May 9, 2025
Dear Interested Readers,
There Are Increasing Challenges to Practice and Medical Research
Until the 21st of January, the challenge to medical practice and research was how to make faster progress. The last eighty years have been a journey of remarkable progress and discovery. At times, the status quo frustrated those who wanted the improvements to come faster. Still, since the failed efforts to repeal the ACA in 2017, we rarely needed to give much thought to losing ground in our efforts to advance toward universal coverage. Until President Trump began to sign executive orders, most of us never imagined America defaulting on its commitment to progress in cancer research, infectious diseases, and other life-threatening problems at home and abroad. The challenge was imagining how we could move more quickly and efficiently in efforts like the Triple Aim and “the moonshot” efforts to defeat cancer.
As the election approached last fall, I doubted that voters on either side of our deep political divide were thinking much about healthcare. Trump had successfully diverted most of the attention to the issues of immigration and the economy. On several occasions, I tried to voice my concerns about what might lie ahead in healthcare based on the strategies and opinions expressed in Project 2025. The biggest surprise for me post-election is not that President Trump is seeking to reduce Medicaid funding, but the degree to which he is withdrawing our efforts in medical research, domestic and global public health surveillance/responses, and the apparent passivity to these destructive efforts from most medical professionals and the public in general.
I have appreciated that Atul Gawande has spoken up. He has pointed out what we have already lost and are yet likely to lose. Early in his administration, President Biden appointed Atul Gawande to run the U.S.A.I.D.’s Bureau for Global Health. You might have noticed that during this time, he has been absent from the pages of The New Yorker and did not produce a new book. I had noted his absence on the printed page and chalked it up to the reality that he was working hard with all of his time devoted to overseeing our international healthcare efforts.
In late January, the president’s executive orders and Elon Musk and his adolescents at DOGE completely negated the ongoing benefits of the work Dr. Gawande had been doing. Perhaps President Trump is so stupid and ill informed that he did not realize the long-term consequences of his actions on the health of the nation and the whole world when he destroyed the work of U.S.A.I.D. and took us out of the W.H.O., but Gawande explains the consequences in a short article published online in late January by The New Yorker that is entitled “Behind The Chaotic Attempt To Freeze Federal Assistance.” Reading Dr. Gawande’s short article should convince you that with his misuse of power, Trump is throwing away decades of effort and damaging the health of millions abroad and potentially creating a disaster for every American.
Gawande points out that the damage done by the destruction of U.S.A.I.D. goes far beyond reducing the life expectancy and overall health of people on the other side of the world. He writes:
The effects go well beyond health. U.S.A.I.D. comprises the largest nonmilitary operational capacity the U.S. has for assisting countries in many other areas of mutual coöperation. The agency has built a network of hundreds of thousands of personnel across the U.S. and the world, and it is supported to do this work mainly through federal grants and contracts. This infrastructure is the engine of American soft power. And in a matter of days—and contravening laws and budgets passed by Congress—the Trump Administration has attempted not simply to redirect U.S.A.I.D.’s policy but to gut the agency’s capacity..
…For a century now, the U.S. has led the world on collaboration and impact in health, which has doubled the life expectancy of all of humanity—and delivered similarly outsized results beyond health. If this Administration really wanted to put America first, it would have built on that legacy. Instead, it is demolishing U.S. standing, our world-leading capacity and expertise, and our national security.
As we know now, and as Gawande predicted in his late January document, the damage that Trump’s misconceptions, biases, and desire to destroy our collective accomplishments were not limited to the U.S.A.I.D. Near the end of the article, he predicted more damage yet to come:
The Administration has seemed intent on deploying this playbook across the entire scope of federal agencies and activities for the United States. There are other institutions driving whole areas of critical work—environmental protection, education, labor, and disease control, to name just a few—that the President has targeted for dismantling… But the agency’s experience reveals what remains at stake—the collective capacity of the American government to pursue the common good.
Damage to the common good was the theme of Gawande’s most recent New Yorker article published on April 21 and entitled “The Cost of Defunding Harvard.” The subtitle, “If you or someone you love has cancer, cardiovascular disease, dementia, Parkinson’s disease, or diabetes, you have likely benefited from the university’s federally funded discoveries in care and treatment,” suggests that Trump’s attack on Harvard is an attack on all of us. The questions that come to my mind are “What in the world is Trump thinking?, “What possible benefit to the country could come from this action?”, and “How can the sycophants that constitute the Republican majorities in Congress justify their silence as he throws away decades of progress and dooms us to losses that we may never overcome?” I don’t expect someone like Robert Kennedy or Mehmet Oz to say that the actions are stupid; they have already sold their souls, but where are senators like John Thune, Bill Cassidy, James Lankford, Tim Scott, and Susan Collins? I think Liz Cheney nailed it when she said, “…there will come a day when Donald Trump is gone, but your dishonor will remain”.
In his article, Gawande gets personal as he reveals how one of his sons has greatly benefited from the research done through grants to Boston Children’s Hospital, a Harvard teaching hospital, where Trump’s attack on Harvard will have a huge impact on the sort of research that saved his son’s life. Perhaps the average MAGA enthusiast just wants to see the imagined “trust fund babies” at Harvard College suffer and doesn’t realize that their own babies and grandbabies are also at risk. Gawande is emphasizing that what many of these loyal “red hat” supporters of the president don’t understand is that they have a big stake in what Harvard won’t be able to do. Gawande writes:
These attacks are part of a broader assault on America’s health-and-science infrastructure. More than ninety per cent of the nine billion federal dollars for Harvard that are now in danger supports life sciences, primarily through the National Institutes of Health. The university itself receives only a fraction of this funding. Three-quarters of it goes to five independent Boston hospitals affiliated with its medical school: Brigham and Women’s Hospital, Massachusetts General Hospital, Boston Children’s Hospital, the Dana-Farber Cancer Institute, and Beth Israel Deaconess Medical Center. The threatened defunding, if implemented, would choke off science and research across all of them.These attacks are part of a broader assault on America’s health-and-science infrastructure.
Gawande continues by giving us a litany of benefits to everyone that will be lost when money from NIH grants no longer supports efforts to which we have already invested significant time and money.
The purge has, for example, all but eliminated regulatory enforcement of tobacco at the F.D.A. and smoking-reduction efforts at the C.D.C., even though smoking remains the leading cause of preventable disease and death. The removals shut down the C.D.C.’s renowned viral-hepatitis lab in the middle of a hepatitis-C-outbreak investigation in Florida…
…The N.I.H. delayed issuing new grants and terminated large swaths of existing ones, including half of the grants for research on improving public-vaccination rates, and also hundreds of H.I.V.-research grants. The sweeping layoffs also removed much of the C.D.C.’s H.I.V.-prevention staff, along with reassigning the top leadership in H.I.V. research at the N.I.H., thereby abandoning the U.S. commitment to end H.I.V. by 2030. At the same time, the Trump Administration has moved to increase its political influence on decisions about future N.I.H. grant funding, F.D.A. approvals, and C.D.C. guidance.
Gawande finishes with the cold reality of what has happened to our efforts to advance medical science.
The U.S. capacity for health, humanitarian, and developmental impact has been largely dismantled, leading to severe consequences for hundreds of millions of people abroad; now the destruction will have severe consequences for hundreds of millions of people here as well—if it’s not stopped.
He spares us for the moment from predicting what is likely to happen to many people’s access to care, and to the damaged quality of care for those of us who do have access to a delivery system that will be greatly stressed as healthcare finance is undermined by shrinking Medicaid dollars. Perhaps, he is working on that article.
If you are a regular reader of these notes, you know that I often find wisdom in the words of David Brooks. That may seem strange since he begins his journey on the right as he moves toward the center. I was raised right of center, moved to the far left as I discovered my own agency and identity, and now find myself moving toward the center on many items. It is not that I have abandoned the dreams offered by a progressive world view, its just that I realize forcing one view on everyone whether from the left or right is usually a recipe for continuing conflicts and little lasting progress. Change is slow without the application of force and submission. Changes that are forced don’t endure. As this moment demonstrates, even the advancements that evolve from collective agreement are also not guaranteed as circumstances change.
Brooks writes with deep insight into human nature. I don’t always agree with his conclusions, but his words allow you to easily follow how his point of view evolved. He also offers words of comfort as well as understanding. As I figuratively weeped and grieved over the damage that Trump has done and will likely continue to do to many of the things that I love and care deeply about, Brooks’ words have been comforting several times. My wife and I listen every Friday to the PBS evening news where we enjoy his informative exchange of opinions with Jonathan Capehart of the Washington Post and MSNBC. His column appears most Thursdays in The New York Times. In the context of my concerns about how to live at peace with the continuing distruction of our country, the damage done as we loose influence in the world, and the disgraceful performances of our president like his juvenile AI generated appearance in papal costume, I frequently find solace in the words Brooks offers.
Last Thursday’s column by Brooks was entitled “How to Survive the Trump Years With Your Spirit Intact.” He begins with words that are relatable to my feelings:
I had forgotten how exhausting it is to live in Donald Trump’s world. He’s not only a political figure. He creates a psychological and social atmosphere that suffuses the whole culture — the airwaves, our conversations, our moods.
He continues by referring to Trump as “pagan.” At first, I thought that was hyperbole, but he made a good case for the label.
If there is one word to define Trump’s atmosphere, it is “pagan.” The pagan values of ancient Rome celebrated power, manliness, conquest, ego, fame, competitiveness and prowess, and it is those values that have always been at the core of Trump’s being — from his real estate grandiosity to his love of pro wrestling to his king-of-the-jungle version of American greatness.
The pagan ethos has always appealed to grandiose male narcissists because it gives them permission to grab whatever they want. This ethos encourages egotists to puff themselves up and boast in a way they find urgently satisfying; self-love is the only form of love they know.
The pagan culture is seductive because it lures you with images of heroism, might and glory. Think of Achilles slaughtering his enemies before the walls of Troy. For a certain sort of perpetual boy, what could be cooler than that? But there is little compassion in this worldview, no concept that humility might be a virtue. There is a callous tolerance of cruelty.
Maybe, Trump doesn’t come across as cruel to you, but cruel is actually closer to what I feel explains what I object to in Trump’s performance so far (it does feel like a performance at times) than “stupid,” the adjective that I chose earlier as a descriptor in this letter to you. Further along, Brooks expands cruelty to mean more than abusing animals and relates it to those who tolerate cruelty. He calls out the “callous tolerance of cruelty,” which rings true for me when I think of all the sycophants who sit around the president’s cabinet table and flatter our pompous “Führer.”
The callous tolerance of cruelty is a river that runs through human history. It was dammed up, somewhat, only by millenniums of hard civilizational work. The pagan ethos — ancient or modern — always threatens to unleash brutality once again. The pagan ethos does not believe that every human was made in the image of God, does not believe in human equality, is not concerned about preserving the dignity of the poor. It does not care much about the universal feelings of benevolence, empathy and faithfulness toward one another, which, it turns out, are absolutely required for a democracy to function.
Brooks continues to make his case about cruelty in our times and expands it to a world wide problem by calling out Putin, Xi Jinping, “tech bros” like Bezos, Zuckerberg, and Musk, and movements like Christian nationalism. Brooks continues by giving us the strategy he advocates to avoid being overwhelmed by the dehumanizing force of pagan cruelty.
If paganism is a grand but dehumanizing value system, I’ve found it necessary, in this increasingly pagan age, to root myself in anything that feels rehumanizing, whether it’s art or literature or learning. I’ve found it incredibly replenishing to be spending time around selfless, humble people who are still doing the work of serving the homeless, mentoring a lost kid who’s joined a gang. These days I need these moral antidotes to feel healthy, resilient and inspired.
Those thoughts made me think of the joy I experienced in past moments of difficulty when it was a relief to go to my outpatient office or the hospital and do my best to deminish the pain, fear, worry, and uncertainty of a patient whose world had been reduced to an effort to find relief from pain, a return to an active life, or just to delay death long enough to enjoy a graduation, wedding, or birth in the family.
He postulates that the horrors of World War II led to a resurgence of care for others and that many promised to “never again fall for the strongman’s seductive promise of domination. That era eventually produced a golden age of public theology — Reinhold Niebuhr, Abraham Joshua Heschel, Martin Luther King — and so much else.”
Brooks is proudly Jewish, but he frequently references his attraction to the message of Christ, and in his book The Second Mountain, reveals that his second wife, Anne Snyder, is a Christian journalist. Against that background, he continues:
Judaism and Christianity confront paganism with rival visions of the good. The contrast could not be starker. Paganism says: Make yourself the center of the universe. Serve yourself and force others to serve you. The biblical metaphysic says: Serve others, and you will find joy. Serve God, and you will delight in his love.
You may be a person of faith or a person of no faith, but which moral atmosphere do you want to live in? The cultural atmosphere you immerse yourself in will slowly form who you are. I don’t fault those pagans for sucking down all those muscle-building diet supplements, but I know the kind of nourishment I need these days for the strength of my mind and the health of my soul.
Brooks continues by describing the resurgence of religion. One wonders what the selection of Pope Leo XIV will have on this trend especially since it seems that he may emphasize the need to support and lift up those who are less fortunate.
This movement was already underway before Trump was elected to a second term. It’s a response to a series of gods that failed: The belief that science and tech could solve our quest for meaning. The belief that we can live like hyperindividualists and still experience a sense of communal belonging. The belief that the right B.M.I. could lead to purpose and peace.
Are we on the cusp of a new religious revival? The evidence is still much too flimsy and fresh to justify that kind of sweeping assertion, so color me skeptical. I think it’s more accurate to say that there is currently a great spiritual yearning in the populace, which the religious institutions have not yet risen to meet.
Brooks is not convinced that religion will make a comeback, but he is hopeful that the brutality and cruelty that seem to be at the center of Trump’s authoritarian nature can be defeated.
…there are millions of humanists — secular and religious — repulsed by what they see. History is often driven by those people who are quietly repulsed for a while and then find their voice. I suspect different kinds of humanists will gather and invent other cultural movements. They will ask the eternal humanistic questions: What does it mean to be human? What is the best way to live? What is the nature of the common humanity that binds us together? As these questions are answered in new ways, there will be new cultural movements and forms.
Brooks is hoping that 2024 will be the end of the slide toward self-interest and cruelty as factors in our politics. He ends up waiting for the moment when “new winds will blow.”
… there has been, over the past decades of neglect, a loss of moral knowledge. We came to a spot in 2024 in which 77 million Americans took a look at Trump’s moral character and didn’t have a problem with what they saw. But the consequences of those character failings are becoming evident in concrete ways.
New winds are going to blow.
I am hoping that it will be a gale force wind that blows away all of the stink of this sad moment in our history. If I could, I would prescribe a strong laxative for our natiton. We have need for a great collective purge of something bad that we have swallowed, and it is making us sicker with each passing day.
Is the New Pope a Reason For Hope?
I am not Catholic, but my wife was raised as a devout Catholic. She attended parochial school until the ninth grade and was the darling of the nuns. She is a graduate of Boston College and got her Master’s degree in nursing as an NP from Regis College, another Catholic institution. Like many Catholics, she felt that the church failed her in the sixties, and has not been an active church member since then.
I had similar disappointments with my background as a Southern Baptist, and for many years rarely attended church, and to this day have doubts that challenge my faith. Suffice it to say, despite disappointments and a sense of having been failed by organized religion, I have always been fascinated by and drawn to the questions of how the spiritual world and the material world coexist. I now attend church regularly with the hope that the positives can outweigh the negatives.
My father was a minister who gave me intellectual reasons to search for faith. My mother, through her kindness and tolerance of everyone she encountered, showed me a great example of how faith can make a difference in our lives and the lives of those whom we touch. The most useful comment about faith that my father ever gave me was that he could not worship a God who was so small that humans could understand Him. There must be mystery.
All these events and thoughts plus others of an optimistic nature, excited me as I contemplated the life of Pope Francis and like so many others was drawn to the fascinating process of choosing the next Pope. As a “warm up,” last Sunday night we finally watched “The Conclave” with Ralph Fiennes. It didn’t win the Academy Award as best picture, but it was a good warm up exercise for the events of this week.
The big question has been whether or not the new Pope would continue the attitudes and progressive stance of Pope Francis. Pope Leo XIV may well continue that process. If he does, it may well be true that a focus on the spiritual aspects of life could improve the material lives of people all over the world which to me would feel like a very foundational way to improve the social determinants of health. There seems to me to be a connection between this hope and the advice that was offered by David Brooks.
We will see. I will remain hopeful for the possibilities this new Pope may turn into realities. The history of Christianity has not always been a straight line upward, but maybe with some help from this new Pope we will enjoy a new moment of ascendancy.
Comments About This Week’s Header
The scene in this week’s header should be familiar. It is one I have frequently offered when my lake is frozen and covered with snow. I have also shown it when the sky is clear, the sun is out, and we are enjoying the bliss of summer. This week was rainy, with dull skies and fog that persisted all day on several days. It seems that fog is difficult to photograph. When this picture was taken, I could not see the other side of the lake, although that reality was not captured by poor photographic skills. We are hoping for better weather by Sunday, but at this time of the year, every day stands alone as a possible positive surprise or a sudden disappointment. Wherever you are, I hope that your weekend will hold pleasant surprises and that you enjoy a very gratifying Mother’s Day!
Be well,
Gene
