A New Golden Age of Medicine

Imagine the 1950s in medicine. Within a generation, public health advances had eliminated communicable diseases; medical discovery brought antibiotics, vaccines, and new medicines; and surgeons performed daring operations to correct conditions of the heart and brain. The family doctor was an approachable, respected professional who often performed house calls. With memories of premature deaths and disability caused by now-treatable conditions, people were grateful for the work of medicine.

Ahead of the establishment of Medicare in 1965, the government discovered that some seniors and the chronically ill did face financial difficulty due to medical expenses. In general, though, medical care was affordable for the out-of-pocket payer: Walt Lillehei was the best in his field, and charged just $400 (or $4,000 today) for each cutting-edge heart surgery he performed in the 1950s, and often did not deposit the check, anyway (1). There were fewer healthcare administrators and managers to take a cut from the surgeon’s pocket; in contrast to today, hospitals were run by experienced physicians, not businessmen.

Things changed. Institutional Review Boards for medical research, informed consent for every procedure, the rights revolution of the 1970s (both on the new age left and the religious right), legalization of physician-assisted suicide, and widespread skepticism seemed to slow progress. Research doctors no longer worked in clinical practice. FDA regulations and the threat of massive lawsuits forced a risk-adverse approach to new medicines, devices, and treatments, to the detriment of patients waiting for a cure.

The convolutedness of medical billing forced a focus on quantity over quality, and closed many private practices: few new doctors today imagine opening their own office. Access to healthcare has improved marginally- many Americans remain uninsured and delay medical treatment due to cost. 1 million Americans declare bankruptcy each year due to medical expenses (2).

At some point, things have to get better. Recently, my friend quit his job in finance and went to medical school, following his old passion: he conducted small public-health research projects in high school, and his father is a physician. Operation Warp Speed, the American effort to discover and produce vaccines against COVID-19, was a demonstration of new prowess. The leading vaccines use mRNA research, which had been conducted behind the scenes for decades, and finally implemented for cancer treatment ten years ago. It is being released to the American public on Emergency Use Authorization: a breakthrough of red tape. Due to the costs of approval, promising treatments for small populations and the developing world had been left to wither, as there was no commercial viability. Hopefully, the new public focus on medical research and clinical trials will push government officials to do what is right for patients. This could be the herald of a new golden age in medicine.

 

(1) King of Hearts, book by G. Wayne Miller

(2) Medical Bankruptcy Statistics (thebalance.com)

Coronavirus: Vaccine is Here and Now

 

But how to get in into peoples’ arms?

On the administration of the vaccine, mathematicians and their game theories have surpassed credentialled public health professionals in predicting how to proceed. Health experts did not predict that a significant number of workers would decline the vaccine (up to 40%), because of immunity acquired from previous exposure, personal choice, or even the preference of an anti-vax supervisor. The “discouraging supervisor” has not been discussed in the media, but will come into greater view if vaccination clinics maintain limited hours which shift workers find difficult to access. There has been hesitance to release unused doses of vaccine, even as early expiration dates come near.

In New York, Governor Cuomo ordered that healthcare providers who circumvented state-mandated priority groups for vaccination would be fined $1 million, and their license revoked. This is not a general statement about maintaining fair distribution of the vaccine, but a substantiated threat as ParCare Community Health Network, a New York State provider, was sanctioned for “fraud” in vaccinating over 800 high-risk adults ahead of schedule before New Year’s Day. This action has had a chilling effect on providers in the state, who have since allowed unused doses to go to waste, instead of administering them to the general public.

As the vaccine is becoming available to greater populations, bureaucracy and appointment-based systems are hampering the effective distribution of the vaccine. At some hospital systems, there is an hour of administrative work for each dose of the vaccine given. As a result, it is not uncommon for a hospital to vaccinate only 20 of its staff in a day. A well-planned clinic, such as the military Branch Health Clinics, should deliver at least 400 doses per day. A Pfizer vial contains five doses, and must be used within six hours of its opening. Emergencies and medical deferrals can cause planned recipients to miss their doses, and in the interest of public health, another recipient must be found. In rural areas, it will be necessary to relax priority groups to ensure that vaccine does not go to waste. I know a ship’s officer who drove 8 hours to get his vaccine in Norfolk, Virginia; this is not a viable option for senior citizens or low-income individuals. Centralized vaccination centers, as Florida and other southern states have set up, have shown great effectiveness in reaching target groups. Nobody likes to wait in line, but practical evidence shows that a queue is necessary to administer the vaccine without waste.

Implosion in Georgia

 To be honest, it feels surreal to be living through today. An insurrection at the US Capitol (with one fatality) that disrupted the conduct of business. The Republican Party of Virginia (or at least individual leaders) are condemning the President in his last two weeks of office.

Both US Senate seats in Georgia appear to be going to Democrats Warnock, and yes, Ossoff. The latter seemed to exude the white privilege that has come under scrutiny in recent years: come from money, fail upwards, and be confident that you’re right, even at 33 years of age. (Yes, even Joe Kennedy III hit the wall this year). For him to win is nothing short of an implosion in the Peachtree State. Outgoing President Trump did everything to cause chaos during the campaign, and apparently some of his loyalists sat out this special election in protest. 

Merry Christmas

In a cheap hotel in Marion, Kansas, future news anchor Jim Lehrer's mother gave her sons a few words on Christmas Day, 1946: "I know this is awfully rough on you boys. None of our Christmases have ever been like this. Remember the others and try to forget this one. We're going to be alright. At least we're all together. That's more than a lot of families have". 

In the aftermath of World War Two, Europe and Asia laid in ruins, and millions of Americans were dislocated from their hometowns on account of military service and war work. Gifts and feasts were simpler- sugar was still rationed, and toy makers on a wartime footing.

But out of this war period came great Christmas music, including Bing Crosby's "White Christmas", and Judy Garland's "Have Yourself a Merry Christmas". In lieu of many toys, savings bonds were given as presents: this new tradition continued until bonds went electronic in the last decade. 

In this present year, things have been stripped to basics for the Christmas season: few parties, less travel. I must say this is a good thing, as many stores, including groceries, have chosen to close for Christmas Eve and Christmas Day.   Certainly a Merry Christmas for many workers, in spite of the year's challenge. I say this as someone who has worked in 24/7 environment at sea.

References:

We Were Dreamers, book by James Lehrer

Christmas in World War II - The Home Front (sarahsundin.com)

Still No Digital Office?

At the end of an intense had school semester, I tackled the piles of paper on my bookshelf, organizing them into a filing cabinet at home. Anachronistic? You bet. What is the hang-up from embracing full digitalization? 

Security- Those working for the government and in the defense sector find their selection of available collaboration tools to be limited. Marking up PDFs can be done, but third party applications like Slack are not used. 

Portability- Paper is more versatile when a file cannot be transmitted readily due to security concerns. It feels easier to work on a sheet of paper during a 5-10 minute interlude than it is to fire up the work computer. Also, wireless internet service - through WiFi or cellular - is still spotty in many places. 

 Kinematics- It still remains challenging to compare documents between two screens. Perhaps working with one vertical screen and one tablet is the best digital option. In the meanwhile, I continue to use a printout while scanning the computer screen for revisions. 

Cost of omission - I must say that the legal profession has mastered digitalization. For them, the slightest change in wording can tip a costly dispute. Eye fatigue remains a real issue with computer screens, but developments like the eye-friendly Kindle hold promise. 

Cost of software- Adobe democratized the PDF format, but as a business, retained certain controls. Their official, $60 per year software is the only tool that works across all update versions and computers. For information transfer, different databases require plain text, comma separated values, and so forth. Sometimes it’s easier to complete on paper and send it in. 

Incumbency- In my undergraduate studies, correspondence courses completed at sea were for the large part completed in pencil and paper, whether it was writing out nautical “rules of the road” verbatim or performing drawings of engine room equipment. This was meant to prevent cheating, and to eliminate the need for laptops in harsh shipboard environments. Autocad - design drawing software - was relegated to a drafting class instead of being integrated into the curriculum. In the workplace, I sketch on paper and use sticky notes- it’s hard to break old and effective habits. 

Nuances of Law and Order

This year, urban protests and general unrest in society created a mixed reaction in the electorate. In some parts of the country, Trump’s rhetoric of liberal politicians “destroying the suburbs” fell on deaf ears. Elsewhere, it was a resounding success. I have a theory why: as we near the middle of the Suburban Century (summed up by Mark Clapson in 1992), what happens in the inner-city does not physically or vicariously affect the lives of citizens in diverse, self-contained and far-flung suburbs.

Virginia Beach, VA

The Virginia Beach Oceanfront serves as the quintessential, walkable downtown for a military-heavy suburb. This spring and summer, tensions were high as protestors called attention to longstanding law-and-order policing on the beach. Over the Labor Day weekend, local group BLM 757 held its “Shut Down the Oceanfront 3.0” protest. True to form, the police gave citations to protestors who drifted from the sidewalk into the street. As a result of afternoon and night-time activity, families chose alternative locations for rest and relaxation; combined with COVID, this proved harmful to the ecosystem of local beachfront businesses.

At election time, Virginia Beach voted for Joe Biden and Representative Elaine Luria, a Democrat. On the same ticket, incumbent mayor Bobby Dyer, a Republican, was re-elected with 57% of the vote; and “RK” Kowalewitch, a conservative whose campaign signs read: “Law and Order”, won another 5% of the electorate.     

 

Suburban Richmond, VA

The Virginia State Capitol and Supreme Court building in Richmond were targeted by protestors as symbols of conservative political leadership. With much of downtown boarded up, the city provided a backdrop for political advertising. The jarring images did not ‘tip the needle’ in nearby Henrico and Chesterfield counties, who chose Biden and Representative Abigail Spanberger (D) by large margins. Both counties are home to a mix of employment options; heavy industry, light industry, service and some professional work. Freeways criss-cross these suburbs, linking towards northern and southern markets, and the international airport and deep-sea port of Hampton roads. Richmond, home to state government, several universities, and museums, is somewhat irrelevant to new suburbanites. Overall, there was no partisan change in Virginia’s congressional representation this year.    

 

Suburban Atlanta, GA

The land that served as a springboard for one-time House Speaker Newt Gingrich, and other conservative Republicans, helped to tip Georgia for Joe Biden. For 20 years, the Greater Atlanta area has been the nexus of a New Great Migration of African-Americans from the North to the South; the impact in politics, seen by the flipping of congressional seats, is very recent. Atlanta is a city of the New South; sprawling development centers on its record-breaking international airport and its freeways. The firewall between city and suburbs may be crumbling: while decades ago, suburban Gwinnett County blocked subway construction, a referendum for a transit tax may have passed, pending recount.

 

Los Angeles, CA

California is no friend of Donald Trump. But recent years of excessive solicitude given to drug pushers, car thieves and vandals struck a nerve in working and middle-class communities across racial lines. Since the Rodney King riots of 1992, Asian-American small business owners have been concerned about inadequate police protection offered to their communities. Legislation to “defund the police” dug up old pain. Voters in the state narrowly reaffirmed limits on affirmative action in the state, which were first put into effect in 1996; and sent new Republican representatives to Congress.  

 

Long Island, NY

During the George W. Bush years, as war deaths mounted, these traditionalist, conservative-of-the-gut counties questioned its allegiance to the GOP. But this year, as in 2016, their hometown son, Donald J. Trump of Queens, NY, did not produce the electoral revulsion seen in other suburbs of similar educational and demographic profiles.

While it appears that North Shore Rep. Tom Suozzi (D) will retain his long-time seat, his Republican opponent led in early counting. On the blue-collared South Shore, Andrew Garbarino (R) is expected to succeed retiring Rep. Peter King. Lee Zeldin (R) holds his seat in affluent Suffolk County. Nichole Malliotakis (R) has unseated Max Rose (D) in representing Staten Island and part of Brooklyn. These latter three seats were considered toss-ups going into the election. The Long Island suburbs are home to well-paid public servants and tradespeople of a vibrant New York City; COVID shutdowns and Bill de Blasio’s social permissiveness cast a malaise across white-ethnic New York. Upward mobility of strivers, from immigrant grandparents to civil service to Wall Street, created an unwavering patriotism and belief in the institutions of America. This legacy was challenged in 2020 by politicians on the left, who maintain that this upward mobility was not fueled by grit, but by systemic racism and unchecked privilege.     

The Real Problem with Warrior Culture: a Cult of the Self

 In certain parts of the commentariat, it is now common to criticize the large presence of recently-returned veterans in the police force, which stands at 1-in-5. Supposedly, they bring home the rules of war: to occupy and to conquer. I do not see veterans in the police force as a problem in itself, since citizen-soldiers have routinely joined the blue line for generations. Where I see room for concern is in how the professional soldier-turned-policeman divorces themselves from life in the civilian world.

During the Cold War, military service- as a servicemember or family member- was a shared experience in every tier of society. The average enlistment was 2-3 years. A soldier would return to his community ties, and find employment with honor established through performing his national duty.  

Today, because of advanced military training requirements, a single enlistment lasts 4-6 years. The world moves faster, the average citizen more mobile, and social media divides geographic communities into tribes. The soldier, especially the combat vet who served multiple enlistments, becomes part of the Warrior Community, mentally separate from the civilian world. This identity applies whether on active duty, on disability pension, in the national security sector or local police. This virtual community has its memes, jokes, common understanding, and values. In contrast to warrior classes of past societies, the American warrior is somewhat detached from the real-politics of institutional power, a holdover from the age of the citizen-soldier.

There are veterans who eagerly reintegrate into civilian society. This has been a national priority since the demobilization after WWII. As a result of GI Bills in 1944 and 2005, the veteran today brings resources to the economy that few younger adults have. Their college education is paid in full, and they have access to good mortgages and business loans. Meanwhile, America's general workforce readiness is in decline: fewer citizens are ready, willing and able to perform in the workplace. Veterans today are hired for the right reasons: proven reliability, hardworking, fit, and with transferable skills. 

The Warrior Community is then one  for a sense of belonging. In previous conflicts, a two-week ocean voyage demarcated the return from the warzone to the homefront. Dislocation was first observed in Vietnam veterans, the first to return home alone on airplanes. Today, the distance is even shorter, as a veteran at home can Skype his friend on the frontlines; and he himself could be recalled to the war zone on 48-hour notice, as a contractor, expeditionary civilian, or reservist. While these post-deployment opportunities are often financially rewarding, the mostly invisible war comes home to the kitchen table. 

Beyond this reality is self-identification. I have curated small libraries onboard warships. Beside the yellowing dime novels were leadership titles with troubling themes.  

-There is the identity of the sheep-dog, protecting sheep (regular people) from wolves (terrorists abroad, street thugs at home). 

-Belonging to a "tribe" is characterized as a binary, all-or-nothing subscription: an 80% ally is nonetheless a traitor to the cause. 

-You are either a superstar or a mediocre failure. 

-One must have a brand of the self. 

- Glorification of lone Special Operations Forces

-"Agile Project Management", with a focus on small, high-performing teams, is taught in STEM colleges. 

Even the Army put out a short-lived campaign advertising "An Army of One", forgetting that only large-scale teamwork liberated Europe and Asia from tyranny. 

In reality, each person works within a larger system of society, and within which is an amalgamation of overlapping communities, tensions and motivators. The Warrior Community operates in a vacuumed ideal. Military housing today reflects the perfect but fictional Mayberry of yesteryear; and beliefs in spartan autonomy can only be practiced in unspoiled wilderness areas. The culture of the warrior must evolve away from the cult of the individual, but reflect the individual as part of the team as part of the whole.

How does this work into present day policing controversies? Many of the shocking misuses of authority, against suspects and innocents, were caused by individuals insulated from wider community interests. Neither were they team players within the police force, who would heed peer advice. As much as it is important for police departments to use community-based policing to integrate with the communities they serve; it is important for individual officers to truly join the community, whether they gained life experience in Baghdad or in Boston.