Physicians and the high cost of healthcare

John Doyle has a short post that I thought I would link to. He discusses the role of Physician costs that contribute to the high cost of U.S. healthcare.

"According to this governmental report, primary care physicians in the US earn about $186,000 per year on average; for specialists it's $340,000. Not surprisingly there's a shortage of primary care docs nationwide, while the vast majority of med school students plan to train as specialists. Physicians in the US are paid more than 5 times the average wage; French physicians, in contrast, make more than twice the national average. Is American doctoring worth it? According to most empirical studies with which I'm familiar, health outcomes and adherence to evidence-based practices are no better in America than in France. And, as has been widely observed, population health is worse in the US than in France."

Here is the link for the full post:
Greedy Physician Bastards

Lake Michigan Sunsets

Only I a few days ago, I found myself sitting atop a sand dune, I was looking down onto the beach of Lake Michigan, then up and out at the horizon as the sun set. For some reason, the sun was pushing its orange glow upward, not down. Only ten minutes ago, however, the lake reflected the sun all the way across, like a laser beam.

I was wondering, as I sat watching the sun set: how do cultures develop in relation to the natural environment. I admire how the Native Americans, as a collective whole, developed a cultural philosophy and way of life that sought to live in harmony with nature. They respected the environment and lived as a part of it, as one species in the ecosystem, so to speak.

I suppose that one never knows how a sunset is going to go down. As the sun was sinking, the clouds hid the bottom half, leaving an orange half-circle visible.

In contrast to the Native Americans, Europeans who "settled" the Americas sought to dominate nature, to "subdue" her and extract as much of her resources as possible. With increasingly sophisticated and more powerful technology, it became possible to take more and more. We hunted with a religious fervor, with a fanatical energy. Each generation seeking to better the prior generation. Each new generation seeking to produce more, build more wealth, to become more prosperous, where "prosperity" is measured in terms of profitability.

I suppose that as a theologian, I'm tempted to say that ideas have consequences, then to trace the theological threads that hold together the fabric of a particular cultural zeitgeist. Usually this is my approach--it's the way I'm wired. But to hell with that for now. I think there is more to it, there certainly is; but I don't know how to describe it. (Perhaps that's why it's easier to stick with ideology.) Yet more and more I'm thinking in terms of a "spirit," a more general term that I think does more to capture the holistic sense in which a group of people "live and move and have their being."

What developments led the Native peoples to view their world as a dynamic, interconnected whole? what forces conspired such that the white man became obsessed with domination and control of the natural world? What is the inherited spirit of those who feel the innate drive to consume, whose identity is success-driven and defined within the marketplace? And perhaps we could discuss yet another group of peoples, the Tibetans, who dedicated their culture to spiritual pursuits, to understand the quiet mind, to grow peaceful and serene, to cultivate compassion.

What's the motion of it all? It's all a dynamic movement, because culture is always changing, evolving. I think that from the divine perspective, each cultural era must appear as diverse--and also as fleeting and ephemeral--as a sunset over Lake Michigan.

A Sunday "Amen"

“If protest depended on success, there would be little protest of any durability or significance…Protest that endures, I think, is moved by a hope far more modest than that of public success: namely, the hope of preserving qualities in one’s own heart and spirit that would be destroyed by acquiescence.” -Wendell Berry

Firmly rooted in life

"This is an age that, by its very nature as a time of crisis, of revolution, of struggle, calls for the special searching and questioning which are the work of the monk in his meditation and prayer....the monk abandons the world only in order to listen more intently to the deepest and most neglected voices that proceed from its inner depth." from Thomas Merton's Contemplative Prayer

I really appreciate a spirituality that is grounded. Even the monk who seems to have abandoned the world is for Merton merely listening more intently to its deepest needs.

"Meditation" and "revolution" are not typically two words discussed together, but I am intrigued by the correlation. What would a revolution look like, if it were born out of meditation, silence, reflection, and prayer? What might our solitary spiritual practices become if they were energized with revolutionary impulses?

Merton wrote Contemplative Prayer as a reflection for monks, but he also recognized that the contemplative path is embraced by individuals outside the monastery.

"Nothing is more foreign to authentic monastic and 'contemplative' tradition in the Church than a kind of gnosticism which would elevate the contemplative above the ordinary Christian by initiating him into a realm of esoteric knowledge and experience, delivering him from the ordinary struggles and sufferings of human existence, and elevating him to a privileged state among the spiritually pure, as if he were almost an angel, untouched by matter and passion, and no longer familiar with the economy of sacraments, charity and the Cross. The way of monastic prayer is not a subtle escape from the Christian economy of incarnation and redemption...

"The dimensions of prayer in solitude are those of man's ordinary anguish, his self-searching, his moments of nausea at his own vanity, falsity and capacity for betrayal."

Again, I really appreciate how Merton's spirituality is a means of going deeper into life and ordinary experience, not a means of rising above it or going beyond it. True spirituality is not a means to an end--it is not a way to escape from the individual struggles of our flesh and bone--true spirituality becomes more aware of its frailty and human struggle.

Merton puts all this in a concise way: "Meditation has no point and no reality unless it is firmly rooted in life."

Contemplative Prayer

I have been reading Thomas Merton's little book Contemplative Prayer, and I would like to share some quotes on Theos Project, perhaps combined with a few short thoughts of my own. For those who have an interest in contemplative Christianity, there are few figures as influential as Thomas Merton. Merton was a Trappist monk, a poet, and a deeply engaged intellectual. He combined the passion of an activist with his love for the contemplative life in the monastery.

My interest in contemplative prayer has developed in the last year. For me, prayer had been an empty exercise for many years. My prayer life in the past centered on bringing my list of petitions, along with some form of emotional exercise of "connecting" with God. The latter often felt like I was trying to force my heart into a particular state of being, one in which I either felt energized by the feeling of God's presence or else some sense of sinfulness, that I had fallen short somehow and needed to experience a sense of guilt. What was most lacking, I think, is the sense of letting myself be, to come just as I am to prayer.

For me, silence has been something that I have been exploring over the last year. I began with a short meditation practice, spending five or ten minutes each morning in silence and stillness. Over time, this lengthened. Many months later, I began to combine this meditation with a ritual of prayer, eventually re-incorporating petitions and requests to God as part of my prayers.

Contemplative prayer seems to me to be the combination of conscious elements of prayer with a certain stillness. The term "contemplative prayer" is seeks to engage God in a stance of openness. I'll save more on defining contemplative prayer for Merton. For many Christians in the U.S., prayer can lack this reflective and contemplative openness. My inclination is to say that such reflection and openness necessitates grace, an unconditional acceptance of everything we are. It may take on many moods, but if prayer does not in some way root itself in grace, then it risks becoming empty activity and routine, and further, without grace we tend to hide certain elements of ourselves from God, from others, and from ourselves. Contemplative prayer, then, is an exercise in grace.

The Guiltys Innocence

Tamie and I teach a creative writing class each week at the Kosciusko County Jail. One is a men's class, the other is a women's class. Each week we try to read the writings of each of our students and type up a response to their writing (not a grade). The goal is to help them become expressive of themselves and alert to their experiences, their "world." We try to stir up creativity and imagination.

Through listening to the stories of these inmates, I have been shaped, in no small way. One starts to see patterns of how people react to lives of domination, exploitation, manipulation, and low expectations. I am forced to deal with the reality that some people simply are left behind in life, from the moment of their birth to the moment of their death. They suffer neglect and abuse as children, they turn to crime and drugs as teens and adults, and then they wind up doing time. What are the ramifications of this for my spirituality and my theology? It's an ongoing answer-less question. One thing is true, though: I am far more sensitive to the context from which a person emerges. We are so fragile.

Through this experience I also find myself with added energy in my contemplation of the system and the powers that run this system. Many people need help. They are addicts, or they are in need of education, self-reflection, spiritual attention, jobs, and a bit of grace. Deprived of some or all of these things, people sit in cages like animals for years on end. When they get released, many go back to the same life. Often they are more hardened than before, hardened by the brutality of their lives in prison or jail.

We have been accumulating a good deal of writings, and we have been posting many of them on a blog. I may have linked to the blog before, a few months back, but I thought I would call it to your attention again, so that you also may be able to hear their voices and listen to their stories.

The Guilty's Innocence

The Grapes of Wrath by John Steinbeck

“They’s somepin worse’n the devil got hold a the country, an’ it ain’t gonna let go till it’s chopped loose.”

John Steinbeck’s Nobel Prize winning novel The Grapes of Wrath has helped to shape the perspective of an era. It is the story of exploited peoples; as a novel it uses the power of human story to stir something in the soul—an outcry against injustice. History, it is said, is written by the winners. While this may be true in a general sense, it is equally true that it only takes on powerful and passionate voice to humanize and dignify “the tears of the oppressed.” Steinbeck succeeds in this effort. He tells us the fictional story of the Jode family, and in doing so he speaks for hundreds of thousand, perhaps millions, of souls who were displaced by exploitation and the passivity of the U.S. government during and before the Great Depression.

Steinbeck wrote about the Jode family as they are driven off of their land in Oklahoma and seek work in California, only to find themselves homeless and near starvation, exploited by large land owners. California was Steinbeck’s home. Published in 1939, Steinbeck drew a good deal of opposition and backlash from many in his home state. However, Grapes of Wrath spoke for the dispossessed of its time, and the novel still to this day forces its reader to reflect on the state of the nation—both on its moral and ethical direction, but also on the wisdom of the system in its entirety: its economic sustainability, the justice of its laws, the shape of its politics, and its movement into the age of the machine. While it raises all of these issues, it is its story that is most compelling, the humanizing of a family struggling to survive.

The Machine Man

The first part of Steinbeck’s novel centers on the technological and economic shift in the U.S.: the small farm is obsolete. This is the age of the machine. A tractor can do the work of ten or twenty farm families. The Jode family is one such clan. They are working land during a drought. They can’t pay the bank, so they have been displaced. Their house is jus in the way now, and it’s time for the Jode’s to move on.

The novel does not accept this technological shift. The man driving the tractor can’t love the land, says Steinbeck. He’s just a “machine man.” He is cut off from the soil. The land is not a living and breathing entity to the machine man. For him, a crop is a matter of science: chemistry and land management. The land is an object, a job, a profit margin, a thing to be manipulated.

“But the machine man, driving a dead tractor on land he does not know and love, understand only chemistry, and he is contemptuous of the land and of himself.”

This new technological age is now normative and unquestioned in the 21st century. Thomas Jefferson’s vision for the nation was small, local farms spread across the fruited plain. Technology has changed this. Technology combined with an obsession with mass production and wealth building. The Jeffersonian vision of life has been replaced by a nation of machine operators and an army of paper pushers living in offices and cubicles.

Why did technology not develop as a support to local farms and local communities? Was this a conscious choice? Or was it out of the hands of anyone? Perhaps it was a force and power with its own volition and will, operating without the resistance necessary to stop it.

Revolution of the Repressed

The Joes have to pack up as much of their belongings as they can inside of their truck. They are heading west! To California! They know there is work in California, because they have handbills that say so—printed handbills—handbills that say there is a need for workers: fruit pickers and farm hands. Why, a fella’ could work for a while, picking oranges and grapes, then buy himself a nice plot of land. Those handbills wouldn’t have been printed out if there were no jobs. That’d just be a waste of money.

So the Joes follow the handbills to California. It’s a difficult journey. Grandma and Grandpa die, and some desert the family when times get tough.

When they arrive in California, things go from bad to worse. There are no jobs in California. The land owners printed the handbills in order to flood the state with desperate, hungry workers. With a massive surplus of labor, land owners can hire workers to work for food, or in some cases for less than enough to feed a family. The plan works great for the land owners. The only problem is that there are now hundreds of thousands migrant workers hungry and virtually homeless. Oops. This could cause a public reaction—it will cause a reaction and public protest; and it is for this reason that the land owners must demonize the migrant workers. “Why, Jesus, they’re as dangerous as niggers in the South! If they ever get together there ain’t nothin’ that’ll stop ‘em.” So local cops burn down the migrant camps and harass the workers. The workers have to keep on the move, live in fear and shame.

Steinbeck consistently alludes to the power of repressed groups: “If they ever get together…” There is a power in the collective. This is a revolutionary tone that runs through the novel. It’s like the revolution is right there, waiting for leaders and organization. “The little screaming fact that sounds through all history: repression works only to strengthen and knit the repressed.”

The novel ends with the young Tom Jode running from the law. He is a fugitive, having struck down a man who killed Casy the preacher, when Casy was trying to organize a worker strike. The suggestion is that Tom could lead the revolution. Meanwhile, the Jode family is without yet another member of their shrinking and starving family. Like a turtle in the wasted, dry land, they move slowly and hopelessly, always on the verge of another tragedy. The novel ends without resolve, like the lives of so many.

"One Big Soul"

Steinbeck’s portrait of free market capitalism is bleak: if each person works for their own immediate gain, everyone works against each other and against the common good. In a truly free market, what is to stop the wealthy from exploiting the poor? And what’s to stop the poor from rising up and overthrowing the rich? It’s like an endless cycle of violence, a form of economic Darwinism: survival of the fittest, might makes right. Grapes of Wrath never suggests that the government should intervene, it’s a bit more radical: the people should rise up and take the land back from their oppressors.

Also at play is the idea that economic individualism fails because it does not take into consideration the interconnectedness and interdependence of all people with each other. The people’s dependence on each other and their mutual dependence on natural resources. A system only works when it is a system that works for all. This is the theological conclusion, voiced by Casy the preacher: “‘Maybe all men got one big sould ever’body’s a part of.’ Now I sat there thinkin’ it, an all of a suddent—I knew it. I knew it so deep down that it was true.”

The novel also chides the failure of technology: “Men who have created new fruits in the world cannot create a system whereby their fruits may be eaten. And the failure hangs over the State.” Technology can create bigger fruits and bumper crops, but it all goes to waste without an economic system that distributes the produce. It is something intriguing that before and during the Great Depression, crops would be wasted and destroyed in some parts of the U.S., while in other parts people starved.

Then, As Now

The trajectory of the U.S. has changed little since the writing of Grapes of Wrath. The disconnect is complete. Technology and economical sophistication have helped to fix the system. People do not starve quite so much, and we have some checks and balances in place to prevent the kind of wide-scale worker exploitation (of U.S. citizens, but not all peoples) that occurred in California during the 1930s. But what have we really gained?

We are more cut off than ever from the basic, essential needs of our lives: we do not know who farmed the food we eat (or often who even prepared our food). We do not know the source of our clothing, much of it made by exploited workers overseas. We have a massive entertainment industry, but as such we find ourselves fairly disconnected from our neighbors. Our work is usually not something life-giving or truly meaningful. We are all either Steinbeck’s “machine man” or office paper pushers or fast food workers or cashiers. All that said, our lives, by and large, are good. We have food to eat, houses, cars, and entertainment. There may be a disconnect, but who really cares?

But someone has to pay. This is as true now as it was in Steinbeck’s day. We may not see the exploited laborer in Asia or India, who makes us a sweatshirt with our favorite team’s logo, but they are there. And illegal immigration from Mexico has created a heated national debate. These starving migrant workers are the result of our “success” in at least some very significant ways: our excessive use of the Colorado River has dried up Mexican farm land that depended on it; our government has subsidized corn (the corporate machine man now actually gets paid by the government), and this corn has been sold to Mexico putting more farmers out of work; and our taste for drugs has put big money into the hands of drug cartels, which has created a dangerous, violent nation, funded by our dollars. The Mexican migrant workers risk their lives, like the Joes, for the money to feed their families, and it shames us at a fundamental level. Is this part of the irrational hatred and fear of the Mexican immigrants? Is this why we are so eager to chase them out, to “crack down” on “illegals?

Why do we need drugs in the land of the free? For recreation, for entertainment, for pleasure, for boredom, and to heal the hole that apathy creates. We live in a system of individuals. There is no concept of “one big soul.” Loving our neighbor means writing a check or creating a new government program. We live with this deep disconnect and sense of fragmentation, a wound that we have not been able to heal. Our contemporary priests and Levites can’t be dirtied by the bloody bodies strewn along the Jericho Road. But the consequences of this turning from our neighbors is an inner vacuum that stubbornly refuses to go away, even in a culture that has invented the most sophisticated psychological and religious language to describe it.

Did anyone create this system? Does anyone control it? Does anyone defend it? Or is it ratified and energized by a mass of individuals with no capacity left for true imagination and creativity?

Steinbeck’s solution was to revolt. In Grapes of Wrath he envisions a collective revolution, but it must come from a movement of the poor as a whole. Isolated, they stand no chance, even in small groups they can be chased out of towns by angry town folks and deputies with guns. But if they were to rise up as a collective? If they were to speak as one voice? That would crush the system.