when politicians who favored giving change a little time pushed back on his concerns about the resolution of the issues of poverty and race. I guess I was accepting of a little less urgency in favor of the reality that things did seem to be getting better.
I fear that complacency created this moment. In retrospect many experts point to how critical the elections of 2010 and 2014 were to the creation of this moment. Many people were also asleep at the wheel in 2016. We now are faced with the possibility of future Fourths when we may celebrate what we once had but now have lost. Between now and the next Fourth lies another “off year” election. I hope that by July 4, 2019 we will see that the nadir of our concerns about the future of healthcare has passed and that a small battle for our “better angels” has been won.
Down a Loon
Barbara Ebert, an interested reader, wrote this week to let me know that the Boston Globe had published a piece on loons. Within the article there is a disturbing fact. Of the 167 loon chicks born in New Hampshire in 2017, twenty five percent did not survive. The article re enforced the experience on my little lake. Friday of last week we had heard the loons calling in an unusual way that suggested that they were upset. I don’t speak loon, but over the years I have begun to get a feel for the variable emotions of their “distinctive calls — tremolo, wail, yodel, and hoot,” as the author of the Globe article describes. My wife was afraid something had happened. She had seen an eagle circling over the area of the lake from where the calls seemed to be coming. Later, while I was out in my kayak fishing, I saw the loons several hundred yards away from me. I could only see one baby with them. It was a little dot going back and forth between the adults. My heart sank. It seemed that whatever happened life was going on. News has also arrived that one of the chicks on Pleasant Lake is also gone. It is a reminder of just how fragile life is in the wild.
Perhaps it is a stretch, but thinking about the vulnerability of the loons both to their natural predators and to the thoughtlessness of people seemed in my mind to connect with the suffering of children who were separated from their parents. The young of all species are vulnerable. If we can track the fate of every loon chick in New Hampshire, why can’t we apply the same level of concern to every child who is in this country. Neither loon chicks or children are where they are by choice, and both depend on the kindness and concern of others if they are to survive in a hostile world.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
