LES MISÉRABLES

Les Misérables - the film - opened yesterday, and David and I were in back row center (my favorite seats) for the six o'clock showing. This was not because we are big fans of Les Miz. David had neither read it nor seen it, and though I saw the stage musical twice in London (the second time because my boss, with whom I was traveling, insisted), I wasn't crazy about it. But hey, it was Christmas Day, we needed to do something while digesting dinner, and it would have been too ironic to celebrate the birthday of the Prince of Peace by going to see Jack Reacher.

Our teenaged granddaughters wanted to know what we thought of Les Miz. Though we made a game attempt, a 2-hour-and-37-minute film is hard to review in text messages, so here are my extended observations.

The story. Quite faithful to Victor Hugo's sprawling novel (1779 pages in one French edition, and no, I haven't read it), this is a set-up, if not for the Oscars, at least for Christianity Today's annual list of most redeeming films. It won't be a spoiler for you to know that the hero, Jean Valjean, is a repentant thief who spends his life selflessly helping people. This is a story that reeks of moral uplift. And that's good: in an age that celebrates ruthless individualism, it is both shocking and inspiring to watch this reminder of the power of forgiveness and self-sacrifice.

The problem with the story. Despite his repeated willingness - if inability - to die for others, Valjean (like his creator, Hugo) supports an armed band of young insurrectionists who hope to overthrow the government. If you believe that peace is created by angry men who shoot the people with whom they disagree, you will find no inconsistency in this aspect of the story.

The historical background. Do read at least a couple of Wikipedia articles before going to see the movie. The one on the June Rebellion is a good place to start. Later you might want to read Charles Dickens's Oliver Twist, if you haven't already, or watch Oliver, the musical that reportedly inspired the French librettist of Les Miz. Oliver Twist was published 24 years before Les Misérables (it takes awhile to write 1779 pages), but the two books deal with the same general time period, and the lives of the poor were just as miserable in England as in France. It helps to realize that there's not much exaggeration in Les Miz, except of course that the poor were unlikely to be as gorgeous as Anne Hathaway.

The opera. Be aware that Les Miz is not just a musical. It's grand opera: "a genre of 19th-century opera ... characterised by large-scale casts and orchestras, and (in their original productions) lavish and spectacular design and stage effects, normally with plots based on or around dramatic historic events." The characters are much more likely to sing than to speak. There are recitatives and arias, rousing choruses, and even a sextet where the conflicting characters lay out their differences in counterpoint and set the audience up for the dénouement.

So what did I think of Les Miz? I liked the lavish spectacle. I thoroughly enjoyed the rowdy song "Master of the House" featuring Sacha Baron Cohen and Helena Bonham Carter. In fact, I enjoyed every scene featuring the evil duo. The sextet and chorus, "One Day More," is quite glorious. David, old romantic that he is, liked "Empty Chairs at Empty Tables."

The other 2 hours and 20 minutes, however, often left me thinking, in the oft repeated words of archvillain Javert, "Shoot me now."

At one point I whispered to David, "There are only two things I don't like about this opera: the words and the music." Apart from a few stellar numbers, the music ranges from insipid to tedious. One or two leitmotifs are endlessly repeated. Worse, a lot of the recitatives are simply drawn-out scales. If you can't come up with actual music, I wanted to scream, just let the characters talk, for Pete's sake.

The words are even worse. When I was a teenager, a particularly bad amateur poet came often to our church and read his supposedly inspirational poetry at us. I kept awake by playing a game: after he declaimed one line, I tried to guess the word he would use to make the next line rhyme. It was amazingly easy. I recommend, dear granddaughters, that you play this game while watching Les Miz. 

The librettist dips into his large sack of easy masculine rhymes (be/me, done/run, know/go, chill/kill) and scatters them prodigally about. He is particularly taken with the near-rhyme Jean Valjean with "on" and "gone." Never does he play with words like Alan Jay Lerner in, say,  Camelot ("You'll never find a virtue / Unstatussing my quo / Or making my Beelzebubble burst ...") or Stephen Sondheim in West Side Story ("I like the isle of Manhattan, / Smoke on your pipe and put that in!") Except for the bawdy tavern song, all the songs in Les Miz are so earnest, so sentimental, so predictable.

Still, as of this writing, 63% of the top critics (surveyed by Rotten Tomatoes) liked the movie, as did 72% of critics in general and 86% of the audience. That's not shabby. You may like it too, and I won't think less of you for it. Just don't put yourself through it three times. Nobody needs to be that misérable.

Violence : It isn't just about the guns

This is not a blog post about gun control. Everything that can possibly be said about that subject, pro or con, has already been said millions of times since Friday. We are talking too much, too soon. In the words of my rabbi, “Judaism teaches that when there is nothing to say we should say nothing….Sometimes only silence gives voice to what has happened."

We Americans should all be sitting shiva.

But when, next week, we rise from our knees and begin working – together, I hope – to reduce the terrible problem of violence in our country, we must realize that our disorder goes much deeper than simply owning too many guns, and that any effective solution will have to go much deeper too.

When they are distressed, some people clean house or do push-ups  I collect data. All week I have been amassing numbers and arranging them in rows and columns, trying to shed light on the question: Why are some nations violent while others are not?

To answer that question would take a lifetime of research and more wisdom than Solomon’s. The best I could do was to look at the homicide rates of the 34 OECD nations, which are the countries that most resemble the United States in culture and economics, and to compare them with rates in other categories. The best I can offer are correlations, not causes.* Here is what I have learned in the last four days.

1. Despite what liberals like myself would like to believe, the homicide rate does not correlate, either negatively or positively, with the gun-ownership rate per se.** South Korea, for example, has a very low gun-ownership rate but a high homicide rate. Austria, Norway, and Switzerland, on the other hand, have relatively high gun-ownership rates but low homicide rates. Japan has low rates all around – very few guns, very few homicides – while the United States has high rates of both gun ownership and homicide.

2. Despite what some preachers (and atheists) have claimed, the homicide rate does not correlate, either negatively or positively, with religiosity. The United States is highly religious and highly homicidal. Japan is barely religious and has almost no homicides. Most nations, though, are an unpredictable mixture of spirituality and savagery.

3. There appears to be some correlation between high homicide rates and a high degree of economic inequality. This seems particularly evident in Mexico, Estonia, the United States, and Chile, who all have lots of homicides and a great gap between rich and poor.

4. The homicide rate correlates most strikingly with three other rates:

• The higher a nation’s homicide rate, the more likely it is to have a high rate of military expenditures.
• The higher a nation’s homicide rate, the less likely it is to have an effective healthcare system.
• The higher a nation’s homicide rate, the less likely its students are to earn high scores in mathematics.

In other words, if you want to identify homicidal OECD nations, look for the ones with the strongest militaries and the weakest social services. 

In case you’re wondering, of the 34 OECD nations, the United States has the third-highest homicide rate. We also have the highest number of guns per 100 residents and the fourth-highest rate of military expenditures (for what is by far the most expensive military in the world). At the same time we have the third highest income-inequality rate. In healthcare outcomes we are in 24th place, and in mathematical achievement we are tied with Portugal and Ireland for 25th place.

Sixty years ago President Eisenhower warned us about the path we were taking:

Every gun that is made, every warship launched, every rocket fired signifies, in the final sense, a theft from those who hunger and are not fed, those who are cold and are not clothed. This world in arms is not spending money alone. It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children. ... Is there no other way the world may live?

Today President Obama announced that Vice-President Biden will "lead an exploration of options" regarding "the renewal of an assault weapons ban, limits on high-capacity ammunition magazines and an end to loopholes allowing gun purchases with no background checks."

Such options, if legislated and enforced, might well decrease our appalling homicide rate. They will not, however, reduce our huge military outlay. They will not make our healthcare and educational systems competitive with those of other nations. And until we prioritize people over power, we are likely to continue down our violent path.

--------------------------------------------------
* This research is about correlation, not causation. Two facts - we'll call them A and B - coexist. A may cause B. On the other hand, B may cause A. Some other fact may cause both A and B. Or A and B may have nothing to do with one another. For example, eating chocolate may cause migraine headaches. On the other hand, an incipient migraine headache may cause a person to crave chocolate. Or possibly some alteration in brain chemistry may cause a person both to crave chocolate and to get a migraine. Or maybe chocolate and migraines are totally unrelated. It takes wisdom, common sense, and often hindsight to sort out how, and if, coexisting facts are causally related.

** I have not studied OECD gun laws, so I do not know what kinds of guns are involved in these countries, who can legally purchase them, or what background checks or training are required before purchase. Nor do I know how laws may have changed over the last couple of decades, or how homicide and gun-ownership rates may have changed in response to changed legislation. Any of those factors could affect their homicide rates.

THE BLACK BOX by Michael Connelly

Harry Bosch fans, it's time to pour yourself a Fat Tire (one of Bosch's favorites), put Art Pepper's "Patricia" (Bosch's birthday gift from his 16-year-old daughter, Maddie) on your iPod, and settle down for an engrossing read. If you haven't yet read any of the Harry Bosch books, that's OK too. You can start with this one and pick up the others later.

--from my review of The Black Box, now up on the Books and Culture website.
Click here to read it.

'Tis the season to read something relaxing

Renoir, La lectrice, 1874

Thanksgiving down, Christmas coming. Parties to attend. Christmas greetings to send. Gifts to buy. Travel arrangements to make. Groceries to buy. Meals to cook. Guest rooms to get ready. Decorations to display. Checks to write.

Nerves to calm.

I dedicate this blog post to my friend Karen, and to everyone else who needs to pour a comforting drink, sit down, elevate feet, and read a diverting novel--one that engrosses you, makes you smile, lets you relax, does not leave you with the taste of ashes.

Actually, you may need more than one such novel. So despite my inordinate fondness for one-offs like Sarah Dunn's Secrets to Happiness and Helen Simonson's Major Pettigrew's Last Stand, I'm going to give you a list of novels any one of which can lead you to four or a hundred similar delectable books.

My rules for series fiction:
1. Start with whatever book grabs your attention. It doesn't have to be the first in the series.
2. If you don't like it, don't bother with the rest of the series unless at least three of your friends have recommended it--in which case, try a second book.
3. If you like either the first or second book reasonably well, read two more books in the same series. By then, you'll either be in love with the series or you'll be ready to try something else.

Here are ten of my favorite authors of series fiction. The links will take you to reviews I've written either on this blog or in magazines.

• Michael Connelly, The Reversal (and others). Detective Harry Bosch is the best in the business. Connelly has written 25 books, 18 about Harry. Newest, The Black Box, came out two days ago. Not a bad place to start. But if you'd rather start with a legal thriller, go for The Lincoln Lawyer.
• Margaret Frazer, The Apostate's Tale. The indomitable nun Dame Frevisse gets involved with a lot of 15th-century mayhem. I like Ellis Peters's Brother Cadfael books, but I got even more attached to Dame Frevisse.
• Sue Grafton, V Is for Vengeance. Start with A Is for Alibi. If the fourth sentence doesn't grab you, nothing will: "The day before yesterday I killed someone and the fact weighs heavily on my mind." W-Z are still to come, but you have 22 books to read before you run out.
• P.D. James, Talking About Detective Fiction. First, read P.D. James's mysteries. They're all good, and you don't have to read them in order. Or just watch the TV adaptations starring Roy Marsden. Talking About Detective Fiction is Dame James's discussion of great mystery writers--dozens of them. Follow her leads and you'll have enough to read until you retire.
• Donna Leon, Death and Judgment. Oh, just start with Death at La Fenice and read all of Leon's Venetian mysteries featuring Commissario Guido Brunetti. He's a lovable cop, and the Italian ambiance is a treat.
• Peter Lovesey, Cop to Corpse. Detective Superintendent Peter Diamond presides grumpily over the Avon and Somerset murder squad. You may not care for him at first--his coworkers certainly don't--but he grows on you.
• Alexander McCall Smith, The Forgotten Affairs of Youth. I find Scottish author McCall Smith more relaxing than a wee dram of single malt. His characters are quirky, funny, and fundamentally good. My review mentions several of his series; fortunately for his fans, he tends to write three books a year.
• Spencer Quinn, To Fetch a Thief. Chet the dog narrates, but these stories are rarely cutesie. They can be pretty darn funny, though--especially to those of us who live with dogs. And there's always an interesting plot.
• C.J. Sansom, Dissolution. Sansom is writing a series of fantastic 16th-century (think Henry VIII) mysteries. These are large books, a bit more serious than some on this list, but utterly engrossing. You can have Wolf Hall and its sequel: I'll take Sansom any day.
• Jennifer Weiner, Good in Bed / Certain Girls. Bright and sassy chick lit. Weiner is a Princeton grad with a rowdy sense of humor. Not to be sexist or anything, but I'm guessing these aren't for guys.

And there are others ... so many others. Laurie R. King is a delight. She's been turning out a lot of books in the Mary Russell (Mrs. Sherlock Holmes) series as well as several stand-alone volumes, but my favorites are her Kate Martinelli books. Jane Langton, who is about to turn 90, wrote a lot of gently humorous New England-based books about ex-cop/current Harvard professor Homer Kelly and his brilliant wife, Mary.

And if you're feeling really, really tired--as I was after open-heart surgery last year--M.C. Beaton's Agatha Raisin and Hamish Macbeth series are silly fun. I read 30 of them while convalescing, and I'm feeling fine, thanks!

Please, readers, add comments (here, and not just on Facebook) about series fiction you've enjoyed...

Black Friday at the pet store

The dog is right - this is the only Black Friday sale I was interested in. In fact, it's the only Black Friday sale I've ever gone to. And the only reason I went to this one is because my scruffy little terrier urgently woke me up at 6:00 this morning. This is the dog who, most mornings, would sleep as late as a teenager if we didn't drag her out from under the covers. I guess she knew about the sale.

So I dragged my protesting carcass to Pet Supplies Plus, vowing to come back home immediately if parking was hard to find - and snagged the space right next to the handicap space by the door.

Inside, a check-out line stretched from the cash register to the west wall of the store, angled right and continued to the premium dog foods on the north wall. A second line heading due north looked equally long. I noticed one shopper in pajamas.

No more shopping carts were available, so customers were using toddler-sized customer-in-training carts, stockroom carts, and dollies. No more of them were available either. Never mind. To save 30%, I was willing to schlep a 26-pound bag of Wellness Core Grain-Free Ocean Formula, a 5.5-pound bag of Orijen Adult Dog Food, a tube of poultry flavored toothpaste, and 2 packets of FrontLine Plus from the back to the front of the store.

The experience restored my faith in human nature.

Nobody was trampled. Nobody shoved. No voices were raised. Even the two dogs in line near me sat patiently - for 50 minutes, which is how long it took to get to the head of the line.

The man in front of me kindly held my place while I went in search of doggy toothpaste.

At 7:45, he commented that the sale was likely to be over before we made it to the cash register. At 7:50, however, an employee distributed cards marked "30%" to all of us in line.

I waved to a friend who was about 10 people ahead of me. After she checked out and unloaded her purchases, she brought her cart back into the store and gave it to me. I then shared it with the man in front of me, whose dog food bag was even bigger than mine.

The check-out clerk was efficient and pleasant. A smiling shopper came up to me as I headed for the parking lot and said, "I'm going to follow you and take your cart when you're done with it." I was happy to give it to her.

Everyone was so helpful and agreeable, in fact, that it felt like the way neighbors bond after a major snowstorm, or survivors after a disaster. Were we all thrilled to have escaped Black Friday unscathed? Or are animal lovers just really nice people?

A JANE AUSTEN EDUCATION by William Deresiewicz

I loved William Deresiewicz's op-ed piece "A Matter of Taste?", a look at how "foodism has taken on the sociological characteristics of what used to be known — in the days of the rising postwar middle class, when Mortimer Adler was peddling the Great Books and Leonard Bernstein was on television — as culture." If you didn't read it, now's a good time.

Be sure to read the author's bio at the end. If you're like me, the next thing you'll do is buy or borrow his 2011 book, A Jane Austen Education: How Six Novels Taught Me About Love, Friendship, and the Things That Really Matter.

The book is part memoir, part literary interpretation, part wisdom literature. The three parts aren't seamlessly integrated, and that bothered some reviewers. I enjoy all three genres and appreciated the author's - let's call him Bill - self-deprecating humor, so I wasn't bothered.

Here's the plot: Bill recounts how he moved from disdaining Jane Austen to adoring her and eventually writing his Ph.D. dissertation about her. In the process, he also moved from being a (self-described) dumb 26-year-old with daddy issues and a dismal romantic life, to being a grown-up guy with an apartment, a job, good friends, and a wife.

Jane Austen, it turns out, was his life coach.

If you already like Jane Austen, you'll probably enjoy Bill's ideas about the messages underlying her six novels.

If you read Jane Austen a long time ago - or just saw the movies and TV miniseries -  don't hesitate to pick up this book. Bill gives enough context that you'll know exactly what's going on.

If you don't like Jane Austen (but have to read her for class), or if you've never tried her at all, go ahead and see if Bill can get you interested. His book is at least as much about "the things that really matter" as about Jane.

Thanks to Bill, I'm now rereading - well, listening to an audiobook of - Northanger Abbey, Jane Austen's hilarious send-up of gothic fiction. It's read by one of my favorite narrators, Wanda McCaddon, under the name of Nadia May (she is also widely known as Donada Peters).

Mr. Metz's 5% health-insurance surcharge

I'm having trouble understanding today's news about "Florida based restaurant boss John Metz, who runs approximately 40 Denny's and owns the Hurricane Grill & Wings franchise." According to an article in the U.K.'s Mail Online, Mr. Metz "has decided to offset [the extra cost Obamacare will bring] by adding a five percent surcharge to customers' bills and will reduce his employees' hours."

Here's what scares Mr. Metz: By 2014, Obamacare will require employers (of more than 50 workers) to provide adequate health insurance for full-time employees or risk paying a penalty (you can learn the details at the Kaiser Family Foundation's website).

If he's scared, it must be because his restaurants do not provide adequate health insurance for their full-time workers. Actually, Denny's does provide what their New Employee Enrollment Guide calls "affordable limited benefit medical plans to all eligible employees." (That was from their guide for hourly employees; salaried employees also get health insurance.) Is Mr. Metz ignoring Denny's benefits package? Or does he believe that the insurance is so inadequate that employees will choose to get insurance elsewhere? Or are his workers paid so poorly that they can't possibly afford even the low-cost option? Or does his own chain, Hurricane Grill & Wings, not offer this benefit at all? Because if he's providing decent health insurance that his employees can afford, he will not have any extra charges and so has no reason to add a surcharge to his meals.

So why is he adding a surcharge and downgrading his workers to part-time status?  According to Fox News, "To further offset the costs, Metz, who oversees roughly 1,200 employees as president and CEO of RREMC Restaurants, LLC, said he also will slash most of the staff's time to fewer than 30 hours per week." If Mr. Metz is providing inadequate insurance - or no insurance at all - to his full-time employees, I can understand why he would want to make all jobs part-time. That way he would face no government penalties for his miserable benefits policy. But if by reducing hours (and hurting his workers even more than he's already doing) he manages to escape the penalties, then why is he adding the surcharge?

Mr. Metz seems to be sending the message that he hates Obamacare. He may not realize it, but he's also sending the message (whether true or not) that he's a rotten employer who provides inadequate employee benefits, would rather cut workers' hours than be required to treat them humanely, and then is willing to make diners pay more for supposed additional costs - even though he has managed not to incur them.

I was going to end there, but then I got to thinking: maybe this isn't only about Mr. Metz. Maybe he really can't give his workers adequate pay and benefits and still stay in business. Maybe this is really about us.

We Americans in the upper 53% have relatively inexpensive houses and cars and clothing and groceries and restaurant meals (when compared with the rest of the world). We manage this by sending much of our manufacturing overseas and by paying squat for services

The people who grow our food, process our meat, bring the food to our tables, wash our dishes, clean our offices, and care for our aging parents often do not earn enough to support their families and must rely on tax-supported programs just to survive (in Florida, Mr. Metz's home state, a person working two 24-hour-a-week minimum-wage jobs, 52 weeks a year with no time off, would bring in $19,144 before payroll taxes; in neighboring Georgia, where Mr. Metz has a few restaurants, the minimum-wage two-job worker would make just $12,854).

But we Americans have relatively low taxes - which means that our social safety net has a lot of holes in it.

Did you know, for example, that "Wal-Mart's poverty wages force employees to rely on $2.66 billion in government help every year, or about $420,000 per store[?]. In state after state, Wal-Mart employees are the top recipients of Medicaid. As many as 80 percent of workers in Wal-Mart stores use food stamps" (check it out here).

So what happens to these underpaid workers if we continue to demand lower prices and lower taxes?

Obamacare, though it needs improvement, is an important step toward justice. Mr. Metz's surcharge could be another step in the right direction if it enables him to insure all his employees.

However, if diners reduce their tips by the amount of the surcharge, restaurant workers will end up with even less take-home pay than before. If Americans continue to push for lower taxes, more and more of the working poor will fall through the safety net. And if Mr. Metz goes ahead and reduces the hours of his full-time workers so that they won't qualify for health insurance, the extra 5% will go directly into his pocket.

"We're the greatest" - an empty boast or a call to action?

I believe we can seize this future together -- because we are not as divided as our politics suggest; we're not as cynical as the pundits believe; we are greater than the sum of our individual ambitions; and we remain more than a collection of red states and blue states. We are, and forever will be, the United States of America. And together, with your help, and God’s grace, we will continue our journey forward, and remind the world just why it is that we live in the greatest nation on Earth.

--President Barack Obama, 7 November 2012

Yesterday I joined a Facebook exchange about whether the United States is indeed the greatest nation on Earth. By quite a few objective criteria, I argued, we trail other nations: health care accessibility, lifespan, maternal mortality, education, infrastructure development, employment, equality of opportunity ... well, the list is frighteningly long. We are clearly not the greatest nation on earth by any standards that people from other nations would accept, and we are becoming less great every year (for a European view of America's decline, read this sobering article - in English - from Monday's Der Spiegel).

Yesterday I also told my two little dogs - Muffin the poodle mix and Tiggy-Winkle the terrier - that they are the best little dogs in the world. By quite a few objective criteria, I am deluded about my dogs. Tiggy  digs holes in upholstered furniture, and she barks so much that she was nearly kicked out of obedience school ("Just give up," the trainer advised; "she's going to bark, whatever you do"). Muffin snores, refuses to cooperate with her groomer, and bites large dogs. But I love my dogs passionately. I wouldn't trade them for any Westminster champions or obedience winners. Several friends, watching me interact with Tiggy and Muffin, have said they would like to be my dogs.

Some people who say America's the greatest really believe that we have the best health care, the best education, the highest incomes, the most liberty, the least corruption, and the most opportunities to succeed. Sadly, these people are deluded. That may have been true in the 1950s, but it is not true today.

However, I suspect that most people who say America's the greatest, including our president, aren't thinking about data at all. They are saying they love America passionately and that they wouldn't consider moving elsewhere even if they found a country that surpasses America in every quantifiable area. They are saying they believe in our founding fathers' vision of America as summarized by Abraham Lincoln: "a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal." They are saying they love the spacious skies, the amber waves of grain, the purple mountain majesties, the fruited plain - and especially the patriot dream that sees beyond the years (I really think "America the Beautiful" should be our national anthem). They are saying they are willing to work hard to make the dream the reality.

The people who truly believe America is greater than any other country need to check their data. They might also want to read Jesus' story about the Pharisee and the publican (Luke 18:10-14) or Percy Bysshe Shelley's "Ozymandias" or Carl Sandburg's "Four Preludes on Playthings in the Wind." Hubris does not make America strong. To the contrary, by blinding us to our problems, it keeps us from fixing them.

But the people who know that America has serious problems and yet love her anyway - love her so much that in their enthusiasm they sometimes say America is the greatest nation on Earth - are the people who can lead our country back to equality of opportunity, who can work to improve our schools, our health care, our roads, our businesses, our environment, our immigration policies, and our working conditions. Most important of all, these are the people who can encourage us to be concerned not only for ourselves but also for one another.

When people in other countries hear Americans say America is the greatest nation on Earth, they tend to think this is an empty boast from a nation of bullies (after all, we do have the biggest military on earth, outspending the next 13 countries combined). If, however, they understood us to mean We love America and want to make it great, I suspect they would be more indulgent toward us, even if they didn't care for our word choice. In the interest of international understanding, we would probably do well to change our diction.

In the late 1930s, as nationalism intensified and much of the world was on the brink of war, Lloyd Stone and Georgia Harkness wrote words to the tune Finlandia that express American patriotism at its best. Here are two of its verses:

This is my song, O God of all the nations,

A song of peace for lands afar and mine.

This is my home, the country where my heart is;

Here are my hopes, my dreams, my sacred shrine.

But other hearts in other lands are beating,

With hopes and dreams as true and high as mine.

My country’s skies are bluer than the ocean,

And sunlight beams on cloverleaf and pine.

But other lands have sunlight too and clover,

And skies are everywhere as blue as mine.

O hear my song, O God of all the nations,

A song of peace for their land and for mine.

This is the language of hope and love, not of bluster.

It is the language President Obama used in his victory speech:

What makes America exceptional are the bonds that hold together the most diverse nation on earth. The belief that our destiny is shared; that this country only works when we accept certain obligations to one another and to future generations. The freedom which so many Americans have fought for and died for come with responsibilities as well as rights. And among those are love and charity and duty and patriotism. That's what makes America great.

It is the language that can lead us to "crown [our] good with brotherhood / From sea to shining sea." And beyond.

Advice for November 6: Choose your battle wisely

Vice-President Aaron Burr spoils his political career by
killing former treasury secretary Alexander Hamilton.

Yesterday during the Prayers of the People at St Barnabas, someone in the congregation spontaneously thanked God that the American election season is almost over. Everyone laughed.

One reason this election has brought out the worst in us is that we are fighting two battles at once. I fear that, no matter who wins the presidency, we will continue to fight these battles. We will probably still be fighting them in 2016.

We are fighting an economic battle between those who believe that the federal government should spend tax dollars on the military and little else, and those who believe that the federal government should also play a major role in assuring health care for all, supporting the indigent and elderly, rebuilding our infrastructure, and aiding disaster-stricken areas.

At the same time, we are fighting a moral battle between those who believe the federal government should allow individuals the freedom to decide whom to marry and whether to carry a child to term, and those who believe the federal government should outlaw abortion and recognize only heterosexual marriages.

The two major parties have divided up our concerns in unexpected ways. The Democratic ticket is communitarian in economics and libertarian in morals; the Republican ticket is just the reverse. This creates a problem for people who are consistently communitarian or libertarian.

A lot of students at Miami University of Ohio, as Bill Keller points out today in "The Republican Id," are consistently libertarian: they are enthusiastic about Republican economics but reject Republican morals. For them, economics trumps morals: the majority support Romney.

Most Catholic bishops, on the other hand, are consistently communitarian: they support Democratic economics but reject Democratic morals. For many bishops, morals trump economics (see David Gibson, "Catholic bishops make last-minute push for Romney"): they too support Romney.

The students are far smarter than the bishops.

If Romney and Ryan are elected, there's a good chance that federal programs such as Social Security, Medicare, and Medicaid will be gutted (click here for five good reasons to be worried, even if you're over 55), along with smaller programs such as highway construction, education, and food stamps. There's not much chance, however, that abortion or gay marriage will go away. Overturning Roe v. Wade would not outlaw abortion; it would return the question to the states. As long as a woman had enough money, she could simply travel to wherever abortion was available.

If you're a student at a highly rated university like Miami, you probably figure you'll be one of the elites that would be helped by Romney/Ryan economics. As one of those elites, you could find your way around Republican moral strictures. So yes, as long as you're not concerned about people who haven't done as well as you, it makes sense for you to vote for survival of the fittest. (In a decade or two you may discover you're less fit than you thought you were, but you can vote differently then.)

The Catholic bishops, on the other hand, are showing themselves to be as wise as doves and as harmless as serpents. Even if they get their way - in the name of religious liberty! - Americans will continue to use contraception. They will continue to marry or live with whomever they please. They will continue to get far too many abortions (though if abortion goes underground, a lot more women will die).

Catholic bishops have little effect on American morals (even among their own parishioners: click here to see statistics on abortion rates and here to see statistics on contraceptive use among Catholics), but if they tip the election to Romney/Ryan, they may have a major effect on American economics - an effect that goes against more than a century of Catholic social teaching. In the name of freedom and small government, more families will struggle to put food on the table, to send their children to college, to find adequate housing, to care for their aging parents. Americans will continue to die younger than people in countries with universal health care. Our highways and bridges will deteriorate, and environmental pollution will increase. We may tumble back into recession or even depression.

Here's my point. Our next president's policies will probably have a major effect on America's economic health and, very likely, the economic health of the world. His policies will probably have a minor effect, if any effect at all, on America's morals.

If you like Romney/Ryan's Darwinian proposals, if you think the financiers who are paying for their campaign will help the middle class, if you believe that trickle-down economics help the poor (or if you think the poor shouldn't be helped), if you think business can thrive in the absence of a strong infrastructure, if you think climate change is a hoax, and if you trust for-profit health insurance companies with your life, then by all means vote for Romney-Ryan.

Just don't think they're going to bring about moral renewal in America.

CALL THE MIDWIFE by Jennifer Worth

"Call the Midwife," a BBC miniseries about intrepid nuns and nurses in London's East End in the 1950s, was the UK's most popular TV show in 2012, with even more viewers than last year's wildly popular "Downton Abbey."

I had not heard of the TV show three weeks ago when, browsing in a Chicago bookstore, I noticed Jennifer Worth's memoir by the same name. Always on the lookout for cheerful stories, I jotted down its title so I'd remember to look for it at my public library.

The book did not disappoint.

In 1965, my parents and I spent a summer in Bracknell, a middle-class suburb about 35 miles west of central London. Some 10 years earlier, Jennifer Worth had been working as a midwife in the London Docklands, about 6 miles east of central London. Only 10 years and 40 miles separated my comfortable (even though it lacked central heating and had altogether too much cabbage) world from the world Jennifer served:

I often wondered how these women managed, with a family of up to thirteen or fourteen children in a small house, containing only two or three bedrooms. Some families of that size lived in the tenements, which often consisted of only two rooms and a tiny kitchen.... Washing machines were virtually unknown and tumble driers had not been invented.... Most houses had running cold water and a flushing lavatory in the yard outside.

It was an area of bombed-out ruins from World War II air raids. "Knifings were common. Street fights were common. Pub fights and brawls were an everyday event. In the small, overcrowded houses, domestic violence was expected." Certain streets were well known as centers of prostitution.

So why am I calling this book cheerful?

Because Jennifer tells so many stories about people who work hard, who love one another, who survive against incredible odds, who welcome new life, who do their best.

Because even her heart-breaking stories--the teen-aged Irish prostitute, the weird old crone who hangs around when babies are due--reveal sensitive humanity under the off-putting exteriors.

Because her nuns, from bawdy Sister Evangelina to spacey Sister Monica Joan, are a hoot.

Because she's so good at describing all her characters, most notably Camilla Fortescue-Cholmeley-Brown ("just call me Chummy"), drolly played by Miranda Hart in the TV series.

Because she included a 13-page appendix "On the difficulties of writing the Cockney dialect."

Because Jennifer's storytelling shows her living by the philosophy she says she learned from a dying nun: Accept life, the world, Spirit, God, call it what you will, and all else will follow.
_______________________________

 "Call the Midwife" is being shown on PBS stations Sunday evenings from September 30 to November 4, 2012. If you've missed some episodes, you can get them online until December 3. Here's a link to Episode 1.

Hormone replacement - will it kill you or make you healthier? What the reports aren't telling you about HRT

"Hormone Therapy Whiplash: Say No to HRT! Say Yes to HRT! Which Is It?"

That's the headline of an article by Melanie Haiken on today's Forbes website. Haiken is  frustrated by conflicting recommendations about hormone replacement based on European and American medical studies.

In the new European study, women began using hormone replacement therapy at about the time of menopause and lowered their likelihood of getting a number of dread diseases. Take HRT, say European doctors.

In the 10-year-old American study, women began taking hormones some ten years after menopause and raised their chances of succumbing to heart disease, breast cancer, blood clots, gall bladder dysfunction, dementia ... well, you get the picture. Don't take HRT, say American doctors.

Aha! say some experts, examining both studies. Timing makes all the difference. Take those pills when you're relatively young. Don't wait until you're over 60 to start them. "If you’re within a five to ten-year window of menopause," Haiken concludes, think carefully about your own circumstances and then "see your doctor for a frank discussion."

Well okay. But somehow I'm still confused. Or would be, if I hadn't noticed something else about the studies.

Unfortunately, Haiken and Hwang - along with just about everybody else discussing conflicting studies on HRT - pay no attention to what may turn out to be the most important difference between the two studies: they used different types of estrogen. 

Participants in the American study took Prempro (a tablet containing conjugated estrogens made from horse urine along with a progestin) or Premarin (just the conjugated estrogens).

Participants in the European study took estradiol (a synthetic form of the principal and most potent human estrogen) plus a progestin if they still had a uterus.

The conjugated estrogen group had bad results. The estradiol group had good results.

Now, I'm not saying that the difference in formula is the reason for the difference in results. It may indeed have more to do with timing, or with some other element in the study. I'm just saying that I can't imagine how responsible scientists and journalists could ignore the fact that these studies were looking at different medications. All estrogens are not alike.

What happens to younger women who take Prempro? Or to women who wait until they're 60 and then start taking estradiol? We don't know, because those questions haven't been addressed.

And why haven't they been addressed? I'm not into conspiracy theories, but I do think that "follow the money" can be good advice. Prempro and its sister medication, Premarin (conjugated estrogens without a progestin), are among the top selling medications in the United States. Estradiol, by contrast, is available in a generic version.

I checked prices at my online pharmacy, Prime Mail, and here's what I found.

• A 30-day supply of Prempro (0.625mg conjugated estrogens plus 2.5mg medroxyprogesterone acetate) costs $94.34.
• By contrast, a 30-day supply of estradiol (1.0mg) plus generic micronized progesterone (100mg a day for 10 days) costs $23.91.
• For women who have had hysterectomies, the progestin/progesterone is unnecessary. A 30-day supply of Premarin (0.625 conjugated estrogens) costs $74.74.
• By contrast, a 30-day supply of estradiol (1.0mg) costs $4.96.

For some reason American doctors don't prescribe estradiol nearly as often as they prescribe Prempro and Premarin. For some reason American researchers pay little attention to estradiol and none, as far as I can tell, to micronized progesterone. For some reason American journalists write as if all estrogens were alike.

And yet the difference between a healthy old age and years of debilitating illness could lie in the difference between an expensive patented medication and its inexpensive generic counterpart. We simply won't know until extensive studies have been completed and analyzed. And since that's not likely to happen during my lifetime, I plan to stick with the medication that costs less and yet appears to give far better results.

The foreign policy debate, the four horsemen of the Apocalypse, and four candidates

Albrecht Dürer, ca 1497-98
The Four Horsemen
of the Apocalypse

Tonight's debate between President Obama and Governor Romney is about foreign policy. This may be the most important topic of the entire [interminable] election season, both to America's future and to the future of the whole world.

If our leaders get foreign policy wrong, we may suffer more than a severe recession. Think world economic collapse. Rampant terrorism. All-out nuclear destruction. Conquest, war, famine, death (the four horsemen of Revelation 6).

Unfortunately, tonight's debate is likely to have fewer viewers than the first two presidential debates: it will be competing against Monday night football. We Americans have priorities.

And, as writers for Forbes magazine recently pointed out, learning foreign languages--perhaps the most important tool for understanding other cultures--is not high on our priority list. Though demand for foreign language learning is increasing, "schools at every level are balancing their budgets and offsetting reductions in government allocations by cutting their offerings and/or eliminating foreign language requirements."

In 2001, before the latest round of language cuts took place, only about one in four Americans could carry on a conversation in a second language (Gallup poll). Half of these were native Spanish speakers. By contrast, "just over half of Europeans (54%) are able to hold a conversation in at least one additional language, a quarter (25%) are able to speak at least two additional languages and one in ten (10%) are conversant in at least three" (Europabarometer survey, 2012).

President Obama agrees about the importance of speaking foreign languages and has apologized for not speaking any himself (though he apparently knows some Indonesian from his childhood).

Governor Romney claims to speak French. After listening to him read a speech at the Salt Lake City Olympics, I'm guessing that he's far from fluent without a script.

Vice-President Biden and Congressman Ryan, as far as I know, speak no foreign languages at all.

OK then, what about the foreign affairs knowledge and experience of these men who want to lead the world?

President Obama lived in Indonesia from 1967 to 1971, between the ages of 6 and 10; for part of that time he attended local schools. His undergraduate major at Columbia University was political science with a subspecialty in international relations. Between 1981 and 2006 he traveled to Indonesia, Pakistan, India, Kenya (three times), and Europe.

Governor Romney lived in France from 1966 to 1968, between the ages of 19 and 21, working as a Mormon missionary. I was unable to find evidence of other overseas trips before this summer's tour of Europe and Israel--a trip that may have contributed to the fact that "the reputation of the US in Europe risks sinking back to Bush-era levels of unpopularity if Mitt Romney becomes president, according to new international polling published on Tuesday" (The Guardian, September 11).

Vice-President Biden was for many years a member of the Senate Committee on Foreign Relations and chaired that committee three times. Over the years Biden has met with dozens of heads of state. The Council on Foreign Relations summarized his positions and achievements (up until 2008) here.

As far as I can tell, Congressman Ryan has had no particular education or experience in foreign policy.

Not so long ago the United States had an administration that understood so little about the world, they really believed they could overthrow the Iraqi regime without giving Iran a license to do their worst--and they really thought that if they did this, Iraqis would fall to their knees in gratitude. We don't need another administration with that kind of dangerous naïveté.

Today the New Yorker magazine, in a long and thoughtful article dated October 29, endorsed President Obama. Here is what they said about Governor Romney's approach to foreign policy:

Holding foreign bank accounts is not a substitute for experience in foreign policy. In that area, he has outsourced his views to mediocre, ideologically driven advisers like Dan Senor and John Bolton. He speaks in Cold War jingoism. On a brief foray abroad this summer, he managed, in rapid order, to insult the British, to pander crudely to Benjamin Netanyahu in order to win the votes and contributions of his conservative Jewish and Evangelical supporters, and to dodge ordinary questions from the press in Poland. On the thorniest of foreign-policy problems—from Pakistan to Syria—his campaign has offered no alternatives except a set of tough-guy slogans and an oft-repeated faith in “American exceptionalism.”

I am posting this four hours before tonight's debate begins. I sincerely hope both candidates show broad knowledge and deep wisdom about questions of foreign policy, because one of them is going to win this election. I also hope that voters have enough wisdom and understanding to be able to tell when they are speaking truth and when they are blowing smoke.

A lot depends on the winner's understanding of and ability to work with other nations. A lot.

P.S. None of the four candidates served in the military. None of Governor Romney's five sons served in the military. One of Vice-President Biden's sons joined the National Guard and has done a one-year tour of duty in Iraq.

Death with Dignity

Seneca the Younger committing
suicide with the help of his friends,
A.D. 65 (Luca Giordano, 1684)

Next month Massachusetts voters will decide whether to allow "Death with Dignity," aka physician-assisted suicide. If a majority vote yes, Massachusetts will become the fourth state (after Oregon, Washington, and Montana) to allow a licensed physician "to prescribe medication, at the request of a terminally-ill patient meeting certain conditions, to end that person’s life."

Father Tadeusz Pacholczyk, a Catholic priest and fierce right-to-lifer who weighed in on the issue in yesterday's Wall Street Journal, plans to vote no.

In "Please Step Back from the Assisted Suicide Ledge," Pacholczyk argues that physicians who provided lethal medications would destroy public trust as surely as policemen who provided guns or lifeguards who provided millstones (millstones?) to despondent people. He then offers two anecdotes: one about a woman who felt betrayed by her grandparents' joint suicide (they did not have a terminal illness, and their deaths were not physician assisted, so her story does not apply), and the other about a friend with multiple sclerosis who is glad he's still alive to enjoy his grandchildren (nobody is suggesting that PAS be mandatory, for Pete's sake, so this story doesn't apply either).

Father Pacholczyk makes me embarrassed to admit that I too would vote No.

I'm not going to make an argument here. I'll just point out that, when it comes to dying, there are more than two or three choices. Some people believe dying people should be kept alive for as long as medically possible, no matter how they or their families feel about it, no matter how much suffering is involved. Other people believe that, in extreme cases, doctors should have the right to administer lethal drugs to dying patients (euthanasia). Physician-assisted suicide lies between these two positions. So do hospice care, palliative care, and other dignified alternatives to either prolonging suffering, on the one hand, or causing death, on the other.

I believe that a lot of people support physician-assisted suicide or euthanasia because they fear they have only one alternative--to be kept alive for days, weeks, months, or even years of misery through painful interventions. Extremism breeds extremism. There are other approaches to terminal illness, however, as Bill Keller's excellent article in Sunday's New York Times points out. Last month Keller's father-in-law, Anthony Gilbey, died in a U.K. hospital of inoperable cancer. In "How to Die," Keller describes the older man's six-day dying process and the decisions--personal, medical, and political--that made his death dignified, loving, and peaceful. "We should all die so well," Keller concludes.

The approach used with Mr Gilbey, the Liverpool Care Pathway, doesn't appeal to extremists on either side, says Keller. "'Pro-life' lobbyists ... portray it as a back-door form of euthanasia.... Euthanasia advocates ... say it isn’t euthanasia-like enough." It is, however, realistic, compassionate, family oriented, spiritually sensitive, and sensible. It allowed Mr Gilbey to die at peace with God and his family, knowing he was loved.

The Liverpool Care Pathway is the standard approach "in most British hospitals and in several other countries [where, by the way, assisted suicide is illegal] — but not ours," writes Keller. "When I asked one American end-of-life specialist what chance he saw that something of the kind could be replicated here, the answer was immediate: 'Zero.'"

Learn more about how we Americans could choose to die with dignity, if only we were willing to give up our politically exacerbated extremism. Read Bill Keller's moving (and short) article. Click here.

THE CASUAL VACANCY by J.K. Rowling

J.K. Rowling's first novel for adults was released a week ago, and a lot of reviewers have weighed in since then (Google them, if you care: some of the best are from U.K. newspapers). The professional reviews mostly range from "OK" to "Oh dear," and Amazon customer reviews stand (right now) at 2.7/5.0 in the U.S., 2.9/5.0 in the U.K. Maybe the higher U.K. score is because more U.K. readers know what Ms. Rowling means when she says things like "the rubber soared right across the room."

In my review for Books and Culture (online edition) I look at an aspect of The Casual Vacancy that other reviewers didn't mention, to my knowledge--its fairly obvious theological underpinnings. (Quite a few other underpinnings are fairly obvious in the book as well, but I decided not to mention them in the review.) It would make me and B&C editor John Wilson very happy if you'd click the link and read my review on the B&C website.

In the review, I argue that Rowling's village of Pagford is post-Christian. Indeed, it is post-moral: love of neighbor is sorely lacking. Instead, we see status seeking. Middle-class chauvinism. Decreasing funds for social services. Increasing poverty. Love of money. Selfishness. Bullying. Disdain for outsiders (gays, people of color, people on welfare, mentally ill people, ugly people). Abuse. Fractured relationships. Polarization. And on, and on. If you've been paying attention to U.S. or U.K. politics recently, the picture will look depressingly familiar.

In Pagford there's a shabby little street called Hope. Three of the book's characters have lived there. One moved out long ago and became one of the town's biggest (literally) hypocrites. One died. And by book's end, one is getting ready to leave. There are still plenty of people in Church Row, though. You just might not want to spend time with them.

A lot of readers have found A Casual Vacancy dull. I understand: it didn't grab me until I was past page 200 (I stuck with it because I had a review to write). Then I read it a second time, and found it interesting right from the beginning. I think that's because by then I knew all the characters and could just read the story without trying to sort out Colin and Gavin and Simon (why do Brits have so many five-letter names that end in "n"?). To make your reading more enjoyable right from the start, here's a list of the book's major characters. Print it out and use it as a bookmark:

• Barry and Mary Fairbrother and four children including the twins, Niamh and Siobhan. Barry, who was born in the Fields but became a banker, dies. The family lives in Church Row.
• Miles and Samantha Mollison and two daughters, Lexie and Libby. Miles practices law and Samantha owns a bra shop. They also live in Church Row.
• Howard and Shirley Mollison, parents of Miles and Patricia (who now lives in London). Howard owns the village deli and is president of the Parish Council (sort of like being mayor); Shirley is a hospital volunteer. They live around the corner from Church Row in Evertree Crescent.
• Colin and Tessa Wall and their son, Stuart ("Fats"). Colin is deputy headmaster at the comprehensive school (=high school vice principal); Tessa is a guidance counselor. Fats is in high school. They live in Church Row.
• Simon and Ruth Price and two sons, Andrew ("Arf") and Paul. Simon works at the printworks; Ruth is a nurse. Arf is in high school.
• Vikram and Parminder Jawanda and three children including Sukhvinder, the youngest, a high school student. Both parents are doctors. They live in the Old Vicarage.
• Gavin Hughes, divorced, a junior partner in the law firm where Miles Mollison is senior partner. He lives outside town at the Smithy.
• Kay Bawden and her daughter, Gaia. Kay is a social worker; Gaia is in high school. They  live in Hope Street. Kay and Gavin have a rocky relationship.
• Terri Weedon and her children Krystal and Robbie. Terrie is a junkie and a prostitute who lives in the Fields (a subsidized housing project). Krystal is a classmate of Fats, Arf, Sukhvinder, and Gaia. Robbie is three years old.
• Nana Cath, Terri's grandmother. At various times she has taken care of Terri and Krystal. She lives in Hope Street.

OK, now you're ready to read. Or to resume reading, if you gave up early. The Casual Vacancy, as everyone points out, is not Harry Potter. All the same, it's worth getting into if you want to think about what the Muggle world might look like without Hogwarts, without Dumbledore, and without Harry.

10 grumpy observations about the first debate

1. Mitt Romney is a bully. We knew that.
2. Barack Obama doesn't know how to stand up to bullies. We knew that too.
3. Jim Lehrer really doesn't know how to stand up to bullies. Jim, just cut the mike.

4. Neither candidate stuck to facts. We are not surprised.
5. This may be because neither candidate knows what is factual. This is worrisome.
6. Or it may be because neither candidate cares about facts. This is even more worrisome.

7. America's economy is in profound poop. No surprise there.
8. Neither candidate has a plan that will help very much. No surprise there either.
9. Only once was the word "sacrifice" uttered--after the debate was over, by commentator Mark Shields (click this link and listen to minutes 7:06-7:24), who pointed out that the concept was entirely missing from Romney's discourse. Shields may know more about how to fix the economy than either candidate does.

10. Will the presidential debates sway the undecided voter? This SNL clip says it all.

Alas, I can't get the actual clip to embed on my blog.
Click HERE to see it. It's less than 2 minutes long.

The best healthcare in the world

I have had only a few personal experiences with European-style healthcare, and they were a long time ago. A Swiss doctor gave me my pre-college physical. A British doctor looked at my adolescent face and prescribed skin cream. What I remember most--and what totally amazed my parents--was that the consultations and meds were free.

I thought no more about the differences between European and American healthcare until, middle-aged, I began working for a U.K. publisher. I was watching TV news one evening when a political ad came on. Cue the scary music, the dark screen. Do you want our healthcare to turn into a big ghastly mess like American healthcare? asked the portentous announcer. If not, by all means vote Labour. Save the National Health System.

Hmmm, I thought... I'd always heard we Americans have the best healthcare in the world. Is this any way to scare Britons?

Apparently, and it's a good way to scare Germans, Italians, the French, and any number of other Western Europeans as well.

Rachel's baby gets his
broken leg set in France

Want to know why? Read Rachel Stone's account of her family's experiences with healthcare in Scotland, Italy, France, Germany--and the United States.

"It should be within every person’s ability to take care of their health, and that of their children, without going bankrupt," Rachel writes. "I think the free market has had a fair shot at making that happen, and lost."

Ah, but Europeans pay awfully high taxes, don't they? Yes, but not because of their healthcare systems. The American government already spends a little more on healthcare than three of those four countries, even though, in addition, Americans fork over much more out of pocket.*

When you add government expense to private expense, American health care is 65% more expensive than France's and 100% more expensive than the U.K.'s. And for that, what do we get? Read Rachel's story. Here's the link again.
___________________________________________

*In 2006, the last year for which comparative data is available, the U.S. government spent $3074 per capita on healthcare. That's $135 more than the U.K., $265 more than Germany, and $880 more than Italy. Granted, though, it's $159 less than France. 

However, government expenditure is only part of the story. No country that I know of pays for 100% of healthcare; some of the funding comes from private insurers, and some comes directly from patients. In America in 2006, for example, our nongovernmental healthcare expense came to $3640 per capita. That's what we paid, on average, beyond the $3074 we had already paid in taxes.  Compare that with Germany's additional expense, $860; France's, $823; Italy's, $651; and the U.K.'s, $422.

(Data is from the World Health Organization.)

Rationing is not a four-letter word

This morning a friend wrote on Facebook about his expensive medications. He's grateful that Obamacare will make them more affordable. "I do have a twinge of bad conscience," he added, "about the cost of my health care coverage." Maybe death panels are a good idea?

Before cutting end-of-life care, I wrote back, we need to control costs. Otherwise "we are going to have to--gasp!--ration care, or soon only the very rich will be able to afford care at all."

A friend with osteogenesis imperfecta--and who has a child with the same condition--immediately jumped in. "Tell me more about what you mean when you talk about rationing care," she wrote. "As someone who requires fairly regular doctors' appointments just to function well, the idea makes me nervous."

The idea of rationing makes everybody nervous. Though one Merriam-Webster definition, "to distribute equitably," is what the propaganda poster above is trying to communicate, most of us think first of Collins's definition: "the process of restricting consumption of certain commodities." Hey, I need all of my office visits, surgeries, MRIs, echocardiograms, and prescription drugs. If my substandard aortic valve starts malfunctioning again, I don't want any bureaucrats telling me I'm  allotted only one surgical intervention.

OK, breathe deeply. Let's look rationally at that word rationing (the two words do have the same root, which has to do with "reason").

1. American healthcare is already rationed. That is, not everyone can have all the healthcare they want. My insurance is very good, but it doesn't cover eyeglasses, adult orthodontia, or cosmetic surgery (darn!).

A lot of people can't even have all the healthcare they need. Healthcare providers tend to be more abundant in areas of high population density and high average income, so people who live in rural areas may not be able to see a top cardiac electrophysiologist in the middle of the night when their tachycardia acts up. If they live in health professional shortage areas, they might have a hard time finding a general practitioner.

2. American healthcare funding is also already rationed. The government rations the amount it reimburses Medicare and Medicaid providers. Insurance companies ration reimbursements to healthcare providers. Before the Affordable Care Act kicked in, some insurers also denied valid claims from people who were getting too expensive, or else they dropped those people's insurance altogether.

The bottom line always wears a dollar sign. If you have enough dollars, your access to healthcare is limited only by your imagination. I doubt if there is any form of healthcare that Bill Gates (net worth: $66 billion) couldn't afford. Americans whose yearly income is in the lowest 20% (less than $27,000), however, can afford almost no healthcare without insurance--and a quarter of them are uninsured.

3. The challenge is to find an approach to rationing--i.e., allocating--public funds so as to make healthcare more, not less, widely available to all.

One way to do this is through policies that increase healthcare resources and distribute them more evenly throughout the country. Other developed nations do this in many ways, such as offering low-cost medical education so physicians aren't burdened with debt; limiting legal liability so insurance payments don't drive doctors out of business; using single-payer or streamlined private insurance systems so administrative overheads don't force medical clinics to double or triple their costs; and putting cost ceilings on medications and medical equipment.

At the same time, we need programs that reduce the need for expensive health repairs by keeping people healthy in the first place.  Adequate prenatal care, for example, can reduce expensive pediatric care for pre-term babies; and a healthy diet can prevent many cases of diabetes, heart disease, and cancer (note to Department of Agriculture: corn subsidies aren't helping).

But there are always more healthcare needs than healthcare funds ... even after we've increased healthcare resources and reduced the need for repairs. How do we ration our resources so that there is indeed "a fair share for all of us"?

Not by insisting that Bill Gates's healthcare must be no better than mine. Heck, his house and surrounding structures comprise 66,000 square feet, just a tad bit bigger than mine even including the basement. I'm guessing he eats in better restaurants and buys nicer clothes than I do too, and I expect he travels first class. That's what "rich" means.

So yes, rich people will get better healthcare than poor people, and people with good insurance will get better healthcare than people with barebones insurance or (heaven and the U.S. government forbid) no insurance at all. However, poor people also need shelter, food, clothing, transportation--and healthcare.

4. We need to get rid of our hypocritical notions about equality--which we aren't practicing anyway--and start thinking in terms of adequacy.

What if we had, say, a three-tier healthcare system? 

The foundational tier would be publicly funded; the patient would pay nothing. If you need basic medical care--an immunization, a routine diagnostic service such as a mammogram or a blood test, meds for a cold or a urinary tract infection--you go to your local pharmacy or public-health clinic and get it done. Such an approach can be wonderfully efficient, cutting out whole layers of bureaucracy.

The middle tier would be funded by private, not-for-profit insurance, which everybody would be required to carry (publicly subsidized if they can't afford it). This would include all other necessary health care--and yes, someone would have to draw lines between what is necessary and what is not. Not every possible treatment would be available to everyone who wanted it. This is rationing, to be sure. We're doing it now.

But if we've done a good job of allocating healthcare resources and reducing the need for repairs, we should have more money to go around rather than less. (For examples of how this is  being done elsewhere, see my August 29 post, "Four Countries That Already Meet the Republican Platform's Health-Care Goals.") My Facebook friend would still be able to meet her fairly regular doctors' appointments. In fact, if our reforms increased the number of physicians to a level similar to Western Europe's,* she might find it easier to get in.

The top tier would allow for unnecessary, but pleasant, healthcare. It would be funded by individuals either out of their own deep pockets or through for-profit insurance policies they've purchased. It could include things like private hospital rooms, private-duty nurses, the very latest designer drugs, face lifts, and hospitals with wood paneling and marble floors (sorry, CDH: I love you, but you do go overboard).

We Americans are smart. We could find a way to provide necessary medical care for everybody. Perhaps someday, when all our present Members of Congress have finally passed away, a totally new set of lawmakers will figure out how to do it. But first we're going to have to realize that rationing can be a tool used for the common good, or it can be a buzzword used to scare people who haven't noticed that haphazard rationing--our present nonsystem--is the cruelest approach of all.
_______________________________

*In the United States, there are 26 physicians for every 10,000 people. By contrast, there are between 27 and 35 physicians per 10,000 people in France, Germany, Ireland, Luxembourg, Portugal, Spain, and Sweden; and there are between 36 and 42 physicians per 10,000 people in Austria, Belgium, Denmark, Iceland, Italy, the Netherlands, Norway, and Switzerland.