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Progressives Anonymous


Progressive activism in the Deep Red South can be a lonely pastime.  The burnout rate is high.  Folks come into it thinking they can apply the same optimism and energy they’ve used successfully for other projects at work or in community groups with the same results—they dream big dreams, and when nothing seems to change, it’s hard not to be discouraged.  Sometimes we wonder why we can’t seem to mobilize our local progressives.  We know they’re out there, somewhere, but most don’t show up at our parties or send letters to the editor.

Theories abound—they’re too busy, too pessimistic, too bewildered, too passive.  I’m wondering more and more how many are just plain too afraid?

Despite our cherished freedom of speech, there’s an astonishing amount of silence among local progressives.  Doctors approach me furtively in the hospital corridor and whisper “I agree with you on healthcare reform” or send me kind notes by mail, but they won’t speak publicly.  They fear antagonizing their partners and patients or losing their jobs.   Progressive politicians and candidates tell me privately they want Medicare for All, but even I have a hard time advising them to say that before an election.

Our local healthcare reform group has worked to bring our message to churches, and I self-published a book for that purpose this year.  Knowing some churches were key in the Civil Rights era, we hoped we might be able to gather that same passion to witness for those dying from lack of health insurance.  Although we’ve had some positive responses, we are still often met with silence or ambiguity in the most progressive churches.  One liberal pastor, nearing retirement age and with a child in graduate school, tells me he must restrain himself to keep his job.

I posted a question on my Facebook page to ask friends if they’ve ever refrained from advocacy for social justice out of fear.  Interestingly, on the public page, our conversation turned into a debate on the meaning of the word advocacy and the effectiveness of various tactics.  My private message box, in contrast, was full of fear stories—a friend newly single and feeling vulnerable, afraid of losing her remaining supportive friends and job if she expresses a liberal opinion; a friend with mental illness forced to listen to clients (whose money she depends on for livelihood) speak disparagingly of others with similar illnesses in front of her.  Some of the stories are heartbreaking.  I know these friends have deeply good, compassionate hearts and that they would do more than just a little speaking out if they possibly could.

I am fortunate to have a job that places less restraint on me.  As long as I am sure to mention that my employer has no connection to my political work, I can do public speaking in my free time.  I have accumulated enough progressive friends that I don’t fear social isolation.  I cross-post my blog on www.leftinalabama.com –  I notice I’m one of the few bloggers using my real name, and wonder if others remain anonymous out of fear?  When I chose the title of my wordpress site, at first I thought I might use  something clever but eventually decided just to use my full name.  My concern over hubris was overridden by the symbolism of committing to accept full responsibility and consequences for what I was about to say.  This frightens my father sometimes—every so often, he tells me to be careful, knowing there are dangerous people in the world who could hurt me.

There are still a few things I can’t do, of course.  A couple of years ago, at a Physicians for a National Health Program meeting, we had an entire session on how to get arrested.  I’m not really afraid of a likely brief imprisonment itself—truth to tell, it appeals to my dramatic Joan of Arc side, and I’m kind of sorry I won’t ever go that far.  But if I’m convicted of a crime, even something like demonstrating in public without a permit or giving a ride to an undocumented immigrant, I could lose my job.  With the shortage of pediatricians who accept Medicaid, some of my patients would have nowhere else to go.  So I am restrained by my fear for them, as well as a more personal fear over maintaining resources to care for my disabled family member.

A purist would say we should not tolerate this kind of fear in ourselves or others.  I suspect Jesus was speaking of something similar when he said we couldn’t serve both God and Mammon—he could have said we can’t serve God and our reputations, our ability to hold a job, the needs of our family or clients, or our need for friendship.  If you are atheist, substitute the word “justice” or “love” for God, and the conflict of interest holds up.  But it’s complicated.  In working for justice, we don’t want to injure the very people we are trying to serve.

How free are you?  When, where and how do you restrain your free speech, not just out of strategy but out of fear?

Surrounded by silenced progressives, perhaps those of us with more freedom to speak have a moral obligation to do so.  When much is given, much is required.  What say you?

 

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Waiting– and Ready– for Real Healthcare Reform


Big news this week– the 11th Circuit Court of Appeals ruled the individual mandate to buy health insurance unconstitutional.  Although they didn’t invalidate the rest of the Patient Protection and Affordable Care Act (PPACA), if the ruling stands it
will render key provisions unworkable. Without a mandate, insurers have a fair objection to protest coverage of pre-existing conditions, for instance. So we’ll have to wait and see what happens once this case makes it to the Supremes.

While waiting, Medicare for All advocates should be busy preparing.  When PPACA hits the fan, we’ll have another chance to get real healthcare reform. We have the data on our side—what we need are better ways to educate the public and more convincing responses to our opponents.  Today I’m going to tackle waiting lists.

Some countries that have enjoyed national health insurance for decades, such as Canada, have had problems with waiting lists for certain specialty procedures like hip replacements. This is not a problem everywhere.  Waiting lists are less a function of the payer than of specific decisions about physician supply and distribution.  In the United States, because we choose to pay surgeons disproportionately high rates, we have more of these specialists and not enough primary care doctors.  In consequence, patients in the US wait much longer on average to get an appointment with a family doctor than patients in other developed countries do.

It is true that if we woke up tomorrow with Medicare for All, there would be serious physician shortages in primary care (we have an abundance of specialists to perform hip replacements). People who already have a doctor would be ok, but the newly insured
would have a hard time finding a doctor with openings for new patients.  They would not be able to get preventive care right away, and they might rely on the ER for minor illnesses. ER’s would need to respond by improving their triage systems, so that patients with life-threatening emergencies are always at the front of the line.

Just for the sake of argument, though, let’s pretend we are really worried about wait times.  It’s as if we had a large banquet hall with a buffet and a line of hungry folks ready to fill their plates.  Over to the side, another group can’t get in line at all because they don’t have meal tickets.  They will stay hungry—their wait time is indefinite. The kitchen is only prepared to feed the ticket holders
anyway.   If everyone suddenly had meal tickets, all diners might have to take somewhat less on their plates than they wanted.  Some would have to wait longer for dessert, until the kitchen caught up.

Some might say only those who already have meal tickets should get their promised meal, and those without can have the leftovers, if there are any.  They will point out that if everyone had worked harder, they could have bought their own tickets.  They are more willing to take the chance some people will die of starvation than they are to risk leaving the banquet hall a little hungry themselves.

Using waiting lists as an objection to universal health insurance is really a way of saying we should let some go without care so the
rest of us can get it more easily.  Even those who believe healthcare is a privilege, not a right, can’t defend this position.  After all, they constantly tell us that America is the land of opportunity and that health insurance is a personal responsibility.  If they were
right and managed to motivate all the uninsured to “think and grow rich”, we’d have exactly the same waiting problem.

We can address waiting lists without depending on some patients never getting in line.  We can plan physician supply more intelligently, to meet the needs of everyone in our country.  This has absolutely nothing to do with whether we want private payers or single payer.

I was told in a Facebook comment last week that I have a “habit of implying” those who disagree with me are “selfish, lacking in compassion, not good Christians, and perhaps even less evolved or brain damaged.”  And that this habit of mine is “tiresome.” If
our opponents proposed alternative plans clearly designed to gain equitable healthcare for all of us, I would offer only practical information on cost and quality, and I would quit dwelling on ethics.  As long as they continue arguing on selfish principles, I suppose I’ll resign myself to being tiresome.  Medicare for All—everybody in, nobody out.

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Six Degrees of Medicare


I’ve been wondering about the fundamental difference between our modern crop of conservatives and progressives, when it comes to critical issues like healthcare and funding programs for the poor.  I suspect it has less to do with compassion and more to do with how we perceive the connections between us.

There’s a funny game called “Six Degrees of Kevin Bacon”, in which any person can be connected to the actor Kevin Bacon using a chain of 6 or fewer links.  It doesn’t always work, but it does more often than you would think.  The point is not that Kevin Bacon is uniquely well-connected but that all of us are—the game should play just as easily between a random uninsured person in Alabama and the CEO of Aetna.

We are connected with each other.  If all these connections were visible, it would look like we were moving in a giant web.  Some of the threads between us, as in a family, would be thick as ropes—we can easily feel the tugs.  Others would be as thin and wispy as the filament from a house spider.  But even the most fragile connections, if we are paying attention, affect us.  When there are many such threads combined (think 51 million uninsured), the pull can knock us off our feet.

I take Feldenkrais lessons, a type of movement practice—I started lessons to help with arthritis pain.  What I’ve learned is that even the smallest, most subtle movement of one toe can be felt all the way up my spine.  The only way to keep that from happening is to tighten up other muscles, which results in pain.  The toe bone’s connected to the neck bone, after all!

Our connections to each other are similar.  Even something as simple as slowing to let another car merge on Memorial Parkway may change the mood of another driver, who may then have a better job interview.  An uninsured person who goes into bankruptcy and foreclosure will change her neighbor’s property value—many such persons will (and did) bring down our whole economy.  Whether they did something to deserve their fate or not is completely beside the point. 

It isn’t wise to reinforce the strands of our web with steel rods—good health requires some freedom of movement, maybe even dancing.  On the other hand, when we try to brace ourselves against feeling the movements of others, we do so at the cost of pain and loss of function for ourselves.  Can we cut the threads?  That’s no more possible than breaking the laws of physics.  To imagine otherwise is delusional.

Recognizing these multiple connections doesn’t actually require a particular moral value or advanced degree of compassion.  It takes only attention and practice.  I suppose it’s possible to become fully aware of the web and respond appropriately without ever caring much about anyone else.  But speaking as one who has experienced just a hint of it and who still has old muscle and mental habits to unlearn, I believe the only sane response is love.

What our conservative legislators have done and want to do to healthcare in the United States cannot break the web between us, but it will hurt everyone in it, conservatives and progressives alike.  A better plan?  National health insurance, birth to death, pre-paid, with no co-pays or deductibles, and no wasted insurer profit or overhead.  Medicare for All.  All of you are in this web with me—how will you move to change our direction?

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Happy Birthday, Dear Medicare!


Happy Birthday, Medicare!  I should send you one of those gag cards that teases you about getting older—but at 46, you’re a year younger than I am, so I won’t go there.  On your special day, a little reminiscing about your life…

You sure did have a hard time in the womb.  Many times, your enemies—the ones we always have with us, those who believe man is an island entire of himself—tried to abort you.  Even the doctors in the AMA worked like the dickens to get rid of you.  They didn’t kill you, thank goodness, but they did succeed in maiming you.  You were conceived as a public insurance for us all, but by the time you were born you had lost the limbs to care for those under age 65.  And you were hobbled so that you could only cover limited services, leaving deductibles and co-pays.

Even with your birth injuries, you’ve managed to do a lot of good in your 46 years.  I’m grateful for the service you’ve given to my grandparents, my father, and my in-laws.  Without your help, my husband and I would have been bankrupt long ago trying to help pay for their medical care.  Folks who worry about being in the “sandwich generation” now probably don’t realize how bad it would be with medical bills piled on top of that sandwich.  Our finances would be panini, or maybe toast.

Your enemies have tried to poison you over the years.  They force you to donate blood to something they call “Medicare Advantage”, private corporations who divert your precious transfusions toward their own profit instead of caring for patients. These same enemies put a gag over your mouth so you couldn’t negotiate with drug companies for fair prices.  Even today, some are working to drain all your blood and give it to private corporate vampires.

These actions have weakened you, but there’s a way to restore you to health.  We’ve got the technology to reattach the limbs you lost at birth, so you can become what you were always meant to be—Medicare for All.  Not only that, but we can improve you—make you cheaper and stronger—by removing your burdensome co-pays and deductibles.

 Some worry you’d be slower with all your limbs. We can plan ahead to solve that problem by training more doctors and other health workers.  Once we remove all those bloodsucking insurance companies from you and the rest of us, you can get your strength back.  Our healthcare system as a whole has had to operate on 2/3 power for decades, while private insurers and the associated administrative costs have siphoned off a third of our medical funds.  Imagine what we can do when fully powered!

Happy Birthday, Medicare!  I’ll quit talking about your enemies—after all, this is a day to celebrate.  You also have friends.  Friends who love you are working tirelessly to help you fulfill your dreams.  Physicians for a National Health Program, Healthcare-Now!, and many other organizations, including labor unions and churches, continue to gain new members working for your cause.  There’s great hope in the next generation of doctors—the largest medical student group, the American Medical Student Association, officially endorses Medicare for All.  Even smart conservatives support you, because you are the most financially responsible way to address our health insurance needs.

So today, it’s all about you!  We’re having parties and singing your song, all over the country.  Happy Birthday, Dear Medicare.  May you have many, many more.

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Fret a Little More: We Need Medicare for All


This post was inspired by my pastor Bob Hurst’s sermon last Sunday, built around the instruction not to fret over how some evil-doers never seem to get what they deserve.  As my mother put it, “life’s not fair” (subtext “quit whining and get over it”).  Bob did a lovely riff on this timely theme, including the pitfalls of punishments and rewards, and managed to work in Bernie Madoff to boot. No sermon on evildoers is complete without Madoff!

As a pediatrician and a parent, I realized years ago that the whole carrot and stick bit was pretty worthless when it came to teaching kids important things like honesty, respect, and courage.  The research literature backs that up at every turn—for both adults and children, punishments are one of the least effective tools at producing desired behaviors, and rewards twist them up terribly.   In any activity requiring higher order thinking, an external reward diverts attention from the good action itself.  The result is cutting corners to check off boxes (e.g., No Child Left Behind) and a loss of internal motivation.  Punishments create ripe soil for more sneakiness, among other problems.

Some writers take this so far as to imply human choices aren’t influenced very strongly by punishments and rewards, but that has always bothered me.  It seems obvious that behavioral modification works sometimes, and I’ve never seen a really good explanation why.  During my sermon-induced meditation on evildoers, I suddenly figured it out.  Rewards DO work—but only to stimulate wrong-doing.  Punishments DO work—but only to inhibit doing good.  Let me explain.

When drug companies reward doctors for listening to their false advertising, we get the wrong-doing of thoughtless prescriptions.  When we give so-called incentives for doctors to perform in certain ways, we get medicine distorted by box-checking and overshadow the best incentives—satisfaction at helping patients be healthier, and pride in good work.  When we pay subspecialists huge fees to do procedures, we get lots of unnecessary procedures.  If a person requires an external reward, separate from the good action itself, performance will ultimately deteriorate. I know someone is going to say doctors won’t work for free, so I’ll try to nip that in the bud.  Read Daniel Pink’s “Drive” for details.  As long as salaries are perceived by employees as subjectively reasonable, so that they do not feel disrespected or taken advantage of, more money doesn’t produce better work.

As for punishment, when corporate insurers issue forth their spin doctors to scare physicians and the public about universal healthcare, they are often successful in getting folks to oppose it or at least to just keep their mouths shut.  That explains why I hear, over and over, “well, I know Medicare for All sounds good, but. . . ”.  After the “but”, insert every variation of propaganda you can think of—this isn’t the time, it’s socialized medicine, government can’t do anything right, we need competition across state lines, etc.  Follow the money and you’ll find out where each sound bite came from.

The Bible passage about fretting encourages us to quit worrying about wrongdoers who seem to get a free pass. We are also advised not to think about whether we will get rewarded for doing good.  I agree.  But the consequences of doing ill or good have never fallen specifically on any one person’s head—the karma of justice is not that targeted.  Allowing private insurers to keep doing wrong is clearly hurting every one of us.

So I looked up “fret” in the dictionary and found another, older meaning of the word I’d forgotten—“to wear away” at something, as by constant rubbing.  When I get discouraged that advocacy for national health insurance is taking too long and I’m not seeing results, I remember that water, over time, can wear away the hardest rock.  We can never remove all the incentives in the world to do wrong—it will always require determination and courage to keep fear from deterring good work.  Let’s fret a little more and a little harder.  Medicare for All—everybody in, nobody out.

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Pay attention to the folks behind the curtain—our health is at stake


Warning—this is a long post. But I hope you’ll stick it out. I can’t get such an important topic into an elevator speech. Yesterday a mom brought her preschooler in for a checkup and asked me for a doctor’s note. Not a return to school note or a medication permission form—she needed authorization for the school not to bathe her daughter’s vulnerable baby teeth in fruit juice.

She had listened to me when I recommended not giving fruit juice, even diluted, to her child, because the combination of acid saliva and fruit sugars is a deadly duo for tooth enamel. Cavity forming bacteria live for it. And all that concentrated fructose is not helping our kids grow at healthy weights either. (Homemade fresh-squeezed vegetable juice, given immediately after juicing along with a meal, is fine). She had asked for water between meals. But that was so unusual to the school that they couldn’t bring themselves to do it without a doctor’s note! This conversation stirred up one of my pet peeves—school food.

 I love knowing that a small part of my tax money goes to help kids from poor families get fed. I wish it was a bigger percentage of the total. But I’m very frustrated when they use my hard-earned money to buy toxic foods that make it harder for me to keep kids in my practice healthy. Last year, I mentored a couple of medical students who studied the content and quality of school lunches and breakfasts in our local schools. They were amazed at how awful the results were. I wasn’t, because I already knew it, but it is still appalling.

Of course, families with more money always have the option of sending a lunchbox instead (I’m amazed more don’t do that). Most of the families in my practice simply can’t manage it, as much as they wish they could. I know many of those families also buy unhealthy foods with their food stamp money, partly out of habit/ marketing and partly because they can get more food for their money that way. If we provided really good food at breakfast and lunch though, it would go a long way towards setting these children up for current and future health.

The longer I practice medicine, the more convinced I am that good nutrition is the most critically important element in disease prevention. I don’t mean just including 5 fruits and vegetables a day or eating whole grain bread. Overall, our Standard American Diet (SAD) has deteriorated to the point where minimally healthy diets look amazing in contrast. We should be eating real food—7 to 9 servings of plant foods (mostly green, leafy vegetables), including some raw salads. White potatoes no more than once a week. Raw nuts. If you believe the data leans towards including healthy fats as I do, add some extra virgin olive oil or coconut oil, cold (heating it changes the chemical bonds too much). If you’re not a vegan, organic animal products without hormones or antibiotics, and don’t brown them. Raw dairy if you can get it. There’s some controversy over grains, but if you eat them, no flour products—sprouted only. Beans. Yard eggs. Fermented foods for the probiotics. Sea vegetables.

What’s NOT on the good list? Almost anything prepackaged. Added sugar in any form, artificial sweeteners, fruit juice, flour products of all kinds or any processed grains, food additives. I don’t recommend soy products, other than occasional fermented soy like miso and tempeh.

This is the way I’ve gradually come to eat myself, and the more I stick to it, the more energy I have. At 47, I now get pretty rapid karmic feedback when I lapse. For breakfast, I have a smoothie made from a couple of big handfuls of raw greens, some raw nuts, and a raw yard egg, sometimes with half a banana or some berries thrown in. I won’t get a friend in trouble by saying the other raw item I add. Takes 2 minutes to make. Might sound gross but actually it tastes great!

When I try to talk to parents about good nutrition, many do listen, like the mom I started this post with. Often I get incredulous stares though. One mom recently, when I outlined a nutrition plan for her son’s ADHD, said “that’s so extreme—poptarts and chicken nuggets are normal food.” She said that even if the diet change made all her son’s problems go away, she would rather him take medicine than eat that way.

Whenever changes are proposed in school lunches, I can guarantee some parent will write a letter to the editor saying “my kid isn’t fat—why should he be punished and forced to eat healthy food?” Well, maybe to prevent cancer? Alzheimer’s? High blood pressure? Arthritis? Let’s don’t punish him though—he has a right to get those diseases since he’s skinny.

I don’t think obesity is as big a deal (pun intended) as we are making it. It is just a symptom of our deadly SAD. Focusing on obesity might be a terrible mistake, if it encourages thin folks to believe they are fine. We are performing a massive evolutionary experiment on ourselves with modern foods, and the preliminary results are that the LD50 (lethal dose that kills half of us) is pretty low. Better to leave them out entirely. Some parents tell me their kids would go on a hunger strike if they didn’t get their burgers and fries. I promise, cross my heart, that in 15 years I’ve never had to put an IV or G-tube in a neurologically normal kid whose parents changed their food buying habits. Eventually, they get hungry and give up.

Ever read the studies about Pottenger’s cats? He gave cats healthy (raw meat and milk) diets and unhealthy diets, and naturally the cats fed badly were sick and died younger. The scary part was that every generation did more poorly. The kittens born to poorly fed cats started off sick and got sicker, and their own kittens even more so. This is likely due to “epigenetic” effects, and I believe that’s what we are seeing with the increased ADHD, mental illness, allergic diseases and possibly autism. Fortunately, Pottenger also showed this disaster was reversible in a few generations with proper nutrition.

So, back to the lunchroom. Check out this video—from 2009 and still very relevant http://www.thedailygreen.com/healthy-eating/blogs/healthy-food/school-lunch-44022302 . It explains the reason behind our poisonous school meals—Big Corporate Food. Just as in health care and everything else political, voters have lost control. We are taxed and not represented.

The first step to fix this is serious campaign finance reform. And encourage your Tea Party friends to eat healthier. Who knows, it might repair brain damage and cure their political confusion! Then we can get universal healthcare, which we won’t have to use nearly as often.

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Medical Patriotism


Every year around the Fourth of July, amid the flag waving and fireworks, I come across an article or two blaming patriotism for the ills of civilization.  I agree with much of the criticism. A constant obsession with being “the best in the world” makes us both arrogant and unrealistic.  Believing we can be truly healthy—economically, environmentally, or otherwise— without considering the roles and needs of other nations is not only immature but dangerous.

As I often do when confronted with a loaded word, I looked up “patriot” in my old Merriam Webster dictionary.  I was struck right away by the short, simple definition:  “love for or devotion to one’s country.”  I’m sure you know it came originally from the Latin for father, pater.  Interesting, since the earth parent is usually a maternal one.  The paternal face of country has more to do with the political structure, historically a masculine creation, than the land itself.

What if we imagined our country, in both earthy and political nature, as a parent?  I don’t mean to invoke the over-protective helicopter version.  I’m talking about our formation as persons—the various influences that eventually make us who we will be.  And how about our reciprocal duty to our parents, as they age and sometimes need us to care for them?  Could we consider how we are serving in that role to our nation, now well over 200 years old?

I’ve worried sometimes, while advocating strenuously for Medicare for All (including visitors and immigrants), that I’m taking a sort of parochial view.  It seems a little selfish to spend so much effort lobbying for my fellow country-people, when much of the world fares far worse in life expectancy.  I wonder if I should be doing something more globally relevant instead.

But all this thinking about land and politics, fathers and mothers, and caring for one another took me in an unexpected direction.  We aren’t patriotic enough.  If we were more patriotic (loving, devoted), and followed the principle of loving other (countries) as ourselves, maybe we’d do better.  There’s no need to hold back our love for this land, its history or its people.  We don’t have to be blind about it either.  In fact, we owe a special duty to address the errors of those we love.  I have a deep love for my state, Alabama, despite its sometimes recalcitrant and difficult ways.  It’s ok to love a city, a certain neighborhood, a particular tree.  We can all start where we are, then extend ourselves outwards, as in the spiritual practice of lovingkindness meditation.

Let’s love our country more.  Tell Congress we want to pay for our nation’s healthcare and not be forced to give protection money to private insurers.  With the savings, we will be in better condition to bring resources to those other (also beloved) lands in need.  We don’t have to limit the borders of our patriotism.  Everybody in.  Nobody out.

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