Today is the 15th of April, and a lot is happening from sea to shining sea.

Here in the Berkshire mountains of Massachusetts, the sun is bright, and all’s right with the world. Except perhaps for you procrastinators who haven’t finished your taxes as the seconds tiptoe by with their index fingers wagging.

In other news, events are unfolding in New York City where a certain former President is…well, we don’t have to mention that today, because today is also the celebration of the anniversary of “the shot heard round the world,” an event of infinitely more importance than anything even remotely connected to he who shall not be named.

On a date four days from now in 1775, the American Revolutionary War began with battles in Lexington and Concord, Massachusetts. Those two battles were the scene of the first American revolutionary casualties: 49 died, 39 were wounded, and five went missing. Consequently, we celebrate Patriots Day, a Massachusetts state holiday. It’s also a holiday in five other states: Connecticut, Florida, Maine, North Dakota and Wisconsin. Personally, I think the other 44 should join the party.

In Massachusetts, from 1897 until 1968, Patriots Day was celebrated on the actual date of the first battles, 19 April. Since then, it’s been observed on the 3rd Monday of April. The Town of Lexington holds a full-fledged reenactment first thing in the morning every Patriots Day. This morning was no different.

And, since 1897, Patriots Day has been the day runners from around the world compete in the Boston Marathon.

Marathon History

The first celebration of the modern Olympic Games took place in its ancient birthplace — Greece. The Games attracted athletes from 14 nations, with the largest delegations coming from Greece, Germany, France and Great Britain. America sent 14 competitors.

On 6 April 1896, the American James Connolly won the inaugural event, the triple jump, to become the first Olympic champion in more than 1,500 years. He also finished second in the high jump and third in the long jump.

Due to its historical significance, the Greek hosts wanted to win the marathon above all else. Spyridon Louis set off from the city of Marathon and took the lead four kilometers from the finish line and, to the joy of 100,000 spectators, won the race by more than seven minutes.

After the success of the Olympiad of 1896, the Boston Athletic Association (BAA) decided to host a marathon competition in Boston the following year, 1897. And that was when the Boston Marathon was born, the first annual marathon in the world. John J. McDermott of New York, emerged from a 15-member starting field and won that first B.A.A. Marathon in 2 hours, 55 minutes, 10 seconds. With that win, McDermott secured his name in sports history.

That first Boston Marathon was 24.5 miles. In 1924, the course was lengthened to 26 miles, 385 yards to conform to the Olympic standard, and that’s the way it’s been ever since.

This morning, more than 30,000 runners took off from the Town of Hopkinton, all setting their sights on completing the ordeal and finishing on Boylston Street in downtown Boston. Some will be arriving well into the evening. Five groups competed at staggered starting times: Men’s and women’s wheelchair; Elite men and women runners; and everyone else who qualified (plus a few who didn’t, but jumped in to run it, anyway).

This morning, a record fell when Marcel Hug, of Switzerland, won the Men’s Wheelchair race in 1 hour, 15 minutes, 33 seconds. That’s less than three minutes per mile—up and down hills. One of the hills, 21 miles into the race, is aptly named “Heartbreak Hill.” It’s broken many a leader. It was the 7th Boston win for Hug. His record is even more impressive an achievement when one considers that in the middle of the race he crashed into a stone wall, tipped over, yet managed to somehow get his wheelchair upright again and continue on.

Great Britain’s Eden Rainbow Cooper won the women’s wheelchair division in her first Boston marathon. She did everything on her own with no sponsors or team to prepare her. Rainbow will likely have sponsors by tonight.

Sisay Lemma, of Ethiopia, set a blistering pace for the elite men and held on to win in 2 hours, 6 minutes, 17 seconds — the 10th fastest time in the race’s 128-year history.

Hellen Obiri  outsprinted fellow Kenyan Sharon Lokedi down Boylston Street to win by eight seconds. Obiri is the first woman to win back-to-back Boston marathons since 2005. She finished in 2 hours, 22 minutes and 37 seconds.

The passion and dedication of world class athletes is awesome to see. The sacrifices made to reach for perfection, and occasionally hold it in the palm of one’s hand, should inspire us all.

And on this Patriot’s Day, we should also remember with pride and gratitude the sacrifices made by America’s Founding Fathers, our original Patriots, each of whom knew if Great Britain won the war he’d be wearing a hangman’s noose.

This is why, rather than write anything today the first trial of Donald Trump, I choose to salute Hug and Cooper and Lemma and Obiri and the tens of thousands who ran after them, as well as the those in 1775 who, risking life and limb, stood up to the mightiest army in the world for the fundamental truths a Virginian would espouse the following year in what became our Declaration of Independence.

Bravo to all, then and now.

“They are now being outshot by the Russian side five to one. So the Russians fire five times as many artillery shells at the Ukrainians than the Ukrainians are able to fire back. That will immediately go to 10 to one in a matter of weeks. We’re not talking about months. We’re not talking hypothetically.”
Army Gen. Christopher Cavoli, head of U.S. European Command

On Wednesday, General Cavoli and Celeste Wallander, assistant secretary of defense for international security affairs, testifying before the House Committee on Armed Services, urged lawmakers to approve the $95 billion supplemental defense bill passed by the Senate two months ago, but languishing since then in the House. The bill would provide $60 billion in funding for Ukraine armaments with the rest targeted for aid to Taiwan and Israel.

General Cavoli emphasized the need for 155mm artillery shells, saying, “The biggest killer on the battlefield is artillery. In most conflicts, but in this one definitely. And should Ukraine run out, they would run out because we stopped supplying — because we supply the lion’s share of that.”

Later in the day, U.S. Army leaders echoed the warnings to the House Defense Appropriations Subcommittee. “The side that can’t shoot back, loses, and at this point Ukraine is really starting to be pressed to be able to shoot back. So I am very concerned,” said Army Secretary Christine Wormuth. “We saw Ukraine lose some territory a couple of months ago. And I think there is a real danger…that the Russians could have a breakthrough somewhere in the line.”

Air defense capacity is particularly urgent. To illustrate that point, consider that yesterday Russia fired 82 missiles and drones into the Kyiv region, a huge attack. Ukraine’s air force said it shot down 57 of them, leaving 25 that got through, including six hypersonic Kinzhal missiles.

The attack totally destroyed the Trypilska Thermal Power Plant (TPP), the largest supplier of electricity to Kyiv, Cherkasy and Zhytomyr regions, according to the plant’s owner, the energy company Centrenergo. The company has now lost 100% of its power generation across its three plants, which have all been destroyed or occupied by Russia.

Over more than two years of war, Russia has systematically targeted Ukraine’s energy infrastructure in an attempt to break the country’s power grid and, with it, the Ukrainian people’s spirit, by depriving them of electricity, heat, water and other essential services. I find it beyond inspirational that the morale of Ukraine’s citizens remains high. They remember what it was like being a Soviet Republic prior to 1992. They remember democracy and true independence taking root with the Orange Revolution of 2004. They remember and refuse to go back to subservience.

Following yesterday’s attack, Ukrainian President Zelenskyy accused the West of “turning a blind eye” to the air defense needs of his country.

The man certainly has a point. The House continues to seem willing to let Russia, with aid from Iran and North Korea, get nearer and nearer to breaking through Ukrainian defensive lines. And Speaker Johnson appears much more interested in keeping his job by kowtowing to the far right elements in the House. And then there’s Donald Trump to please.  Today, the Speaker was in Mar-a-Lago genuflecting and kissing the ring, a true love story in the making.

Meanwhile, an unescapable fact remains — Ukraine cannot win if it can’t shoot back.

“If the Congress doesn’t help Ukraine, Ukraine will lose the war.”
Ukrainian President Volodymyr Zelenskyy, 8 April 2024

That’s about as stark a statement as you’ll see. And he means it. Ukraine faces no bigger disaster than losing its war with Russia, a war it did not start. Russia invaded this sovereign, independent democracy in February, 2022, because its egomaniacal dictator hungered to resurrect Joseph Stalin’s Soviet Union, and capturing Ukraine was the first step in his plan.

Tens of thousands of innocent Ukrainians have died. And with the continued help of Iran and North Korea, Russian forces are now better armed than Ukraine’s troops, especially with respect to artillery shells. Everything Ukraine needs to repel the invaders is in short supply, and its soldiers are bone-tired. Russia’s success in taking the city of Avdiivka in February, along with its territorial gains since, have caused many to reassess the potential for Ukraine to prevail in this hellish war.

Of course, that reassessment might not be as dark as it appears to be if the U.S. House of Representatives would provide the $60 billion in Ukraine aid it has bottled up for two months. This failure to act is even more perplexing when one realizes most of the needed funds would be spent in the U.S., because American workers at American companies would be making the weapons so desperately needed.

None of this seems to matter to a few rabidly ambitious and self-centered members of the House who, on Donald Trump’s orders, have prevented a vote on the bill passed by the Senate in February. And Speaker Mike Johnson, a seemingly mild-mannered, deeply Christian, but very sly, backbencher, who woke up one day to find himself in the third highest position in government, is now trying to walk down the edge of a political razor blade while searching for some way to advance Ukraine funding without losing his new cushy job. He is not emerging as a “profile in courage.”

Meanwhile, back in Ukraine, it’s seat-squirming time, as losses mount despite the heroic  efforts of so many to save their land. As Ben Barry, Senior Fellow for Land Warfare at the International Institute for Strategic Studies (IISS) puts it:

The IISS assesses that Russia can sustain its campaign for some time. Moscow has been able to bring on enough contract soldiers to sustain its force structure and should be able to replenish tank losses on the battlefield for two or more years. It also has put its economy in a war setting, with total military spending now representing one-third of its national budget and reaching about 7.5% of GDP. Supply of artillery ammunition, loitering munitions and ballistic missiles from Iran and North Korea also shifts the balance of firepower against Ukraine. That means that over the coming year Russia will probably be able to generate sufficient missiles and drones to maintain its recent level of pressure on Ukraine’s air defences, attack its defence industry and attempt to erode Ukrainian civilian and military moral.

Without American aid what this means is that, at best, Ukraine will be in a defensive posture for some time; at worst, it will need to withdraw and cede valuable territory to the aggressor. The dilemma for Ukraine’s army becomes choosing between a forward-defense posture to keep Russian forces from cities and towns at the cost of higher casualties, or pulling back to conserve troops. To prove that last point, President Zelenskyy said at the Munich Security Conference last month that the Avdiivka withdrawal was aimed at “preserving soldiers’ lives.”

And if that’s not enough, into this latest mess parachutes Donald Trump.

Last Sunday, Isaac Arnsdorf, Josh Dawsey, and Michael Birnbaum of the Washington Post reported that Trump has privately said that after winning the upcoming election he could end Russia’s war in Ukraine by pressuring Ukraine to give up some territory, according to people familiar with the plan. Trump’s proposal consists of pushing Ukraine to cede Crimea and the Donbas border region to Russia, according to people who discussed it with Trump or his advisers and spoke on the condition of anonymity. This plan may or may not be true, because in what passes for Donald Trump’s mind, pigs really can fly.

You will recall Mr. Trump and President Zelenskyy, three months into his new job, had an interesting phone call on 25 July 2019, during which Trump pressured Zelenskyy to open investigations that could damage former Vice President Joe Biden heading into the 2020 election. At that time, long before the current conflagration, all the former comedian and newly-elected Ukrainian president could do was smile.

A lot of flotsam has floated down the political river since then, but it seems to me if President Zelenskyy, who has grown to become Ukraine’s George Washington, was ever asked to respond to Trump’s brilliant diplomatic proposal, he might do so with no smile and two, well-chosen words, which Mr. Trump would have no trouble understanding.

“War is hell.” — Union General William Tecumseh Sherman, in a speech to graduates of the Michigan Military Academy in 1879.

Sherman was right, and at this moment his three-word phrase is ringing true, especially in Ukraine and Gaza. Inhumanity is on full display.

When wars end, somebody has to pick up the pieces — in more ways than one. First, there is the massive rebuilding that will confront the survivors whenever the bullets and bombs stop flying. I’ve written about what Ukrainians face when that longed-for day comes. Palestinians will require the same kind of herculean effort in Gaza when that horror stops, if it ever does.

Second, and not as well recognized, is the peril of unexploded ordinance and landmines that survive the battle to lie in wait for some poor innocent to take the wrong step into the hereafter.

More than 700 million artillery and mortar rounds were fired on the Western Front between 1914 and 1918, of which an estimated 15 percent failed to explode. Every year these leftover shells kill people — 36 in 1991 alone, for instance, when France excavated the track bed for a new high-speed rail line. Dotted throughout the region are patches of uncleared forest or scrub surrounded by yellow danger signs in French and English warning hikers away. The French government employs teams of démineurs, roving bomb-disposal specialists, who respond to calls when villagers discover shells; they collect and destroy 900 tons of unexploded munitions each year. More than 630 French démineurs have died in the line of duty since 1946.¹

When those 36 French people Adam Hochschild cited in his masterful history, To End All Wars, died in 1991 laying a track bed for a rail line, World War I had been over for 73 years.

Many of the First World War’s live explosives dotting the French landscape lie in the Zone Rouge, the Red Zone encompassing much of the territory of the Battle of the Somme, which took place from 1 July to 18 November 1916. This was one of the bloodiest battles in history, with over a million casualties. On the first day, alone, Britain saw 57,470 of its soldiers killed — you read that right, 57,470 soldiers killed — in one day. During the entire battle, the British and Germans fired more than 37 million artillery shells, 1.7 million in the first week.

At the end of the nearly five-month Battle of the Somme, the British had managed to gain a grand total of six miles of territory. It might not seem like much, but the losses Germany incurred forced its troops to retreat to the Hindenburg line in early 1917.

Today, a potentially worse problem than unexploded shells faces Ukrainians, because not only do they have that problem, they also face the nearly impossible task of finding and neutralizing more than a million anti-personnel land mines Russia laid in Eastern Ukraine before its troops pulled out in 2023. These land mines are killing and maiming people every day.

Anti-personnel landmines are prohibited under the Convention on the Prohibition of the Use, Stockpiling, Production and Transfer of Anti-Personnel Mines and on Their Destruction (or Mine Ban Convention), adopted in 1997. More than 150 countries have joined this treaty. Russia is not one of them. Neither is Israel. Or Iran. Or China.

Nearly 1,000 civilians in Ukraine have been killed by mines since the war began, according to aid groups. Most of those civilian casualties were caused by anti-vehicle mines planted in areas Ukrainians were trying to return to in order to revive their farms. But a bigger problem now is the anti-personnel variety, the ones that are strewn over field after field. The ones people step on. Most Ukrainians who step on mines and survive face foot and leg amputations. Clearing these is heroic work.

Last night, Scott Pelley, of CBS’s 60 Minutes, reported on the anti-personnel land mine horror facing Ukraine now. It was compelling, even hard to watch, because it showed what land mines are doing to innocent civilian Ukrainians whose only crime appears to be being Ukrainian. Like the French, who continue to be bedeviled by bombs from 73 years ago, Ukrainians will be dying from these Russian gifts for generations.

The anti-personnel land mines are an obvious war crime. That’s easy for me to say. What do you think? Why not watch Pelley’s award-worthy (and dangerous) reporting and decide for yourself?

Now what do you think?

______________

¹Hochschild, Adam, To End All Wars: A Story of Loyalty and Rebellion, 1914-1918. Boston, Houghton Mifflin Harcourt, 2011.

Yesterday, Manhattan Judge Juan M. Merchan rejected Donald Trump’s bid to delay his April 15 hush money criminal trial until the Supreme Court rules on presidential immunity claims he raised. Consequently, the wheels of justice continue to grind slowly, but exceedingly fine, and the trial will begin in eleven days.

And what of Trump’s claims of immunity? Writing in The Conversation this morning, Professor Wayne Unger, who teaches constitutional law at Quinnipiac University, said, “If a student of mine had submitted a brief making the arguments that Trump and his lawyers assert in their Supreme Court filing, I would have given them an F.”

Professor Unger writes that, in an attempt to cozy up to Supreme Court Justices, especially the ones he nominated, the Trump Brief cites a 2009 law review article by Judge Brett Kavanaugh, and claims it showed Kavanaugh supported his position. Kavanaugh wrote, “[A] President who is concerned about an ongoing criminal investigation is almost inevitably going to do a worse job as President,” and Trump relies on that sentence as evidence of support for the position that a president requires absolute immunity.

But according to Unger, the article concludes the exact opposite. According to Unger:

But even a cursory reading of Kavanaugh’s article reveals that Kavanaugh argued only for a deferral of a criminal prosecution until after a president leaves office.

As Kavanaugh states, “The point is not to put the President above the law or to eliminate checks on the President, but simply to defer litigation and investigations until the President is out of office.”

And that is exactly what is happening right now with Trump out of office.

It would be interesting to know Justice Kavanaugh’s opinion of Trump’s lawyers trying to mislead the Court by referencing a law review article of his.

The legal maneuvering of Donald Trump, the born-on-third-base, but-everyone-knows-I-hit-a-triple man, made me think of something that happened on this date 151 years ago in Philadelphia, Pennsylvania. For that was the day in 1871 that 33-year-old Carrie Burnham, a woman with more legal acuity in her little finger than all of Donald Trump’s high-priced lawyers put together, finished her masterful two-day, 90-page argument before the Pennsylvania Supreme Court advocating that election officials in Philadelphia’s Ward 14 had illegally refused to accept her ballot.

A lower court had first ruled against her suit by claiming the Pennsylvania Constitution only allowed “freemen” the right to vote. This was its entire and only position. The court had written:

Carrie Burnham’s entire case rested on the meaning of the word, freeman. 

In 90 pages of legal erudition, rarely, if ever, seen in that, or any other court, she eviscerated the lower court’s position, beginning with the Teutonic origin of the word—frei mann. Citing Greek and Roman history, the Magna Carta, a wealth of English Common Law, the U.S. Constitution (particularly the 14th Amendment), as well as the Constitutions and court cases of various American states (particularly New Jersey, where women had the right to vote from 1790 until 1807), Burnham conclusively proved the word freeman was always intended to be generic, referring to both genders.

Well, as you’d expect, the lady lost her case. Although, two of the court’s judges asked her for copies of her brief, and one sent it along to Harvard Law School, where it continues to be taught to this day.

But Carrie Burnham was much more than is told in this story.

She wasn’t even a lawyer when she appealed to the Pennsylvania Supreme Court. She was able to do that, because the state had a law that allowed supplicants to plead their own cases.

She studied law privately, because no law school would admit her. When she requested taking the bar exam in 1873 and 1874, she was denied. After a decade of lobbying, however, she became the first woman admitted to Penn’s law school, in 1881. After graduating, Carrie Burnham was the first female lawyer in the city of Philadelphia, and first woman admitted to the Bar in the Commonwealth of Pennsylvania.

Today, a residence hall at Penn is named for her.

Extraordinarily, at a time when few women worked outside the home, she managed to become not only a lawyer, but, after an extended legal battle, also a medical doctor, making her an early and dynamic leader in the struggle for women’s rights in America.

She got her medical degree from New York’s Bellevue Hospital, one of only 30 women in a class of 500.

The women faced harassment from the men, including at least one professor who “repeatedly exposed” patients, both male and female, in front of the women, in hopes of shocking them into quitting the program. After these classes, the male students would line the hallways, forcing the women to walk an intimidating gauntlet to leave the building. But, she wrote, “[W]e continued our studies without noticing apparently any of the insults heaped upon us.”

She earned her degree of Doctor of Medicine and worked as an assistant physician at a medical institute in Boston. There she helped a male doctor prepare a book on physiology, but received no credit when it was published.

She continued to practice law for 21 years after her admittance to the Bar, and died in 1909.

Her 1871 argument in support of her right to vote apparently alarmed some men, because the next year, a state convention amended Pennsylvania’s constitution to say that only “every white male citizen” could vote.

That is praise, indeed.

In 2005, the late Thomas Crombie Schelling won the Nobel Memorial Prize in economic science for “having enhanced our understanding of conflict and cooperation through game theory analysis.”

Schelling is also known for his 1961 article Dispersal, Deterrence, and Damage, in which he coined the term “collateral damage.”

Militarily, collateral damage has been a constant since the dawn of humanity. I saw it on a couple of occasions during my time in Vietnam, and, to this day, there is still a never-to-be-healed tear in the fabric of my soul because of it.

Yesterday, collateral damage was on full display in Gaza when Israel launched an airstrike on a convoy of World Central Kitchen (WCK) trucks delivering 240 tons of aid to Gazans in desperate need of it.

The attack killed seven WCK staffers, as heroic a group as you’ll ever see. Six of the killed are from Australia, Poland, the United Kingdom, Palestine, and one was a dual citizen of the U.S. and Canada.

Founded by noted Chef José Andrés in 2010 in response to a devastating earthquake in Haiti, World Central Kitchen has gone on to feed millions around the world when disaster has struck, which is why the organization has been laboring in Gaza where food has all but disappeared.

“This is not only an attack against WCK, this is an attack on humanitarian organizations showing up in the most dire of situations where food is being used as a weapon of war. This is unforgivable,” said World Central Kitchen CEO Erin Gore.

World Central Kitchen said that its convoy had “coordinated movements with the Israel Defense Forces (IDF), that they were traveling in a deconflicted zone, and that their vehicles were clearly branded.”

One shell tore straight through WCK’s logo on top of one of the vehicles, put there so military aircraft could see it.

Two other convoy vehicles were incinerated and mangled, indicating multiple hits.

According to Israel, its IDF suspected an armed man of being a terrorist and hiding in the convoy. Consequently, its Air Force fired three consecutive missiles at the multi-car convoy — even as the aid workers in the vehicles tried to move cars and send messages that they’d been attacked following the first hit. In the end, the armed man wasn’t even in the convoy; he’d stayed back in the food warehouse.

Yesterday’s strike on the aid workers came hours after a new delivery with some 400 additional tons of food and supplies organized by World Central Kitchen and the United Arab Emirates arrived in three ships from Cyprus, following a pilot run last month.

Around 100 tons were unloaded before the charity suspended operations, and the rest was being taken back to Cyprus, Cypriot Foreign Ministry spokesman Theodoros Gotsis said.

Additionally, the United Arab Emirates has suspended its aid that travels the same route, pending assurances from Israel that its convoys won’t suffer the same fate.

Finally, Anera, a Washington-based aid group that has been operating in the Palestinian territories for decades, said that in the wake of the strike it was taking the “unprecedented” step of pausing its own operations in Gaza, where it had been helping to provide around 150,000 meals daily.

The strike on the WCK convoy wasn’t the only instance of collateral damage caused by Israel’s IDF yesterday.

Two other Israeli strikes late in the day killed at least 16 Palestinians, including eight children, in Rafah, where Israel has vowed to expand its ground operation despite the presence of some 1.4 million Palestinians, most of whom have sought refuge from fighting elsewhere.

One of the strikes hit a family home, killing 10 people, including five children, according to hospital records. Another hit a gathering near a mosque, killing at least six people, including three children.

Jamie McGoldrick, the United Nations humanitarian coordinator for the Palestinian territories, said the strike on the WCK convoy was “not an isolated incident,” noting that around 200 humanitarian workers have been killed thus far in the war.

Early this morning, Israel Prime Minister Benjamin Netanyahu addressed the WCK incident moments after being released from hospital following hernia surgery.

Addressing the media, Netanyahu said, “Unfortunately, on the last day, there was a tragic event of our forces unintentionally hitting innocent people in the Gaza Strip. This happens in war; we are checking thoroughly, we are in contact with the governments, and we will do everything to prevent this from happening again. I would also like to thank you, the multitudes of citizens of Israel, for sending your wishes for recovery.”

Then he went on to thank his doctors for their great work.

Let’s think about all that for a moment.

“Unintentionally hitting innocent people?” Not quite accurate. There were three trucks. The IDF suspected one armed man, who might (or might not) have been a terrorist, of being in the convoy. So, aircraft fired three missiles that destroyed all the trucks in an attempt to kill everyone.

“This happens in war?” Netanyahu’s right. It does. But it doesn’t have to with a little care. The World Central Kitchen folks had done everything right, and seven of them died.

And thanks for all the good wishes? No words are necessary.

The frigid lack of empathy is breathtaking. I doubt there’s much of a tear in the fabric of that man’s soul, presuming he has one.

From 2003 through 2020, I was a Founding Director of Commonwealth Care Alliance, a non-profit Massachusetts HMO serving dual-eligible beneficiaries.¹ From 2017 until my retirement at the end of 2020, I was Chair of the Board.

In 2006, we were excited to enter the world of electronic health records, EHRs. Doing so was expensive, but we believed the new technology would allow us to make a giant leap forward in serving our members. Little did we know that the uncharted territory we were about to enter would also resemble a minefield the deeper in we got.

Every health care organization in Massachusetts, as well as the federal government, encouraged every health care provider to make the move to EHRs. This meant that for-profit businesses soon emerged to build bigger and bigger EHR systems, which they could then sell to the nation’s health care community. And so it went.

Eighteen years later, the administration of EHRs is one of the reasons America is losing physicians, especially Primary Care Physicians, PCPs. On average, physicians spend 9.2 hours a week filling in documentation for electronic health records, forcing many of them to stretch workdays into the evenings. This phenomenon is so common that it’s frequently called “pajama time” as doctors continue working on charts after putting their kids to bed. A 2022 JAMA Internal Medicine study estimated, “Assuming a 5-day work week and 47-week work year, US physicians spent 125 million hours documenting outside office hours in 2019.”

And when was the last time you saw your PCP (if you have one; a quarter of the nation doesn’t) without a laptop in hand, into which he or she would stare while entering information throughout your appointment? The one-on-one time is often more with the laptop than the patient. Entries into that laptop have to be precise, because everything is tied to billing. The researchers in the cited study reported, “84.7% of surveyed physicians agreed that documentation solely for billing purposes not only added to their administrative burdens, but was also perceived as onerous.”

Time spent documenting is often time not spent with a patient. The average time a patient spends sitting in a waiting room (20 minutes) now exceeds the average length of a primary care appointment (10 to 15 minutes). Long wait times, general inconvenience, and quick-like-a-bunny appointments drive down patient satisfaction and discourage some people from seeing doctors altogether.

It also weighs heavily on doctors and discourages many from remaining in the profession they worked so hard and paid so much to enter. Moreover, it discourages many young people from entering it in the first place, so much so that the number of America’s primary care physicians has been declining since 2015.

The cost of medical school

Another reason for the steady decline in the number of PCPs is the cost of medical school. It’s expensive.

The annual cost of the average four-year medical school is now more than $58,000.  For a public medical school the cost is nearly $53,000; it’s about $65,000 for a private institution. Elite schools, like ones in the Ivy League, are all around $75,000 per year. The most expensive medical school in the nation for in-state residents is Hackensack Meridien School of Medicine, at $80,203 per year. For out-of-state residents, the University of Washington School of Medicine is the most expensive school at a whopping annual cost of $96,489.

As you can imagine, upon graduation, newly minted physicians  are deep in debt from undergraduate and medical school loans.

According to the Education Data Initiative, medical school graduates owe a median average of $215,100 in total educational debt, undergraduate debt included, when they enter the profession.²  The average physician ultimately pays $135,000 – $440,000 for an educational loan—plus interest. At current interest rates (6.54% as of September, 2023), a $200,000 loan can double over ten years.

Medical school costs in the U.S. are orders of magnitude higher than the costs in European medical schools. For example:

• France: At about $633 per year, medical school is nearly free;
• Germany: Medical school is free;
• Switzerland: The cost is $912 per semester;
• Spain: Public medical schools charge $3,505 per year (however, private, elite schools are much more, averaging $27,376; still, this is not even half elite school costs in the U.S.); and,
• United Kingdom: The cost in $9,250 per year, but after year five, there is no cost.

All of which is why physicians in America, both PCPs and specialists, are paid nearly double their peers in the most developed countries in Europe. They owe so much in debt, they have to be.

On top of this seemingly ridiculous paradox is the fact that total health care costs in America are, and have been for many years, nearly double the average for the other 38 developed countries in the OECD.

Despite this, life expectancy in America, at 76.4 years, is lower than two-thirds of all the countries in the OECD, including all of the ones cited above. Yes, uninformed Americans denigrate the UK’s National Health System, but, at 80.4 years, that nation’s citizens manage to live four years longer than we do.

What can be done to right our foundering health care ship?

Perhaps not much. The highly consolidated health care system in the U.S. is so deeply rooted with so many vested interests, doing anything other than nibbling around the edges seems herculean. But that doesn’t mean we shouldn’t try.

For a start, we could make going to medical school easier and cheaper.

We could take a hard look at NYU’s Grossman School of Medicine, which, since 1841, has been nationally recognized for the excellence of its degree program. More important for this discussion—tuition is free. As the school puts it:

We are proud to offer every student enrolled in our MD degree program Full-Tuition Scholarships as part of our tuition-free initiative. We believe providing tuition-free education will lead to better patient care and will benefit society as a whole by turning the best and brightest future physicians into leaders with the potential to transform healthcare.

If a medical school in the heart of New York City can provide free tuition, do you believe it possible for others to do the same?

Well, two others are now. As of August 2024, tuition will be free for all students attending Albert Einstein College of Medicine, also in New York, thanks to a $1 billion donation from Ruth L. Gottesman, chair of the school’s board of trustees — the largest gift ever to a medical school.

And students at the Uniformed Services University’s (USU’s) F. Edward Hébert School of Medicine not only attain a medical degree for free but are paid during their studies.

Those pursuing an MD degree from USU enter the institution as commissioned officers of the Army, Navy, Air Force, or Commissioned Corps of the U.S. Public Health Service. As such, they receive a graduate student stipend while enrolled. They also get other benefits, including free medical care, a housing allowance, and paid time off.

Students at USU receive over $70,000 annually through base pay and other allowances, according to USU. That is in addition to not paying tuition while enrolled.

In return, the program requires a seven-year commitment to active military duty. Time spent in graduate medical education, such as in a residency, does not count toward the required commitment.

These three schools are demonstrating in three different ways that succeeding in medical school does not have to entail being lashed to a long-term, onerous financial anchor.

New physicians from these schools will still have to face the documentation burden that awaits them, but at least they will be spared the added burden of coughing up more than $2,400 per month for ten years to repay loans they did not have to secure.

I am certainly not such a fool as to think that free tuition at  Grossman, Einstein, and USU will cause a radical shift in how we produce the doctors we so dearly need. But it’s a start.

And if we can get beyond three, we may have the beginning of a Movement.

____________

¹ People eligible for both Medicare and Medicaid. Known as “Duals,” these are the sickest of the sick and the poorest of the poor. They make up ~5% of the population, but consume nearly 40% of all health care dollars. Helping them to become healthy also lowers costs, a real win-win.

² In 1978, the average medical school debt in the U.S., adjusted for inflation, was $53,648 (Actual debt in 1978 dollars was $13,500).

On 24 February 2022, the day that began Vladimir Putin’s invasion of Ukraine, Russian armored vehicles and soldiers crossed over the southern border from Crimea, the region captured in another invasion eight years earlier. The new invasion force rolled into Henichesk, a sleepy settlement of some 20,000 souls in southern Ukraine.

When they arrived, the Russian invaders encountered not the cheering, open-armed, welcoming people they’d been promised. Instead, they saw Ukrainians who in addition to being unimpressed with the arrival of their “liberators,” were also  downright hostile, although hostile only in a verbal sense, as most of the townspeople were on the other side of 60.

On that day, one older woman, looking every bit the mild-mannered grandmother, asked an enemy soldier, in an exchange filmed on a phone, “What the fuck are you doing here? You’re occupiers! You’re fascists! You came to my land uninvited.” She then tried to hand him a packet of seeds. “These are sunflowers seeds. You should put them in your pockets so that they will grow on Ukrainian land after you die. From this moment you are cursed!”

Two months later, the occupiers introduced a familiar figure to the townspeople. Dressed in a three-piece suit, and sporting his familiar goatee and moustache, Vladimir Lenin stood tall on his new pedestal. The Russians had erected his statue outside the town’s main council building. They flew Russian and Soviet flags from the roof. Just in time for Lenin’s 152nd birthday.

Well, things have gone steadily downhill from there in Ukraine.

As we find ourselves in the third year of this war, Ukrainians continue to do their best to expel Putin’s invaders, all with ever dwindling ammunition and weapons, thanks to Republicans in our Congress. Although probably quite the understatement, Ukraine’s Defense Ministry reports that, thus far, the nation has seen more than 31,000 of its soldiers killed in the conflict, as well as nearly 11,000 innocent civilians. It also claims its forces have killed more than 414,000 Russian soldiers since the start of the war, Putin’s cannon fodder. More than likely, these figures are inaccurate on both ends. I write  from the experience of dealing with “body counts” during the Vietnam War.¹

Humanity isn’t all the Russians have destroyed in Ukraine. Russian missiles and drones (many of them Iranian), as well as airplanes, have wiped out vast swaths of Ukraine’s infrastructure, which, as I and others have written, will require a Marshall-like Plan to rebuild.

However, there is one thing that’s gone unnoticed until now, and it is reminiscent of German actions during World War II — Russia’s looting of museums and destruction of its churches.

James Brooke, writing for the Berkshire Eagle,² reports this is occurring on a mammoth scale. In response, Ukraine has assembled its own team of Monuments Men working to catalog and repatriate stolen art. This new unit of Ukraine’s Territorial Defense Force is also gathering evidence to prosecute Russian military looters and vandals, if they can ever find them.

As Brooke writes:

It will be a big job. In the biggest cultural destruction Europe has seen since 1945, the United Nations Educational, Scientific and Cultural Organization’s latest tally pegs the two-year toll at damage to 343 sites — 127 churches, 151 historic buildings, 31 museums, 19 monuments, 14 libraries and one archive. Ukraine’s Culture Ministry says 1,189 cultural objects have been damaged or destroyed.

Brooke believes there is more going on here than stealing valuable art and busting up churches. He reports that Kyiv’s Maidan Museum Director Ihor Poshyvailo said recently in a Zoom call with American historians, “This is also the heritage war. It’s a war against our memory, historical memory. Against our identity. Against our culture. And, of course, against our future.”

Mystetskyi Arsenal cultural center director Olesia Ostrovska-Liuta added, “This Russian war in Ukraine is very tightly connected to culture. The basic assumption which lies beneath this assault is that Ukraine should not exist as a separate phenomenon with its own political agency. Any Ukrainian otherness from Russia should be erased. It is genocidal in its attempt and in its action … culture is in the very core of this war.”

During three years of horror in Ukraine, we have seen the deliberate bombing of Ukrainian hospitals, schools, and apartment buildings; corpses strewn in streets and stuffed into mass graves in Bucha; the veiled threat to resort to nuclear war if the West keeps supporting Ukraine; the Hermann Göring-like theft³ of the country’s magnificent cultural treasures. After seeing all that, how can we casually walk away?

But that is what we appear to be doing. That is what the world sees.

Congressional Republicans, falling all over themselves to do whatever Donald Trump demands, no matter how unpatriotic, are helping Putin and his Russian thugs to defeat Ukraine.

They are also helping to destroy its soul.

___________________

¹ I was once ordered by my Commanding Officer to get into a Light Observational Helicopter to go look for what someone in another chopper had reported “might” be the body of a North Vietnamese soldier. That “body” turned out to be a big tree branch; that’s how desperate we were to add to the body count.

² The Berkshire Eagle is a Pulitzer Prize-winning newspaper in Pittsfield, Massachusetts.

³ Smithsonian reports Nazi military leader Hermann Göring amassed his own personal collection of art stolen from museums and private homes. His collection totaled more than 1,000 items, valued at $200 million in 1945, most of it stolen from France. The art was hidden at various locations in Berchtesgaden, Germany, in the Bavarian Alps until discovered by the Monuments Men. The recovered artwork was then collected at Unterstein before transport to the Central Collecting Points at Munich and Wiesbaden.

Looking at sinners from last to first
The hypocrite seems to me the worst.

For some reason, recent events, unfolding like slow-motion train wrecks, have me thinking about Abraham Lincoln and the way he got things done.

In Team of Rivals, Doris Kearns Goodwin described how Lincoln, considered a “backward bumpkin” by his adversaries, co-opted all of them with the force of his strategic intellect. A pragmatist who played the long-game, Lincoln, with humility I can’t find in politics today, never let his ego or self-interest get in the way of his well-thought-out goals.

William Seward had been Lincoln’s main rival for the presidency, and the recently elected Lincoln knew the brilliant former Governor of New York had much to offer. Consequently he offered Seward the position of Secretary of State, which Seward accepted. When Lincoln was preparing the speech for his first inauguration, he asked Seward for his advice about it. Seward, whose ego was large, read the speech, complimented Lincoln on it, and said he only had three problems with it — the beginning, the middle, and the end. He offered Lincoln a host of suggested edits. Rather than show Seward he was offended, which he must have been, Lincoln thanked him for his counsel, accepted a few of his edits, but rejected all the others. This little interchange let Seward know who was President and who was not and set the tone for their future relationship, a relationship in which Seward was to become devoted to Lincoln.

On 10 August 1863, Lincoln had his first meeting with Frederick Douglas, the ex-slave who was to become perhaps the most influential social reformer, abolitionist, orator, writer, even statesman, of the 19th century. He was certainly the greatest leader of the movement for African-American civil rights.

The previous January, Lincoln had promulgated the Emancipation Proclamation, which freed the slaves in the Confederacy, but not the slaves in the states loyal to the Union. Douglas approved of this, because he could see it as the first step toward total freedom, but he was nonetheless upset with Lincoln for a different reason.

Shortly after Lincoln announced the Emancipation Proclamation, the Government had established the Bureau of Colored Troops to manage what it hoped would be great numbers of newly freed black soldiers. Douglas had been asked to help recruit these potential soldiers for army service. He agreed to do it, and he was successful at it. However, he had discovered the new recruits were not being paid as much as white soldiers. Neither were they receiving the same benefits or promotional opportunities.

This inequality was the source of Douglas’s anger, and he wanted Lincoln to know it when they met for the first time in the White House. He felt he had been betrayed.

Lincoln told Douglas he knew about the inequities and was committed to remedying them, but curing them would take time. Lincoln must have been persuasive, because Douglas believed him. He continued his recruiting endeavors. And, sure enough, the following June, Lincoln convinced Congress to pass a law requiring freed slaves to be paid as much as other soldiers, to receive comparable medical care, and to have the same  promotional opportunities as white soldiers. This opened the door for black soldiers to enter the Officer Corps. In addition, Congress made the new law retroactive to the Emancipation Proclamation.

In their encounter, both Lincoln and Douglas set their personal self-interest aside for the greater good. We don’t seem to be able to do that anymore in America. Putting country above self almost seems an anachronism.

From the triumph of Donald Trump in South Carolina, to his racist comments during his speech at the Black Conservative Federation (BCF) annual gala last Friday, to the falling-all-over-themselves backtracking of stalwart Christian politicians reacting to the Alabama Supreme Court’s in vitro fertilization decision, to the blatantly undemocratic, even treasonous, speeches at last week’s CPAC convention, to the continued nonchalant dismissal of funding to keep Ukraine alive — all of these, and more, are examples of the hypocrisy, selfishness and conceit that overshadows today’s political landscape.

Now, as Donald Trump closes the noose on the Republican Party, the Party of Abraham Lincoln, I do not see his incendiary rhetoric becoming any less unhinged or unbridled. Everyone in the Party seems to be lining up to grab onto his MAGA coattails, climb up into his pockets. You’d think there wouldn’t be any room left in there.

I ask myself, “What would Lincoln do?”
The answer? “How I wish I knew.”

“Disbelief, denial, all the stages of grief. … I was stunned.” — Dr. Michael C. Allemand, a reproductive endocrinologist at Alabama Fertility, which provides IVF services.

I hold a seed in the palm of my hand. It’s a Sunflower seed. Is the seed a Sunflower? Or, is it just a seed that, were I to plant it, water it, throw in the Miracle Grow, might (probably not, knowing me) turn into an actual Sunflower?

That seed is ready to grow. If I do everything right, it should rise and grow into a beautiful Sunflower, the kind Vincent van Gogh used to paint. But, looking at my palm, I don’t see a Sunflower; I see a seed.

But according to the logic behind an Alabama Supreme Court decision announced last Friday, I should not be calling my seed a seed; I should be calling it a Sunflower.

Last Friday, the Alabama Supreme Court ruled on a case brought by three couples over the accidental destruction of extra embryos they had frozen in their efforts to have children. The couples had successfully sought IVF treatment at a fertility clinic operated by the Center for Reproductive Medicine in Birmingham, Alabama. But, as in most IVF treatments, there were extra embryos, which had not been used in the successful treatments. Those were stored at a local hospital. In 2020, the hospital suffered a security breach when a, presumably unbalanced, patient got into the restricted area where the embryos were stored, extracted them from their containers, and dropped them after they burned the patient’s hand. This caused their destruction.

Instead of suing the hospital for negligence, the three couples sued under Alabama’s Wrongful Death of a Minor Act, which allows parents of a deceased child to recover punitive damages for their child’s death. Maybe it was all about the money?¹

Regardless, the very first paragraph of the Alabama Supreme Court’s decision reads:

This Court has long held that unborn children are “children” for purposes of Alabama’s Wrongful Death of a Minor Act, § 6-5-391, Ala. Code 1975, a statute that allows parents of a deceased child to recover punitive damages for their child’s death. The central question presented in these consolidated appeals, which involve the death of embryos kept in a cryogenic nursery, is whether the Act contains an unwritten exception to that rule for extrauterine children — that is, unborn children who are located outside of a biological uterus at the time they are killed. Under existing black-letter law, the answer to that question is no: the Wrongful Death of a Minor Act applies to all unborn children, regardless of their location.

In his majority opinion, Justice Jay Mitchell wrote, “all members of this Court agree that an unborn child is a genetically unique human being whose life begins at fertilization and ends at death.” Embryos may be “genetically unique,” but there is no scientific data to support a legal assertion that they are human beings.

At another rather fanciful point in his decision, Mitchell writes that considering a frozen embryo a “child” is a “natural, ordinary, commonly understood meaning” of the word. Commonly understood by whom, if you please?

On page 12 of his decision, Mitchell writes: “the ordinary meaning of “child” includes children who have not yet been born. ‘This Court’s most cited dictionary defines ‘child’ as ‘an unborn or recently born person.'” And, sure enough, if you head over to Merriam-Webster’s unabridged dictionary you find the meaning of “child” as “1. a: an unborn or recently born human being.” 

I would like to have a conversation with the person at M-W who came up with that definition of “child.” I would like to show him or her my Sunflower seed.

The decision takes a weirder and even more biblically Christian turn in Alabama Chief Justice Tom Parker’s concurring opinion in which he writes the decision is grounded in the “theologically based view of the sanctity of life.” Frozen embryos must be considered children, according to Parker, because “human life cannot be wrongfully destroyed without incurring the wrath of a holy God, who views the destruction of His image as an affront to Himself.”

He also wrote in his scripture-draped concurring opinion, “even before birth, all human beings bear the image of God, and their lives cannot be destroyed without effacing his glory.”

Parker’s opinion could have been written by Jerry Falwell.

What exactly happens in IVF? According to the Mayo Clinic’s explanation, “a woman’s extracted egg is fertilized by injecting a single sperm into it, or mixing the egg with sperm in a petri dish.” It is then a fertilized egg and is called an embryo. According to Alabama’s Supreme Court, it is also called a “child.”

In  his prescient dissent, Justice Greg Cook, clearly seeing where this is going, wrote:

The main opinion’s holding will mean that the creation of frozen embryos will end in Alabama. No rational medical provider would continue to provide services for creating and maintaining frozen embryos knowing that they must continue to maintain such frozen embryos forever or risk the penalty of a Wrongful Death Act claim for punitive damages.

And this is exactly what happened yesterday, when the fertility clinic at the University of Alabama at Birmingham, the biggest in the state, announced it has stopped offering IVF treatments. Other clinics will certainly follow. If nothing changes, and the only way it could, as Justice Mitchell’s decision makes plain, is by the Alabama legislature doing something it most certainly does not want to do — passing legislation declaring embryos are not children — this could spread to other states. Already, in today’s Boston Globe, IVF clinicians are voicing alarm at what could be a disastrous future for them and the patients they serve. “This changes the whole dynamic for how you help overcome infertility,” said Dr. Pietro Bortoletto, director of reproductive surgery at Boston IVF Fertility Clinic. “This feels like a big wake up call for infertility doctors everywhere.”

The Alabama decision is a knife through the heart of all of its citizens desperate to have children, but unable to do so without IVF. The Associated Press printed interviews with some today. The people interviewed were heartbroken.

The majority’s opinion clearly says the Justices got their marching orders from the U. S. Supreme Courts decision in Dobbs, which overruled Roe vs. Wade, the landmark 1973 decision that opened the door to legal abortion in America.

I cannot help thinking this unforeseen affair is one of the most striking examples of “The law of unintended consequences” I have ever seen.

Or, is it? The battle over frozen embryos has been going on since the George W. Bush Administration, and, while most of America thought the battle over, many just waited for a moment like this to take up the cause again.

And smack dab into the middle of all this drops Donald Trump, who, in one of fate’s stranger twists, is scheduled to address the annual convention of the National Religious Broadcasters (NRB) Association tonight at 8:00pm in Nashville, Tennessee.

The NRB, composed of evangelical broadcasters across America, claims 141 million Americans “watch or listen to Christian broadcasting every month,” and that there are “4000+ active Christian radio and televisions stations in the United States.”

In its Statements of Religious Beliefs, the NRB clearly shows its support for and agreement with the decision of the Alabama Supreme Court:

From the moment of fertilization until natural death, every human life is sacred because every human life has been created by God, in His image and likeness.

From the moment of fertilization, every human life must be recognized, respected, and protected as having the rights of a person and the inviolable right to life.

The right to life and physical integrity of every unborn human life is inviolable—it is not a concession made by society or the state, but is instead inherent to the unborn human life by virtue of its creation in the image of God.

Because human life begins at the moment of fertilization, it is against our religious and moral conviction to formally or materially cooperate in the termination of unborn human life.

With this audience, how can the former President possibly avoid speaking about this issue? Will he agree with the Alabama Supreme Court’s decision and say so? Will he mention it, but not give an opinion? Or, will he just rant about the radical left persecuting him? Personally, I think Trump too clever to get sucked down the IVF rabbit hole all caught up in the tangled judicial robes of Alabama’s Supreme Court Justices? But I don’t know how he’ll avoid it.

The IVF Genie is out of the bottle. Now what?

_________________

¹ Although, in their lawsuit, the couples assert strongly their belief in IVF and “fervent” hope their suit does not in any way harm the aspirations of other couples desperate to have children through in vitro fertilization.