December 4, 2020
Dear Interested Readers,
Continuing to Look Forward From A Strange Moment In Time
It is very hard to think about the future when you are mired in the realities of a week as disorienting as this past one. Can you believe that the president delivered a 46 minute rant chocked full of lies to an empty room during which he continued to claim that he was the winner of the election while on the same day almost 3000 people died of their coronavirus infections, 100,000 were hospitalized with COVID-19 infections, and 200,000 people tested positive for the virus?
This president has never understood that the best way to ensure America’s future greatness was for him to do his job in a way that protects all Americans from real threats and not the imagined threat of immigrants. In his book, A Promised Land, Barack Obama names and discusses the primary responsibility of the office. On page 308 he writes:
IT’S A TRUISM that a president’s single most important job is to keep the American people safe. Depending on your political predispositions and electoral mandate, you may have a burning desire to fix public education or restore prayer in schools, raise the minimum wage or break the power of public sector unions. But whether Republican or Democrat, the one thing every president must obsess over, the source of chronic, unrelenting tension that burrows deep inside you from the moment you’re elected, is the awareness that everybody is depending on you to protect them.
That was the former president’s introduction to his discussion of the most difficult problem he faced, reversing the downward trajectory of the economy in the throes of the Great Recession, when he took the oath of office at noon on January 20, 2009. Even before he took the oath of office, the briefings he got from the Bush managers of the economy and his own economic team was that the problem was much worse than the public realized and was going to get much worse very soon. The two major challenges that he needed to manage to protect the American people were to prevent more bank failures and to pull the auto industry back from the brink of collapse. A failure to either stabilize the banking system or to prevent a collapse of the auto industry would likely turn the recession into a “full on” depression that would financially devastate millions of families and individuals. What follows that introductory statement is his description of the difficult decisions and tradeoffs that he made with the help of his team during the first few weeks of his presidency. Now in retrospect he realizes that what he had to do diminished his ability to accomplish some of the things that he had hoped he could do. We all know that the public was not thankful for being “rescued” and groused about all the bankers who were never prosecuted and the promises of hope and change that fell short of what he had wanted to accomplish. In retrospect he believes he did the right thing. It will take a few more decades before there is enough perspective from historians to accept his analysis or demonstrate what he should have done.
My point of choosing this flashback to 2009 is that President Obama put his sense of responsibility to protect the public over his political agenda. He cared about every American and especially those who might be classed as “the least of these, my brethren” in terms of resources. He sought out the best advice. He listened to experts debate the alternative actions he could take. He managed a process. He made decisions. He understood that his responsibilities trumped his personal agenda. He stayed a course that was unpopular with many, not understood by most, and immediately resisted by Republicans. Whether the midterm losses in 2010 to the “Tea Party” Republicans were precipitated by the financial recovery plan or by the plan plus the fall out from the ACA is hard to know, but what is certain is that President Obama did not fail to act on the economic challenge and the nation experienced a quick recovery followed by an unprecedented decade of economic expansion that benefited the vast majority of Americans that perhaps would still be going on were it not for the pandemic.
It seems appropriate to me to contrast the success of President Obama’s response to the incompletely understood threat of the Great Recession and his ability to accept the advice of experts to what Donald Trump has done since last March when his advisors informed him of what COVID -19 could do to the country. President Obama accepted the responsibility of keeping the American people safe. Donald Trump did not. After a few weeks of weak leadership and in the face of a falling stock market, Donald Trump rejected the advice of experts. He refused to encourage our compliance with the strategy of social separation which was the only plausible way to manage the pandemic. He began to have rallies where he denied the threat and blamed everything on the failures of other people, the Chinese, the governors, even his advisors. He encouraged the premature opening of businesses. He did not move to quickly shore up our medical supplies, and said that management of the pandemic belonged to the governors and local leaders while he belittled and undermined the efforts of the governors who were trying to follow the advice of public health experts.
It is hard to know what strategic concept is behind another person’s actions or what “lies in their heart” behind the lies that they tell, but if the president chose a path that he thought would defend the economy and get him reelected, he defeated himself and we all have suffered from his miscalculations and subsequent lack of leadership. One must believe that the 74 million faithful followers who voted for him would have given some consideration to practicing social distancing if he had been a vigorous advocate for what the experts recommended.
Perhaps in his calculations the possibility of losing a few hundred thousand lives was a reasonable price for sustaining the market. What he did not seem to appreciate or care about is the fact that many Americans don’t have stocks and the balance in their 401Ks is zero. The first stimulus bill worked, but without another stimulus for which the president could have advocated in the early fall with all the strength of his office but did not, crushing economic problems and the possibility of hunger and homelessness await millions now as the last of the economic benefits of the Cares Act and other decisions of the early days of the pandemic expire. More than fifty million Americans are in poverty, and millions are at risk of eviction from the homes they rent or from foreclosure on the homes they bought but were unable to make mortgage payments on after losing their jobs to the pandemic.
A Vox article by Dylan Matthews that was published yesterday makes the case that “Joe Biden is taking office amid a poverty crisis.” The article suggests that we could be on a trajectory that will be worse than the Great Recession:
The upshot is this: Depending on the scale of the broader economic recovery, between 4.9 million and 11.8 million more people will be living in poverty in January 2021 than were in January 2020.
This is a large increase even compared to the Great Recession. The same Columbia research group estimates that from 2007 to 2011, poverty measured the same way rose from 14.4 percent to 16.1 percent of the population, a 1.7-point increase. The best-case scenario of 5 percent unemployment in January 2021, by comparison, registers as a 1.5-point increase in poverty, similar in scale to the Great Recession. If we don’t get down to 5 percent unemployment, the effects could be worse than the Great Recession.
The reality is that at best there will be a “large decline” in living standards for low income Americans. Over my seventy five years I have “intellectually known” that there were Americans who struggled in poverty, but for me and most of the people I know the poor are pretty much out of site. Even in medical practice my contact with them did not require that I try to help them make progress against the enormous social and economic odds for failure that existed in their lives, but not in mine. I was taught that it was important for me to be aware of the economic and social stresses of my patients, but my job was to manage medical issues and not be their social worker. The organization where I worked, and later led, was committed to the Triple Aim, but the majority of our board felt that its fiduciary responsibility was to the economic success of the practice. Our mission was to promote the health of our patients, and not act directly as a force for social justice. We favored social justice, but it was someone else’s responsibility. On one occasion our board did have a debate about whether we could afford to accept Medicaid patients “at a loss.” I am proud to say that we did, but we never addressed the issues that complicated their lives and made them Medicaid recipients. One of my main motivations for working o implement a Lean transformation of the practice was to enable us to have a large Medicaid practice and remain solvent.
It is easy to have concern about an individual, it is much harder to maintain concern about the root cause issues that create the individual’s problems. When I became aware of a patient’s economic distress I referred them to social services. Sometimes I was able to help them get a break on their prescription payments. On many occasions I helped refocus their requests for social security disability after several unfair refusals. A few times I did the ill advised act of handing them a few hundred dollars as a “loan,” but I never really joined them in trying to plot a course to financial stability, nor did I get involved in the repair of the root cause problem other than to vote for politicians who said they would improve things. I felt bad about my patient’s problems, but I saw my role as managing their health. It was not my responsibility to address economic challenges or inequities. I had sympathy, but acknowledging all the advantages that I had taken for granted in my life, it would be wrong to say that I was empathetic. I could not say like Bill Clinton did, “I feel your pain” because I had not personally known their pain. In my life I had experienced some occasional financial difficulties, but there was always some place that I could go to get bailed out of my short term worries. My family had resources. There was a floor below which I could be sure I would not fall.
Ironically, my exposure to the real stress of poverty did not occur until I retired and began to get active with organizations in my community that have a mission of helping those with financial emergencies. I don’t live in a town with much poverty. New London has the feel of an affluent Boston suburb. We have handsome homes on fine properties, but just a few miles away in many of the neighboring towns of the Kearsarge region things are different. In Boston it is the same. It is a short ride from the luxury condos on the waterfront to the crumbling triple deckers of Mattapan and Roxbury. I am certain that if a formal “needs assessment” that might be the foundation of a robust attempt to improve the social determinants of health was done in the communities that surround New London, it would show that our problems are affordable housing, secure sources of food, transportation assistance, jobs that produce a living wage for our local economy, and much more robust mental health services for substance abuse, depression, and domestic distress. I am a big fan of the “compassionate conservatism” that is in the air where I live. It is great for those of us who want to help others, but it is inadequate to address the core issues that prevent many of the people I see in poverty from gaining the economic security that would be a foundation for better health for them and their families.
Over the last five years I have been to food pantries with clients. I have delivered food and wood to those who literally have no money for their rent, or are at risk from the cold because they have no oil or propane, and the dealer will not deliver more until they pay their balance that is long past due. I have learned where emergency resources can be found, and I have gotten to know several town welfare officers and now know how to build a case that they should pay one more months rent or buy a couple of tires for a person who has a new part time minimum wage job to add to their full time job that still doesn’t provide a subsistence level of income.
What this exposure has revealed in a way that I never appreciated in practice is just how hidden the poor are, and how many barriers they must cross to get through each day. We usually don’t see them because even in a small town we travel on different roads or the same roads at different times of the day. Their home may be near the noisy Interstate, behind some store front, or down a country road. Sometimes their home is in a rusted out RV or the back of their car. What the terrible year of 2020 has also revealed is that security is a passing illusion unless every American is protected.
The teachers in the local schools know who the children in need are and fortunately they have “backpack” programs that give many children food to get them through the weekend until they can get breakfast and lunch at school during the school week. Prior to the pandemic we just needed to focus on how to get food to these children on weekends and during the summer. When there is no school there are new logistical problems to solve.
I have had enough experience over the past five years to reject the idea that the poor are lazy and looking for a dole from the government. Most of the people I have met would prefer to work, and hate asking for help. The movie now showing on Netflix by Ron Howard which is an adaptation of J.D. Vance’s book, Hillbilly Elegy: A Memoir of a Family and Culture in Crisis, has gotten some poor reviews. (I liked it, and would highly recommend it to you although it is tough to watch.) The story line is pretty faithful to the book as I remember it, but rather than a continuous progression from past to present the story is presented through flashbacks. What is missing is the very insightful testimony that Vance gave at the end of the book, in chapter 15, about improvements that could be made based on his personal interaction with public welfare programs. He states that he felt abused because of the failures of the programs that exist for the poor and the children of the poor. He contends that the poor don’t want to be on a dole, but they do need help at critical moments, a “thumb on the scale.” They want opportunity. He writes:
There are policy lessons to draw from my life—ways we might put our thumb on that all-important scale.
His focus for improvement is on the child welfare system and how to minimize the trauma that children feel from the “system” that means well but never fully understands the whole picture and has an agenda and rules that can crush the future through well intended but misguided systems. As I reread his words, after watching the film, I was temporarily overwhelmed by the challenges for change that implementing his suggestions would require. How we protect children and offer real opportunity to the children of disadvantaged Americans must be a cardinal objective if the society our founding documents envision is to ever become a reality. To accomplish that goal there are many barriers to overcome. Job one is to deal responsibly with the challenges to the poor in this moment. Building from the medical adage that “if you can’t make it better, don’t make it worse, we can’t begin to “build back better” until we stop letting it get worse.
The first step in the process of not letting it get worse is to finally accomplish the passage of a second stimulus bill, what some would call “CARES II.” Using all the power of the presidency to ensure the protection of the 50 million most vulnerable Americans should be what the president is doing right now rather than contesting the results of an election which he clearly lost by over six million votes. The other individual who must rise to the occasion is the Senate Majority Leader, Mitch McConnell. If it happens it will occur because Democrats give in on their request for an adequate package of help to individuals, small businesses, and local and state government. Most economists, including Jay Powell the Chairman of the Federal Reserve, believe that too little stimulus is worse than too much. It is hard not to believe that McConnell puts the issue of party dominance before his concern about the welfare of millions of Americans. After four years of Trumpism it is hard not to believe that the only thing Donald Trump cares about is himself. Mitch McConnell has been his most effective enabler.
I would venture the idea that President Obama’s contention that the single most important job of the president is to keep the American people safe meant more to him than to be the commander-in-chief of a mighty military force. I would guess that under safe he would also mean being protected from hunger, homelessness, and the hopelessness that is associated with very limited opportunities in a system where many do not have a ticket to ride. Jack Welch once said that a good CEO was an organization’s principal human resources officer. I don’t think it is a stretch to expect that our president should be the highest public official responsible for the health and welfare of all Americans. There is every reason to believe that Joe BIden ascribes to the concept that job one is to protect every American from “all threats both foreign and domestic.” Donald Trump failed because he had no interest in much beyond himself. In many ways the Senate with McConnell as its leader, and with all of its mechanisms of control, has become a domestic threat.
As much as I dream of a healthcare system that is equitable, effective and affordable for every American, I know that job one is to emerge from the pandemic and the economic chaos it has created. The first step in the long task of building back better is to prevent further losses. I think the administration in waiting understands the situation and will begin the work on the afternoon of the 20th of January. What worries me most is the size of the job that they will face and the success that they may achieve depends a lot on what can be accomplished between now and then.
As The Seasons Change, Keep Your Distance
It’s been a gloomy week all around. Gloomy seems to be the common denominator in all our common affairs. It is even gloomy during my daily afternoon walks. My walks are partly motivated as a futile attempt to support my effort to live forever, or at least to my 100th birthday in 2045. My calculations suggest that if I want a chance of meeting my great grandchildren I will need to last at least that long. Living to be 100 was a goal that my father had. Yesterday would have been the day he made it, but he died on September 27, 2018. In retrospect I think he died of too much medical care. He was very active, but had a pacemaker to compensate for his slow AF with a high degree of AV block. His coumadin was discontinued because of fall risks, and he was maintained on a small dose of aspirin as a hedge. The aspirin prevented a stroke, but it precipitated a huge GI bleed.
Rather than transfuse him and manage him conservatively, his doctors subjected him to an invasive work up that would have been more appropriate for a man of 57 than a man of 97. He never really recovered from the ordeal although he lived for over a year bouncing back and forth from rehab to home to hospital to rehab, and then finally when totally exhausted to hospice. Perhaps my memories this week plus the weather account for the gloomy feeling that motivated my walking. I was looking for solace and beauty that I might share with you as a photograph.
The weather has a lot to do with any success I might have in finding solace and beauty on my familiar walks.This time of year there is a lot of variation in the weather. One day it may be sixty and sunny as it was last week. Then rains may come in torrents as was the case earlier this week. Snow squalls with a brisk wind can pass through and then be followed in less than an hour by the sun at a late afternoon angle peeping through scattered clouds. The instability seems to be a warning of more dramatic weather that is sure to follow in a very short time.
My walk on Tuesday began in a chilly wind and under a dense cloud cover that made any idea of exercise a challenge and pretty much guaranteed that I would not discover the picture that I was hoping to take. A snow squall roared through about a mile into the walk, but I trudged on with the lowered expectation of just marking off another day of walking. About a mile and a half from home I pass an old road that is now barely perceptible and looks more like a tunnel as it passes through dense woods and proceeds a hundred yards or so down to the lake. I know that more than fifty years ago there was a summer camp on this site. As I peered into the woods the clouds cleared enough to allow a lot of light to be reflected from the lake. I said to myself, “Aha, there is light at the end of the tunnel.” Scroll back up to the header and see for yourself.
Be well! I hope that you enjoyed a very special, and very safe Thanksgiving, and plan to do even better as we roll through the holiday season on our way to January 20 while anticipating the better things that might come. Anticipate your vaccination next spring in a way that will allow you to tolerate wearing your mask and continue to practice social distancing as best you can until the vaccine is a reality for you. Look for opportunities to be a good neighbor. If MItch and Don won’t help then you need to pitch in. Let me hear from you. I would love to know how you are managing the uncertainties of our times.
Gene
