The Mail

Note: I attempted to place this in the "Comments" section of "Nov.30 Ways & Means", as it was written in response to a writer's commentary on that posting. I was unable to do so, initially because of technical difficulties, but ultimately due to length. And so here it is as a new post. To whoever posted their response to "NANDA" (which was really a response to "Nov.30 Ways & Means"), I did NOT delete your response, I just moved it to Nov. 30. Thanks! -N.H.

Dear writer,

Thank you for your response to my posting; I have relocated it from “NANDA” to this post, on which it comments. You raise a number of excellent points which I will try to address.

First, thank you for the reminder that I am writing, as a family physician, from a position of both power and responsibility. It is my hope and aim to never abuse either. I am, at the same time, human. I make mistakes. I do not always live up to my hopes and ideals; I nonetheless try, and I see your response as an opportunity for reflection. My path is always, I hope, one of learning. It should also be noted that the views and opinions expressed in my blog are mine alone and do not necessarily reflect those of my employer or of anyone else associated with me.

I am also aware that I am writing not in a vacuum but in the context of a small town. As such I am constantly reminded of the importance of relationships with all people. To this end my goal in interactions is no different than it has been my whole life, which is to say, to treat everyone with respect.

To whatever degree I have treated you in a way that you saw as disrespectful, I apologize. I do ask that if you would like to address this further with me, you do it in the context of our relationship as doctor and patient in the clinic, as this appears to be the source of your anger, and not in this blog. Out of respect for your comments I have left them as they stood, with the exception of the deletion of your use of profanity.

Secondly, thank you for the chance to point out something I should have stated explicitly: each patient example I gave represents a composite of multiple patient stories from my practice over the last five years in Seattle, Auburn, and here. As such, while any one patient might be based mostly on one person, there are always details that I have changed or borrowed from another patient to avoid identifying one person.

Thirdly I would like to address your question of why I and/or the clinic do not simply give our most needy patients the financial help they need. While I have and will continue to make individual donations to patients, the reasons that I cannot make this the mainstay of my efforts are many. One, I would go broke. Recognizing, again, that as a doctor I am in a position of great power, my resources are still finite. I have a family to support. With me already six years out of medical school, we still have over $100,000 of student loan debt. I rent a 2-bedroom house, drive a used car, and do not own a television. If I were to help out every patient who needs money—which is virtually everyone—I could not carry on what I hope to be a lifetime of service. Two, I would happily pay higher taxes to support a more just and moral healthcare system. As I pointed out in my blog, our current taxation system promotes gross inequality. Three, it is this system of inequality which I believe is doing our patients and our world the most harm, and which I have and will continue to devote my efforts to try and change. Not on behalf of one person, but for us all.

This brings me to the fourth point you raise, which is a very valid one: why on earth am I taking time away from clinic to go to Olympia and speak out?

You should know that my activist efforts are done on my own vacation time, at my own expense, and that every time I leave town for whatever reason I face a sizable stack of back-logged work when I return. So I do not do this lightly.

The reason that I still do it is that I believe in fighting for a more just system for everyone. Because I understand that I have power as a family doctor, I see part of my responsibility, as stated in my address to the legislators, as speaking out on behalf of those with no voice.

Is this effective? I cannot say. But I can tell you that one Senator on the Ways and Means Committee, to whom my efforts were addressed, found it compelling. Here is the link to her site:
http://blog.senatedemocrats.wa.gov/keiser/health-care-needs-exist-across-washington/

Finally, you might ask, if my efforts are addressed to the State Legislature, “why don’t you keep it to that, and not post in a public blog as a member of this small town?” The answer to that is that I hope to raise awareness amongst my own friends and contacts. While I do not promote my blog in any way to patients, I recognize that anyone can search my name and find my blog, as you did. I welcome that too. I aim to foster open discussion amongst anyone who takes these issues seriously.

As such, I also aim to enter into such discussion with an open mind, the awareness that I may be wrong on any issue, and always with respect. I ask that you do the same.

. . .

p.s. If your dissatisfaction with me had anything to do with me running late or not spending enough time with you (and if it was something else entirely, I again ask that you address this with me in clinic), first I apologize, and second I encourage you to speak up. I tend to run behind because I try to listen to patients; I would love to work in a system that allowed me to give you the time you deserve. Even before the budget cuts, we are under pressure to see more and more people in less time. Speak out! You as a patient have a voice—use it! Call your local representatives and let them know your concerns!

. . .

Final Note: To see the comments to which I was responding, please see "Comments" under "Nov.30 Ways & Means". Again, I moved the comments by "Little Cat" from its original location under "NANDA" to there, as this was the post it deals with.

Acrobaticalists

NANDA: A Review

“Nothing touches a work of art so little as words of criticism: they always result in more or less fortunate misunderstandings. Things aren't all so tangible and sayable as people would usually have us believe; most experiences are unsayable, they happen in a space that no word has ever entered, and more unsayable than all other things are works of art, those mysterious existences, whose life endures beside our own small, transitory life.”
—Rainer Maria Rilke

Twisp, Saturday night, December 10. The 15-degree air snatches away breath and shutters doors. The sun is a distant memory. To attempt movement, much less “unbounded imagination and creative agility”, seems an absurdity.

But in the Community Center gymnasium the absurd is about to take form. The air hums with energy as in the front, on mats, a tousle of kids is instructed to stay there: What is about to happen could be dangerous. Keep your head down. Don’t stick out any limbs. NANDA is about to begin.

As the lights fade to black and a screen rolls with dramatic opening credits (NANDA presents a NANDA production starring NANDA…), I am once again 7 years old and the world is magic. The music builds, the curtains part, the stage explodes into action, and the next 3600 seconds are measured in pure joy. When it is all over and my entire torso aches, I realize I have scarcely stopped laughing the entire time.

What is NANDA? Trying to touch NANDA with words is truly to take the unsayable and try to pin it down. From an opening scene of kung-fu fighting to a medley of air guitar and swaying hips, from a daring heist involving invincible robots to a comic radio-surfing lunch break, from one impossible juggling feat to the next, NANDA defies. Expectations, conventions, stereotypes, propriety, and most of all the laws of gravity are utterly ignored. For 3600 seconds this “four-man acrobaticalist performing arts troupe” demands my attention and it is theirs.

According to their website (nandatown.com), “Nanda” is a colloquial Japanese expletive for “What!?!” This is an apt name for a group with enough testosterone to fuel an F16 and enough whimsy to make Bambi blush. In a time when so many role models—male and female alike—espouse a pseudo-Darwinian view of conquest through superior strength, NANDA turns this all on its head.

It’s not just that the winner of a ninja fight scene may be the guy who gets to put on the silver spandex. It’s that winning may involve everyone doing a musical number à la the Rockettes.

To say more would only be to go further down the path that Rilke cautions against. The show will live on far beyond these meager words. NANDA is what??!, and what!?? is NANDA. Don’t miss it.

Olympia, Nov. 29th, Ways & Means Commitee

My name is Ned Hammar. I am a family doctor working at a community clinic in Okanogan. I drove six and a half hours to be here.

I am here today on behalf of those who have no voice.

I am here today to speak for my 38-year-old patient with pelvic cramping. She had light spotting of blood and found that her IUD was coming out. We tried to get another IUD to replace it but could not because she had no insurance. We tried to offer her condoms but she declined them because her husband beats her up if she uses them. We tried to offer help but she said she couldn’t leave the situation because of her children.

This woman faces an unplanned child born into an abusive relationship in a family already struggling to get by, because she can not afford safe and effective contraception.

I am here to speak for my 47-year-old patient who just wants to get back to working as a short-order cook, but can’t because the voices in his head tell him to kill himself. He’s been into our clinic five times in the last year in suicidal crisis. Each of those times we’ve tried to get him admitted to emergency psychiatric care but each time this has been denied because he can’t pay. He can’t afford a medicine that keeps the voices at bay and costs $17 a month.

I am waiting for the phone call to tell me that he is dead, because we couldn’t help him find $17 a month.

I am here today to speak for my 9-month-old patient. This little girl was born to a mom who had just one prenatal visit. She appeared normal at birth but at her 1-week check-up she stopped breathing and turned blue. In the hospital she started seizing, and she was sent by air to Spokane. There she had a massive stroke and lost 90% of the temporal lobes of her brain. Somehow she lived. But she will never walk. She will never talk. She will never play patty-cake, or read a book, or sing a song.

This girl had a herpes infection that reached her brain, which could have been prevented if her mom had received adequate prenatal care.

I am here to tell you that our system is failing, and it is failing those who have very little left to lose. If these budget cuts go through, you are asking them to let go of one final thing. It may seem like a small thing but in my experience as a family doctor it seems to be the only thing some folks have left.

You are asking them to let go of hope.

I have heard that one of the accusations leveled against the Occupy movement is that they don’t have an “ask.” So I’ve thought very carefully about what my “ask” is, if I’m going to come here and take up your time.

My “ask” is very simple. My “ask” is that you tax the wealthiest individuals and corporations in order to pay for basic healthcare and education for all.

You might say, “Well, that failed. I-1098 last fall put that exact choice to the people and it was voted down.” To which I would point out that for 6 of the 7 months that polls were conducted, I-1098 was supported, initially by a margin of 66% for to 27% against. Only an aggressive and highly-funded campaign which played to baseless fears was able to convince people to vote against their own best interest.

More to the point, I would remind you that Washington State has the most regressive tax structure in the nation. The poorest fifth pay 17% of their income in taxes, while the richest 1% pay only 2.6% percent. From 1979 until now, the income percentage of almost everyone has dropped, but the richest fifth have increased their share 6 points from 43 to 49%—and the wealth disparity is far greater.

This is an outrage. There are people dying on our streets and in our clinics, in my clinic, every day, while the richest of the rich linger over the choice between a new yacht and a private airplane. This is an outrage.
The argument against raising taxes on the wealthy is that we will no longer attract the best and the brightest minds to our State to be the innovators and doers of tomorrow. I ask you, what about the minds we have here? Are we willing to write off 80% of our population as worthless? Are we willing to pin our hopes on the richest 1-2% of individuals and corporations, hoping that somehow they will smile on the rest of us? If we are, then the last 30 years should give us some idea of what to expect. Do we have better schools? Better clinic? Better health? Safer neighborhoods? Cleaner air? Better transportation? A secure economic future?

Study after study shows that the health of a community can be best predicted by one single measure: a lower income gap between rich and poor. Over the past 30 years our income gap has widened, and our schools, neighborhoods, clinics, our health, our future, our hope have suffered as a result.

I can’t pretend that reversing this trend will be easy. The defeat of I-1098, a measure which would have directly benefitted 98% of our people while asking a nominal tithe of the remaining 2%, illustrates the power of the wealthiest individuals and corporations.

Nonetheless I ask you to try. John Burbank and the Economic Opportunity Institute offer some specific measures which would close corporate tax loopholes and protect social services, while both protecting the environment and stimulating economic growth. I ask you to look at these and other measures which more equally share the responsibility for our current crisis. We the people need you to try. Our future, which is to say the future of Washington itself, depends upon it.

I ask you to give us hope. Not the gaunt, stretched, thin hope that my patients barely survive and sometimes perish on, but a real hope, a robust hope, a hope nourished by true investment in our future. Thank you.

a jump in the lake

This blog was headed for disaster.

When I was a kid—when I was a little kid—when I was 5 years old I would tell my mom stories. She would write them down, I would draw in the pictures, and we would create little books together about an 8-year-old boy who sailed the high seas in a 3-masted wooden sailboat saving princesses from pirates and seeking buried treasure. Not incidentally, this boy was named Ned. My name, at the time, was not Ned, but that’s another story…

Throughout grade school my authorly aspirations grew and blossomed, and up until a short time before college my intention was to be a writer. In high school, however, this goal was supplanted by the belief that I would be most effective at saving the world (princesses being recruited to help) though a career in science, perhaps the development of a good 5-cent contraceptive or a renewable source of energy.

This belief collapsed.

The further I went in science and eventually medicine, the less I believed that progress in these areas correlated to that of humanity or the world. Instead, and nowhere more vividly than in the time I spent in the Peace Corps in South Africa, I saw the overwhelming effect of a world divided between the haves and the have-nots. Divided, and inextricably linked, as the labor of the poor provided the wealth of the rich. It was not so much that technological progress was the enemy as that it was too often used as another tool of the powerful to consolidate their power.

Along the way I was fortunate to meet the real Dr. Hunter “Patch” Adams. Here was a human being who had dedicated his life to the betterment of life on the planet. But his message to me was so much more important, so much more meaningful, than one of responsibility. His message was one of joy.

“If you need a break,” Patch says, “I want you to take one that day. I don’t want you working under stress. We look at teachers, nurses, doctors, social workers, and we say, ‘Why would I ever want to do that?’” Patch wants us to make a life of revolution the most attractive, fun life imaginable.

Which is why, when the inspiration struck me at age 30 to create a children’s book, I was excited. Here was a chance to have loads of fun doing something meaningful, and something that took me full-circle back to my childhood dreams of authorship.

The other part of this was that I worried that if I ever sat down and tried to write prose, what would come out wouldn’t be joyful. It wouldn’t be fun, or funny. It would be yet another painful, wordy, semi-autobiographical first novel that might, if you were lucky, leave you pissed off at the state of the world.

What I hadn’t realized is that this blog was becoming that novel.

Today, my day off from work and best chance to write, I struggled to feel creative, to create. The bitter cold outside didn’t help. At the end of the day I had a painful, wordy novel, and I felt pissed off at the state of the world.

And then I remembered Patch Adams, and my commitment to not take any of this so seriously, and I decided to go jump in the lake.

Omak Lake on a 43-degree day is no bath. The freezing jolt to the system was exactly what I needed. After jumping in, getting out, and jumping back in twice more, breathing was painful and my skin tingled from head to toe: I was alive. This blog, and the life it reflects, were averted from disaster, despair, and all the rest of the melancholy I’ve been dwelling in recently.

If this becomes more that an occasional trip, of course, it could start getting really cold…but hey, there’s always snow rolling!

The International Association for the Advancement of Creative Maladjustment

~
It is Monday night and I am parousing around the internet when I come across a rare find: information that borders on knowledge, even wisdom.

Having just suffered through James Gleick’s The Information on cd in my car, this is not a trivial distinction. According to formal information theory as developed by Claude Shannon, information is a quantifiable property of anything worth looking at—an NPR news broadcast, a poem, a storefront, or for that matter, a face, a flower, a bark beetle—that is independent of meaning, which we assign to such information.


My trail went something like this: James Gleick --> the library of Babel --> Jorge Luis Borges --> magical realism and The Attack of the Killer Tomatoes --> the real Patch Adams, who was recently named the honorary chair of… --> the IAACM --> the originator of the idea for the IAACM, namely Martin Luther King Jr.

As it is impossible to overstate the wisdom (that is to say, the meaning I assign to the work) of Martin Luther King Jr., here simply is the link to the speech in which he says, “I'm about convinced now that there is need for a new organization in our world. The International Association for the Advancement of Creative Maladjustment…”

Martin Luther King Jr.'s speech at WMU:
http://www.wmich.edu/library/archives/mlk/transcription.html

Among the reasons these words speak to me is my own never-ending struggle to adjust to life and work at a community health center. Confronted with the daily injustices that I view as being in no small part the direct health outcomes of poverty, it is inspiring to reflect on these thoughts from King.

“Modern psychology has a word that is probably used more than any other word in modern psychology. It is the word "maladjusted." This word is the ringing cry to modern child psychology. Certainly, we all want to avoid the maladjusted life. In order to have real adjustment within our personalities, we all want the well-adjusted life in order to avoid neurosis, schizophrenic personalities.

“But I say to you, my friends, as I move to my conclusion, there are certain things in our nation and in the world which I am proud to be maladjusted [to] and which I hope all men of good-will will be maladjusted until the good societies realize.

“I say very honestly that I never intend to become adjusted to segregation and discrimination.
“I never intend to become adjusted to religious bigotry.
“I never intend to adjust myself to economic conditions that will take necessities from the many to give luxuries to the few. (my highlight)
“I never intend to adjust myself to the madness of militarism, to self-defeating effects of physical violence."

~ ~ ~ ~ ~

I never intend to adjust to a segregated health care system.
I never intend to adjust to the idea that the norm, for those who do the important work of social justice, is to burn out. (Patch Adams has some great thoughts on this).
I never intend to become adjusted to waiting for justice to come with time.

"We must always help time and realize that the time is always right to do right.”

The time is right to do right. Be creatively maladjusted!

~ ~ ~ ~ ~

Some great commentary on King’s words in our modern context:

"Informed Comment", Juan Cole:
http://www.juancole.com/2010/01/mlk-international-association-for.html

Guns & Mosquitoes

It is Friday evening, LL is gone for the weekend, and all the external factors mentioned a month ago—i.e., the affairs of the world—haven’t exactly improved. The internal front is equally bleak. Staff shortages have led to work being even busier than before. I’ve been struggling valiantly to reach out and ask for help, but help right now is swamped, flooded, snowed in, choose your aqueous metaphor. And while I have no illusions of fostering any grand social movements in the next couple of hours, it would have been nice at least to talk with someone; at this hour it’s looking less and less likely.

Which is why, when I get the invitation to a barbecue, I almost stay home and work on my nascent (nearly non-existent) guitar skills. It would be so easy to hunker down: it is the path of familiarity.

But I’m interested in change! Right? Surely the pits of despair haven’t been for naught? So I assemble a mixed six-pack of beer, slice some avocados for a food offering, and go.

And that is how, these odd hours later, I come to be writing about mosquito spraying and gun control.

The mosquitoes had been on my mind for a while. The train of thought went something like this:
1) There’s a great quote from activist Bernice Johnson Reagon which I first encountered in a Real Change newspaper, “If you're in a coalition and you're comfortable, you know it's not a broad enough coalition”.
2) How broadly does this idea of an alliance for a common goal extend? If the common goal is a healthier planet, then surely it has to reach not just to all humans, but to all life interconnected—all species.
3) “All species” includes…mosquitoes.
4) How uncomfortable are we willing to be in order to get along with each other? Are we willing to tolerate a few more mosquitoes instead of aerial bombing our own neighborhoods with the biotoxin malathion?
5) What about the agricultural watering that is feeding the mosquito population in the first place? Are we willing to grow less food? Never once, in the history of humans and food production, has increased food led to a net decrease in human hunger, never mind suffering…

Not one among this sequence of thoughts is a topic of discussion at the barbecue. There is, however, much discussion of something that makes me quite uncomfortable: guns. Guns, in the hands of people, kill people. The night before, a woman had shot and killed herself and another woman in a struggle and wounded a third. This happened just down the street from our clinic, and just next door to one of the potluck-goers. In a town this size everyone is connected to someone. It would have been impossible not to discuss.

In the course of talking various opinions come out on gun control. Being new to the group I mostly listen. It isn’t surprising in rural eastern Washington that there are staunch gun rights advocates, even among what I assume to be a relatively liberal subset of folks. Having grown up in rural eastern Oregon this is familiar territory.

It does, though, make me question my own tolerance of difference—how willing am I to sit down and try to reason with people of polar opposite opinions? Is there some common ground here? The discussion eventually turns to “the worst movie you’ve ever seen,” and no one really pushes the envelope on guns. I’m left to ponder this for the time being on my own.

How on earth does this relate to mosquitoes? Well, long after the fact, I have a brilliant idea. Why not let all those in favor of unlimited gun rights, and those in favor of mosquito eradication, find common cause in a mosquito hunting season? It could run from April through October, no limits, anything suspected of being or being near a mosquito is fair game.

Just to keep things interesting, though: Arm the mosquitoes.

Despair

“Despair is the only cure for illusion. Without despair, we cannot transfer our allegiance to reality…it’s a kind of mourning period for our fantasies. Some people do not survive this despair, but no major change within a person can occur without it.” —Philip Slater, Earthwalk

In March, in response to an email I’d written about feeling overwhelmed, a figure whom I see as a mentor wrote back, “Despair is not a useful option.” I am sad to say that until now I had not responded to this email.

The past year has held ample cause for despair. The movies "Collapse", "Inside Job", and "The End of Poverty(?)" offer glimpses of the problem. In Washington State last fall voters failed to pass an initiative that would have taxed only the wealthiest 1% and very specifically used that money for public healthcare and education. In Washington D.C. this week a group of freshmen lawmakers, for the sake of upholding tax cuts for the nation’s wealthiest individuals and corporations, is failing to compromise on legislation that will allow the U.S. government to pay its bills. And every day in my clinic I see the human consequences of this failure. The 51-year-old man who has to choose between paying for his medicines and his rent, having already cut back on food. The 63-year-old woman who was evicted from her home and is living in a motel with her daughter and grand-daughter. The 47-year-old patient who begs me to be hospitalized. He cannot buy the medicines that stave off the voices telling him to kill himself.

In my head I am trying to balance these two approaches to despair—despair as a non-option, and despair as the only cure for illusion. The one says, “If you give in to your despair, then who will do the work? Who will fight on behalf of your patients?” The other says, “By continuing to work at the level you are working, what are you actually changing? A life here, a life there, but the system is collapsing around you.”

Which brings me closer to the heart of the matter, which is to say: “On what level am I most useful?” And this causes a lump to form in my throat. Because I know the answer to that question. I know it, and I have been unwilling to face it. I have been unwilling to allow myself the despair that will actually allow me to change.

The truth is: I need you. The answer to that question, the question of how I can work for change on a deeper level than individual patient care, is that I need to reach out to others. Patch Adams says: “We need each other, more deeply than we ever dare to admit, even to ourselves.”

The question then becomes, what am I willing to give up in order to ask for that help? Asking for help, working with others—in a meaningful way—takes time and energy. Where has my time and energy been going? It would be easy to say, “Well, duh! You’ve been taking care of patients...you haven’t had time to stay in touch with friends and family.” And that is part of the story. The easy part. The harder part, the part that takes me into despair, is that I have clung tenaciously to an idea, a fairly simple idea, an idea that has kept me from making positive change in my life.

The idea is this: “I am the hero of the story.”

That is it. It is simple, and pernicious. I am the hero of the story. It is the idea that has kept me from reaching out to friends and family (“I’m tough, I can get through this on your own, I always have!”), from fully engaging patients as partners in their own health (“You’re not ready for the whole truth—that our world is collapsing—so let’s keep this at a superficial level”), from admitting to myself when I’m NOT the positive and healthy person that I strive to be. And in this denial, in this denial of despair, I’ve ironically allowed myself to be the victim. To say, “It’s the overwhelming daily work that’s keeping me from doing the things I want to be doing.” In trying to maintain my hero status, my self-image as the can-do cowboy, I’ve put on hold the essential work of self-reflection and dialogue with others.

And this is not trivial work, not a luxury to be afforded only when things are going well. In fact it is probably most important at the very moment when it seems that there isn’t time to do it. It is not that despair is not a useful option. It is that despair needs to be discussed in bars and shouted from the rooftops.

At the same time I must caution myself against the ebullient joy I feel welling up as I write that last sentence. I have a tendency to flip too easily between self-despair and self-resolution, to think I’m back in the saddle again when I haven’t actually addressed the underlying issue that threw me off. And in this case, as identified above, I need to get rid of the horse and saddle all together, and start the more demanding—and ultimately, ojalla, rewarding—work of coalition.