Lincoln

Nearly one year after I chanced a brief Sunday morning repose in Robert E. Lee’s family pew at Christ Church in the Old Town section of Alexandria, Virginia, I found myself seated in a different sort of theater to view and reflect on the issues that led to our national schism and the bloodiest conflict in American history. Yesterday at a local movie house I took in a matinée showing of Steven Spielberg’s “Lincoln.”

Drawn from Doris Kearns Goodwin’s 2005 best seller “Team of Rivals: The Political Genius of Abraham Lincoln,” Spielberg’s cinematic chronicle of the last few months of Lincoln’s administration and life provides a fascinating window into the tumultuous times that led to the conclusion of the War Between the States.

Shaped by the times into which he was born, Lincoln strove to complete the second act of the great American drama that had been initiated by the founding fathers and would be carried forward in the Civil Rights Movement a century later.

Here we see Lincoln the man (deftly portrayed by Daniel Day-Lewis) wrestling with the members of his cabinet, arguing that the time is expedient to push forward his agenda for the equality of all men. A constitutional amendment would ensure its propagation for all time — or at least for as long as the nation for the last best hope on earth might endure.

Through Spielberg’s direction and Tony Kushner’s lines brought to life by the superb renditions of Daniel Day-Lewis, Sally Fields and Tommy Lee Jones, we witness the gruesome horrors of war as well as the messiness of the political process inside the beltway. (I use that term “beltway,” because it appears as though little has changed within the confines of that circumscribed area over the past 150 years. Despite the preponderance of political spin, the wheels of democracy turn ever so slowly, both then as now.)

Lincoln the man was given to fits of melancholy. He shared his disturbing dreams of isolation and loneliness with his wife, whose own constitution frequently bordered on hysteria. Rightly or wrongly, he expected that she would bear the same grief without complaint as he himself struggled to do. One scene where Lincoln and Mary engage in a vehement verbal exchange in the bedroom brings to mind Ingmar Bergman’s “Scenes from a Marriage.” The same scene repeats in slightly different form on the floor of the House between verbally abusive representatives Thaddeus Stevens and the gentlemen from New York.

Here also we glimpse the gentleness of Lincoln the father in his dealings with Tad, his youngest son; as well as the stern uncompromising stance with Robert, his oldest, in his refusal to allow the young man to enlist. Cloaked in the power of the presidency, Lincoln will refuse to compromise on what will become the 13th Amendment; while in his Second Inaugural Address he will also advocate for a gentle reconstruction of the southern states, “with malice toward none and charity for all.”

As the final credits roll and the viewer rises from his seat, he reflects that what he has just witnessed over the previous two and a half hours is in many ways a re-enactment of the political process of the past four years. Politics is a messy profession; yet a necessary one, if as a democratic nation we are willing to struggle toward those loftier goals dreamt of in uncommon hours.

To paraphrase Lincoln’s words, if we advance such freedoms, what greater good might lie ahead for us to discover?

Picking up a prescription

“This is Ahmed, our newest pharmacist.”

The owner of the drug store presents the immaculately groomed gentleman in the white coat. I smile and extend a hand over the broad expanse of counter top between us.

“I work in one of the medical practices in town,” I inform him, citing the name.

“Ah yes, I have filled prescriptions which you have written.”

“I’m here to pick up two of my own,” I say. “I called ahead to verify that they were ready.”

Ahmed searches the shelf. “Here they are,” he says, reaching for the white paper bag. “It looks as though your insurance company has applied the cost toward your deductible. You have a deductible, yes?”

I shrug my shoulders. “I don’t know. I just pay what I’m told.”

“We put it through your insurance and this is the final amount.” Ahmed shows me the printout—sticker shock.

He swipes my credit card to complete the transaction and places the charge slip on the counter for me to sign.

“We had to order the antimalarial preparation special,” he says. “Where are you traveling to?”

“Nigeria,” I tell him. “Medical mission.”

“Ah, I am from Africa too—Egypt—but I have never been south of the Sahara.”

“Just this week I have seen two Egyptian families in the office. Both are headed back to Cairo for the summer. There seems to be quite a bit of political dissatisfaction there right now.”

The smile fades from Ahmed’s face. “Yes, we are electing a president. But neither candidate is very popular with the masses, for various reasons. And this latest debacle with the high court—well, that has everyone upset.”

“So I understand.”

“It is a period of transition for us. Such transitions take time. It will be a long time before things settle out,” Ahmed says. “But, I am happy to hear that there are a couple of Egyptian families in your practice.”

“They are good people,” I tell him.

“Good luck on your journey,” he says. “I hope things go well.”

So do I. Transitions take time, and some take more time than others.

Town Meeting

I was exhausted from the six-hour drive home through the rain from Pennsylvania. I unloaded the car, stowed the gear, sorted through the mail and grabbed something to eat. The town meeting convened at 7:00 PM.

It was a short walk down to the local church. The parking lot was full. People filtered into the building, pausing at the small desk to sign the petition before ascending the stairs to the main parish hall.

Folding chairs had been set up in rows. Many folks ended up standing in the back and along the sides. Up at the front representatives from the postal service prepared their presentation. The community TV station camera panned the audience.

The meeting opened with remarks by the first selectman and the USPS district manager. The public relations spokeswoman presented a generic slide show, highlighting the financial plight of the postal service. Revenues had dropped by $30,000 at our local post office over the past two years. They were looking at profitability factors. No, they hadn’t made a decision to close the post office. That was the reason for the meeting. They wanted input from local residents. Everyone would be given a chance to speak.

A postal workers union representative voiced his dismay at the way the situation had been handled. Documents delineating proposed closings were circulated late; meeting times and places were unclear. In place of communication, Chaos reigned.

The union rep was clear. Be vigilant, take notes, draft documents, contact the powers that be. Keep the pressure on. Don’t allow them to get away with their underhanded approach.

One by one members of the audience rose to speak. Some voiced hardship in having to drive seven miles for mail, when before they could walk to the post office at the center of the village. Some wanted to know if the postal service was considering alternative locations in town. Others questioned the validity of the figures provided.

One erudite villager decried the modern postal service model. “You don’t seem to understand that the future of the USPS depends upon one thing—service. No one wants to drive miles to wait in line to be treated poorly by annoyed clerks who consider you a nuisance. At the village post office, one person serviced the needs of over 500 families, and she did it efficiently with a smile. That’s the sort of model you should be striving for—not the impersonal attitude of the DMV.”

Another fellow who had moved to the village from Brooklyn spoke. “In my old neighborhood, the postman knew everybody’s name. He knew the names of the kids on the block. He handed you your mail with a smile. That’s the sort of service I’ve come to know in this village.”

The spokeswoman responded to each comment in kind: “Thank you for voicing your opinion, thank you.”

Finally a man raised his hand to be recognized. “After you vacated the former location when the landlord told you the structure was unsound because of the snow on the roof, when were you advised that it was safe to return to the building?”

A hush fell over the crowd. The district manager stretched his neck from the tight collar of his shirt. “Two days,” he said.

The uproar was deafening.

“Two days! Two days? You mean you could’ve reoccupied the building in two days, and instead you made the decision to gut the office and move operations to another town? And you stand there telling us that you haven’t made a decision to close our local post office!”

More folks stood to speak. Several comments came on the heels of questions and observations from the audience before the postal representative could answer. I envisioned a meeting of the Sons of Liberty. Wasn’t New England the birthplace of the revolution?

In the end everyone had a chance to voice his opinion. As the meeting concluded, one woman summed up the general sentiment. “We might be a tiny town of two thousand people, but we’re diverse. We organized, we’re intelligent and we’re not going to let this rest. You haven’t heard the last from us.”

A thunderous round of applause erupted. Later, private discussions ensued, both inside the parish hall and outside in the parking lot.

An old-fashioned town meeting, New England style.

Who said all politics are local? I want to shake that person’s hand.

The rebirth of an idea

Along with most everyone else on the planet I watched the recent popular demonstrations in Egypt and their aftermath—most notably the subsequent downfall of Mr. Mubarak, the dictator who ruled that country for 30 years. And I must admit a certain titillation from observing the revolutionary fervor that has been sweeping across the Middle East in their wake.

The most fascinating thing about these spontaneous uprisings is the relatively peaceful nature of those demonstrating against their oppressive regimes. Granted, there have been armed confrontations; and sadly, people have died; but for the most part the resistance has remained firmly passive.

How pleased I was to learn that some of the basis for this resistance stemmed from the writings of a rather obscure, shy American now in his eighth decade. Prior to reading the New York Times article about Gene Sharp, I had never encountered the man’s name before.

As much as I am for insisting that credit be given where credit is due, I was somewhat bemused that the Times made no mention of former advocates of civil disobedience: Henry David Thoreau, Mahatma Gandhi and Martin Luther King among them.

It was Thoreau who penned an obscure essay in 1848 arguing for public refusal to support an amoral or unethical government—in his day a government that condoned the buying and selling of human beings as chattel. Thoreau registered his protest by refusing to pay his poll tax and was subsequently thrown in jail by the local constable, Sam Staples. He was released the following day when an unknown admirer paid the tax on his behalf. Indirectly, Thoreau’s essay helped to spur on the abolitionist movement, the Civil War and ultimately Lincoln’s Emancipation Proclamation.

Gandhi adopted Thoreau’s idea of passive resistance and used it to bring about effective political change in South Africa and India. “Civil Disobedience” was used as a manual for the Danish resistance against the Nazi invasion during World War II. Martin Luther King built upon the same set of ideas as he led the American Civil Rights movement in the 1960s.

Despite initial fears that the demonstrations in Cairo would lead to the establishment of an Islamic fundamentalist state, it has become apparent that the uprising was spawned by a secular civil base.

The Egyptian people have chosen to embrace their own political destiny, even though the ideas that inspired them have their roots in the writings of an American thinker.

A Socratic dialog on health care reform (VII)

Socrates pays Hippocrates another visit to discuss the latest political rumblings concerning the health care reform legislation.

Hippocrates: Good day, Socrates. I see that you walk with the step of a healthy man these days. I trust the former injury to your foot is now well healed.

Socrates: To be sure, my good friend and physician. Once again I find myself healed well, if not well-heeled. (chuckles to himself) But tell me, Hippocrates, what do you make of the recent resurgence of heated political debate in the Senate concerning our newly passed health care law?

Hippo: Ah, my good Socrates, know you not that the opposition has sworn to dismantle the law even before it is enacted? For they have sworn an oath to have it annulled before the legislative session is brought to a close.

Soc: By whose authority?

Hippo: By the mandate of the voters in the mid-term elections of last fall. The opposition is claiming victory on the basis of the mandate for change.

Soc: But I was of the understanding that the law contained many desirable provisions to enhance the coverage of health care for the citizens of Athens—forbidding third-party payers to deny coverage for preexisting conditions, guaranteeing the portability of coverage, removing the provision for lifetime caps on payments for care, and so on.

Hippo: What you say is true, my friend. But those of the opposition argue that the law is unconstitutional because it mandates coverage for all citizens—

Soc: (breaking in) Excuse me, Hippocrates, but is that not a good and desirable thing, to have coverage for all our citizens?

Hippo: To be sure, it is—but in this instance the law mandates that coverage be purchased by individual citizens if they have no provision for coverage from their employer.

Soc: I was under the impression that universal coverage was to be enacted as a right of every Athenian citizen.

Hippo: Alas, the single payer option was defeated in the preliminary debate. The lobbyists for the health insurance industry made certain of that through the influence of much silver coin in the pockets of the politicians. Likewise, the sorcerers bought their influence to insure that the price of pharmaceuticals could not be negotiated in the Agora.

Soc: It seems as though that which began as a good and noble idea has been degraded through bribes, trickery and quiet whisperings behind the scenes.

Hippo: Legislation is crafted much in the same way as sausage, good Socrates. In each instance the process is best left undisclosed to prevent a sudden surge of nausea and queasiness of the stomach.

Soc: Tell me, Hippocrates; is there no way to retain the noble points of the law while discarding the undesirable tenets?

Hippo: Undesirable to whom, Socrates? To those with influence and power? They will see the entire piece of legislation rescinded before compromising on these points. In the end we live in an era where the winner takes all in politics.

Soc: But our Athenian government is based on the premise of democratic rule. Ultimately, the people decide their common weal.

Hippo: Have you not heard that our supreme court has ruled that the multimillion drachmae corporations must be considered as bona fide entities having a political voice? A fist full of drachmae speaks louder than the jingle of pennies in a purse.

Soc: Then our democracy—

Hippo: Is but an oligarchy, my dear Socrates. Or better stated, a plutocracy in which the great wealth of the few controls the destiny of the many.

Soc: And what of the middle class, those of the artesian guilds and such?

Hippo: Alas, Socrates, they continue to disappear from the Athenian social strata. The gap has widened between those who have and those who have not.

Soc: What! Is there no political solution to this dilemma, Hippocrates?

Hippo: Perhaps, Socrates. You should pose that question to your old student and politico, Plato. He might be able to offer a feasible plan. I’m told he spends his days engaged in drafting a treatise that deals with such issues. He calls it The Republic.

Soc: Indeed, he has written “the price of apathy towards public affairs is to be ruled by evil men.”

The End of Something

The most stressful thing about a trip to Spain is the connections.  You have to wait, many times for several hours, to begin the next leg of the journey.  This time around things went well until I hit Madrid.  What should have been a 3-hour layover turned into a 4½-hour layover.  As a result, I arrived in Santiago late.  Thankfully, my sister-in-law was there to meet me.

After two more hours behind the wheel, we stopped at a local restaurant for something to eat.  It was a clean simple place, and the food was very good.  My sister-in-law treated me to a plate of pulpo a la gallega (octopus) and an entrée of rapé, a type of fish.  We finished the meal with a demitasse of coffee on the veranda.  It was a good way to wind down from traveling.  Half an hour later we rolled into Santa Marta.  It was just as I remembered it.  Everyone was there to greet me at the house in the narrow cobblestone street.

I was on my feet for close to 37 hours before I finally crawled into bed.

The next day I went for a long walk on the rustic path that runs along the edge of the estuary to the beach.  The sea undulated at my feet in gradations of blue and green, extending to the far horizon where it gave way to the faultless blue sky.  On either side the mountains rose up from the sea like prehistoric dinosaurs, their jagged peaks draped in torn green blankets where outcroppings of grey rocks broke through.  As I stood there buffeted by the wind, I understood once again why I love this country too much for my own good.  I lingered for quite some time before heading back to the village along the road.

Saturday was the wedding.  We gathered at the ancient stone church for the nuptial mass.  Outside, a small band of musicians played the drums and bagpipes as we exited through the courtyard.  Afterwards we boarded a bus for the next village down the coast, where wine and hors d’oeuvres were served by attentive waiters under a long white canopy on a small bluff above the beach.  The main meal lasted nearly four hours:  gambas, percebes, cigalas, rapé con patatas, carne de ternera, postre, an enormous amount of wine, both red and white, and to top off the meal, whiskey on the rocks and café solo.

At one point during the evening I stepped out and walked down to a small overlook and stood by the railing to watch the sea bathe the beach beneath a nearly full moon.  One of the guests, who had come from Navarra, appeared and struck up a conversation about the Spanish bullfight.  He spoke about José Tomás, the most artistic of all of the current matadors in Spain, who is recovering from a bad cornada, an injury to the femoral artery which he incurred when he was gored in Mexico this past spring.

The day before I left Spain, the provincial government in Barcelona voted to outlaw the corrida de toros.  As of Friday, July 30, 2010, there will be no more bullfights in Cataluña.  In an act of political capitulation, the Spanish national government voted to subsidize the salaries of workers in all industries associated with the corrida in the province of Cataluña for the next 90 years.

When Spain won the World Cup, Barcelonan taxi drivers displaying the national Spanish flag on their cabs were fined by the provincial police.

We are witnessing the beginnings of the disintegration of the Spanish state.

What’s Wrong, What’s Right?

In a New York Times op-ed piece on the healthcare legislation, The Fight Is Over, the Myths Remain, Brendan Nyhan states:

Studies have shown that people tend to seek out information that is consistent with their views; think of liberal fans of MSNBC and conservative devotees of Fox News. Liberals and conservatives also tend to process the information that they receive with a bias toward their pre-existing opinions, accepting claims that are consistent with their point of view and rejecting those that are not. As a result, information that contradicts their prior attitudes or beliefs is often disregarded, especially if those beliefs are strongly held.

Nyhan addresses the curious tendency we humans have to regard opinion as factual information—in his example, popular myths about the content of the recently passed healthcare bill, now signed into law.  In short, it all comes down to preconceived personal perspective.  Here the old axiom about drawing your curve and then plotting your points is apropos.  We tend to view the world through tinted lenses, all the while assuming that we are the only ones who see objectively.

I was intrigued to read about the former medical student Michael Burry who turned his economic insights into a popular financial blog.  Impressed with his knowledge, Wall Street gurus began to take regular notice of his predictions.  Indeed, many of the financial companies he endorsed turned out to be winners in the market.  Everyone, it seemed, was on the same financial page, until Burry noticed a disturbing trend.  Solid institutions that went on to fail shared one thing in common:  all had invested heavily in subprime mortgage securities.  Eventually, Burry convinced Wall Street to issue credit default swaps through which he bet against the popular tide—and subsequently won big.

This scenario demonstrates Nyhan’s premise:  when faced with the same set of factual data, observers generate wildly different interpretations.  As a consequence of acting on the basis of these observations, the risks are enormous:  you could win big (like Burry), or you could lose big as well.

Which brings me to the role of science in contemporary society.  Just how objective a discipline is science?  When confronted with the same set of facts, how is it that scientists formulate theories with markedly different import?

Global warming:  true or false?

Health care reform:  good or bad?

Wall Street reform:  desirable or undesirable?

In his new book Wrong, science journalist David H. Freedman wonders why scientific pronouncements often turn out to be misleading, exaggerated or entirely off the mark.  Part of the problem, he opines, is that many times scientists are forced to rely upon surrogate measurements, because they cannot get at the things they need to measure directly.  Thus, they have to make inferences from suboptimal data.

Economists, for example, rely on economic indicators extracted from bits of data to identify trends and forecast the economic outlook. Unfortunately, most research papers published in economic journals don’t conclusively prove anything one way or the other.  Freedman wonders:  “If tests of the exact same idea routinely generate differing, even opposite, results, then what are we supposed to believe?”

Freedman highlights the work of Dr. John Ioannidis, an M.D. with an undergraduate degree in mathematics, originally published in JAMA (John P.A. Ioannidis, “Contradicted and Initially Stronger Effects in Highly Cited Clinical Research,” Journal of the American Medical Association Vol. 294, No. 2 (2005): 218-28).

According to Ioannidis, “most medical treatment simply isn’t backed up by good, quantitative evidence.”

The whole point of carrying out a study is to rigorously examine a question using tools and techniques that would yield solid data, allowing a careful and conclusive analysis that would replace the conjecture, assumptions, and sloppy assessments that had preceded it. The data are supposed to be the path to truth. And yet these studies, and most types of studies Ioannidis looked at, were far more often than not driving to wrong answers.

Ioannidis felt he was confronting a mystery that spoke to the very foundation of medical wisdom. How can the research community claim to know what it’s doing, and to be making significant progress, if it can’t bring out studies in its top journals that correctly prove anything, or lead to better patient care?

The largest source of wrongness in scientific studies is publication bias.  Prestigious medical journals eagerly publish studies that demonstrate novel or unanticipated results.  Witness Andrew Wakefield’s bogus study published in the Lancet that purported to link the administration of the MMR vaccine to autism.  This problem is compounded further by the mainstream media, which is only too quick to disseminate such conclusions to the public at large.  Such misperceptions have a tendency to persist for years.

In his classic treatise on The Structure of Scientific Revolutions, Thomas Kuhn argued that “professionalization” leads to “an immense restriction of the scientist’s vision and to a considerable resistance to paradigm change.” He opines that scientists become captives to a paradigm “like the typical character of Orwell’s 1984, the victim of a history rewritten by the powers that be.”

Perhaps scientists themselves possess their own set of preconceived notions, which in turn dictate how they interpret the data they measure.  I suppose that it all depends on which side of the emotional aisle you happen to take your seat.

As Mr. Nyhan writes: “People seem to argue so vehemently against the corrective information that they end up strengthening the misperception in their own minds.”

A kind, big-hearted, gentle person

Daniel Mongiardo, a physician in Perry County, Kentucky, and also Lieutenant Governor of that state, recently described his colleague Dr. Dennis Sandlin as “a kind, big-hearted, gentle person.”  Dr. Sandlin had been in practice for over thirty years at the Leatherwood-Blackey Medical Clinic in southeastern Kentucky when a disgruntled patient showed up with a gun and shot him dead.  The dispute was reportedly over a prescription for narcotic drugs.

I was amazed at the vehement responses submitted as online comments to a recent editorial in the Journal of the American Academy of Physician Assistants which advocated that healthcare professionals counsel their patients on firearm safety.  Here are a few choice reader remarks:

Cars, swimming pools and tobacco can certainly be blamed for far more deaths than firearms. Quit being a nanny and do your job.

Since you seem to know nothing about firearms or their owners, I suggest you stick to practicing medicine.

You’re trotting out all the tired old anti-gun arguments in your text and you advocate disarmament.

Doctors should really advise us not to exhale, as the EPA has listed carbon dioxide as a dangerous pollutant. It certainly would cut down on all the hot bags of wind that try telling us in crappy little articles that they know better than I do when it comes to my safety.

The most amazing thing about every one of these emotionally charged comments is that their authors seem to have missed the entire point of the editorial, which advocated counseling patients on gun safety in the interests of keeping a safe environment in the home.  (Note:  All of these comments have been deleted by JAAPA editors because they did not adhere to comment guidelines and were deemed to be outside the scope of professional discourse expected on the journal’s website.  As of this writing, comment posting on this editorial has been closed to discourage members of the public from pursuing private agendas at this site.)

When I was a boy growing up in Pennsylvania, adolescents were required to complete a rigorous hunter safety course as a prerequisite to obtaining a hunting license.  The state was not advocating gun control or restricting the use of firearms—it merely wanted to insure that those who used firearms would do so in a safe and responsible manner.

Outside of the first year of life, the number one cause of mortality in the pediatric age group is accidents—deaths related to automobile accidents, drowning in backyard swimming pools, accidental poisoning by mouth, falls, choking hazards, burns from hot liquids and house fires (including smoke inhalation), and accidental deaths from firearms.  A good part of primary care pediatrics is centered on prevention of morbidity and mortality.  Included in this armamentarium of preventive medicine are the timely administration of childhood vaccines, monitoring the growth and development of young children, and counseling parents on how to keep their children safe.

Although I am not an advocate of carte blanche gun control, as a practicing pediatric clinician I do spend time counseling parents about how to keep their children safe.  Firearm safety is one piece in the accident prevention paradigm, and counseling patients on how to stay safe—regardless whether the issue is sexual practice, drinking and driving, substance abuse or proper handling of firearms—should remain an integral part of preventive medical practice in primary care.  The American Academy of Pediatrics has issued a policy statement on office based counseling for unintentional injury prevention which includes firearm safety.

Could gun control have prevented the death of Dr. Dennis Sandlin, a kind, big-hearted, gentle clinician, revered by his patients and the members of his community?  Perhaps; perhaps not.  But regardless of how an act of violence is eventually carried out, it is first formulated in the psyche of the perpetrator.

While we can all agree that when it comes to divisive issues, spirited debate is healthy and perhaps even desirable; those who resort to the use of threatening, abusive and demeaning language should be granted no voice in professional forums.

A Socratic dialog on health care reform (VI)

Toward the evening of a long day of discussions with Aeschylus, Plato, Aesculapius, Apothos, and Litigius, the philosopher Socrates makes his way to the home of Hippocrates, the father of medicine.

Socrates:  Hail, Hippocrates!  Are you at home?

Hippocrates:  Socrates, good fellow, welcome!  Come in, come in.  But I perceive that you walk with a limp.  What ails you, my friend?

Socrates:  An infection on the sole of my foot, Hippocrates.  I consulted Aesculapius, who cleaned and dressed the wound; then purchased an antibiotic potion from Apothos.  The rubor and dolor have already begun to subside.  But enough of my woes.  I came to consult you on a related matter:  that of the state of contemporary medical practice in Athens.  I desire your opinion on our health care system, as there is much discussion in the Agora and the Senate.

Hippo:  Ah, yes; as of late I’ve had my ear attuned to these myriad discussions myself.  Truly, they have become intricate and arduous, a snare to all who dare to enter into the fray.

Soc:  Fair Hippocrates, if you, the father of medicine, find these discussions convoluted, can the rest of us hope to make any meaningful sense of them?

Hippo:  I dare say that it would be difficult.  But I shall endeavor to enlighten you as best I can, Socrates.  Ask away, and I shall mix you a bowl of wine in the meantime.

Soc:  I appreciate your hospitality and willingness to dialog with me, Hippocrates.  Now tell me, what is your opinion of the system of health care delivery in Athens?

Hippo:  In a word, broken; although it pains me to say it.  The system has devolved from what I had originally envisioned it to be into a massive and complex enterprise of business.  All relationships are now contractual, defined by the solicitors and their ilk.  Products and services are bought and sold in the medical marketplace like milk and meat in the Agora.  All participants profit at the expense of the citizenry.  The cost of care escalates, and from what I read, the system will soon be unsustainable.

Soc:  How did all of this happen?

Hippo:  It is the fate of mankind, Socrates.  All men want just one thing:  a little more than they already have.  More silver, more material things, more pleasure—and longer lives to enjoy it all in.  Health care is no exception.  The more we create, the more we consume.

Soc:  But speak to me of the health of our citizens, Hippocrates.  Is it not vastly superior than it had been when you first formulated the tenets of medical practice?

Hippo:  In some aspects, yes.  We have managed to lengthen the average lifespan of our people through improved housing and sanitation services.  Overall, we enjoy a more healthful diet.  And when it comes to intricate technology, we lead the entire Mediterranean world in procedures such as open heart surgery, organ transplantation, and artificial joint replacement.  Yet this has come at an enormous price to our society.  Many of our citizens are still unable to obtain basic health care.  It grieves me deeply to read of the numbers of children who fail to receive their immunizations and in some instances proper nutrition.  At its inception I had envisioned that the system would care for all of our citizens, not just those who were well off.

Soc:  I perceive a certain sadness in your words, Hippocrates.  There is much wrong with the system, and yet much is to be admired as well.  Certainly you have strived to elevate ethical practice in the healing arts.  Why, look at the oath that you and your students have drafted—an example of high ideals and excellence of care.

Hippo:  True, perhaps; but I fear that the system corrupts many of those who elect to practice the art.  And many of those it does not corrupt experience burnout and choose to depart the ranks of the profession.  You see, Socrates, we have amassed a great deal of knowledge that has allowed us to immensely improve the health and longevity of our citizens.  But what we lack, what we truly lack, is the wisdom to guide us in meting out the resources of care.

Soc:  I understand that 4 out of every 10 Athenian healthcare drachmae are spent on caring for the old and the infirm at the end of their lives.  Is that true, and if it is, can you enlighten me as to how this came to be the case?

Hippo:  Indeed, it is true.  Many families desire that every effort be made to prolong the lives of their elders, even though the situation is hopeless in many cases.  A good deal of silver is spent shunting patients back and forth from assisted living facilities to hospitals, where procedures of questionable merit are performed, instead of allowing nature to take its course.

Soc:  But surely we can not stand by and allow our elderly to die when we have the means to restore them to health!

Hippo:  Restore them to health, or merely prolong their existence?  I need not remind you, my dear Socrates, that unlike the gods, we humans are mortal.  At some point our bodies will wear out and pass away.  Death, merely the last stage of life, will eventually hush us along.

Soc:  I perceive now that your title of father of medicine is one well bestowed, Hippocrates.  You are not only a healer, but a philosopher as well.  But, to return to our previous line of thought, where can we procure the wisdom to guide us in formulating a more just and equitable system of health care delivery?

Hippo:  You, the wisest of all men in Athens, ask that of me, Socrates?  It is I who should be asking that of you.

Soc:  But in truth, Hippocrates, I recognize that I know not the answer to this dilemma.

Hippo:  As you well know, Socrates, admission of ignorance is the wisest place to begin a rational dialog.  If we can come to an agreement on the problems, perhaps then we can hope to ameliorate at least some of them.

Soc:  If we should find a remedy to this medical morass, I must remember to ask Crito to sacrifice a cock to Asclepius.

A Socratic dialog on health care reform (II)

The philosopher Socrates encounters his former student of political science in the marketplace.

Socrates:  Good day, Plato, if my dim ancient eyes do detect this human form to indeed be Plato, who lately sat at my feet in the Academy of Athens.

Plato:  Socrates, my former mentor and fellow citizen!  How good to see you; how well you look!

Soc:  And you also, my friend, though you seem to have filled in about the midriff more than a mere smidgen.  The life of a politico must agree with your constitution.  I have lately encountered Aeschylus along the Parathenaic Way, who tells me that you have been engaged in extensive dialog in the Senate chambers regarding proposals for the reform of our health care system.

Plato:  Aeschylus speaks the truth, good Socrates, albeit with a lower case “t”.

Soc:  What—how say you now, that Truth is no longer Truth?

Plato:  True enough, Socrates.

Soc:  But how can this be so?

Plato:  In the political realm the fine lines between truth and opinion blur the vision.

Soc:  I perceive that you, like the clever foxes, have spoken wisely.  But tell me, how goes the debate?

Plato:  Formerly, not well.  But our August recess has allowed us to plant seeds of doubt amongst those citizens formerly in favor of democratic proposals for a public option.  We have also been able to mount a media campaign in the Agora against the liberal idea of government run health care, which, if truth be known, would undoubtedly bankrupt the Athenian treasury.

Soc:  And what is the proposal of those of the republic?

Plato:  For the time being, to leave things as they are.  There is plenty of time for discussion and debate.  The last thing we want to do is to rush prematurely into redesigning a system which has become the envy of the Mediterranean world.

Soc:  Aeschylus has spoken to me of its vile corruption, of the unethical behavior of those of the insurers’ guild, the sorcerers, and some of the guild of Aesculapius—that many are motivated by profit at the expense of the citizenry.

Plato:  Aeschylus is a poet, a dramatist, a tragedian.  He knows not of what he speaks—all health care is based on the business model.  In the end profit is good, for what profits me ultimately profits you.

Soc:  How so then?  Please explain this concept to me.

Plato:  If the reward of potential profit motivates me to deliver a better product or service, you benefit from those improvements, in whatever form they happen to take.

Soc:  In this case improved health care delivery means better health for all citizens of Athens?

Plato:  In theory, yes.

Soc:  How so, “in theory”?

Plato:  It depends upon those products or services.  For example, if you need a heart transplant—”

Soc:  A heart transplant!  What next—will they take my soul as well?

Plato:  My sources tell me that they’re working on that too.  But we digress.  As I was saying, if you need a heart transplant, you can get one done in a timely fashion right here in Athens.  In Macedonia, you would have to wait months, perhaps years, and never be guaranteed a heart in the end.

Soc:  So you infer that, meantime, I might die of a broken heart?

Plato:  Exactly!  But you live in Athens, where the health care is the best in the Mediterranean world.  Why would you want to change it?

Soc:  Tell me, Plato, what is the cost of such a procedure?

Plato:  The cost of a heart transplant?  Off the top of my head I can not say—perhaps 100,000 drachmae—

Soc:  One hundred thousand drachmae!  Why, that is outlandish!  With costs of that magnitude, how can we hope to sustain the present system?

Plato:  Those of the insurers’ guild will increase premiums to cover costs.

Soc:  Aeschylus tells me that much of the silver coin remains in the purses of the insurers.  Is this true?

Plato:  Not much—only one drachma in five.

Soc:  One drachma in five!  That’s 20 percent.

Plato:  That’s part of the business of health care.  Remember—profit is the incentive that motivates progress.

Soc:  And what should it profit mankind if we gain the whole world but lose the health of our collective soul?

Plato:  As I said before, good Socrates, we’re working on fixing that one as well.