Last Friday’s letter was an attempt to begin to explore the relationships between what we chose to do and how we are compensated. I spent a long time backing into this difficult subject by going all the way back to 1965 and trying to draw some wisdom from my favorite quote from Dr. Robert Ebert who was the Dean of the Harvard Medical School between 1965 and 1977. The sketch of Dr. Ebert in the full listing of all the Deans of Harvard Medical School reads:
1965-1977 Robert Higgins Ebert
Dr. Ebert’s research focused on tuberculosis. He wrote about problems in medical education, including the roles of full-time and part-time faculty and the responsibilities of teaching hospitals to the communities around them. He developed a new faculty appointment category, Clinical Full-Time, thus expanding the School’s function in the clinical arena. In 1969 Dr. Ebert was instrumental in forming a distinguished group that founded the Harvard Community Health Plan, the first university-sponsored plan to provide comprehensive health care to a subscriber population.
The parts of that description that I like most are the reference to his interest in medical education, the recognition of the responsibilities of teaching hospitals to the communities around them, and his role in launching the Harvard Community Health Plan. Dr. Ebert was always aware of the world around healthcare and the responsibility that healthcare leaders and their institutions had to assess the health needs of the community and respond to those needs with a strategy.
Early in his career, at the end of World War II, Dr. Ebert was stationed in Japan where he studied the health impacts of the atomic bombs that we dropped on Hiroshima and Nagasaki to end the war. I do not have any data or written information to say with certainty how that experience impacted him and the things that he subsequently did in life, but it would be hard to believe that it did not fit into his future actions and choices. I do know for certain that he always had an interest in the health of the community and the social aspects of healthcare. From my personal observations of him and my reading of some of the things he wrote, I know that he had significant concerns about the inadequate care of the urban and rural poor and saw it as a personal responsibility to try to make a difference.
The intertwining of poverty and diminished health expectations persists today. We have developed a larger vocabulary than we had in 1965 that enables a fuller description of the problems and their connection to the whole of society through inequities and economic realities, but the problems still exit with an equal or even perhaps greater impact on everyone now as they did almost sixty years ago. As Jeff Madrick points out in Invisible Americans: The Tragic Cost of Child Poverty many of us still believe that the poor have earned their misery. Madrick writes:
America has long been resistant to adequate poverty policies because of its strong strain of thinking that the poor are responsible for their own situation, no matter their suffering.
The progressive movement of the 1890s and early twentieth century represented a shift from this bias toward a balance that built on the observation that the poor had a lack of job opportunities, housing, access to health care, and education that arose from economic and social factors that were far beyond the control of any one individual. “Horatio Alger” stories are heartwarming and inspiring, but they are more like the fantasies of “Cinderella” and “Jack and the Beanstalk” than the real opportunities that most people in poverty can generate for themselves. The camp that saw poverty as a societal and economic problem rather than an issue of personal morality believed that progressive government action was key to lifting people out of poverty. Much of our deep political divide today reflects this dichotomy in concepts and solutions for poverty that is currently being revisited with new tension in the president’s 2.3 trillion dollar “American Jobs Act.” We are in a continuing conversation that goes back to shortly after the Civil War and is always intensified by racial stereotypes and xenophobia. Dr. Ebert was well aware of the same tensions in his day. He felt the social responsibility of his role as the leader of an institution that could produce a new generation of socially responsible doctors that could multiple his individual efforts to make a difference.
I think that Dr. Ebert saw the effort to improve the health of the community as a potential catalyst for positive change in our society. There is no doubt that health suffers from a lack of adequate healthcare for those in poverty. Could the reverse be true? Would a focus on improving the health of those in poverty through improving their healthcare result in a reduction in poverty and the high toll that it takes from the lives of those who must endure it? If so, what is the optimum role for physicians and other individuals in healthcare, and what is the role of the institutions they lead and the affiliated industries with which they do business?
I know from Dr. Ebert’s letters and speeches that he felt that the pendulum of our attention and action in the hospitals and medical schools of the country had swung much too far toward the advancement of medical science and away from preparing physicians and other healthcare personnel for participation in developing public policy and being vectors for social change. He did not want to de-emphasize science, but he saw a real need to increase the attention on the social issues related to health. He saw that the emphasis on science should be balanced by an increased emphasis on social issues and the social responsibilities of healthcare.
I think that he realized that healthcare professionals reflect the attitudes of society and that among us some believe in the power of progressive public policy to improve health and many others believe that health is a product of personal choices and is an issue of personal responsibility. We are not a homogenous industry or profession. Like all citizens, we are split between a camp that believes in personal responsibility as the answer and another camp that believes that poverty and the poor health outcomes experienced by those in poverty exist for economic reasons beyond the control of the individual and can never be resolved without a progressive public policy which we can help enact.
To move toward a more progressive view of the origins of poverty medical students needed a learning lab which was part of his vision for the Harvard Community Health Plan. With the creation of HCHP, he moved from contemplation to action. It is the rare individual who when directly exposed to inequality suggests that we should have more inequality. I would like to believe that he realized that his students would be closer to the inequalities that poor people endured in the ambulatory environment where the objective was to prevent disease than they would be in the sterile disease-oriented academic environment of the hospital.
It is ironic that as the dean of a medical school whose students and faculty members led or would be the next generation of leadership in the clinical positions and research laboratories of some of the nation’s most prestigious hospitals he was dissatisfied with the status quo. He felt that the hospitals were not addressing some of the most significant health needs of the nation and that the doctors coming out of the nation’s medical education system were not adequately prepared to “meet the health needs” of the nation. I think that he felt it was important for him to do what he could to initiate a transformation of medical education and care delivery.
Dr. Ebert was very aware of the cost of care and that our poor got care that was not much better than what was available to the inhabitants of a third-world nation. In 1965 preventative care was more of a concept than a common reality. As an example from many possibilities, we had no data to confirm the benefit of treating blood pressure or cholesterol as a path toward preventing heart disease or strokes. We thought those treatments were wise, but there was debate, and the definitive studies had not yet been done. There was little effort to extend the benefit to those who were had little or no access to care.
Dr. Ebert knew that he needed to present a compelling “reason for action” if a transformational change were to occur. He saw his school producing medical students who were more than competent in the science of medicine but had no sense of their social responsibility. A “compelling reason for action” will motivate some to move into action. Without the motivation that stems from a belief that persistence of the status quo will always perpetuate harm and never lead to improvement, no one will ever have the energy or will to participate in the adaptive change process of transformation that is required for progress.
Climbing the learning curve of change takes a lot of energy and expending energy requires motivation. It is the role of a leader to create the case for change and the vision for the future that empowers the transformation. My favorite quote touches a lot of bases. It is a statement of the current state, “…The existing deficiencies in health care…” The reason for action, “provide optimally for the health needs of the population.” He hypothesizes that the strategy if we are to reduce the cost of care, is a more efficient system built on a framework of finance that allows us to do more without increasing our investment in personnel and buildings.
What is not stated but was his reason for writing the letter to the Commonwealth Fund that contained the statement was that he hypothesized that a program of prepaid ambulatory care with an emphasis on prevention and early intervention would be a better way to deliver care. He was asking for the funds to support a pilot that would prove his thesis. I can testify more than five decades later that experience has proven him to be right, and that despite the evidence of efficacy, we have not generally adopted the strategy. Where it has been applied the quality and cost of care are improved. It is a strategy that always works, and is often deferred for lack of will or leadership.
I have also argued that his statement is the foundation for the Triple Aim. It imagines or implies better care for individuals that improves the health of the nation at a sustainable cost.
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
By the mid-sixties, Dr. Ebert was convinced that American healthcare needed to change. He offered a solution There is a parallel between those times and these times. The metrics of cost, quality, and equity were suboptimal then and they remain suboptimal now. I see Dr. Ebert’s call for change as reflected in his desire for organizing the personnel, facilities, and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population, as being similar to the calls for improvement addressed in Crossing the Quality Chasm in 2001, reflected in the ACA in 2010, and persisting now in our concept of the Triple Aim and recognized as essential in the discussion of healthcare inequities as revealed by the pandemic.
Events in the late ’60s gave Robert Ebert the opportunity to demonstrate leadership and personal courage and how to manage ambiguity and differences in philosophy in ways that called all sides to the efforts to solve problems. In 1969 when Harvard students pushed back against ROTC and the supposed support of the university for the war in Vietnam by occupying the buildings in Harvard Yard, Dr. Ebert was there registering his concern and seeking to provide aid to the students and anyone who was injured in conflicts with the soldiers and police. His New York Times obituary describes the difficult position he tried to occupy between protesting the war and working with the corporations that were benefiting from it.
Dr. Ebert actively supported his medical students as they protested the Vietnam War, both on and off campus, and he took part in antiwar rallies, too, even though he was trying to build support for the medical school at the same time among corporate executives who supported the war. Critics of corporate-sponsored research worried that such work might be skewed from pure medical research, but Dr. Ebert endorsed the partnership and helped expand it.
I think that he was a pragmatist that knew we lived in a complicated world rife with complex problems without simple answers. The principles of character and leadership that he demonstrated are always appropriate for difficult times. I think that there are few people today who can balance with grace the apparent contradictions that exist in our world better than he balanced those divisions in his world. We need leaders now who can model his insight, leadership characteristics, and commitment to participation in the emergence of a better more equitable world. He was right to believe that there is always a better and fairer operation system and finance mechanism. Such a system would diminish healthcare disparities and lift every American to a higher level of existence. What we can see now more clearly than anyone could see in the sixties is we can tie addressing social and medical inequities to better healthcare, to greater productivity, to saving the environment, to resolving issues of immigration, and to an overall better world for our children to continue to improve. I believe that our starting point in 2021 is very similar to his starting point in 1965.
I deeply believe that if we can embrace the responsibility to articulate our current “reason for action” and are blessed in our time with leaders like Dr. Ebert we will be able to gain energy for the idea of creating new solutions or further implementing the solution that he advanced. I hope that with reflection on his example we will be able to “see the way” toward the transformation in ourselves and the organizations where we work that will lead us closer to the world we want to see.
