The Pause

The Pause

I am on the river and it is not raining. This is noteworthy not so much for the lack of rain–very normal for July on the lower Salmon River, which gathers courage and volume from the Sawtooth, Bitterroot and Lemhi Mountains before wending its way through a high desert canyon to join its former tributary, the now-larger Snake–as for the fact that it was several hours of rain, solid rain, that delayed the start of our trip yesterday. Today it is not raining and I am teaching my brother-in-law to row. In so doing I discover the pause.

I am on the river, and it is not raining. There is just enough itinerant cloud cover (are we rowing through it? or is it reaching out to us as it flies overhead to parts unknown?) to make the day not blazingly hot, and yet, as we are in Western Idaho instead of home on the Northern Olympic Peninsula in Washington, neither is it chilly, despite the morning hour. It is perfect.

Back, flip, dip, pause, pull, lift, roll, back, flip, dip, pause, pull, lift, roll, back, flip, dip, pause. 

Never before had I broken it down so completely. After the pull on the oars, with the blades perpendicular to the water, lift them out of the water. Before bringing them back for the next stroke, roll the wrists. Now the blades are parallel to the plane of the river’s surface, and will slice through a wave, if needed, to get back to the starting point for the next stroke. This “back” motion, achieved by pushing forward on the oar handles, can even be done entirely underwater. Now, flip back to perpendicular and dip for the next stroke.

And…breathe. Pause. Before that next stroke. Is the oarblade perpendicular to the water? Is there current there? Or eddy, or slackwater? Is your other oarblade perpendicular? Do you want to in fact push instead of pull on one or both oars? Where is the current taking you, and is your boat oriented how you’d like it? Where is the next biggest wave, rock, or hole to avoid?

Or are there no dangers present, and you can just...pause?

I am on the river, it is not raining, and after yesterday’s morning rain (punctuated by a horizontal squall precisely at dinner time, for which we employed the tarp we’d driven from the put-in site back to Grangeville to purchase) the air is delightful and I can imagine that the brown-and-sagebrush-grey canyon walls are just a little greener and I am not at work and I am with people I love and trust and I can pause.

Later, I will need to row. Through Half-N-Half and Snowhole and China and Skeleton Creek, and down 20 miles of the Snake after the confluence. To catch eddies for campsites and lunchsites, to avoid eddies and follow Ariadne’s thread of current through a labyrinth of slackwater, holes and rocks. So, too, my companions: my brother and his wife, my mom, and my brother-in-law, who is picking up the feel of rowing with alacrity and vim. For now, though, we are allowed a pause.

In pausing I can calibrate my oars. Where is the larger current of my life taking me? Am I oriented in such a way as to be able to pull back from giant waves, or square up to them when necessary? Do I need to eddy out and secure the frame, or scout the next rapid?

Am I even in the right river canyon?

Everything about our lives–let me pause right there. Everything about my life has been forward momentum; in looking around me, I think this is true for a great many of us. 

Certainly, the current power structure, the status quo, gains nothing from having me pause, think, question, be goofy. As long as I produce widgets and algorithms and patient encounters (I've never been good at treating patient encounters like widgets; my apologies to my patients for always running behind)...and then soothe my frazzled nerves by consuming property and widgets and algorithm-generated entertainment...the great machine rolls on, and I am but flotsam. I am not rowing, and if I am, it is but to accelerate my blind journey down an unquestioned torrent.

And so here I am. Pausing. In writing I have always found a pause; often, I end up at a place entirely different than what I expected when beginning the exposition. To return to my earlier and unexpected metaphor, I am, like Theseus, lucky, in love and in life. In my friends and family, and most of all, in my wife (who is planning to come with our boys on the trip next summer, and who was so wise to let us work out all the kinks without her this summer), I have my Ariadne’s thread. 

In pausing, I can pick up that thread, again and again, and row, and pause, not blindly. With intention.

A word after a word after a word

I was driving to the hospital when these words from Margaret Atwood flowed out of the Canadian Broadcasting Corporation radio:

"A word

after a word

after a word

is power."

Three words.

Subject, verb, object. Or something else. 

Trees catch fire. The Earth warms. Winter arrived timidly. Birds fly home. Babies need food. 

Why this moment? Against all odds. Hope never dies. Will you help? What's your name? Can we try?

If not now...everything everywhere all at once. Simultaneously. Are there limits?

I love you.

Three words can change a mood, change a mind, change a motion. A different emotion can catch fire. Light a candle. Inspire another to change of heart, of action, of word.

I love you.

To quote another favorite author, Ursula K. Le Guin: "Only in silence the word, only in dark the light, only in dying life: bright the hawk's flight on the empty sky."

Against now five years of silence, I write a word, after a word, after a word. In hope. To try and help. Myself and maybe others. By committing, on paper, or out loud, or in pixels, as it were. To myself, to my sons, to my wife, to my parents and siblings and friends, to my patients, to my community, to the world:

I love you.

And from Edward R. Murrow: Good night, and good luck.

ACEs in the Era of Inequality and AGEs

link to full text article will open in a separate window:

ACEs in the Era of Inequality and AGEs

To reduce adverse childhood experiences and build healthy communities, we must address inequality in the context of adverse global experiences

Abstract

Adverse childhood experiences, or ACEs, affect a diversity of health outcomes from substance use to cardiovascular disease. We now understand some of the biologic pathways that translate this trauma into poor health, and exciting work to link this research with community improvement efforts forms the NEAR sciences: Neuroscience, Epigenetics, ACEs, and Resilience. A separate and substantial body of research has found wealth inequality to strongly and adversely affect a comparably wide range of health outcomes, including child well-being; it could be argued that inequality is upstream of ACEs. Finally, overwhelming evidence spanning the breadth of scientific inquiry shows how human activity threatens planetary health in what might be called “adverse global experiences,” or AGEs. We have a unique opportunity to make explicit the links between individual and global health. To improve the health of all we must address ACEs and AGEs and everything in between. Such a monumental task will only be achieved when we succeed in an even larger one—a sea change in our collective vision. Herein lies hope. That sea change may be so intrinsically appealing that its adoption may surprise us with its speed.

Introduction

“The health of the individual cannot be separated from the health of the family, the community and the world.” 
—the real Dr. Hunter Patch Adams

10 years into my medical career I took a 2-day training on the NEAR sciences: Neuroscience, Epigenetics, Adverse Childhood Experiences (ACEs), and Resilience. I’ve since shared this with audiences from physicians to teachers to parents struggling with their own ACEs. There is now tremendous hope around reducing ACEs and mitigating their effects through resilience research and interventions. Yet the data shows that childhood adversity is increasing.[1] Correspondingly, US mortality, already worse than in 35 other nations, has increased for 3 consecutive years, unprecedented in modern history.[2] Why is this happening?

The answer is complex. It carries us beyond the scope, as large a scope as it is...

keep reading: ACEs in the Era of Inequality and AGEs

(link will open in a separate window)

.  .  .  .  .

Posting #100

Okay so this is going to be my second blog in a month after not writing for over a year. As may have been obvious from the entry I just posted, I didn’t really know where I was going with it. That’s not unusual in and of itself. Often I’m not sure where an idea will take me. Mathematical concepts are an easy fallback and I found myself thinking about the idea of 6 degrees of separation, which is where the whole calculation about how much time it could potentially take to collect and share ideas from 7 billion people came from. Anyway you slice it, though, there wasn’t much said in that essay.

I just put the boys to bed after watching the 1953 version of Peter Pan with them. There was a fair amount of general sadness afterwards, nothing to do with Pan but rather with Mama not being present for bedtime. This was the first week back to school for both boys, so understandable there would be a little bit of angst.

Because of said angst, I delivered on my promise to tell an extra bedtime story after lights out. I asked if they wanted a giraffe story. Starting a couple of years ago I developed a whole Serengeti world replete with a four-member Giraffe family, Old Elephant and Baby Kale, Young Lion, Wise Baboon, Mama Hippo and Baby Amanzi (which means water in Zulu), and several others. I was tired and a giraffe story, like a blog about math, would have been an easy fallback. But Felix didn’t want a giraffe story. He wanted a story from when I was little boy.

Felix asked, wasn’t there a story about a mean teacher you had? I had to think about that and was drawing a blank, fortunately most of my grade school teachers were pretty kind, until he reminded me that I’d told them about a time when I was so afraid of our computer lab teacher in early grade school that I’d wet my pants rather than ask to use the bathroom. I can still remember that. I can still remember the surprise I felt at how much pee there was, still remember pretending to feel sick and going down to the principal’s office and asking for my mom and her coming to get me, and I can still remember my principle, Mr. Koopman, giving me the benefit of the doubt and commenting on how rainy and wet it was outside, that was obviously how I’d gotten so wet. Mr. Koopman was kind. That can make all the difference.

I didn’t, however, revisit that story, beyond acknowledging it. Instead I told them about third grade, when I really wanted to be an author, and the stories I used to write. I told them about my third grade teacher, Mrs. Johnson-Lamb, whose husband was a real life auctioneer. I figured it might make them laugh if I tried to imitate an auctioneer.

Then Felix asked, Dada why did you decide to become a doctor, instead of an author, if that was what you really wanted to be?

And I said that I became a doctor because I really wanted to help people, which is true, but that also some part of me still wants to be an author, and Sam asked which part, and I said my left knee and we laughed. And then I said that maybe I still will be an author someday, I’ll keep being a doctor but I’ll be an author too, because it’s possible to be more than one thing, like how you both want to be musician welders. Or welder musicians. I forget which and sometimes the order is very important, to my four- and six-year-old.

Maybe someday I will be an author. A doctor author, or an author doctor. Right now the order isn’t so important, to me as a forty-something-year-old. Can I be three things? A dad doctor author? Really, if I had to choose just one right now, that would be it. A dad.

September 2018

Next Tuesday will mark the 17th anniversary of 9/11.

In those 17 years the world has added more than a billion people. For Earth to reach its first one-billion-person mark (i.e., 1 billion people alive on the planet at one time) took, depending on when one defines humankind as a species, between 500,000 and 3 million years. In fact, it was only 10,000 years ago when Earth's total population was only 10 million. Twice this number now live in greater New York City.

If all 7.5 billion people alive today spoke aloud 100 words—as of this next dash, I’m writing 102—each taking 45 seconds to do so (it took me 46 seconds to read to that dash), then it would take one person 142 lifetimes of 75 years each to hear every spoken word.

If anger, such as that that led to 9/11, is grounded in fear, fear is grounded in misunderstanding, misunderstanding might be overcome through dialogue, and it is mathematically impossible for even one single person to hear just 100 words from every other person, we clearly have to find another route to peace. Fortunately there are attainable routes open to us. Let’s say every person alive met for an hour in groups of 10 people to come up with one best idea for peace and a representative to carry that idea forward, the following day the representatives met in groups of 10 to select the very best of the 10 ideas, and so on. Within 9 hours spread over 9 days, 100 “best of the best” ideas selected from the voices of all the world’s population could be identified.

Somewhere in between 9 hours and 142 lifetimes, then, might be the time required for humanity to better understand itself, stop fighting wars, and perhaps slow and reverse our growth rate to the point that we could live sustainably on our finite planet. If the last 17 years are any indication then we are on a timeline closer to the latter number. Let us hope—and, thankfully, there are indications of this—that our capacity for justice, compassion, and sustainability might accelerate in a matter akin to the acceleration of so many other trends. We are the ones we’ve been waiting for. The time is now.

The Realm of Monsters

Every time I turn on my computer
I dive down to Lalotai
the realm of monsters
every time I have to look up something
such as, was it the realm? the world? the domain of monsters?
every time I open thesaurus.com to find another word for realm,
I am confronted with a monster in a hairpiece attacking our planet
and a brilliant little beetle called the Natural Resources Defense Council
asking for pennies to fight him
every time I make it to another tab to type in Moana
I learn that Moana is not the name of a Disney movie Moana is our grandmother
the Pacific Ocean
and looking up THAT takes me to a blog on the cultural appropriateness
of a movie depicting Pacific Islanders
by one Amulya Chintaluri
who lives in Hyderabad
which is the fourth-largest monster in India
(India is not a Pacific Island)
Hyderabad, India, the fourth-largest monster on the Indian subcontinent
at only 6.7 million humans and counting
(you have to get to Guwahati, #47, to drop below a million
[just 10,000 years ago the human population of our entire planet
was 10 million])
every time I push the little round button with the open circle
and a line at the top
and listen to the ominously musical machine whirring to life
I know that death awaits at every turn
at every turn is distraction leading down a tunnel to blackness
to tentacles grabbing and spiky fish swimming past
cartoon heroines and vapidly overstuffed heroes
vying for my attention and not caring
not caring
whether I land on Motunui, paradise,
or am struck down by Te Ka, the lava monster
not caring
if my cursor alights on Lalotai or the crime against
Standing Rock
or the effrontery that is an indoor ski resort in 110-degree Dubai
not caring whether I drown in the beautiful waters of Cenote Il Kil
or choke on the 34-times-the-size-of-Manhattan amount of plastic
that we dump into the Ocean every single year
caring only
that the seconds
and the minutes
and the hours
tick away
on my computer screen.
That is how the monsters win.

Climate Change and Health

NOTE: At the time I drew these pictures a year ago, to accompany a Resolution presented to the Washington Academy of Family Physicians House of Delegates, the focus was on climate change and the family physician. The lessons apply to us all--and we are, or can be, healers, in the broadest sense.

Hopefully the pictures mostly speak for themselves. A few points of clarification and intent:

First, on the “less-busy” side: On a finite planet, any species must eventually reach equilibrium with its environment. In a traditional graph it’s difficult to appreciate that this holds true for humans. To capture our growth in the last 200 years from 1 billion to 7 billion, everything prior to 1800 looks pretty flat. Yet it’s anything but. As the log-log scale shows, we’ve had one series of exponential leaps after another, and every time the curve gets close to flattening, a new “advance” results in another order-of-magnitude population growth. The great hazard is that our last two (or more) leaps have likely been unsustainable. Oil provides both the energy, through mechanized harvesting, as well as literally the substance, through petro-fertilizers, of our food growing. And biotechnology, while it has delayed the crashes predicted by Paul Ehrlich’s 1968 “The Population Bomb”, has resulted in further dramatic growth while increasing our reliance on mono-crops, which could prove susceptible to massive failures of disease, drought, or heat. The larger question is, even if we could produce vastly more food, would this result in improved quality of life, or even less worldwide hunger? To date it hasn’t.

The bottom of the page shows atmospheric CO2 in the last several hundred thousand years. Though we don’t have one continuous, unbroken record dating back to Earth’s formation, we do have, from ice cores looking at different carbon and oxygen isotopes, excellent data. What this graph can’t show, because of scale, is a comparison to the last known major warming period post-dinosaur extinction (65M years ago). But we know a lot about this period, called the Paleocene-Eocene Thermal Maximum or PETM, which occurred 55M years ago. At that time, massive release of carbon dioxide led to a period of global warming. Geologists have often used the PETM as the best recent analogy to today’s warming and CO2 levels. It has been offered in the lay press as a reassuring comparison, because while certain ocean species suffered extinction rates of at least 50%, most land animals did well. However, as described in geologist Robert Hazen’s 2013 book “The Story of Earth”, recent ice-core evidence has shaken scientists by revealing that The PETM’s 5 degree Celsius warming occurred over a time period of 10,000 to 20,000 years, and the CO2 release was also slow. Today’s rise in CO2 levels is at least 10x as fast, and the projected temperature increase—currently we are on track for 5-6C by 2100, the non-binding Paris agreement doing nothing concrete to slow this—is thus occurring at a rate 100 to 200x as fast.

This brings us to the “busy” side and the heart of the matter starting with Wile E. Coyote in the upper left: we are stepping off a cliff. What that cliff represents is a huge number of positive feedback loops, processes we’re setting in motion that will likely continue even if all emissions stopped tomorrow. This in combination with our population growth makes our current history frighteningly akin, as journalist Elizabeth Kolbert argues in “The Sixth Extinction”, to the K-T boundary (dinosaurs) or one of Earth’s other 5 mass extinctions. I call your attention to three of those: in the far upper right, as the permafrost melts, it will release huge sinks of methane, which is 20 to 80 times more potent than CO2 at trapping heat. Near the bottom left, as the ocean acidifies, we’re facing the loss of the very phytoplankton that both absorb CO2 and provide half of our breathable oxygen. And back to the upper right: Severe weather, such as multi-year droughts that Syria and other places are already in the midst of, are causing or exacerbating civil unrest while simultaneously stripping the resultant climate refugees of land to which they might otherwise relocate.

Thus in the center of the page: We are, already, in a crisis of the health of the public. Here and abroad the entire public sector is being slashed and/or privatized even as the wealth of the very very richest increases. This phenomenon is well-described by Naomi Klein in “The Shock Doctrine” (one example being New Orleans during and since Hurricane Katrina), and in her latest book, “This Changes Everything” she makes the compelling case that climate change could push public infrastructure past its breaking point.

And finally, the lower right, the family doctor! Why the family doctor? Because no one is talking about this. Because we give voice to our most vulnerable patients and communities. Because we have an opportunity to build something better. It would be easy to say, “If the door to 2 degrees C closes next year, does it really matter what we do?” Yet we really do have a unique chance to both slow down emissions and, in the process, mitigate the effects of climate change by building a more just, equitable, and sustainable society.

For a moment, and it is likely a brief moment, there is more than enough wealth in the world to bring about enormous good. The challenge is that wealth is concentrated, as per the extreme lower right corner, in the hands of a very very few individuals. Over a decade ago a study found that the world’s 3 richest men controlled assets greater than the world poorest 48 countries. The statistics have only worsened since then. In America today top CEOs make more in a year than their employees could make in 350 years, or 7 generations each working 50 years. Nearly everyone in the world would benefit in the short- and long-term by investing some of this wealth in the strategies proven to increase world peace and stability, namely, improving the educational status, economic status, and reproductive rights of women and children. And even the super-rich would benefit from this approach in the long-term, because no ultimately no one wins, if we all lose a livable planet.

This, I believe, is what we must stand up for. If not us, who, if not now, when?