cold November rain

One month and twenty years ago tomorrow, I walk into the front doors of our 100-student high school to learn that one of my best friends, Matt Halley, has taken his own life with a gun over the weekend.

I am there now like it was yesterday, the halls quiet for a Monday, the bounce in my step collapsing as my sister’s friend Kindra tells me the news. I do not have words. There are no words, there is no air, the walls suddenly loom close. Somehow my feet carry me back outside. Without thinking I drive back up to the forested mountains above our house, five minutes from the front door of the Pine Eagle High School, where the scream that has building inside me can escape and lose itself in the ponderosas.

It is not raining. The sun is bright and the day is warm for the first of November. I ask the pine trees, “Why? Why? WHY?!” The tears stream down my face and all that I can do is follow my legs as they climb up and up.

Matt Halley. One grade younger than me. Great jumpshot from the upper left corner of the key. A smile and a laugh that catch you off guard and then catch you up in a contagious delight at the world. We got to ski together at Brundage Mountain, once, on a rare break from the all-consuming winter basketball schedule, and it was all I could do to keep up in speed, never mind form. Matt was the kind of kid who everyone wanted to be, precisely because he was comfortable being himself. I had a crush on his sister Miranda, who was in art class with me, but I don’t think Matt ever knew that. I would never get to tell him now. I would never get to go skiing with him, or shoot hoops, or suffer another long bus ride together. Was there a note? Was there a phone call? Was there something that could have been done, differently, by any of us? All I knew was that there was a gun.

I arrive at a clearing, where in spring the arrowleaf balsamroot explodes in yellow. Now their leaves are dry and brown, awaiting winter’s insulating snow. For the first time I feel the ache in my legs. My breath comes in ragged gasps. My screams have been spent but the tears will not stop.

From here I can look out over our little town, our little houses, our school. The already-white peaks at 10,000 feet hide behind the wooded ridge immediately above me. Another winter will come, another basketball season, another ski trip. The tears continue to slide down my face.

At this point I cannot know that Matt Halley will not be the only, or the closest, loss I will experience to suicide. I can only feel the raw ache of a life torn away too soon, a thread ripped out of the fabric leaving jagged edges and holes where before was a pattern. And I cannot know, hopefully will never know, the loss that his parents experience.

Mark and Gail, wherever you are, I am thinking of you.

It is late and I am tired

Everything I've ever read about writing emphasizes the importance of just that--writing. Writing every day. Writing whether or not one feels creative or inspired. Writing, perhaps, in hopes of finding creativity and inspiration. Writing even if it is late and one is tired.

To that general premise (to which I can only say that I aspire; even the effort of maintaining a blog monthly is something I can't always muster) I would hold up the contrarian perspective that the world is filled with those who have something to say and never do and those who have nothing to say and keep on repeating it. And that I would hope to avoid falling into the latter company.

And yet, what truly marks a work of genius? Simplicity. The ability to take a complex idea and put it into words that make the reader say, "Obviously. Even I could have written that." Daniel Quinn and Patch Adams come to mind, as does Malcolm Gladwell. At the other end of the spectrum is Salman Rushdie, though for me his linguistic trapeze act is a delight unto itself.

Which then raises the question of whether it is possible to ever fully delight in an idea with which one does not already agree. Quinn and Adams, for me, speak truths that seem self-evident. I am well aware of my biases (I see!, said the blind carpenter to his deaf wife, and picked up his hammer and saw), yet I wonder the extent to which these biases color not only how I read what I read, but in fact what I read. In other words, am I predisposed to only see that which I already believe?

It is late and I am tired. As my dad would astutely observe, I have managed to fill four paragraphs with words without saying anything. Each keystroke is one more pixel of non-renewable energy, another toe in my already large carbon footprint. For all you writers out there--and I'm including myself in this admonition--write, yes, please write, and also maybe think, beforehand.

Leonardo and GMO

What would Leonardo da Vinci have to say about GMO?

At our recent Washington Academy of Family Physicians Public Health meeting we debated GMO foods, specifically, “Yes” or “No” on 522, the Initiative to label GMO. The question had been raised no less than 4 months earlier. Though against GMO (and thus in favor of the public’s right to know), I had managed little in the way of objective research. Then, during the 5-hour Omak-Olympia drive, I listened to a compelling audiobook build the case against one specific GMO crop, wheat. I used this example, in the broader context of human-manipulated food, to argue for “Yes” on 522. Our Board ended up deciding not to be “neutral”, which would have implied that both sides were equally compelling; our position of “no position” suggested insufficient evidence for either. Or that we hadn’t taken the step of due diligence to ferret out what evidence there might be.

The whole affair left me unsettled. Not because I disagreed with our decision or the process by which we’d reached it. I agreed with both. Nor because my arguments weren’t given a fair hearing. At the time of our meeting, I had not yet synthesized my thoughts into a coherent argument, yet my fellow physicians graciously heard me out. In the 72 hours after the meeting I scrambled together a position statement for our online journal. I regretted not having invested the effort months earlier, which might have allowed me to state my case more effectively and respected my colleagues’ time by letting them ponder it pre-meeting.

Only a few weeks later was I further able to put a finger on the pulse of my disquiet. Ironically the insight came while while relaxing on a family vacation in Port Townsend, from a book my father-in-law had left on the coffee table: Fritjof Capra’s “The Science of Leonardo”.

What could the 15th-century “Genius of the Renaissance” have to say about 21st-century GMOs, due diligence, and disquiet of the heart?

Quite a lot, as it happens. From Capra’s careful examination of previous biographies plus thousands of pages of da Vinci’s notebooks, what emerges is a man who above all took a holistic view of nature. Capra argues that Leonardo was centuries ahead of his contemporaries in his use of what would become the scientific method. Even more than that, Leonardo was far ahead of outstanding 16th-through-20th-century figures such as Bacon, Descartes, and Darwin, who, in Capra’s eyes, introduced an artificial and even destructive split that has permeated Western scientific thought ever since. This paradigm would separate mind from body, human from nature, the art of medicine from the science.

“Leonardo’s synthesis of art and science,” writes Capra, “is infused with a deep awareness of ecology and systems thinking.” He quotes Leonardo on “the so-called ‘abbreviators’, the reductionists of his time: ‘The abbreviators of works do injury to knowledge and to love…of what value is he who, in order to abbreviate the parts of those things of which he professes to give complete knowledge, leaves out the greater part of the things of which the whole is composed?’” Capra goes on, “Our sciences and technologies have become increasingly narrow… We urgently need a science that honors and respects the unity of all life, that recognizes the fundamental interdependence of all natural phenomena, and reconnects us with the living earth.”

Whatever Leonardo da Vinci’s vote on I-522, I am inclined to believe that he would see our modern industrial food production, including but not limited to GMO, within the context of the fossil fuel it consumes, the chemicals it unleashes into the environment, the inequality in distribution of our surplus of food (only surplus can result in population growth), and the idea that we can change the genetic code of our own food supply without consequence. This is not to say that Leonardo, the engineer and scientist, wouldn’t be busy designing better irrigation systems, tractor mechanics, and perhaps even techniques of gene splicing. But Leonardo the humanist, the ecologist, and the scientist—the systems thinker—would advocate that we step back and think carefully before each step of change. This step has been grossly lacking in the last 50 years of change to our food technology, not to mention the last 500 years of technologic change overall.

To the question of due diligence, one of the qualities I admire most about our WAFP: just as Leonardo spent hours in dissecting the shoulder muscles of a cadaver and making preliminary sketches of an arm in motion before ever putting paintbrush to easel, so it is our responsibility as physicians and scientists to assemble the best available evidence and share it with our peers for an informed discussion. In reading Capra’s book, I also appreciate differences between myself in 2013 as a physician with a family of my own, and da Vinci in 1490. As far as we know da Vinci had no family to which to devote his energy. He was able to secure positions that let him delve without distraction into his studies, his brilliance allowing him to work as few as two hours daily on actual commissions. While highly regarded by his few peers, Leonardo also seems to have led a highly secretive and even solitary life, so devoted was he to work that went largely unknown for centuries. Reading this, I’m able to forgive myself for balancing my time between personal research projects and my roles as a doctor and father.

At the same time, there are luxuries we enjoy and situations we face in 2013 that should also urge us to act, even when we do not have something like, in this case, hard evidence of direct human harm of GMOs. We enjoy the luxury of free and open exchange of ideas without fear of censure or death. And we have the situation of a world in such rapid flux, and in peril of ecologic and human catastrophe on such a massive scale, that we might recognize a larger systems problem. We might do well to recognize that our food supply has already been radically changed in the last 50 years without any safety trials having been conducted, and that ours is the first generation in history to face higher morbidity and mortality than our parents’.

Because we have the luxury of freely discussing such things—and perhaps, using our leverage as family physicians, the ability to change the broader course of human and global health for the better—we also should seize that chance. Specialists have their place within medicine. Our role, the one role we can fulfill better than almost any other profession on the planet inside or outside of medicine, is to be systems thinkers. We have the chance to be the Leonardos of our time, minus the secrecy and isolation.

This is what makes me proud to be part of an Academy that holds me accountable for reviewing what evidence is available (which I had not done in this case) and still tolerates, in fact encourages, broader thinking and exchange of ideas.

Indeed, if our individual limitations of family and work make it impossible for any one of us to paint a Mona Lisa, we should remember that our strength is in our collaboration, that together we might do work that would make even the Genius of the Renaissance proud.

Cars

I have a confession to make: I have never seen the movie Cars.

Actually I have several confessions to make, so we may as well begin. I hate cars. Hate is a strong word…I dislike, disdain, am disgruntled by cars. More properly, it is not the cars themselves that put me off so much as my own dependence on them. And last night when I saw that LL had brought home a pair of Cars sippy cups for our toddler, I allowed this feeling to play upon my face in what translated, in no uncertain terms, as disparagement.

In that one wordless moment (followed by clarifying questions on the part of LL, to which my feeble replies only revealed my pettiness) our evening was transformed. Minutes before we’d said goodnight to friends and were winding down a relaxing evening. Now the air was not so much pulled taut with tension, as deflated, a circus tent collapsing after the show ended and the lights went down. The dull sadness of condescension softly weighed on the air and there was nothing I could say or do to prop the tent back up. My unconsciously withering look upon seeing the Cars purchase had negated all the amazing thing LL had done with her day: laundry, groceries, mail, preparation of a fabulous meal, all while taking care of our 16-month-old. At bedtime my recitation of the light-hearted picture book Bubble Trouble buoyed our spirits. But only a little.

Lest I be accused of reliving this memory only to the end of yet again deflating the spirit—let it not be so! In reflection I seek, selfishly, only to learn. To see where I might make the world a little bit lighter. And in the light of day, the hypocrisy of my disparagement makes me laugh out loud.

First of all, let’s face it: not only do I rely on cars, but I am no less guilty than the next person of abusing their convenience. Since moving to our little town, I almost always drive to the grocery store. I drive to the hardware store. I drive to the gym, only 4 blocks away, because my time is So Important and I couldn’t be troubled to get my bicycle fixed. I did finally take my bike in for an overhaul and now I use it, sometimes. Were there public transit, would I use it? You bet. Am I out there organizing, lobbying, doing sit-ins for it? No. I am Too Busy.

Second is that cars are a symptom and not the underlying problem. For that discussion see every other blog I’ve posted, or read Daniel Quinn’s Ishmael.

Third, it’s a sippy cup! We needed one, my wife bought it. It happens to have a cartoon car on it. BIG DEAL! To whatever degree I wish to safeguard our child from pop culture, I should keep in mind the cautionary lesson of a family I knew growing up. With strictly religious parents denying them almost all contact with “stuff”, each child went to the wall upon escaping: teen pregnancies for the two daughters, a turn as a Chippendale for the son. RELAX, dad!

Finally, if I’m going to say anything, let it express my profound gratitude that our family enjoys the luxury of such things as cars, and the freedom to work towards better options; sippy cups, into which we can pour clean, safe drinking water from our tap; and exposure to media and information—yes, exposure to cars, but also to all the other things that I want our baby to know: dolphins, and deserts, river canyons and caterpillars, clouds and fractions and Hugh Masakela and the water cycle, plate tectonics and double helices and Alice Walker, hobbits and redwoods, A Wrinkle in Time and soccer and starfish. Let me give thanks that that our child is growing up in a two-parent household, surrounded by love.

A solution to global warming

At 11:17 I sit down for what feels like the first moment in days. It hasn’t been that, of course, but there is nothing quite like parenting to make one curse Einstein for the relativity of time. I notice a tickle on my eyebrow and reach up to investigate. A fleck of something—what?—I taste it: ah yes, peanut butter; how did that get there?—ah yes, only a few minutes before nap time, facial topography though investigation by tiny peanut-butter-covered fingers. “Eyes,” I say, as Felix touches them. “Nose,” as I rotate head to avoid finger actually in nose. “Mouth!” and I take his whole gooey hand into my mouth. He squeals with delight.

Last month I was too overwhelmed, too busy, to write. That was a choice. The time, as Einstein would say, is always there. I chose to do other things instead of sitting down to put reflections into words. And that is a micro-choice which at the macro level may be heating up our beleaguered planet.

What was I doing instead of writing? Well…working, driving, shopping, cooking, planning, eating, reading, exercising, driving, parenting, talking, swimming, building, driving, biking, loving, caring, driving, preparing, driving. Pouring water into tubs and watching Felix climb in and pour it out. Chopping vegetables and putting them on skewers for the grill. Going into the hospital for a late-night admission. Driving out to Omak Lake and trying to dodge the wasps and seagull poop precipitated by too much garbage left by too many people. Drafting resolutions to try to reverse the widening income gap between rich and poor with its attendant misery. Following the unfolding war in Syria on NPR. Listening to TED talks while doing dishes. Trying to keep up on my physical therapy for an Achilles tendonitis. When it is all too much, distracting myself surfing the internet.

Once, on a river trip, I had the rare pleasure of finishing my work early. I was running the baggage raft, the often-overloaded 18-foot boat that runs down through the day’s whitewater ahead of everyone else to secure a site for the night’s stay and set up the immaculate camp demanded of outfitters. On this day we were only going from Oregon Hole to Sheep Creek. At that time Sheep Creek had a small cabin staffed by the Forest Service. The man staying there for the summer was named Ed Carr. I’d known him as a boy, when he swam with my older brother and I in his pond and helped us make a treefort in the jungle by his creek. Ed had a bushy beard, warm smile and a quick wit that hadn’t faded in the years since I’d seen him. He showed me around the cabin, through a garden exploding with abundance, and gave me his theory of the world.

Of note, what follows is only the best I can recall and doesn’t do justice to Ed’s lively tongue.

“The problem,” Ed said, “is that humans are too smart. We buzz around like busy bees. We’ve figured out how to drill into the earth and take out all these rare and precious metals. Then we concentrate them into building our skyscrapers and jetboats…what we need is to become dumber. We need some sabertooth tigers to thin us out a little. We need to make fewer bombs, fewer roads, and fewer babies, and we need the smart people especially to die off…we need to do less.”

At the molecular level, heat is simply increased motion. The more active the molecules, the warmer the substance. If the globe is an atomic soup and we humans the predominant molecules, we are doing an awful lot of activity—and it’s getting hot in here.

But I would put a slight twist—or what I think was actually the intended meaning—of Ed Carr’s idea of “smart”. The molecules among us who are doing the most activity are those who control the most resources, and I, simply by virtue of being an American and a physician (albeit a family doctor and not a cardiothoracic surgeon) fall towards that end of the spectrum (though again, it is also worth comparing to a Fortune 500 CEO). I like to think of myself as smart.

The last month’s busy-ness has made me question that. Whatever our ontologic reason for being here, whether self-perpetuation, beneficence to others, or simply the pursuit of happiness, there is ample evidence that doing more results in less.

And doing less, for me at least, seems to result in more. “Do what is essential”, said Leo Buscaglia, and he meant that we should spend more time loving each other, and less time doing things. The smartest people I have met are far from the most successful or active as measured by our material standards.

So before I rush off to wash the dishes, let me take a moment to cool the planet. To sit, and do less, and savor the memory of a peanut-butter-covered finger exploring my eyebrow.

Inequality and Health

What follows is the resolution that was introduced and successfully passed at the 2013 Washington Academy of Family Physicians (WAFP) House of Delegates. Sorry that the references aren't superscript!


Resolution on Inequality and Health: Background

We as family physicians treat patients in the context of their lives outside our exam rooms, and we can choose to advocate for societal changes that will improve health. Three areas in particular have a strong impact on health outcomes: income inequality, tax structure, and educational status. Negative trends in all three areas in Washington State pose a significant threat to our health. Though the three are often pitted against each other in budgetary discussions, this resolution will present a unified approach to improving all three areas, and in so doing, significantly improve the health of our patients.

Income inequality correlates with poor health outcomes.1-9 Greater equality correlates with better health, and not just for the poor, but for all members of a society. Studies that compare areas on a gradient of low to high income inequality consistently find a strong correlation with better to worse health, respectively. This relationship has been demonstrated in a variety of settings, including comparisons of low-inequality to high-inequality countries and states. One of the findings of this research is that among developed nations the degree of income inequality (having a larger “gap” between rich and poor) is a more accurate predictor of health outcomes than is the actual average income of a country or state. On average, areas of high income inequality suffer from three to ten times worse outcomes compared to areas of low income inequality.1

Furthermore, there is a body of peer-reviewed evidence published in respected scientific and medical journals that finds that this association holds across a wide variety of health measures.1-9 These measures include child well-being, drug abuse, education and educational performance, incarceration rates, mental health, a host of physical health measures including lifespan and infant mortality, degree of social mobility, teenage birth rates, and violence and homicide rates. Serum biomarkers of inflammation have even been studied as well.9 All indices measured have better outcomes in settings of greater equality.

Local, state, and national tax structure can serve to alleviate or exacerbate the effects of income inequality.10 Tax structure also directly impacts spending on education. Educational status is strongly associated with health outcomes,11-14 and this association is even stronger in areas with a steeper income inequality gradient.1 In other words, if one lives in an area with a bigger gap between rich and poor, having a better education is even more important for good health.

The U.S. ranks at or near the bottom in income inequality among developed nations. As predicted by the inequality-health relationship, it ranks 30th out of 30 in health outcomes.1 How does Washington State fare within the U.S.? It is illustrative to compare Washington with our neighbor, Oregon.

Among the 50 States, Washington ranks 16th best in income equality, and ranks even nearer the top (13th, at $56, 835) in median income15…but is absolute worse in fairness of tax structure.16 Here, “fairness” is the degree to which taxes are progressive (rate increasing proportionately with income) rather than regressive (rate decreasing as income rises). In Washington the tables are upside-down: The poorest 20% of earners pay 17% of their income in taxes while the richest 1% pay only 2.8%. While still managing to come in at 13th best for health outcomes,17 our State ranks 28th in K-12 public school revenue per pupil, and 46th—only 4th from the worst—in school revenue per personal income.1 This is a drop from just 20 years ago, when Washington ranked 17th and 24th in these two measures. Over the same time period our ranking in high-school graduation rates fell from 20th (with a 78% graduation rate) to 37th (with 73.7%). We now rank 47th in the percentage of young adults enrolled in college.18 Given the degree to which educational status predicts health, these are worrisome trends.

Our neighbor to the south tells a different story. At first blush, Oregon might seem our twin, tying us at 13th best for health outcomes, but a closer look reveals a very different trajectory. Although coming in $10,000 lower for median income (31st in ranking, at $46816), rating worse for income equality (23rd), and even having a much higher poverty rate (37th in ranking with 17% poverty compared to Washington’s 21st in ranking with 14%),15 Oregon has the 4th fairest tax structure in the U.S.16 While spending only slightly more on education per pupil, Oregon has raised its high-school graduation rate from 33rd (70.8%) in 1990 to 27th (76.5%) in 2012, almost exactly opposite Washington’s course.17 Paralleling this educational improvement, Oregon has seen its health outcomes rise from 28th best in the nation in 1990 to its current standing at 13th. Washington, after enjoying a brief rise upwards from 14th best in 1990, fell steadily backward, ending up again at 13th in 2012. The two states’ tax structures appear to play a major role in their ranking.

Contrary to popular media portrayal, tax levels overall are at historic lows.1 At a time when a “budget crisis” pits cuts in education against healthcare, it is important to remember that both State and national taxes collected per $1000 of income have fallen to their lowest level in 50 years. Washington’s rate of collection is well below even the national average.

Why does Washington rank 50th out of 50 States in fairness of tax structure, and what implications does this hold for our future in terms of education, equality and health? A report from the nonpartisan Economic Opportunity Institute titled “House of Straw” details how our current tax structure worked well when it was designed, in the 1930’s.10 As one of only seven states lacking an income tax, Washington relies on its sales tax to provide 48.8% of General Fund spending. In 1930 the majority of state economic activity fell under taxation from the sales tax and provided for our educational, transportation, and public health and safety needs. Since then we have shifted to a largely non-taxed service economy; the tax base relative to the needs of our growing population has shrunk considerably. In 1979, when the sum of personal income was just under $50 billion, taxable retail sales represented 56% of that sum. By 2010 they made up only 35%. During that time, personal income grew more than six-fold to over $300 billion, while taxable economic activity grew to barely over $100 billion—meaning that more than $200 billion of our State’s economic activity goes untaxed.

These untaxed economic gains have gone almost exclusively to the super-rich.10 From 1979 to 2007 the income of the wealthiest 1% of Americans went up 275%, compared to a meager 18% increase for the poorest fifth. And in Washington State, as above, the poor shoulder an undue tax burden as a percentage of their income. Everyone buys bread, clothes, a car. Beyond that, the richer you are, the less of your income goes to taxable goods.

Taken together, the effects on health outcomes of poor and falling investments in education and the most regressive tax structure in the U.S., against a background of a high level of income inequality and falling public revenue at the national level, present a formidable threat to the health of our patients in Washington.

Importantly, areas that achieve good health outcomes matched with low levels of income inequality do so through a variety of means. These range from high levels of redistribution through spending on social programs, as in Sweden or Minnesota, to low social spending but also a low level of pre-tax income inequality, as in Japan or New Hampshire.2 Areas with poor outcomes are often beset by the dual challenges of low spending on social programs as well as high income inequality, as in Washington State.

A final note is that addressing income inequality represents perhaps the single most cost-effective approach to improving health outcomes, in sharp contrast to spending more on healthcare. The U.S., largely driven by an inverted pyramid of high-cost specialty care, spends more per capita than any country in the world, yet falls behind 29 other countries in terms of health outcomes.2 While shifting costs within healthcare to invest more in primary care has been shown to improve outcomes, simply spending more in total is in fact associated with worse outcomes.19,20

Family medicine is primarily focused on the health of the individual. At the same time, each individual presents in the context of his or her environment, and to offer medical treatment void of that context can be costly, inefficient, and ineffective. If as physicians we have the opportunity to positively impact our patients’ contextual environment and thereby better their health, we should seize that chance.

Resolution on Inequality and Health

WHEREAS, family physicians treat patients within the context of their broader lives, and,

WHEREAS, increased income inequality correlates consistently and strongly with worse health outcomes for all citizens across a wide range of measures studied,1-9 a regressive tax structure further exacerbates the negative health effects of income inequality,10 and lower educational status correlates with worse health outcomes,11-14 and,

WHEREAS, among developed nations the U.S. has a high level of income inequality1,15-16 and poor health outcomes1 despite high spending on healthcare,19-20 and,

WHEREAS, within the U.S., Washington State has a shrinking tax base10, ranks 50th out of 50 in fairness of tax structure15-16, 46th in spending on K-12 education10 and 47th in young adult college enrollment rates18, and, has fallen in our health outcomes ranking despite a high per capita income17 , and,

WHEREAS, Washington State’s high income inequality, regressive tax structure, and low relative education levels all are associated with worse health outcomes of all of our citizens, therefore, be it

RESOLVED, that the Washington Academy of Family Physicians shall support reforms at the national and state level which reduce income inequality, and,

RESOLVED, that the Washington Academy of Family Physicians shall support reforms in Washington State which increase tax fairness, where fairness is defined as the degree to which taxes rates increase proportionately with income, and,

RESOLVED, that the Washington Academy of Family Physicians shall support reforms in Washington State which increase spending on public education through funding from new tax sources rather than from any cuts to existing programs.

REFERENCES
1. Pickett, Kate and Wilkinson, Richard. The Spirit Level: Why Greater Equality Makes Societies Stronger, Bloomsbury Press; Reprint edition 2011, ISBN-10: 1608193411
2. Wilkinson RG, Pickett KE. Income inequality and population health: a review and explanation of the evidence. Soc Sci Med. 2006 Apr;62(7):1768-84. Review. PMID: 16226363
3. Bezruchka S. Income inequality and population health. Hierarchy and health are related. BMJ. 2002 Apr 20;324(7343):978. PMID: 11965671
4. Bezruchka S, Namekata T, Sistrom MG. Interplay of Politics and Law to Promote Health: Improving Economic Equality and Health: The Case of Postwar Japan. Am J Public Health. 2008 April; 98(4) PMCID: PMC2376982
5. Kondo N, Sembajwe G, Kawachi I, van Dam RM, Subramanian SV, Yamagata Z. Income inequality, mortality, and self rated health: meta-analysis of multilevel studies. BMJ. 2009 Nov 10;339:b4471. Review. PMID: 19903981
6. Spencer N. The effect of income inequality and macro-level social policy on infant mortality and low birthweight in developed countries--a preliminary systematic review. Child Care Health Dev. 2004 Nov;30(6):699-709. Review. PMID: 15527480
7. Sengoelge M, Elling B, Laflamme L, Hasselberg M. Country-level economic disparity and child mortality related to housing and injuries: a study in 26 European countries. Inj Prev. 2013 Feb 12. PMID: 23403852
8. Granados JA. Health at advanced age: social inequality and other factors potentially impacting longevity in nine high-income countries. Maturitas. 2013 Feb;74(2):137-47. PMID: 23276601
9. Clark CR, Ridker PM, Ommerborn MJ, Huisingh CE, Coull B, Buring JE, Berkman LF. Cardiovascular inflammation in healthy women: multilevel associations with state-level prosperity, productivity and income inequality. BMC Public Health. 2012 Mar 20;12:211. PMID: 22433166
10. Watkins, Marilyn. House of Straw: How Washington’s tax structures undermines our economic future—and how to fix it. Economic Opportunity Institute, Oct. 2012. http://www.eoionline.org/tax_reform/reports/house-of-straw-wa-tax-structure-oct12-web.pdf
11. Cutler DM, Lleras-Muney A. Education and Health: Evaluating Theories and Evidence. 2006. Natnl Bur Econ Reseach working paper No. 12352. http://www.nber.org/papers/w12352
12. Fiscella K, Kitzman H. Disparities in academic achievement and health: the intersection of child education and health policy. Pediatrics. 2009 Mar;123(3):1073-80. Review. PMID: 19255042
13. Backlund E, Sorlie PD, Johnson NJ. A comparison of the relationships of education and income with mortality: the National Longitudinal Mortality Study. Soc Sci Med. 1999 Nov;49(10):1373-84. PMID: 10509827
14. Braveman P, Barclay C. Health disparities beginning in childhood: a life-course perspective. Pediatrics. 2009 Nov;124. PMID: 19861467
15. Ojha H, Weber M, Syzmanski C. The unequal state of America: Data Interactive, SOURCE: 1990 Census; 2000 Census; 2006-2011 1-year American Community Survey. http://www.reuters.com/subjects/income-inequality/list
16. Who Pays? A Distributional Analysis of the
Tax Systems in All 50 States. Institute on Taxation & Economic Policy, January 2013. http://www.itep.org/pdf/whopaysreport.pdf
17. America’s Health Ranking: United States Overview 2012. Source: State-Based Health Surveys; US CDC; US Census Bureau. Accessed Feb. 2013. http://www.americashealthrankings.org/ALL/2012
18. America’s Health Ranking: United States High School Graduation Rate (1990 - 2012). SOURCE: National Center for Education Statistics. Accessed Feb. 2013. http://www.americashealthrankings.org/ALL/Graduation/2012
19. Shi L. Primary care, specialty care, and life chances. Int J Health Serv. 1994;24(3):431-58. PMID: 7928012
20. Gawande, Atul. The Cost Conundrum: What a Texas town can teach us about health care. The New Yorker, June 2009.

dawn

dawn:
pink
blue
pastels holding portent of rain, percent chance: 20,
and poop, 100.
outside the rising sun sets afire the elm, the sagebrush,
sending embers of burning rimrock sailing
across the Okanogan
through the open window
bouncing off the floor-level mirror
and alighting on the cheeks of our 10-month-old:
light, alight, delight.
later
after breakfast perhaps
will come the inevitable bonk
the innumerable slings and arrows of unpredictable countertops,
shiftless laundry baskets, wily carpets—
percent chance of recovery: 99,
while outside the sagebrush, the river, the vigilant eagle
bear insults more predictable and less forgiving
development, diesel fumes, the thoughtless Coke bottle—
percent chance of recovery? shhh.
for a moment
I yearn
with every cell of my body
for a paintbrush, big enough to paint over our past,
undo the last decade of war, the last century of carbon emissions,
the last millennium of unchecked growth,
to make the world outside
as whole again
as my glowing son


written the day after the OLT poetry night, 2013
Okanogan River Watershed, Omak

New Year's Day

for LL, the love of my life.

New Year's Day 2013

Today I fell on the ice and hit my head.
Apparently, it was not hard enough:
what I want is to get out of the same path,
and move into a new one--a path that is not
my path,
but our path--
this is the work to be done,
this is the important work,
and it does not start here with my pen
on this page.
It starts when I put this pen down
and walk up the stairs
and tell you that I love you.
Today I fell on the ice and hit my head.
I love you.
I love you.
I love you.
I love you.
I love you.

300 revisited

On 1/11/10, I wrote a blog titled "300", referring to the number of emails in my inbox.

I have dropped below 300 for the first time since then. (A month ago I was at 729.)

What I have realized--having just completed my second training from the Center for Mind-Body Medicine--is that I was distracting myself from dealing with life (and life's emails).

It feels good to be back. Maybe more on that in an upcoming blog.

For now, I'm going to simply hang up (as it were), finally paste in my completed blog for December (which I finished around the 10th), stop using parentheses,

and go to bed. It feels good to be back.