LITTLE ECONOMIC STORIES
In 1990 I visited Nairobi to work with pediatricians at Kenyatta National Medical Center. On the second day two Kenyan pediatricians took me to one of their “Under Five(years of age) Clinics” in one of Nairobi’s poorest neighborhoods. The streets we walked on the way to the clinic were teaming with people—mostly men, many of them idle. Of the few women seen, most were balancing large bundles of kindling on their heads. Many people were silently, unemotionally gazing at the passing traffic, which included smoke-belching lorries, colorful over-stuffed matatus (buses), and many Mercedes Benz-type sedans carrying white “ex-patriots” between their places of business and their gated homes on the outskirts of Nairobi.
The contrast between the lives of the “ex-patriots” and the lives of those on the streets was striking, a legacy of decades of colonialism. I was perplexed, however, by the passivity of the Kenyans gazing at the passing sedans. Why did they show no outward signs of resentment, anger, or defiance? Why were they so apparently accepting of their situation and that of the privileged “whites” in the sedans? Were they fully aware of the inequity, but choosing to exercise extraordinary self-control? Were they unaware? Was it too dangerous to object?
I turned to my pediatrician friends, both of whom were impressively capable Kenyan women, and asked them, “Why the apparent acceptance?”
“Because they assume that the white people somehow deserve their privileged status, and they (the Kenyans) somehow do not,” answered the first pediatrician, with the other nodding in agreement.
“But, surely, the two of you don’t feel that way.” I replied.
“Of course not,” they said. “But, we are educated; they are mis-educated.”
WE ARE PUBLIC!
Each February, Canton McKinley High School Natatorium hosts the annual Ohio State Boys and Girls High School Swimming Championships. All Ohio high schools participate in this two day event—-large schools, small schools, public schools, private schools—-all compete together. Teams, parents, and fans of 1150 public high schools and 208 Private high schools fill the natatorium to slightly beyond capacity, making the Fire Marshalls extremely nervous. The cheering is deafening during every event, especially during the relays.
There is always only one state champion boys team and one state champion girls team—-there are no Division 1, 2, 3, or 4 champions (based on school size), nor a Catholic/Private school champion and a Public School champion. Each year it is just one big competition, with one team for each gender being crowned State Champion.
Each year only a few schools have a legitimate shot at winning the high school state championship, and usually it is the same group of high schools that contend—several large public high schools that have developed strong swim programs, and several Catholic high schools that have developed even stronger programs that have enticed students to move to those Catholic schools, specifically because of the success of their swim programs. The boys’ team from St. John’s Catholic school in Toledo, for example, is a perennial contender and often wins the boys championship.
One year Toledo St. John’s had a particularly strong team and was dominating the competition, as it typically did during previous years. Likewise, St. Ursula’s girls’ team was well on their way to winning a third straight girls state championship. This success was a source of great pride among the private Catholic schools and their fans. That pride bordered on arrogance and a sense of superiority, privilege, and entitlement.
Towards the end of the second day of competition the entire St. John’s boys’ team, enjoying their comfortable lead, started loudly, proudly, and rather annoyingly chanting, “We are, St. John’s! We are, St. John’s! We are, St. John’s!”
Then, a fascinating thing happened. In one corner of the natatorium two swimmers from a tiny rural public high school team started softly chanting, “We are, Public. We are, Public. Their chant was nearly drowned out by the St. John’s chanting.
However, like a wave moving from the corner through the crowd, more and more swimmers from the public schools joined in the chant. Soon, all of the public school swimmers, their parents, and their fans were loudly and proudly chanting, “We are, Public.” The loudness of the chant was deafening, louder than during any of the most decisive relays. As the chant continued and increased in volume, the natatorium swelled with Public pride. It did not matter that none of the public schools was even close to winning a championship. Certainly, the two swimmers who started the chant had no shot at winning anything. But, every soul in the natatorium that day understood and deeply felt the joy, the pride, and the meaningfulness of being “Public.” Even the boys from St. John’s wished, at that moment, that they were part of the Public. They stopped their chant, and one of them, with tears of appreciation in his eyes, started wistfully chanting to himself, “They are, Public! They are Public!
It was a magical moment, started by two humble, creative swimmers from a small farm town in central Ohio. They, intuitively, knew what was important, what nourishes the human soul, and what warms the human heart. St. John’s and St. Ursula’s each won another state championship, but the Public enjoyed a lasting and inspiring moment of Selfless Freedom and Social Beauty.
In 1967 our Russian language class spent 6 weeks in the Soviet Union. The goal was to practice our Russian language skills and learn about the history and culture of Russia. We were hosted by the Komsomol, the young adult wing of the Communist Party in the Soviet Union. In each of the six cities we visited, the Komsomol had arranged for our group of 15 students to meet, over dinner, with about 15 Russian students. This was an excellent opportunity to practice Russian and get to know Russian students of our age.
At each dinner, conversation eventually turned to discussion of the War in Vietnam. (The War in Vietnam was at its height in 1967.) This discussion was always initiated by the Russian students. They seemed to be genuinely curious to know why the USA was waging this war against the North Vietnamese. They kindly and patiently asked us : “What does the USA not like about the social philosophy of Ho Chi Minh? What is your understanding of Ho Chi Minh’s social and economic philosophy? What is the social and economic philosophy of the USA, and do you personally agree with it?” I was surprised by their curiosity and questions, and I was struck by how embarrassingly unprepared I was to answer these questions. I had never before been involved in discussions of these questions. Worse, these questions had not really occurred to me—despite the fact that I would have been drafted into the US Army to fight in Vietnam, had I not had the undeserved privilege of a student deferment. I had no idea what Ho Chi Minh’s social philosophy was. I had not really thought about the social and economic philosophy of the USA and whether I agreed with it, or not. All I knew was that the USA was fighting (heroically, I presumed) against Communism (the scourge of Communism, I supposed), because Communism was bad and capitalism was good (or so I had been taught). Embarrassingly (and shamefully), I was unable to discuss capitalism or socialism in any depth whatsoever.
In contrast to my ignorance, the Russian students proceeded to explain, in considerable detail, not only the social and economic philosophy of Russia and the North Vietnamese, but also their understanding of the social and economic philosophy of the USA. They explained that Ho Chi Minh believed in developing a Public Economy and a Public Culture, as opposed to a private capitalist economy and a private individualistic culture. For example, Ho Chi Minh believed that health care is a human right and that all citizens should have full access to health care. They then went on to explain that the USA, as they understood it, believed in a private capitalist economy and a culture based on individualism and vast competitive private activity (as opposed to vast collaborative Public Activity). For example, in the USA health care is not considered to be a human right.
I was astonished to realize that the Russian students had developed a rather deep understanding (at least compared to my understanding) of both the Russian/North Vietnamese point of view and the USA point of view; whereas, I had virtually no understanding of the Russian/North Vietnamese point of view and only the most superficial understanding of my own country’s point of view. They understood both sides of the issue; I did not even understand the USA’s side of the issue, much less the opposite side. This realization was even more astonishing to me when I realized that I could very well have been sent to Vietnam to fight against Ho Chi Minh’s soldiers—without a clue as to what I was fighting for or against.
Now, granted, the Russian students may well have been purposefully and extensively rehearsed (“brainwashed,” the USA would say) to ask these questions and to give their answers to them. But, at least they had been exposed to the fact that there were two sides to the issue, and they had been exposed to the idea of thinking from the opposite point of view, as well as their own country’s point of view. I did not really have much of an idea of my own country’s point of view, and it had not really occurred to me to learn about the point of view of the other side. So, who, really, was more “brainwashed.”
Ironically, it was the Russian students (even if they had simply been brainwashed to say what they said) who taught me to think from the other point of view, as well as from my own point of view—to think backwards. They drove home to me how important it is to think critically and to understand alternative points of view. I have been “thinking backwards” ever since, and it has helped me to be a better physician and a better person. I have always felt grateful to those Russian students.
It was the first day of pediatric residency training for 20 new residents at Victor Hugo Children’s Hospital. One of those “first year” residents was a young man from a prominent family in a country in the Middle East. He had lived a life of luxury and privilege and had received the Education of Wealth.
This first year resident was assigned to a two month rotation in the neonatal intensive care unit (NICU). Also assigned to this rotation was a second year resident, whose job, in part, was to teach the first year resident. The second year resident was a teacher’s son from Tanzania. Except for both being Muslim, the two residents had little in common, regarding their upbringing. Overseeing both residents were three experienced neonatologists who were ultimately responsible for the care of the sick newborns.
The NICU rotation was the most difficult of all of the pediatric rotations. There were 30 sick newborns, almost all of them premature, some being 3 months premature and weighing less than two lbs, many on mechanical ventilation (respirators). They needed constant blood gas monitoring, frequent adjustment of the ventilator settings, complicated intravenous nutritional supplementation, and prompt evaluation for potential life-threatening infection.
The rule was that the two residents assigned to the NICU were to take in-house call every other night, which meant that one resident would stay the night in an on-call room adjacent to the NICU—grabbing some sleep when they could. In addition, both residents worked together during each day of the week. So, each resident was on duty for 36 straight hours, off for 12 hours, then back on duty for 36 hours, and so on. The three senior neonatologists provided back up call from their homes.
On the first day of his NICU rotation, the first year resident from the wealthy family in the Middle East was shocked and dismayed that he was expected to take call every other night. “I have two young children and a wife,” he said. “I cannot and will not take call every other night! This is insulting!” He refused to take his share of call. He also balked at taking call every third or fourth night.
This created a problem. A physician needed to be on call, in-house, every night. It was part of the resident’s learning experience, as well as his/her duty to provide this in-house call. Most importantly, the newborns depended on this 24 hour immediate coverage.
The second year resident from Tanzania overheard the first year resident telling the senior neonatologist that he refused to take call every other night. After that discussion ended, the second year resident went up to the perplexed senior neonatologist and said, “Don’t worry, I will take his call, as well as my own. I don’t mind.”
The second year resident was on call for the next 5 consecutive days, day and night. He found this total immersion to be quite interesting and much appreciated by the nurses and senior neonatologist. He enjoyed and benefitted from the experience. He learned a lot and was able to get sufficient and efficient sleep.
On the sixth day the first year resident started taking call every other night, for the rest of the two month rotation. It was unclear to the second year resident what discussions had, or had not, taken place.
Two months later, the second year resident was informed by the pediatric faculty that they wanted him to be the next Chief Resident.
As for the first year resident, he proceeded to carry out his duties and training in an increasingly
exemplary fashion, as his Education of Wealth was supplanted by the Education of Medicine—as his altruistic capacities were given increased expression and practice while his selfish capacities were down-regulated; as emulation, moral incentive, and selfless freedom replaced his learned individualism. One year later, as a second year resident, he was assigned to work with a new first year resident in the NICU. The new first year resident was the son of a right wing oligarch in Brazil. When told of the every other night call schedule, the new Brazilian resident refused to comply with such a schedule. It was beneath him to take such frequent and exhaustive call. After witnessing this refusal, the second year resident smiled and knowingly nodded to the senior neonatologist. The senior neonatologist smiled and nodded back. No words were exchanged. None were needed. The second resident, the one from the Middle East, took call for the next 5 days, after which the Brazilian resident started to fulfill his duties.
The transformation of the Middle Eastern resident had become complete. A new cycle of transformation was beginning. The Middle Eastern resident went on to become Chief Resident. Then he completed a fellowship in nephrology. He served children very well, including his own.
Such is the transformative power of moral awareness, selfless freedom, emulation, and the associated up-regulation of our altruistic capacities and down-regulation of our selfish capacities.
Note: Since the 1970s, when the above story took place, it has been recognized that residents (and the patients they serve) need to be protected from sleep deprivation. Accordingly, on-call schedules have been reduced to every 4th night, and on the following day the on-call resident has the day off.
NEONATAL TRANSORT FLIGHTS:
When I was a general pediatrician at the University of Kansas-Wichita School of Medicine, one of my best friends was a brilliant, dedicated neonatologist, named Sergio. He almost single-handedly ran the Neonatal Intensive Care Unit (NICU), which cared for sick newborns, many of them air-transported from all over the state of Kansas. During nights and week-ends, he needed help with the neonatal transport program, which typically made at least one plane or helicopter flight each night. Sergio, another pediatrician, and I shared night call for the program—one of us being on call every third night, for flights.
I was happy to do this, primarily to help my over-worked and appreciative friend, but also because it was gratifying to fly out to small town hospitals in rural Kansas to resuscitate tiny desperate newborns and bring them back to Sergio’s care. I viewed this work as part of my way of contributing, as an academic physician ad as a friend. Both Sergio and I were on a fixed annual salary ($32,000 at the time, 1978). Our income was not affected by how many nights we were on call, or how many flights we made, or by how many babies we assumed responsibility for.
I did this for two years. At 1:00 AM, for example, I would receive a pleasant appreciative call, asking if I could please be at the helicopter pad as soon as possible. I would jump out of bed, speed to the hospital, and board a helicopter, where I would join an enthusiastic nurse and respiratory therapist. The camaraderie amongst our team, and the gratification generated by the mission, plus Sergio’s appreciation, made these trips enjoyable and meaningful.
Toward the end of the second year, Sergio moved to the University of Arizona. A new neonatologist replaced him, and things changed. I continued to take call, but the middle of the night missions no longer started with a warm appreciative request for my presence. Instead, I received an abrupt, impersonal, matter-of-fact order to be at the plane in 15 minutes. When I got to the plane, I joined a nurse and a respiratory therapist who sluggishly went about their business without spirit or emotion. There was decidedly less exhilaration and camaraderie. My presence seemed fully taken for granted. The mission seemed to have no soul.
Initially, I did not understand what had changed. But, soon, I recognized that I was the only one on the flight who was there only for the sake of helping. The nurse and the respiratory therapist, who in the past (like Sergio and me) had contributed their services as part of their salaried responsibilities, were now being paid bonus money, by the hour. For them, the mission was primarily an opportunity to make extra money. There was nothing altruistic about their motives or behavior. It was just a job.
It had been the joint participation in an altruistic effort that had generated the exhilaration, spirit, camaraderie, and sensitivity that I had experienced on past missions. Without that altruism, the flights had become cold, impersonal, soul-less missions.
Shortly into the third year, for reasons that I did not fully understand at the time, I gradually stopped taking neonatal transport flights.
THE KIDNEY DOCTOR:
One morning in the hospital cafeteria a physician friend and I were discussing economics. I was suggesting that our hospital convert from practicing the Capitalistic Fee-For-Service Economic Model to practicing the Academic Physician Model (Economic Altruism). My physician friend, an academic pediatric nephrologist (kidney doctor), was very skeptical that the “Academic Physician Model” would ever work, because “it depended too much on altruism and underestimated the importance of the profit motive.” He did not think people would do their jobs well if there were no monetary incentives to motivate them.
Now, this pediatric nephrologist happened to be one of the hardest working members of our academic pediatric department. Until he was finally given a partner, he was on-call virtually every day, night, and week-end for ten consecutive years—during which time he repeatedly went into the hospital in the middle of the nights to dialyze children whose kidneys had acutely failed. He continually took on a huge clinical work load and did it pleasantly and superbly, always with a wonderful sense of humor. He also took time to teach younger physicians and to conduct research. Throughout this entire time he received a fixed annual salary, never receiving, or asking for, extra money for all of the extra work he did.
When I pointed out that during his 20 years of service at Children’s Hospital he had done far more than his share of work without any monetary incentive being involved, he thought for a moment and said, “Oh, I guess you are right.” He agreed that monetary incentive, the “profit motive,” had notbeen necessary for him. While defending the “necessity” for the Capitalistic Economic Model and denying the practicality and feasibility of the altruistic Academic Physician Economic Model, he was not realizing that he had been superbly practicing the latter model for the past 20 years and had not needed the capitalistic model for motivation.
When I asked him what had been motivating him over the past 20 years, he said, “I guess I just wanted to do a good job. I have always wanted to make sure that I was providing the best possible care for the children, and I always thought it was my duty to try to do so. It seemed like the right thing to do. The gratification of seeing children get better has always seemed to be sufficiently rewarding. Maybe it has been pride, in part.
Since he, and most (if not all) of the pediatricians in the department have not needed the “monetary incentive” and have superbly practiced the altruistic Academic Physician Economic Model (Economic Altruism), I then suggested that the Academic Physician Model could probably be successfully practiced by all workers, throughout the entire hospital, even throughout the general economy. He then became very skeptical again. “No,” he said, “that is unrealistic, because we are physicians and physicians are not representative. Most people do need monetary incentive.” I then softly pointed out the unconscious arrogance of his statement and the paucity of data to support it. Over the years had he not noticed the impressive altruism and dedication of the nurses, researchers, and so many other hospital employees, including the janitors who kindly interacted with patients—all of whom were on fixed annual salaries?
It is remarkable that many people who superbly practice the altruistic Academic Physician Model (teachers, nurses, researchers, government workers, policemen, firemen, rabbis, priests, ministers, to name just a few) fervently argue that the Capitalistic Economic Model, with its emphasis on monetary incentive, is the “only realistic economic model” and insist that Economic Altruism could not possibly work—apparently unaware that their own behavior represents strong evidence to the contrary.
FREEDOM TO CHOOSE:
In 1979 I flew into Cincinnati to interview for a fellowship position at Children’s Hospital. I stayed in a quite nice hotel downtown. Enroute to breakfast on the first morning, I stopped to buy a newspaper in the hotel lobby. An older black man was simultaneously tending the newsstand and a shoe shine chair. On display were two local newspapers—a stack of Cincinnati Posts and a stack of Cincinnati Enquirers. I looked at the two stacks for a few moments, then looked up at the man and asked, “Which is the better paper?” The man looked at me, and with an unchanging serious expression, said, “It depends…on whether you are a conservative…or a bigot.”
THE 9/11 TERRORIST ATTACK ON AMERICA:
A most enduring and impressive image associated with the 9/11/01 attack on the World Trade Center (WTC) is that of hundreds of firefighters and other “first responders” who risked their lives (more than 300 dying and many more becoming permanently damaged) in order to recue employees of the businesses head-quartered at the WTC. These first responders spontaneously and naturally displayed an enormous capacity for altruism. They felt a deep moral duty to help.
It was the first responders’ courageous self-sacrifice that so impressed our nation and filled it with pride. The first responders made us proud of the human capacity for goodness and unselfishness, and made most people proud to be Americans. People all across the country felt the need to show their respect, support, and thanks for the rescue workers’ heroic altruism. A natural way to express feelings of national pride and appreciation was to wave the American flag and sing our patriotic songs.
There is great irony here, however. The corporate businesses housed at the WTC have never had much faith in the human capacity for goodness. They, and American corporations in general, practice an economic model, capitalism, that is based on an incomplete, inaccurate, and excessively negative view of Human Nature. Their model insists that human beings are primarily motivated by self-interest and need the profit motive in order to perform well. Their model encourages (even requires) and rewards selfish behaviors. Proponents of this economic model have resisted any economic approach that emphasizes altruism and denies need for the profit motive.
So, the irony is that the remarkable altruism displayed by the salaried rescue workers, as they attempted to save business employees, reveals that human beings have a far greater capacity for altruism than those businesses and the American economic model would have us believe. And, a major reason for the outpouring of patriotism in the wake of the WTC tragedy is pride and faith in a behavior (altruism) that our current economic system says we cannot rely upon. We should be very proud of the American altruism demonstrated by the rescue workers. But, how proud should we be of an American economic (business) model that disrespects and marginalizes that very altruism.
If we want to show our appreciation and thanks to the first responders, if we want to give meaning to their deaths (and all of the tragic deaths associated with this heinous attack), perhaps we should dedicate ourselves to examining our current economic model and giving Economic Altruism a chance. No greater tribute could be made to the first responders’ heroic altruism than to replace capitalism with an economic model that is based on the very altruism that they so instinctively and instructively exhibited. Nothing would be more consistent with the teachings of Christianity, Judaism, and Islam than a transition from Capitalism to an economic model based on altruism. Nothing would be more pleasing to God/Allah. No greater pride would result. Nothing would contribute more to peace on Earth.
Incidentally, two important questions about the 9/11 atrocity remain unanswered: Who, honestly, orchestrated the event? And, cui bono?
THE GAS STATIONS:
When my daughter was 5 years old she asked an instructive economic question. We were driving through one of our town’s intersections. There were gas stations on two of the four corners of the intersection. Perplexed, she asked, “Why is there a gas station on that corner and another one right across the street?”
CULTURES TURNED UPSIDE DOWN:
For 2100 years (from the late Zhou and early Han dynasties until the 21st century) Chinese civilization held a traditional belief in the “four occupational groups.” The first and most highly respected group was the scholars (shi). The second group was the farmers (nong). Third were the artisans (gong). Fourth, and least respected, were the merchants (shang). Merchants were held in such low regard because farmers grew food, artisans made useful and/or beautiful things, but merchants merely sold (and made profits from) what others had toiled to produce. Merchant behavior was considered to be ignoble and rather parasitic.
Over the past couple of decades, the 2100 year old Chinese traditional view of occupation has been completely turned upside down. Now the merchant is king. Just look at Alibaba billionaire, Jack Ma, and all of the other obscenely wealthy merchants in today’s China. Currently, merchant behavior is being practiced at a higher level of intensity in China than almost anywhere in the world.
A similar story has unfolded in India. Throughput most of its history, India’s society has traditionally been divided into a four-caste hierarchy: Brahmin (priests, scholars), Kshatriya (warriors, landowners), bania (merchants), and shudra (laborers). Traditionally, merchant occupations have been held in low regard, at least officially. Over the past two decades, however, money-making has rapidly become more respectable, and the merchant class has been enthusiastically hoisted to the top, with Modi leading the way. A “baniaization of Indian society” has occurred.
Dividing societies into classes is an offensive idea in the first place, and ordering of such classes makes the idea even more obscene. This aside, it is worth noting that two ancient civilizations with long traditions of guarded enthusiasm (at best) for merchant behavior, have suddenly given such behavior so much support, respect, prestige, and power. Hierarchical division of society into classes is bad enough. To simply turn the hierarchy upside down, putting merchant behavior on top, seems even worse.
AN ENEMY OF THE PEOPLE:
One of the greatest “little economic stories” ever written is Henrik Ibsen’s play, “An Enemy of the People,” which was written 137 years ago (1882). It reveals the difference between the way capitalist Merchants think and the way Physicians think. The motivations behind each group’s thinking can also be compared. The play also warns us of the pitfalls to avoid when our recommendations are frustratingly ignored. A synopsis of the play appears below:
The play is about Dr. Stockmann, a physician in a small coastal town in Norway. The town is economically dependent on a lucrative hot-springs spa and a successful mining company. Dr. Stockman, who is the medical director of the spa, notices that several patrons of the spa have mysteriously fallen ill with gastrointestinal complaints. He determines that faulty sewerage disposal at the mining site is contaminating the aquifer and, hence, the spa. A prestigious laboratory in Oslo confirms his findings.
Dr. Stockmann writes an extensive report (manuscript) documenting his findings and explaining his detailed recommendations, which include temporary closure of the spa and expensive, but essential, improvements in the mine’s sewerage disposal system.
Dr. Stockmann proudly presents his manuscript to the mayor and the Town Council. Navely, he assumes they will be appreciative of his great discovery and wise remedy. He is surprised, however, by their hostile reaction to his report. Aware of the report’s conclusions, the town’s administrators read little or none of the actual report and simply dismissed the data and logic within it. They belittle Dr. Stockmann’s analysis and chastise him for making recommendations that threaten the economic interest of the town.
Dr. Stockmann’s repeated, and initially calm, efforts to explain the merits of his analysis are met with entrenched dismissiveness, denial, and derision. This increasingly frustrates Dr. Stockman. With calm perseverance he tries different ways to get his points across. But, his persistence results in his being fired as medical director of the spa.
The climax of the play occurs at a public meeting when Dr. Stockmann, overwhelmed by increasing feelings of exasperation and hopelessness (due to the intransigence of the town administrators and townspeople), suddenly shouts the unfortunate overstatement that “The minority is always right!”—an ill-advised statement that accurately reflected his mounting frustration, but was obviously not reflective of the cogency of his position. The town’s administration immediately pounces on this statement as proof that Dr. Stockmann is a disturbed, irrational man—“An Enemy of the People”—whose arguments need never be taken seriously. Broken and befuddled, Dr. Stockmann is left alone to cope with his predicament.
Ibsen’s intention is not just to warn us of the power of those with “vested economic interests” to impede the process of critical, objective analysis and problem-solving. He also warns of the naivete of many reformers, and their tendency to fall into the trap of becoming so exasperated (by the intransigence and close-mindedness of the powerful) that they utter careless statements and behave in unrepresentative ways that belie their true nature and do harm to themselves and their cause. Most commonly, Ibsen points out, this trap is unwittingly set by naïve, well-intentioned, but mis-educated proponents of the status quo. Occasionally, though, this trap is purposefully set to deviously discredit the opposition.
Like Dr. Stockmann, and in keeping with the tradition of medicine, social clinicians are motivated to determine the root cause of problems and are committed to using a disciplined, rigorous, problem-solving approach to do so. Like Dr. Stockmann, their analysis and recommendations are apt to be misunderstood and/or dismissed by more powerful people whose motivations, commitments, and ways of thinking are different, and who play by different rules. Like Dr. Stockmann, social clinicians are determined to persevere.
Warned and inspired by Ibsen, social clinicians should aspire to avoid the pit into which Dr. Stockmann fell.
WHAT TAKES US SO LONG?
When I was in high school, in the 60s, we had a boys’ swim team of some repute. There was no girls’ swim team, just as there was no girls’ basketball, tennis, or track team. In fact, the only sports-related opportunity for girls was to be a cheerleader, for the boys.
Recently, my twin sister and I were reminiscing about our boys’ high school swim team. We both love swimming, particularly my sister, who has been an avid swimmer since grade school and always enjoyed summer swim meets in her youth. As we talked, it amazed us that we had had a high school boys team, but no girls’ team. But, what bothered us the most was that almost nobody, back then, had thought to ask why there was no girls’ team. The unfairness and inappropriateness of having only a boys team apparently never occurred to most, not even to most girls and their parents. It surprised us that the absence of a girls’ team was so unquestioningly accepted.
That total unawareness, back then, is frightening and embarrassing to us now. It is similar (though not in scale) to the embarrassment and shame we now feel about the fact that America (including Thomas Jefferson) once assumed that slavery was perfectly acceptable; or that men (and even many women) once assumed (until 1920) that only men should be allowed to vote; or that many whites once assumed (until the 1960s) that blacks should not be allowed to use “whites only” rest rooms and restaurants; or, that (until the 1980s) it was okay for people to smoke anywhere they wished, including throughout hospitals, even in patient rooms. This makes one wonder what other unfair and inappropriate social decisions we have been unconsciously and unquestioningly accepting, practicing, and even cheering.
When will we become surprised and embarrassed by our current acceptance of the Capitalist Economic Model and our unawareness of the desperate need for a healthier and more just economic model (like the Academic Pediatrician Economic Model—i.e. the Public Economy Model, or Economic Altruism)? When will we ask, “Why did we accept, and even cheer for, the Capitalist Economic Model for so long? How could we have been so unaware? What took us so long?”
My old high school now has a girls’ swim team, one of great repute. How could we have been so unaware in the 60s? What were we thinking? More accurately, why weren’t we thinking more critically about what we were doing? More importantly, what was Thomas Jefferson thinking? What were men thinking? What were whites thinking? What else are we currently unaware of? What else will eventually surprise and embarrass us? What takes us so long?
DOES “COMPETITION” LOWER COSTS, OR RAISE THEM?
In one of the Great Plains states there was a fairly large city that had three hospitals. One was a young, dynamic Protestant hospital. The largest was an old Catholic hospital, run by an altruistic order of nuns. The third was a rather new, rather mediocre “family-oriented” general hospital, staffed primarily by family practitioners. (There was no Public Hospital.) These three hospitals competed aggressively and jealously for “market share,” by advertising and by continually remodeling their services to attract patients and physicians.
Aggressive tactics by one hospital were countered by even more aggressive strategies by the other two hospitals. The competition became so stiff that the large Catholic hospital’s top administrator, a kind-hearted and very competent older nun, had to be “let go” because she was too hesitant to make the moves that would “keep the hospital competitive in the new, ever-changing health care market-place.” She was replaced by a young man with an MBA, from Harvard, no less!
The obstetrics services were particularly big “revenue generators” at all three hospitals. Each hospital advertised “excellence in obstetrics and newborn care.” Although the city needed and could afford to superbly staff only one tertiary newborn intensive care unit, each hospital had its own “excellent” newborn ICU. Such duplication was necessitated by “market realities.”
One day, the Protestant hospital decided that it could win greater market share if it fancied up its obstetrics wards. It invested a large amount of money to renovate the rooms—making them much more plus and “homey.” This resulted in increased charges for labor and delivery, but the market researchers assured the administration that the “market would bear” the increased charges, and the investment would attract more pregnant women. The strategy worked.
The large Catholic hospital, threatened by the Protestant hospital’s maneuver, countered by not only remodeling their obstetric wing, but also by offering “free” candle-light wine and filet mignon dinner after the delivery, and by dressing up the delivery rooms to resemble “bed and breakfast” suites. This drove up hospital costs and obstetric charges, but the hospital’s new MBA assured the Board that the investment would attract more patients—and, it did, even from the protestant hospital.
The third hospital, which was rapidly losing its market share and increasingly gaining a reputation for mediocrity, boldly went one step further. It built a brand new “state of the art” obstetric wing with beautifully furnished “birthing suites” that made the other hospitals’ quarters look already out of date. Furthermore, the soon-to-be fathers were not only allowed to be present throughout the delivery, they could have a seat right next to the physician and could actually deliver the baby themselves under the physician’s guidance. And, all of this would be recorded by a digital camera and transmitted instantaneously to family members around the country by computer, “free of charge.” This, of course, drove up costs, which were, of course, passed on to the patients—but, it worked. Patients started coming back to the third hospital.
In the end, all three hospitals were able to maintain the same market share they had had prior to the “up-grading.” Each “remained competitive.” The advertising, remodeling, and re-building resulted in a tremendous rise in the cost of having a baby, but none of the hospitals thought it had a choice. Competition, the threat of losing market share, forced them to make these expensive changes. This is an example of how “competition” does not necessarily bring down costs. In fact, in our current “competitive” health care environment, competition typically increases costs.
Note: Some might ask, “Why didn’t ‘market forces’ ultimately regulate and subdue this expensive process?” For example, weren’t there patients who wanted a less expensive birth experience, and weren’t the involved insurance companies in a position to deny coverage for such lavish obstetric care? For one thing, effective advertising created an accepted “need” and “desire” for such lavish services. Secondly, health insurance companies were willing to cover such expensive services because they could re-coup the losses by increasing premiums. In fact, according to the business mentality of health insurance companies, the higher the costs, the more profit they can make—because of the “economy of scale.” Furthermore, the fact that the three hospitals, collectively, had a monopoly on care meant that the involved insurance companies had little choice but to tolerate the high charges—because, to deny coverage would risk having the patients (or the companies they work for) switch insurance carriers.
ECONOMIC AND PSYCHOLOGICAL WARFARE IN THE BUILDING OF HEALTH CARE EMPIRES:
The following is not a true story, but it illustrates a mentality and tactics that have truly been used by the US government to achieve its geo-political/economic goals:
In a large mid-western city, two major health care systems were vying for domination of market share. Both had developed ever-enlarging health care empires that had effectively driven all other would-be-competitors to the margins. Now, the slightly larger empire (Empire A) wanted to dominate, even eliminate, the slightly smaller empire (Empire B). A meeting of the Board of Directors of Empire A was called to discuss how to accomplish this goal.
The first Board member to speak was the current CEO of a prominent accounting firm in the city. He suggested a massive investment in advertising that would proclaim the excellence and superiority of Empire A. “We need to send a message that we are ‘number 1,’ in virtually all fields of Medicine,” he said. “If we repetitively bombard the public with this message, the public will increasingly believe it.”
The next Board member to speak was a retired pediatrician. “I don’t like the idea of simply declaring that we are ‘number 1.’ I think we need to earn that image by actually developing care that is unparalleled in excellence and kindness. The fact is, we are not currently better than Empire B in many respects. If the goal is to attract a greater share of the health care market, my suggestion is to create actual, proven, superior care—by investing in more physicians and researchers, recruiting the most knowledgeable and kind physicians available, and make sure that their clinical care is unrushed and superb. We should also make sure that we have excellent nurses, and that our nurses and other employees are not over-extended. If we do this, we will develop a truly earned reputation for excellence and kindness, and patients will prefer to come to our institution. I see no need for wasting money on excessive advertising. Word of mouth, from patients, might be sufficient—if, we truly become excellent.
A third Board member then spoke up. He was the current CEO of a military hardware company and had formerly worked for the US State Department. He took great pride in knowing “how the real world works.” During his stint at the State Department he had worked with the likes of Elliott Abrams and other CIA-types. “I think both of you are being naïve—especially you,” he said, turning to the pediatrician. The most effective way to achieve dominance over the opposition is to wage a campaign of destabilization, mis-information, demonization, and economic sabotage. Let me explain:
The first step is to plant seeds of doubt in the minds of the Public, regarding the quality of care provided by our competitor (Empire B). We can find disgruntled patients and post their stories in the newspaper and on TV. We can even fabricate stories of missed diagnoses and botched care. We can also fabricate stories of erroneous laboratory results. Or, we can actually infiltrate their labs with individuals whom we train and pay to deliberately falsify results, using untraceable techniques. Borrowing from techniques developed by US biological warfare operations in Africa, it is even possible to infect hospital wards with strains of infectious diseases that shut down those wards and make the Public hesitant to go near the hospital. Also, we can work with pharmaceutical suppliers to curtail shipment of critical drugs to Empire B, thereby creating artificial shortages. These shortages, as well as the other problems we create, can then be blamed on the incompetence and negligence of administrators at Empire B. We can also fabricate stories of corruption among the administrators. As you can see, there are a variety of ways to demonize and sabotage Empire B, making the Public wary of using its services.
I can assure you that such a campaign will work. Over the past 70 years the USA has successfully used campaigns of destabilization, mis-information, demonization, and economic sabotage on numerous occasions to achieve desired regime changes, with the American Public being totally unaware of what their government was doing. Not only is it possible to get away with these tactics, this approach is less expensive than the investment in excellence that you prefer, Mr. Pediatrician.”
The pediatric Board member and several other Board members were shocked by the above presentation. “I can’t believe you, or anyone, would consider such an approach,” said the pediatrician. “It is unconscionable to me that such an approach would cross anyone’s mind, much less be implemented. It would be absolutely criminal to do any of those things, especially deliberately exposing a hospital to dangerous infectious agents. These acts amount to crimes against Humanity, and those committing them must surely be held to account. I can’t imagine anyone getting away with such tactics.”
The third Board member countered: “Well, although it is difficult for you to imagine, these tactics, and worse, have, in fact, been used repeatedly by the US government to achieve its geo-political/economic goals—and, although it is difficult for you to imagine, the USA has repeatedly gotten away with these tactics. Furthermore, despite your government’s repeated use of these tactics, most Americans— including you, probably—still consider the USA to be the greatest country on earth—“the exceptional and indispensable nation,” according to Barack Obama. So, don’t be so shocked by my suggestions. Don’t be so naïve. Please recognize your own hypocrisy. Your government, including the government over which Obama presided, has used these tactics over and over again. Unless you are willing to hold your US government accountable, I would suggest that you get off your high horse.”
Fortunately, the former State Department official was over-ruled. But, so was the pediatrician. The Board settled for a massive advertising campaign. The former State Department official did, however, succeed in injecting some misleading and demonizing information into those ads.
THE DIRT SWEEPER:
In 1981 I worked with pediatricians at Beijing Children’s Hospital (BCH). Of all the children’s hospitals in which I have worked, BCH is my favorite. Containing 650 beds, BCH was one of China’s largest and very best children’s hospitals, at that time. The hospital campus took up an entire, large, square city block. The hospital, itself, was located in the middle of the campus and was surrounded by a courtyard and 3-story high apartments that lined all four sides of the square block. All of these apartments were contiguous, such that they completely sealed in and protected the Children’s Hospital and the courtyard. All of the hospital’s employees lived in these perimeter apartments—all of the physicians, nurses, lab technicians, janitors, etc. In the apartment-surrounded courtyard there was not only the hospital, but also a school for the employees’ children. This seemed like an excellent living-work arrangement to me. No one had to commute to work or to school. Physicians who were “on-call” could stay in their apartments, because they could quickly go to the hospital when urgently needed. It was a great arrangement for pediatric residents, too, because if they needed help, they could easily visit their mentors at their mentor’s apartment for face-to-face consultation. The Chief of Pediatrics, Dr.Zhu Fu Tang, lived on a first floor apartment. His was no different from any other apartment. I stayed in a guest apartment next to Dr. Zhu’s apartment.
Back then, everyone in China was still wearing Mao jackets and pants—some solid navy blue, others solid gray. The hospital, the apartments, and the courtyard grounds were modest. Nothing was fancy; everything was functional. The hallways in the hospital, for example, were bare cement. There was no grass on the courtyard—just manicured dirt. When I looked out my apartment window, I could see the hospital and the school. Parents and patients would be hurriedly moving about. And, a common sight was that of the dirt sweeper, a young man who, with his primitive straw broom, diligently manicured the courtyard dirt.
The dirt sweeper waved to me each morning, while he was sweeping in front of my apartment. We soon became friends—he practicing his English, while I struggled to learn some Mandarin. His name was Hu Yi Jing. I could tell that he was a bright guy. He seemed capable of doing much more than sweeping and manicuring dirt. He seemed to cope with the tedium of sweeping by artfully creating intricate designs with his broom.
One day I asked Yi Jing why he had been assigned this job. “Everybody who is capable of working must work,” he said. “Everyone receives a guaranteed annual salary, but it comes with the recipient’s obligation to work and the government’s obligation to provide the recipient with a job. No able-bodied person is allowed to receive a salary and not work. It is not easy, though, to find jobs for everyone. They try not to play favorites. I came from the countryside to Beijing only a few months ago. This was the only job available at the time.”
The purpose of my visit to BCH was to help develop a pediatric rheumatology program, ideally with a research component. It quickly became clear that the new program we were creating would benefit from having a full-time research assistant to collect, maintain, and analyze patient data. Based on my experience at children’s hospitals in the USA, I assumed that BCH probably could not afford to hire a full-time research assistant for the program. On many occasions I had tried to obtain such an assistant for my pediatric rheumatology program in the USA, only to have my request denied each time because there was “no way to pay for it.” My hospital did not want to fund a person who could not generate any revenue. My hospital’s administrators told me that the only way for me to get a research assistant would be to obtain a grant for such from an outside funding organization. My US hospital rigidly stuck to this policy, even though it was financially doing extremely well—thanks to the huge profits it was making from all of its revenue-generating activities. Since BCH was a quite poor hospital, in a quite poor country (in 1981), I did not think it would be able to afford a research assistant for our program.
The next day I met Dr. Zhu in the courtyard outside of our apartments. He asked how things were going, regarding the development of the pediatric rheumatology program. I reported our progress and mentioned that it would be ideal to have a research assistant. Dr. Zhu agreed that a research assistant would be very helpful. He looked at the dirt sweeper. Yi Jing had impressed Dr. Zhu in the same way that he (Yi Jing) had impressed me. Dr. Zhu called Yi Jing over and discussed the proposition of changing his job from dirt sweeper to pediatric rheumatology research assistant. Both agreed that the latter job would represent a much more productive way for him to earn his guaranteed annual salary.
Two days later Yi Jing became the research assistant for the new pediatric rheumatology program at BCH. What had been impossible to afford in my US hospital was easily arranged at BCH.
BETTER THAN WHAT?
When I was in Third Grade, I had a substitute teacher who gave a homework assignment that I have never forgotten. We were to find an advertisement that had the word “better” in it. For example: “For a better wash, use Tide (laundry detergent)!” Ford cars give you a better ride!” “All-State (insurance) provides your family with better protection.”
The next day she asked each of us to read our advertisement aloud. After each reading she calmly asked the same question, “Better than what?”
Her point was that the advertisers were able to give an impression (to the unwary or uncritical buyer) that their product was better than all other competitors, without actually stating so. By avoiding statement of what, exactly, their product was “better” than, they could not, technically, be held accountable for their claim.
She was teaching us, as third graders, how to think critically, carefully, and accurately. She was suggesting that, before we accept a claim that one product is “better,” we need to know what, exactly, it was compared to and what the actual data were.
This was my first exposure to critical economic analysis. It was also the last such exposure I can recall having during my K-12 school years. Apparently, economic philosophy and critical analysis of economic models and behaviors was not a curricular activity of high priority.