I Love It When a Plan Comes Together

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Imagine a half-dozen or so college students in hip boots, brandishing wide nets and paper punches, invading your quiet, secure home. Fortunately, fish don’t think much at all, so the fish in the woodland pond that my ecology class visited back in 1963 probably don’t recall our visit to their ancestors, but I still do.

We set out to calculate the number of fish in the pond. The method required catching and counting a sample of fish, hence the nets. Then we marked them with a small, neatly punched hole in the thin membrane of their tails and carefully released the known number of marked fish (= M1) with detailed instructions to go and mix-and-mingle with their companions for a week. (Indicator dilution, for you purists.)

One week later, back in the hip boots, we netted a new sample and counted those with (=M2) and without (=M0) tail punch marks. With this much information, we could calculate the number of fish in the pond:
If x = number of fish in pond
Then M1/X = M2/M0 and the rest is algebra.
This was my favorite experiment in all my academic experience. Imagine getting OUTSIDE in HIP BOOTS and doing something scientific. Like a stonefly emerging from the depths of the library, I turned into an environmentalist.

Stay with me for just a few more minutes. As an almost-ten-year-old growing up in northeast Ohio, I remember the November 1952 picture of the Cuyahoga River on fire that ended up in Time Magazine a month later – a truly arresting image showing flames leaping up from the water, completely engulfing a ship. Over the years, as a physician, I’ve followed the stories of various health problems that seem to have had roots in the environment; Dan Fagin’s Toms River is one of the best. A few years ago, I first read Steven Johnson’s marvelous book, The Ghost Map, the story of John Snow and the London cholera epidemic of 1854.

Then, just this morning, I had a real “Ah-ha!” moment. I read Margaret Talbot’s New Yorker article (The New Yorker, April 2, 2018), “Scott Pruitt’s Dirty Politics,” and my son David, an environmental economist, sent me a piece from the American Public Health Association on environmental health.
“Many communities lack access to nutritious, affordable food; are denied safe           places to walk and exercise; or live near polluting factories. The health risks for these families are greater. We support research and action to help ensure healthy environments for all.”–APHA Executive Director Georges Benjamin

All of these issues are related. It all comes together!

We are not separate from the environment. In populated areas, we ARE the environment, or at least, the environment is largely man-made.

Some individuals with political power do not seem to understand the connection between environmental health —clean air, clean water, open spaces— and human health. Those individuals will not be swayed by facts. In fact, they actively reject science as a basis for public policy.

For now, we can support the public organizations that do battle on behalf of the environment, particularly those that wage their battles in the courts. And soon, we can, we should, we must…VOTE.

PS: The photo this month is an outhouse in the Chinese section of Arrowtown, New Zealand. The Chinese, who came to New Zealand as gold miners, were keenly aware of the importance of sanitation.

Polarization, 1900

“How can I maintain a balanced, centrist, well-informed point of view in such a polarized society?” This was the major problem as the United States headed into the election of 1900. William McKinley was nominated by acclaim at the Republican convention. After a brass-knuckle back-room fight, McKinley had to accept Teddy Roosevelt as his running mate, largely as a concession to keep TR away from New York state electoral office. As in 1896, McKinley faced William Jennings Bryan, this time with Adlai Stevenson as Bryan’s vice-presidential hopeful. The front page of the Akron Daily Democrat of Friday July 6, 1900 covered the three polarizing issues. The democrats had pinned their hopes on the free-silver plank, and the “overthrow of imperialism and trusts.”

 

The free-silver issue rapidly lost steam as improvements in mining technology expanded production and filled the stores of the US Mint. In his first term, McKinley had put the United States firmly on the gold standard, and there it would stay. The trust issue also slipped to the back burner for the time being. McKinley, the prototype incrementalist, viewed trusts largely as a problem for the states.

 

Meanwhile, imperialism came to the fore. The United States, under McKinley, had acquired Puerto Rico, Guam, and the Philippines as the spoils of the Spanish American War and had added Hawaii as a territory by annexation. Not all Americans celebrated these island acquisitions. The “robust opposition movement included former presidents Harrison and Cleveland, …college presidents and academics, labor leaders, prominent clergymen, and famous writers….” There was no shortage of opposition to, and polarization about, American “imperialism.”

 

With the parties firmly at odds, the New York Times described Bryan’s democrats as “the army of the discontented.” Bryan proposed changes in “currency, banks bonds taxes, trusts, wages, and labor law.” He faced McKinley, “who spoke to the sober-minded, conservative, property-owning Americans.”   (Merry, p.445)

 

Into this fray rode Teddy Roosevelt, the former “Rough Rider” hero of the Spanish American War. “In eight weeks of campaigning, he traveled 21,209 miles in delivering 673 speeches to an estimated three million people in 24 states.” (Merry, p447) How important was TR to McKinley’s election victory? How much did his image as an outdoorsman and his popularity with the troops he had commanded help to swing a large segment of the populist vote to the Republicans? These are still issues for historians to debate.

 

The lessons 1900, however, are more straightforward. The 1900 electorate was highly polarized, between populist Democrats and middle-of-the-road incrementalist Republicans. Today, the labels are reversed but the divisions are not all that different. Who brought the country back together? A somewhat manic Harvard graduate that no one wanted on the ticket – no one, that is, except the voters.

 

High marks for Robert W. Merry’s book, President McKinley: Architect of the American Century.  Simon & Schuster, New York. 2017

How Often Do You Pull Out the Map?

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The photo above, taken on our recent visit to New Zealand, illustrates an irrevocable commitment. We did not explore this particular activity, bungee jumping, at any level deeper that photography!

This week, The Packet has arrived with two items, both well-seasoned, about leadership and learning.

Here’s some news from 1898. At the time, William McKinley was the President of the United States, the last president to have served in the Civil War.

On May 1, 1898, Commodore George Dewey led a United States Navy fleet to victory in the Battle of Manila Bay, in the Spanish-American War. In the words of Robert Merry, author of a recent, well-received biography of McKinley, Dewey’s victory “brought forth a kind of serendipitous imperialism.”

As a result of a very short conflict, the United States had gained control of Puerto Rico in the Caribbean, and Guam and the Philippines in the Pacific, and annexed Hawaii as well.

To continue Merry’s story, “The president, it was said, began his education on the Philippines by tearing a small map from a schoolbook, and when a government official arrived with more detailed charts he received them avidly while acknowledging his limited knowledge. ‘It is evident,’ he said, ‘that I must learn a great deal of geography in this war.’”

My point? McKinley had enlisted in the Union Army as a private; he attained the rank of brevet major. Before he was elected president, he had served in Congress, and as the governor of Ohio. Faced with the sudden, unexpected turn of events that transpired in the Pacific, what did he do? He immediately set out to educate himself.

That’s what leaders do; they look for information.

Fast forward to the New York Times Magazine of October 12, 2010. In a piece by Peter Baker titled “Education of a President, Baker says, “To better understand history, and his role in it, Obama invited a group of presidential scholars to dinner in May in the living quarters of the White House. Obama was curious about, among other things, the Tea Party movement. Were there precedents for this sort of backlash against the establishment? What sparked them and how did they shape American politics? The historians recalled the Know-Nothings in the 1850s, the Populists in the 1890s and Father Charles Coughlin in the 1930s. “He listened,” the historian H. W. Brands told me. “What he concluded, I don’t know.”

The two items span 112 years. There’s not much recently.

Come back soon for more photos of New Zealand.

“Medicalization”

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I have just carefully read through several editorials in the January 16, 2018 issue of JAMA, the Journal of the American Medical Association. This issue reflects a growing enthusiasm among medical editors for what’s generally called a “focus issue.”

Since I’m not an editor, I have only a vague idea of how this works. In my mind’s eye, I see the editor sitting at a very large, cluttered desk with accepted but unpublished manuscripts piled by subject. As a pile grows to a threshold size, say seven and three-quarters inches, the editor says, “Aha! A focus issue.” Then he or she gathers up the pile and says to the staff, “Print all these together in 6 or 8 weeks, and we’ll be done with them.”

Readers know that I have no intention of writing about the focus of the issue, which happened to be obesity. What I do want to reflect upon are the social changes that have moved obesity from a straightforward statement about body composition to a medical problem worthy of a focus issue of JAMA, arguably one of the most prestigious medical journals in the world.

When I was a kid, turning to a dictionary definition of the assigned subject provided an easy “out” for starting an essay. I hope I’ve become a bit more sophisticated; now, I’ll turn to Harvard Magazine instead. I quote from the issue of April 23, 2009: “There are perhaps few academic topics of equal interest to scholars of history, law, anthropology, neuroscience, and literature. But this was part of the point when scholars of these disciplines gathered on April 22 for a symposium on medicalization—a phenomenon, they argued, that has infiltrated nearly every facet of modern life.” Not exactly stirring prose, but I’m sure you see the point. Or do you?

Beginning roughly in the mid-1970s, when faced with really tough social-behavioral problems, particularly those that have serious health consequences like alcohol abuse, drug addiction, and obesity, Western society has declared them medical problems.

This process, “medicalization,” relieves broad swaths of professionals from dealing with insoluble problems. Physicians, however, seem to willingly accept the process. We seem to say, “Give us your obese, your addicted, your anxiety-ridden… Send these to my clinic, to my hospital, I lift my stethoscope beside the golden door.” Not only do we engage in this altruism, we campaign to make their diagnoses “official” and billable, and then try to find treatments.

Lest this sound a bit negative, the Harvard conference attendees catalogued the forces that help to drive the trend toward medicalization:

  • “the very existence of health insurance (costs are only reimbursable when associated with a definable medical condition
  • death certificates (the need to give a name to what caused a person’s death)
  • research funding (funding is more likely for problems defined as diseases)
  • drug trials and approval
  • and even a desire to wash one’s hands of blame for one’s condition (for instance, by considering obesity a disease that assails people rather than the result, at least in part, of one’s own actions and lifestyle).”

As I become more senior in the medical community, my awareness of the importance of communication, both among doctors and between doctors and patients, continues to grow. How long will the medical community continue to accept the process of medicalization before we say, “Look, we can help to manage the physical consequences of behavioral problems. If you are too heavy, we can replace your worn-out joints, get your cholesterol and blood sugar down, and help with your blood pressure. But we can’t modify your behavior; you have to decide to do that.”

Sending off the final draft

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This is Monday, January 08, 2018. About 3 PM on Friday the 6th, I sent my (new) publisher the final draft of a new book, a memoir-conversation with my long-time friend and double-sculls partner, Bernie Witholt. It’s like sending a youngster off to prep school. Someone else will look at her and correct a word here, or delete a comma there. She’s not ready to graduate yet. She needs proofing, formatting, and a pretty cover. But she’s largely out of my hands.

Over the weekend, I have thought a lot about her. I would like to introduce her. How about just three paragraphs in which Bernie describes his first symptoms?

I was one of some 150 people at a Zurich Stock Exchange Symposium on new high-tech startups emanating from the ETH and other Swiss universities. I came in late and, finding no seat, stood leaning against a steel railing. I did not feel good and I wondered why a few of my students, seated only a few meters away, did not jump up to offer me a seat.

About an hour after the meeting started, after the first two or three talks, I felt a strange rattling in my chest. This was new and quite unsettling. Was this a heart attack? What else might it be? I felt weak, eager to sit down, but there were no empty seats. The next speaker had just started. I looked around; no one else seemed to hear the rattling. I leaned harder into the railing. After ten or fifteen minutes the rattling subsided; the speaker finished his presentation, and I felt better.

With the rattle gone there seemed to be no reason to leave immediately, and so I stayed. The meeting ended a few hours later. I had no interest in chatting with other participants, but had some juice and left. This meant negotiating stairs from the auditorium level up to the higher street level. This was unpleasant. When I reached my car, I sat contemplating what had happened. Whatever it was, it did not seem trivial. I decided to go home this time, but to go to the emergency room of the University of Zurich hospital if it happened again.

Her name, unless the publisher decides to change it, is “240 Beats per Minute. Life with an Unruly Heart.”

Sending her off has left me with what people in my generation called “post-exam letdown.” As we advanced academically, end-of-semester exams became more and more important. At least, we thought they did. Performance on exams determined where we went to graduate school, medical school, or law school. And then, once in a graduate or professional school, better exam performance would mean a “better” post-doc, internship, or clerkship.

As a result, we studied intensely and after all the bubbles were filled with #2 lead pencil and the blue-books turned in, we crashed. Or, at least, we deflated. So it is with sending off the final draft. Even though now, it’s just a matter of hoping that people will like her.

I have neglected my blogging in the push to get her ready. Now that she’s out the door, I’ll take a deep breath and get back at it. Next week.

 

Cold nights are coming. Curl up with a good book

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The Amherst gymnasium, the site of JFK’s last speech.

 

Although Paul Dimond’s novel, The Belle of Two Arbors, appeared in April of this year, the epic story begins in the early twentieth century. Based on the temporal setting, the Weekly Packet can bring it to your attention without violating the underlying principle of reporting well-seasoned news.

I’ve just finished reading the 800-plus page story. I will admit that I am a “story” reader, not an “ear reader.” I skimmed lightly over many of the poems that Martha Buhr Grimes contributed to the novel in the guise of Belle, the central character.

Set primarily in what is now northwestern Michigan’s Sleeping Bear Dunes National Lakeshore, and in Ann Arbor, Dimond has constructed a rich story line with a dynamic female protagonist, a complex and powerful family, three world-famous poets – Frost, Roethke, and Auden – and the academic politics of two great American institutions, the University of Michigan and Amherst College.

The 200 to 250-page novel has become fashionable in recent fiction. Dimond’s 800-page story reminded me of Annie Proulx’s Barkskins. Both authors have created complex and fascinating families and followed them through generations. In both books, the author’s passionate commitment to the environment infuses the story, and each writer addresses the injustices done to native Americans.

The story of Belle and her family makes for the old-fashioned reading experience than I enjoy most: curling up in a big leather chair with a lap-blanket and escaping to another world for an hour or two in the evening as the story unfolds. Immerse yourself in it, and reap the rich rewards.

The author, Paul Dimond, is an Ann Arbor lawyer and writer, and an Amherst alumnus, Class of 1966. He, too, was in the audience in October, 1963 when President Kennedy spoke about poetry and power at the dedication of Amherst’s Robert Frost Library. Like many who heard that speech, Paul credits it with a long-lasting impact on his life and his career.

A fifty-four-year retrospective assessment of the impact of a single speech on a single day is fraught with hazard. The possibility of overweighting JFK’s words in the balance of long-ago decisions certainly exists. Nonetheless, I urge you to read The Belle of Two Arbors. As you enjoy the story, you’ll be amazed by the depth of Paul’s research and the clarity of his values. Surely with this sustained creative work, he has honored Kennedy’s proposition that, “art establishes the basic human truths which must serve as the touchstone of our judgement.”

One Fall Day

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Last week at this time, I was at the American Heart Association 2017 Scientific Sessions meeting in Anaheim, CA. I’m not going to risk a libel suit for telling you what I think about Anaheim.

I’m sure that anyone who has read my previous posts knows that events of only a week ago have not aged sufficiently to write about anyway. But being at the AHA brings back memories. I attended the 1977 AHA meeting that was held in Dallas, and I have never entirely gotten past it.

If you remember, President John F. Kennedy was assassinated in Dallas in November, 1963. The 1977 meeting was my first visit to Dallas, and the United States had just traded Gerald Ford for Jimmy Carter in the Oval Office. The loss of JFK was still fresh.

On a sunny but chilly day in early November, I walked the several blocks from my downtown hotel to the Texas School Book Depository building. At the time, the building was in a sort of renovation limbo, and it looked haunted. It was impossible to keep from looking at the sixth floor and wondering which window Lee Harvey Oswald shot from.

I’ve never felt good about Dallas, or the American Heart meeting since.

President Kennedy gave his last public address at Amherst on October 26th, 1963. I was lucky enough to be in audience. I have joined a group of classmates (some of whom are shown here) working on a documentary that looks at the content and impact of that speech, and offers some commentary on its relevance today. As part of the effort, our group met at Amherst College on October 28th   for a Saturday event called “Poetry and Politics, A Celebration of the Life and Legacy of JFK.”

The day was not unlike the October day in 1963 when the President spoke: a crisp, sunny fall day in New England, enough leaves on the ground to rustle as you walk, and enough still on the trees to stand out in color against the blue sky and high, thin clouds. After three outstanding presentations by current students and a panel discussion, the 150 or so of us who were “celebrating” gathered on the grassy quadrangle in front of the Frost Library, the building JFK had come to dedicate.

The keynote speaker looked familiar as he stepped vigorously up to the podium. Congressman Joseph P. Kennedy III is unquestionably one of “the” Kennedys. He looks more like his grandfather, Attorney General Robert F. Kennedy, than his great-uncle the President, but the resemblance is strong.

After the speech, I took a little private walk around the campus. I looked at the second floor of James dorm where I lived, at the Chapel where I had listened to Robert Frost say his poems, and the playing field at the foot of Memorial Hill where I had watched JFK’s helicopter land.

The young Congressman gave a good speech. Not perfect, but perfectly adequate. He’s just 37; there’s time, and there’s hope.

Yankee Ingenuity

In previous posts on The Weekly Packet, I have offered the idea that fifty years is a good amount of time to gain perspective on issues.  As often happens, a recent trip has changed my thinking somewhat. Travel, of course, is a good thing.  That sounds straight out of Martha Stewart, so let’s turn to Mark Twain, who said, ““Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one’s lifetime.”

So we (Katherine and I) took a short trip to get together with some of my Amherst fraternity brothers. The whole story of the Amherst fraternity experience (very benign in our era) will prompt another story.

Our travel took us to Old Saybrook, CT. where the 406 mile-long Connecticut River flows into Long Island Sound. Our host has a lovely old home on Ayers Point, and this is how we stumbled onto a bit of 246 year-old news to share with you. In Revolutionary War days, Ayers Point was the site for the fabrication of the Turtle, the first military submarine to attempt an attack on an enemy vessel. The standard information says only that Sgt. Ezra Lee, of the Continental Army was the operator of the one-man vessel, and that he unsuccessfully attempted to drill a hole in the hull of a British ship.

Actually, the story is considerably more interesting. David Bushnell, who had attended Yale, designed the Turtle and, enlisting a number of skilled craftsmen in the area, he solved a myriad of technical problems, not only constructing the boat, but also designing a timing mechanism to allow the boat to escape after attaching an explosive mine to the enemy vessel. But he needed someone with brawn to operate the boat. The operator had to move the boat forward and backward with a front propeller driven by a treadle and a hand crank and also supply the muscle required for a vertical propeller on the top of the boat that assisted with ascent.

Enter David’s brother, Ezra Bushnell. Younger and considerably stronger, Ezra must also have been either somewhat less bright or much more courageous. Perhaps he combined both attributes. Nonetheless, Ezra provided the crew and the power for the Turtle’s initial trials that took place just off Ayer’s Point. By all reports, Ezra became quite proficient at maneuvering the vessel.

The intrepid submariners loaded the Turtle onto a boat, and headed for New York Harbor, where the British fleet with its flagship, HMS Eagle, were anchored. Before they could mount an attack, Ezra Bushnell became seriously ill. This brought Sgt. Lee into the picture, as a volunteer to step into Ezra Bushnell’s spot. The Connecticut History website details Lee’s courageous but unsuccessful efforts against the Eagle.

The “news” from almost 250 years ago?

Invention, ingenuity, creativity, and craftsmanship combined to make the impossible happen; a submerged vessel with a single man aboard attacked the flagship of the British fleet.

The success of the venture depended on the skills of one man, who was laid low by illness, and a second, who made a gallant effort on short notice.

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Today, we may have more powerful technology, but we would be hard-pressed to match the mind and spirit of the Connecticut Yankees.

 

Note: see also Manston R.R., Frese F.J.,  Turtle: David Bushnell’s Revolutionary Vessel. Westholme Publishing

Goldilocks.

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The Coast Range, British Columbia

 

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The Bulkley River, British Columbia

 

This has been a busy summer! I spent a week in Brooklyn with my son as he underwent and initially recuperated from a total hip replacement. During my stay, I had the opportunity to read Goldilocks and the Three Bears not just once, but several times. Probably about 11 times.

My grandson, Walker, (think Walker Percy, the writer or Walker Evans, the photographer) obviously thinks highly of the story and so do I.

Actually, my interest in Goldilocks began some years ago when I was managing immunosuppressive medications. The trick with immunosuppression is, of course, not too little and not too much! Abstracted a bit more, the story tells us that in many of our activities, the relationship between a given parameter (temperature of soup) and a desired outcome (good taste of soup) is not linear. These relationships often take a U-shape or a J-shape, depending on how one draws the graph.

Walker lost interest when I tried to explain how to graph his story (increasing soup temperature on the X-axis, increasing tastes good on the Y-axis = upside down U.) You shouldn’t. This is how a lot of things work in life. Now we’re going to talk about one of them.

The August 22 issue of JACC (the Journal of the American College of Cardiology) has now completed preliminary seasoning. It has rested quietly in a stack of printed material on the breakfast counter, slowly making its way to the surface.

In it are some interesting data, along with a thoughtful editorial. (data, Xi et al, J Am Col Cardiol 2017; 70:913-922 and editorial Gaetano and Costanzo, pgs 923-925.)  The data are a re-confirmation of the J-shaped relationship between alcohol consumption (gm/day) and the relative risk of total mortality.

If one sets the baseline relative risk of dying at 1.0 for “never consumed alcohol” abstainers (this excludes problem drinkers who are abstaining for health reasons), the relative risk of dying from any cause actually decreases to about 0.85 for those who take a drink or two a day. Then it heads right on up, so that when you get to a half-dozen or more pops a day, your risk is well above 1.0.

What does this mean? However the Goldilocks story began, it means that the concept of getting something “just right,” whether it’s the dose of cyclosporine or the temperature of the soup, is something that humans have been working on for a long, long time. Probably almost as long as they have been fermenting stuff…

Note: 20170827-DSC02182.JPGThe two landscape photos are panoramas of multiple shots with my Nikon D7100, put together in Adobe Lightroom. Enjoy!