Bill Moyers Journal

by Bill Moyers

  From your perspective, what’s wrong with our health care system?

  For many, many years, we’ve been working under the fantasy that if we come up with new drugs and new treatments, we’re done. The rest of the system will take care of itself. In my view, the rocket science in health and health care is how we deliver it. Unfortunately, there’s not a single medical school that I know of that actually teaches the delivery of health care as one of the essential sciences.

  What we’ve learned about organizations is that it is very difficult to get a complex organization, a group of people, to work consistently toward a goal, especially a goal as complex as providing great health care. In the business world, if you don’t do it well, the market gets rid of you. You go out of business. But many hospitals that are executing very poorly persist for a very, very long time. My own view is that we have to fundamentally rethink the kind of research we do and the kind of people we educate so that they’ll think about the complexity of delivery as a topic that we need to tackle as a science.

  Complexity of delivery?

  Yes. Just think about a single patient. A patient comes into the hospital. There’s a judgment made the minute that patient walks into the emergency room about how sick that person is. And then there are relays of information from the triage nurse to the physician, from the physician to the other physician who comes on the shift. From them to the ward team that takes over that patient—there are so many transfers of information. Yet we haven’t looked at the transfer of information the way that, for example, Southwest Airlines has. Apparently they do it as well as any company in the world. It seems that Southwest Airlines has taken seriously the human science of how you transfer simple information from one person to the next. In medical school, and in the hospitals that I’ve worked in, we’ve mostly done it ad hoc. Sometimes we do it well, sometimes we don’t do it well, but we haven’t treated it as a science despite knowing that transfer of information is critical to good patient care.

  What we need now is a whole new cadre of people who understand the science, who really are committed to patient care, but who then also think about how to make those human systems work effectively. We’ve been calling it, aspirationally, the science of health care delivery. And we do it at Dartmouth. Thirty years ago, one of our great faculty members, Jack Wennberg, started asking a pretty simple question: why is there variation in the number of children who get their tonsils taken out between one county in Vermont versus another? Because one of his children was in school at one place, another of his children was in the school in another place.

  In one place, almost everyone had their tonsils out. And in another place, almost no one did. And of course, he found that there happened to be a doctor in one of the counties who liked to take tonsils out and benefited from it. So he kept asking this question about outcome variation. He called it the evaluative clinical sciences.

  That’s a fancy name. What does it mean to the layman?

  It means, how do you evaluate clinical outcomes? How do you understand variation in doctors’ practices, for example? And ultimately, how do you fix the problems? Why is the Medicare reimbursement rate almost a third in the Mayo Clinic area in Minnesota of what it is in Miami?

  Why have we been so resistant to doing this? It sounds so sensible.

  I’ve noticed over the years that when it comes to our most cherished social goals, not only do we tolerate poor execution, sometimes we celebrate poor execution. Sometimes it’s part of the culture. You know: “These folks are trying to solve this terrible problem, they can’t keep their books straight, they really don’t know what they’re getting, they don’t measure anything, but they’re on the right side, so that’s okay.” I think we’re in a different time.

  What can we learn from the health care partnerships you’ve spent the last twenty-five years creating around the world?

  One is that community health orkers—members of the community who help people go through very difficult treatment regimens—can work anywhere. We did it first in Haiti, then we did it in Peru, and then in Africa. But most remarkably, we’ve also implemented that program in Boston, and are now thinking of implementing it on the Navajo reservation in New Mexico.

  And in essence, it means what?

  It means that for people who are, say, taking HIV medications that are very difficult, that they have to take every day, that they have to really be careful about, with nutrition, et cetera, that having someone who just visits every day, just to make sure that you’re taking your medicines and you’re doing okay, has a huge payoff down the line in terms of overall health outcomes. Almost a decade ago, we found a group of patients living with HIV in Boston who were really falling through the cracks. We implemented almost an identical program to the one we developed in Haiti, and we’ve had really astounding results. The cost of their care has gone down, and they’re back working, and they’re productive members of society. They’re not landing in the emergency room when their disease gets out of control.

  We’ve got to bring the best and the brightest to work on health care delivery and the only way to do that is to get more people thinking about it every day. Right now, the physicians who are running these hospitals have never been trained in the skills they need to run such complex enterprises. Most of them have never been trained in systems thinking, in strategy, in management.

  One of the big disappointments to a lot of people is that the White House seems to have made a deal with the drug industry not to use the power of the government to negotiate lower drug prices through Medicare and Medicaid. I know you learned something about negotiating for lower drug prices when you were at the World Health Organization, right?

  It’s a very complicated business. Of the three major killers—HIV, tuberculosis, and malaria—the only disease for which we have really good drugs is HIV. It’s very simple why—there’s a market in the United States and Europe. So we know that market incentives to drive drug delivery are critical. We have to maintain them somehow, because if you don’t have market incentives, we have almost no new drugs. Now, having said that, I’ve worked a lot with the drug companies to say, “Okay, so make as much money as you can on the HIV drugs in the first world. We will work with you to protect those markets and protect your intellectual property. On the other hand, in those areas where you make no money anyway, work with us to make those drugs available.” And they’ve done that for HIV drugs in a way that’s really quite astounding.

  We’ve got to make sure that the incentive for the drug companies to make new drugs is still there, but at the same time, be reasonable about making sure that people have access to them.

  There was a strain of TB that could be cured by a drug, but the drug was so expensive that poor people couldn’t afford it in the developing world. What did you do about that?

  We looked at the cost of these drugs for a complete cure for a patient living in the developing world. When we started, it was about $25,000. But what we later learned was that the only reason they were so expensive is because they were only sold in first world countries. So we got everyone who was interested in purchasing these drugs. We went to Doctors Without Borders, we went to other health organizations and said, “Can you help us get the Indian and Chinese drug industry to start making these drugs?” And they did it. Now, the real key was at Eli Lilly and Company, which was making two of the drugs. They came on board and said, “You know what? We’re going to help you with this program. We don’t make any money off these drugs, they were off patent a long time ago. We’re going to actually help you find manufacturers in those countries that can make these drugs at a lower cost.”

  It’s one of the greatest acts of corporate philanthropy I’ve ever seen, Eli Lilly and Company helping us craft the overall response to drug-resistant tuberculosis. We’re not there yet. If there were a market for tuberculosis drugs, then I think we’d have lots of new drugs. But because there’s not one in the developed world, we’re still struggling.

 
So we’ve learned a couple of things. One, intellectual property is important—but the drug companies, if you keep working with them, they’ll see that there are great philanthropic and humanitarian achievements that they can claim for themselves by helping to make them accessible. We’re not there yet, but the Gates Foundation, for example, is working very hard to fill the holes that the market is not filling. We’ve all got our fingers crossed, hoping that Bill and Melinda Gates will be successful in getting us these new drugs and vaccines.

  But when you see health fairs where people who are so poor in this country go because they can’t affo rd to have a toxic tooth pulled, how do you justify spending that much effort and that much money in Africa and Haiti and South America when we have such desperate need in this country?

  They’re two very different problems. Both of them break my heart. In the developing countries what we’re doing is taking annual expenditures on health care from $2 or $3 per person up to maybe $15, $20, or $30. In the United States, where we’re spending, on average, $7,000 per person per year, we should be able to find a way to provide health care for everyone. And I think we can do that fairly quickly if we put our minds to it. An example of the problem with health in the developing world is drug-resistant tuberculosis. The majority of the cases of drug-resistant tuberculosis in the United States are among the foreign-born, but it is not a smart idea to think that those kind of diseases are over there, and we’re immune from them. We’re not. In terms of infectious diseases and other health problems, we are one planet.

  Yes, but friends and viewers write or say to me, “Moyers, don’t bring us any more bad news. We don’t want to see any more starving children in Rwanda, sick children in the Congo, or dying children in Haiti. If Bill Gates can’t save them, there’s nothing we can do.” What keeps you from getting depressed?

  For twenty-five years, in working with Partners in Health, we’ve really seen some tremendous changes. Haiti suffers from so many problems, including deforestation, poor health care, poverty, all these different kinds of problems, but in our one little area, not only have we built a health care system that now sees almost two million patients a year, but the trees have come back.

  We just sort of did this almost quixotic little project where we kept planting trees. And the area around our clinic looks almost like the rain forest that it once was. So in going to those really difficult situations, first of all, it brings out a kind of humility that I don’t feel unless I go and see the most excruciating thing on the face of the earth, which to me is a mother who can’t feed her child. Having the experience of seeing those things does something to me as a person, to my soul. But then in seeing the possibilities, the programs that can turn things around, that’s the most inspiring thing that I’ve ever seen.

  Where does this passion come from in you? If an anthropologist walked in here and said, “Who is that person, where is he from?” what’s the answer?

  I’ve been very fortunate. You know, my father came by himself, across the North Korean border, when he was seventeen and hadn’t seen his brothers or sisters or parents since then. He died some time ago, but never saw any of his relatives that he left behind in North Korea. My mother was a refugee in war-torn Korea and was plucked, because she was a good student, to come to Scarritt College in Tennessee. So there have been so many accidents of luck that have gotten me to this position. We first came to Dallas, Texas. My father had been a well-established dentist in Korea, but then had to do dental school all over again, because they didn’t recognize Korean degrees. So he got his dental degree from Baylor’s dental school, and then we moved to a small town in Iowa where I grew up and graduated from high school. My mother, who lived through war, graduated from Scarritt College and was given the great opportunity of completing her master’s degree in divinity with Reinhold Niebuhr and Paul Tillich at Union Theological Seminary.

  Two great theologians of the twentieth century.

  Absolutely. It was one of the most exciting intellectual environments in the country at that time, in the 1950s. So we always had the sense from my mother that we should do something great, that there are great things to be done in the world. She would read to us the speeches of Martin Luther King in 1968. She even gave me Booker T. Washington to read when I was in grade school. So I had exposure to a lot of great thinkers. She kept trying to convince us that we had a responsibility in the world.

  Now, my father was a dentist, one of the most practical people on the face of the earth. When I came back from my first semester at Brown University, he picked me up at the airport and we were driving home and I said to him, “Dad, I think I’m going to study philosophy.” So he slowly pulls his car over to the side of the road, looks back at me, and says, “Look, when you finish your residency, you can do anything you want.” It was clear: if I was going to make it in this country as an Asian American, he said, “You’re going to need a skill. You can do anything with that. Whatever you do after you have that skill is okay.” But, he said, “I can’t go to my grave without knowing that you have some way of supporting yourself if everything else falls through.”

  Were you the only Asian family in that little town?

  We were.

  What was that like?

  Well, we were comfortable economically. But if you go to a mall, just up the road, where they don’t know who you are, of course, back in those days Kung Fu was the big exposure to Asian culture. So you know, everyone would come up to us and either be fearful or mocking. So racism was there. But I’ve come to understand that the racism that we felt wasn’t the kind of racism that impacted African Americans in the South in the ’30s and ’40s and even more recently. It was different. I think I developed a sensitivity for people who are marginalized and outcast, but I don’t have any illusions about me being an oppressed person. My father was a dentist, my mother was a philosopher. We loved Iowa Hawkeye football, so we had a great time there.

  And you went on to train as an anthropologist as well as in medicine. What do you think the eye of an anthropologist sees that a physician on his or her own might not see?

  In medicine, what we’re trained to do is to look for patterns, to build order out of great complexity, out of very subtle signs and symptoms, and then have a plan where you can act. Anthropologists are a little bit different; we don’t often act on what we see. So I’m sort of in the middle now. I do the ethnography, to try to get a sense of what the culture is. If you want to know what anthropologists do, one of my great professors, Sally Falk Moore, once said that it’s very simple. You walk into a room and you say, “Who are these people and what do they want?” So if you’re constantly asking that question, over time, you build up a sense of how a particular social system works. That’s always what we’ve done. What is it that we need to do to actually change policy around HIV treatment or drug resistant TB treatment? That anthropological piece of it, linked to a physician’s approach to solving a problem and putting a solution on the table, taking people through difficult times—that’s been a very good combination for me.

  W.S. MERWIN

  A poem by William S. Merwin is a finely crafted thing. So is Merwin’s life. He began the crafting of it at the age of eighteen, when Ezra Pound told him, “If you want to be a poet you have to take it seriously ... and you have to do it every day.” And “the way to do it is to learn a language and translate. You can learn a foreign language, but the translation is your way of learning your own language.” Merwin listened, and went off to Princeton to study Romance languages. He began his career as a translator in England, France, and in Majorca, Spain, where he tutored the son of poet Robert Graves. He and started to jot down ideas for poems on “useless paper, scrap paper,” which he keeps until he “can find out where it goes from there.”

  His first book of verse, A Mask for Janus, was chosen for the Yale Younger Poets Prize by none other than W.H. Auden, whom Merwin later angered when, in 1971, he won the Pulitzer Prize and donated the money to the antiwar movement. Over
the past half century Merwin kept winning major awards as he produced more than twenty-five volumes of poetry, a score of translations, ten works of prose, several verse plays, and a memoir, Summer Doorways. In 1976, he moved to Hawaii to study Zen Buddhism. He later married Paula Schwartz, and the two of them built a solar-powered home on an abandoned pineapple farm. Together, inch by inch, they restored the surrounding tropical rain forest, proving that nature, too, like a poem, can be a finely crafted thing.

  In July 2010, W. S. Merwin was named the seventeenth poet laureate of the United States, officially known as the consultant in poetry to the Library of Congress. We talked when he came to New York to accept his second Pulitzer Prize for his latest collection, The Shadow of Sirius.

  —Bill Moyers

  Sirius is the Dog Star, the most luminous star in the sky, twenty-five times more luminous than the sun. Yet you write about its shadow, something no one has never seen, something invisible to us.

  That’s the point. The shadow of Sirius is pure metaphor, pure imagination. As we talk to each other, we see the light, our faces. But we know there’s the other side that we never see. It’s the dark, the unknown side, that guides us and that is part of our lives all the time. It’s the mystery, always with us. And it gives depth and dimension to everything else.

  “The Nomad Flute” is the first poem in the book. Would you read it?

  THE NOMAD FLUTE

  You that sang to me once sing to me now

  let me hear your long lifted note

  survive with me

  the star is fading