Healthcare Musings For September 1, 2023

September 1, 2023

Dear Interested Readers,

 

After 60 Years, Dr. King’s Dream Has Not Come True

 

If you read these notes regularly, you probably realize that I consider Dr. Martin Luther King, Jr. one of our greatest American heroes. There were many mountaintop moments in his short life and none has had a more lasting impact as a description of a better America than his “I Have A Dream Speach” which was delivered sixty years ago from the steps of the Lincoln Memorial on August 28, 1963. The speech was the culmination of the “March On Washington For Jobs and Freedom” that had brought 250,000 people to the Mall.  As he rose to speak, Dr. King was introduced as “the moral leader” of America. I would posit that in the intervening years, there have been other American voices that have appealed to the “better angels” of our society, but no other voice has had more moral authenticity than Dr.King’s. 

 

Even though the sixtieth anniversary of the speech was last Monday, and even though you may think you know what he said, I would suggest that you listen and watch the speech once again by clicking on the link above. Every time I listen to the speech I appreciate some new nuance or gain some new insight. I hope that will be true for you and worth a seventeen-minute investment of your time. It is said that Dr. King departed from his prepared remarks and spontaneously inserted the part of the speech that we remember best. As one reference says:

 

King improvised much of the second half of the speech, including the “I have a dream” refrain. Improvise means “to deliver without prior preparation.” It does not mean that King completely made up the words on the spot. In fact King delivered the now familiar refrain, or at least a version of it, two months earlier at Cobo Hall in Detroit. Remarkably, if you read the text of the Detroit event, you’ll see that he did not recite the same sentences word for word. His mesmerizing words and sentence structure were truly delivered extemporaneously. It’s an example of rhetorical dexterity at its finest.

 

The speech was the culmination of the long-planned and much-resisted “March on Washington For Jobs and Freedom” that began the final miles of the journey toward the Civil Rights Act of 1964 and the Voting Rights Act of 1965, the crowning achievements of the Civil Rights Movement. Unfortunately, the Supreme Court has chipped away at those achievements and that has contributed to the reality that Dr. King’s dream of equality and prosperity for all Americans still lies someplace far over our horizon.  

 

I frequently hear people extol how much better things are now for Black Americans than they were in the sixties. You can tell that to the families of the three people shot at a Dollar General Store in Jacksonville, Florida earlier this week. I don’t see how that event is much different than the lynchings of the Jim Crow era. The resistance to the full participation of Black Americans in our society has become quite sophisticated and disguised as political conversations about “affirmative action”.  The persistence of a healthcare system that is rife with inequality and barely camouflaged implicit racial biases suggests that we have a long way to go before we realize Dr. King’s dream. We still witness the spirit of Jim Crow in the fight to eliminate any discussion of the horrors of slavery or any aspect of critical race theory from the school curriculum in Florida and other states. In the most absurd of educational documents, a new curriculum in Florida suggests that some slaves benefited by learning new skills in their chattel bondage. (Chattel is a tough word that implies one person is the personal property of another.)  Technically, the era that we call “Jim Crow” is gone, but there is an ugly persistence of the economic realities of its apartheid policies on the social determinants of health. Jim Crow may have left the building, but the damage he wrought is far from repaired. Crow’s misery persists in the lives of too many impoverished Black Americans who get little if any effective retribution from those of us born into a more advantaged state.  

 

Dr. King was a visionary, but he was also a realist. I wonder what he would think and say if he were to return today. I was surprised to see an op-ed piece this week in the Washington Post from Joe Biden. I thought it began well even though it was an obvious campaign statement reviewing some of the Biden administration’s accomplishments. The president (or a staff member putting the president’s feelings into words) writes:

 

Sixty years ago, the Rev. Martin Luther King Jr. and hundreds of thousands of fellow Americans marched on Washington for jobs and freedom. In describing his dream for us all, Dr. King spoke of redeeming the “promissory note to which every American was to fall heir” derived from the very idea of America — we are all created equal and deserve to be treated equally throughout our lives. While we’ve never fully lived up to that promise as a nation, we have never fully walked away from it, either. Each day of the Biden-Harris administration, we continue the march forward.

That includes a fundamental break with trickle-down economics that promised prosperity but failed America, especially Black Americans, over the past several decades…

 

The line that appealed most to me was;

 

While we’ve never fully lived up to that promise as a nation, we have never fully walked away from it, either.

 

The journey continues. I think that President Biden’s analysis is an honest statement that suggests that the current administration cares about the unfulfilled dream. Any examination of public health data, life expectancies, maternal/ child outcomes, or outcomes from the COVID pandemic reveals that we are a long way from healthcare equity. The gap persists because of the lasting impact of discriminatory policies, persistent implicit biases that impact care and outcomes, and discrepancies in the lingering deleterious social determinants of health that impact education, housing, and employment. Our prisons which are disproportionally filled with young Black men also suggest that there is no equity in our justice system. History reveals that it does not take long for a person of color who commits some crime to be brought to justice. Civil Rights greats Bayard Rustin and W.E.B. Dubois were harassed in federal courts, and Rustin spent 28 months in a federal penitentiary for his point of view. Dr. King and many of his followers were incarcerated for various lengths of time for their non-violent protests.

 

These days justice seems to come at a much slower pace, if at all, for those whose policies and actions in office help to perpetuate inequality. Racist policies are not a crime. But, an attempt to negate the transfer of power after losing an election is, or should be considered a crime against us all. We have been both afraid and slow to hold the masterminds of one of our darkest hours accountable for their attempts to block the peaceful transfer of our most powerful political office. It has already been two and a half years since President Trump’s grand efforts to stay in office sent thousands of angry insurrectionists to attack our Capital in an outrageous attempt to perpetuate his administration that often advocated for policies that undermined equality. 

 

The January 6th rioters were motivated by Trump’s lies, as they marched across the same real estate where 250,000 people listened to Dr. King advocate for greater equality so many years ago. Dr. King’s speech did not result in his hearers turning and attacking the Capital.

 

Many of the foot soldiers of that infamous January 6, 2021 event, listened to the rants of Mr. Trump and his coconspirators and were motivated to use force in a riot to attempt to subvert the Constitutional process of confirming an election. Many of Trump’s foot soldiers have been brought to justice. Some have been given long jail terms, but how many more years will it be before those who were the masterminds of that tragedy hear the results of their day in court? Equality in justice still seems as far in the future as economic and healthcare equity. 

 

The sixtieth anniversary of “I Have a Dream” and the March on Washington For Jobs and Freedom should be celebrated for what they envisioned. We should use the passage of time as a reminder of how hard it is to achieve a dream of equality that will undermine the advantage of one group over others. As we dream, work, and wait for equality in healthcare, we should realize that until equality and tolerance of differences are achieved in all aspects of our society, collectively, we are increasingly vulnerable to the instabilities created by inequity. 

 

Back to My Story and the Origins of My Healthcare Values

 

We often imagine ourselves in one or two major dimensions when in fact there are many dimensions in all of our lives. Recently, I learned a new word, intersectionality, which I have enjoyed using in these notes. Technically, it refers to the fact that an increasing number of people are members of multiple minorities or oppressed groups. For example, one might be a black, transgendered man who was biologically female at birth. I sort of like the idea of a word that reminds us of our unique individuality.

 

Being a member of multiple “tribes” is perhaps a concept that is closer to what I am trying to describe. It is definitely possible to be a member of multiple “tribes.” You can be an evangelical female lawyer who is a Red Sox fan and enjoys running marathons. I realize that I am stretching a point. Simply said, we are all complex mixtures of how inherent internal factors, over which we have little control, have interacted with external forces over time in our individual lives to create our unique personalities and opinions. The possible permutations and combinations of factors that determine who we are and what we think are virtually endless while when we are viewed from a greater distance we seem to fall into distinct populations. 

 

There is no doubt in my mind that who I am at seventy-eight is the product of many internal realities and external influences that have resulted in my temperament and worldview. I also have had agency in how I respond to those influences. As, I said a few letters back, I thoroughly believe that who we are as individuals is a unique blend of “nature and nurture.” The combination of factors on the “nurture” side of who we are allows for amazing variability even within families. Not only does birth order make a difference, but the experience with the outside world creates great variation even among siblings. Recent science even teaches that your environment substantially impacts how your genes are expressed which suggests that how we are “nurtured” within our environment by external forces even impacts the “nature” of our basic genome.

 

For the past few weeks, I have been reflecting on my educational and training experiences and the people and events to which I was exposed because I know that these people and events were important in shaping my professional opinions and my “values” that are fundamental to how I react to the moral challenges that feel so common today in the stressful lives of medical professionals. The discussion began with the consideration of “moral injury” versus “burnout” as the explanation for the intense dissatisfaction that many in healthcare are feeling about their responsibilities.

 

These reflections have been enlightening for me. The more I try to make my evolution into a description of my interaction with people and events that fall in place over a timeline of training, the more I realize that there were multiple levels of influence that have made me who I am and have impacted how I think and act that predated my training or ran parallel with it over the formative years of my professional life. Even in retirement, that process of evolution and clarification of what is important continues. I am nearly overwhelmed by my attempt to balance the factors that have determined who I am and how I react to the current challenges to American healthcare. 

 

My increased field of vision on my story has been prompted in part by recently reading TESTIMONY: INSIDE THE EVANGELICAL MOVEMENT THAT FAILED A GENERATION which was published this April by Jon Ward who is an experienced conservative journalist, political analyst, and author who is currently the chief national political correspondent of the Yahoo News service. Ward’s book traces the history of the evolution of his personal values as he rejected some, but not all, of the values to which he was exposed as he grew up in one of the new evangelical churches that evolved from a blend of charismatic-Pentecostal theology, the “Jesus movement” that emerged on the West Coast in an environment of 70’s rock music, and the “New Calvinism” of the 1990s.

 

In a podcast with Russell Moore, the editor of the evangelical publication, “Christianity Today” from last February, just before the book was published in April, Ward discussed his sense of alienation from family, friends, and former associates in his church when he tried to balance his faith and his conservative political views with the policies and attitudes of the MAGA movement and the dishonest and hedonistic realities of who Donald Trump is. 

 

Russell Moore was an interesting person to be on the other side of the conversation with Ward. They have a lot in common. Moore who occupied a very high position within the Southern Baptist denomination recently left a very high position. He was a rare “never Trumper” in the leadership of the Southern Baptist Convention. He is a former professor and provost of Southern Seminary in Louisville, Kentucky. My father received his Ph.D. and met my mother in classes they shared at Southern Seminary. She earned a master’s degree from the seminary’s women’s affiliate. I was born at the Baptist Hospital in Louisville while they were still students.

 

Moore has said that his departure from the Southern Baptist Convention which was virtually an excommunication was not about his opposition to Trump. He has published that he resigned over his outrage about attempts to hide clergy sexual abuse and the denomination’s negative stance on Critical Race Theory.  At the time he left, he was serving as the President of the denomination’s “Ethics and Religious Liberty Commission.” In his column in the New York Times, David Brooks has cited Moore as a voice trying to save evangelical Christianity.

 

In Ward’s book and in his conversation with Moore, Ward describes how through Donald Trump, many of the people who were attracted to these forms of religious expression saw a path to achieving objectives like the reversal of Roe v. Wade and how they cling to him today as a continuing way of influencing public policy toward the formation of an national environment that is consistent with their theology. Ward describes the difficulty in finding the harmony between a philosophy of life that seeks purity and religious perfection and excludes scientific facts through political power.  Ward’s hope is that his book might help maintain the ideal of a democratic, pluralistic society that depends on provable facts despite the fact that we are facing a relentless storm of lies told to a population that will not question authority. Ward has found personal resolution and an ability to persist with the tension by focusing on the hope that voters will reject the MAGA movement and elect leaders with policies built on facts and actions that always are founded on love and respect for everyone. 

 

The Baptist Church of my childhood bears little resemblance to the politically active evangelical Christians of today. That church was a mainstream protestant denomination like Methodists and Presbyterians that was not a shill for any political party. That church was the religious home of Harry Truman, Jimmy Carter, Al Gore, and even Bill Clinton. Intellectuals, scientists, and journalists like Bill Moyers, E.O. Wilson, Marshall Frady, and Robert Wright were also Southern Baptists before the denomination took its turn to the right toward Christian Nationalism in the 70s.

 

A cardinal tenet of the Baptists of my day was the complete separation of church and state. When I moved to Boston in 1967 the religious right had not yet captured the Southern Baptist denomination. Since the church’s lurch to the right, I have had only minimal contact during visits to see my parents with the Southern Baptist Church. It’s my bias that the takeover by fundamentalists began in Dallas at Southwestern Seminary and the huge First Baptist Church of Dallas. 

 

While I was a medical student and through my first few years of post-graduate training my former wife and I attended a small Baptist Church in North Cambridge that was affiliated with and financially supported by the Home Mission Board of the Southern Baptist Convention. The senior minister was a friend of my father’s from their days at Southern Seminary. The staff included a social worker who had a budget for outreach to the economically disadvantaged people of Cambridge, Somerville, and other nearby towns. Also on the staff was a very dynamic young associate minister who was a graduate of Princeton Theological Seminary. His primary responsibility was for student ministries at Harvard, MIT, and other area colleges where many students, like me, were from the South and were Baptists. He was very active as a pastoral councilor. In a way, the church created a core of relationships for many of us that was a home away from home.

 

I attended the church through medical school and through most of my years as a trainee at the Brigham. During my junior residency year, the young associate minister developed acute myeloid leukemia (AML) and was admitted to the Brigham under the care of one of the Brigham’s grand old clinicians, Dr. William Maloney, a pioneer in the use of chemotherapy for the treatment of leukemia.

 

Dr. Maloney’s team included some of the brightest and most caring junior faculty members in the medical school. His service attracted so many patients from all over New England that it was easy to think that leukemia was a common disease. In fact, even today there are only about 4 new cases of AML per 100,000 every year, and most of those are in people, over 65. with more males than females. The minister’s disease was a rarity. As chance would have it, I was a resident on the “private service” at the time, and my team admitted the young minister. He was strong and capable of withstanding the challenges of primitive chemotherapy and was fortunate to achieve remission. 

 

My friend and minister was one of those ministers who attracted a lot of admirers because he was theologically liberal and willing to deal with the ambiguities that develop between religion and science in modern life. He was also a handsome man who looked a lot like Kris Kristofferson who was then a former Rhodes Scholar in his prime as a philosopher songwriter and actor. Suffice it to say, many people, especially young women in local universities as well as nurses and even at least one female physician in training at the Brigham were attracted to him and sought his council. He was interviewed about death and dying by the media. In retrospect, I think that he became an expert on living with a fatal disease as a way of managing the pain and anxiety associated with his condition. A crueler statement would be that “he played it for all it was worth.” 

 

Once he lost his initial remission and began to have recurrent hospitalizations to induce new remissions followed by yet other admissions for exacerbations of his disease, he became even more attractive as a man doomed by his disease. He became very adept at publically describing the experiences of his illness in a way that elicited enormous sympathy from all those who knew him or met him.  He became a male form of the character in the tearjerking 1970 film with Ali McGraw, “Love Story.” 

 

As my minister was admitted again and again to the Brigham, over twenty times in three years, I avoided any further involvement in his care and assumed the role of an “inside” friend who was willing to help optimize his hospital experiences and listen to his concerns and fears when things inevitably deteriorated. I was frequently at his bedside late at night as his condition continued to decline. He was “rescued” many times as his illness went on for three years. During the last days of his life, he told his wife about his numerous romantic relationships over many years with many women in the church, in the hospital, and in every environment where women came to him for help. He had been adept at exploiting women, and with his tragic illness even more were vulnerable to him because of the attractiveness of his courage in the face of death.

 

It was my first experience with how the “power” of a professional position of authority can be misused by people with a personality disorder to bend vulnerable or impressionable others to their will. After his death in 1975, many people were confused between their grief and their anger. I left the church and did not actively participate in any form of religion for several years.

 

.Ward’s book describes his experience with different but similar forms of abuse by church authorities. The problem of sexual abuse by people in authority is not limited to the Catholic clergy or evangelicals. Abuse has been a sad discovery of the “# Me Too” movement. There are medical professionals and indeed even politicians, businessmen, teachers, coaches, scout leaders, and even parents who abuse their positions of power and responsibility which gives them the ability to prey on others. 

 

Ward’s book has helped me understand the frailties of the religious heritage into which I was born and how the church in which I was nurtured has been coopted by far-right religious fundamentalist and even less radically conservative Christians. The evangelical church has become the core of the populist movement within the Republican Party.  The members of evangelical congregations are a major part of the base of ardent supporters of Donald Trump, a man whose whole life has been lived in contradiction to the theoretical religious principles that are supposedly the foundation of their church’s worldview. Not only do many Americans vote against their own economic best interests, but it seems they also vote against their religious principles. Ward struggles to extract what is valuable from his experience and how to apply it to a future where uncertainty, disappointments in figures of authority, and the evolution of a society with more focus on personal liberty than participation in community are increasingly obvious. 

 

On reflection, the progression of knowledge in my life in medicine took me away from the easy answers of blind faith and in some way prepared me to be able to tolerate the realistic path of uncertainty and ambiguity that leads toward expanded awareness of others.  Caring about and helping others is at the core of all religious thought. All religions teach that we owe each other the universal respect, goodwill, and fairness that  Dr. King hoped would eventually characterize our entire society. I believe that those principles are also foundational requirements for a system of care that extends the equity King called for to the healthcare of every person. I think that those basic principles were to be found in my family of origin because of my parent’s beliefs. Those values have been augmented by almost every medical mentor worth remembering that I encountered in my training. 

 

It takes the luxury of time with the patient and the backup of human and material resources to provide the good care that every patient deserves without sacrificing the professional and emotional health of care providers. Dr. Francis Peabody died in 1927 long before I came to Boston and saw my first patient in the Peabody Building of the old Boston City Hospital. He trained at the Peter Bent Brigham in its earliest days. In 1927 shortly before he died of cancer at the age of 46 he published an essay in JAMA entitled The Care of the Patient  which contained the wisdom:

 

One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

 

I was fortunate that my training exposed me to teachers and colleagues who were both experts in the science and practice of medicine and almost universally practiced Dr. Peabody’s admonition to care for the patient as an individual. In that same essay Dr. Peabody espoused the importance of caring about and understanding the social circumstances of a patient’s life and by extension, his/her community of origin. 

 

The experience with my friend and minister was perhaps the most significant event of my years of residency, but there are a few more points from those years that I will return to next week. If it had not been for Jon Ward’s book I may have left this most significant memory locked away in the basement of my mind. 

 

What’s Going On!?

 

The weather app on my phone claims that there will be only bright skies and summertime temps for at least the next eight days. The weatherman on the local TV channel from Manchester declares the same good news and adds that it will be the first time in over three months (the entire summer) that we will have gone more than four days without overcast skies and a downpour. As luck will have it, the same good news applies to Falmouth on Cape Cod in Massachusetts where we will be attending an annual end-of-summer gathering of expatriates and persistent residents of Wellesley, Mass and the Wellesley Hills Congregational Church where we felt quite at home between 1985 and 2013. Our hosts, like us and many of the other guests whom we will be so happy to see again, have abandoned the anxieties of driving in the constant heavy traffic of greater Boston and have opted for a slower pace for the time we have left. 

 

Life is different when you can set your own pace and there is not a patient to greet and a new problem to solve every fifteen minutes. There was a time when I was delighted to be involved in the lives of so many people, but in reflection, I realize that the pace and the continuous responsibility did deny me the time to slow down and get a good look around at what was happening in the world or even at my doorstep. These days, when the weather is as it is forecasted to be, I enjoy my daily walks again and again over the same few routes. Some of the most glorious things I see are even in my own yard! For example, we had a huge Rose of Sharon on our front lawn in Wellesley that I rarely stopped to enjoy. Now August is a huge joy because that’s when the Rose of Sharon that we planted a few years ago is covered with blooms like the one you can see in today’s header. You are never too old to learn something new. I did not know until this summer that the Rose of Sharon is a hibiscus! Who knew? Not me.

 

I hope that you have a terrific Labor Day weekend where it is not too hot, too wet, or too windy. You deserve a great last week of summer!

Be well,

Gene