Friday, October 24, 2008

Daily Bread and Medical Care

I have been thinking about how to fix health care, and the injustice in it, which now seems outrageous to a majority of people. The underlying question is whether health care is a right or a privilege, and whether there should be a uniform standard, or gradations of care which respond to money. Because we can't get the minimum wage up, and because we tend to believe that everyone deserves to have the best care available, we have rising costs which will make it untenable to give "basic care" to huge numbers of people. In other countries there is an acceptance of the problem that there are not infinite resources, and that some unfairness is going to occur. I am afraid of an increasingly complex bureaucratic system; over-legislated, and very cumbersome. While the government threatens to lower the Medicare payments to docs by more than 30 percent over the next 6 years, the costs have been rising at 12-20% per year. Also 36 governors met to try to decide what to do with what the feds won't cover. In California, the elderly now account for 12% of Medi-Cal, and it will go to 20% in the next several years. We have the lowest payments for Medi-Cal (Medicaid) in the entire USA. The California budget is the seventh largest in the world, and we are running with about a third of the budget costs in shortfall from inadequate taxes. So the pressures are extreme, and no single answer is going to solve them all. We are the "canary in the coal mine" for the whole US system because of the extremes of overhead costs and low payments here. I hope we get national structural malpractice reform, and insurance regulatory relief and support. The highway robbery of the insurance companies, giving money to Wall street and investors, is unconscionable. Health care should be regulated as a sort of "Public Utility". One idea is a "Federal Reserve Board of Health" which would help to distribute the health-care "pie" more fairly. But we are still left with the aging population, more sophisticated medications and diagnostic and surgical options, and the question about when resources need to be evaluated against some scale of cost-effectiveness; and norms for how much we should pay for things which will give minimal gains in treating patients at end-of-life.
Also, we have a lot of people frightened to death that they will have no job-security and health-care benefits as they age. Last year the new workers at top companies wanted lots of guarantees of job security, retirement benefits, and health-care fail-safe contracts. Currently Boeing employees are striking for union job security-- as the company wants to outsource jobs to non-union workers.
Meanwhile I listen to Rachel Remen, MD, my mentor for patient-centered care and wisdom, and I watch and try to learn from my own patients. We all will die, and for some of us, it is coming soon. We all want to be loved, respected, handled with dignity, and given a voice in our care. We need to be "witnessed to," and to share our common humanity. We want someone to hold our hands and kiss us good night. We need pain medicine when things hurt. It is amazing that we sometimes have "redemptive" insight, when our own suffering is seen in a context with others' suffering. There are so many people who feel their victimization, yet very few who seem strong enough to look beyond their personal sufferings, to care and help by being the nurturers. The women are working, and can't come home, and lose their benefits and seniority to nurse the aged, infirm and sick in their families.
In my opinion, one of the most important functions of Jesus as a human person is to make us all have a larger-than-self paradigm of life, in which our uniting ourselves to Christ's redemptive purpose allows us to look beyond our own well-being and selfish interests. Uniting ourselves to Christ gives us a way to make sense of our experience, both sufferings and joys.
Recently at Mass, I was touched by how many of us see ourselves "in community" there. It is the only place not work-related, where large numbers of people meet-- which is not shopping. To many of us, it appears that the real religion in our country is shopping! Father Ron mentioned a couple going through the excruciating suffering of a stillbirth. She still had to go through labor, when he left the hospital that morning. He asked us to keep this couple and their family in our prayers. Aggie, who has diabetes, was overcome with grief for this family. She was brought out of her focus on her own pain, and her family's problems, in thinking about this couple's pain. Father said we all come with our struggles, with imperfect choices, with our problems, acute and chronic. We come to be fed, and to be healed by the only source of real peace; peace the world cannot give. We come to ask for daily bread and daily help in our struggles, and we ask for this help for each other, also.
One of the baptismal questions, which strikes me as more and more apt, is "DO you reject the glamour of evil, and refuse to be mastered by it?" I would like to say that I have always recognized and refused to be mastered by the glamour of evil, but since it usually is ego-enhancing glamour, it is hard to renounce it, even to recognize it. In my experience, glamour always masquerades as a great good, and is very tempting. I frequently have been taken in by the glamour of evil. Giving up glamour is hard. And then there are the other things I need to be forgiven for, and to actually ASK forgiveness for. Snapping turtle behavior. Entitlement. And darker feelings. The easy road to cynicism and resentment. The fast road to selfish concerns. I just could not make it a day without faith. Not triumphalism, but the kind that is begging for daily bread, daily help. And it somehow seems more true, when we are not asking each for ourselves alone, but we are standing there holding hands, praying and asking for these needed goods for all of us together. To believe we are children of the same God is to realize that none of us has more right to having our needs met than any other of our siblings. And perhaps that is the beginning of an understanding of justice and charity.

Debt and Desire

By Martina Nicholson on Wednesday, August 24, 2005
Regarding debt and desire;

When my accident happened in October 2004, I couldn't drive for 90 days. I had a mid-thoracic fracture. it hurt to put my arms out in front of me, even to carry a teacup to the kitchen. Since I live out of town, it was a very isolating experience. I was weak and in pain, and dependent on my husband and children to get things from upstairs for me, and to bring me cups of tea; and to help me get out of the bath. I spent a lot of time looking out the window. I did not want to nag, which would have made them want to get away from me, and isolate me more. 6 months later, when I could drive again, it was the rainy season of spring, and I was afraid of the slick roads, since my accident was due to hydroplaning. I did not go to the store. My husband did the shopping. I re-read the books in my own house.
Also, since I couldn't work, we decided at the office I would not get a paycheck so that the overhead would stay covered; and there would be a lag in pay when I came back to work, to finish paying off the ongoing overhead. The disability insurance only started after 90 days, and they delayed another month sending it. It was not enough to cover 6 months' loss of income, but it helped. I needed to buy a reliable car, as mine was totalled. So we bought a good used car; but that added more debt, as I didn't have much to put in, as a down-payment. When I got back to work, I could only do a very little of my previous workload. No surgery, labor and deliveries only with back-up, and cautiously.
8 months after the accident I got to go to the store to "shop". I bought a pillow, and I felt like I just hit the jackpot! I felt like I did when I first came home from the Peace Corps, and saw the bewildering array of options of things to buy, huge quantities of things. Such an experience tunes one again to the difference between needs and wants, and illuminates the basic costs of the infrastructure of one's life.
Doctors are prone to the temptations of "champagne tastes." Desire rises in us; little flames of desire rising in our egos, nudging us to buy. But to look at where the money goes, and to try to direct it, instead of following it, is an enormous task. Especially if the spouse and children are not tuned to the same goals. Especially if one lives in a consumer culture. All around me, I see the middle class cracking and disappearing. People are sinking deeper into debt. Housing in our area is extremely expensive. A friend of mine whose job is to give housing loans, looks at the applications and shakes her head; she says there are too many people buying homes with no down-payment, living from paycheck to paycheck, with huge loads of debt. Young mothers will never be able to stay home to breastfeed their children. The numbers of families with hunger and homelessness is rising. Patients are budgeting whether or not to come see us, as they decide whether they can afford the co-pay. And I live in a "vacation area" where there are lots of people with no health insurance, who drive Mercedes cars, and go to Hawaii to surf, and to Idaho to ski. No matter what your income is, there are tons of televised models of how to spend more than you have.
I think the Buddhists are right, that the place to start is recognizing the "ephemeral" quality of desire. To let go of desire, to let it pass through without grasping, is the antidote to consumerism. Envy and covetousness are the underpinning of our society. I am not immune. After a night on call, I want to go buy something to reward myself. Usually I am careful about the cost, but the instinct to do it is very strong. There is a deep feeling of entitlement. There are very few voices telling me it is NOT ok, and they are easily drowned by the advertising all around me. Because of my experience in the Peace Corps, I am more immune than some doctors; but still, the little flames of desire rise up inside me, as I see things to want. And then there are the things that need to be maintained. I bought a refrigerator this summer. I always ridiculed my paternal grandmother, who loved appliances, and got them as presents. To me, a present should be a luxury item or a work of art. But I am so happy to have the new refrigerator, I see how I am also like my grandmother. Having a home, safety and security, and some beautiful things matter to all of us. Learning to live with less, becoming more ascetic, is a necessity; as they pay us less, as our overhead rises, and we have to remember what matters most. We have to learn to budget more carefully, and to resist more effectively the desires that flame up.
An interesting side-effect of the near-death experience is the recognition that time is more precious than money. If you are like me, you have squandered time as well as money. Learning to hoard it, to use it wisely, to direct how this precious resource will be spent in better ways is another learning experience which we might otherwise put off or never get around to doing. Rachel Remen, in the stories and parables in "Kitchen Table Wisdom" and "My Grandfather's Blessings" constantly points to these kinds of lessons.. I find them endlessly jewel-like and helpful. I just re-read the story about the boy who died of the congenital abnormal coronary artery in the first year of medical school, and how the young doctors felt as they passed his heart around the anatomy lab. Ostensibly it was about the ability to mask our feelings. But it was also about how we use our time, our true wealth.
It also occurs to me that we can't know how to do something more cheaply or more efficiently, until we have done it the long way or the hard way. We can only become better at something by practicing. Some of what we need to learn about managing our desire, and disciplining our use of financial resources can only be learned by doing it the "hard" way. So I am also trying to be s bit gentle with myself, in learning these lessons.

Wednesday, October 22, 2008

Village Fountains

One of the worries I have about privatization is that they will stop people from having enough water to drink, water for the thirsty. All across Spain, walking the Camino to Santiago de Compostela, the piligrimage is made possible, and reinforced, and helped by the village fountains. One stops at each, fills the water bottle, rests, drinks and thinks about the gift of water, and how for centuries, each pilgrim has come here with the same needs. The water comes cold and clean from the ground, up into the village fountains, which are a centering place for the community. Even though most homes now have running water, it is a meeting place in the long afternoons, and evenings.
I was reading a poem by Elizabeth Bishop about Brazil, and a boarded-up fountain, whose three-headed mouthpiece is now in a museum, and the spout just opens into the air, and splashes down into the basin, and all the poor women come with their plastic bottles to fill up here. One hopes that the pipe has not become contaminated, and that the groundwater has not become contaminated. We have seen dysentery in these communities, without bathrooms and indoor plumbing, where the dogs and pigs and chickens are running down the streets in the rivulets of human excrement; and the little kids are playing kickball and running through the area in oblivion to the public health menace that it is.
WILPF is worried about the rights of communities to their own water supply. Here in California, water is a subtext for every battle of ownership and legal expense for farmers and city folk alike. We don't have enough. When I went to Louisiana, I was amazed, and almost brought to a feeling of deep-boned greed, for that much water. Water drowning the country, so that only the tallest trees stood out. If only we could have some of it!
WILPF has started helping people amass the literature and legal briefs to help themselves get the rights to local water supplies. This is tremendously important in Central America. Here in Santa Cruz county a German company had bought the local water supply, and it was expensive to buy it back, and it was a BIG lesson in getting the community involved.
The fact that Sarah Palin is riding on her giving everyone in Alaska a piece of the oil earnings is very interesting. She is getting credit for work someone else did. I wonder who wrote the law that gave every citizen a part of the earnings from natural resources. God bless whoever it was. Maybe THAT law is the law we should be looking at to use as a model for the water rights.
Next, I hope that communities will start planting fruit and vegetables alongside freeways, and in public schoolyards, and in every place that useless ornamental plants are now being used for landscaping. Maybe if people started seeing FOOD instead of useless plants, we would start to share with the community the impetus to eat healthier, and eat locally produced food. And once the food was growing, people might start to organize to help harvest it, and produce local jams, canned goods, and dried fruits. We could learn to be more communitarian and healthy members of society. I think Wendell Berry is right about connecting to the earth. We need to be "grounded" in order to be healthy. When the world is full of orchards, we will also have bicycle paths, and walking paths, and "commons" and "heaths" again. Towns will be built around the human scale for walking to the store and back.
I hope to walk the Camino to Santiago some day. I want the feel of walking 500 miles across Spain, on a thousand-year-old path, through villages which have kept their character and their ways of being organized around the village fountain for all these years. I believe in solar cooking and "green" architecture, but the next step is protecting the water supply, and integrating local farming into our towns.

Sunday, October 19, 2008

Finance and Nuclear Winter scenarios

The New Yorker this week has a little essay about a financier, surveying the Verdun of the view from his office in Manhattan after the financial collapse. No money to borrow. And they say this interesting thing:
"Interbank lending is the photosynthesis of finance." And then they go on to say "hoarding is panic's quiet twin". And somewhere in there, the man says "nobody trusts anybody". And then, the estimation that in the past, Americans just worked harder, but there are now "not anymore hours in the day, or enough incentives, or enough to work ON."
We will all be poorer, and we will all work longer, and harder. Paying down our debts is the hardest thing we will have to do. I have been trying since my accident 4 years ago to pay down the debt we took out on an equity loan, and I have not been able to do it. Every time I get it down a by quarter, we end up re-using it for taxes or an emergency. I have been feeling this grind for a long time. I keep remembering the scene in Anna Karenina, when her brother-in-law leaves his wife and 5 children out at the ranch with Anna, and goes to St. Petersburg and eats a meal fit for an emperor, knowing he cannot afford the meal, and is essentially bankrupt. I remember he has oysters. And there are tremendous descriptions of each course they eat, and the beautiful place in which they eat it, (which I embellish with "Tavern on the Green" memories from my time in New York). He is languid with food and wine, and the scene is luscious.
And I remember and worry, and plan. I still wonder how those financiers could just overlook all the holes in the loans they made, and the unreasonable hope that it would all work out-- some kind of esoteric pyramid scheme, gone awry. The financier says that "it will take ten years for Americans to get stupid again". That sentence makes me really wonder. In the first place they say that lending is the photosynthesis of finance. But really production is the basic element. We get paid for doing work, and making things. If our salaries are insufficient to buy things, we are "poor" in relation to the luxurious way we wish to live. And still, they never speak of raising the wages. We are always compared to China, where people ARE working 16 hours a day, and not getting any time off, and living in cubicles. There is no way any of them could ever eat just one of the meals described in Anna Karenina. Floating along in life is not possible for most of us. We are working very hard to stay in the middle class, to be able to own a home, to be able to have 2 week vacations, to be able to drive our cars, which are necessary because of how our towns are built. We are scared because our health insurance has doubled in cost in the past year, and every other cost in our homes is also rising. But they still don't talk about helping increase wages. So I think the only solution is a better tax structure. Essentially, lowering taxes will increase what we get to keep. And although the government has wasted so much tax money that it is obscene, we can hope that better regulation of the corporations and the financial institutions, and appropriate taxation of those institutions will help us to live in the middle class. I think that is what Obama's reforms are about. So I really hope he wins, and that he can put these ideas into practice.

Saturday, October 18, 2008

Radical Perseverance

"Radical perseverance" is truly a great ideal to put into practice in this time. I have been trying to get to the pool every day to swim, and have only missed a few days, so that finally I am managing to have a habit of exercise. When people would say "you have to take care of yourself," I never could make myself do it before. It is interesting to have the bite-size pieces, and to see what it takes to motivate myself to do it. I have started telling patients that they should buy themselves some gold stars, just like you got in kindergarten, and give yourself one every day you do the half-hour walk for heart health. After 10 gold stars, you get a present, and after another 10 gold stars, another present; and each of the presents have to be something which supports and nurtures healthy lifestyle choices. If it works for kindergartners, it should work for us, too! And it helps to stop self-critical voices, replacing them with positive feedback and rewards. My favorite present for the 10 gold stars is a massage. Second favorite is a pedicure. Meanwhile, it is bolstering the cardiac fitness, and bone health.
For bone health, the second level is to do 10k steps a day, which is about 5 miles. But start with a pedometer (you can get it at Big 5 sports) and check what is your average day like. Most women have about 3,000 steps. So you are going to try to go up to 3,500. Every day you do it, you get a gold star. And after a couple of months, giving yourself rewards for every 10 gold stars, you can go up to 4,000. The goal is to prevent osteoporosis, and to be healthy and dancing when you are 90!
Most people who lose weight gain it back. But doing the exercise first, and as a basic platform, helps you be one of the people who can keep it off. For weight loss, I now tell patients to aim for 25 lbs in 50 weeks. That way, you never trigger the famine response, which is to put 10 extra pounds on, after you diet. And you get increasingly fit, and feeling stronger the whole time.
Swimming is helping my back get stronger, so that I can do more, and now I started increasing my surgery load again. For awhile I kept thinking I was going to just have to quit operating, but last week I did two good laparoscopic-assisted vaginal hysterectomies, and it made me feel great that my patients were so happy, had so little pain, and went home soon, feeling good. Part of getting older is still trying to have enough "productivity" to be happy with myself and my work.
To persevere in the face of all that binds us down is a core part of aging gracefully. I really like the Vaclav Havel post about hope. Hope is for the not yet, and the "yeasty" things in life. I am trying to live with radical perseverance, and in joyful hope.

Wednesday, October 15, 2008



In Spanglish
And in Frarabic,
Let us pray five times a day:
To the God who is running things,
God Almighty, Yahweh, Allah,
Jesus and Mohammed and Buddha,
And the Holy Spirit,
The God who is letting things flow,
Evolve, bloom, grow,
Alpha and Omega,
Brahma/ Vishnu/ Shiva,
And any other of the million holy names,
Whether you believe or not,
Pray five times a day;
In solidarity
With the known and the unknown,
The great mystery,
Let it be; let it be; let it be; let it be…
With acceptance and actions,
Bliss/ Consciousness/ Energy
Green grass daily rising,
Breath on breath,
Galaxy beyond galaxy,
Singing Psalms, or Om,
With all our alphabets,
Our metaphors and murmurings,
Five fingers touching,
Five toes dancing,
Five senses playing together,
Five Benedictine and Islamic prayers---
The rhythm moving through life for
At least five centuries,
Five decades of a life,
Five times a day.

Sunday, October 12, 2008

Blessings of Goodbye

Blessings of Goodbye

Sometimes it is hard to know how to help a family when they are saying goodbye to a dying loved one. People stand around the room and out in the corridor wondering how to be helpful, how to express themselves without being a burden, how to say goodbye. For this moment, there is actually a wonderful thing nurses and physicians can do, or any loving person witnessing the situation. Tell one of the family members to begin a blessing ceremony.
Start with the head.
"We bless your head, which thought for us, with vision and helpful solutions to problems; offered us laughter and jokes, gave us imagination and intelligence.
We bless your eyes, which saw the world with beauty, and looked for the good.
We bless your ears, which listened to us with compassion.
We bless your mouth, which told the truth, with courage and gentleness.
We bless your hands, which touched us with kindness, and helped do the hard work.
We bless your feet, which walked the walk, and helped you stand up for the right things.
We bless your heart, for all the ways you loved us."

Families can take over, and add things they think of; memories, precious qualities of the person, things they have shared. Asking for a final blessing on all the people present can give the dying person a way to leave a blessing behind; a loving touch, a nod, a wink.

Some families may also want to actually make a gesture of blessing the dying person. You can fill a bowl with water and ask them to each touch the person with the water, perhaps on the forehead or hands. Some people might use a scented oil, or hand cream, and do a little massage of the hands or feet.
Some catalogs contain electric candles which can be plugged in at the bedside. These are quite beautiful, and realistic, like beeswax candles. Even though you can't have an open flame at the hospital, these candles can be a comfort next to the bed.
The main thing in using such ceremonial blessings is that it can be done by the family and friends, and doesn't need to be elaborate. Telling people how gives them permission to go ahead. For some families, these will be the most beautiful and meaningful memories to share later, of their time of grief.

Friday, October 10, 2008

Pursuit of Happiness

The question of gay marriage has been dogging me for awhile. I have several good friends who are gay; and this coming weekend I am going to the wedding of a couple who have been together for two decades. I love them, and they are a good team. They went through a lot of hell as young twenty-somethings, trying to find their way in the world.
I thought about the founding fathers, and how suspicious they were of religious power and the abuse of individuals with "a big club" of dogma. I thought about Jesus Christ, standing before Pontius Pilate, and staying silent. And how, in every circumstance when he could have said an exclusionary doctrine, he instead reached out to include and love the ostracized persons. He did not do it for whole groups, it was always to one person at a time. The only people he excoriated as a group were the rule-setters with legal power to make other people miserable.
SO I decided that the right answer is to allow gay marriage. For each individual in our country to "pursue happiness," the right to form lasting unions must be present. And the unions must be given due dignity. The gay people I know have the same struggles as the straight people in making their marriages healthy and strong. But it is definitely a better thing to have a partnership which lasts, than shallow, serial love-affairs.
When we discuss the process of becoming a mature human being, and how to accomplish that, and how to be a gift to the community we live with, we need to consider that no human being was meant to be a throw-away. Too many murders and ostracisms happen because of one group finding fault with another, or defining themselves by who they believe are their enemies. Too many young gay people have committed suicide, because they can't find a way to be themselves in the world. I personally believe that God loves all of us to the fullness of our capacity to be loved. I don't think God is against homosexuality. But I do think that shallow relationships and secrecy, and fear, can ruin people. We all need to be loved to become who we are at our best. So the healthiest thing would be for all of us to be able to overcome whatever blocks there are to love and loving relationships. This is not about strip joints, pornography or child molestation. This is about deepening love relationships between adults, to the depth at which one can say "I want to spend my life with you."
Perhaps the answer, for those who are offended at this, is to consider a difference in sacramentality. The civil marriage is not a sacrament. Perhaps those who wish to hold the sacramentality of marriage sacred must hold onto some mysterious strength in the generative power of heterosexual unions. Even though I am a Catholic, I think this is true. It seems to me that the dogmatic position of the Church is a form of bullying people into doing something that they would not otherwise find it in their conscience to do. Catholicism is actually founded on the primacy of the individual conscience, and I think we must cling to that, in this sort of issue. I am voting for the right of gays to be married.

The New Yorker

The editors have outdone themselves at explaining the lack of vision and follow-through of the Bush era. My prayers are that somehow we can recover. I have felt that we teeter like Rome, from Republic to Empire. We need to have a Cicero who helps guide us back to the Republic. And self-discipline, caution, and the urge to peaceful cooperation instead of T. Rex raptor status. I have said that we need most desperately to see ourselves as producers, not consumers.
It is not enough, though, for us to have a decent vision as citizens. We need to have a government which lives up to the ideals of the cooperative endeavor-- to be a "beacon on a hill."
I went to a conference with the guy who helped introduce the "credit card". He said we are on the edge between chaos and order, and he called it the "chaordic" edge. I really like that term. Because all of our institutions and social infrastructures need to be re-evaluated and reformed, in the best sense.
To me, it seems ludicrous that California, with one seventh of the population of the USA, should only have two senators, equal to each of the tiny states on the Eastern seaboard. Yes, we have more members in the House, but we need better representation in the legislative body with the greatest power. And we need massive reform of the lobbying process.
I pray for the country. I pray for all of us to listen to the "better angels of our nature". I actually believe we have them!

Thursday, October 2, 2008

"Hope" by Vaclav Havel

"Hope is a state of mind, not of the world. Either we have hope within us or we don't; it is a dimension of the soul, and it's not essentially dependent on some particular observation of the world or estimate of the situation.
Hope is not prognostication. It is an orientation of the spirit, an orientation of the heart; it transcends the world that is immediately experienced, and is anchored somewhere beyond its horizons.
Hope, in this deep and powerful sense, is not the same as joy that things are going well, or willingness to invest in enterprises that are obiously heading for success, but rather, an ability to work for something because it is good, not just because it stands a chance to succeed. The more propitious the situation in which we demonstrate hope, the deeper the hope is.
Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out."