July 15, 2022
Dear Interested Readers,
Thoughts on Dualism, The “War of Attrition” in Ukraine, Inequality In Value-Based Reimbursement, and Inherent Biases in Medicine.
From time to time when I am thinking about all the human misery in the world that is caused by biases, greed, ideas of racial supremacy, or just plain self-serving actions by individuals, groups, or nations, the little song, “Jesus Loves the Little Children,” runs through my head. I must have learned the song at age three or four while I was a member of the “Sunbeam Band” at the First Baptist Church in Okmulgee, Oklahoma where my dad was the minister from 1946 until we moved to Miami, Oklahoma in 1949 when I was four. I was a virtuoso on the “sticks,” but I most enjoyed playing the “triangle.” I am the boy in the middle of the second row looking to his left while all the other children are looking at the camera.
The first verse of “Jesus Loves the Little Children” is the part of the song that is the “chatter” that occurs in my head when I hear about another missile hitting an apartment house in Ukraine or if I think about the inequities that are such a significant part of our lives that we are numb to them. If you don’t know the song and are not already humming it to yourself as you read my rambling intro, listen here and then read the verse below.
Jesus loves the little children
All the children of the world
Red and yellow
Black and white
They are precious in His sight.
Jesus loves the little children
Of the world.
Given that these words have been learned and sung by millions of American children over the years and probably tens of millions of children worldwide, it surprises me that the spirit of universal love, inclusion, and non-duality that the song presents doesn’t seem to stick with a majority of humankind into adulthood. I guess the message works with children because most of the kids I have known have been very empathetic, eager to play with anyone, and deeply moved by the pain of others.
Another curiosity is that the majority of our politicians and even Vladimir Putin claim to be loyal church-goers, but the policies they favor and the actions they often take seem to suggest that they have forgotten the non-dualistic message that is projected by the little song. (If you click on the link, you can hear a short video explanation of dualism given by Father Richard Rohr, the funder of the Center for contemplation and Action in Albuquerque, New Mexico.)
My own definition of duality is our tendency to decide who is “in” and who is “out.” My own belief is that the core message of Christ was not about “in or out” but rather about a universal oneness under God that is rooted in a deep concern for all. His famous “Sermon on the Mount” (Matthew, chapters 5-6) was not about how to get into heaven. It was a strategic discussion about how to avoid the hell we experience on earth when we have difficulties living together. We often make these judgments instinctively, and the implicit biases that are baked into us at an unconscious level are a big part of the explanation for the existence of our dualistic thinking. As Father Rohr suggests, shedding dualistic thinking requires practice and continuous effort. I believe that nondualistic thinking is essential to patient-centeredness and equity in healthcare.
It is amazing to conceptualize Putin as a man for whom religion is important as he has claimed in many speeches and as a partial justification for his invasion of Ukraine. He seems only to be a believer in his own prowess. What is even more amazing is that there is only one self-declared atheist in our Congress, and that is Kristen Sinema. According to The Pew Research Center that is strange since 26% of U.S. adults are religiously unaffiliated – describing themselves as atheist, agnostic, or “nothing in particular,”
The Pew Research Center contrasts the diversity of religious thought in the country with the fact that eighty-eight percent of the current members of Congress, a far higher percentage than in the general population, profess to be Christians, and with the exception of Senator Sinema, every member of Congress, that’s all the Senators and Representatives, say that they believe in a God. That seems strange to me because they have consistently voted for policies that promote dualism and policies that are remarkable for the implicit racism and inequality that create disease.
It is sad to contemplate how little practical impact the message of love and equality that many of our leaders probably sang about as children has had on their conduct in office. Love, generosity, and acceptance are at the center of most of the world’s religions, but those attitudes seem to be forgotten when Congres meets to do its business. Dualism creates deep partisan divides when we forget what we ostensibly learned and intuitively accepted as children. It makes me wonder what St. Paul really meant when he penned I Corinthians 13:11:
When I was a child, I spake as a child, I understood as a child, I thought as a child: but when I became a man, I put away childish things.
The attitudes and actions of our leaders as adults suggest to me that they must have forgotten the message and sentiment of the little song.
Our Supreme Court also seems stuck on using dualistic thinking and their religious beliefs as a way of determining who is in and who is out and what constitutes personal freedom. In my mind, there is not much separation between extreme orthodoxy in religion, and an autocratic government that limits personal freedom and describes very narrow pathways of advantage for an “in-group.” It seems strange that many politicians and judges see a right to own military-grade firearms arms, the right of a public employee to create a possibly uncomfortable situation where young athletes much watch him pray, and a new opportunity to use public funds to support religious education at the expense of public education, but don’t see an equal obligation to mitigate poverty or provide equitable universal healthcare.
There is a recurrent phrase that I am hearing lately in reference to the war in Ukraine. Tom Freedman used it in his New York Times column this week, and Barry Levy and Jennifer Leaning, a former colleague at Harvard Vanguard, also used it this week in a New England Journal article. In describing the current phase of the conflict both articles used the phrase “war of attrition.” Levy and Leaning wrote:
The recent shift in Russian strategy to a war of attrition carries ominous implications for civilian survival, the future of Ukraine as a nation-state, and the restraint that North Atlantic Treaty Organization (NATO) countries must practice to ward off Russia’s threat of nuclear escalation. This conflict, initiated by an unprovoked Russian invasion, has inflicted death and widespread suffering on Ukrainian civilians and military personnel. More than 7.1 million Ukrainians have been displaced within their country, and approximately 5.3 million have crossed borders to become refugees in other European countries. Appropriately, the war has prompted a massive humanitarian response — but Russia’s assault has intensified and time is running out.
Since the war began in February, I have followed Friedman’s columns closely because his analysis seems informed and logical even when what he sees coming is very dark. On Tuesday he wrote:
…the Ukraine war seems to have settled into a grinding war of attrition — with Russia largely standing back and just shelling and rocketing Ukrainian cities in the east, turning them to rubble and then inching forward — you might think the worst of this conflict is over.
You would be wrong.
On the evening news last night there was an ugly presentation of what a war of attrition looks like when Putin is the instigator. Putin’s targets yesterday were the citizens of the small city of Vinnytsia which lies a few hundred miles from the eastern front where the “war of attrition” has devolved into soldiers trapped in trenches with volleys of artillery and missiles being exchanged overhead. The report in the Times said:
A volley of Russian cruise missiles hit a shopping center, a dance studio and a wedding hall in central Ukraine on Thursday, killing at least 23 people and setting off a frantic search for dozens more lost in the rubble, in a latest strike to hit a civilian area far from the front lines.
The Washington Post reported that three of the victims were children. On the ABC Evening News, we were shown the video of a toddler in a stroller that was taken a few minutes before the rockets hit. They then showed a video of a twisted stroller after the attack and reported that the little girl was one of the three children who were victims of this event in Putin’s “war of attrition.”
You have probably seen the before and after pictures of the scene. A version is even in my hometown paper today. The photo above is not as cropped and comes from a BBC report. The larger picture shows more of the devastation in the background that was shown in the video report from ABC. The scene documents another war crime against the civilian population in Putin’s war. The BBC commentary was:
Ukrainian officials said one of the three children who died in the attack was a young girl called Liza, who was returning from a speech therapy session with her mother when the rocket strike hit.
Social media footage reposted by Ukraine’s defence ministry appeared to show Liza pushing a pink pram as she walked alongside her mother earlier in the day.
A pram that resembled the little girl’s was later photographed on its side outside the building hit by the rocket strike. Other images showed what appeared to be the same pram with a child’s body lying beside it.
Putin does not seem to care about the impact of his war on little children.
I hope that you read Levy’s and Leaning’s thoughtful discussion about how the war has destroyed much of the ability to provide healthcare in many parts of Ukraine. Not stated as directly, but implied is the threat the war represents to the health of all people on the planet. They finish with a soft suggestion that healthcare professionals take note and contemplate some action:
Russia’s war of aggression in Ukraine provides the latest demonstration of the catastrophic health-related consequences of war and eclipses Russia’s previous destruction of Chechnya and bombardment of health facilities and neighboring populations in Syria. While nations and their peoples take essential action to isolate this dangerous state, we also believe that health professionals have responsibilities not only to respond to the needs of current victims but also to engage in preventing the devastating, long-lasting, intergenerational effects of war on human health and life.
Not knowing exactly what we can do and feeling vulnerable to circumstances beyond our control are thoughts that Friedman also discussed in his column. I will leave it to you to read his analysis and his report of the best thoughts about what might happen over the next few months. “Uncertainty,” especially the uncertainty of predicting what Putin will do as the summer fades to fall and winter is Friedman’s theme. He never mentions “ambiguity” directly, but he is very clear about the fact that no one has enough data to predict for sure how it will all end. One uncertainty is whether or not our support and the support of Ukraine from Europe will fade as time goes on and the loss of Russian sources of energy makes life more difficult. He sums up his concerns with the distressing opinion that the end of the conflict is not near as long as Putin rules Russia.
There is only one thing that I am certain of: This war in Ukraine will not end — really end — as long as Putin is in power in Moscow. That is not a call to overthrow him. That’s for Russians to decide. It’s simply an observation that this has always been Putin’s war. He personally conceived it, planned it, directed it and justified it. It is impossible for him to imagine Russia as a great power without Ukraine. So, while it may be possible to force Putin into a cease-fire, I doubt it will be more than temporary.
In short: This Ukraine war is so far from over that I can’t even see over. (Friedman’s emphasis)
It has been a tough week that seems to underline again and again the downside of living in a divided, dualistic world. Events like the fires threatening the giant sequoias in Yosemite, drought in many places, and floods from violent storms in others along with cities in the South and Southwest that suffer from triple digit temps day in and day out have become so commonplace that unless they are directly impacted most people seem to accept a hotter future with more violent weather. Like COVID that keeps coming back again and again it appears that the strategy we default to is an acceptance of the turbulence we can’t improve while hoping that as individuals we and our loved ones can “weather the storm” since we can’t figure out how to set aside what divides us long enough to collectively address what commonly threatens us. There is a very big downside to “duality” for everyone.
The high point of my reading week was that this week’s New England Journal had three more articles as noteworthy as the Levy and Leaning article. I want to bring each one to your attention and make a brief comment about why each one is important.
“REACHing” for Equity — Moving from Regressive toward Progressive Value-Based Payment is a terrific article that describes the new ACO offering from CMS that focuses on equity. The acronym REACH stands for Realizing Equity, Access, and Community Health. One of the things that I am most proud of during my time as CEO of Atrius Health was our participation in the first CMS ACO offering, the Pioneer ACO. I knew when we accepted the challenge that the methodology was flawed and favored those systems that were high-cost providers. We were low cost and our previous successes meant that we were given less from which to turn a savings. Lowering the cost of care while improving quality and safety was the objective. This new model focuses on producing health equity as well as savings. I see it as evidence that something has been learned!
“Expanding Accountable Care’s Reach among Medicare Beneficiaries” is offered by authors from CMS as both a review of Medicare’s experience with the ACO model since the Pioneer ACO, and it also contrasts the “Performance on Selected Quality Measures among MIPS Group Practices and Medicare Shared Savings Program ACOs” for 2020. To save you time, the ACOs, even with their structural flaws, do better than the MIPS groups. I hope that the future belongs to the ACO model. You may not know it but CMS has an objective for 2030.
Ensuring high-quality, accountable care for all traditional Medicare beneficiaries by 2030 will require strategic alignment among CMS’s ACO efforts. We are considering several changes to the Shared Savings Program and new models to expand participation in ACOs, increase savings for participants and for Medicare, and make access to ACOs more equitable.
I think a review of my letters would prove that I have always believed that ACOs with a structure that is an “improved capitation” model with the objectives of Crossing the Quality Chasm represent the most realistic and probably the only practical path to the Triple Aim and the healthcare equity that eliminates healthcare disparities.
The final article of the fabulous four articles in the Perspectives section of this week’s New England Journal, “Tackling Implicit Bias in Health Care” is the one article I would hope that you would read if you are inclined to read any of the four. Dr. Janice Sabin skillfully demonstrates how the implicit, or unconscious, biases that we all possess create policies and behaviors that perpetuate inequity. To eliminate healthcare inequity we must not only provide resources, but we must also change the culture. The culture won’t change until we confront our implicit biases. She writes:
…our individual biases operate within larger social, cultural, and economic structures whose biased policies and practices perpetuate systemic racism, sexism, and other forms of discrimination. In medicine, bias-driven discriminatory practices and policies not only negatively affect patient care and the medical training environment, but also limit the diversity of the health care workforce, lead to inequitable distribution of research funding, and can hinder career advancement.
She doesn’t say it, but my interpretation is that the attitude that we must seek to achieve a victory over our implicit biases could be expressed by a simple modification of the little song that keeps running through my head:
All the children of the world
Red and yellow
Black and white
They are precious…
And deserve equality
It’s only right
It’s not good poetry, but until we find a way to make it true, we have only grief ahead. Our dualistic world is not working very well, and there is not much relief in the short term on the horizon.
Balancing The Desire For A Great Summer With COVID Worries
It has been three years since our grandsons in California have been able to come east for a visit with us. We have gotten by with video chats and by making three trips west to see them. We drove an RV across the country in the fall of 2020, and flew west last summer and at Christmas after getting vaccinated. Our youngest grandson is only four and was not a candidate for vaccination until recently. Wisely, his parents did not want to bring the family to see us and risk infection from the long flights as long as he was not vaccinated.
I am happy to report that my four-year-old grandson was the first child under five to get the COVID vaccine at the Scott’s Valley office of Kaiser! His older brother who will be eight on the 24th also had his vaccine as soon as his age group was eligible. Both parents are vaccinated and boosted, and both of them are now pretty sick with COVID which is running wild in their neighborhood. My son, the dad of the boys, had to fly from San Jose to San Juan, Puerto Rico on business last week, and he came home with COVID. He said that on flights to Newark and then San Jose and back again there were never more than ten people with masks. He wore his mask for both long trips except when he was eating. Our hope is that they will all be well and able to travel by the last week in July when they are scheduled to come. In the last two months, three of my four sons and two of my four daughters-in-law, and my granddaughter have had COVID, and all of them were vaccinated. Our ordeal is not over. I fear “COVID fatigue” may lead to much unnecessary suffering.
So far this summer my wife and I have enjoyed three outdoor concerts offered in our neighborhood. Last Saturday evening we enjoyed “Nick’s Other Band” on the green in Wilmot Flats. You can see the scene in today’s header. Nick’s Other Band is composed of great local musicians, several of whom were/are faculty members at Procter Academy located in nearby Andover. The evening was great fun because I had not yet heard at the time that there is a growing concern that the latest variants are so infectious that they can be acquired outdoors. COVID is surging in Northern California and in New Hampshire. So far I have avoided the plague by being very careful. I guess for the time being I will count myself lucky to have enjoyed three outdoor concerts and will get my music on the radio until this wave passes for sure. I hope that whatever you have planned for the weekend that you will factor in the realities of COVID.
Be well,
Gene
