Healthcare Musings For October 1, 2021

October 1, 2021

Dear Interested Readers,

 

Why Do We Make Choices That Don’t Promote Our Wellbeing?

 

The news is full of the manifestations of our national uncertainties and deep divisions. At this moment Congress is engaged in a great debate about the wisdom and finances of the president’s far-reaching proposals for economic development, infrastructure repair, and a vastly expanded social safety net. If you are a liberal or a progressive you imagine that the result of the president’s proposals, if passed, would go a long way toward eliminating inequality, saving the environment, and returning America to a position of true leadership in the world. If you are conservative you are more likely to imagine or believe that the president’s proposals are excessive. If you disagree with the president you might imagine that his proposals would give advantages to lazy, irresponsible, immoral people, and immigrants that don’t deserve much from the public coffers. You also believe that more government involvement in our lives is always dangerous and threatens the advantages of capitalism.

 

There is increasing evidence that race, education, and social status are factors in how individuals decide on which side of the divide they will stand. These opposing attitudes have been at the core of the political debate in America for decades. Our state of political polarization seems to be accepted as a national malady for which there is no remedy although it is likely that the vast majority of Americans suffer daily from the damage polarization brings to individuals, to our communities, and to us collectively. We seem incapable of mitigating the damage that polarization and racial animus do to healthcare and accept the difficulty that polarization creates for the improvement of the access to quality care that can make a difference in lives. The tragedy of this division can be measured in lives lost and lives lived in poverty that could be eradicated.

 

The wider world also suffers from our strange affliction of polarization because our strife creates opportunities for autocrats to advance their interests and the associated human suffering they foster around the world. One might argue that our polarization is in fact a greater threat to our future than global warming or the current and future pandemics we will endure because polarization precludes acting together to find viable solutions for these threats that have replaced nuclear annihilation as our recurrent collective nightmares. 

 

Surveys of the population reveal that a significant majority favors reproductive rights, more effective gun regulations, investments in traditional infrastructure, expanding the definition of infrastructure to include more human services like childcare, support of developing effective strategies to reduce global warming by investing in alternatives to fossil fuels, expanded public education on both ends–preschool and college, adequate housing for everyone, and universal healthcare. The big questions to be answered and barriers to be overcome if we are to realize these goals and improvements are not technical, they are political and cultural. Some of the political questions are positive concerns about how to best distribute opportunity and improve equity. There are also negative political concerns about how to preserve existing advantages for the wealthy and to retain controls in the service of the self-interests of a minority. 

 

It amazes me that a minority has crafted a strategy that so far has preserved its advantage. That strategy has not been built on providing real benefits to enough voters to win elections. The strategy takes advantage of a collection of unusual historical events and procedural concessions made to small states over two hundred and thirty years ago to win their approval for a federal constitution and the very strange evolution of the filibuster in the Senate that now means that a party must have supermajority control of the Senate to pass significant social legislation. These two unusual opportunities have been coupled with an unholy ability to use race to induce fear in a substantial number of white Americans who are made to feel vulnerable to any policy proposal that offers assistance to Black Americans or immigrants. There is increasing evidence that this “worried” white population seems willing to accept personal injury or economic loss to preserve their perceived racial advantage in society. It is amazing that the Democrats allow the filibuster to persist especially since doing away with the filibuster would have enabled the passage of laws like the For the People Act and The John R. Lewis Voting Rights Act that would have protected our elections.

 

Over the past couple of decades political scientists, psychologists, and social scientists have been trying to understand why so many disadvantaged white Americans consistently vote against their own best interests. In 2004 Thomas Frank wrote What’s the Matter with Kansas? I must admit that I have not read the book, but have read much about it. Wikipedia sums up the observation that the book addresses. I bolded the most important concept for this discussion.

 

According to the book, the political discourse of recent decades has dramatically shifted from social and economic equality to the use of “explosive” cultural issues, such as abortion and gay marriage, which are used to redirect anger toward “liberal elites.”

Against this backdrop, Frank describes the rise of political conservatism in the social and political landscape of Kansas, which he says espouses economic policies that do not benefit the majority of people in the state

 

Professor Arlie Russell Hochschild explored the same questions when she developed deep relationships with many very conservative White voters in Louisiana in her attempt to understand why they did not question or resist the damage done to them and their state by big oil and chemical companies and the conservative politicians that exposed them to disease and economic devastation. The New York Times review of her 2016 book Strangers in Their Own Land: Anger and Mourning on the American Right, distills the message of her book down to a few lines:

 

…the resentments she finds are as toxic as the pollutants in the marsh and metastasizing throughout politics. What unites her subjects is the powerful feeling that others are “cutting in line” and that the federal government is supporting people on the dole — “taking money from the workers and giving it to the idle.” Income is flowing up, but the anger points down.

The people who feel this are white. The usurpers they picture are blacks and immigrants. Hochschild takes care not to call anyone racist but concludes that “race is an essential part of this story.”

 

Her book was published before Donald Trump became president. Trump did not invent the politics of White fear and government resentment, he just carried it to new levels of potential national destruction and despair. When Professor Russell-Hochschild was visiting Louisiana a decade ago it was the “Tea Party” that was stirring the pot of White resentment. It is no surprise that the Tea Party coalesced as a conservative movement in the aftermath of Barack Obama’s election and the “Great Recession” of 2008. 

 

I have mentioned before that in 2019 Jonathan M. Metzl wrote Dying of Whiteness: How The Politics of Racial Resentment Is Killing America’s Heartland. I learned of the book when I listened to Ezra Klein’s New York Times podcast interview with Ibram X. Kendi. Klein always ends his interviews by asking the person he is interviewing for three book recommendations. Kendi’s response was: 

 

Well, I guess let me recommend two books that we’ve already discussed, and that’s Heather McGhee’s “The Sum of Us.” I would also recommend Jonathan Metzl’s “Dying of Whiteness.” And a third book, I would recommend, especially since we talked a lot about policy and its impact, I’d recommend Keeanga-Yamahtta Taylor’s book, “Race For Profit,” which I believe was a finalist for the Pulitzer Prize.

 

I had previously read Heather McGhee’s book. I now have read Dying of Whiteness and Race For Profit is waiting in the on-deck circle. I have since discovered that the New York Times has published a syllabus of books from Kendi, “Ibram X. Kendi’s Antiracist Reading List.” The subtitle of the article is “Ibram X. Kendi on books to help America transcend its racist heritage.” He is a professor; so creating a syllabus to facilitate the study of the history of race and racist policies is in his wheelhouse. 

 

What I discovered when I opened Dying of Whiteness was that Metzl is a psychiatrist and a professor at Vanderbilt University. He is the Frederick B. Rentschler II Professor of Sociology and Psychiatry at Vanderbilt and director of its Center for Medicine, Health, and Society. His academic concern is public health and Dying of Whiteness is all about the decline in our public health and the issues that we call the diseases of despair that have lowered the life expectancy of  White men over the last decade. He grew up in Kansas City, Missouri, and is well acquainted with the politics of Kansas and Missouri over the last several decades. He now lives and works in Tennessee. In his book, he uses his personal knowledge of the culture and people of these “red states” to inform his exploration of how concerns about race and the advantages of “whiteness” have propagated the presence and lethality of guns in Missouri, the unwarranted reductions of taxes that have destroyed education and infrastructure in Kansas, and the rejection by Tennessee of the Medicaid expansion offered by the ACA. With his public health expertise, he uses reams of data and interviews of poorer and lower-middle-class White citizens to search for the answers to many of the perplexing questions that were raised by Frank and Russell-Hochschild in their books.

 

Metzl follows Hochschild’s lead and largely avoids calling the people that he meets and interviews racists. In a PBS interview that I would encourage you to watch he describes how he tried to remain objective through the research and the writing of his book despite the reality that he is a lifelong Democrat. I think that he succeeded in managing his biases and as he says in the interview he admits that he has no idea of what is in the hearts of people. Like Kendi and Russell-Hochschild he understands that most people feel more comfortable within their own culture.

 

Most of us are capable of positive relationships with people of other races and even functional relationships with people from other social classes and other places. Kendi has revealed his own intense “racism” in multiple interviews and in his books. What unites Kendi and Metzl is their insight that the fact that people have racist ideas or feelings is not the main problem. The problem at the core of inequality is racist policies which are propagated by people who have much to gain in power and wealth by creating these racist policies that create inequality.

 

The creators of racist policies justify their actions by offering racist ideas to people who are afraid of losing their perceived advantages that arise from their “Whiteness.” Metzl adds to our understanding of the frequently lethal consequences of race, racist policies, and the politicians who use culture to create the controversies that cause polarization to support their self-interests and desire for political power. Racist policies that create inequity ultimately threaten the health of everyone in this country and the well-being of everyone on this small planet. 

 

For years, Metzl has studied the complex problems associated with “Whiteness” from his perspective as a psychiatrist and as a public health researcher. If you don’t have the time or interest in exploring what he has learned by reading his book, I hope you will use the link above to hear him describe in the PBS interview what he has learned. If you would prefer to read something that is short and to the point let me offer you an interview with Sean Illing published in Vox in 2019 when the book was published. 

 

A third brief offering worthy of your attention is an opinion piece that Dr. Metzl published in the Washington Post in August of 2019 entitled “It’s time to talk about being white in America.”

 

For too long, many white Americans have avoided this conversation, and we’ve done so for a reason: We don’t have to see the color white. Race scholars often argue that white privilege broadly means not needing to reflect on whiteness. White is the default setting, the assumed norm. A white American does not have to think about being white when walking down the street — while people marked as not-white are often noticed and surveilled. White people have the superpower of invisibility.

 

Further down in the article he writes:

 

Trump did not invent insecure whiteness. He is only a skilled manipulator of the fears at its heart.

For the past eight years, I’ve studied how these politics of racial resentment have profound negative consequences for working-class white communities. I traveled across southern and midwestern states to track the everyday effects of anti-government, anti-immigrant politics and policies. Time and again, I found that the material realities of working-class white lives are made worse not by immigrants and citizens of color — but by GOP policies that promise greatness but deliver despair.

 

Toward the end of his opinion piece he begins to offer solutions to the issues that he has identified:

 

One place to start is by avoiding what psychologists call “zero sum” formulations of race relations — in which there are “winners” and “losers” in fights for power or resources. Equitable societies are healthier for everyone, and alliances among groups with common socioeconomic interests (rather than identities) are more successful in achieving shared objectives. A white Kansan has more in common with his Hispanic neighbor than with a white Tennessean.

Unpacking whiteness also requires white people speaking openly — not by proxy conversations about immigration or guns — about the strengths and limitations of American whiteness. This means reflecting on white traditions of generosity and resilience, and not just the anxieties, biases and fears of white communities. It means talking about ways that white Americans can enhance or thwart American prosperity. And about how, to make America truly great, we need a more communal version of racial justice to emerge.

 

When I think about “…to make America truly great, we need a more communal version of racial justice to emerge…,” I am reminded of the exclamation “You can’t get there from here!” That is the punch line from a “Burt and I” routine, “Which Way To Millinocket” by the Maine humorists Marshall Dodge and Robert Bryan. Can we get from where we are now in the aftermath of four years of Donald Trump to where polarization is no longer killing us? How do we begin to move on from the politics of racial animus that has killed so many White and Black Americans over the years? Our culture wars have been fought on many battlefields north, south, east, and west in America that have been littered with White and Black bodies that have been sacrificed to pointless ideals that advantage no one in the long run even if they offer short term profits to a select few. The landscape in all directions from each of these many battles is becoming increasingly hot and subject to violent shifts in weather that result in even more loss.  In the midst of this continuing loss, much of organized healthcare seems preoccupied with its own profitability or lacks the courage to say, “Enough!” It seems such a tragedy to realize how much there is left to lose, and how it all could be saved if there was just a little more insight or desire to change.

 

Reason and data don’t seem to be enough to shift the balance which means that short of a miracle there are more losses to come. Dr. Metzl has done his exam. He has formulated his diagnosis. The lab tests confirm his professional opinion. We suffer not from a lack of analysis or information. We suffer from our ineptness and lack of will that are multiplied by fear that is multiplied again by the pursuit of short-term objectives that might maintain the power of a minority. I fear that our current inability to resolve our fears that are rooted in race could suggest that the only thing that is certain is that we face a very uncertain future. We could reduce that uncertainty if we could find the will to replace our fears and distrust of those who are our neighbors and fellow citizens, but who are not just like us with concern and a desire to offer a more equitable future to everyone. If we could do that, the Triple Aim would be a slam dunk. 

 

Beauty In Transition

 

I like big mountains, deep lakes, and wide vistas. I have come to realize that I often just miss the joy that I can be realized from little things that seem quite ordinary. When a source of beauty that is always with me but has gone unnoticed finally captures my attention, I ask myself what else have I been missing. 

 

We are now in the trough between summer and fall. This wasn’t the most consistently beautiful summer of my life, but I am grateful for the fact that there were many stunning days with clear skies, warmth in the seventies and low eighties, and low humidity even if frequently interrupted by unsettled weather. This summer was like the Red Sox’s season. Both the weather and the Sox have been spectacular on some days. Just like the Sox, the weather has been unable to sustain a winning streak that lasted for any appreciable stretch. There have been plenty of gray and stormy days to interrupt the balmy ones. 

 

Summer is gone, but I haven’t quite given up on the Sox. It’s possible that they could win a wild card game and then find the sustained success that they have not demonstrated since the All-Star break. Only a true fanatic like myself holds out for the possibility that a miracle will occur and the Sox will find enough steam to carry them deep into the playoffs. If this summer and the Sox of 2021 are remembered at all, it will be for their lack of consistency. The Sox of 2021 may still have a chance for glory. The summer of 2021 is pretty much over, and I am left to examine the little bits of residual beauty that I had previously overlooked because I am who I am. 

 

Today’s header is a good example of the beauty that I have failed to appreciate. What you see are flowers at the edge of my front yard that are still in bloom against the background of woods that are still at least a couple of weeks from full color. Neither source of potential beauty will survive the next few weeks. The transient nature of the flowers and the fact that all the leaves on the trees will soon be down reminded me that I need to try to expand my field of vision to include smaller sources of joy and beauty. 

 

I rarely pay attention to my front yard. My attention is fixed on the view from my deck toward the lake on the other side of our property. The landscape architect who helped us shape the presentation of our retirement home did understand that the front yard was what visitors would see first. She changed the path of our driveway to provide a view of the lake, designed a granite parking area and stone walks, and had wildflowers planted over much of the area between the road, the drive, the woods, and the front of the house. After a year or two of waiting for the architect’s vision to materialize, I was disappointed because the flowers did not meet my expectations and so we asked the man who mows and plows for us to replace the wildflowers with grass. 

 

After I thought the wildflowers were history, I never paid much attention to the side of the yard where the flowers were removed until about a week ago when I was surprised to discover that some of the flowers had come back! They aren’t the overwhelming focus of beauty that the landscape architect had imagined and sold to us as a good idea, but for me, they were a lovely surprise. I know that they will not last long. Our first frost is probably not far away. Summer has gone and fall falls off in beauty as soon as the leaves fall and that happens fast. We probably have 10 days till the peak fall color and not much more than a couple of weeks after that till all the leaves will be down. After the leaves come down, my next shot of local beauty will be the first snowfall. The cycles continue and seem to spin faster and faster. The lesson for me is to look for the little bits of beauty that I have so often overlooked as the spin continues.

 

I hope that your weekend will offer you a chance to find some overlooked beauty and enjoy a lovely early fall day. 

Be well,

Gene