I need to begin this entry by noting that Julie and I have again skied the hill across the road.
Again, conditions were treacherous. I performed the season’s first full-on face plant. Julie skied beautifully all the way down, not falling, not even once.
She wanted you to know.
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Vaccine news: We have no idea when we’ll get vaccinated. The St. Luke’s My Chart appointment schedule was overwhelmed within a few seconds of 8:00 a.m. last Monday, when it was opened to those sixty-five and above. No times were available when I could finally log onto their system. I am now on the waiting list at the clinic in Stanley. I will remain on the list until vaccination.
Today I got an email from St. Luke’s, thanking me for my patience, noting that adjustments to the system were ongoing, and suggesting that I check with the “state, local health districts, pharmacies, or other health care providers about Covid-19 vaccination openings and to schedule an appointment.”
Then: “THANK YOU FOR YOUR UNDERSTANDING. We know this is a challenging time for everyone, and your health remains our priority. Our goal is to get the COVID-19 vaccine to as many people as possible as quickly as possible. Thank you for your patience [again] and your partnership [partnership?], in achieving that goal.”
I understand that we have, in Idaho, hundreds of thousands of people wanting vaccines. We don’t have the vaccine for them. We won’t for some months. I also understand that here in Sawtooth Valley, due to our low population and isolation, we’re far down the priority list. I understand we’re going to have to wait.
I don’t understand St. Luke’s calling me a partner. It’s a bit too much like Amazon calling its warehouse employees associates.
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In 1980, I was hired by a Ketchum, Idaho start-up company, Health Data International, to write a layman’s book on heart disease. My intended audience was composed of people who had survived myocardial infarctions and their families.
I was told to take the language of scientific studies and medical textbooks and turn it into writing that eighth-graders could understand. By that time, I had taught eighth-graders, and knew that they responded well to concrete, impossible to misinterpret language. I titled my manuscript So You’ve Gone and Had a Heart Attack, and got to work.
My manuscript was never published, because Health Data International went bankrupt before they could publish books and start distributing them. My words—concrete, impossible to misinterpret, hundreds of pages of them—rest in a law firm’s archives somewhere in New York state.
If I had to sum up the meaning of those pages, I would say, “Everybody gets old and dies. No exceptions. If you’ve had a heart attack, especially if you’ve had heart-muscle damage, your life will become much more limited but will still be worth living. If you have a second or third heart attack, there are worse ways to go.”
Health Data International went out of business because its target customers didn’t like its language. They preferred the anesthesia of near-incomprehensible medicalese to the blunt-force trauma of plainly put truth.
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Before my employer’s bankruptcy, I was sent to Atlanta, D.C., New York, and Boston to interview cardiologists who had written seminal papers on heart disease. For two weeks I navigated airports, hotels, and the maze-like corridors of research hospitals, talking to people who had taken time away from saving lives to answer my questions. The medical knowledge I acquired is mostly obsolete now, but I did take away lifelong common-sense lessons: stay in shape, stay away from cigarette smoke, moderate my alcohol intake, and don’t get too angry at anyone or anything.
One of my interviews was the dean of the medical school at SUNY Buffalo. He didn’t want to talk about heart disease, though. He had been a bellhop in the early 1950s at the Sun Valley Lodge and he told me that when he saw I was from Ketchum, he cleared his afternoon schedule. “Those two years were the best of my life,” he said. “If I could stand the lifting, I’d go back to it in a minute.”
We talked about Ketchum in the 1950s, about Ernest Hemingway and his suicide, about Sun Valley and the changes it had gone through in thirty years. He asked me how old I was and I told him I was thirty. I had been born in the Sun Valley Lodge—the hospital was on its third floor—about the same time he was carrying suitcases there. “I’ll bet you’re having a good time,” he said.
I reminded him of the purpose of my visit. He told me to put away my questions. “Let me tell you about this industry,” he said, and began describing a strike at a medical-equipment factory that had cut off the local teaching hospital’s supply of pacemakers.
“We haven’t installed a pacemaker in six weeks,” he told me. “We’ve got a huge bunch of patients—we’ve told them they’ll die without one—waiting. So far we haven’t lost anybody. We’re over-installing the electronics, in case you don’t know what that means.”
I said I couldn’t put that in my book.
“There’s a huge bunch of things you can’t put in your book.” He put his fingers on his breastbone. “I’ve had bypass surgery. You know what most people who have had bypass surgery say? ‘I’d rather die than have bypass surgery again.’ We know what we’re talking about.”
If I had been a more experienced interviewer, I would have steered the conversation back to state-of-the-art developments in cardiology. Instead, I listened as he said, “We’ve turned medicine into a soulless profit center in this country. We’re squeezing more and more from our patients, and from our doctors, for that matter.
“I see our graduates go on to internships and residencies, and they get through them all right,” he said. “They’re waiting for the salary, and the Porsche, the family, the vacations in Paris. What they get is eighty-hour weeks for the rest of their career, divorces, malpractice insurance. They lose patients they love. Their kids are strangers to them. They get bitter and angry, and it ends up hurting their patients. I think the system we’ve set up is causing more suffering than it cures.
“Look at Hemingway. His doctors could have saved that mind, that talent, if they’d sat him down after his last plane wreck and told him to quit drinking. Instead, they waited until he was in alcoholic dementia and then gave him shock treatment. It destroyed what little was left of him.”
I couldn’t put that in my book, either. But, as we say in the interview business, I was learning some shit. “You’ve thought this through,” I said.
“Enough to be behind this desk rather than in an operating theater,” he said. “Even here, I listen to a lot of cynical old people who were idealistic young people a couple of years ago. It’s enough to make me wish I’d stayed a bellhop.” He paused. “Not really. I’m proud of what I’ve done with my life. But I’ve got this fantasy that I’m carrying Hemingway’s bags to his room in the Lodge when I have a heart attack and die. He puts me in one of his stories. It’d be like Death in the Afternoon. But no kitchen knives tied to a chair. Just too much luggage.”
He grinned. The interview ended with me unable to tell where his memories ended and his relationship with death began. No wonder he had ended up in the dean’s office.
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Julie and I have an ongoing conversation about how the pandemic would have unfolded if the fatality rate was twenty or thirty percent, like hantavirus, and if it hit young people harder than us old folks. We have speculated that many of the people now demanding freedom from masks would start demanding prison for people who refused to wear them. The either/or nature of their thinking wouldn’t change, but with a couple of dead children in every other family, mobs would demand curfews and lockdowns instead of unlimited church and sporting event attendance.
The trouble with our conversation is that it isn’t hypothetical. The 1918 flu did hit young people harder than the old, and although the fatality rate stayed below three percent, a third of Americans got it. Slightly less than three-quarters of a million of them died.
The downriver town of Challis, never overly welcoming to outsiders in the best of times, put checkpoints on the highways leading into town and stopped travelers at gunpoint. Still, the flu got in. I don’t know if the infected were expelled to Stanley or Mackay, but I am sure that would have been the civic impulse.
The people of Challis had a point. Out in the wider world, cities that refused to lock down, or that opened too soon after lockdowns, paid for it in deaths. Cities that effectively ceased economic activity had fewer deaths and recovered their economies more quickly once the pandemic was over.
Millions of people who lived were disabled for months or years. The president of the United States got it, and it probably killed him by causing a severe stroke.
The flu went on for two years before disappearing in 1920. Since that time, flu pandemics worldwide have killed millions every decade. Very few people, over the years, have conflated freedom with the flu.
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Ever since my interview in Buffalo, I’ve been a student of industrial medicine. Nothing that I’ve learned contradicts what that former Sun Valley bellhop told me. If you combine the expensive and inhumane procedures performed to extend a life a week or a month, the malpractice industry, administrative bloat, the impoverishment and inequalities attendant to insurance, Medicare and Medicaid fraud, the deliberate addiction of millions, prescription cascades, diagnostic errors, abusive training practices—you can make the case that industrial medicine causes more suffering than it cures.
Should the tragedy Julie and I talk about come in 2022 or a few years later—and it will come, according to every epidemiologist I’ve read—St. Luke’s won’t be effective in fighting it. Industrial medicine is a system designed to fill hospital beds, not keep them empty. It’s too big to respond quickly to a pandemic threat, too dependent on other institutions to take responsibility for life-and-death decisions, and too complex to have as its single purpose the prevention of disease and suffering.
When a pandemic comes along, a finely-tuned financial mechanism that depends on a steady input of the sick stops working. Some of its profit centers get overwhelmed by oversupply, others cease to work because of shortages. Quick response to changing conditions becomes impossible, and first-line workers burn out, retire, or become sick themselves. Their lives become one long emergency. We call them heroes, but don’t demand that their employers treat them like heroes.
If all of this sounds unfair, remember that not long ago, doctors and nurses didn’t have the drugs, procedures, and infrastructure we have now. Their cure rate wasn’t that great, but they did have their share of unexpected recoveries.
Their level of systemic harm was far lower. Their level of empathy was far higher, and I suspect patient quality of life was higher, too. I’m not saying we should get rid of the medical advances of the last eighty years, but we could administer them in a much more humane and human way, one that treats patients as something other than units of added value.
At the risk of sounding like the demented fascist Margaret Thatcher, let me assert that there is no medical industry. There are only patients and their families and the people who take care of them. As long as corporate medicine exists as a mechanism for extracting money from the sick, those patients and families and caregivers will suffer.
Saying so goes against the tide of corporate evolution. But to paraphrase Joseph Tainter’s The Collapse of Complex Societies, any organization adds complexity in response to stress until it runs into diminishing returns. When the maintenance costs of complexity exceed the returns it delivers, the organization breaks down. Its choices are a return to simplicity or death. History suggests that death is more popular.
St. Luke’s and other vast medical organizations do not exist in a vacuum. They are responding to an era of offshoring, just-in-time supply chains, pharmaceutical industry malfeasance, employee abuse, treachery toward clients and customers, and the financialization of everything. The difference is that lots of people within the medical industry have sworn an oath to do no harm. If they let themselves think about it, they may find their consciences at odds with corporate culture. Over time, that’s a recipe for crazy.
I don’t have a recipe to avoid collapse, but I can say that if we have a choice, returning to simplicity is better than death. If the way medicine is practiced in this country were simpler, smaller-scale, more humane and flexible, and less fragile and subject to disruption, we’d all have a better chance of living when the next pandemic hits.