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By Lindsey Shultz

It’s so very easy to fall into disillusionment.


And this is coming from someone who has always been drawn toward to the dystopia of Brave New World over the pastoral hijinx of Jane Austen, to the acrid, sardonic humor of the Brits over Will Ferrell and Seth Rogen, to the tragedies rather than the comedies.  My DVR is a melange of wonderfully sociopathic and self-destructive characters from Dexter to Don Draper, though lately I’ve been thinking that Toddlers & Tiaras might be reasonable addition to the mix.


I remember in the early days of medical school, being told how refreshing our idealism was, how young and hopeful we seemed.  Having long considered myself a pragmatist with a strong grounding in the realities of science and medicine, I would glance around and try to figure out who exactly these lecturers and attendings were talking about, because it certainly wasn’t me.  As time went on, I saw who they meant, in some of my peers and colleagues.  They brought a genuinely optimistic view of medicine and the role we were to play in our convoluted, messy world.  And this was not something I saw bludgeoned out of them by the grueling hours and emotional quagmires.  My colleagues who began with easy smiles and sunny dispositions- are now sincere and hopeful attendings.  And I am still someone who begins with “reasonable” expectations, and finds small improvements in outcomes a pleasant surprise. 


And even I find myself struggling to maintain forward momentum on some days.  Health and health care continues to be bogged down by not just arenas innate to the field, but all of the fields with which it intersects.  The inequality gap continues to grow, putting more stress on the health care system and to some indications having a direct adverse effect on health.  Obesity levels continue to rise, making whole swaths of populations both overweight and malnourished.  Attempts to remedy the situation with moves even as simple as proclaiming that pizza is not a vegetable or that even thinking about a tax on sugary and otherwise unhealthy items are anathema to freedom.[1] Where a decade ago we were living in what seemed to be a golden age of global health (think PEPFAR, the rise of the Global Fund, the Gates Foundation, the MDGs, huge increases in funding from a number of sectors), we now find ourselves in an era of looming austerity with stagnating financial support for health overall.  Instead of praising and reinforcing the Global Fund for its transparency and admirable effort at self-regulation (try to remember the last time you heard those words in a proactive manner)- it is struggling for survival.  And where for all its faults- the ACA promises to do great things to modernize and reorganize our ungainly health care system, it stands a very real chance of being undone by a Supreme Court whose decision will come largely on the semantic difference between market activity v. inactivity.  I even find myself reading the occasional article which puts a negative spin on EMTALA rather than looking to the larger issues of how to address growing health care costs or patients who fall through the cracks.[2]

But, then there are the days I find myself reading about the falling mortality rates of malaria, through devoted efforts by both local and international groups.  The number of HIV patients on treatment has never been higher, and there has never been better proof that efforts like USAID’s focus on circumcision, maternal-fetal transmission, and treatment-as-prevention may actually have a shot at working.  Economists like Charles Kenny are publishing books called “Getting Better”, reminding us that despite all our grumbling and failings, quality of life markers are almost universally improving, regardless of economic growth, and that there are effective short-to-mid range solutions out there.  Psychologists like Steven Pinker remind us that the world is getting less violent than it has ever been as long as hominids have been wandering about.  Political scientists note via various indices that the number of people living in democracy is on a capricious but steady climb upward. The revolutions across the Middle East and North Africa give hope that individuals taking to the streets may lead to convulsions that eventually culminate in institutions that are just a little bit better.  There is a doctor at the helm of the World Bank.


Domestically, there are more rigorous trials and experiments littering the literature, spreading the use of RCT’s to questions far beyond the realm of clinical medicine. [3]  Local innovation is sprouting up all over the country, tinkering with everything from payment structure to care implementation. The CMS Center for Innovation continues to lay the groundwork for determining what kinds of these cost-saving and quality improving initiatives seem scalable.  The talk of transparency and outcome metrics may be in its infancy, but is becoming the lingua franca of health reform.  The sexiness of medicine and health has evolved to the point that doctors and epidemiologists like Atul Gawande and Hans Rosling are rock stars in the TED world.


And- there are groups like Doctors for America where I have had the opportunity to find others who share my same concerns, and my same hopes.  Most of those colleagues I spoke of- the hopeful, smiling kind who do indeed love their jobs and their patients- seemed to inhabit a different world, one that when I asked, they are better able to maintain by not venturing into this bigger, messier network in which health & health care is embedded.  But then there are the others- new colleagues met, old friends who still have the same passions we did back in medical school, now taking the stage at places like Doctors for America and TEDMED[4]. It’s reassuring and inspiring to see other physicians and activists working in this same intersection, and it is all these moving parts which will add up to a stronger whole. 


For me- Zeke Emanuel struck a chord at the conference, speaking on the future of health care, saying, “Now, I’m an optimist... except of course when I’m a pessimist.”  But for me- I guess I’m a pessimist, except when I’m an optimist.  And seeing the good work being done makes that glass at least half full.  Fine- maybe a little more.

[1] Check out this special report from Reuters for a good synopsis.

[2]This one stood out in particular:

[3] From Esther Duflo and Abhijit Banerjee’s Poor Economics to Dean Karlan’s More than Good Intentions, lots of great reads have been published in the past few years.


[4] Hard not to feel hopeful when someone working with the IOM on new med school curricula wants applicants to  be “someone who has studied two or three different disciplines in his college, someone who has articulated a vision of what they think health should be in 50 years.”

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