December 11, 2020
Dear Interested Readers,
Trying To Survive The Moment While Waiting For The Slow Evolution of Positive Change
It has been a gruesome week in Lake Wobegon and across the land. It turns out that even in Lake Wobegon strange and frightening things are happening. Garrison Keillor describes disturbing events in his recent book, The Lake Wobegon Virus, which I have just finished reading in an attempt to find a few moments of escape from a crumbling world that is stranger than fiction. In the book a strange virus associated with raw cheese made from reindeer milk causes many very conservative people in Lake Wobegon to lose their social inhibitions and do embarrassing things. Keillor, a long time hero of mine, must have some sense of empathy for his characters since he fell from fame and social grace three years ago. NPR fired him in a flash when he was outed for “inappropriately touching” a woman.
There is a whiff of that event in the recounting of a moment of public humiliation which will live forever on YouTube for the character that is supposedly him in the book. Several characters in the book who did embarrassing things because of their affliction with the virus feel bad about their inappropriate actions and seek to gain some degree of forgiveness and redemption. The book may represent an attempt by Keillor to begin a road back through his own literary attempt at explanation and confession of error. We will see. He has just published a memoir that I have not read yet.
We all make mistakes and do embarrassing things that create problems for ourselves and others as we pursue personal advantage in a complicated world. I guess that we can divide the world into two groups. There are those who are aware at some point that their pursuit of self interest has been a problem for others and they feel bad about it. Then there are those who never give evidence that they question their own motives or care at all about how their pursuit of what is best for them might lead to loss or pain for others.
As bad as it has been in Lake Wobegon with their unusual virus, it has been a lot worse in the real world for the rest of Minnesota, and for all of us across the country from coast to coast and from border to border as we have struggled to remain safe from our virus, the coronavirus. It is staggering for us to try to process losing over 3,000 people a day to the virus, and to simultaneously hear that the worst is yet to come. There are no words to politely express the astonishment that in the midst of such a loss of human life the only thing that we have heard from the president is that he really won the election.
I can remember that my report cards back in elementary school had subject grades on one side and measurements of social behavior and achievement on the other side. There were three levels of social accomplishment there were graded across a few behaviors that were listed–first, was “S” for “satisfactory, meets expectations; second was “I” for “is showing improvement;” and finally, “N” for “needs improvement.” One of the categories for grading was entitled “Is aware of and respects the rights and feelings of others.” I can remember a sense of great personal humiliation when during one grading period in the second or third grade my teacher gave me an “I” and checked “is showing improvement” in the category about “awareness of the rights and feelings of others” which implied to me that I was deficient in that assessment of development. I was shamed and reluctant to show my otherwise exemplary report card to my parents. I promised myself that I would do better. For the grading period covering the president’s first term the majority of the electorate has checked the “needs improvement” box on the president’s report card. So far he does not seem to have gotten the message.
Life and loved ones are not the only thing that people are losing. Almost a million people have lost their job over the last week or so, and millions more are lined up for food at food banks. And there is more. Many of those people in the lines at the food banks are on the brink of homelessness and yet the House and Senate are slow to offer any relief suggesting that collectively they too have a problem with empathy and need some improvement in recognizing the “rights and feelings” of others. It is a staggering reality that the House and Senate where their members can’t agree on a relief package for those who live in fear of hunger and homelessness are clubs for millionaires. Both David Perdue and Kelly Loeffler who are running for reelection to the Senate from Georgia have enormous wealth. Both have been accused of insider trading because they sold stocks on the basis of intelligence gained in Senate briefings early in the pandemic.
There are sad stories of unexpected losses across the country, even as there is hope that perhaps over the weekend the first doses of vaccine will be given to front line healthcare workers and our most vulnerable seniors. This week the pandemic has flared in my little state. Cases and deaths are up sharpley. In one nursing facility in Hanover 90% of the patients and 22 employees are positive for COVID-19. This morning’s newspaper reports a second death among the residents who are infected. The most shocking event of the week and the headlines again in today’s Valley News was the death of the Speaker of the New Hampshire House, a 71 year old man who was elected at an outdoor session of the House held on the UNH campus has died of his COVID infection one week after he was elected. There are several New Hampshire officials who are positive–possibly because there was a recent indoor caucus of Republicans where some participants did not wear a mask. More than a quarter of the Democratic legislators skipped the swearing in ceremony for the New Hampshire House which was the speaker’s last public appearance because they knew that many Republicans had attended the indoor caucus without masks. What will it take to make the point that the virus does not care who you are? It jumps on any vulnerable host it encounters.
The virus does practise perfect equity. We have come to realize that what happens to put victims in its way, or how those victims are managed after getting infected is not so equitable. It is now generally recognized that there are more Black, Latinex, and Native American who get the virus and die from it, because they are the people who hold the low paying “essential worker” jobs and their access to the care, especially access to scarce medications and hospital resources is not equal to the access and care of wealthier Americans. Sheryl Gay Stolberg published the facts earlier this week in a New York Times piece entitled, “Trump and Friends Got Coronavirus Care Many Others Couldn’t: Rudolph W. Giuliani became the latest in President Trump’s inner circle to boast about the treatment he received for Covid-19, as hospitals across the country ration care.” Ms. Stolberg writes:
“If it wasn’t me, I wouldn’t have been put in a hospital frankly,” Mr. Giuliani, the president’s personal lawyer, told WABC radio in New York. “Sometimes when you’re a celebrity, they’re worried if something happens to you they’re going to examine it more carefully, and do everything right.”
Mr. Giuliani’s candid admission once again exposes that Covid-19 has become a disease of the haves and the have-nots. The treatment given to Mr. Trump’s allies is raising alarms among medical ethicists as state officials and health system administrators grapple with gut-wrenching decisions about which patients get antibodies in a system that can only be described as rationing.
The remainder of her article is a broad survey of the inequities in care and the rationing of resources across the country that explain why it is the social factors and inequities in care and not genetic differences between populations of otherwise similar people that cause results to vary along a continuum from poor to wealthy. It’s a picture we have seen before. It’s your ZIP code and not your genetic code that explains how you fare in our system of care. Economic and social inequities are determining outcomes before we begin to try to quickly answer the question of who gets the vaccine first. In the months until the virus is vanquished we are likely to continue to struggle with the rationing of care. The article underlines the reality that we have not learned how to equitably resource and distribute the superior levels of care that have quickly rescued vulnerable targets like Donald Trump, Rudy Giuliani, and Chris Christie even as similar patients die.
For me the most striking absurdity of the week is the president’s silence about the fact that the daily death count keeps rising past 3000. It is interesting to remember that in May a leaked government paper predicted we could soon see 3000 deaths a week. That warning was renewed in September. The president was wrong in the spring and again in September when his actions and words implied that there was nothing to worry about. Now we know that the scientists were right and ignored. A significant number of Americans followed the words and example of the president and now thousands of Americans are dying every day. We will soon pass 300,000 lost American lives. And all he can say is that he really won the election, and he is trying to take his complaint to the Supreme Court via a case filed by Texas Attorney General Ken Paxton, who also filed the Supreme Court case against the ACA.
Paxton was once again joined by seventeen other “red state” state attorneys. This coalition was essentially the same crowd that said that the ACA was unconstitutional without the mandate. As the week has progressed, Trump has not set aside his own concerns long enough to offer any perspective on the crisis, let alone offer a fake sense of loss and condolence for those families of the thousands who have died. Since the election there is not much evidence that he is paying any attention to his responsibilities. He did stop by one of two White House Hanukkah parties for hundreds where there were masks but social distancing was optional. During his short appearance he regaled his guests with the completeness of his victory.
These are strange times. I hope that by the time you read this note the Supreme Court will have once again refused to hear the president’s case. The good news is that we have several vaccines that individually or collectively might stop the pandemic over the next several months. The bad news is that there will be tens of thousands more, like the New Hampshire Speaker of the House, who will die waiting for their turn to be vaccinated.
Long ago I learned that most of what is happening today is the result of decisions and events that occurred months or even years in the past. What we do today may have some small impact on tomorrow or next week, but most of the important things that flow from today’s decisions will play out over years. If you give any attention to what I have been writing over what is now almost thirteen years, you know that I believe in the long view. The ACA is a perfect example of a product of the long view. It made its way through the legislative process during 2009 and the first months of 2010. Most of the changes it introduced were not implemented until 2014. But the story has a very long prequel. Most of the principles in it were transferred from Crossing the Quality Chasm (2001) and Romneycare which passed in Massachusetts in 2006. But the story is much longer than that. The quality movement can be traced to the late seventies and early eighties. Romneycare has a similarly long history. “Romneycare” had at least a twenty year gestation before it appeared in 2006. It had evolved from sources as varied as a conservative think tank in the late 80s, and an activist movement in Massachusetts with roots in the 70s that coalesced into an effective voice of advocacy in the late 80s called “Healthcare For All.” Healthcare for All was also the name of a law that failed to accomplish its objective that was passed during MIchael Dukakis’ administration in 1988. The true history of the evolution of our perspectives on our progressive concepts of healthcare can be traced back to the progressive agenda of Teddy Roosevelt’s failed Bull Moose Party over a hundred years ago. And he drew his ideas from movements in Europe that reached deep into the 1800s!
Change is a slow process. If you remember the conversations about “Medicare For All” from the Democratic Presidential Primary Debates from last fall and early this year before the first lock down, there was a sense that universal coverage would be a reality soon after a Democratic president was sworn in on January 20. It is increasingly obvious that without the miracle of large Democratic margins in both the House and Senate, or the even greater miracle of bipartisan cooperation, “quick change” remains an impossibility. I am encouraged by the appointments that Joe Biden has made so far. I thought Xavier Becerra would make a great Attorney General, but I think he may also be a surprisingly good Secretary of Health and Human Services where he will manage the CDC and also be responsible for CMS and CMMI. Coming from California he is well aware of what can be accomplished to promote increased access to care through improved quality, waste reduction, and cost savings through administrative directives. There are many millions of Americans who could be added to the ACA through expansion of Medicaid in all the “red” states. There is much that can be done to improve quality and reduce waste and cost through payment mechanism evolution that has been neglected by a Trump administration whose only goal was to undermine the ACA. It will be interesting to see what Biden can accomplish through a talented administration based on the options that are currently available through the ACA as it stands.
Forty one days stand between where we are and the beginning of a better future. There remains some small risk that we will encounter violence triggered or encouraged by the president or some other last ditch act of desperation from him that could negate the election and mark the end of our democracy. I hope not. I think not. But 2020 has taught me that the unexpected is possible. I must realize that the slim possibility for disruption will persist until Biden is in the White House. If we do have a President Biden on January 20, he will face an enormous set of challenges. There is a huge mess to clean up and he will need and deserves our support and patience. If COVID-19 has shown us anything, it has revealed that we are a land of opportunity where great accomplishments are possible, but we have plenty of opportunities available to be better and more equitable at getting better. Have we learned anything from what we have seen? Will we remember what we have learned once COVID is gone? Only time will tell.
I Saw Ice!
There are two times of the year that I find tedious in northern New England. The worst time is what we call “Mud Season.” If you clicked on the link and read the article from DownEast magazine you learned that “mud season” arrives in late March, or very early April when the snow has melted and before the trees and other vegetation wake up from their winter dormancy and begin to take up water from the soil and pass it into the atmosphere as they begin to grow. Part of the problem is that New England is mostly rocky. We were covered with ice a mile thick less than 15,000 years ago. Our top soil is not thick and rich. It is mostly clay from the silt of the glacier, and water does not percolate through easily. It just makes mud. I live on a pile of glacial rock and silt that is a natural dam that has created a lake. Fortunately for me the road to my house is paved.
As mud season progresses we experience an invasion of flies and other annoying insects. By mid May or early June we get some spring and everything is beautiful until the leaves fall during the last couple of weeks of October. There is no name for what we experience between the shedding of leaves from the trees and the full flower of winter. The time from late fall after the leaves are down until early winter has no poetic name. It is just a drab time. This period of almost two months after the leaves fall and until the snow and ice cover everything, is the second time of the year that I endure with pain. It is the time of transition between the browning and falling of leaves and the beginning of the real winter which begins when we have a frozen lake and a covering of snow. Winter is a wonderful season. The best image of this drab transitional time of the year comes from the 60s pop song “California Dreamin.”
All the leaves are brown (all the leaves are brown)
And the sky is gray (and the sky is gray)
Brown leaves and gray skies may be all the winter you get in some places, but where I live that is a description of the weeks we endure in the run up to the real winter. The time between the colors of fall and the full beauty of winter is pretty dull. We usually get through it with a combination of football, Thanksgiving, and the parties and social events of early December in the run up to Christmas, Hanukkah, and New Years. In the awful year of 2020 most of those distracting events have been modified or cancelled and we must deal with the brown leaves and the gray skies without much relief from holiday excitement.
You can imagine my delight when we got a barely adequate blanket of snow over the weekend. I took it as an announcement that the drab season was almost over. Predictions were that we might get 6 or 8 inches, but unfortunately the heaviest snow from the storm passed to our south and east. We did get a covering of snow that was especially beautiful as it clung to the tall white pines and hemlocks that line the road to my home. Most importantly as a sign of the coming of real winter was that the temperature stayed in the 20s for five days. Each morning I looked out at the lake hoping that I would see ice. On my Tuesday walk I was delighted to discover that the shallow pond with the colorful name, “Goose Hole,” that is downstream from my lake was frozen. I took that as a good sign although the water in Otter Pond, which is downstream from Goose Hole, still had choppy waves, as did my lake, in response to a brisk and chilly wind out of the northeast.
Thursday morning my wait was over, as the picture in today’s header proved. The whole lake was calm under a thin patina of ice. It will get thicker as the days go by. It will be a little warmer over the weekend, and we may have some rain, but the ice will survive and by Christmas I expect to see skaters. I enjoy taking an auger out onto the ice and drilling holes with the hope of catching fish. Most years by mid January the ice in those holes is two feet thick, and it lasts until mud season. “Ice Out” usually occurs a week or so after baseball’s opening day and for me is Opening Day has been a reliable marker for the beginning of “mud season.”
Opening day brings up another sad reality that we have had to endure in 2020. The Red Sox were awful during the shortened season from the pandemic after the owners let Mookie Betts get away. In 2021 I won’t have tickets to Sox games to look forward to during mud season for the first time since 1977. It just wasn’t worth the expense or the time to sit in the cold in April and early May to watch some losers when I can see the sad spectacle for free from my easy chair by a warm fire. I must be getting old.
In a time when we have pandemics and unusual elections to worry us, it is reassuring that the ice cometh. The ice reassures me that there is still a little bit of predictability and reassurance for our souls in the circular nature of the seasons. I will know the end is near, if through global warming, we lose mud season and if the ice never comes. A year like 2020 puts a lot of previously experienced seasonal discomfort into perspective.
Be well and look for joy in what will be a strange holiday season! I hope that you see some snow soon and that you are having all of your holiday parties on Zoom. We will all wait our turn for the relief of the vaccine and the moment when we can safely return to our parties and professional conferences. Someday in 2021 we may be able to safely discard our masks. In three weeks we will wave goodbye to 2020, a year that we will assign to infamy. As we prepare for a winter of gloom and more loss, look for opportunities to be a good neighbor. Drop me a line if you have the time. I would love to know how you are managing the uncertainties of our times
Gene
