a ‘safely modern’ Pandora’s Box
P R E F A C E & C O N T E N T S
10 pages — 1 —
P R E F A C E
“You will write, if you will write,
without thinking of the result in terms of a result,
but think of the writing in terms of discovery,
which is to say that the creation must take place
between the pen and the paper,
not before in a thought or afterwards in a recasting.
Yes, before in a thought, but not in careful thinking.
It will come if it is there and if you will let it come.”
^
“Writing is the only thing that, when I do it,
I don’t feel I should be doing something else.”
Gertrude Stein (1874 – 1946)
PERSONAL ANGST
Before retiring in 2016, I was a Primary Physician and belonged to a small group, private practice along with one steady colleague and periodically one other physician. Our group opened our clinic in 1975 and closed it 41 years later. We moved to a new address that was 10 blocks west in 1992. Both locations had been less than 1/2 mile from the northwest edge of the city in 1975. By 2016, the unchanged location of our office was near the geographic center of Omaha.
Thirty years before closing, our practice added 20-30 newborns a month. During the last 5 years, we offered our Primary Healthcare to about 3 additional newborns a year. These changes represent a snapshot of our practice during its 41 years. In spite of the demographic changes, the total number of active patients had been stable from year to year, variably between 2,500 and 3,000. For the clinic, an active patient was someone who had been seen for at least one office encounter within the previous 18 months. The number of people who were seen once or twice, but never returned, was apparently equal to the number of people who were seen once every two to three years.
Personally, I became increasingly dismayed by the national governance deficiencies within our nation’s healthcare industry. But to a larger degree, I became particularly saddened by the concerns and frustrations of our patients as they experienced their healthcare. These concerns represent the aspirations of our patients who had individually invested in their HEALTH through our practice for extended periods of time. Many of these patients, maybe 2/3, were members of Extended Families known by our office for more than 30 years. Above all else, I dedicate any value of this extended collection of essays to these Families as a recognition of their contribution to the therapeutic community of our office.
It is my hope that each resident person within every community and their Primary Healthcare Physicians could experience the privilege of contributing to a similar therapeutic community. Eventually, healthcare reform should create the basis for a reconfigured and permanently dynamic, Complex Adaptive System. This reform process should assure that each resident person has a caring relationship with a Primary Physician who is associated with an enhanced Primary Healthcare clinic. Throughout every urban and suburban community, these clinics should be located within 1/2-1 mile of every resident person’s close neighborhood. By exploring the PAGES of NATIONALHEALTHUSA.NET , I invite you to consider my belief that this collection of essays describes a possible means to this end, community by community.
WHY NOW!
The initial impetus for this Blog occurred in November of 2007. I had then attended a ‘community lecture’ here in Omaha given by Henry Aaron, Ph.D., a health economist associated with the Brookings Institute in Washington, D.C. His projections for the future of health spending for our nation’s healthcare led me to one conclusion. The annual health spending trend by our nation’s healthcare industry could not be sustained within our nation’s economy. A year later, I began an avocational effort to learn more. Within the following year, I had written several short essays for myself about healthcare reform. One of them is listed as the FIVE HEALTH STORIES ‘SUB-PAGE’ which accompanies this ‘SUB-PAGE.’ — 3 —
Soon, my search for information and new ideas began to assume its own momentum. Eventually, I began to perceive that a solution, based on old ideas newly revisited, could unlock the paradigm paralysis afflicting our nation’s healthcare industry. This WordPress Blog first appeared in November of 2008. Since then, it has been regularly revised in fitful spurts. Over and over, my experience with this WordPress hosting site affirms the view of Gertrude Stein about writing. For me, she was and continues to be correct.
HISTORICAL ORIGINS FOR HEALTHCARE
The ubiquitous stethoscope, shown on the HEALTH PROSPECTUS Home Page, became 200-year-old technology in 2019. For perspective, blood pressure measurement using a sphygmomanometer, viz., blood pressure cuff, originated in 1881. The thermometer is somewhat older, estimated at about 1617. Considering the measurement of time, the century of about 1500 B.C. seems to be the consensus for its origin.
I aspire for a new test that would accurately assess a person’s resiliency in real-time to maintain stable homeostasis. It could be used at any time during a person’s life, beginning with perinatal survival. How about 2025 as a goal date? As a possible HINT, the test results should be available using the results of a Fourier transform analysis. Thus, some 3,000 years since the measurement of time began, we have encountered the pervasive cognitive dissonance associated with the evolving era of Quantum Mechanics and its various iterations. While technically, healthcare continues to evolve its scientific accomplishments, it is substantially overwhelmed by the worldwide shadow of degraded Human Dignity. Herein, I offer the following quotation from Baron C. P. Snow:
“I believe the world is increasingly in danger of becoming split
into groups which cannot communicate with each other,
which no longer think of each other as members
of the same species.”
Baron Charles P. Snow (1905 – 1980)
C P SNOW
Read by itself, this quotation from Baron C. P. Snow might be viewed as referring to the geopolitical divisions within our current worldwide community. This view would not, in fact, represent its original context. On May 7, 1959, Baron Snow gave an invited lecture at the Senate House located on the University of Cambridge campus in Cambridge, England. He described a view that a communication gap was progressively evolving between the knowledge realms of the humanities and the sciences.
Could it be that the communication gap between these two realms actually represents the essential root cause of root causes that plague our nation’s POPULATION HEALTH and its PRIMARY HEALTHCARE? Also, could it be that the communication gap between the two realms also contributes substantially to the level of uncertainty as our nation adapts to a rapidly evolving, new world order? To consider the dimensions of these communication gaps, the concept of cognitive dissonance applies. Professor Leon Festinger long ago described this concept in his book published in 1957. It remains the sentinel analysis about the arena of cognitive dissonance.
For our nation’s POPULATION HEALTH and its PRIMARY HEALTHCARE, the humanitarian mandate for each resident person’s Basic Healthcare Needs and the scientific mandate for their Complex Healthcare Needs are neither adequately served by our nation’s evolving traditions. Remembering the thoughts expressed by Baron Snow in 1959, could it be that a high level of cognitive dissonance between every person’s Basic Healthcare Needs and their Complex Healthcare drives both the current deficits involving our Population Health as well as its healthcare? Could it be that a cluster of rapidly conspiring, ‘social, political, & economic’ phenomena has occurred since WWII? And finally, could it be that a Design Epistemology for POPULATION HEALTH, a New Strategy, and 4 National Projects will be required to prevent, mitigate, and ameliorate maternal mortality, childhood poverty, and adolescent homicide/suicide? — 5 —
C O N T E N T S
The breadth and depth of complexity underlying the fundamental character of our nation’s Population Health and its Primary Healthcare as of 2023 may not be substantially perceivable. The complexity of the fundamental disruptive processes that disturb every person’s Stable HEALTH have not been fully characterized, especially their cosmological dimensions. For instance, the current ecological and cultural trends occurring within most communities have uniquely interacted over time to disengage the pervasive Family Traditions necessary to promote ‘Stable Health’ for each member of their Family. For instance, family mealtimes during early childhood have been recently identified as a strategy to prevent late childhood obesity. Since 2020, new reports increasingly verify the benefit of Family Mealtimes for preventing childhood obesity principally from within the Home Economics arena of knowledge.
Every community has an evolving and uniquely established, heritage of ecological and cultural traditions. Ultimately, any national commitment to improve our nation’s Population Health will require a nationally prompted, community-by-community New Strategy. The social adversities that afflict too many lives in every community are best prevented, mitigated, and ameliorated initially by an augmented safety net. As the safety net achieves success for its disaster prevention and mitigation, its associated collaborative sociality can be focused on ameliorating the social adversities that are the most difficult to ameliorate. The 9 “PAGES” and their associated “SUB-PAGES” describe a far-ranging Proposal to achieve the GOALs described by “PAGE 4”.
PAGE 1. HEALTH PROSPECTUS
As a Homepage for 5 ‘SUB-PAGES’, the second is the most important: DESIGN EPISTEMOLOGY. Briefly introduced, it presents a cluster of 30 inter-connected definitions that have been chosen to represent the broadest arena of knowledge that underlies Population Health and its Primary Healthcare. There is an intent to incorporate new, rapidly evolving conceptual systems, viz., quantum mechanics, human dignity (Moller 2020), and human morality (Tomasello 2016). Our most pressing national problem is likely to be the declining Family Traditions of each Family, viz., Page 27 of the DESIGN EPISTEMOLOGY, SUB-PAGE for a definition of a Family and its Family Traditions.
PAGE 2. VINTAGE TRADITIONS
As this overall concept for healthcare reform began to evolve, the need to preserve certain traditions of our nation’s healthcare was important to identify. These essays represent a cluster of essays to carefully identify certain known traditions as a reference for all of the other PAGES and their SUB-PAGES. It is likely that these essays will require revision over time. The MEDICAL SUB-PAGE might be the most universally important. A DESIGN EPISTEMOLOGY may be considered as a means to assure that these valuable traditions do not prevent the formation of new traditions that are required for the successful reconfiguration of our nation’s Population Health.
PAGE 3. EXECUTIVE SUMMARY
Beginning in 1969, a paradigm shift (Kuhn 1962) began to evolve after Medicare/Medicaid had become steadily available for funding the healthcare provided to our nation’s eligible, resident persons. Since 1965, the steady growth of our nation’s health spending has annually grown faster than our nation’s economic growth. Variously formed strategies have been enacted by Congress for its control. Simultaneously, our nation’s Primary Healthcare has become neither equitably available to nor ecologically or culturally accessible by every resident person for their Basic Healthcare Needs. As of 2019, there is no evidence that neither our nation’s Population Health nor its Primary Healthcare is improving. In addition, our annual health spending has increased from 5.0% of our nation’s GDP in 1960 to 18.0% of our GDP in 2019, viz., an increase of 360%, viz., an increase of 5% annually as adjusted for inflation and economic growth.
The most harmful attribute of our nation’s Population Health may be most notably viewed as represented by our nation’s maternal mortality. It has steadily worsened annually since 1978. Most succinctly described, there are 600-700 women who die annually that, at least conceptually, would still be alive if they had lived in another English-speaking Nation at the time of conception. This loss of nurturing “social capital” by each of their Families is permanently irreplaceable.
This SUB-PAGE describes a newly conceived strategy to identify the originating heritage that requires reconfiguration in order to improve our nation’s Population Health and its Primary Healthcare. The Design Epistemology is necessary to guide this reconfiguration to assure that those valid traditions and their heritage are not disturbed. In addition, any new institution to coordinate this national commitment must also be guided by the Design Principles for Successfully Managing a Common Pool Resource, the appropriate portion of our nation’s GDP (probably 13% or less). These Design principles were validated and tested, long ago, by Professor Elinor Ostrom (Ostrom 1991) for which she received a Nobel Prize in 2009. — 7 —
The EXECUTIVE SUMMARY Page has several diverse SUB-PAGES to further augment its somewhat extended text. New perspectives for the NATIONAL HEALTH Proposal are its two SUB-PAGES: DISRUPTIVE PROCESS and GLOBAL TASKS. A ‘Disruptive Process’ represents an alternate conceptual structure as a basis to potentially identify the ultimate disturbances that interact to promote a person’s unstable Health. ‘Global Tasks’ represents a strategy to adequately define the character of an institution’s Operation Statements for its Policies and Procedures. They assist with defining the initial implementation of NATIONAL HEALTH and its associated Strategic Plan.
PAGE 4. GOALs
Ten years after its initial Meeting, the Board of Trustees for NATIONAL HEALTH would have specific requirements for its continuing Congressional authorization, including a sunset clause within its instituting Charter. This PAGE defines these specifically and an initial SUB-PAGE describes further attributes possibly chosen by the Board of Trustees. The other 4 SUB-PAGES describe preparatory institutional and functional needs.
PAGE 5. NATIONAL HEALTH Proposal
This PAGE and its five SUB-PAGES propose the core Global Institutional Tasks for initiating the affairs of NATIONAL HEALTH. They are: ORGANIZE GOVERNANCE, PURSUE ‘VISION’, BUILD COMMUNITY, MANAGE RESOURCES, and DEVELOP SKILLS. Further explanatory SUB-PAGES associated with the GOALs PAGE apply: OPERATIONAL DESIGN, Initial GOVERNANCE, and Initial STRATEGIC PLAN.
Generally, the structure of the new institution emphasizes decentralized governance as a Complex Adaptive System. Its Home Office would be located near the population center of the continental States, viz., Saint Louis, Missouri. The second layer of governance would arise from Regional Offices located centrally within 9 Regions, each representing nearly equal numbers of census-identified citizens. The Board of Trustees and the Boards of Directors for the Regional Offices would collaborate to manage the overall affairs of NATIONAL HEALTH based on an Advice and Consent interaction. Each Regional Office would offer national recognition and technical advice to 90 Community Health Forums, each on average associated with @400,000 resident persons. Finally, each Regional Office would assume a specific arena of expertise to manage the day-to-day affairs of NATIONAL HEALTH while the Home Office located in Saint Louis would manage the national affairs by its Board of Trustees.
NOTE — The next two PAGES describe the core elements of the New Strategy to be promoted by NATIONAL HEALTH for Improving Our Nation’s POPULATION HEALTH and its PRIMARY HEALTHCARE.
PAGE 6. Community HEALTH Forum
Citing again, Eleanor Roosevelt long ago conceived the originating theme for the NATIONAL HEALTH Proposal: “It’s better for everybody when it gets better for everybody.” Assuming approximately 37 million resident persons within each of the nine Regions involving contiguous, state or groups of states, it is possible to identify 90 contiguous Community Health Forums within each Region for which each Forum would encompass, on average, 400,000 resident persons. The actual number of a Forum’s encompassed resident persons would range between 100,000 and 600,000 to account for population density and population growth.
The initial 810 national Forums would each assemble their locally relevant stakeholders 1) to assure the equitable availability of Primary Healthcare with a Community Health Plan and 2) to assure that their local Survival Commons, viz., augmented safety net, maintains a Master Disaster Planning Strategy and its associated prevention, mitigation, and amelioration of poverty. Each Forum would be eligible for national recognition and technical support from NATIONAL HEALTH based on the level of collaborative connections with their contiguous Forums. The shared selection of a Social Capital monitoring, data collection model would be most important.
Ultimately, the growth of City, Township, County, State, and Federal government jurisdictional collaboration will be important for the NATIONAL HEALTH Board of Trustees to promote. The Board of Trustees would also promote the FOUR NATIONAL PROJECTS that will be required to augment the progress occurring in association with the 810 Forums. The SUB-PAGES of this PAGE represent initial considerations for their community formation and sponsorship. — 9 —
PAGE 7. FOUR NATIONAL PROJECTS
As a Complex Adaptive System, the NATIONAL HEALTH Proposal would prompt the formation of 810 locally initiated, sponsored, and promoted Forums that sustain their resilience by establishing collaborative connections with their contiguously neighboring Forums. Eventually, the availability of Primary Care Providers (PCP), viz., physicians, physician assistants, and nurse practitioners will be necessary to achieve locally responsive health care for every resident person’s Basic Healthcare Needs.
Simultaneously, the FOUR NATIONAL PROJECTS will be necessary to establish a commitment to define 1) Primary Healthcare and its uniform national, certification standards, 2) its undergraduate and post-graduate education including its underlying pedagogy, 3) assuring its adequate capitalization, and 4) eventually its participation in a national financial risk-management process that is applied based on the collaborative approval by each Forum’s Primary Care Providers.
PAGE 8. APPENDIX
The APPENDIX PAGE has two SUB-PAGES both of which are virtually self-explanatory. The Bibliography SUB-PAGE includes the References for NATIONAL HEALTH and the GLOSSARY For Healthcare SUB-PAGE includes the Design Epistemology as well as another 42 terms and concepts. Its SUB-PAGE includes an explanatory differentiation of the two lists. They are then listed as one alphabetical arrangement.
PAGE 9. LAST WORD
Of the three attached SUB-PAGE, the Personal SURVIVAL Plan answers the question: “How can I eventually die with a young mind and a worn-out heart?” A goal first voiced this dilemma many years ago by an English sociologist. The Plan doesn’t assure that a random encounter with dangerous, disruptive processes doesn’t occur. It seems likely that in combination with a “mentored Personal SURVIVAL Plan,” each person should encounter a few birthdays that occur after the age of 90 years.