April 22, 2022
Dear Interested Readers,
Remember the Alamo! Remember Azvostal! Remember The Triple Aim!
I became an enthusiastic student of history in the seventh grade. By the eighth grade, I received the DAR medal for being the best student in American History. Winning that award may have been the most satisfying moment of my education since it was the first time that I set a goal and then achieved it. I don’t know what they are teaching these days in Texas, certainly not “critical race theory,” or whether they even use books, but sixty-five years ago we studied Texas history in the seventh grade, American history in the eighth grade, and world history in the ninth grade. The focus in all of those classes was being the best. We were told that Texas was the greatest state and had been its own country. There was no doubt about “American exceptionalism.” We had a destiny and God was on our side. America led the world, and Texas led America.
The highlight of my seventh grade Texas history course was the field trip our class took by bus from Waco to San Antonio to see several of the famous Spanish missions in and around that lovely city. The most famous of the missions is the Alamo. We don’t remember the Alamo because of its missionary work. It is remembered because it was the site of the Battle of The Alamo where for almost two weeks about 180 men defended it to the death against the 1500 man army under the command of the Mexican General Antonio López de Santa Anna. I did not need the trip to know all about the battle and its heroes like Davy Crockett, Jim Bowie, and William Travis because Walt Disney had already given me the story in living color. I also knew that about a month later at the Battle of San Jacinto near what is now Houston, a larger group of Texas under the command of Sam Houston and shouting “Remember the Alamo” had defeated Santa Anna’s army and then captured him. He was sent back across the Rio Grande to Mexico to secure independence from Mexico for Texas. Texas remained an independent nation for about nine years before it was finally annexed and joined the union in 1845 as the twenty-eighth state.
It should not be a surprise to you that I have remembered the Alamo over the past few weeks as we have witnessed the brutal destruction of Mariupol and the atrocities that have occurred there which have culminated in the retreat of the last two thousand defenders of the city to the fortress-like Azvostal Ironworks. It has been distressing to know that there are at least a thousand civilians including many women, children, and the elderly who have also sought refuge in the underground passageways that connect the many buildings of the sprawling operation. that covers four square miles.
The defenders have refused to surrender and like the Texans at the Alamo have resolved, if need be, to die defending their position to protect their country. Their position and bravery reminded me of the Texans at the Alamo. I should add that after I visited the Alamo for the first time with my class in the spring of 1958 an even larger movie about the Alamo came out in 1960 with John Wayne playing Davy Crockett and Richard Windmark starring as Jim Bowie.
I should not have been surprised to learn that other people have made the same association between the Alamo and the brave defenders of Mariupol. My search reminded me that going back to the Spartans at Thermopylae in 480 BCE, and perhaps even before recorded history there are true events and stories of those who would rather die than surrender and that often their sacrifice resulted in encouragement to the living that enabled a complete victory later. I recommend that you read a very good Washington Post piece published yesterday by Andreas Kluth entitled “Mariupol Could Be the Thermopylae of the 21st Century.” In the article, Kluth reminds us of Thermopylae, the Alamo, the defenders of Masada in the year 74, and the Japanese samurai army that chose to die during the Satsuma Rebellion rebellion of 1877.
Near the end of the article Kluth conjectures about the motivations of those who are willing to make such sacrifices:
No matter the particular circumstances, for those of us in more humdrum life situations, last stands remain mysterious. What motivates men and women to face such overwhelming force, and near-certain death? It may be that they’re heeding a primal instinct to fight injustice — even if it only means making the enemy pay the highest possible price. If we sell our lives dearly now, the instinct may whisper, future attackers will think twice about coming after our kin.
This war has already begotten some amazing surprises. It was about six weeks between the time when the Ukrainian soldiers on Snake Island refused to surrender to the Russian ship Moskova and when the Moskova was sunk by two Ukrainian Neptune rockets. Perhaps that was what was on Putin’s mind when he surprised us yesterday by saying that he would not attack the defenders at the Azovstal metal works. It is said that Putin studies history. Perhaps, he is backing off from his threat of total destruction for the defenders of Mariupol who are under siege at the Azovstal plant because he fears his own “Battle of San Jacinto” with the Ukrainian soldiers yelling “Remember Azovstal” as they send his soldiers scurrying back to Russia.
I was intrigued by a column written in the New York Times on Tuesday by their conservative columnist, Bret Stephens entitled “Why We Admire Zelensky.” Pre Donald Trump, many Republicans like Stephens were true conservatives that had values that supported things like free elections, the Constitution, and the role that America was required to play as the leader of the “Free World.” Stephens caught on early to the wrong turn of his party and said in early 2017 that he could never vote Republican again. Not much has changed since 2017. In fact, my guess is that Stephens would say that things are worse. After January 6, 2021, he told The Hill that Republicans were “walking to the edge of moral irredeemability.”
Irredeemable or not, the Republican Party is now dazed and confused about where it stands on many issues including the position of many of its wannabes on the values that are demonstrated by President Zalensky and what appears to be most Ukrainians. Thomas Edsall documented the confusion within the GOP this week in a Times commentary entitled “With or Without Trump, the MAGA Movement Is the Future of the Republican Party.” Trump’s hijacking of the Republican Party has left many ethical conservative writers like George Will, David Brooks, David French, and Bret Stephans without much of a home. In the second paragraph, Stephens answers his own question about why we admire Zalensky by saying:
We admire him because, in the face of unequal odds, Ukraine’s president stands his ground. Because he proves the truth of the adage that one man with courage makes a majority. Because he shows that honor and love of country are virtues we forsake at our peril. Because he grasps the power of personal example and physical presence. Because he knows how words can inspire deeds — give shape and purpose to them — so that the deeds may, in turn, vindicate the meaning of words.
We admire Zelensky because he reminds us of how rare these traits have become among our own politicians.
He expands his answer a little further along and connects the core value which I have bolded with the future of Ukraine with our future:
We admire Zelensky because he has restored the idea of the free world to its proper place. The free world isn’t a cultural expression, as in “the West”; or a security concept, as in NATO; or an economic description, as in “the developed world.” Membership in the free world belongs to any country that subscribes to the notion that the power of the state exists first and foremost to protect the rights of the individual. And the responsibility of the free world is to aid and champion any of its members menaced by invasion and tyranny. As it goes for Ukraine, so, eventually, it will go for the rest of us…
…We admire Zelensky because he rouses the better angels of our nature. His leadership has made Joe Biden a better president, Germany a better country, NATO a better alliance. He has shaken much of the United States out of the isolationist stupor into which it was gradually falling. He has forced Europe’s political and mercantile classes to stop looking away from Russia’s descent into fascism. He reminds free societies that there can still be a vital center in politics, at least when it comes to things that matter.
I have not transferred all of the characteristics that Stephens lists that cause us to admire Zalinsky, but he ends by pointing out the hope for ourselves that Zalensky ignites:
We admire Zelensky because he holds out the hope that our own troubled democracies may yet elect leaders who can inspire, ennoble, and even save us. Perhaps we can do so when the hour isn’t quite as late as it is now for the people of Ukraine and their indomitable leader.
One risk that threatens the collective solidarity of the free world in its efforts to support Ukraine occurs this weekend in the form of the French presidential election. President Macron is expected to defeat again, as he did in 2017, his far-right opponent Marine LePen, but victory is not certain. A win for LePen on Sunday would undermine the solidarity of Europe and NATO in their resistance to Putin.I will be nervous awaiting results from the French election on Sunday, as I reflect on our 2016 election that produced President Donald Trump. It would be devastating for the people of Ukraine if the President of France were in Putin’s caamp.
I remain in awe of all of the Ukrainians, the heroes willing to die in Mariupol, and the man who reminds us of the values we were at risk of forgetting before he told us that he needed ammunition not a ride to safety. I also remain in awe of the glimpses of care for one another that I see in news reports and read about in my news links.
Life goes on here, and this week I was reminded that we like to focus on American exceptionalism and frequently overlook our own needs for improvement. From time to time I have given you a glimpse of what I see around me in this rural 99+% caucasian environment in which I live. If you are interested, the two most recent case reports that I mentioned about a month ago have good endings. The fellow who needed to have electricity brought to his home so that he could return with an oxygen concentrator is getting electrified. His town contributed over $4000 and the organization of which I am a member, Kearsarge Regional Ecumenical Ministries, and a local Catholic organization, Loaves and Fishes, each contributed $1500 dollars to complete the project.
The other man that I mentioned who needed help with his car repairs also benefitted from a consortium of payers that included the town of Sutton, KREM, the Baptist Church in New London, and a nearby community charity founded more than a decade ago by my old colleague and the Atrius CFO, Tom Congoran, who died last September, and his widow Mary. Their organization is named Contoocook Carry Community Fund.
When I was practicing I was always devastated by the death of a person for whom I had provided care. I felt that each loss deserved an analysis. Continuous improvement toward the Triple Aim is a value that I feel should be of cardinal importance to healthcare providers as the agents of health for our nation. As a believer in the power of Lean to move us toward important objectives, I came to believe that the road to better health for everyone ran more through the analysis of our failures than through the celebration of our successes. If I am going to tell you about our recent successes, I feel it is necessary to report our failures. I want to tell you about the life and death of an unfortunate thirty-five-year-old man whom I will call Gary.
Midday on Tuesday, Gary was found dead in his bunk at a homeless shelter in Claremont, New Hampshire about thirty miles to our west. Gary lived most of his life in the Kearsarge region and many of us knew him. Gary’s dad died from complications of his alcoholism when Gary was three years old. His mother died of breast cancer when he was seven. After they were orphans, Gary and his brother and sister were placed in foster care with people his mother had chosen before she died. Despite the connection his mother made, Gary reported to me that he felt abused and was never happy in his new home. Everyone who knew Gary was impressed with his intellect. He was a talented workman who was widely admired as a builder and repairer of stone walls. Along the way, he was given the diagnosis of being bipolar and it may have been his attempts at self-medication that lead to his alcoholism.
Gary had many many admissions to detox facilities and to medical facilities in attempts to manage his alcoholism and his biopsy-proven cirrhosis. After a midwinter hospitalization at Dartmouth Hitchcock, he was followed closely at a local community clinic. A friend of Gary’s told me that at Dartmouth he was told that if he continued to drink he would probably die within two years because of the advanced state of his liver disease.
I first met Gary a couple of years ago when he was renting a room in a local home and needed help with the rent and his share of some of the utilities. At that time he told me that he was of proud Scandinavian heritage which was obvious from his family name. Let’s call him Gary Johansson, although that was not his name.
As time passed I had several conversations about how he might be helped with the town welfare officer in his community who knew him well. She knew him well from her attempt to help him and because he had attended the local high school along with other people she knew. The pattern of detox, work, disruptions, minor interactions with the police, and loss of housing fueled by increased drinking, and then a return to detox, continued. I lost contact with him for a year or so after he fought with the people who were offering help with the hope that the cycle might be broken. I did not see Gary, but I would be contacted for advice from time to time by his only real friend who was herself a recovering alcoholic with almost a decade of sobriety. She described herself as his guardian angel.
While Gary was hospitalized at Dartmouth this winter his friend asked me for advice and I was surprised to learn that although he had Medicaid he had no disability benefits. His greatest problems always occurred in the winter when he could not work and had no income. About a month ago his friend asked if I could talk to him about whether our organization would try to help him again. As I said before, he had rejected our help and “fired” the counselor we provided more than a year ago.
I agreed to talk with him and was surprised by how logical and simple his requests were. He said that he had been recently robbed at the shelter and his money and his work boots were taken. He needed $138.00 to place an ad in the local weekly “Shopper” where handymen, cleaning services, and merchants advertised. He also needed about $150 for new boots that would protect his feet when he worked.
Our organization believes that we should not do for someone what they can do for themselves. I asked him to set up the ad which he had done before. I promised that we would handle the payment. That was easily accomplished. We agreed to talk at least once a week with the goal of eventually finding housing and work for the winter when he could not build stonewalls and sleep in the woods. We spoke a few times about when he would need the boots. I last spoke with him on Friday, and all was well. He was optimistic because he already had a job that would begin soon and would yield $8000. He had planned to “camp out” near the wall while doing the work since he did not have a car. His friend thought he might benefit from an e-bike since he had no car and had lost his driver’s license years ago,
Tuesday morning Gary texted his friend that he was feeling “very sick” and was going to lie down. Three hours later the local police knocked on her door to tell her that he had been found dead in the bed.
I think that all doctors and nurses are profoundly moved and reflective when they lose a patient. They usually spend time thinking about what might have been done that was forgotten or not considered. I was not Gary’s doctor, but our group was trying to help him. I was the person in direct contact with him although all of our contacts had been by text and phone since he was more than thirty miles away at the homeless shelter. I should add that the shelter was trying to help him optimize his benefits. We did have objectives related to his well being so in essence it did feel like a therapeutic relationship that brought forth a lot of old practice reflexes and emotions
Gary was a member of several very vulnerable populations. His medical problems were cirrhosis and a seizure disorder which were both probably secondary to his alcohol use, but I must believe that the biggest problems were a very traumatic childhood, bipolar disease, substance abuse, and his social circumstances. An autopsy is being performed. I hope that it will not reveal a drug overdose or a significant alcohol level.
Gary’s several populations are ones that we don’t serve well. Sequentially, he was a child in poverty who was a ward of the state. He had emotional and psychiatric issues that would challenge any system of care. I am not going to try to explain how his alcoholism developed but he was a member of the population of alcoholics, but I feel certain that in part his alcoholism was an attempt at self-medication. Not as obvious as a problem was the fact that Gary lived in a small town/ rural environment where services are limited. The town welfare officer who knew him well said that attempts to get him treatment for his problems in Hanover, Concord, and Manchester were always complicated. He signed himself out of all of the programs he was offered. There are plenty of problems that offer a host of potential explanations for Gary’s outcome.
Gary is not alone. Tens of thousands of people of all ages die in this country every year of their unmanaged emotional and social issues, substance abuse, and unmanaged psychiatric problems. We use these problems as explanations, but they should not be used as excuses. Our challenge remains to translate those explanations into programs of effective treatment that are available to everyone. We do not devote equivalent resources to problems like the ones that caused Gary’s death that we devote to cancer, cardiovascular disease, pulmonary disease, neurological diseases, and congenital diseases. The list of disorders and diseases that we approach more effectively than the combination of issues that killed Gary is long. I know that we can do better.
I hate to say it, but I think Gary would have had a better chance in a larger more progressive state that better supported social services and provided a more robust social services safety net. He would have had a better chance if he lived in a city. I think that Gary suffered from a certain type of inequity that we often ignore, but is real in small towns in small states. It is a sad reality that you do not have to live in Mariupol to die an avoidable death. The concept of the Triple Aim is utopian and there has never been a lasting utopia or an attempt at one that survived more than a few years even with the best of intentions. Check out Brook Farm.
Utopian societies invariably fail, but improvements occur every day. I think that there must be improvements that could be made that will be too late for Gary, but I know that there are many men and women who suffer in the same ways Gary suffered and I must believe that we could help them avoid his fate if we had the will to do so. Perhaps if the troubles in Ukraine remind us of some of our fading values the outcome will be that we will find a way to give those in need like Gary who is nearer to us some of the help they need in time for the efforts to make a difference. Saving lives, improving health, and reducing suffering is what healthcare has always said was its purpose.
It’s Not Really Winter Again
The header for this week’s letter might suggest that we are still in the grips of winter. It was below freezing Monday night and we did wake up to a covering of snow on Tuesday morning, but by 3 PM it was in the mid-fifties and most of the snow was gone. I hope it was one last encore for the dead season; but, I could be wrong. I well remember an early May snowstorm in Boston back in the mid-eighties when all the trees had their leaves and many limbs came down under the weight of six or eight inches of wet gloppy snow. Late spring snowstorms can follow a day at the beach in New England.
Spring is a season of surprises. I think that I have enunciated my theory of the seasons in New Hampshire in these notes, but it seems appropriate to do it again. Winter is the dominant season in New Hampshire. Winter begins whenever it desires, often between Halloween and Thanksgiving, and continues off and on through Memorial Day although it occasionally takes a few days off in April and May. Spring tries hard to impress us with intermittent appearances as winter allows through late April, May, and June. Spring is more a state of mind than a fixed reality. Summer is well defined. It begins on the fourth of July and ends at 6 PM on Labor Day. Labor Day is like a door we walk through into fall which can be interrupted by violent weather coming up the coast from the Gulf. Fall is done when the leaves are gone in late October unless winter decides it wants to come around Columbus Day. I accept spring as an intermittent experience. I need to be prepared to take advantage of any spring day that might show up. There have been a few sunny but chilly days this week, and the weatherman is trying to convince me it will be warmer this weekend. If that prediction turns out to be true, I might get out on the water in my kayak sometime this weekend and catch my first fish of the season.
Even if I don’t muster the courage to fish, there are other signs of “intermittent spring” to give me hope of better things to come soon. I can see a few green shoots in our flower beds that may soon become yellow daffodils and the maple trees along the shore have a reddish hue from their buds that are about to become leaves. We are still waiting for Loon number two to arrive.
I hope that your weekend goes well and that you continue to protect yourself from COVID. My son and daughter-in-law in Brooklyn were pretty sick for a week even though they were fully vaccinated and boosted. I think that Paxlovid helped them recover. Now, my granddaughter who is a student at Bowdoin is quarantined to her room until at least Saturday when she hopes her test will be negative. She was also fully vaccinated and boosted. Most of her teammates on the Bowdoin Women’s Volleyball team plus her roommate have been infected. I think the federal judge in Florida, Judge Kathryn Mizelle, who ended the CDCs mask authority may have done many vulnerable people a great disservice. It is interesting that she is a 33-year-old 2020 Trump appointee who was deemed “unqualified” by the ABA. It seems her chief qualification was that she clerked for Clarence Thomas. We live in strange times.
Wear your mask when it makes sense, and be well,
Gene
