The Death of a President

 
In psychiatry, a great deal depends on timing, including the correct diagnosis. For instance, while you may have experienced or witnessed a traumatic event or may have had prolonged exposure to highly stressful, traumatic, or abusive conditions, you can't be diagnosed with PTSD unless your symptoms have persisted longer than six months. Under six months, we call it acute stress disorder. PTSD symptoms can persist a long time.

Looking back, I definitely think 9/11 resulted in the semblance of a nation-wide case of PTSD from which we've done a fairly good job of recovering. We're more alert to danger but less likely to shut down the entire country over an isolated, local threat. We're no longer quite so eager to send in the troops at the sound of gunfire on the far side of the world. Life has begun to approximate "normal," though we're more aware of our vulnerability and the memory of tragedy is still there and always will be. Even the extreme political right seems more intent on defeating the president's health initiative than tackling terrorism. I don't think we've done as well with November 22, 1963.

I've often thought the free love, abundant drugs, and Tune-In, Turn-On, and Drop-Out mentality of the 60s was more an expression of anger -- acting out -- than typical adolescent rebellion. For the first time in our history, almost an entire generation gave the establishment the middle finger. Its hero was dead, LBJ had taken office, the Warren Commission was established, there was a national day of mourning, and now, it was time to move on. But this generation wasn't ready yet, and we would all have to wait for Kubler-Ross (On Death and Dying, 1969) to inform us the funeral was only the beginning.

Watching the 50th anniversary of the Kennedy assassination programming the past few days, I've been struck by how often someone uttered the phrase, "People don't want to think Kennedy could have been struck down by a single individual, acting alone. The magnitude of his personality as president seems to demand much more."  I'm not certain this is accurate. I don't believe his personal magnetism or his role as the nation's leader are nearly as important as the magnitude of his loss. Ongoing conspiracy theories and the tendency of 2/3 of Americans to doubt the findings of the Warren Report symbolize the depth of grief many still feel, as well as an abiding need for it to be recognized. Mistrust of government may have burst into full flower with Watergate, but it is rooted in the mismanagement of national grief over the death of a president.  

This is likely an unfair generalization, but there is still some truth in the statement that Lyndon Johnson's generation was more accustomed to putting tragedy behind them than paying close attention to what it means and mourning its significance. Anyone who's watched the HBO presentations of Band of Brothers (2001) or The Pacific (2010), or talked at length with veterans from the Great Generation knows how exceedingly reticent they are about digging up old wounds. The idea that the country as a whole needed time and leadership in the matter of grieving was unheard of in 1963. In a very real sense, we needed a president who understood and embraced his role as nation's chaplain as well as it's chief executive. Unfortunately, this was not one of JBJ's strengths, in contrast with our current president who has been known to take hours comforting the victims of gun violence.

I was also struck by the numbers of interviewees who commented on how America had changed, subsequent to the assassination. They lamented a loss of optimism, hopefulness, and the belief anything was possible. Whether those feelings are shared by all is debatable. There were and still are, sectors of the population that make no secret of their hatred of Kennedy and the causes he and his brothers championed. Nevertheless, his loss was felt by far more and the feelings associated with it have lasted far longer than anyone might have imagined. 
 
Grief isn't resolved, if it's ever truly resolved, by assigning blame, getting even, and nursing the satisfaction gained from a moment of passion. We learn to deal with our losses, to live with them, making them part of ourselves, by refusing to play down their impact and brush them away like crumbs from the table. Grief has to be honored and mourning respected if we're ever to regain the optimism, hope, and sense of the possible that seems forever out of reach when we feel bereft. If there are lessons worth learning from the past 50 years, this is one to take to heart. 


(Creative Commons image of eternal flame at grave of John F. Kennedy by Tim Evanson via Flickr)

Remembering Where I Was, How I Felt, and Why

They say days like today, you always remember where you were when you got the news. I was in my classroom, it was lunchtime, and a fellow student rushed in, out of breath, and announced, "Kennedy's just been shot." I was too young, I suppose, to understand what that would mean, though I recall going through the rest of the afternoon with a feeling of tenuousness in my stomach and I couldn't wait to get home. 

Two years earlier, during the presidential campaign, an older teacher admonished our class that if JFK was elected, "we'll be under the Pope." Obviously, that never materialized but it reflects the mindset of some at the time. Change was difficult for them to envision and embrace, not unlike it seems now. All I knew was, my parents voted Democratic, they liked Kennedy's youth and energy, and neither cared whether he was Catholic, Baptist, or Jewish. He served in the military as had my father and we watched PT-109 (1963) with pride. 

That night, though, we watched the news all evening long. The information was mixed and we weren't certain from one minute to the next whether he'd survived or not. All I really remember was midnight and the screen flashing the American flag. The national anthem played, my mother wept, and so did I. Dad, as always, was the pillar we leaned on, but I vaguely remember him wiping his eyes as he led me down the hall to bed.

Days later, I stayed home from school and we watched the funeral. Everything and everyone moved so very slowly, to me it seemed endless. I had met death twice by then, my dog and pony both having passed away two and three years earlier. But I'd never encountered it in human form and seeing John Jr. and his sister, I was so glad it wasn't my father we were laying to rest.

In November 2000, it would be, replete with military honor guard, the firing of rifles, and a bugler playing "Taps." I wasn't thinking of John Jr. and Caroline then, nor was I thinking of their father. Not until later, when Barack Obama was running for president and I felt the same optimism and hope my parents talked about in 1963. Not until a snowy day in Portland when I met John's brother, Ted, campaigning for the president. And not until today, when I remembered where I was and how I felt and why.

 
(Creative Commons image by the smuggler via Flickr)
 

Healthcare Without Politics: The Future is Now

Is it even possible anymore, healthcare without politics? 
I don't know, but I hope so. I'd hate to think the only place it could exist was Disney World. I hope we can reach the point midst all the  maneuvering and jockeying for power and influence where our concern for those who need healthcare exceeds its value as political capital. Sadly, we're not there yet.

Back in the day when, for the average person, Blue Cross/Blue Shield was pretty much the only health insurance game in town, coverage protected in case of catastrophe, i.e. hospitalization. I've described in other posts my own experience of kidney stones necessitating two major surgeries. My family paid out of pocket for outpatient doctor visits and prescriptions, grateful our Blue Cross policy meant the cost of my hospital stay wouldn't hit us with the force of a tsunami carrying the threat of bankruptcy in its wake.

At the time I was recovering from kidney stones and for a few years thereafter, doctors were reimbursed by insurance for services rendered. It was called a fee-for-service system. More services meant greater reimbursement. Eventually, managed care firms came into existence and in the effort to control the costs of operation, they established criteria that must be met, justifying tests and procedures, before  insurance claims would be paid and doctors reimbursed. Soon it became necessary for providers and/or policy holders to obtain authorizations for treatment before managed care considered itself obligated to pay. If you think about it from a business perspective, this makes sense. A company can only pay out so much before it is unable to pay at all.

The road to hell is lined with good intentions, as the saying goes, and while management of healthcare costs was doubtless a factor in the evolution of managed care, we have to remember, healthcare insurance is still a business and the first priority of any business is to make a profit. To accomplish this goal, a business has to increase revenues and/or reduce expenses. Determining which procedures or medications were clinically indicated, ostensibly based on empirical evidence, was one way of setting limits on expenses. Refusing to cover pre-existing conditions was another. Over time, decisions of medical necessity were taken over by managed care and stories of treatment denial, some of them truly horrible, started surfacing. You've heard them on the nightly news as have I.

Despite public outcry, doctors' frustration with a growing insurance beuracracy, and the efforts of congressional leaders like the late Senator Ted Kennedy, insurance reform lagged. Ours is a free-market economy, it was argued, competition lies at the heart of the American Way. Socialized medicine in Canada and Europe, opponents declared, provided poorer quality care and ours was the best in the world. The reality, however, failed to live up to the evidence even as the arguments proliferated.

Families on the verge of collapse because of alcoholism or drug abuse may resort to performing an intervention, confronting the substance abuser who is unwilling or unable to get treatment themselves. Not dissimilarly, someone had to intervene if healthcare insurance was going to obtain the "treatment" it had long needed. Relying on competition to even the field failed to yield more affordable coverage and the number of uninsured Americans continued to grow. Either free-market theory was wrong or the industry discovered how to prosper in spite of it. Although many believed there were good reasons for reforming the system, there was insufficient motivation for the system to reform itself.

Enter the Affordable Care and Patient Protection Act, the function of which is to enable one to obtain affordable healthcare insurance and provide protection against potential abuses by the insurance industry. Under its umbrella, patients can no longer be denied coverage because of preexisting conditions. The determination of medical necessity has been placed back into the hands of those who are committed to serve the needs of patients. Doctors now have the right to review private insurance company files that identified physicians with high utilization patient populations and directed new referrals to those whose patients were regarded as healthier and therefore cheaper to insure. 

It's not a perfect solution but imperfection doesn't automatically render it a bad one. If anything, we're discovering it's a work in progress and we'll need to adjust and adapt it as we go. I don't think it represents a step toward socialism anymore than the Selective Service represented a step toward a police state. Most of us are too smart to believe that line, even if politicians aren't smart enough to find a better one. 

The Affordable Care Act is an attempt to reform a system sorely in need of reform, not only for the sake of patients and policy holders, but for its own sake as well. As with any intervention, the insurance industry finds change painful and naturally responds with anger, disbelief, and a desire to bargain, hoping to retain something of the status quo. Over time, acceptance will ensue and the industry will find itself better off for the changes that have been made. In the meantime, we're past the point of no return; pretending the good old days were the best days is a fantasy and Fantasy Land is for cartoons. We live in Tomorrow Land and the future is now. 


(Creative Commons image of Walt Disney Politics by sbwoodside via Flickr)

The "Other" Ted Kennedy

I spent last evening watching the wake for Senator Ted Kennedy at the presidential library in Boston. Long-time friends spoke, sharing personal memories that rarely reach the public eye. At the funeral of Israeli Prime Minister Itzhak Rabin, for instance, Ted privately took soil from the graves of his brothers, and spread it over Rabin's grave after the crowds had left the scene.

The Vice-President Joe Biden related how Ted had been like an older brother, helping him find his way as a senator. Had it not been for Ted, he said, he'd not be where he was in life. Bobby's eldest son, Joe Kennedy, thanked Ted's children for sharing their father because he, his siblings, and Jack's children, needed a father figure and Ted was there for them.

There was laughter as stories about sailing, practical jokes, and family trips to historical sites surfaced. Some talked about the visible change that took place in Ted's life when he met his wife, Vicki. Everyone talked about how, in one way or another, they felt like they were members of his extended family, whether by kinship or by friendship.

I was struck by one thing in particular. The Ted I had met was the same one they had known. This was his way with everyone, it seems, and I wondered what made him so. As I listened to their stories, I came to believe his pain had made the difference. Not simply losing his brothers, but the failure of his first marriage, Chappaquiddick, his own struggles with alcohol.

Whatever history or those who somehow feel qualified or justified in passing judgment might say, I think he learned from his pain and turned it into compassion. Love helped immensely. Watching his wife that snowy day in Maine, she struck me as natural, unaffected, spontaneous, and kind. She took a man 22 years her senior and helped him find his heart. The debt many feel they owe Ted, they owe her as well.

A community choir sang last night -- not the great hymns of faith that one might expect, but rather the bluesy-jazz-gospel mix you hear in an African-American church. And like Ted, when I first met him, at the very end they led the crowd in singing, When Irish Eyes Are Smiling. And that's when I lost it.


(Image by Barack Obama via Flickr)

Meeting Ted Kennedy

Image via Wikipedia

It had snowed fairly heavily the night before but it was a spring snow, full of water, and the downtown streets were soon more awash with slush than ice. I drove through neighborhoods that smelled of old money, where hundred-plus-year old brownstone mansions reminded me I was a newcomer to New England. I found a parking place a block from the site where the Obama rally, if it can even be called that, was to take place. It was an assisted living facility and the speaker was going to be Senator Ted Kennedy.

I'd gotten there early, anticipating a crowd, but I needn't have worried. There were plenty of seats in the living area where a piano stood in the corner. Older adults gathered, a few at a time, filling the chairs. I took my seat, quite happily, on the floor as close to the podium as I could get. I'd never seen him before, in person, and I knew this was my chance -- if I wanted to meet the man who'd played football with Jack and Bobby, it was now or never.

Eventually the media arrived and anticipation grew as noise and bustling was heard down the hallway. Ted, his wife Vicki, and their two Portuguese Water Dogs walked in as though visiting family and made their way to within ten feet of me. It was all so casual I nearly laughed out loud. No police, no secret service, no relocating of ordinary people like me to the periphery.

He spoke entirely off the cuff, introducing his wife, his dogs, and then talking about the issues as though the entire election depended on this small gathering. I felt like I was witnessing a much younger man running for Congress at a time when "the press" meant a reporter with a pad and pencil. I can't tell you much of what he said, partly because I was so caught up in watching him and his wife. I remember how he looked at her, how she looked back, and there was no question I was in the presence of two people in love.

Before I knew it, he was finishing and asking us all to stand and join him in singing, When Irish Eyes Are Smiling. I didn't know the words but I couldn't have sung them anyway, so choked up I was becoming. So, I stood there, blinking back tears and waiting for my moment.

As the crowd thinned and he started to make his way from the podium, I seized it. I laid my hand on his shoulder, he turned, shook my other hand, and looked me in the eyes. Not the, "is there someone more important I should be talking with" sideways glance that politicians polish, but eye to eye and person to person. It was brief and that was what I expected. What really mattered, was simply meeting him -- anything else would have been like pie a la mode. For me, it's always the pie that counts.

And, yes, I did meet his dogs, they were delightful, and I passed along greetings from mine to them both.


(Image via Wikipedia)