Rebecca Jones, MD Responds to NYTimes article on Hospital Rankings

I am a physician. Someone asked me recently why the medical system is for profit, since the conflict of interest is so obvious. I replied “because it can be.”

Here is the original article link: http://www.nytimes.com/2013/07/28/sunday-review/the-hype-over-hospital-rankings.html?emc=eta1&_r=0

Until there is pushback, this is the behavior we will see. The problem, of course, is that medicine is complicated, and “consumers” of medicine are desperate. You know what isn’t complicated? Health. (It may not be easy these days–but it isn’t complicated). Imagine if we had a real HEALTHCARE system, where the quality measure wasn’t how well a hospital treated your breast cancer, but how well the government regulated industry to keep endocrine disruptors out of the food and water supplies. Or, how affordable healthy food was, to allow people to control obesity (associated with breast cancer). Doctors and hospitals cannot do the regulating ourselves, but we could be a louder voice demanding such regulation. After all, our income is supposed to be based on the trust patients have in us. A good way to earn that trust is to act more like advocates.

View of the Gonda building at the Mayo Clinic in Rochester, MN. (Photo by Dede Cuumings for The VT Greenprint for Health.)

View of the Gonda building at the Mayo Clinic in Rochester, MN. (Photo by Dede Cummings for The VT Greenprint for Health.)

The Skinny on Public Transportation, Bicycling, Health and Human Rights—in Vermont, and Beyond

Why we need a great (convenient, affordable, clean, fast, dependable, beautiful, walk/bikeable) public transportation system in Vermont/New England/ the US of A:

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Human rights
We don’t often think of transportation as a human right, but I think we should.  Article 13 of the International Declaration of Human Rights states  “everyone has the right to freedom of movement.  The ability to travel at will allows people to hold jobs they like no matter where they live; it frees the elderly and the young from isolation; those who cannot earn a driver’s license to still earn a living.  We do not question the need for highways, we do not question the taxes we pay to keep them open.  Is it such a stretch to say we need a transportation system that works for you even if you can’t or don’t want to drive?  Is it such a stretch to say that our taxes are paying for a system that everyone can use, and a system that is not destroying our environment and our future?  Think of the investments we could make in ourselves and our communities if we could direct some of the $8000.00 + annual cost of owning and driving a car, toward something better.
CarandpricetagHealth
Driving is killing us.  I mean it, literally.  Car accidents, pollution, climate change (more later), obesity–even skin cancer (It is not true that car windows protect you from the sun: we see significantly more skin cancer on the left than the right side of the body.)  So lets talk about obesity.  Somehow this “disease”, which we know we can cure through diet and exercise, is knocking our medical system, and therefore our economy, to its knees.  Make healthy food affordable, but how do we get everyone to exercise?  Compare walking a half mile to a bus or train, with walking the half a step from front door to car.  22 minutes a day of exercise is all you need to stay healthy, and walking to and from a bus or train would satisfy most of that formost people.

begreenClimate change
To say that climate change both overshadows and engulfs the other issues is an understatement.  We are knowingly making our environment uninhabitable for ourselves, and in Vermont, it’s mostly coming from our cars. In Vermont, half of our greenhouse gas emissions come from cars.  Every time you get in your car you are contributing to climate change, but even climate change activists have virtually no choice but to drive everywhere.  Choice is the important word here—right now you “choose” to drive, because your alternatives really aren’t alternatives.  You could walk or bike to work, except that it’s too far, too dangerous, too hard.  Our communities are not designed around walking or biking: they are not designed around people—they are designed around cars.  Consider traveling from southern Vermont, where I work, to the capital, some 100+ miles away; it is a three-day roundtrip by train (if you were planning on being in Montpelier during business hours), because the train only runs once a day.  We are used to having freedom, and we sometimes think that means we have choices.  We have the freedom to travel wherever we want, but we don’t have the choice to do so in a way that supports human rights, supports our health, and supports our future.

We are at a point where we know we need to do something. Should we have started this decades ago?  Of course, but for better or worse we don’t work that way. The trouble is that the “something” that will finally really address climate change is going to require real change. We have been waiting for our elected officials to make the first move because we have forgotten that they obtained their positions through popularity contests, and people who win popularity contests are rarely the ones who lead change.  So we have to start talking collectively about what is to be done about climate change, and do it.
Rarely do such discussions end with a truly constructive solution, but that is what I am doing here.  I want to be able to walk to a train every day to get to work.  I want to feel good about how I am living my life and know I am not destroying my and my children’s future.  I want to cure my climate change anxiety syndrome, and the only way I can do that is to insist that we start making real changes.  What if that real change was something that also supports human rights and makes us healthier?  What if we took some of the enormous investments we make in our own cars, and in our healthcare system, and direct them toward making a fabulous, beautiful, enviable public transportation system?  Tree-lined streets, nice wide sidewalks, bikepaths everywhere… and all connected with busses and trains that are fast, affordable, dependable, reliable and clean!

To you naysayers I say 1.  First and foremost, it is imperative we move away from fossil fuels, so we have to figure out how.  2.  I am not inventing something new: even Vermont had a public transportation system 100 years ago.  You could take a train to hike the Appalachian Trail! We would pay several times over every year for a public transportation system with the savings from health care. Seriously.  Consider that in 2000 Vermont’s healthcare costs added up to $1 billion, and they are now at $5 billion despite an only 20% increase in population—and the cost is rising dramatically. There is no reason we can’t bring our healthcare costs down to that level again, and part of doing so requires we tackle obesity.  And from a pragmatic standpoint, technology can make the system even more efficient with electronic devices that let busses and people communicate with each other.
Cars are the number one killer of Vermonters and Americans between ages 5 – 35. Cars are the number one killer of active transportation. Inactive transportation is a key driver of obesity. Obesity is a top killer and the key driver of chronic disease. Cars are a key driver of climate pollution. And climate change is the largest global health threat of the 21st century.

A transformative public transportation system built around walking and biking, built around people, not cars, will be a key solution to the climate crisis, the oil crisis, the obesity crisis, the health care cost crisis, and will save a whole lot of lives that would have been lost in the invisible epidemic of motor vehicle fatalities.

Sure, Vermont’s a rural state, and that’s an extra challenge when it comes to public transportation. All the more reason for us to hurry up and get started.

 

Rebecca Jones MD is a practicing dermatologist in Brattleboro Vermont, the Vermont State Director for Doctors for America, and a climate change activist and member of 350Vermont.  She trained at Dartmouth Hitchcock Medical Center and UMASS Medical School.

 

Cross-posted, with permission, from PPS, the Project for Public Spaces

Placemaking as a New Environmentalism

By Ethan Kent, Vice President of PPS    (Originally posted at PPS.)

What kind of places do we want to create? What kind of communities do we want to live in? What kind of world do we hope to see in the future?

These questions are at the heart of environmentalism today, but are seldom posed. Environmentalism can perhaps best accomplish its goals for humans to impact less by leading the conversation on how we can impact more.

Crisis drives people to action but often does not lead us to address underlying challenges and opportunities. Through the years environmentalists have effectively drawn attention to many problems, galvanized action to remedy them and limited the overall damage. But today the movement can seize an opportunity to launch a discussion about the world we want and how we can empower people to make it happen.

Creating places where people thrive is the only way to create a world that will ultimately accomodate us.

Project for Public Spaces is rooted in the founding of the environmental movement and our work has been shaped by calls to action on issues like resource overconsumption, ecological breakdown and climate change. We continue to consider environmentalists as key allies and remain as concerned as ever about what’s happening to our natural ecosystems, but we also see that the core of humans’ dysfunctional relationship with the environment lies in our communities.

Ecological Transformation Starts Outside Your Door

Since 1975, PPS has been invited into thousands of communities in more than 40 countries around the world, where we continually find that communities’ ability to care about and address these larger crises are undermined by the failures of their immediate environments.

It is in fact these immediate environments that humans most directly interact with and experience, and it is this place level or community scale that Environmentalism has largely ignored. We can perhaps best ramp people onto a broader environmental agenda through engaging them in and challenging them to take responsibility for and shape these public realms beyond their homes. This is a process we call Placemaking, which is dedicated to encouraging and empowering people to take ownership over and contribute to the world beyond their private property and work together to improve them. Placemaking is the common sense process through which the human places we most value are created and sustained.

How we connect to and interact with the world outside our home lays the foundation for our Environmentalism.

Only by helping people connect to, care for and shape the world beyond their front doors will we be able to instill people with a capacity to redress the larger environmental crises. Incorporating Placemaking as an essential element of Environmentalism will lead to a reinvention of citizenship and the discovery of new tools and strategies to change the world.

Reinventing Environmentalism With Placemaking

Environmental action today tends to work in silos around seemingly abstract issues with incremental goals, perpetuating a very passive role for citizens.  For instance, the narrow goal of consuming less carbon is limiting the outcomes that Environmentalism and carbon can bring about. As the building block of life, carbon’s potential for creativity is perhaps its biggest reason for conserving it. It is when we use carbon for goals that do not create life that we are putting it to waste. Having less impact is noble, but aspiring to have a big impact, to create the world we want starting in the place where we live, work and play, is a transformative agenda that inaugurates the next phase of the environmental movement.

Place Capital entails the shared value of the public realm, including the natural and built environment.

Environmentalism is still largely focused on limiting pollution and changing consumption patterns, which are important goals but ultimately don’t go far enough in offering a compelling vision for fundamental change. Rather than concentrating our energies on narrowly consumerist and technological issues, we can co-create sweeping solutions by instilling public demand for far-reaching change and showing how we can collaboratively envision the world we want. Greener technology and products will advance at a quicker pace if there’s a broad movement to create better communities and a stronger planet.

How to Put the New Environmentalism into Practice

A new environmental agenda that draws on the strengths of Placemaking will continue to ask the familiar questions about any new project or action:

  • Is it sustainable?
  • Will it minimize harmful impacts on ecoystems?
  • Does it use the best ecological practices?
  • Does it celebrate “nature”?
  • Is it the best technology we can create?

But we will also be asking new questions:

  • Is it enhancing life, both natural and human?
  • Will it maximize the potential for creativity and broad social changes?
  • Does it reflect love and care for our surroundings (environmental, community, social, cultural, historical, and economic)?
  • Does it support the broader ecological and social systems of which we are a part?
  • Is it the best we can do to nurture nature, communities and people?

Let’s REALLY Do The Math Part 3: California + Math = Size Matters

In Part 1: Counting What Counts, I claimed that the entrenchedness that prevents us from starting from what we want, rather than from what (we think) we’re trapped in, is “fractal.” It is.

If you agree the US 2020 carbon target shows the need for a cumulative carbon budget that’s accountable to the amount of carbon dioxide we want in the atmosphere, you’ll savor the added twist of the California target we’re going to look at in this post.

The Do the Math campaign compares the global carbon budget with the fossil carbon pools (reserves of fossil fuels) already on the books around the world. The point of the comparison is that we have a lot more fossil carbon than we can burn, given our commitment to avoid dangerous interference with the climate system.

Let’s have a look at what happens when we don’t use a cumulative carbon budget and instead try to compare the size of a newly “added” fossil carbon pool to the size of estimated emissions reductions. It’s an interesting and clear example of the perils of the entrenched carbon emissions vantage point, that of “emissions reduction targets.”

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Let’s REALLY Do The Math Part 2: What is the US Carbon Budget and Why?

The Obama Administration has established “17% below 2005 levels by 2020” as the standard by which US carbon mitigation efforts are to be evaluated. Representatives Waxman and Markey and Senator Whitehouse wrote a letter to Barack Obama a couple of weeks ago, urging the president to:

Lay out specific steps federal agencies will take to ensure that the U.S. emissions of heat-trapping gases are reduced by at least 17% below 2005 levels by 2020, the goal you set for the nation during the 2009 United Nations Climate Conference.

Frankly, it’s a fairly random, not to mention unambitious, standard. Historical accounts of where this — and the Obama 2008 campaign’s similar target —  “came from” are available, but I’ve yet to see a logical explanation, a justification, an account of the reasoning behind this target. (If you have the reasoning, please share in the comments.)

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Let’s REALLY Do The Math Part 1: Counting what really counts

Once upon a time — a couple of years ago, more or less — Becky and I were talking about the Escher-esque illogic of “healthcare.” We talked about perverse incentives in healthcare, how the goal is not health, but management of ill health. We needed a large sheet of construction paper to map out these two “worlds,” one in which a sick patient lies on a gurney at the center, another in which a healthy, happy person turns cartwheels at the center.

Man vill bara hjula!

When we think about “cutting healthcare costs,” our starting point is more efficient coordination among hospitals, physicians, and insurance companies (and maybe patients..), reigning in pharmaceutical companies, eliminating unnecessary tests and procedures, and, maybe, programs according to which “care providers” talk about smoking, diet, and exercise with their “patients” (conversations for which care providers are not particularly well-trained and for which they have no tools).

Our thinking about healthcare starts from disease, not health. What if we planned healthcare as if we were planning for the health of the people we love?

We don’t count up from what really counts. Instead we kind of try to subtract away from the bad, the stuff we wish we didn’t have to count at all. There’s all kinds of disincentives here, all kinds of reasons for getting the math wrong.

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A New Year: The Need for Gun Control

It is now a few weeks after the Sandy Hook shooting. With 26 dead, we are scrambling to come up with a way to deal with, not only the grief that such a tragedy elicits, but widespread confusion about gun control in its aftermath.

Let us start with this piece of clarity: 20 children should not have been shot to death. There is no argument there.  So what is it then? Maybe it is our sense of decency that is keeping us confused.  No decent person is willing to easily “go there”—to that realm of possibility where an industry would be so greedy and corrupt, it would create a business model based on death and destruction.  It is hard to find words that don’t sound foul coming out of our mouths. For us to say the NRA and gun companies profit from and cultivate a culture of violence would imply such deviant thinking, such reprehensible acts that it is hard to admit to even thinking an official and respected organization would do such a thing.
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