Opinions and Reflections 

Opening Our Eyes: Seeing The World – First, please note that “The Occasional Perspective” became a bit longer than I originally anticipated primarily because of the importance of the issue. As a result, there are fewer of the Consulo Indicium (i.e. shorter) blog items. They were displaced by this longer missive. Also, as you read this section of The Fickenscher Files, I’ve taken the thoughts of Bethany Bruzzi, DO (SEE above quote) to heart. In fact, a “global thought process is ingrained when you work in primary care.” And, it is in that vein that I offer up the following perspective on a very important issue facing societies around the world.

I just returned from our annual trip to Greece for a visit with our adopted Greek family. It was – as usual – an incredibly relaxing visit that met all of my culinary dreams as well as the frequent “discussions” on a wide range of issues facing the world, random observations about people, places, and things; and, the solutions to global problems 😊. On the side of the observation, I noted the much more relaxed, “open collar” wear of passengers traveling to and from Greece who were there from throughout the world. There was also less of a business-like atmosphere at the airports by both visitors and attendants in their interactions with one another. It was a notable change in atmosphere. At the same time, the usual friendliness of the entire Greek community was evident throughout our entire visit.

While I was ruminating on the discussions, debates, and dialogues that were ongoing all around me, I received a download from The New Yorker on “The Case Against Travel” that reviewed both the upside and downsides of travel. At first, I was taken aback by the notion of the article seemingly chastising travelers for “experiencing” interactions outside the norm of their personal boundaries. As I continued the article; however, it became clear that a deeper understanding of what we “see” when we travel is often missed by the traveler. Over the years, I’ve always tried to step back from my usual customs, norms, and bias to observe. It has helped me to gain a better perspective on the cultures and peoples of the places I’ve visited. Although I’m clearly not an expert in that regard, the article encouraged me to continue my efforts toward gaining a better appreciation of all those people and places outside the bounds of the United States. It’s a work in progress…

So, as I engaged in the conversation side of the travel equation suggested in the article, I was struck by the Greek reaction to the many global issues which are coming to dominate the experience of the human species. For example, climate change is not only a central focus of discussions in the USA but also a dominant topic in Greece and throughout the entire world. These factors are at the forefront of discussions throughout all of Europe, the Middle East, Africa, Asia, or the entire world for that matter. The discussions are somewhat different in all of these nations depending on how climate change is directly impacting a particular society. However, regardless of the specifics, it is very clear that global warming is directly impacting the economics, culture, politics, and social capacity of all nations – including the Greeks and others in the Mediterranean basin. Furthermore, the impact is accelerating.

And, the questions that come to the forefront when one travels overseas are:

• Are we listening to one another?
• Are we seeking solutions that solve problems?
• Or, are we putting bandages on open, compound wounds?

One of the issues that came to the forefront for me during my visit to Greece this year is the increasing migration of people all over the world from areas of climate devastation to places where people are only now beginning to experience the direct impact of climate change. In particular, I was struck by the similarity of discussions that emanate not only from my friends in Greece but also from friends in Texas, Florida, California, and other “entry” points of immigrants to nations from around the world. For example, Greece has served as the entry point to the European Union for the Pakistani diaspora of about 200,000 immigrants to date. The other European members “cherry-pick” the Pakistani diaspora for workers at a level that meets their particular national needs. However, cherry picks only represent a relatively small percentage of the overall immigrant population. As a result, Greece is left with the responsibility for managing, integrating, and resourcing the new members into their society which is creating increasing anxiety, conflict, and militancy on the issue at the local, community, and national levels across the country.

The politics in Greece – like the USA – is becoming increasingly divisive! Greece for all intents and purposes serves as the “primary entry point” for the immigrant populace from Africa into Europe, much like Texas, Florida or California do in the United States for Latin America. As a result, in both the United States and Europe there is a diversity of opinion on how best to manage the immigrant issue depending on where you live. For example, I suspect – although I have not checked the accuracy of this statement – that the immigrant issue is not as dominant in my original home state of North Dakota as it would be in the three states I just mentioned. I leave it to you to determine why?

At the same time, in much of Europe and the United States, there is a shortage of entry-level workers. In Maine – my adopted home state – we are woefully short of workers for the hospitality, restaurant, and other service industries as well. Much like my family in the 1890s who were immigrants from Germany, the immigrants of our era desire work and are very willing to work (Remember: all of us emanated from immigrant families – except our native colleagues). And, not to be forgotten, the new immigrants are willing to work at jobs that many existing folks in both Europe and the USA would turn down.

But, have we created an environment that allows the new immigrants to work and build a sustainable future? I don’t think so. Rather, we divert attention by sending busloads of people to distant cities or pushing them to cross borders into other countries as the “solution” to the problem. However – rather than solving the problem – we are exacerbating the problem. Furthermore, problems are not resolved through polemics and public diatribes. Rather, we accomplish solutions when a diversity of opinions and perspectives sit down and work together to come up with long-term solutions. They evolve from dialogue, debate, and decisions emanating from leaders who recognize their role in resolving the issues of the day! Has this been the focus in Europe and the USA? I don’t believe so…

People do not naturally pull up roots and head off to some strange land arbitrarily, especially when life and limb are at risk. Immigrants most often decide to move from their home country for reasons of life, liberty, and the pursuit of happiness (we’ve heard that before, I believe) or family. In my case, the Fickenscher clan moved from Germany to the USA to avoid inscription in Chancellor Bismarck’s wars. According to family lore, they left Bavaria with steady jobs as weavers to become homesteading farmers on the prairies of Nebraska. They were part of that great wave of immigrants from across Europe that moved to the USA throughout the latter part of the 1800s.

So, why do we see immigrants now? There seem to be two prevalent reasons: 1) as I mentioned, the evolving environmental devastation occurring as a result of climate change is a major factor; 2) the growth of illegitimate and corrupt autocracies across the globe; and, 3) the economic disruption to people’s lives due to the secondary effects of events like the war in Ukraine. If I were being subjected to the same experiences that face the multitudes of immigrants from Central and South America as they head north or the vast corruption and famine in Africa – I too would be an immigrant not just for me but for my family as well. So, it seems to me that we are only at the formative stages of the “immigrant problem” that will be facing the more developed and privileged nations of the world over the coming decade.

In 2022, the World Bank issued its ongoing Groundswell Report noting that more than 200 million people across six world regions will be on the move by 2040. This includes 86 million Sub-Saharan Africans, 49 million East Asians and Pacific Islanders, 40 million South Asians, 19 million North Africans, 17 million Latin Americans; and, 5 million Central Asians. Those are whopping numbers!!

OK, Kevin. What’s this got to do with health care? In a new report from the United Nations Office of the High Commissioner (UNOHC), the impact of climate change highlights several other issues that are adversely impacting the immigrant populace. The report – released on July 12, 2023 – notes that nearly one-half of all humanity, or, about 3.3 billion people – are living in nations that expend more money paying the interest on their national debt than they spend on health care or education. As noted by UN Secretary -General Antonio Guterres: “Half our world is sinking into a development disaster, fueled by a crushing debt crisis.”  The global public debt problem has now reached a record $92 trillion (with the USA representing 1/3 of that number) and now includes nearly 59 nations compared to a decade ago when the number was 22 nations with “debt beyond their limits to pay”. Furthermore, developing countries carry a disproportionate amount of the overall world debt. Is this not going to make a bad problem even worse? I think so. When families cannot obtain access to basic health care services, when food cannot be put on the table, when basic community capacities like clean water are no longer available, and, where education is thrown aside to pay for debt – primarily to the “have” nations – we have a staggering problem on the horizon. It’s not about people crossing borders. It’s about WHY are they crossing borders? If we think the immigrant problem is going to resolve itself without a consensus approach to the real problems rather than polemic and rhetorical stunts – we are sadly mistaken.

Frankly, I am increasingly worried about the USA debt level and the potential impact it will have on our social programs of Social Security (21% - $1.2 Trillion); and, the national health programs of Medicare / Medicaid / Childrens Health Insurance Program / Affordable Care Act (25% - $1.4 Trillion). These two social commitments now consume[1] roughly one-half of the entire federal budget. So, we are facing a compounded problem (= financing our social programs) on top of a set of exploding problems (= massive debt by developing nations and climate change impact). There once was a Roman Emperor who fiddled away while his capital burned! Are we engaging in the same behavior? I think so. And, we are hearing proposed solutions that will never work: border walls that are clearly porous, deportation policies that force immigrants to attempt other entry points, busing people to cities for political stunts, and the like… This is not a Texas, Florida or California problem. This is a United States problem! The health of the people demands it.

As healthcare professionals, we need to step forward and actively participate in developing and offering solutions. The health of the people demands it. As I noted earlier, I’ve just returned from a two-week hiatus in Greece, the home of Hippocrates – the Father of Western Medicine. He was born around 460 BCE on the Island of Kos with his paternal heritage extending back to Asclepius and, his maternal heritage to Hercules. For the very first time in my life, I read Aphorisms – the writings of Hippocrates. His very first missive in the collection which covers the waterfront of serving as a physician back in his day (PS – we’ve come a long way 😊) was as follows:

“Life is short, the Art long, opportunity fleeting, experiment treacherous, judgment difficult. The physician must be ready, not only to do his duty himself, but also to secure the co-operation of the patient, of the attendants, and of externals [emphasis added].

Wise words from across the millennia. Your thoughts – as always – are appreciated! 

[1] https://www.cbpp.org/research/federal-budget/where-do-our-federal-tax-dollars-go

Opinions and Reflections

Kudos for Jack Resnick, MD – As part of his outgoing speech before the Annual Meeting of the American Medical Association, Dr. Jack Resnick called out the growing chorus of legislative initiatives aimed at the LGBTQ* community. To quote him, he said: "Shame on political leaders, fueling fear and sowing division by making enemies of public health officials, of transgender adolescents, of physicians doing anti-racism work, and of women making personal decisions about their pregnancies." We in the healthcare community need to be more vocal in protecting the rights of individuals and to have access to the care needed – as determined by their providers. Legislating the practice of medicine including which procedures, processes and other elements of care delivery should not be tolerated by the profession. We are entrusted through our State Medical Boards and other groups to provide quality care – care that legislators without any experience and/or insight will not be able to fully understand unless they pursue a career as a healthcare practitioner.

Managing And Regulating AI/ML – It’s probably very clear to everyone that discussions, debates, dreams and predicted disasters seem to be at the forefront of the health care world. There is “much ado” about the AI/ML conundrum:

How should we manage it, or not?
Is it time to regulate it?
What do we do to protect people from unscrupulous users and adopters?

And, these are just the beginning of the questions that are percolating to the top of the health care community. In a recent article from the MIT Technology Review, six options for managing the evolving AI/ML equation were reviewed. It’s definitely worth reading the entire article (Check the hyperlink). The synopsis includes the following:

Option 1: A legally binding AI treaty – The Council of Europe is a human rights organization with membership derived from nations across the globe. The present count of members includes 46 – and, obviously extends outside of Europe. For example, the USA, Canada, and Mexico from the Americas sit in on the Council as well as Israel, Ukraine, Japan and others from other geographies. The Council is finalizing a binding treaty on AI/ML for the members who sign on to initiate steps for ensuring that AI is designed, developed, and applied with the inherent protections of democracy and human rights in mind. The intent is to have a “draft” treaty available for review some time in November 2023 according to one of the advisors to the Council. While it may be a good idea, trying to get all 46 members aligned in some type of common strategy and implementation approach where the treaty represents a commitment “to do” rather than the implementation of a “common law” is a real stretch. But, at least the discussion is good.

Option 2: Adopt the OECD AI Principles - The Organisation for Economic Co-operation and Development (OECD) was formed in 1961 to implement the Marshall Plan in the wake of World War II and has continued to be a viable entity for assisting the European Union to become a reality. OECD has agreed to adopt a set of nonbinding set of principles for managing and supporting AI/ML development. These principles include a focus on: transparency, security, safety, accountability as well as respect for the rule of law, human rights, democratic values, and diversity. The principles also call for AI systems that contribute to economic growth – not economic destruction (yet to be defined). OECD has been working diligently to gain the support of the European Union members and is tracking adherence to the principles as well as the economic impact of these tools. Their work is only beginning and will require ongoing investments and adherence on the part of the European community.  

Option 3: Creation a Global Partnership on AI – Two leaders are taking the lead on this massive undertaking. They include Prime Minister Justin Trudeau of Canada and President Emmanuel Macron of France. The Global Partnership on AI (GPAI) was founded in 2020 as an international body with a focus on fostering shared research and information related to developments in AI/ML as well as supporting international research collaboration. To date, the GPAI includes 29 countries, some in Africa, South America, and Asia. In fact, the development and deployment of such a body has been advocated by a large number of AI experts across the globe as the best approach. In fact, it is similar to what has been done through the UN Intergovernmental Panel on Climate Change. Now, the question is: will such a group move fast enough to keep up with all of the AI/ML developments or will become embroiled in internecine debates among the nations of the world?

Option 4: Adoption of the European Union AI Act – The European Union is in the process of finalizing the AI Act. It was first proposed in 2021 as a bill to regulate AI/ML across the European Union with a focus on education and health care for starters.  The bill could hold bad actors accountable and prevent the worst excesses of harmful AI by issuing huge fines and preventing the sale and use of noncomplying AI technology in the EU. It seems to be a classic “regulatory” bill from the EU that would identify and manage the various risks and potential problems associated with AI/ML development. In fact, the EU version is the first cross-border regulatory approach that will be deployed so it will no doubt create pressure in other geographic regions to adopt similar – if not identical – options for regulation of AI/ML.  But, we wait and see…

Option 5: Industry Takes the Lead in Deploying Standards – There has already been some efforts on this front with the International Organization for Standardization (ISO) deploying standards related to management of the development process, risk management, and impact assessments once AI/ML is deployed. One of the debates; however, is whether a bunch of techies is the right group to be developing, managing, and deploying standards that have clear ethical, humanitarian and economic principles and standards. While they should clearly be at the table, the question is: Who should lead the discussion and framing of the principles? 

Option 6: Engage the United Nations – The UN gets called on regularly for all manner of international problems and considerations. With 193 member countries – at last count – the UN is the type of international organization that could potentially create global coordination on the AI/ML front. In fact, it appearsthe UN wants to be the focal point for solving the AL/ML conundrum. In fact, the UN created a UN Envoy in 2021 and adopted a voluntary AI ethics framework the UN wants to be the focal point for solving the AL/ML conundrum. In fact, the UN created a UN Envoy in 2021 and adopted a voluntary AI ethics framework whereby member nations would pledge their support for a set of principles related to the ethical, economic, and environmental of AI/ML tools. But, again – we shall see…

Are Big Box Stores The Future? – As a follow-up to the quote above, Health Leaders Media did an interview with Stacey Malakoff, the Chief Financial Officer for Hospital for Special Surgery based in New York City. She asked this question because of their ubiquitous presence in the retail environment where many of us seem to hang out. Back in 1985 I made the provocative, tongue-in-cheek “prediction” that Sears was going to tear out the carpet department in their stores and convert them into clinics staffed by “alternative providers” and that everyone upon arrival would be given a “beeper” to be “paged” when the provider was available so that they could wander around in the Sears store. The intent was for the “clinic” to be 15 – 20 minutes late so that everyone would have a chance to wander the Sears store and make those unplanned purchases AND be able to get their health care needs resolved before heading home. I was off by a couple of decades and Sears is not the model but CVS, Walgreens and others have picked up on the idea. 

Opinions and Reflections

The Debt Deal: It Ain’t Over Till It’s Over – While we may have averted Armageddon the problems the USA has with its overall debt continues to loom on the horizon. Perhaps not as much for the Boomers but for everyone else THIS IS A BIG DEAL. The USA debt load is now more than $31 Trillion dollars and there are 331.7 million citizens in the USA. Now, if you do the math (please double check me!!) – you will come up with an amazing number that each American citizen owes $107,000 dollars in overall debt to the USA government before getting to their own problems at home. And, THAT IS NOT SUSTAINABLE. 

And, What About Social Security And Medicare? – Over the years there have been any number of proposals put forward for addressing the Social Security and Medicare fiscal shortfalls. But, Congress has been glacial in its response despite the fact that the last 12 Trustees Reports have pointed directly at the fact the Social Security's Old-Age, Survivors, and Disability Insurance (OASDI) Trust Fund reserves will (not maybe) become depleted between 2033 and 2035 under an “intermediate set of assumptions” provided in each report. Why? It's largely because of Left-Right politics. Meanwhile, the USA situation is facing a massive increase of stress on these programs due to the large increase in the number of aged in our society. What to do?

There are several options that focus on saving the entitlement program money with the left-leaning advocates noting that such moves are primarily focused on benefit cuts. On the right, we hear about another common proposal to raise the retirement age [NOTE: raised loudly and clearly by Candidate Nikki Haley in her recent CCN Town Hall]. At present, citizens are eligible to start collecting Social Security benefits at age 62 although an early sign-on can reduce your lifetime payments by up to 30%. In fact, if the full retirement age were shifted to 70 for future retirees about 1/3 of the SSA deficit would be wiped out.

Another option is to reduce benefits for higher-income Americans. In essence this would be implemented with a “cap” on the benefits payment structure. However, it only raises 10 – 15% of the solvency cap resources for solving the problem. Yet another option is to apply the SSA tax rate of 12.4% - which is evenly divided among employers and employees on a 50/50 basis to more than the current maximum of $160,200. If you make more than that amount, there are no further SSA increased contributions. Medicare – on the other hand – applies the 2.9% total payroll tax rate to all wages with high-income Americans subject to an additional 0.9% Medicare tax.

And, as we seemingly move more toward a “gig economy”, we should anticipate that retirement programs will no longer be a staple benefit for American workers. In 1937 when the SSA programs were created, 92% of earnings were covered but that has fallen to about 83% in the current marketplace. Therefore, in the long term, the dependency upon the Medicare and SSA programs will increase – not decrease.

In essence, ALL OF THE OPTIONS need to be put on the table and a serious debate needs to begin on the future of SSA and Medicare. This is critical when it comes to sustaining a viable health care system as well. We of the healthcare community would be well-advised to become engaged advocates in SSA/Medicare Reform so that a sustainable approach is finally offered to the American people.

 

Opinions and Reflections 

What’s Love Got To Do With It? –  The American Heart Association’s website on the “heart” carries a substantial amount of information on heart healthy activities, heart-related medical symptoms and the like. In addition, they also recently included a subset of info on what happens when we have the “love” feeling take over our souls. Given that we just passed Valentine’s Day, I thought it might be a useful bit of information for all of us who are working to maintain an emotionally sensitive, aligned and robust attachment to the ones we love. Check it out! 

Much Ado About Something – If there’s a consistent “information technology” theme over the last several weeks, it’s that ChatGPT has inextricably changed the environment across the waterfront from healthcare, to finance, to politics, to education to whatever industry you care to discuss!! One of the louder voices on the potential downside of augmented intelligence (AI) over the last couple of weeks came to us from the former CEO of Google, Eric Schmidt. He spoke at a session sponsored by the Carnegie Endowment for International Peace on augmented intelligence (AI). The online discussion covered the waterfront. But, the example he shared that captured my attention was a podcast between Joe Rogan, the ultraconservative podcaster and Steve Jobs, the former CEO of Apple – which never happened!! Schmidt points out in the podcast that while AI can potentially be a very valuable tool for “good”, it also has the potential for creating “bad” or “erroneous” information that – if not scrutinized – will be digested by a gullible public. Schmidt pointed that: "There are people who will use this for terrible outcomes. We don't have a solution in society for this." In essence, he argues that while the AI toolsets offer some very clear advantages to us in our work, the tools have not yet caught up to the nuance of being human and the policies for managing the tools are way, way behind! Having spent over an hour on the phone with a computer system this past weekend to simply change an airline ticket AND being unable to get a “human” on the line, I think Schmidt is correct. Or, as some may argue, “Houston, I think we have a problem…” By the way, in a separate piece, I learned that ChatGPT passed the US Medical Licensing Exam without the benefit of any assistance from a clinician. Hmmm – robotic doctors on the horizon? – I wonder? Check It Out!!