What all of us can learn from T.E. Lawrence (Lawrence of Arabia)

All men dream: but not equally. Those who dream by night in the dusty recesses of their minds wake up in the day to find it was vanity, but the dreamers of the day are dangerous men, for they may act their dreams with open eyes, to make it possible.” T.E. Lawrence, Seven Pillars of Wisdom: A Triumph

Thomas Edward Lawrence, aka Lawrence of Arabia
Thomas Edward Lawrence, aka Lawrence of Arabia

I am finishing reading a fascinating biography on Thomas Edward (TE) Lawrence called Hero, by Michael Korda. It is a great study of how a 5’5’’ illegitimate son of an undistinguished, upper middle-class Englishman and Irish nanny became one of the most influential men in history.

Today Lawrence (1888-1935) remains one of the most celebrated and controversial figures of the 20th century. He was both a liberator of the Arabs against the crumbling Ottoman Empire and a sharp instrument in the militarism and diplomacy of the colonial powers—England and France—to carve up the Arab lands into pliable territories that became nation states. As time has shown, these countries had no religious and ethnic cohesion, and it now seems they may not stand the test of time.

For me, however, Lawrence was so many things. A certified hero and brilliant military tactician in guerilla war. A born leader of men. A charismatic fighter. A scholar and linguist. A consummate and tough-as-nails explorer. A great writer. A global celebrity, before there were celebrities, thanks mostly to a multimedia show after the war about his wartime exploits by the brilliant American publicist Lowell Thomas. An innovator in military strategy far ahead of his day.

Perhaps even as important as any other influence in his life, he was also a bastard—an illegitimate child at a time when such stigma had far greater stains than it does today. As a bastard myself (I was adopted), it is a link I have in common with Lawrence, as well as having visited places in the Middle East where he fought, including Aqaba, Wadi Rum, and the Sinai (all as a tourist in my case).

Winston Churchill, himself both a great World War II leader and controversial apologist for the colonial system he defended much of his life, called Lawrence “one of the greatest beings alive in this time.”

Aqaba a Feat of Imagination:

Of all his many exploits, Lawrence’s role in the Arab conquest of the port city of Aqaba, on the Red Sea, in July 1917, remains one of the singular most amazing feats of arms, logistics, and unrestrained imagination.Aqaba Is Over There

In 1917, when it appeared the Allies could lose the Great War, Lawrence and his band of Arab fighters travelled 600 miles on a weeks-long trek was through terrain so inhospitable that the Bedouin called it al-Houl (the Terror). The Arabs numbering 2,500 men entered Aqaba without a shot and lost just two men. Their opponents melted away. Lawrence then crossed the Sinai to Cairo to inform the new British commander-in-chief, Gen. Edmund Allenby, of this history-changing victory.

The event is the centerpiece of the 1962 epic film Lawrence of Arabia. For me, the scene that defines Lawrence and dreaming large is when he stays up all night and envisions how to change the tides of a war. In the morning, Lawrence convinces his ally, Sherif Ali, to join him with just 50 fighters, with the taunting line, “Aqaba is over there. It is only a matter of going.”

To this day, I keep a picture of that scene on my Facebook page as a reminder of acting boldly and dreaming impossible dreams.

What We Learn About Lawrence from Korda:T.E. Lawrence Posing

Korda’s depiction of Lawrence provides keen insight to the real man’s complicated life. As I read it with multiple lenses, I am impressed by many things that come through that have relevance to anyone today:

  • Lawrence followed a classic pattern of mastery: apprenticeship as an archaeologist with a master, multiple areas of intellectual interests, rigorous training and self-directed study, curiosity, open mind, willingness to take great risks.
  • Lawrence achieved military greatness by not being a soldier, but by being atypical and an anti-soldier, which was the right strategy for the right place at the right time. He did know how to shoot and use explosives too.
  • Throughout his life, Lawrence built and used powerful networks. This included the British intelligence-gathering for the Middle Eastern theatre, top cabinet officials in London, the Foreign Office, the Secretary of War, Arab tribal leaders, and military officers. Lawrence built his networks by leveraging the importance of what he could do for them and say to them. And vice versa.
  • Lawrence was supremely confident in his views, which were grounded in rigorous personal experience with first-hand encounters in the field, in dangerous situations, and with an expert understanding of multiple disciplines (cartography, language, military history, religion, and culture).
  • Lawrence never wasted time doing thing that were not of interest to his curiosity and imagination.
  • Lawrence was never afraid of pain and embraced it as a means of understanding limits he always tried to break. Great leaders have always been able to respond to and even master their pain and suffering and not be bent or broken by it.
  • Lawrence was a good judge of character, and understood who to align himself with in his career path–always choosing the right master, such as Gen. Allenby.
  • Lawrence always made his work stand out, and the quality of his work caught the eye of wise superiors, from his work analyzing the Arab revolt for his military peers in Egypt that was keenly followed to his Oxford thesis on Crusader architecture in the Middle East that opened doors to field work in the desert.
  • Lawrence relished the outdoors, adventure, drama, the myth of a hero’s quest, and creating links where others failed to see what he understood.
  • Lawrence fully understood the importance of symbols, such as the knife he bought in Arabia, the Arab dress he wore, and his physical place in a march among leaders of the revolt.
  • Lawrence mastered theater and stagecraft in his actions to influence opinions and motivate and inspire people in a guerilla war.
  • Lawrence inspired others by taking great personal sacrifices and showing he was willing to sacrifice himself for the good of the larger mission.
  • Lawrence never disowned his upper middle-class upbringing, and he used it to navigate his way out of some early young mistakes to positions of power afforded only to the privileged.
  • Lawrence realized that ideas with deep historic and religious roots are what motivate movements, not weapons and tactics alone.
  • Lawrence recognized the importance of storytelling and myth making, and he used all of his talents to control his story and brand.
  • Lawrence was a shape shifter, who could be different things to different people, but always himself.

Becoming Great on Your Own Terms:

T.E. Lawrence fully understood the value of appearances in working with other cultures.
T.E. Lawrence fully understood the value of appearances in working with other cultures.

I think one of the most telling periods of his life came after he graduated from Oxford and spent four years in the Syrian/Turkish desert at Carchemish on a dig, where he learned his craft (1911-‘14) under the auspices of Sir Leonard Woolley. (That relationship would be revived when Woolley became part of the Arab Bureau in Egypt that Lawrence was assigned to.) Lawrence used his time well on this project. This experience meant organizing projects, motivating workers, settling cultural disputes, finding friends in all ethnic groups, studying the larger political world around him, and seeing the chances this knowledge could bring.

Every one of these skills he employed later in his more active setting at war. Lawrence took what appeared to be useless skills and made them his strongest attributes that no other person in the British army had. He had made himself indispensable by following his own path.

For anyone looking for a bit of a reboot in their life, in terms of making more of a mark with their job, their relations, their purpose and meaning, I say, give Korda’s book a look on a long trip or holiday. You may find some lessons to be learned from someone who truly dreamed his life in daylight, and then died young.

So, You Want to Know More About the Motor City?

(Ed. Note: Dozens of links are provided below, after the introduction.)

Miichigan Central Station
Miichigan Central Station

Detroit’s unwanted celebrity status nationally and internationally continues to fascinate me. Detroit is now known as a failed American urban experiment. For the more cynical or the painful realists, it represents the dark end to America’s middle-class dream, and the embodiment of the decline of American power and even its civilization.

Detroit rose like a phoenix at the beginning of the 20th century and then experienced the near death of the American automobile industry at the start of the next one, culminating in the taxpayer-funded bailouts of General Motors and Chrysler during the Great Recession. Once the nation’s fourth largest city, the population has fallen from 1.8 million to less than 800,000 in 50 painful years.

Since the violent Detroit riots of 1967 that killed 43 and burned more than 1,000 buildings, the community has transformed into a nearly all-African-American city. Sadly, it now ranks as the country’s murder and arson capital. Multiple factors, well beyond Detroit’s control, spurred these changes. These include white flight and suburbanization, along with national racial politics and globalization.

From a public health perspective, there are not many major cities doing worse. Entire neighborhoods have been vacated. Burnt out shells of homes and businesses dot the urban landscape that now is turning to seed. Nearly half of the city’s children live in poverty. Once glorious buildings that were testament to the confidence in industrial capitalism, notably the ghostly Michigan Central Station, stand vacant as monuments to a past glory. They are our America’s modern-day Roman Colosseum, symbol of a dying or dead empire.

Detroit is also my home town, where some of my family have long roots as Michiganders. It is the place where my life story began, at the intersection of two stories of my adoptive and biological families, who all eventually fled or simply moved away.

To help others understand Detroit Motor City and why it matters, now more than ever, I have compiled some of my favorite links to resources, films, books, and online content that I have uncovered recently. Take a moment to learn more about this famous place that once was the world’s greatest industrial city.

Detroit, Enduring Icon of Decline and “Ruin Porn” CelebrityAndrew Moore Book Cover

  • Detroit Disassembled, photo book by photographer Andrew Moore (highly recommend)
  • The Ruins of Detroit, photo book by Yves Marchand and Romain Meffre (highly recommend)
  • James Griffioen, Detroit photographer of decay (recommend)
  • Five Factories and Ruins (web site)
  • Lost Detroit: Stories Behind the Motor City’s Majestic Ruins, by Dan Austin and Sean Doerr, provides historic and architectural background
  • American Ruins and The New American Ghetto, by Camilo José Vergara, depict dereliction and abandonment in cities like Detroit, Camden, N.J., and Chicago
  • Julia Reyes Taubman, socialite ruin photographer of Detroit and subject of some blowback for photographing decay while protected by a wall of money
  • Detroit 138 Square Miles, website that accompanies photographer Julia Reyes Taubman’s photo book
  • Beautiful Terrible Ruins, art historian Dora Apel examines ways Detroit has become the paradigmatic city of ruins, via images, disaster films and more and notes that the images fail to show actual drivers in the downward spiral, such as globalization, neoliberalism, and urban disinvestment
  • Diehard Detroit, a time lapse video of many of Detroit’s famed architectural ruins, abandoned factories and homes, monuments, buildings, and freeways, with absolutely no perspective on the meaning behind the mayheim, just titilating entertainment with great technique and a cool drone toy (it is stunning visually, and thus classic “ruin porn”)
  • Detroit’s Stunning Architectural Ruins, and Why Documenting Its Faded Glory Matters (an article by the Huffington Post, a liberal blog which exploits unpaid “contributors” more than Henry Ford ever did his factory workers)
  • Urban Ghost Media, photos of the much-photographed and now infamous Eastown Theater

Detroit and Media Coverage

Must-See Detroit Documentary Film: Burn

The great documentary about arson in Detroit and the men who fight it.
The great documentary about arson in Detroit and the men who fight it.
  • Burn, a documentary film by Tom Putman and Brenna Sanchez, tells a year-long story of the year in the life of Detroit firefighters, who battle uncontrolled arson against all odds (amazing filmmaking!!! … from the firefighters interviewed: “That is how you burn a city down. One at a time.”)
  • Interview with filmmakers Putnam and Sanchez on their documentary Burn (great read on scrappy filmmaking with a purpose)
  • The Making of Burn—so, you want to make a great film no one in power gives a crap about, but you have to do it anyway

Must-Read Books on Contemporary Detroit

Detroit, The Former Glory

Pro-Detroit Media Coverage and the “Re-Birth” Branding

Detroit, Industrial IconDiego Rivera Mural, at the DIA

Nice Photo Essays of Before and Now:

Detroit Stories and Research of Interest

Detroit is dying and does this country give a damn?

Broken down Detroit Homes (Photos by Rudy Owens)
The River Rouge neighbhorhood is lined with broken and burned homes, like these.

As a native of Detroit, I present this first of several essays, with a profound sense of sadness. (See my photo blog for my first photo essay.)

Here's the proof if you need it--Michgian verifies I am a Native Detroiter.
Here’s the proof if you need it–Michigan verifies I am a native Detroiter.

It is hard to accept that my birthplace, this once great global city, has become a symbol for American industrial decay and capitalism’s larger ills. At one point, Detroit boasted nearly 2 million residents in the 1950s. Today is barely counts 700,000 residents. [Updated census figures, 5/5/2015.]

In its heyday of bustling industrial production, Detroit served as a global icon for American ingenuity, industrial might, and economic power. During World War II, when the larger metro area produced the country’s war weaponry to defeat the Axis powers, Detroiters proudly called their city the Arsenal of Democracy. In the 1920s and 1930, about 40 percent of all automobiles were manufactured in the Motor City and the Ford River Rouge plant was the world’s largest.

Today, Detroit is known more as the murder capital of the United States, and the arson capital. All told, 90,000 fires were reported in 2008, double New York’s number—for a city 11 times larger—according to Mark Binelli, author of Detroit City is the Place to Be. It is the epitome of racial politics. Binelli notes, 90,000 buildings are abandoned, and huge swaths of the 140-square mile urban area are now returning to nature. Beavers, coyotes, deer, packs of wild dogs, and foxes are now reported in the city.

Photo Courtesy of Detroit Dog Rescue: up to 50,000 wild dogs roam Detroit.
Photo Courtesy of Detroit Dog Rescue: up to 50,000 wild dogs roam Detroit.

I just visited Detroit, and the trip had a more profound impact on me than I was prepared for. How is it that our country could undertake two overseas wars to conquer and rebuild nations—Iraq and Afghanistan—and yet abandon a city that helped to make the country the global power it once was.

National partisan politics have played a role, with Detroit becoming a symbol of the Democratic Party’s failure, as a black city and union city, in the eyes of white and conservative detractors. Then there are NAFTA (pushed by Bill Clinton) and industry fleeing the country for cheaper manufacturing from global suppliers and gross mismanagement of the Big 3 automobile companies, two of whom were bailed out by U.S. taxpayers in 2009.

White flight eventually followed long-simmering racial tensions. There have been Detroit race riots in 1863, 1943, 1967, and 1987. Those riots were stoked by historic racism, redlining, job discrimination, and the building of freeways that helped to destroy America’s inner cities. Today, some criminal fringe actors among Detroit’s mostly black residents are burning what’s left of their own city, for at times just the hell of it.

Burned home Detroit Photo
A burned and destroyed home is a common site. This one is near Livernois and I-75.

Charlie LeDuff, author of Detroit, An American Autopsy, painted a heart-breaking tale of the city’s self-destructive conflagrations through the tales of firemen trying to combat the arsonists. “In this town, arson is off the hook,” said a firefighter to LeDuff. “Thousands of them a year bro. In Detroit, it’s so fucking poor that a fire is cheaper than a movie. A can of gas is three-fifty, and a movie is eight bucks, and there aren’t any movie theaters left in Detroit so fuck it.” (I will do a photo essay of fire-ravaged homes shortly.)

That latest malaise, on top of repeated political scandals and corruption by the city’s bureaucrats and criminal politicians, was a crushing bankruptcy filing in the face of an $18 billion debt. In December 2014, after a year an a half in limbo, a grand bargain was struck with creditors, the city, the state, and private industry that prevented the city from selling its city-owned artwork (Rembrandts, Van Goghs, and more) in the world famous Detroit Institute of Arts.

Diego Rivera Mural DIA
The Diego Rivera Mural at the Detroit Institute of Arts highlights the brutal and still glory days that once were Detroit, the Motor City.

As I wandered the glittering white palace that is the DIA, I wondered, what’s more important, this art or the blocks and blocks of emptied neighborhoods that most of this country has forgotten.

Tweet After Returning to Portland From Detroit
Coming back to Portland was hard. I posted a comment on Twitter as soon as I arrived back home how bizarre it was to be back in the whitest city in North America, Portland, after spending time in the city that America defines as African-American.

Ripping off the system, one patient at a time

This week, I attempted to do what consumers world over try to do: figure out the cost of a transaction to make an informed decision before I acted. Everyone from market shoppers in Malawi to mega-billionaires choosing to invest their capital does this. They all are promoting their self-interest and also trying to save or even make money.

I wanted to know what a doctor’s visit would cost and how much truly might be or might not be covered. If needed, I wanted to know if I had to find a better bargain, if the first option would not be an affordable activity with my plan. It might have been easier to walk across the Sahara barefoot, without water.

What I tried to do is impossible for American consumers trying to figure out the price of just about every medical procedure, doctor’s or dentist’s visit, and hospital activity.

Photo courtesy of Harvard, showing people protesting for health care access. But most of us want health pricing information too, and are prevented from getting that by providers and insurance companies.
Photo courtesy of Harvard, showing people protesting for health care access. But most of us want health pricing information too, and are prevented from getting that by providers and insurance companies.

Today, except the for very rich who do not need insurance, there is no such thing as a functioning U.S. health care market, where consumers can freely choose to pick their providers and choose lower-cost options. Insurance companies and providers do everything possible to hide prices and bully and even threaten insured consumers who are trying to make choices that occur in rational and functioning markets.

The Commonwealth Fund notes, “… the U.S. health care market is unlike any other market: patients rarely know what they’ll pay for services until they’ve received them; health care providers bill different payers different prices for the same services; and privately insured patients pay more to subsidize the shortfalls left by uninsured patients. What’s more, prices for health services vary significantly among providers, even for common procedures such as laboratory tests or mammograms, although there’s no consistent evidence showing that higher prices are linked to higher quality.”

The Commonwealth Fund argues that even some modest reforms in pricing transparency, with our broken system, could lead consumers to “receive high-quality services from lower-cost providers … This, in turn, could encourage competition among providers based on the value of care—not just on reputation and market share.”

So what does this have to do with me and my experience? Everything, actually.

Gauging consumers one by one: the thousand cuts approach:

For years, I have consistently tried to get dentists and doctors to give me a price quote before a visit. To date, I have never had any medical provider provide me prices or codes without fighting tooth and nail, and often it is with caveats that claim they are exempt from any responsibility if their pricing information is wrong, even with the diagnosis code for a routine checkup.

Here is how the health provider and health insurance fraud and rip-offs work, patient by patient, and this is how it recently happened with me.

Step one: Call the provider and have them evade sharing information.

  • “We can’t provide you a diagnosis code until you see the physician.” To which I reply, “I am trying to understand if the charge will be covered by my insurance company.” They answer, “We can’t do that because the doctor may do [fill the BS line that you prefer].”

Step two: Call the insurance company and have them not tell you if a possible charge by a provider is within their “usual and customary charges”—a term that is behind a wall of secrecy and never shared with consumers, ever.

  • “Hello, I’m trying to determine if my visit to my physician is covered and if the charges are within your accepted ranges.” They reply, “Sir, we can’t do that. We’d need to know the diagnosis codes and procedure codes before we can possibly investigate that.”
  • To which I reply, “Sir/mam, I don’t have that. Doctors’ offices never tell you that. I don’t have the codes.” Or, if I was able to get a code for a check up, “Here is the diagnosis code [fill in code], what is your accepted charge.”
  • The reply could be, “Sir, I told you we would need the diagnosis code to investigate…” Me interrupting, “Sir/mam, I just told you they won’t give me that code, and no doctor…” Them interrupting, “Sir, you are becoming agitated, stop interrupting me. I was saying we need the diagnosis….” Me interrupting, “I am not becoming agitated. I am behaving perfectly rationally. I just want to know what this will cost and how it will be covered.”
  • They reply, “Sir, I have already told you, without a diagnosis code and procedure code, we are not able to provide you…” Me interrupting again, “Sir/mom, did you just hear me when I said the office will not provide me with a diagnosis code.”

Usually such a song and dance can go on for about five or 10 minutes. In the end, the insurance reps will likely have bullied the consumer and employed their standard and tested propaganda that justifies preventing nearly all consumers from knowing if any medical procedure will truly be covered and at what level. The same works for hospitals, clinics, and other practices, who will not share their prices.

In short, they have created a system that perpetuates waste, fraud, and abuse, one patient at a time, systemwide—and it is a system that remains protected by powerful special and political interests who profit from this.

Who the hell created this mess and what it means:

We can thank our political process that encourages special interests to buy influence and bankroll candidates with campaign donations for a good chunk of this mess. We can also thank the so-called health insurance companies from protecting their market share that makes the United States the most inefficient and most expensive health care system among all developed nations.

The Commonwealth Fund in 2014 reported the U.S. trailed other developing nations in health care outcomes and costs.
The Commonwealth Fund in 2014 reported the U.S. trailed other developing nations in health care outcomes and costs.

The Commonwealth Fund also has found that the U.S. system underperforms and has worse outcomes than 10 other industrial nations, mirroring past findings. No surprises there—this fact has been reported by health and public health researchers now for years. The U.S. economy devotes an absurd 17.7 percent of GPD to health care spending, almost double that of its peers.

How the United States compares to its peers in health care spending by GPD. Source: Commonwealth Fund.
How the United States compares to its peers in health care spending by GPD. Source: Commonwealth Fund.

The Center for American Progress has described the consolidation of power by the bloated middlemen of our dysfunctional health care system as a crisis, due to consolidation and market control. The center reports the “lack of competition has led to growing insurer profits, increased costs and reduced coverage for enrollees, an epidemic of deceptive and fraudulent conduct, and rapidly escalating costs.”

Theodore Roosevelt in 1912 led one of the earliest efforts to support a national health plan in the United States, and received support from progressives at the National Progressive convention that year.
Theodore Roosevelt in 1912 led one of the earliest efforts to support a national health plan in the United States, and received support from progressives at the National Progressive convention that year.

From the early 1900s to the present, major efforts to reform the U.S. health care system to create a national health system have failed. Some of the principal profiteers that have safeguarded the status quo are the monolithic health insurance companies, like Premera Blue Cross, my provider.

Other bloated health benefits providers include Aetna, Wellpoint, UnitedHealth Group, Cigna MetLife, and Humana. All of these companies are major political players who donate generously to members of Congress and state officials.

The health insurance model is a system vigorously defended by the GOP-controlled Congress, whose members theoretically support open markets, when in fact GOP members have attempted to derail the Affordable Care Act more than 50 times as of January 2015. And that reform was ultimately about reforming the existing health insurance market, not changing the system to promote openness in pricing or improving population health that is linked to universal health care systems.

The ACA only offered modest efforts to promote transparency. The law requires hospitals to publish and annually update a list of standard charges for their services. Other provisions about requiring exchanges to show prices are at best failed and complicated efforts that do nothing to break the wall of secrecy that has fed the beast that is our health insurance market.

The most pathetic part of this is, when I as a consumer try to do something, I am labeled a problem and seen as the bad guy. But I am OK with that, because doing the right thing always will meet with resistance. I have never kissed a doctor’s feet or behind, or those of companies that profit through monopolistic practices. I do not intend to start now. It just rubs me that today when I see the doctor, and tell him to make his pricing transparent, he will roll his eyes and give that “whatever look.”

My note to the Oregonian about its amazingly bogus reporting on “immunization debates”

The resurgence and outbreak of the most contagious virus on the planet, measles, has led to a swarm of media stories that have tried to report responsibly about the pockets of perpetrators of bogus science.

Even in the face of rock-solid research, done at the population level, proving without question that there is no link between autism and autism spectrum disorder and the measles, mumps, and rubella vaccine, the naysayers continue to promote ideas that have the same validity as racial eugenics of scientific quacks and Nazi racists. There are many parties who are helping to fan the flames of ignorance that threaten innocent children who have no ability to tell parent deniers that they put infants at serious health risks when they do not have their kids immunized from extremely infectious and very preventable illnesses.

This photo, courtesy of the BBC, shows a vaccine vial for the commonly used vaccine used to prevent the spread of very contagious viral illnesses.
This photo, courtesy of the BBC, shows a vaccine vial for the commonly used vaccine used to prevent the spread of very contagious viral illnesses.

Former Playmate Jenny McCarthy and clusters of deniers on both sides of the political spectrum are partially responsible for the resurgence of measles we are seeing around the country today.

What is particularly irresponsible is when formerly balanced media outlets choose to fan the debate flames to promote their products when there is no scientific or medical basis for claiming the issue is “a debate” as opposed to a public health crisis that requires layers of interventions to ensure the best health outcomes for all of us.

Tonight, I read the Oregonian newspaper’s story seeking to solicit input from science deniers with this astounding headline: “In the debate over vaccines, where do you stand?” At the bottom of the story were numerous blog comments that were not moderated. No surprise the journalistic adventure gave Portland’s now world-famous anti-fluoride, vaccination-denier, and anti-public-health community another platform to spout nonsense. Such sloppy journalism keeps bogus science alive and well, even when quackery like eugenics is now considered bad and un-modern. (In the end, quack science is still quack science.)

The Oregonian newspaper ran this story in its online edition on Feb. 4, 2015, which helps promote skepticism that is thorough debunked as junk science.
The Oregonian newspaper ran this story in its online edition on Feb. 4, 2015, which helps promote unproven public health skepticism that is thoroughly debunked as junk science.

Reporter Kjerstin Gabrielson wrote, “What influenced your decision to immunize or not immunize your children?  Has the recent measles outbreak in the United States swayed your opinion? What concerns do you have about immunizations? What concerns do you have about the diseases vaccines are designed to prevent?”

In response to the Jenny McCarthy style journalism I found, I chose to write this note directly to the reporter. Here it is. I hope she can make amends later for her journalistic transgressions and learn a little bit more the history of communicable diseases in the Oregon, where diseases like smallpox literally helped to wipe out many Native American communities before most white settlers arrived.

Letter Sent Feb. 4, 2015, by email:

Ms. Gabrielson: What exactly were you and your editors possibly thinking framing the public heath issue of a scientifically proven health intervention (MMR vaccination) that is used globally to save lives by giving precedence to  perpetrators of junk science whose ideas have now been thoroughly disproven by peer-reviewed, country-wide, and massive population-based studies showing absolutely no proven link to autism and the MMR vaccine?

Do you even understand what a population-based study is? Do you understand statistical significance or P-values? Do you understand the perpetrator of this bogus original article has been thoroughly debunked? Do you even know the history of this state where infectious diseases literally wiped out entire Native American villages on a scale that makes Ebola look like a mild chest cold?
 
If I were to start claiming, say that European Jewry was responsible for causing World War I and helped to defeat Germany, would you print an article with a headline talking about, tell us your thoughts on the debate about Jews’ role causing WWI. Would you open up your comment blog to Nazis and skinheads who will speak with utter sincerity using widely disproven racial eugenics theory that have the exact same scientific validity as those perpetrated by former Playmate Jenny McCarthy?
 
Wow.
 
Maybe you should learn about what happened to Native Americans in Oregon barely 160 years ago, due to smallpox and malaria. Maybe that might inspire you and your paper to use your brains. Promoting profits for junk reporting at the expense of public health is rather disgraceful if you ask me.
 

Robert Greene’s insights into power and mastery

Robert Greene, popular author
Popular author Robert Greene

How is it that a classics major, a guy who reportedly held 80 jobs, and a not-so-successful screenwriter became the big man of big ideas in a span of 15 years, now doing lectures at places like Google? Today, writer Robert Greene is known by everyone from corporate CEOs, to rappers like 50 Cent and Jay Z, and even to retired dictators like Fidel Castro.

Many people are most familiar with Greene’s seminal 1998 work, The 48 Laws of Power. The book is a compendium of principles of success for the modern-day prince and even low-level office worker on how to succeed. Some of those frequently mentioned laws include “Court attention at all costs,” “Crush your enemy totally,” “Learn to keep people dependent on you,” and “Pose as a friend, work as a spy.”

He also wrote other popular books drawing on the same formula of turning to the past and historic examples to shine relevance on the present and also on achieving success.

Greene’s works also include The Art of Seduction (2004), The 33 Strategies of War (2007), The 50th Law (2009) that involved collaboration with rapper 50 Cent, and more recently Mastery (2012). Greene is a man clearly on a mission. I recommend anyone who is interested in organizational behavior or simply how to get along better with a rival or coworker read one of his works.

Rebooting those ‘stale’ classics and lessons of history

The 48 Laws of Power, in essence, reboots the well-read and well-studied writings of Niccolò Machiavelli, historic Chinese military strategists like Sun Tzu, and tactics of leaders such as Prussian leader Otto von Bismarck. These are texts and persons that liberal arts majors by the hundreds of thousands have studied, yet few others have stitched together to have such contemporary modern relevance for everyone’s day-to-day life. As someone who has read many of these classic works and who studied history, nothing here is new to me, and thus not surprising.

Having sold well over a million copies of The 48 Laws of Power alone, Greene is today the subject of professional jealousy from those who have not achieved his notoriety and also praise from those who practice his stratagems that have appeared repeatedly in history. (This is just one of many summaries of those laws found online, and they are worth downloading and reviewing.)

Some professional groups, like the American Public Health Association, even published the laws of power, and quizzically asked public health leaders, “So, now that you’ve read the laws, how appropriate are they for you, as a health care administrator?” Having worked in the field, I can assure you many of these laws most certainly apply to public health bureaucracies and managerial aspirants in them who are more obsessed with power games and personal ambition than with promoting public health. But this is not news to anyone, in any profession.

As Greene told the LA Times in 2011, “These laws … people might say, ‘Oh they’re wicked.’ They’re practiced day in and day out by businesspeople. You’re always trying to get rid of your competition and it can be pretty bloodthirsty, and that’s just the reality.”

48 Laws of Power, by Robert Greene
The 48 Laws of Power

The ‘dark side’ or the ‘real side’?

Consider Greene’s dark view in the opening to The 48 Laws of Power. “If the world is like a giant scheming court and we are trapped inside it, there is no use in trying to opt out of the game. That will only render you powerless, and powerlessness will make you miserable. Instead of struggling against the inevitable, instead of arguing and whining and feeling guilty, it is far better to excel at power. In fact, the better you are at dealing with power, the better friend, lover, husband, wife, and person you become.”

For Greene, The 48 Laws of Power was a personal journey that built upon his fascination with Greek and Roman history, and the lessons drawn from that era. In Greene’s case, his failures in Hollywood led him to attempt to duplicate Julius Caesar’s crossing of the Rubicon River to launch a civil war against his rival Pompeii (dramatized brilliantly in the HBO miniseries Rome).

A statue of Julius Caesar in Rome (taken in 2006). Like Caesar, Greene also had to cross his Rubicon to achieve mastery and success.
A statue of Julius Caesar in Rome (taken in 2006). Like Caesar, Greene also had to cross his Rubicon to achieve mastery and success.

Greene notes how he arrived at his own Rubicon to reboot the tired, old classics into a modern bible for aspiring climbers and those trying to cope with amoral people and broken organizations: “My situation is much less intense, but I will follow Caesar and not only write the proposal, but take three months to do it right. I would have to borrow the money and cut my ties with the film world. As Caesar revealed to me, the more I had to lose, the harder I would work. The treatment turned into the best-selling The 48 Laws of Power and represents the turning point in my life.”

For those who are not familiar with history or its lessons, they may be missing Greene’s larger and longer long view of human history and behaviors that transcend time and culture. He told Forbes that his secret goal is to make “reading, studying the classics and philosophy something hip, so that young people were inspired to step away from the TV and the Internet and challenge their minds, rethink the world and return to our origins.”

We already knew a lot about the laws of power

When I posted a section of Greene’s writing on my Facebook page, describing people who are psychopathic and display passive aggression to the point of becoming warriors at this art, one of my colleagues responded, “OMG. If this does not describe one of my co-workers, I don’t know what does. Thank you for this.”

For me, many things Greene discusses have been well trodden by writers from William Shakespeare to Mark Twain, and anyone who has worked as a news reporter knows the realities that always lie beneath the surface veneer, particularly among those who exploit others and use power.

This is not to say students of history are cynics. Great students of history also are great leaders, notably Abraham Lincoln, who used his deep knowledge of America’s founding fathers and the actual intent of the U.S. Constitution’s authors to persuade voters that they did not intend slavery to remain a permanent and immoral institution in the country. Lincoln’s passion for history and his knowledge of power and human ambitions in fact made him one of the greatest leaders ever.

Mastery, by Robert Greene
Mastery

Mastery takes a more optimistic tone

I was deeply impressed with Greene’s delightful 2012 book, Mastery. The book uses profiles of contemporary masters and historic “geniuses,” such as Charles Darwin, Albert Einstein, John Coltrane, Leonardo di Vinci, Johann Wolfgang von Goethe, Wolfgang Amadeus Mozart, and others. (Many examples, but not all, are white men.) Why did they break down barriers, have astounding creativity, and achieve brilliance that crossed boundaries of thought.

Greene’s answer lies in the deep, thoughtful, apprenticeship type work one does before one becomes a master. He shows that through this applied study, the most innovative work happens in sports, science, research, art, military endeavors, and more. For Greene, through an applied apprenticeship that normally lasts five to 10 years, learning real skills and innovative thinking occur at the neural level, where great insight comes from.

“The goal of an apprenticeship is not money, a good position, a title, or a diploma, but rather the transformation of your mind and character—the first transformation on the way to mastery,” he writes. These involve three modes:

  • Step One: Deep Observation—the passive mode
  • Step Two: Skills Acquisition—the practice mode
  • Step Three: Experimentation—the active mode

During the acquisition mode, an apprentice will log at least 10,000 hours of practice, before charting his or her own course as a master. “This number has an almost magical or mystical resonance to it,” Greene writes. “It means qualitative change in the human brain. The mind has learned to organize and structure large amounts of information. With all of this tacit knowledge, it can now become creative and playful with it.”

For Greene, mastery is more than becoming simply proficient. This is about deep creativity and achieving one’s life purpose, which he suggests is a challenge that will confront most of us. “No good can ever come from deviating from the path that you were destined to follow. You will be assailed by varieties of hidden pain. Most often you deviated because of the lure of money, or more immediate prospects of prosperity. … Not seeing clearly ahead of you, you will end up in a dead-end career. … There is no compromise there, no way of escaping the dynamic. You will recognize how far you have deviated by the depth of your pain and frustration.”

The answer, according to Greene, lies in pursuing the path used by masters time and again, which he acknowledges is full of challenges and pleasures. “Make your return to the path a resolution you set for yourself, and then tell others about it,” writes Greene. “It becomes a matter of shame and embarrassment to deviate from this path. In the end, the money and success that truly last come not to those who focus on such things as goals, but rather to those who focus on mastery and fulfilling their life’s task.”

Franklin’s lesson in power and mastery

According to Robert Greene, Benjamin Franklin was a master who had great social intelligence.
According to Robert Greene, Benjamin Franklin was a master who had great social intelligence.

One the masters cited by Greene is Benjamin Franklin, because he was an innovative inventor, writer, and businessman who possessed great social intelligence. Greene shows that this latter skill is absolutely key to becoming successful and a master. Franklin is also one of my many role models. He excelled at nearly everything he did and had amazing people skills that always left a positive impression, like influential people I have known in my life.

Clearly, Franklin was one who learned about power well, in the most classic sense. Greene notes that as a young man, Franklin was terribly duped by Pennsylvania’s governor when he went to England and found himself practically penniless, without promised letters of introduction.

A copy of the daily schedule of Benjamin Franklin.

Franklin thought deeply and then grew. He resolved never to make an error of character judgment again and think about a man’s intentions carefully before making a response. And he always resolved to work at building his networks and turning enemies into allies, if possible. It worked time and again as he kept having success after success, but after great work and careful deep thought. Greene also shows that Franklin, as a master, also always stayed curious, and some say youthful until his 80s. The rest is, as they say, history.

Franklin perhaps is a Machiavellian case study in early American power, by becoming a revolutionary, co-author of the Declaration of Independence, and “founding father.” But by achieving excellence through the path of apprentice to master, he became much more.

On my wall, I have hanging a clip from Franklin’s daily planning calendar. On one side, he wrote the question for the morning: “What good shall I do this day?” For the evening hours, his calendar ended with the evening question, “What good have I done today.”

 

 

A few thoughts on management, leadership, and the greatest of ’em all, Abe Lincoln

About two years ago, I was tasked with doing a summary of the essential differences between management and leadership. This is one of the great topics in all of management and organizational behavior literature. Walls of books line bookshelves by experts from every field, from sports to defense to business.

This difference impacts all of us, because the effects of good or bad leadership filter down to all of us, either as government policy or work environments, or in extreme cases, life and death outcomes as seen in conflicts raging in Syria, South Sudan, and other troubled areas.

As someone working in public health, I am acutely aware how this woefully underfunded field needs inspirational leaders to tackle the challenges posed by public health threats, but also to inspire and steer public thinking and win support for greater public health funding.

Without strong leaders, from small agencies to leading scientists to figureheads like the U.S. Surgeon General (see my post that touches on how Dr. C. Everett Koop set the standard), the profession may continue to be relegated to third-tier funding status in federal budget priorities and not gain greater acceptance by a wider majority of Americans. (Note to my international readers, I am writing this post with an American context.)

With management and leadership issues very much on mind this past week because of some interesting developments I have observed, I have decided to publish a short summary document I did on this topic two years ago focussing on Abraham Lincoln as an example. He continues to inspire me, even when I hit roadblocks and get discouraged. And isn’t that what good leaders do, inspire?

“Towering genius distains a beaten path. It seeks regions hitherto unexplored.” Abraham Lincoln

Abraham Lincoln is the most written-about American and also considered the greatest citizen this country has ever produced. He exemplified many of the traits that today's theorists consider to be those of a highly inspirational and effective leader.
Abraham Lincoln is the most written-about American and also considered the greatest citizen this country has ever produced. He exemplified many of the traits that today’s theorists consider to be those of a highly inspirational and effective leader.

What Is Management and Who Are Managers:

Management has been defined as “the art of using all available resources to accomplish a given set of tasks in a timely and economical manner.” Management provides the basis for the system of control needed to maintain and operate an organization. It is also about getting things done through others and delegating work. Managers motivate employees to accomplish tasks with a variety of tools (intrinsic or extrinsic awards).

Typical Management Activities:

Planning, decision-making, organizing, staffing, directing/actuating (the process of leading through teaching), directing, and controlling (determining what the organization does in relation to its mission).

Management Theories:

– “Classic” management theory, dating back to the 1950s and 1960s, suggests managers have to rely less on technical skills and more on conceptual skills the more senior rank they hold. However, in the down economy as our class’s manager interviews found, managers at higher levels in lean organizations still have a lot of technical skills because they are doing a lot of frontline/skills-related activities.

– Classic models: Henry Mintzberg’s “10 managerial roles” (informational, interpersonal, and decision), similar to Robert Katz’s “skills of an effective administrator”  (technical, human, conceptual).

Scott Adams extremely insightful comic strip Dilbert captures an essence of management that likely resonates with millions of workers who find themselves led by those who fall short, very short of is well-document as being a good leader. Go to Adams' web site for more of his great work: http://www.dilbert.com.
Scott Adams’ extremely insightful comic strip Dilbert captures an essence of management that likely resonates with millions of workers who find themselves led by those who fall short, actually very short, of what is well-documented as being a good leader. Go to Adams’ web site for more of his great work: http://www.dilbert.com.

Management vs. Leadership:

Managers marshal resources to achieve the vision of others, and if they are good, help each person cultivate their talents and grow. Leaders are “visionaries, strategic thinkers, activators.” A talented few may excel at both.

Managers: rely on analysis and rationality, stress conformity, more like scientists, project power over people, seek obedience, emulate other successful managers/leaders.

Leaders: envision, rely on intuition, have self-confidence and take risks, project power with people, are creative and spontaneous, emphasize team building, explore new possibilities, inspire people to follow their vision.

Key Characteristic of Great Leaders: Emotional Intelligence (the principal theorist of this theory is Daniel Goleman):

  • Self-Awareness: Ability to recognize one’s emotions and their effects.
  • Self-Regulation: Ability to think before acting and suppress disruptive moods.
  • Motivation: A passion for the work beyond salary or status. Optimism, commitment, drive to do better.
  • Empathy: Ability to understand people’s emotions and treat them accordingly.
  • Social Skill: Good at building relationships and networks, finding common ground.

Leadership: Innate Ability Helpful, Practice Is Essential

Management experts debate if leadership is innate or learned; research suggests the latter. But innate traits such as drive, desire to lead, integrity, intelligence, and skill make it more likely that an individual will become a leader but are not the only factors in play. Research has shown that individuals can develop their leadership skills if they are given the right opportunities and mentored.
– Leadership as Innate: Intelligence and technical skill are key, and both are at least partially determined by genetics. Emotional intelligence—main predictor—tends to run in families and be greatly influenced by personality and childhood experience.
– Leadership as Learned: Businesses believe leaders can be created and invest a lot of time and money to identify and train individuals to assume leadership positions.
– Transactional Leaders, focus on meeting organizational goals. Make adjustments as needed to complete tasks for group.
– Transformational Leaders use personality/relations with followers to inspire the team to go above and beyond expectations. They are defined by charisma, vision, integrity, symbolism.

Abraham Lincoln, the Embodiment of Strong Leadership:

  • Lincoln Model, Emotional Intelligence: By the time he had become President, Lincoln had mastered his emotions and exercised great control by not sending “hot letters.” When the time came for action, he acted decisively, but only after deep analysis of the full situation. His greatest asset was his astounding empathy to understand his rivals, allies, and especially his opponents, including the slaveholding South. He was also a beloved storyteller and well-liked and admired by his peers. Lincoln also learned from missteps and made amends with opponents when victorious, and he did not carry personal grudges. He was driven to have a life that fulfilled a higher purpose and to preserve the Union—a nation he believed that had great future promise.
  • Lincoln Model, Learned Leadership: With just one year of schooling, Lincoln embodied personal drive and self-learning, as well as integrity. Lincoln spent years practicing his craft, in Whig party politics and then in the Illinois Legislature. He lost to his then-more renown rival Stephen Douglas in a U.S. Senate bid in 1856. He then won a brokered convention of the Republican Party in 1860, held in Chicago, after becoming the foremost speaker on the greatest issue of his day, the expansion of slavery. He credited the assistance of many benefactors and friends for believing in him and helping him rise to political prominence.
  • Lincoln Model, Not One Style of Leadership: Lincoln mixed authoritarianism (suspending the writ of habeas corpus, etc.) as a wartime president, but had a democratic style with his cabinet (his “Team of Rivals,” the most capable politicians of his day he personally recruited). He was transformational; his peers recognized his greatness, inspiring them to work harder.

Policy, systems, and environmental change: the current, faddish, cow-patty flavor of public health

One thing I have never shaken since my days as a rookie reporter is my penchant for calling out the obvious. This is one of the sacred duties of the press: to speak truth to power. This also means calling a spade a spade, and bullshit for what it is, and what it smells like.

Anyone who has ever worked in the business of reporting news and telling facts knows this is one of the press’s sacred trusts—and myths—and the clearer we are in doing that, the better our society is from having that unbiased information.

I captured these various images on Google when I typed in a few keywords, and clearly this concept has a lot of widespread acceptance by people who know a cow patty when they smell one.
I captured these various images on Google when I typed in a few keywords, and clearly this concept has a lot of widespread acceptance by people who know a cow patty when they smell one.

Today, I stumbled on Marcy Wheeler’s blog, the Empty Wheel, which tackles many hot-button policy issues. Last year she blogged about climate change in a piece called “The Cost of Bullshit: Climate Change, National Security, and Inaction.”  She pointed out that the cost for maintaining the status quo was too high, even when major government agencies from the Department of Defense and the Department of State concluded that the issue was a critical concern to U.S. national interests. Yet, no actions were being taken by the government, and all of the reports on the emerging crisis were “mere bullshit—more wasted government employees’ time and taxpayer money.”

Sure easy for a blogger not on the payroll to diss hard-working public workers and policy-makers, right? Or, is Ms. Wheeler simply calling out the obvious, like reporters have always done, or thought they were doing.

Will a public health fad meaningfully address the main killers of Americans?

The cost of bullshit has been on my mind late, particularly regarding public health jargon that inflates busy-looking arm-waving, but does not change reality.

For me, one of the most frustrating aspects of working in the public health is the field’s faddish way it labels its collective actions to address chronic disease issues, such as obesity, using fancy sounding concepts like “policy, systems, and environmental change.” Mon dieu, what big words, what big ideas.

This is an expression coming from the top, from the venerable U.S. Centers and Disease Control (CDC), to explain national efforts to tackle the monster that is chronic disease—the leading causes of death in our ever-fattening and ever growing income-unequal country.

These diseases kill seven in 10 Americans, and of the CDC’s meager budget of under $7 billion for our national public health effort is a mere drop in the bucket compared to other priorities of the $1.2 trillion national budget that is so-called “non-discretionary spending.”

The Congressional Budget Office released this info graphic on government spending and revenues for 2013. Go here for original: http://www.cbo.gov/publication/45278.
The Congressional Budget Office released this infographic on government spending and revenues for 2013. Go here for original: http://www.cbo.gov/publication/45278.

The CDC still estimates 18% of U.S. GDP spending is on healthcare, and a third of it at the place where the most outrageously overpriced and at the same time least effective primary care interventions can take place—hospitals.

So what do public health officials do, when faced with a handful of breadcrumbs thrown to them from Congress? They invent concepts that make it appear that public health is doing something, when there is little or no clear evidence population benefits are accruing based on investments at this level in the large ocean. Yes, I am talking about the catchy and jargon-laden ideas like “policy, systems, and environmental change.”

This is a hodge-podge of activities that encompass everything from starting farmers markets to promoting smoke-free buildings. Here are a couple of definitions I randomly found from some online sources:

  • State of Mississippi: “Our environment and the policies and systems in it shape the pattern of our everyday lives and have a profound influence on our health. The design and walkability of communities, the availability of low-cost fruits and vegetables, and the smoking policies in our workplaces have a direct impact on our physical activity, diet and health.”
  • State of Maryland: “Policy, systems, and environmental change (PSE change) refers to public health interventions that modify environments to provide healthy options and make healthy choices easy for everyone.”
  • Fairfax County Virginia: “Policy, systems and environmental change is a way of modifying the environment to make healthy choices practical and available to all community members. By changing laws and shaping physical landscapes, a big impact can be made with little time and resources. By changing policies, systems and/or environments, communities can help tackle health issues like obesity, diabetes, cancer and other chronic diseases.”

Budgets for this kind of intervention exist in most public health jurisdictions, and public health leaders are doing to the talk, because they have so few funds to do the walk. But public health experts end up playing in a small sandbox when these investments are measured against other spending, and then we spend a lot of time trying to convince ourselves through published papers, webinars, conferences, and the like that this is working. The illusion is powerful, like the illusory power of the Iron Throne in the Game of Thrones, except the shadow from a fad still does not make meaningful change when the numbers are crunched and the costs are calculated regarding chronic disease.

From the Game of Thrones, a lecture on power and illusion, for Westeros and beyond.
From the Game of Thrones, a lecture on power and illusion, for Westeros and beyond.

Public health departments who get funding through competitive grants from the CDC spearhead these efforts and then spend extensive amounts of time documenting their work trying to prove the bread crumbs made a difference to the overall health crisis facing Americans.

About $200 million was doled out from 2011 and 2012 through an effort called Communities Putting Prevention to Work (the amount initially announced in 2010 was about $380 million). In one case, Public Health-Seattle & King County published findings that show its CPPW-grant-funded efforts in schools cut youth obesity in specific schools by 17 points. Great job, except the funding was not permanent and it was not renewed when the grant ran out. The program is now in the past tense.

In 2014, public health professionals learned another funding source, the Community Transformation Grants, which also promote the policy, systems, and environmental work, is being cut too. Some can argue the money is being allocated to other programs that tackle chronic disease, focusing on heart disease and diabetes.

More musical chairs without really changing the big picture again?

I do not mean to belittle the work of public health people doing this work. They are my colleagues. I respect them. And the work being done, like promoting activities to reduce tobacco use and get more people eating healthy food, should be continued.

But as a field, I am convinced this type of work is self-delusional because it hides the nasty realities of how much larger issues shape the public’s health, such as how transportation budgets are allocated, how cheap petro-based energy is spurring obesity in measurable ways, how legislation is crafted by special interests at the state and federal level, and how the principle of health care is considered a privilege not a right in the United States. (In Denmark, by contrast, the public funds about 85% of all health care through taxes, and the system is rooted in both law and a social contract that is premised on system where all citizens are provided free and equal access to quality health care.)

Emilia Clark, mother of dragons in the smash HBO TV series Game of Thrones, is a good visual metaphor of what public health is not in the bruising world of budget appropriations at the state and federal levels of government.
Emilia Clark, mother of dragons in the smash HBO TV series Game of Thrones, is a good visual metaphor of what public health is not in the bruising world of budget appropriations at the state and federal levels of government.

The nasty realities we do not want to think about, using a contemporary TV metaphor, would be what happens when the violent kings of Westeros cut deals and cut heads, to maintain order in that mythical, lovable place with White Walkers, a giant ice wall, and fire-breathing critters. Mother of Dragons, public health is not, that is for sure!

I imagine a new fad will emerge in public health in the next three years, like it does in management. We might change the concept, but we likely may even have a smaller piece of the government pies.

No, public health jurisdictions cannot stop working until we see changes on these fronts. But the more we in public health delude ourselves that we are making a difference with scraps from the table, the more easily we are duped into accepting that the larger model is as it should be, and how it shall always be.

We will continue kvetching about farmers markets and soda machines, but not moving in a rigorous way upstream, where budget deals are made with transportation dollars, for starters. And I think we have to start being honest with ourselves about what we are accomplishing in the sandbox and whether this is the best use of our meager and diminishing resources.

How the 10 essential public health services handicap a weakened profession

Public health, as a profession and system to improve population health, continues to fall short in the United States.

Since the start of the Great Recession, nearly a quarter of all employees working for local health jurisdictions have been downsized or laid off because of funding cuts to already meager budgets. The National Association of County and City Health Officials pegs the attrition at nearly 44,000 workers–a fact reported on this blog before.

Proportional changes in inflation adjusted spending for public health (CDC) versus health care spending in the United States.
Proportional changes in inflation adjusted spending for public health (CDC) versus health care spending in the United States.

Today, most Americans have little idea what public health does, why it matters, and why its funding is critical to improving health outcomes at the population level. For that matter, half of all Americans cannot even identify what the core elements of health insurance plans are. 

From its start as a profession in the United States in the early 1900s, public health was deemed to have a political-activist function. In fact, noted public health pioneer C.E.A. Winslow, Yale’s first chair of public health, promoted universal medical care in the 1920s as a principle of sound public health policy, backed later by other public health practitioners in the next two decades who unsuccessfully called for a form of universal health care.

Winslow’s often-quoted definition of public health called for the “development of the social machinery which will insure to every individual in the community a standard of living adequate for the maintenance of health.” Such efforts were overt and unashamed calls for political action and advocacy, the likes of which are mostly not heard today from the profession.

10 essential public health services: a recipe for political impotence?

Since 1994, the U.S. Centers of Disease Control has pushed the “10 essential public health services” model as the gold standard for defining public health’s realm of practice. As far back as 1999, the CDC claimed, “The overall goal for public health’s infrastructure is to have every health department fully prepared with capacity to fulfill the Ten Essential Public Health Services and every community better protected by an efficacious public health system.”

The 10 essential public health services is the U.S. model, not a global model, for defining the profession.
The 10 essential public health services is the U.S. model, not a global model, for defining the public health profession’s realm of practice.

This model has rippled outward to every public health agency, every school of public health, and all professionals in the field as the benchmark to measure quality and effectiveness. Logic models have been developed to see how well health departments were doing according to this standard.  Anyone who works in the field is told that these services define who we are and what we do.

All the while, public health budgets have been slashed nationally, and at the state and local level, workers have fled or were pushed out of the profession. Still the field of public health continues to push its competent but still toothless model for what is considered a best practice—the 10 essential services.

While evidence-based and certainly valid, this 10-step model is also a self-defeating set of quasi-religious commandments that fails to address the harsh political realities related to developing legislation and orchestrating fights over budget appropriations. It also fails to call for advocacy and political activity, which can and have pushed public health efforts far greater than these prescribed activities.

Politics, money, and real power

For-profit entities working in the health sector thrive because advocacy and political engagement are fundamental to their business models and bottom lines, unlike the model of inefficacy promoted for the public health profession.

For instance, pharmaceutical powerhouse Pfizer unabashedly states, “We believe that public policy engagement is an important and appropriate role for companies in open societies, when conducted in a legal and transparent manner. … The Pfizer Political Action Committee makes contributions to candidates for federal office, and fully discloses its contributions on a regular basis to the Federal Election Commission.”

Pfizer, multinational pharmaceutical firm, published its political spending activities in the United States for the first half of 2013.
Pfizer, the multinational pharmaceutical firm, published its political spending activities in the United States for the first half of 2013.

While for-profit health interests march forward, with ever more dollars and clout, public health continues to retreat. The President’s budget request in 2014 for the CDC, the agency charged with protecting America’s health, is a measly $6.6 billion (for its program level expenditures)—a drop of $270 million over 2012.

This dip likely reflects pushback by GOP lawmakers in the current Congress, who view CDC’s public health activities as synonymous with overt advocacy. Language in funding measures, in the current session of Congress, has attempted to limit federal dollars for grassroots efforts by public health practitioners to lobby on behalf of specific legislation, particularly on efforts to address chronic disease and obesity.

Generally, public health advocacy is not lobbying, which is prohibited when it involves federal or earmarked funds. Exceptions include study or research and discussions of broad social problems.

So it is not surprising that government-funded public health bodies have been generally shy, and in the case of firearms legislation, nearly totally muzzled, from discussing firearms deaths since congressional language banned funding of firearms research starting in 1996. (In my opinion there has been a failure of leadership in public health when such leadership was needed on the issue of firearms violence, which is a legitimate public health concern.)

But should bans on using public funds for lobbying mute the profession from pushing for advocacy approaches and political engagement?

Daniel Callahan and Bruce Jennings’ 2002 article in the American Journal of Public Health examined the ethics of public health advocacy. They noted, “Politics is a necessary component of public health, moreover, precisely in order to achieve public health policies and practices consistent with American traditions and values. Politics is the messy arena in which ultimate questions of the public good are worked out.”

Public health’s failures in the political mosh pit

A perfect example of what happens when public health was not fighting tooth and nail was President Obama’s Affordable Care Act of 2009, which ultimately squashed efforts for a single payer system—the long-held dream of public health advocates from the 20th century—and advanced a health insurance industry, market-based model for “health care” reform.

All told, advocacy groups in 2009 spent $3.47 billion for D.C.-based lobbyists to parse out issues, according to left-leaning Center for Responsive Politics. Not surprisingly, the lion’s share of that spending went to fight the health reform battle. Businesses and organizations that lobbied on “health reform” spent more than $1.2 billion on their overall advocacy efforts.

APHA lobbying 2013
Source: The Center for Responsive Politics

For its part, the American Public Health Association (APHA) spent less than $500,000 annually on lobbying at last count in 2013. (See spending chart for lobbying expenditures by APHA from 1998 to 2013.)

The good news is that this marked a jump of more than 300 percent from what APHA spent in 2012. It would appear that some in the field are waking up to the realities of fighting for public health where the most meaningful impacts can be achieved – through policy and legislation.

By comparison, just one big pharma company, Pfizer, spent more than $800,000 in the first six months of 2013, from local to congressional candidates and political parties nationwide (see chart above).

What is most discouraging is that future leaders entering the profession continue to be shortchanged by graduate programs that do not know how to prepare practitioners to win in the bruising political environment known as “upstream.” This is my general assessment of not just my graduate MPH program, but of the field that I still see through its obsessive and yet parochial obsession with the 10 essential public health services.

The CDC's 10 essential public health services.
The CDC’s 10 essential public health services.

A very smart resource guide developed by the California Endowment sharply noted: “… many public health faculty do not possess the skills or experience to teach advocacy effectively. Faculty surveys show, for example, that despite advocacy for health being recognized as an ethical responsibility and required competency of health educators, many health education faculty do not see themselves as competent for teaching advocacy and lack instructional materials to do so. Degree-granting programs in public health need to provide systematic training in social advocacy. In the absence of formal training in social change, public health graduates must learn this information and develop these skills on a catch-as-catch-can basis. Working in this way means that some will be less effective than they otherwise could be in advancing the health of the public.”

Public health’s evolving role promoting U.S. military interests

The seal of the U.S. Department of Defense, representing seven branches of the U.S. military.
The seal of the U.S. Department of Defense, representing seven branches of the U.S. military.

The U.S. Department of Defense (DoD) remains one of the most sophisticated media production machines on the planet. Its ubiquitous advertising filters into every aspect of our lives, from public schools to product placement in the lucrative gaming industry to traditional online ads.

In 2007 alone, according to a Rand Corp. study, the total recruiting budget for the Army, Navy, Air Force, and Marine Corps exceeded $3.2 billion. Rand Corp. analysts also deemed those investments as successful as measured by recruitment, even during two ongoing wars in Afghanistan and Iraq.

Events with military personnel always feature sophisticated press and social media coverage. One of the more nuanced and I think effective messages I have seen from the DoD is how the military is not just about defense, but about a more deeply and morally resonant “good.” The U.S. Navy’s very slick videos call the branch a “a global force for good,” and show Navy SEALs in action carrying that message.

This clip from a U.S. Navy recruiting video shows a successful branding effort by the U.S. Department of Defense to promote its global activities as a moral good, including special ops efforts by U.S. special forces
This clip from a U.S. Navy recruiting video shows a successful branding effort by the U.S. Department of Defense to promote its global activities as a moral good, including special ops efforts by U.S. special forces.

Helping to prop up that messaging is the country’s long-standing integration of public health services into the DoD and overall military readiness. The military is successfully integrating public health activities, and it is branding these as part of its global efforts, including on the new battlefield in Africa.

Through contracting opportunities that support these efforts, many U.S. based firms who specialize in development and traditional public health activities are actively supporting these initiatives, in order to monetize their own business models.

Chasing contracts serving two masters: public health and defense

I recently stumbled on a job posted on the American Public Health Association (APHA) LinkedIn page by a company called the QED Group, LLC. The position was similar to ones I see posted on their job site now, for work on a “monitoring and evaluation” project in Africa.

This is one of many government-contracting agencies that chase hundreds of millions of contracts with U.S. government agencies and the major public health funders like the Bill and Melinda Gates Foundation.

In this case, the company was specifically targeting those in the public health community, who are entering the field or currently have positions with backgrounds in public health, economics, science, and health. The 15-year-old company itself actually began as a so-called 8(a) contractor, which means it could win no-bid and lucrative government contracts that are now the center of an ongoing and intense controversy over government waste. (These companies were created by the late Alaska Sen. Ted Stevens, who created the provision to steer billions in government contracting to Alaska Native owned firms that partner with companies like Halliburton and the Blackwater overseas and in the United States.)

QED Project in NorthAfrica
The company QED Group showcases its recent work evaluating anti-terrorism-related efforts in North Africa.

Today, QED Group, LLC claims “it is full-service international consulting firm committed to solving complex global challenges through innovative solutions” by providing clients “with best-value services so they increase their efficiency, learning capacity, and accountability to the public in an ever more complex and interconnected world.” It lists standard international development and public health contract areas of health, economic growth, and democracy and governance.

QED Group is not the only multi-purpose public health and development agency chasing military and global health contracts in Africa.  Another health contracting company called PPD boasts of its “long history of supporting the National Institutes of Health, the nation’s foremost medical research agency,” and that it was “awarded a large contract by the U.S. Army.” It claims its is also a “preferred provider to a consortium of 14 global health Product Development Partners (PDPs), funded in part by the Bill & Melinda Gates Foundation.”

As a public health professional, QED Group looks like a great company to join. However, if one scratches deeper, one learns that this company also uses its public health competencies with the U.S. military, which is spearheaded in Africa by U.S. Africa Command, or AFRICOM.  This raises larger questions of the conflicting ethics of both promoting human health and public health and also serving the U.S. Department of Defense, whose primary mission is to “deter war and to protect the security of our country.”

AFRICOM’s emerging role flexing U.S. power in Africa

AFRICOM’s demonstration of “hard power” is well-documented through its use of lethal firepower in Africa. AFRICOM is reportedly building a drone base in Niger and is expanding an already busy airfield at a Horn of Africa base in the tiny coastal nation of Djibouti. On Oct. 29, 2013, a U.S. drone strike took out an explosives expert with the al-Qaida-linked al-Shabaab terrorist group in Somalia, which had led a deadly assault at a Kenyan shopping center earlier that month.

One blog critical of the United States’ foreign policy, Law in Action, reports that the AFRICOM is involved in the A to Z of Africa.  “They’re involved in Algeria and Angola, Benin and Botswana, Burkina Faso and Burundi, Cameroon and the Cape Verde Islands. And that’s just the ABCs of the situation. Skip to the end of the alphabet and the story remains the same: Senegal and the Seychelles, Togo and Tunisia, Uganda and Zambia. From north to south, east to west, the Horn of Africa to the Sahel, the heart of the continent to the islands off its coasts, the U.S. military is at work.”

U.S. efforts in Africa require health, public health, and development experts. As it turns out the company, QED Group,  won a USAID contract examining U.S. efforts promoting “counter-extremism” programs in the Sahel. That study evaluated work using AFRICOM-commissioned surveys, all designed to promote U.S. national security interests in the unstable area.

The area is deeply divided between Christians and Moslems. It is also home to one of the largest al-Qaida based insurgencies known as al-Qaida in the Islamic Maghreb, which has similar violent aspirations as the ultra-violent Boko Haram Islamic militant movement of violence-wracked northern Nigeria. Al-Qaida in the Islamic Maghreb military seized control of Northern Mali in 2012, which ended when U.S.-supported French military forces invaded the country and routed the Islamic extremists in January 2013.

Public health’s historic role with U.S. defense and national security

“Hard power” and “soft power” are tightly intertwined in U.S. overseas efforts, where health and public health personnel support U.S. interests. This is true in Afghanistan and is certainly true in North Africa. This particular QED-led program used the traditional public health method of a program evaluation of an antiterrorism program to see if a USAID program was changing views in Mali, Niger and Chad—all extremely poor countries that are at the heart of a larger struggle between Islamists and the West.

That research methods used in public health–and which I have used to focus on health equity issues in Seattle–can be used equally well by U.S. development agencies to advance a national security agenda is not itself surprising.

However, faculty certainly did not make that case where I studied public health (the University of Washington School of Public Health). I think courses should be offered on public health’s role in national defense and international security activities, because it is nearly inevitable public health work will overlap with some form of security interests for many public health professionals, whether they want to accept this or not.

U.S. Public Health Service Corps members proudly serve their country and wear its uniforms.
U.S. Public Health Service Commissioned Corps members proudly serve their country and wear its uniforms. This photo published on the corps’ web site demonstrates that pride.

Public health in the United States began as a part of the U.S. armed services, as far back as the late 1700s. It was formalized with the military title of U.S. Surgeon General in 1870. To this day those who enter the U.S. Public Health Service Commissioned Corps wear military uniforms and hold military ranks.

A good friend of mine who spent two decades in the Indian Health Service, one of seven branches in the corps, retired a colonel, or “full bird.” He always experienced bemusement when much larger and far tougher service personnel had to salute him when he showed his ID as he entered Alaska’s Joint Base Elmendorf Fort Richardson looking often like a fashion-challenged bum in his minivan (he frequently had to see patients on base, and was doing his job well).

The U.S. Public Health Corps' web site shows the different uniforms worn by their members.
The U.S. Public Health Service Commission Corps’ web site shows the different uniforms worn by its members.

The U.S. Army’s Public Health Command was launched in WWII, and it remains active today. One of its largest centers is Madigan Army Medical Center at Joint Base Lewis McChord, in Pierce County, Washington. Public Health activities are central to the success of the U.S. Armed Services, who promote population-based measures and recommendations outlined by HealthyPeople 2020 to have a healthy fighting force.

AFRICOM charts likely path for the future integration of public health and defense

Africom photo
This screen snapshot of an AFRICOM media file highlights the public health and health related efforts AFRICOM personnel undertake in the region, where military efforts are also underway to suppress and disrupt Islamic extremist groups.

Today, the U.S. military continues to use the “soft power” of international public health to advance its geopolitical interests in North Africa.  In April 2013, for example, AFRICOM hosted an international malaria partnership conference in Accra, Ghana, with malaria experts and senior medical personnel from eight West African nations to share best practices to address the major public health posed by malaria.

At last count, the disease took an estimated 660,000 lives annually,  mostly among African children.

At the event, Navy Capt. (Dr.) David K. Weiss, command surgeon for AFRICOM, said: “We are excited about partnering with the eight African nations who are participating. We’ll share best practices about how to treat malaria, which adversely impacts all of our forces in West Africa. This is a great opportunity for all of us, and I truly believe that we are stronger together as partners.”

I have reported on this blog before how AFRICOM and the United States will increasingly use global health as a bridge to advance the U.S. agenda in Africa. And global health and public health professionals will remain front and center in those activities, outside of the far messier and controversial use of drone strikes.

It is likely this soft and hard power mission will continue for years to come. Subcontractors like QED Group will likely continue chasing contracts with USAID related to terror threats. Global health experts will meet in another African capital to discuss major diseases afflicting African nations at AFRICOM-hosted events. And drones will continue flying lethal missions over lawless areas like Somalia and the Sahel, launching missiles at suspected terrorist targets.