February 24, 2024
Dear Interested Readers,
A Potpourri Of Anniversaries and Observations
I apologize for making a self-congratulatory statement, but anniversaries are meaningful. This is the fifteenth anniversary of these Friday letters. There has been one every Friday except for the first three Fridays after October 25, 2013, when I announced my retirement. I am eternally grateful to my good friend and mentor John Gallagher who asked why I had stopped writing. My answer was that it was inappropriate and unfair to those who would take my place for me to continue to write to my colleagues at Atrius Health since I had announced that I was leaving and the leadership team was in transition. John pointed out that although the letter had started as an exercise in internal communication, many of my readers were people outside of our practice who were interested in what I had to say.
The salutation of the letter had morphed from “Dear Harvard Vanguard Colleagues” to “Dear Atrius Health Colleagues” before I acknowledged the “outside” readers and began to write to “Dear Atrius Health Colleagues and other Interested Readers.” After John’s comment and the brief rest from writing which felt very strange, the salutation became “Dear Interested Readers.” There have been about seven hundred and seventy-seven Friday letters since February 22, 2008. For about five or six years from 2015 to sometime during the pandemic, I also wrote on Tuesdays which means that there have been more than a thousand letters.
It amazes me when I realize that before our practice adopted Epic as our medical record system in 1995, I could not type. I don’t type fast now. I think slowly, and I type even slower than I think. My method of typing is quite unique, a patient was once watching me type into her medical record and commented that I typed by the “Bibical Method.” I asked for clarification, and she responded, “Seek and ye shall find!” I explained to her that I had passed on taking typing in high school because since I was going to be a doctor, I imagined that I would always have a secretary. That was 1961 and a very different world. It amazes me that despite my continuing typing deficiencies, I have probably typed between three and four million words for other people to read over the last fifteen years! I still marvel at those who can type without looking at the keyboard.
Over the years there have been changes in what I write about. I apologize for the fact that the letters are often long. I am aware that most are well over three thousand words. Google and WordPress count my words. There have been some letters with many copy-and-paste segments from articles that I wanted you to read that have exceeded six thousand words. I have a problem. When I edit what I write, I think of other things I want to say, and the letter gets longer. Before I retired, I had an editor, Marci Sindell. Marci kept me around two thousand words and tried to convince me that less was more. I miss Marci. Currently, I owe much gratitude to Russ Morgan, my technical guru over the last eight years, and to my son Jesse who faithfully letters the header of these notes each week.
I don’t see an end of the road, but I do know that somewhere beyond the horizon the road does end. In the beginning, my primary emphasis was on the joys and concerns of practice, the complications of medical group dynamics, the challenges of quality and safety in practice, and the efforts required to produce a patient-centered delivery system that is sustainable. I realize that my emphasis now has moved much more toward the social determinants of health and the politics of healthcare policy. I am constantly trying to balance all of those subjects. One justification for the change in my emphasis is that because of interdependencies between complex issues healthcare discussions need a wider field of vision. Patients and the delivery of care are touched by everything in our modern world including wars, concerns about the environment, the threat of the emergence of authoritarian governments at home and abroad, and most certainly culture wars.
I often reflect on the fact that we live in a VUCA world where things are increasingly volatile, uncertain, complex, and ambiguous. In a VUCA world, there are almost no degrees of separation between healthcare concerns and strategies for improvement from other current problems and events that may on the surface seem totally separated and unrelated to healthcare. At a minimum, these other issues divert resources and energy from the effort to improve healthcare. I offer the derailment of the Norfolk and Southern train in East Palestine, Ohio as an example of pursuing profit without regard to safety as an issue that ultimately impacts the health of the public. Political considerations seem to have led to the repeal of government regulations which coupled with the railroad’s desire to maximize profits, and the necessity to transport potentially toxic chemicals that are a part of critical industrial products, issues have intersected in a way that potentially creates a public health risk. Events like the derailment seem to be the result of the pursuit of profit without concern for the possible impact on the health of the public or the environment. Corporate greed seems to me to be a justification for writing about almost anything that might ultimately impact the health and well-being of individuals. Enough said.
The four things that seem to be of greatest interest and concern to me this week are the war in Ukraine at its one-year anniversary, the beginning of the fourth year of COVID, the decline in the health of Jimmy Carter, and final thoughts as we finish our celebration of Black History Month.
It has been exactly one year since Putin stunned us all by doing what our foreign policy experts had predicted, but none of us really thought or hoped would happen. On February 24, 2022, Putin’s tanks rolled out of their staging areas in Belarus and headed for Kyiv less than a hundred miles to the south with the expectation that within the week all of Ukraine would be under Russian control. When I first heard the news, I immediately remembered the opening lines of W.H. Auden’s poem, September 1, 1939, one of the most famous English language poems of the twentieth century. You may remember the poem from some English class in high school or college. The poem has almost a hundred lines. It begins with the simple image of the author sitting alone in a bar:
I sit in one of the dives
On Fifty-second Street
Uncertain and afraid
As the clever hopes expire
Of a low dishonest decade:
Waves of anger and fear
Circulate over the bright
And darkened lands of the earth,
Obsessing our private lives;
The unmentionable odour of death
Offends the September night.
Auden is referring to where he was and what he was doing on September 1, 1939, when Hitler’s panzers rolled into Poland to start World War II. By the end of the day Britain had declared war on Germany and over five years of conflict and millions of deaths lay ahead. It took Hitler only twenty-six days to defeat Poland.
I wasn’t sitting in some bar in New York City or New London, New Hampshire when I got the news of Putin’s invasion. I was sitting at home in front of my fire reading the New York Times and watching CNN, but I was filled with the same sense of tragedy, senseless waste, confusion, and dread of what would surely follow, that must have afflicted Auden as he sipped his drink.
On February 24, 2022, we did not know how tenacious and heroic the Ukrainian people would be or that their diminutive comedian-turned-politician/president would emerge within a few days and weeks as a true leader and defender of democracy. A year ago, he was a joke to many. Now some have called him the greatest hero of the twenty-first century. Time magazine named him “Man of the Year.” Now, one year later as President Biden said in Warsaw on Tuesday:
“One year ago, the world was bracing for the fall of Kyiv. Well, I have just come from a visit to Kyiv, and I can report that Kyiv stands strong. Kyiv stands proud. It stands tall. And most importantly, it stands free.”
Our president seems at his best, and his age is a benefit when he speaks earnestly to us about the many threats at home and abroad to freedom and democracy. he looked good and appeared to be strong in Warsaw as he denounced a year of war crimes.
Auden did not like his own poem, especially one of the lines late in the poem:
“We must love one another or die”
Auden even tried to republish the poem without the line or with it modified. others found deep meaning in his words. He learned that after a poem is released it no longer belongs to the poet. It is my favorite line in the poem and a fact of life that Putin doesn’t understand. I don’t know exactly how many have died in the last year in Ukraine if you count all lives, the Ukrainian and Russian soldiers plus civilians, and we know that the killing is not over. Some estimate that there have been more than 200,000 Russian deaths and casualties alone in the first year.
I would elevate the concern in Auden’s line to a more universal level and suggest that a possible outcome of this conflict might be a worldwide bloodbath as the possibility of a Russian defeat becomes unacceptable to a man who clearly does not see the big picture and seems willing to do anything not to lose. Time will tell, but in the interim, I fear that most Americans don’t fully understand just how vulnerable we are. It is hard to keep the improvement of healthcare in focus when we are witnessing a horrible loss of life which could spread faster than a viral pandemic through some accident or one man’s insanity,
COVID has become like the annoying neighbor who keeps popping in to disrupt your day when you least expect him and have other plans. What has happened since the lockdown was initiated almost three years ago (March 2020) is not what most of us expected. After a long struggle and some phenomenal medical miracles, we have found a way to go forward, but I don’t know anyone who thinks we will go back to the bliss of ignorance we enjoyed before COVID invaded our world. In Wednesday’s New York Times, David Wallace-Wells wrote a piece entitled: “Is the United States Ready for Back-to-Back Pandemics?” We have a collective PTSD that makes a question like the one Wallace-Wells asks very disturbing. Early in his piece, he writes:
…In the first year of the pandemic, it was common to hear predictions that however brutal and harrowing the near future seemed, the world would find itself, at some point, celebrating the end of Covid-19 — perhaps in a grand bacchanal to recall the dizzying decade that followed the Spanish flu of 1918 and 1919, which killed 675,000 Americans.
But that end never really came, not definitively. That the pandemic is no longer seen as an emergency is obvious; just look outside. But the country didn’t turn the page so much as limp forward, through a fog of exhaustion and loneliness and long Covid, into the dawn of a new period in which the coronavirus has retreated for most as an everyday threat but may well continue as gothic background noise, killing tens of thousands of Americans each year.
A true postpandemic period may still arrive, perhaps even a real Roaring Twenties. But in recent weeks, as researchers have registered one after another mammalian outbreak of the avian influenza H5N1, or bird flu, another possibility has loomed into view: back-to-back pandemics — a new one potentially driven by a disease that over the past several decades has killed about half the humans with known infections.
After chastising us for what we haven’t learned from COVID and pointing out our willingness to maximize our ability to exercise collective denial, he finishes with a forecast that casts a shadow of uncertainty which a large portion of the general public and the leadership of many states and members of Congress will choose to ignore like global warming:
…human fallout from new disease is no more inevitable than from carbon emissions. Here, the cost of accumulated indifference could be similarly high, and not just in the obvious human toll. In welcoming eight billion of us unmistakably to a new pandemic age, a new outbreak would cast a sort of permanent viral shadow on the decades to come…
COVID is still inflicting misery in my little town. The assisted living facility in the middle of town is in the midst of a resurgence of COVID over the past few weeks. Many of the residents plus a significant number of staff are sick with COVID. My pilates instructor has been out for two weeks with COVID. She is a healthy woman in her early fifties but has been quite ill, and her very fit husband has also been pretty sick. COVID is not gone, but we have tried to move on like a man walking with a rock in his shoe. I wish it weren’t so, but there are just so many worries that compete for our attention that we have decided that we are done with the pandemic. It’s like we have a collective preference for an attitude that says “It’s a good day to die” which is not unlike my adopted home state’s motto of “Live Free or Die.” I feel that the more appropriate attitude is “Heaven Help Us.”
I must admit that I became choked up last Saturday when from a news flash from my iWatch I learned that Jimmy Carter was going into hospice care. I have been a fan of Carter’s through thick and thin ever since I read his political autobiography, Why Not The Best? I read the book in early 1976 just as he was beginning his long-shot candidacy for the presidency with his unexpected win in Iowa. If you click on the book title, you can read a review of his book written before he became president. The article was as much an analysis of the man as it was a review of his writing.
What is clear in retrospect over the intervening almost half century is that there is no “fake” in Carter. He is as good an example as any in our history of the real McCoy, the man who is who he says he is and apparently without effort holds himself to a standard that the world does not understand or believe is humanly possible. In my mind, only Barack Obama has a chance of challenging Carter for the title of “Our Best Ex-President.” There are other similarities. Both are very complex men who are capable of great humility and great empathy that arises from a deep well of commitment to equality and universal opportunity. He believed in universal healthcare access, but he rightly understood that as a political reality, it would be achieved incrementally, if ever at all. He did come close, and in his opinion failed because of Ted Kennedy’s desire to replace him as the Democratic nominee for president in 1980. What we got instead was Ronald Regan and over thirty years of waiting for the ACA.
Perhaps what caused my tears, was that Carter’s decision was very much like the decision my mother made. Her hospice experience was a joy for us all. Her frequent trips to the EW ended. All of her medicines which for her were mostly more toxic than therapeutic were discontinued. She was comfortable in her hospital bed in her own home. She enjoyed the visits from the hospice nurses and the occasional weeks of care at the hospice center that gave my father some respite. She lived for seven months after going into hospice care during which time our family had some of its most memorable experiences. In the end, she had some sort of CNS event that left her essentially aphasic after which for the final days of her life all she could say with a smile on her face was, “I will see you in heaven!”
I hope that the Carter family will have a similar experience. Would it not be wonderful if every American could expect the same benefits and compassion at the end of life? In retrospect, I think Carter’s greatest gift to us all has been the example of a life well lived for the benefit of others.
Speaking of Carter is a good way to segway into my final subject in this potpourri of items. If you followed the link above to the 1976 review of Carter’s book you would have read:
As in his campaign speeches, what comes across most clearly is his sensitive feeling for black people and for the South, the commonality of his and their hard, church‐centered, rural life. His concern for the mentally retarded and for other handicapped persons, as well as his commitment to the environmental values of unspoiled land and clean air and water also come through as genuine.
I frequently connect Dr. Martin Luther King, Jr. and Jimmy Carter in my mind. You might ask, “How so? Their impact on history was sequential and not simultaneous.” I think that in their time both were frequently misunderstood and underappreciated. Their fame grew after they left the spotlight. Carter left in defeat to Reagan. King was cruelly murdered. Superficially, both were from Georgia which has been at the center of the Civil Rights movement and Black progress for much of the last seventy years. A less than immediately obvious link between King and Carter is that they each had a close relationship with former Ambassador to the UN, Andrew Young. On the website of the King Institute at Stanford University, we read a quote from Young who at the time of King’s death was one of the people standing next to him when he was shot on a balcony at the Lorraine Motel in Memphis.
Andrew Young’s work as a pastor, administrator, and voting rights advocate led him to join Martin Luther King, Jr., and the Southern Christian Leadership Conference (SCLC) in the civil rights struggle. Young, who entered electoral politics shortly after King’s assassination, credited King with giving “purpose and sustenance” to his life. “He left his mark on me, both in indelible memories and in the spiritual and practical lessons of our trials and triumphs,” Young recalled. “It is by the quality of those days that I have come to measure my own continuing journey.”
This week Young was interviewed about his experience with Jimmy Carter. From the article we read:
President Jimmy Carter made an enormous impact not just throughout the world but right here in Georgia where he was born and raised.
Carter appointed another Georgian, Andrew Young, to become the first Black ambassador to the United Nations in 1977. On Sunday, Ambassador Young reflected on not only Carter the president, but the person as well.
“He had more sensitivity and a stronger conscience than any other person that I’ve known,” Young said.
Young said President Carter was the most disciplined person he’s met in his entire life. He believes Carter’s legacy will be that of a peacemaker both during his presidency and throughout his work at the Carter Center.
Carter’s childhood growing up in rural Plains., Ga. helped shape him into the man he became.
“He grew up in an area that is poor and both Black and white. He didn’t segregate poverty,” Young said. “He probably had more Black friends than white friends.”
Carter appointed more women and people of color than all of his predecessors combined. That includes Ambassador Young, who said Carter was a long-term planner.
“I’d say the priority issue in his cabinet was world peace,” Young said.
I would say that another connection between Carter and King was that we think we know them both from history, but they are deeper, more reflective personalities than the average person, especially those who were not alive when they were most active, probably appreciates. I have often thought that like many saints Martin Luther King, Jr. was martyred as an unwelcome messenger or prophet from God. Like Christ, much of his message was lost on a confused crowd that wanted something else.
As I finish my considerations of Black History and we watch the focus fade into the background of noise about teaching Critical Race Theory and other efforts to unwind and understand our tortured history that is manifested daily in an abysmal state of persistent racist policies and inequalities in the form of the Social Determinants of Health, we should not forget that as Carter was denied at the ballot box the opportunity to finish his work as president (there is a book entitled The Outlier: The Unfinished Presidency of Jimmy Carter) so too was KIng denied the opportunity to finish his work by the bullet of an assassin,
Last month Ezra Klein of the New York Times did a podcast interview with Brandon Terry, the John L. Loeb associate professor of social sciences at Harvard, where he specializes in Black political thought. Together, they explored the breadth of King’s work, They explored the paradox, as Klein says, that despite the fact that Dr. King is one of the most celebrated figures of the twentieth century with monuments, a national holiday during the week of his birthday, the frequent quotes, the references to his speeches, few people actually search out the depth of his wisdom by reading the things that he wrote. Klein explains his opinion:
Most of us can cite a handful of his most famous quotes, but King’s actual teachings span five books, countless speeches and sermons, and years of detailed correspondence…In this conversation, we follow the commitment …to take King seriously as a philosopher, rather than as purely a political actor. And it turns out that King understood a lot about politics that we’ve lost sight of today. We discuss why a “romantic narrative” of the civil rights era stops us from taking King seriously as a philosopher; the true radicalism of King’s nonviolent philosophy; King’s complex views on the relationship between race and class; how King wrestled with the demands of “respectability politics”; King’s wide-ranging economic views, including the idea that the economy should be subservient to the community (and not the other way around); King’s enthusiasm for tenant unions and welfare rights unions as critical democratic inventions; whether the state should embrace the same nonviolence it often demands of protesters; the roots of King’s opposition to the war in Vietnam; whether we’ve lost the ability to grapple with “virtue” in politics today…
I hope that you might consider ending your observance of Black History Month by listening to this podcast. The discussion underlines the reality that no person of the last century or this one had a deeper understanding of the Social Determinants of Health and the political resistance to improving the lives of all of America’s poor, both Black and White, than Dr. King.
It feels to me like the review of this potpourri of issues underlines how inept we are at correcting the things that threaten us with even more harm than we have currently experienced. It seems like we know so much but can accomplish so little.
Auden hated his poem and its message, but I think that he was right even though he would not accept his own wisdom:
“We must love one another or die”
Here Comes Winter Again!
We have had a weird February. There were a couple of days of record-breaking sub-zero temp followed by three weeks that would have been more appropriate “in these parts” in late March or early April. Now it seems like winter has returned. I took the picture in today’s header just as the temp was falling and just before the snow returned.
The scene is from the crest of Burpee Hill looking south across some open fields toward Mount Kearsarge. It is about a one-mile uphill walk from my house. A ninety-degree turn from this spot and you would are looking west at Mount Sunapee and its many white ski trails that stand out like big veins. Turn another ninety degrees, and you are looking north toward Croyden Peak and Grantham Mountain. If it is a clear day, you can see past Croyden Peak to Killington and Pico Peak in mid-Vermont.
I like this spot, and it is easy to see in the picture that it takes more than three weeks of warmth to melt the snowpack we accumulated in December and January even though we are far below our annual average snowfall for the year. I am sure the folks running the ski lifts at Sunapee and the merchants who benefit from the ski traffic feel a great sense of relief since the President’s Day week is one of the biggest weeks in their business year.
I actually welcomed the return of about four inches of fresh snow overnight between Wednesday and Thursday and another inch or so last night. The long-range forecast is for much more snow and subfreezing weather over the next week or so. That is how it should be, and you know I like things to be as they should be. I want Spring to come, but I want it to come when it is supposed to come!
Some would say the warmer weather has been a blessing, and it is true that people have needed to burn less oil, less propane, less wood, and use less electricity than normal since the prices are so high for all of those sources of heat. I can’t change a thing about the weather. How I feel doesn’t raise or lower the temperature even a fraction of a degree, but it is true that all of us together could collectively do more. We are putting our heads in the sand if we aren’t willing to be more effectively engaged in solving the problem of global warming. Auden’s comment applies again, and the message is both more personal and more universal if you insert a few words that clarify the message:
“We must love one another enough to protect the planet or we will die”
I heard someone say recently that no matter what happens with Global Warming, the planet will survive even if the human race doesn’t. The planet doesn’t need us any more than it needed the dinosaurs. It has absorbed a lot over its several billion years. We may not be so durable.
I hope that this weekend you will enjoy some winter fun if you live up north, and if you live someplace that is warmer than New Hampshire you will find something exciting to do outside before the heat that will eventually come drives you into an air-conditioned world. The baseball players are loosening up in Florida and Arizona so warmer times are coming soon for everyone.
Be well,
Gene
