October 8, 2021

Dear Interested Readers,

 

Reflections on Failed Good Intentions And Inequality

 

My fiftieth-anniversary medical school reunion was this past June. COVID turned it into an online event. I understood the necessity, but it was a disappointment that reminded me of all the graduations, weddings, funerals, concerts, and sporting events that COVID has canceled. 

 

One thing that COVID did not cancel for me was my reflection on those first days of medical school back in the fall of 1967, all of the events of the next four years of progress toward graduation, and then the way I felt that I had changed by the time graduation came. My class began with 120 students. At the start of the third year forty classmates, most of whom were transfers from Dartmouth which was still a two-year program, joined our class. We were changed in those four years prior to graduation, but the transformation was only getting started as we became interns. We know from biology that organisms change from predetermined internal events, but externalities, the world around them, and many influences beyond their control, also play extremely important roles in determining the outcomes. The late sixties and early seventies were certainly a time when change was primarily driven by externalities. 

 

When I look back on who we were on the first day of medical school it seems like we were comparable to undifferentiated stem cells at the time. Like stem cells that are the common substrate that begat every organ and every form of tissue, each of us had the potential to spend our careers in any branch of medicine, its basic sciences, or its professional infrastructure. No one ever said it specifically, but I am sure there was an expectation that over the next fifty years many of us might become part of the defining leadership of medicine. 

 

Fifty years have passed, and as I scanned the little book of self-declared accomplishments that was produced as part of the occasion that never was, I saw that since graduation my classmates had spread to every region of the country, entered every known specialty, were doing research in many forms of basic science, and yes, there were some noteworthy leaders. Some in our class had become small-town primary care doctors, others had held positions of power at major universities, or were in influential positions in professional societies or government. Most of those who were not yet retired seemed to be giving the inevitable some serious consideration. We were in the waning moments of our opportunity to create positive changes in healthcare.

 

When I think back to that late September day when we all gathered in the lecture hall of “Building C” to be welcomed by the Dean, Dr. Robert Ebert, to the school and to the next step on our professional learning curve, I suspect that most of us were still idealists. It was the sixties, an age of rebellion and resistance to old social norms. Over the next couple of years, we would return early bribes from the pharmaceutical industry that appeared in the form of medical bags and diagnostic gear. We protested the war in Vietnam and marched together across the Charles River to be part of the 1968 outrage over the confrontation between Harvard and its students. We wanted to prove that we were idealists who could not be bought or intimidated.  

 

When I think about those earnest young faces that surrounded me I have to believe that the large majority of the group was motivated by a deep desire to make the world a better place. Some of us wanted to do that by helping individuals in need or in pain. Some of us were planning to make a contribution by advancing basic medical science or by creating some device or process that would promote health. Altruism in all of its many forms and replete with naivety was palpable. 

 

I know from reading what Dr. Ebert wrote and presented in lectures that he was motivated to help create a generation of socially responsible physicians who gave more effective attention to the plight of the urban and rural poor. We did not understand that he was advocating a focus on population health.  Dr. Ebert was arguing that we could do better than to wait to treat a disease until after it made the patient ill. He believed that a more robust program of preventative healthcare would reduce the misery of disease, the expense of healthcare, and sustainably improve the health of the nation. He realized that there was a great inequity in the access to care. He believed that negative social factors were the equivalent of pathogens and that our school needed to promote social responsibility just as much as it promoted excellence in the practice of bedside medicine, the focus on specialty practice in the hospital, or the advancements of the basic sciences and technology in our research labs.

 

I don’t think I ever heard anyone say that they were going through the long and demanding process of becoming a doctor or were tolerating the exhausting hours of their internships as a first step toward being wealthy or powerful. We accepted the long hours, the serfdom of being a house officer, and occasional humiliation on rounds as necessary prerequisites that we needed to endure and sacrifices we needed to make if we were ever going to have the skills we needed to help people. We never talked about it, but I believe that most of us were in training for the potential good that we might do, and the difference that we might make. Some of us believed that if we really tried we might extend our ability to help a troubled patient to make a difference in a troubled world that would touch many many people. I doubt that anyone ever had the thought, “I can hardly wait to make a lot of money and be part of the influential and powerful status quo.”

 

The personal stories of what happened over the last fifty years that were published in the little book that accompanied our Zoom reunion suggest that despite no expressed desire to be part of the status quo, or desire to join the establishment or to earn large salaries, that is what has happened to most of us. A cynic might say to we matured out of our “good intentions.” Many of the articulate young rebels of the late sixties and early seventies are now corporate board members, equity partners in influential practices and corporations, or policy creators in their areas of influence.

 

In my darkest moments I want to say that we sold out to the world we wanted to change, but that would not be accurate. When I am kinder to myself and others of my era I see more naivete about how hard it is to change the direction and momentum of the status quo and established practice and power than greed or malice as the explanation for the failure of my generation to make the substantive changes in healthcare that would have created the equity that Dr. Ebert said was missing in American healthcare. I think everyone in my class could point to individuals and events, patients they served, or programs that they fostered, that made a difference for a few, but left the bulk of our national healthcare embarrassment unchanged.

 

In the sixties, American healthcare was declaring itself to be great when there were so many underserved and suffering people in the inner city, on the farms, and in the factories of the country who were not getting its benefits. I am sad to say that after fifty years most of the problems of the sixties persist and we have added pandemics, gun violence, opioid abuse, deaths of despair, and an increasing threat to our health from climate change to our problem list. Despite the progress we have not made, we still proclaim ourselves to be the world’s best, and indeed our technology is great if you are among those who have access to it. We have a very limited field of vision when we look to identify for whom we have actually made a difference. More and more medicine seems to be focused on the individual with the means or good fortune to pay its price. Others like those who survived on charity in biblical times glean what they can or just don’t get the care they need. It is sad to say that after fifty years there are still people who die as much from economic inequity and unaddressed social problems as from the diseases that we are so proud to say that we can treat.

 

Fifty years ago we received little or no instruction in the care of populations. The institutions where we ended up practicing had always been compensated for their care of individuals and not for improving the health of populations. That is still the reality. Dr. Ebert tried to develop an organization that was compensated through capitation, but the primary care focus on the elements of population health was immediately lost when an individual needed hospitalization or services that our specialist could not provide. Perhaps the explanation for the fact that my class has failed to lead an extension of the potential benefits of the American system of care and its fabulous technologies to more people if not every person in the country is that we tried to be actors on a stage that we did not really understand, that was much larger and interconnected than we realized within a medical-industrial complex that had no interest in populations in need, and that was controlled by forces that most of us did not fully appreciate within a system with business and policitacl complexities that we did not completely understand.

 

I don’t know exactly what is taught in medical schools these days. Do they teach anything about race in the history of medicine? Do they review how public policy since the nineteenth century contributes to the healthcare disparities that we see now?  I know that when I was in medical school we did not study the inequities that existed in the late sixties in healthcare. I do remember hearing the acknowledgment that the urban poor lacked the care they needed, but that reality did not initiate any programs or policy changes other than chronically underfunded and variable programs in Medicaid and the partial coverage of Medicare which has always needed to be more robust in its offerings and the population it serves. Social problems were recognized, but the responsibility for solutions belonged to no one. 

 

I do remember a passing mention of the horrors of the Tuskegee syphilis experiments and the benefits that had been yielded from the use of the cell lines developed from the tissue harvested from Henrietta Lack’s cancer, but just as it was true that until recently most white people in Virginia saw no problem with the statue of Robert E. Lee in Richmond, we did not connect these events in medical history to the world in which we practiced. If African Americans had increased health concerns it was a fact to know and not a problem that necessarily needed to be corrected.

 

The desire to do “good” in a complex and hostile world is not a new attitude. Failing to appreciate how difficult it will be to change a world that has momentum toward inequity and exploitation is not a flaw that was developed in the sixties. As a nation, we have been able to look away from the economic origins of many of the health problems of African Americans from long before the creation of our union.  

 

I have read a lot of literature over the last few years about the origins of the healthcare disparities which have been so dramatically uncovered and demonstrated during the COVID pandemic. The remarkable thing about the controversy over teaching Critical Race Theory is that it is a public expression of the fact that many people have no interest in knowing what really has happened over the last four hundred years and what the impact of that history is in our current world. Failing to recognize or admit what has happened makes it almost impossible to fix. I have had conversations recently with people who still would prefer to explain the origin of all of the problems that challenge Black Americans as manifestations of poor choices that Black Americans made as a result of flaws in their character. President Regan and countless demagogues before him have convinced them that “welfare queens” exist, and that neglect is their just reward. Donald Trump rubbed salt in an open wound to the cheers of millions who preferred his lies to the facts of history.

 

I wonder if the issues that face Black Americans are currently taught to our next generation of doctors. I am certain that we are still teaching about the mutation that has occurred in the hemoglobin gene that creates sickle cell anemia, but do they teach that increased rates of asthma are related to policies that expose minority populations to more polluted environments?

 

This note is too short to dive deeply into the persistent echos of slavery in our society, but I would offer you a quote from a Matthew Desmond article in the New York Times’ “1619 Project” entitled “In order to understand the brutality of American capitalism, you have to start on the plantation.” Desmond won the Pulitzer Prize in 2017 for his book, Evicted: Poverty and Profit in the American City. He now leads a think tank at Princeton where poverty and policy are studied. In Evicted, Desmond demonstrated how the state and federal housing policies that disadvantaged minority populations contributed to the social factors that we package as “healthcare disparities” as they made slum landlords richer. 

 

In his “1619 Project” article Desmond is doing a little “Critical Race Theory” work when he discusses the origins of American Capitalism and uses the term “low road capitalism.”

 

When Americans declare that “we live in a capitalist society” …what they’re often defending is our nation’s peculiarly brutal economy. “Low-road capitalism,” the University of Wisconsin-Madison sociologist Joel Rogers has called it. In a capitalist society that goes low, wages are depressed as businesses compete over the price, not the quality, of goods; so-called unskilled workers are typically incentivized through punishments, not promotions; inequality reigns and poverty spreads.  

 

If you are a member of the privileged one percent or even the most fortunate ten percent you may not care about theories concerning the origins of our inequality:

 

Those searching for reasons the American economy is uniquely severe and unbridled have found answers in many places (religion, politics, culture). But recently, historians have pointed persuasively to the gnatty fields of Georgia and Alabama, to the cotton houses and slave auction blocks, as the birthplace of America’s low-road approach to capitalism.

Slavery was undeniably a font of phenomenal wealth. By the eve of the Civil War, the Mississippi Valley was home to more millionaires per capita than anywhere else in the United States. Cotton grown and picked by enslaved workers was the nation’s most valuable export. The combined value of enslaved people exceeded that of all the railroads and factories in the nation. New Orleans boasted a denser concentration of banking capital than New York City. What made the cotton economy boom in the United States, and not in all the other far-flung parts of the world with climates and soil suitable to the crop, was our nation’s unflinching willingness to use violence on nonwhite people and to exert its will on seemingly endless supplies of land and labor. Given the choice between modernity and barbarism, prosperity and poverty, lawfulness and cruelty, democracy and totalitarianism, America chose all of the above.

 

There are those among us who aren’t interested in the history of race in America or how we still feel its impact now. But, if we blind ourselves to the implications of history when we analyze the data we see when we look at the health of the poor in this country, we are left with “blaming victims” rather than understanding a pathological process that has impacted their health. Desmond is a convincing writer and his last paragraph is powerful: 

 

Nearly two average American lifetimes (79 years) have passed since the end of slavery, only two. It is not surprising that we can still feel the looming presence of this institution, which helped turn a poor, fledgling nation into a financial colossus. The surprising bit has to do with the many eerily specific ways slavery can still be felt in our economic life. “American slavery is necessarily imprinted on the DNA of American capitalism,” write the historians Sven Beckert and Seth Rockman. The task now, they argue, is “cataloging the dominant and recessive traits” that have been passed down to us, tracing the unsettling and often unrecognized lines of descent by which America’s national sin is now being visited upon the third and fourth generations.

 

I found Desmond’s comments from 2019 while I was researching opinions about the book that Beckert and Rockman edited in 2017, Slavery’s Capitalism: A New History of American Economic Development. I happened onto this book a few weeks ago. It is a collection of sixteen essays written by historians of economics. The essays are powerfully written and brutally review a history that makes you cringe even as you can look around and see its truth and the continued impact of the connections that are revealed.

 

I believe that one of the most significant realities in the legacy of slavery and our inability to address it with intellectual honesty is our current problem of inequity in all aspects of our society, but especially as demonstrated by healthcare disparities arising from the negative social determinants of health that are manifestations of economic inequities that were planted by slavery. I wonder how differently my generation might have approached our work and our desire to help others if we had really appreciated in 1967 what is being revealed now and is resisted as Critical Race Theory. It may seem inappropriate to teach history and economics in medical school, but until we create new policies and programs that repair the damages of the racist policies of the past and the attitudes that persist that were espoused to justify those policies, future generations of doctors will need to continue to try to find professional satisfaction around the edges of the big issues that threaten the health of the nation.

 

I am convinced that one thing that has been missing from the good intentions of helping individuals is that we have forgotten that much of what threatens all of us now is a product of economics and history that we must address by caring about vulnerable populations. We may know how to teach the care of the individual, but we don’t know how to effectively involve all of healthcare, every doctor, and every institution, in a  productive conversation about how to address the economic and historical issues that are the origin of disease in populations.  We won’t come up with effective solutions if we are not working from commonly accepted concepts of the problem and the outcomes we desire. We have not made much progress in the last fifty years and will not in the next fifty years if we keep defining our success by the individuals we save with our advanced technologies while we worry about the bottom lines of our practices and hospitals while forgetting the needs of those who continue to experience healthcare disparities. 

 

There Is A Lot Of Work To Do Every Fall

 

The work of spring is full of positive expectations. I am getting boats in the water, taking deck furniture out of storage, setting up a hammock, getting all the necessary gear onto the dock, and checking out my fishing tackle. As I do these annual tasks I am full of positive expectations. I have positive images in my mind of time on the water, time on the deck, and all of the expansive interactions you can have when you are spending a lot of time outdoors. 

 

The work of fall is involutional. In a way, it feels like getting your last will and testament in order. The work is all about undoing. I must store the boats, prepare the dock to be removed, and clear the deck of all the chairs and tables that have made it such a comfortable place for most of the last five months. Everything is moving into the more confined space of indoors.

 

There is much to briefly enjoy about the fall. Last week while we had guests we took a ride on the Kankamangus Highway to see the fall colors. They were not at the peak intensity, but they are getting there soon. We showed our guests one of my favorite places in the White Mountains, “The Flume.” I was delighted to discover that to see the Flume in the era of COVID you must take a two-mile hike that carries you over a lovely wooded trail with only a little bit of climbing that was well within the capability of some in our party who would define themselves as sedentary. 

 

Today’s header shows one task that is part of the routine every fall. We burn between two and three cords of wood every winter. All the positive feelings associated with the deck in the summer are relocated to in front of the big fieldstone fireplace in the living room. It’s a much smaller world that is made much more pleasant by a crackling fire that usually burns from when I rise in the morning until we go to bed at night. Monday the first cord was delivered and dumped on our parking area in front of the garage. I have finally found the perfect woodman. He delivers well-seasoned wood at a fair price, and he always arrives when he says he will which is much more than you can say about a lot of other professionals. Perhaps he is a “throwback.” We could use more people like him. When this load is stacked there will be another, and then another. It is good that this next week is predicted to have several good days because I have work to do. My consolation is that I will still be outdoors in an intensifying kaleidoscope of colors. 

 

I hope that you will have a great fall holiday weekend whether you call the Monday holiday Columbus Day or Indigenous Peoples Day. The Sox played a terrific game against the Yankees, but they were flat last night against the Tampa Bay Rays. I am hoping that Alex Cora finds a magic elixir and by early next week the Red Sox will have defied the predictors and will be closer to the World Series! October baseball is the best.

Be well,

Gene