Friday, November 20, 2015

United Health Care Might Exit The Exchanges

There is some consternation today over United Health Care's considering exiting the field of the Health Insurance Exchanges – the Affordable Care Act's policies for individuals. Does this mean that the ACA is not working?
Well, it's a complicated situation. I am indeed afraid that the ACA is not working in a very significant way: the ACA has incorporated High Deductible Health Plans into its midst, and they suck, as both the NYT and the Boston Globe (below – quoting me!) have pointed out graphically this week:
The worse the plans are for people the more enrollment will fall, and I have to think that the high deductibles make people feel they are not getting much for their money, so some don't enroll or reenroll.
But I think the UHC issue is different, and doesn't indicate ACA failure as such. UHC is very big and the exchange programs are a relatively small part to their business. They can probably make a profit on them, even though they say they can't, but the profit might not be big enough for them to want to concentrate on it. GE's strategy under Jack Welch was to make sure that every GE unit was #1 or #2 in the industry, and if they weren't, they either had to be built up or sold. From a corporation's point of view, you need to have some focus. And as we appreciate that point of view, I guess it's not such a bad thing to see them exit from this business segment. It's just a decision that there are more profits to be had elsewhere, and a corporation can't do everything. Is it such a bad thing for us that UHC can't find that much profit in Exchange programs? I think it's fine.
Looking back, the idea of the ACA was to make insurance companies make money a different way from the way they did it before, which was largely by excluding subscribers by underwriting, and writing tricky policies. Instead, insurers would have to make money by efficiency and service. That was a big gamble for both sides -- can insurance companies reform themselves? Can corporate cultures change? If not, then better to exit the field, concentrate on traditional markets, and other health-related fields like Optum.
Here is the way I put it six (!!!) years ago:
There will have to be a period of time where old companies try to adapt, and where new companies could even come into being to meet the new standard. The new companies might emerge from health care delivery models themselves, I would think. We'll just have to see.

Budd Shenkin

Saturday, November 14, 2015

EMRs, Government, and Capitalism

I wrote in my last post how the government screwed the pooch on Electronic Medical Records by not requiring interoperability as it invested $30 billion in the enterprise. With that kind of money going to by EMRs and equipment, surely the proviso that they be interoperable could be included. Was it corruption or incompetence that omitted that proviso? I couldn't be sure. Maybe a mixture

So here's a follow up from JAMA, September 22/29, pages 1213-1215, a medical news article: “On the Road to Interoperability, Public and Private Organizations Work to Connect Health Care Data.” The reporter, Julie Jacob, interviews the Office of the National Coordinator for Health Information Technology (ONC) spokesperson, Erica Galvez MA. The article states:

Although the ONC road map presents the movement toward interoperability as a smooth, straight road, in reality it's more like fitting together the pieces of a giant jigsaw puzzle. Several public and private organizations are working on different pieces, including organizations creating technical standards, establishing health information exchange (HIE) networks, connecting those HIEs, and developing principles of governance and usage. The hope (emphasis added), according to health care information technology experts, is that all the pieces eventually will interlock.

Because the Feds have basically opted out of direct action and laws requiring interoperability, several organizations have formed to try to fill the breach, one from the AMA called Healtheway, another called CommonWell Health Alliance which was spawned by the EMR industry sans Epic, and which requires a fee from participating institutions. Another older one is the Indiana HIE. Epic has their own system called Care Everywhere, available for a fee when you buy Epic and which was charging for each chart searched when Epic was presented to me, which links together Epic systems and some others who choose to join (for a fee which has been waived for five years, I guess under some pressure.)

Why all the flailing around? The JAMA reporter:

The highest barriers are financial and policy ones, not technical ones, noted those with expertise in health care technology.

Technology is almost never the obstacle,“ noted Indiana HIE's (John) Kansky. “It is really the governance of the data and getting organizations with different agendas to agree on what you are going to do.”

In other words, it is precisely the role of government that is not being well filled here. Government has taken a hike. Amazingly, this is the ONC goal:

...electronic exchange of health information among clinicians, health facilities,and patients should be widely available within 10 years.

Holy moley – 10 YEARS!! Let's see: Kennedy's speech, 1961; moon landing, 1969. ONC is not what we would call, let's say, overambitious.

I was interested that the spokesperson from ONC JAMA interviewed had only an MA degree, so I googled her, and got a hit from four days ago. From Healthcare IT News:

Former ONC Interoperability Manager Erica Galvez joins Aledade.”

What is Aledade?

Aledade was founded in 2014 by Mostashari with a focus on supporting independent, primary care physicians creating and or running ACOs. They provide healthcare technology, business transformation services and upfront capital.

More from Forbes:

Farzad Mostashari, who was formerly national coordinator for health information technology, raised $30 million in series B funding for Aledade. ARCH Ventures Partners led the round, with participation from return investor Venrock, bringing total funding to $35 million.
Mostashari, an internist, oversaw the nationwide implementation of electronic health records in the initial stages between 2011 and 2013. Last June, he founded Aledade to help doctor practices, as small as one, band together in so-called accountable care organizations (ACOs).
...By the end of the year, Aledade expects to have more than 100 physician practices in its ACOs, managing 75,000 Medicare patients. Practices pay a membership fee of $500 per general practitioner per month. They keep 60% of savings, with 40% going to Aledade.
In other words, the former head of ONC left to raise money for a private venture and hired a former staffer for him at ONC to come to the private venture. Let me note, however, that Aledade actually is interesting in that it focuses on private practices and has software that is designed to keep them independent of large hospital networks. Still, as they used to say, is this any way to run a railroad? But I have to say that I myself was in government early in my career, and looking around at what took place there, I decided that it was not a good place for me in the long run, much as I learned and loved some of my years there. I can't criticize others for making the same decision.

So, here is the picture. There are so many loose ends in the current non-system, it's not at all clear that this puzzle can be put together. To my mind, the Federal government has never looked so bad. They fail to look forward to see where private enterprise – here, EMR development – needs some help, some regulation if you please, to pave a road ahead so that companies can innovate and compete, but still develop a system that works together for the public's benefit. Companies themselves put a low priority on working together, as would be expected; that's why government is needed, as a convenor. Even when the Feds have a $30 billion windfall from ARRA, which would ensure they had the clout to enforce standards, they fail to exercise it. ONC continues to be meek and silly, setting a 10 year horizon for something that has governance and political impediments rather than technical ones. Government continues to fail to see, or at least talk about, the implications for the system as a whole, where some large capitalistic systems will benefit from lack of interoperability to the detriment of true competition and progress. Government accepts the role of bystander and beggar. Private companies seek to fill the government void of data coordination and interoperability. The problem of rotation of personnel from government to private business continues in health care as with other fields. Given the toothlessness and fecklessness of government, one can hardly blame them, although I'm sure there is much connivance from the private world. In fact, perhaps I am blaming the victim as I blame government. Who knows?

What I do know is, this really sucks.

Budd Shenkin

Sunday, November 8, 2015

How the Government Screwed the Health Care Pooch

When I get angry, I've learned to think, who do I think should be doing something that they're not doing? Then I can think, is that expectation valid? Sometimes it is, sometimes it isn't, and even when it is valid, thinking about it still kind of tempers my anger. At least, after a little bit. Personal anger management.

And so it is with our Federal government and Electronic Medical Records (EMRs). I complained to my brother Bob, who said, “What do you expect? Who do you think is in the government? The best? What kind of person wants to become a government employee?” He did not reference Donald Trump, but he could have, because that's one thing Trump is right about.

It's a well recognized phenomenon. When the ACA website imploded, veteran official Leon Panetta was thunderstruck: “Obama left that to the bureaucracy to do???” In other words, if it's important, make sure the government doesn't do it. Or, as I read in the WSJ yesterday about how Medicare doesn't check on the possible validity of claims before it pays them, as a modern credit card company would: “The government – yesterday's technology tomorrow.”

“The government” is a collective noun. It is composed of lots of people and agencies, and also the “advisers,” outside of government, often in academia, often in industry, who are supposed to be supplying the intellectual power. Maybe they're the ones I should be complaining about.

Anyway, here's the thing. When Obama came into office he needed to stimulate the economy with ARRA, the American Recovery and Reinvestment Act of 2009. Good, it was needed; in fact, more money than what they put into ARRA was needed, and he could have gotten more if he hadn't negotiated with himself, which I notice he has stopped doing, his current philosophy being, “I don't give a fuck.” Good; nice philosophy. But I digress.

So the health care “experts” thought that a program that put Electronic Medical Records into hospitals and medical offices would be just the ticket – marry the needs of the economy with the needs of health care. They claimed too much for what EMRs would do, they didn't really know much about them, and they didn't think they needed to know much about them. They had their theories, they had their analogies to other industries, they didn't need to get their hands dirty actually seeing what these programs were like. Details, details. The fact that EMRs generally suck didn't have to be addressed. The fact that it would slow down rather than speed up health care didn't have to be addressed. The fact that EMRs turned doctors into data input clerks didn't have to be addressed. Those were mere facts. In theory, it was brilliant.

My San Diego colleague Stu Cohen pointed out that the now-billionaire owner of Epic, Judy Faulkner, the major EMR system adopted in America, was a major Democratic donor and on the committee that inaugurated HITECH, the ARRA EMR program. A little self-dealing, seems like. What else is new?

When the Feds shelled out the money to get these EMRs into hospitals and offices, they unforgivably stupidly or cravenly or somethingly, (I don't know really how it was done so I don't know who to hate) didn't mandate that all the computer programs be standardized enough to be able to talk to each other., which is called interoperability. So here they all are all over the place, and they can't cooperate with one another.

In the words of North Carolina colleague Graham Barden:

What is even more WTF is that the Rand Report that was often quoted as saying how EMR’s were going to save vast amounts of money for the country, stated in the paragraph just above the often quoted figure something to the effect, “Once interoperability is achieved, ….” Unfortunately our 20 something leaders either did not read that paragraph or did not understand the big word…”

And more from Pasadena colleague Glenn Schlundt:

Over the years, there certainly appears to be a recurring and persistent, not improving theme about EMRs. Whereas a few people on this list sing their praises, and can't appear to imagine life without them, a significant fraction of posts speak to legitimate, persistent, and meaningful limitations that many EMRs presently appear to impose.

Here's my "off-the-top-of-my-head" list:

1. They don't talk to each other, so communication between them is essentially impossible.
2. They are absurdly expensive, and the return on investment on balance, while debatable in some instances, is pretty negligible.
3. They are expensive to maintain. The initial capital costs lead to monthly maintenance costs.
4. They are inefficient in that it takes doctors longer to do the same tasks, usually with little if any apparent benefit to the quality of clinical care provided.
5. Liability costs resulting from security risks, including HIPAA violations, may be considerable.
6. Some young physicians are declining to take employment positions where they will have to use hospital EMRs because they are unwieldy, inefficient, and time consuming (this from a
    previous post to this listserv).
7. They purport to allow doctors to collect data that will improve both patient care and cash flow, but other than auto-correcting doctors' previous undercoding, or allowing other doctors
    to purportedly "game the system" by clicking a few additional boxes,  well-publicized data or evidence for clinical or economic improvement appears lacking. Little convincing data suggests
    the financial benefits of EMR outweigh its costs, when measured directly, indirectly, or both.
8. They can weaken the doctor-patient relationship because some patients feel the doctor spends so much time looking at their computer screen, the doctor does not even know what their
    patient looks like. This has been used as a selling point for telemedicine, where, in a bizarre and peculiar twist, patient have reported they prefer telemedicine because "at least the doctor
    knows what I (the patient) looks like."
9. They can alter the way doctors are audited to include only data that supports downcoding or an insurer's interpretation of a clinical encounter based on data that is displayed. Several
    members of this listserv have noted that the medical decision making portion of their documentation, as measured by the software they use, drives payments, even when this does not
    appear to be the only or best criteria for medical work using CMS criteria.
10. The companies that sold or maintain them can decide to go out of business or change the terms of their contracts, creating additional access and liability issues

When one takes a Corporate Management of Risks in law school, one is taught that one frequent source of liability is over-commitment to a project or plan based on the time, effort, and resources that have already been invested. In short, one is taught that people and organizations find themselves in hot water because they are unwilling to objectively re-evaluate projects as they progress. At some point it is time to cut bait.

I'm not suggesting there is no role for EMRs; clearly in some cases they work, and work well. Nor do I mean to be either indiscreet or provocative here. What I don't understand is why, if having adopted a system that clearly has so many flaws and that it impedes efficiency, tarnishes one's balance sheet, increases liability and diminishes quality of life, why, at some point, the whole system doesn't find its way into the trash, and doctors don't just go back to the good ol' days (which, based on the animus transparent in many of the posts on this list, really are perceived as the good ol' days), until something genuinely better really comes along?

Why not just go back to paper for the time being?”

OK, that's bad, there was self-dealing, the programs are not ready for prime-time, and they don't talk to each other. Lots and lots of waste, and worse.

But, here's the deeper point of this post (sorry it took so long to get here.) There is an under-appreciated implication of the horrible omission of not requiring interoperability, which is brought out in a recent post from Boston health policy colleague Paul Levy:

Short look back: before the computer revolution, one of the foremost thinkers in health care organization was economist and ex-McNamara Whiz Kid Alain Enthoven. He proposed the model he called Managed Competition (MC). He envisioned many ICNs competing for business. He was a corporatist, and in those pre-computer days, the transaction costs of communication and information gathering were intimidating. Managed Competition was an attractive model.

The current incarnation of MC is called the Integrated Clinical Network (ICN) model, examples of which would be Kaiser, or the VA. In an ICN, when you are in the network, that's where you stay. Need a referral to neurosurgery? Off you go to the Redwood City Kaiser, where all their neurosurgery gets done. Need a neuro MRI? Off to Richmond, or wherever. It's all in-network. In theory, such specialization is good, more efficient, expert. But, if you are a clinician in a network, you don't have overt competition. The plan's members are a captive audience. You have to do well, maybe, but you really don't have to be the best. Each individual unit is shielded by the collective – the patient might choose Kaiser knowing there are some substandard units she hopes she won't need.

But now, with computers, another patient-centered model is possible. This is called the Centers of Excellence (COE) model. In a COE, you come to me, your primary care doctor. You need a referral. My job as your doctor is to get you to the very best place possible, and I have not just my in-network choice, but a full choice of the whole Bay Area, or even beyond. Several centers are competing for my business, and that's good for the patient. If they start to screw up one way or another, they will lose my business.

This is the real significance of interoperability of EMRs. The Mother Jones article cited above by Stu, written by an author with complex medical problems, points this out in great detail. To deliver the best care most efficiently, the primary care doctor and the referral unit need to have the same medical record in front of them. If the EMRs are interoperable, problem solved, COE feasible. If not, we have the same old difficulties of coordination, cooperation and efficiency.

If the EMR is not interoperable, referral within the system is easy, but referral to a possibly superior or more convenient center for x or y specialty is hard. But if patients might suffer, the same is not true of the ICN institutions at all. Although our economic system is based on competition, the role of individual corporations is to try to escape that discipline as much as possible, by combining with others to form oligopolies, or by fencing customers in to your network (as Apple does, for instance). So Epic won't cooperate with other systems – they sure don't want a small computer company that is great for a primary care doc networking into their system – God forbid! And for the integrated networks like Kaiser as well, interoperability is a threat rather than an opportunity.

The consequences of the Feds' decision not to require interoperability when they allocated $30 billion for EMRs are clear, then? This decision skewed the fight in favor if the ICN model, when the COE model has much to recommend it from the patient's point of view.

Maybe this situation is an example of LUC – the Law of Unintended Consequences. But “unintended” doesn't mean “unforeseeable.” The Feds, and if not them then their advisers, should have foreseen this consequence. Is this an example of inside dealing? Is this an example of selling out to corporate interests? Were the Feds convinced by others that “it would be too difficult” for them to insist on interoperability, and they settled for something less so they could “get the money out there?”

I don't know how it came about. They say when you need to choose between ignorance and malice, choose ignorance. Maybe. But at this time in our history, there is a very strong trend of increasing concentration within every industry, of corporate domination of government, of weaker and weaker government ability, and more and more violation of individual rights and welfare.

Sometimes it makes me mad, and sometimes it makes me sad. But either way, it sucks.

Budd Shenkin

Saturday, October 31, 2015

Hollywood Violates History Once Again

Hollywood and its apologists continue on their merry, hubristic, and for me, at least, ultimately dispiriting quest to bend facts to their predilections. The latest lamentable lapse into factual revisionism, perhaps the least significant of a series of misrepresentations, is “Steve Jobs.” Joe Nocera, for one, has taken great offense. A financial columnist before arriving at his Oped post at the NYT, he knew Jobs personally. Nocera says that virtually nothing about the movie is actually true. Instead, the very talented Aaron Sorkin has appropriated Jobs' persona and fills him with thoughts and feelings that never existed. “Is it a biopic?” he is asked. “I'm not sure what to call it,” he answers. Nocera knows what it is: “That's easy. Fiction,” he says.

When it comes to truth and history, what a sordid history Hollywood has! I just read that before our time, in the 1930's, Louis B. Mayer changed film elements that offended the Nazis – this really happened, even before the blacklisted 10. (reference: Philipp Blom, Fracture –
Those were instances of Hollywood's bending to political pressures. In our time Hollywood bends to the “artistic sensibility” of the auteur. Oliver Stone alleges conspiracies that never were. Kathryn Bigelow glories in the fruits of torture that never existed. Ava Duverney libels one of the greatest enactor of civil rights who ever lived – the white man Lyndon Johnson – as a cynical bigot. Why?

Here is their defense: UCLA professor of Theater, Film, and Television Richard Walter writes in the NYT letters that Nocera displays the “the height of arrogance” for thinking he knows the truth about Jobs – Nocera, who knew him, vs. Sorkin, who didn't! The fatuous Professor Walter adds: “The role for the creator of dramatic narratives is not to catalog an inventory of 'facts,' but to engage, indeed to provoke, upset, discomfort and disturb audiences.” He refers to “the lie that tells the bigger truth.”

And my God, it's not only Hollywood. Lying science takes a bow in today's NYT: “Take, for example, Prof. Diederik Stapel of Tilburg University in the Netherlands, who in 2011 faked experiments to show, among other things, that eating meat made people selfish. (He later said that his work was “a quest for aesthetics, for beauty — instead of the truth”).”

OK, my own aesthetics are offended, because for some reason I like truth. But is this only an aesthetic preference, or something greater? Does truth matter, even though so many people think that there is no real discoverable truth, that everything is just stories, since even historical facts are selected to make a story out of events? Am I just old-fashioned?

Yes, I learned about the problem of selection for history in my very first semester of being a history major. And yes, I'm for provoking and challenging and making people think. Good. But so we really want to consciously lie to provoke and to seek a self-defined “higher truth?”  Go ahead, call me old-fashioned, call me stuck in the conventional mud, but I'm opting for factual truth over the calculated lie. 

What an age where one has to defend that proposition!  But here goes.  An honest inquiry into factual events needs to deal with explanations and facts that contradict an overall narrative. Doing so is one of the major disciplines of finding truth. Let me fall back on medicine, as I tend to do. In medicine, when you are looking for a diagnosis, and when treatment depends on that diagnosis, there is no “higher truth.” There is only an understanding of the disease process as it actually is, complex though it may be. And in arriving at a diagnosis, there is every chance for error. The Institute of Medicine, a really great organization (and you all know how skeptical I am, so when I praise an establishment organization, it's noteworthy) sees diagnostic error as a huge problem. At the core of diagnostic error are errors in cognition.

What are errors in cognition? There is a huge number of them – An example is confirmation bias, where you have an opinion on the diagnosis, say, and if contrary information comes in, you ignore it as a “testing error,” or “weak indicator.” Or there is the recent case error, whatever that is officially called, where you tend to see the diagnosis as the same as a case you recently saw, or heard about in a lecture. These errors happen all the time, and that's when you are trying to stick to the truth, not lying intentionally! But in medicine, you get to see the result of your error in the course of your patient. There is a final accounting.  In Hollywood, what you get is a "higher truth."  What horseshit.

So, history is harder, because there is no therapeutic test that will judge objectively. But that doesn't mean that truth isn't available and important. There are rules, like prolonged civil unrest brings out the crazies. You learn from the rules you find by searching for truth in history. You avoid undue civil unrest if you can, to avoid the crazy consequences. You try. Truth matters, and if you don't think so, start painting, but don't talk rationality.

If you want to screw around with facts, that's your right as an individual. And if we were talking about some obscure e-book, well, who would care? But movies are something else. To quote myself in “Selma,” movies “shuts you in a room, dampens any other sensory distractions, focuses your attention on colors and giant images that are as clear as can be, and envelopes you in surrounding sound. There is nothing like a movie. Movies are the most persuasive, impactful, and indelible of any media ever invented. Movies are not only powerful, they are so easily accessible; more people see movies than read books or see plays by orders of magnitude.”

Since movies are the most powerful and accessible medium we have, what people learn at the movies is most often the full amount a person will know about the subject in question. So a lie, no matter how well intentioned, is really a sin against human understanding. Unless you are so arrogant that you think you are the one with the higher truth. But guess what – nobody is that great.

What has been gained by Stone's lies about the Kennedy assassination? What about Bigelow's? What about DuVerney, who when confronted with her character assassination of Johnson replied, “Well, that's my truth.” These are the higher truths of the Hollywood geniuses?

What they have in common besides their lies is one big thing – they all made money. You never found one of these guys violating the truth for something less remunerative, did you? Or is it the thrill of aesthetics? Hmmm. I wonder.

Color me outraged.

Budd Shenkin

Wednesday, October 7, 2015

Hillary Is Better Than Obama On Health Care

My opposition to High Deductible Health Plans is well known to readers. (See for the ineluctable conclusion that they suck on a multitude of levels.) I have also condemned the general heedlessness of Obama to the finer points of health care financing, and his administration's concern with only the poor, to the exclusion of the working class that they purport to be very concerned about. In this case, policy does not meet up with words. In general, I think the Obama health team's health approach has lacked, shall we say, fine tuning.

At the same time, if Obama's political approach has been marked by preemptive surrender, Hillary's 1990's approach erred on the other side. With disastrous results, the Clintons treated Washington policy makers as they would have treated the Arkansas legislature, as a bunch of rubes, which they weren't, especially the insurance lobby. But if Hillary lacked astuteness of political approach in those early years, she did know policy. She and Bill basically knew what they were talking about.

Hillary is a lot older and one can only hope, wiser, if not a better candidate. Hey, I wish she were, but one person can only do so much. She is married to Bill, but she isn't him – and that's OK. At least she is smart and good on policies. (I just wish she could stop being so reactive with her propensity for declarations. I wince when I hear “MY PLAN WOULD ….” She can't get away from a tone of preemptive hectoring, that I feel is yelling at me the audience, borne of criticisms I haven't leveled at her. But at this point, I'm just hoping the polls turn around for her.)

What she is saying now on health policy is needed and smart. Apparently her guru is Neera Tanden, who seems smart. See:

Basically, she is attacking the HDHP program, and proposing to take on the drug industry. Good! Limit the out of pocket, and include three visits a year without a deductible. Excellent. Lower the advantages that accrue to pharma – they have enough, and lowering margins won't inhibit innovation.

I also think she's right to plump for rescinding the coming penalties on Cadillac plans, even though it might be a stance directed on gaining union support. I say, let people have as much insurance as they can get, and forget about their “having skin in the game.” You need other ways to reduce expenditures than making people feel pain when they are sick. She doesn't have a program to decrease the in-hospital and procedure costs yet, but no one does. I would think that that would come; it's the logical extension of less reliance on HDHPs. Maybe she has something in her back pocket, but you don't have to talk about that yet, unless in general terms when pressed to speak about cost.

So, I write this as a note of celebration. Good for her! Health is one area that a Clinton II administration would improve the Obama approach. Maybe we'll get to see how the rest of her agenda goes. However it goes, hers would certainly be better than a Rubio-Kasich approach. God, the risks we are running....

Budd Shenkin

Sunday, September 27, 2015

Perhaps I Am Not A Liberal

I'm not really sure if I'm a liberal. I honor warm feelings for others; I certainly support the First Amendment very strongly; I believe in collective action as represented by government. But I'm also pretty practical. I don't believe in feckless charity; I don't believe in sloppy thinking; I honor some of the principles of conservatism, as in Edmund Burke and his Reflections on the Revolution in France. But I'm not in bed with anything like what passes for conservatism currently in America – no, siree Bob!

In medical school two friends and I founded the Public Health Club. Dean Robert Ebert assigned Dieter Koch-Weser as our advisor. It was then I learned about the Law of Unintended Consequences (LUC). For our first meeting he assigned readings about what happened in areas where doctors and public health authorities abolished malaria. LUC prevailed in these articles. With malaria conquered, population increased, with a resultant increased suffering from human congestion and increased poverty, if that were possible, all from the best of intentions.

Decades later I read about Western beneficent organizations alleviating the suffering during African famines by importing food. Critics pointed out that the LUC would then ensure that the next famine would be even worse, with even greater suffering, since core problems would not be addressed.

So, with that attempt at an exculpatory introduction, what about the refugees descending on Europe? You could say that the refugees are consequent to an awful civil war in Syria, as well as unlivable conditions in other countries. Certainly that is true. But civil wars do not erupt out of nothing. The refugees are fleeing with their pitiful families, which number how many? Six, eight, ten? We pity them the more for their numbers, but what are they doing with all these kids? It's their culture. (I've said for a long time that the Palestinian strategy is to have as many kids as possible and then don't educate them, but that's another matter.) Yes, that's their culture. They have overpopulated their home country, which became manifest when the severe drought came and they fled the rural areas for the cities. They countries are not cohesive, but rather divided into religious tribes who get along sometimes, but when push comes to shove, they fight each other. Overpopulation plus lack of cohesion equals misery.

While the civil war might be the proximate cause of the mass flight, the deeper cause is overpopulation resulting from a culture of human fecundity. In the natural world we see bees overwhelming the hive and then a group leaves to form a new hive elsewhere. It's not a stretch to recognize the same dynamics at work here, even as the outcasts tug at our hearts.

It is only natural to think Europe should be generous and take the refugees in. But, are the refugees say that they want to become Europeans? Maybe some are. But I think most are saying that they want a better and safer life for themselves and their large families, not that they want to change themselves. They don't want to give up their culture. They want room to create a new hive.

I remember the story of Kosovo. It used to be Serbian (I hold no brief for the Serbians, btw, but I believe that this is the fact.) Then fecund Albanian Muslims moved in, proliferated, became a majority, and now they rule, as they and others feel they have every right to do, because they are now a majority. Without firing a shot (at least initially), they gained new land.

As I write this, Ann and I are on the Silver Seas Shadow traversing the North Pacific. We sat with some Brits the other day and conversation turned (not on my initiative, as it happens) to Muslims in Britain. Our new friends told us that in their neighboring towns between Manchester and Leeds, five times a day, loudspeakers blast out call to prayers, invading the auditory space of what used to be quietly Christian towns. And we also read in the papers a day or so ago that in France Islamic prayer services are spilling out onto the streets surrounding mosques in various towns, leading to proposals that this not be allowed. This can be uncomfortable for some; I certainly would not like it; others might feel more at peace with this increase in diversity. Opinions vary, I guess. I think I'm just pretty conservative here.

For many centuries now, after the terrible consequences of wars based on religion, the European tradition has been for religion to be a private affair, and for disparate religious groups to interact with common understandings in quotidian life. The United States has shown how possible it is to benefit from the influx of other cultures; the intention of most immigrant groups to the US has been, however, to become Americans. They have been able to keep their religions and still fit in comfortably, and make the US better. So the big question is this: how does that apply to the would-be Muslim immigrants to Europe? Would it be their intention to fit in? Could they do it? And would the Europeans allow it, and even facilitate it?

To my mind, these aren't easy questions. I think of the Iraqi immigrants to Sweden, who came because of Sweden's commitment to human rights for all. One result of the influx was that a Davis Cup match between Israel and Sweden could not be freely played in Malmรถ because of anti-Israel protests by the immigrants. The match was played to an empty stadium. Others might think a five time daily call to prayer over loudspeakers in their hometown is acceptable. Would they also think that this imposition of Iraqi prejudice is also acceptable?

France hasn't been able to handle Algerians, who have been banished to the banlieus, from which emanated the assassins of Charlie Hebdo. Cast blame where you will, but isn't that a foreseeable result from warm feelings of wanting to help the refugees? We might say that France should “do better” by the refugees, but maybe they just can't. You have to know your own capacities. Should they willingly admit the refugee bees from the Middle Eastern hive when the foreseeable result is more empty stadia when Israel comes to visit, or more assassins for those who exercise free speech?

I don't think the Syrian civil war is the fault of the West; it's an internal problem. Still, you can't just let people suffer when they appear at your doorstep. I don't have great alternatives.

I wonder if it would be possible with strong united military power to establish a safe zone in Syria to which civilians could flee – but who would govern it? What rules would there be for separating factions? What would the future be, when we know that the highest birth rates on earth occur in refugee camps in the Middle East? This can't happen, I'm sure.

So what about asking the refugees to choose one of two options:
  1. Choose to apply for permanent citizens in the new country, adopting it as their home, and obligating themselves to learn the language fully, to educate the children in the country's schools, to educate themselves about the new country's customs and laws, and to keep their own customs and religion in their private life only. The host country would be obligated to help in seeking a job for at least one of the parents of the family and providing the integration services, and the welfare costs, etc. It would be expensive.
  2. Or they could choose to be a temporary visitor who will be required to migrate back to the home country when the host country would deem it safe. In the meantime they could take welfare or jobs might be found, and the kids educated in the Western style, not in madrassas.

There is a reason the world in agog with what to do here, because it certainly is not easy. I'm not hard hearted, but I've seen enough to respect LUC. You don't have to be a fascist Hungarian to be careful to preserve what you have.

Budd Shenkin

Thursday, September 10, 2015

Atul and Andrea

Atul Gawande is a genius, a gift to us and himself, a prime example of why we benefit from immigration. I used to think we were stealing the world's resources by being the recipients of others' brain drain, but now I acquiesce, because I think plants need the right light and earth, and although there is usually plenty of the literal light and earth where these treasures come from, it seems that the cultural, political, sociological, psychological, and economic light and earth are what's really important for them. At home they might not wither and die, although they could, but they certainly usually would not grow and prosper and produce and express their genius the way they can here in the US. They would do some good, but they would be running on kerosene, not super-fuel, and they just wouldn't get as far and as fast. Yes, eventually they might change their home countries, but probably not. Stupid and unimaginative and acquisitive and unenlightened people of tradition would most likely just squeeze the life out of them if they stayed home in bitter frustration or resignation. Better they should come here.

Now I say that. Back in 1973 when I finished my Fellowship in Global Community Health in the US Public Health Service, and after languishing in Washington for a month or two before they figured out what to do with me, I was brought into a small meeting of five or six with Assistant Secretary of Health Charles Edwards and his Deputy Henry Simmons. One issue presented was how to facilitate physician migration to the US. They were trying to figure out how high to place me in their administration, maybe make me one of their special assistants because they knew how smart I was, but, I, I, I spent my capital by self-assuredly and self-indulgently and hostilely expressing the obvious truth that by facilitating immigration we were denuding the rest of the world of their human capital and it was immoral. Good for me! After all, what did I want to do when I was offered success? Why should I listen to Charlie Edwards when he softly suggested that it was the promise of America they were after?

I think at about the time I was expressing my self-righteousness to the Nixon Administration the Gawande family was settling into Athens, Ohio, and the topic of Being Mortal, what Marcia Angell calls his best book, was in the future. At that time the Gawande family of two doctors and two children was young and decline and fall was ignored, just as I myself ignore the same prospect today. I've seen the retirement homes, the assisted living institutions where my father and mother retired to, and I'm not having it for myself. I'll fight to the end! I'll make it on my own! I'll get some relative of our illegal immigrant housekeeper to come around and … do what? Gawande shows us in vivid portraiture what it's like. You keep going and are spry and active and alert and involved, until you're not. Your arteries clog up and your organs decay and you just can't do what you used to do, think as you used to think. You don't go live with a host of relatives whose generations live together in a rural Indian village. Just who is it who will really take care of me? Ever the hero, I've just said to myself that living is optional and when I've had enough I'll know how to leave. Actually, I'm full of shit. I'm caught just the way everyone else is, with the fruits of winning the longevity race not an olive branch crown but the cesspool of old age decrepitude sooner or later in institutions, which are changing but probably not fast enough.

What is most trenchant about Gawande's exegesis, however, is his indictment of the medical profession for losing its way, which I have felt and expressed in my non-genius, cynical (because I can't mount the attack that Gawande does) way for years. From the time I heard people described as “interesting cases” in medical school; from the time I was frustrated as medical school presented not the history of discovery of how to help our fellow human beings and what we have found, but rather presented the revelations of science where interesting cases were gifts to science; from the time when I saw that the ideal was effete intellects walking around hospitals that house human beings that will never be us, because we are doctors and therefore immune, of course until we're not; from that time to this I have thought the same thoughts that Gawande presents. We are taught by our profession of medicine to deny, to ignore humans and their needs; we are taught to fight to conquer disease and death and die trying. And Gawande shows brilliantly how the medical conceit, along with sociological and economic development, has led to the warehousing of human beings and treating them as decaying cogs in a grand wheel. Good for you, Atul! You have nailed it, and in a way that no one can ignore, in a way that points the way, in a way that shows compassionate hope for a profession that has denied compassion in reality if not in pious and hypocritical declaration of do what I say and not what I do within those high, white, institutional walls of science rather than human kindness and feeling.

I've always thought that I deny my future, but maybe that's not so. In graduate school in public policy I learned that planning is overrated, which I was happy to hear because I'm not very good at planning. Look at what I did with Edwards and Simmons, although maybe it was a proper if not graceful exit there, since I knew somewhere that I was not suited for bureaucracy. The alternative to planning is figuring out the next place in the foreseeable future you would like to be and leaving it to your own future good sense to figure out the place you would like to be after that. I'm an ENTP in Myers-Briggs typology – extroverted, intuition, thinking, perception. (To the uninitiated – you might want to look it up, Myers-Briggs, it's a powerful way to understand who you are and who everyone else is, and what strengths and problems we bring to the table). Heavy on perception, which means I don't like to make judgements now but would rather wait for more information, see what happens next. So, I resonated to that non-planning regimen, figure out the next step or two and have confidence you will chart a good path in the future. That's me. Maybe I don't deny, I put off. Sometimes it works, sometimes it doesn't.

Well, I wanted to write about Gawande, but I'm already off onto another book, reading Sarah Hepola's Blackout: Remembering the Things I Drank to Forget. And then Lola came over after school in her second week of kindergarten, and I told her there was a small neighborhood get-together up the street at the house Jackie Bandel used to live in, getting on everyone's nerves even before she got feeble and then died, and now it's going on the market and the realtor thought it would be a good idea to let the neighbors see the house first, and he had a taco truck out front with free food and a pastry maker frying a pure sugar concoction in the driveway. Lola is not one to miss a party and neither am I – both “E” in Myers-Briggs typology – so we meandered up there with Ann. It's not much of a house, but our neighborhood is terrific, so I guess it will fetch a hefty price in this market.

The neighbors were there and Andrea from up the street at the corner had a cane, for some reason. Was that really necessary, I wondered? I see her all the time up at the Claremont gym, taking her tall and strong body to swim in the pool and she's been fine. Guess she twisted her ankle. “What's with the cane, Andrea?”

She hesitated, but she is ENTJ, probably, emphasis on the E and T, so with lips quivering a bit she said to me, was eager to say to me, “I have metastatic lung cancer.”

She hadn't wanted to have a knee operation but it got to hurting so bad she had to go to Kaiser even if it meant an operation; something had to be done. An Xray led in another direction. An MRI scan showed tumor in bone – the right leg – and in the brain, with primary in the lungs of non-smoking and health-oriented Andrea. She blurted it all out as I led her to sit on the steps and put my arm around her shoulders and my wife Ann wondered what the hell was going on between me and Andrea as she talked to our fried Catherine, Andrea's next door neighbor. Kaiser had done well, Andrea said, sending her to their various sites – Richmond, Redwood City, etc. – for the cyber-knife, the enhanced MRI, etc. Now she was on an advanced drug that targeted her mutation. Kaiser had it all together.

Although what they don't have together is humanity. They gave her the increasingly bad diagnoses by telephone, and she didn't have anyone to talk to directly each time. But July 6 diagnosis to first week of August chemo is pretty damn good. And I know that when it comes to hospice Kaiser will probably shine. What I will do when and if I get my diagnosis in the non-Kaiser system will be a lot more chaotic, probably no more humanitarian, and going all over the place for services with no common record to rely on, probably. The system sucks. And I did promise myself that when and if I get a diagnosis, and if as I suspect maintaining weight will be an issue, I will get myself coffee milkshakes while I can still taste them, thousands of calories I deny myself while healthy.

Andrea is the giraffe lady. She has her house, much roomier than Jackie's old what might be craftsman but still dark and cramped with neighbors just feet away on each side, expensive piece of old shit. Andrea's house is filled with giraffes – dolls and toys and statues and pictures and dresses and everything you could think of giraffe. Maybe Andrea's height and slight awkwardness draws her to the giraffes. She took Lola and me on a house giraffe tour a year or two ago. What will we do now for Andrea? She's not a close friend, a neighborhood acquaintance, an interpersonally awkward emphasis on T, but someone who reaches out and I value the E. I'm awkward right back at her, now especially. What the hell do you say? I said that they do so much more with treatment now, which is so true. She answers that it is not curable and quivers. True enough. Where does it go?

How is Rick, her husband, I ask. He's back to work, if that's what you mean she answers equivocally. I meant that it must be very hard on him, too, and she doesn't seem to quite get that. She's such a T. I expected her to say that he's been devastated, too. Is she reaching out to me because she is so quivering inside and he, being T also, can't reach her, that no one can reach her? Don't get self-important, Budd; she's who she is and that's what she does. I told her I hadn't heard. She said that she figured everyone knew. Not us. I told Ann and she took it in. I told her I supposed she was wondering what I was doing over on the steps with Andrea.

When I was in practice in Walnut Creek and we were getting bigger as a practice, we had my colleague Beverly doing our rounds for the practice at Children's Hospital. That's where she liked to be and we were starting to differentiate roles. There in Walnut Creek I had a mother of a five or six month old call me in the office to tell me one of her son's eyes was deviating, and asking if that was important. I'm not the greatest diagnostician in the world, but I knew all too well what that meant. I referred her to an ophthalmologist, which was the wrong thing to do but at least I did it quickly, and from there it wasn't long until the MRI showed a brain tumor that was incurable. She asked me if I would be there with her during this process. I told her that the way we were organized she would be followed by Beverly, and that I couldn't be there for her. She asked me again and I said no. Shit. I might as well have been Kaiser.

Did I not want to see her son die? Did I not want to cope with her grief? I don't know, maybe. I cheated her out of the doctor she wanted to be with her and to hold her, and I cheated myself out of being a doctor the way a doctor should be. Did I go into pediatrics because the patients are usually well and it's a nice time of life, not a time of coping with decrepitude? Yes, certainly. I couldn't be a good cancer doctor, I would wilt. My denial would be shattered. But I could have done this for her. Shit.

I said to Andrea to call on us for anything, a forlorn hope. What to do? I think I'll take Lola up and see the giraffes again. Don't move away, move toward.

I hope Andrea didn't have big plans for her decrepitude. Probably not. She's more like me, probably, waiting to see what the end will bring. At least we have hospice care and the beginnings of what medicine should really be, as Gawande brilliantly points out. He's a genius and a light to the world. He shines it here on the long neglected part of our medical mission that is hopefully awakening and not being smothered by science, science, science, and all the men and some women who think think think and cannot feel feel feel, until it's too late. Which is what Marcia Angell found when her husband Arnold “Bud” Relman, former editor of the New England Journal of Medicine before she took that same post, was dying and finally died an excruciating death because, she says, Massachusetts doesn't have a permissive end of life policy. The F finally overwhelmed the T for her. Maybe the balance is being restored. But it will be a long time coming, as the scientists in charge of the medical schools still keep admitting more and more scientists, who don't get old fast enough to find their F.

Budd Shenkin