April 1, 2022
Dear Interested Readers,
Are We All April’s Fools?
I made an interesting discovery on the Internet. According to Wikipedia, Odessa, the resort city of Ukraine on the Black Sea, is the only city in the world where April 1 is an official holiday. Everything has some sort of history, and so does April Fools’ Day. What I never expected was the bit about Odessa’s April Fool’s Day history.
April Fools’ Day has become the day that Odessa — a city weighed down by history — celebrates its tradition of wry humor and charming scoundrels. The practice began 40 years ago under the wary eye of the Soviet authorities. It has been marked by such episodes as a taxi driver who drove his rickety sedan all the way down the 400-foot staircase that is the city’s most recognizable symbol, where he was greeted by a complement of militiamen.
Tourists poured into Odessa on Monday for the festival, called Humorina.
Perhaps Odessa’s enjoyment of April Fool’s Day is an attempt to find some relief from a history full of pain that for some might make enjoyment of jokes unthinkable:
It is impossible to extricate Odessa’s famous wit from the horrors that took place here. [Issac]Babel was shot by a firing squad in Moscow in 1940, accused of spying. Nazis took control of Odessa the following year, sending Soviet fighters and ordinary citizens to seek refuge in the labyrinth of catacombs underneath the city. Thousands of Jews were moved to a nearby village and killed; thousands more were dispatched to concentration camps. Those who were left emigrated when they could. Odessa’s Jewish population, once 40 percent of the city, was down to 6 percent by the mid-1980s, according to the city’s Jewish Museum.
The strange fact of Odessa’s special connection to the pranks and jokes of April Fool’s Day seems to have been born as an expression of Ukrainian bravery in the form of “laugh at your oppressors.” The article continues:
Humorina was born of an act of censorship; in 1972, Soviet authorities decided to take a televised improvisational comedy competition off the air. A team of comics from Odessa had been winning, and local Communist officials, chagrined by the cancellation, supported their proposal to hold a festival, said Valery I. Khait, one of the festival’s founders.
History suggests that the desire for freedom and the willingness to endure great hardship in the pursuit of freedom and sovereignty seems to have always been a trait of the Ukrainian people and has recently been manifested once again with such drama and intensity that it has caused the rest of the world to marvel and reconsider our own shrinking commitment to democratic values in the light of their heroism. I wonder what April Fool’s 2022, or Humorina as the Ukrainians call it, will be like today. Perhaps in the midst of the fighting someone will yell “April Fool’s!” as a Russian tank is blown up. Fortunately, so far Odessa has been spared the level of destruction seen in nearby Mykolaiv and in Kherson and Mariupol further to the East.
The question that always leaves us in a state of bewilderment is “How will this end?” In my mind, there is an equally important follow-up question which is “How will Putin be held accountable for the needless loss of thousands of lives, the destruction of so much property, and the extensive damage to the economy of the world that he has done?” All this loss for what? Was it some bizarre attempt to pursue a twisted idea of Russian greatness and destiny? Was it Putin’s own personal form of megalomania that requires the world to kowtow to his faux hypermasculinity? When President Biden made his famous nine-word ad-lib last Saturday he expressed what many people felt needed to be said.” In case you missed it the president said: For God’s sake, this man cannot remain in power,”
High officials here and diplomats and leaders in Europe immediately began to walk the president’s comment back for fear that his words would pull the chain on Putin that is connected to his fear of America’s history of supporting “regime change.” The comment may have been a bridge too far, but I think the comment was an expression of the frustration that arises from the reality that it is hard to figure out how to effectively resolve a situation with someone who may be willing to use chemical or nuclear weapons rather than lose face. Nevertheless, for many people, myself included, the president’s frustration was understandable and an expression of the extreme uncertainty of the moment.
For the past month Tom Friedman of the New York Times has been writing about the uncertainty and risk associated with how the war will end, and the risks that Putin may be willing to take that have reduced our degrees of freedom in responding to him. He makes his point in articles with names like “Putin Has No Way Out, And That Really Scares Me.” Because of his personality, Putin has an inherent advantage if we examine everything we might do through the lens of “will this start World War III.” This week Friedman wrote:
It is impossible to predict how the war in Ukraine will end. I fervently hope it’s with a free, secure and independent Ukraine. But here is what I know for sure: America must not waste this crisis. This is our umpteenth confrontation with a petro-dictator whose viciousness and recklessness are possible only because of the oil wealth he extracts from the ground. No matter how the war ends in Ukraine, it needs to end with America finally, formally, categorically and irreversibly ending its addiction to oil.
Nothing has distorted our foreign policy, our commitments to human rights, our national security and, most of all, our environment than our oil addiction.
Friedman’s conservative colleague at the New York Times, Bret Stephens, had an interesting take this week on Russia’s apparent decision to withdraw from its attempts to capture Kyiv and focus on the East while they begin to negotiate. The piece begins with Stephens raising the possibility that Putin has not made as many mistakes as we would like to think. The column is entitled “What If Putin Didn’t Miscalculate?” Stephens does us a favor when he suggests that when the stakes are high we should not jump to conclusions and consider a wide range of possible explanations for the motivations of our opponent. He begins:
The conventional wisdom is that Vladimir Putin catastrophically miscalculated.
He thought Russian-speaking Ukrainians would welcome his troops. They didn’t. He thought he’d swiftly depose Volodymyr Zelensky’s government. He hasn’t. He thought he’d divide NATO. He’s united it. He thought he had sanction-proofed his economy. He’s wrecked it. He thought the Chinese would help him out. They’re hedging their bets. He thought his modernized military would make mincemeat of Ukrainian forces. The Ukrainians are making mincemeat of his, at least on some fronts.
Putin’s miscalculations raise questions about his strategic judgment and mental state…Several analysts have compared Putin to a cornered rat, more dangerous now that he’s no longer in control of events. They want to give him a safe way out of the predicament he allegedly created for himself. Hence the almost universal scorn poured on Joe Biden for saying in Poland, “For God’s sake, this man cannot remain in power.”
After reviewing the conventional wisdom of the moment, Stephens raises concerns about conventional wisdom when dealing with someone as slippery as Vladamir Putin.
But what if the conventional wisdom is wrong? What if the West is only playing into Putin’s hands once again?… Suppose for a moment that Putin never intended to conquer all of Ukraine: that, from the beginning, his real targets were the energy riches of Ukraine’s east, which contain Europe’s second-largest known reserves of natural gas (after Norway’s). Combine that with Russia’s previous territorial seizures in Crimea (which has huge offshore energy fields) and the eastern provinces of Luhansk and Donetsk (which contain part of an enormous shale-gas field), as well as Putin’s bid to control most or all of Ukraine’s coastline, and the shape of Putin’s ambitions become clear. He’s less interested in reuniting the Russian-speaking world than he is in securing Russia’s energy dominance.
Well, maybe. What is clear is the reality that what actually will happen remains to be seen and that Putin is not trustworthy. It is a fact that Putin is not predictable and his statements are usually false. Those realities are what make it so hard to know what to do. Friedman is right in asserting that we do enable Putin’s ability to frustrate us by choosing to live with little regard to how much oil and gas we burn. If there are any long-term possible upsides to this harrowing experience they are that we are reminded that strong democratic values are important if we want to imagine a peaceful and equitable future, that success in securing peace when the opponent is devious is effective cooperation, and that we must accept the transitional inconvenience and expense of moving from fossil fuels to other forms of energy.
So, are there connections between what the world will be like because of the sacrifices we will need to make to bring the war in Ukraine to an end and the future of healthcare? My first reaction is that when it is over it won’t be over. There are always many great challenges to overcome when a war ends. Wars don’t end crisply like the end of a Broadway play or The Suoer Bowl. They linger on in rubble, human displacement and confusion, and disruption of economies and ordinary lives that persist for many years. Good examples of that reality are the period of reconstruction after the American Civil War, the confusion and long periods of reconstruction after World War I and World War II, and the confusion that existed at the end of the “cold war” which was itself a response in part to World War I and World War II plus the evolution of competing (actually warring) philosophies from the late nineteenth century through most of the twentieth century. Even “little wars” like Vietnam and our adventures in the Middle East after 9/11 still impact us.
The aftermath of war lingers on for decades and even multiple generations. There are emotions in Europe and the Middle East that are attached to wars that ended over a thousand years ago. The effort to improve healthcare has not been a war. It has been a coordinated effort that at times has felt like a struggle. Most of the issues we have addressed like poor access to services, continuing cost increases, work/life balance for healthcare professionals, and a lack of equity in service and quality persist.
With the rapid succession of Trump’s election, COVID, concerns about police violence, the rights of the LGBTQ+ community, the rights of all minorities, the economy, the environment, plus the war in Ukraine, concerns about how to address the issues of healthcare moved out of the central field of vision of the public, and perhaps don’t seem as important even to those who work in healthcare. In easy-to-define ways, healthcare is connected to all of these concerns but is often not considered.
Rising healthcare costs, medical workforce issues, access issues, concerns about quality, and the deterioration of systems of care get lost within the larger discussion of inflation, supply chain failures, worker dissatisfaction, the dehumanization created by the digitalization of every aspect of life, and the surprising hostility we see on social media. Just as it is hard to know how the war in Ukraine will end and what will follow, I feel it is equally difficult to predict the future of healthcare reform and the trajectory of improvement of healthcare in America in the years to come. Like climate change and the deterioration of our infrastructure, failing systems of healthcare and what to do about them seem to get lost as we attempt to deal with the garage of problems that seem to be more acute. Just because our attention is diverted these chronic issues don’t go away. They continue to grow.
In recent years we have felt good when we were able to hold the yearly increase in the cost of care year to less than three percent. Last December, even before the war in Ukraine and the rapid increase in overall inflation, CMS was predicting an almost 6% increase in cost for this year and that healthcare would be 20% of the economy by 2028. As in the past, the cost of care will be rising significantly faster than the growth in the economy. Healthcare is a major part of the economy and the trend has been to shift more and more of its cost to the consumer which impacts poorer people differentially. The cost of labor including doctors and nurses is rapidly increasing as people age out or leave their professions at rates that overwhelm our ability to develop their replacements. The outlook for healthcare as an industry is confusing, but the outlook for consumers is not confusing at all. Consumers can expect to have more and more of the cost of care shifted to them. Consumers can expect to encounter systems of care that are more complicated and harder to navigate. Consumers already know that it is harder to get access to a system that costs more for less. Consumers can also imagine that the attention of politicians will be directed elsewhere. Consumers may get the idea that in all the confusion of our times those that lead healthcare may be more focused on the financial health of their institutions than on the cost, access, and equity of the care they provide.
I have always thought that healthcare does not need to choose between managing the escalating costs that are a burden to its consumers or its own potential for financial failure. What happens in other industries to simultaneously lower the costs of service while continuing to have a positive bottom line? The answer is often innovation and succeeding in the competition to provide a better product at a lower cost. Systems improvements that have worked in other industries have never been widely embraced in healthcare. We talk about innovation in healthcare, but it has been my experience that innovations in healthcare are almost always associated with an increase in cost that managers try to justify by claiming that there are developmental costs that must be reclaimed. Competition has been negated by mergers and affiliations that promise operational efficiencies that are never experienced as consumer savings.
There has always been a dedicated core that has worked hard to make the Triple Aim a reality that improves the health of the nation. That core has been more than blocked by the status quo. Healthcare has the ability within itself to lower the cost of care while improving quality and safety while improving the professional experience and compensation of caregivers. Pioneers like John Toussaint and Patty Gabow have shown the way. Large organizations like Kaiser have shown that more does not have to cost more.
I think that there are difficult realities for the future that will be hard to manage without the full engagement of a majority of healthcare providers. Our current methods of practice are unsustainable with an acceptable level of quality without changes that healthcare initiates. We have an aging population with increasing requirements for chronic disease management. Our population is using more and more surgical procedures to manage large joint degeneration. Our increasing public health concerns from newer more virulent viruses will continue to disrupt the status quo. Our continuing pandemics of substance abuse and disabling emotional distress that are partially explained by the stress of our times will not go away, and our system of care inadequately addresses these issues.
We need new and more efficient ways of providing care. Telehealth has been a mostly positive technology but is it the long-term answer to our access issues? There are many complex questions that I am sure someone is studying but we have a poor track record of moving from old systems to more efficient processes that require a learning curve or some social change for adoption. In the past, I have mentioned Atul Gawande’s observation that we were once ignorant, but now we have knowledge. We are no longer ignorant, but any objective assessment would suggest that we may be inept. Ineptitude is correctable. I reject the idea that we don’t care, but I do believe that things will not move forward until healthcare decides within itself to solve the problems that are a growing problem for those who come to us for care. I am not going to say, “April Fool’s!”
Two Steps Forward One Step Back
If you did not notice it, I have been anticipating Spring with mixed emotions. On the one hand, Spring can’t come too soon, and if the pathway to warmer weather passes through an early ice-out, mud season, and a swarm of black flies, so be it. The downside is that an earlier Spring is almost for sure an indication of the unblocked process of global warming. I heard on the radio that the average temperature during the winter in Aspen, Colorado is up three degrees since 1980 and that has translated into thirty fewer days of skiing. Under the rubric of “thems that gots gets” the solution for many of Aspen’s regulars who fly in on their jets, will just be to fly to some other mountain where there is still snow. Most of us don’t have that option.
To my surprise, after getting ready for an extremely early Spring, winter made a brief comeback. As you can see in the header for today’s letter, we had a little more snow. More significantly, the temperatures dropped into the low teens, the wind chill factor dipped near zero, and it stayed that way through midweek. It was a step back into winter. It was a brief reprieve from mud season because all the mud froze! I sort of enjoyed it, Now we are back on track for that early spring and sort of a relatively early ice-out just in time for the first game of the baseball season next Thursday. I hope that you will be able to take a walk in warmer weather this weekend. There is no better way than a moment in nature to enjoy a few moments of reprieve from the worries that otherwise fill our days.
Be well,
Gene
