|Number 117||July 20, 2001|
I said on April 27th that I would be taking a break, and that there would be no Nygaard Notes "for a couple of weeks." Well, that was 11 weeks ago, and I'm sorry about the long hiatus. Dealing with cancer is a time-consuming thing. It also has taken almost all of my creativity to deal with the incidentals (insurance, for instance), which is why my brain has not been able to conjure up an issue of the Notes for so long. Some of our brain- and spirit-draining experiences are worth passing along, so the next several weeks of the Notes will include "Tales From The Cancer Front." Installments #1 & #2 appear this week.
Now, for a little business: I have promised all of my subscribers that there will be at least 44 issues of Nygaard Notes each year. There won't be that many this calendar year, since 52 minus 11 is only 41. For those of you who make an annual financial contribution, I will not ask for a renewal until three months later than your 1-year period. How's that? And for those of you who do not make an annual financial contribution...well, what the heck is wrong with you, anyway? I will not be asking you for a contribution on any regular schedule, so no change in plans is required.
The last thing I was talking about back in April was the idea of replacing the tired political labels of "left" vs. "right" with some more useful conceptions, along the lines of "individualistic" vs. "social." A close look at how the medical profession deals with cancer yields some insight into this discussion. Some thoughts appear this week in the essay "Physical Health and Social Health."
Welcome to the new subscribers who came aboard while the ship was in drydock, and a big THANK YOU to the many readers who wrote to say they missed the Notes. I missed you all, too. I am very glad to be back in the saddle again.
-- Ron Lilek, senior vice president of human resources (sic) for Fairview Health Services, speaking at a rally for affordable housing. He was referring to the fact that finding affordable housing is "a serious problem for many of Fairview's 17,000 workers," about 35% of whom earn between $7 and $11 an hour. I'd like to be present when someone asks Ron why Fairview's insistence on paying low wages is the government's problem.
#1: Authorizing the Past
Among the many letters we have received from the HMO (Blue Cross/Blue Shield) is a letter "Re: Prior authorization for right modified radical mastectomy; left breast prophylactic mastectomy." This "prior authorization" was followed by a list of eight items. One of the items that was checked off reads as follows: "This procedure, medication, supply or service does not require prior authorization. Reimbursement for services is dependent upon appropriate CPT coding at the time of claim submission." Handwritten in the margin are the words "with – diagnosis of breast cancer." (No, we do not know what "CPT coding is.)
The second item checked off reads: "This service is subject to contract eligibility. Please call the Provider Service Center for contract benefit eligibility."
In other words, Blue Cross "authorizes" a mastectomy, but may not pay for it. People in our socioeconomic position would likely want to call to find out, since the cost of the possibly-ineligible surgery runs in the $10,000 range.
We didn't bother to call, though, since the notice arrived at our house on the day after the surgery was performed.
#2: Out of (DEEP) Pocket Expenses
Chemotherapy has begun, and it is not a pleasant experience. Fortunately, there are many prescription drugs one can take to mitigate the common side effects. The prescriptions my partner was sent home with after her first chemo session came to $2,395.54. Blue Cross requires that the patient pay up front, and then they reimburse later. We were expected to pay cash on the spot. No one mentioned this before we came in. No one even suggested that we bring a checkbook.
The pharmacy came up with the idea that we pay with a credit card. My partner's credit card has a $1,000.00 limit (I don't have a credit card.) So much for that idea. Fortunately, many friends have contributed to a cancer fund for my partner, meaning that we had sufficient cash to cover this "surprise" bill.
What if we didn't have the money? Since this surprise came at the end of an eight-hour day of very trying toxic treatments, we didn't ask.
One of my favorite questions in public opinion polls goes like this: "Do you think things in this country are generally going in the right direction or do you feel things have gotten pretty seriously off on the wrong track?" (This is the wording in the ABC News/Washington Post poll; the other major polls are similar.)
It's an important question, yet I can't imagine what the average American could possibly be thinking when they answer it. I can easily imagine what the news organizations are thinking when they ask it: "Do you like Brand X (Democrats) or Brand Y (Republicans) better?" Possibly that is what goes through the mind of respondents, as well; there's no way to tell, which is partly why it is one of my favorite questions.
Whatever people are thinking about, it is interesting to note that these "respectable" polls show that somewhere around half of all Americans think the country is "seriously off on the wrong track." In the Gallup/CNN/USA Today poll of this past May, the alienated outnumber the satisfied by 50% to 46%. How about that? According to the Pew Research Center for the People & the Press, in their poll of just last month, it's 52% to 43%. The Harris Poll actually has something called the "Harris Alienation Index." (Also the less-interesting "Harris Feel Good Index," if you like a positive spin.)
In the following essay, I ponder what might possibly be meant by "being off on the wrong track." In the meantime, if details are of interest to you, you could go to this polling website for more details than you would ever care to know: http://www.pollingreport.com/right.htm.
One of the things I have learned in the past two months is that the conception of cancer is very different when seen through different philosophical lenses. Most Nygaard Notes readers are likely familiar with the standard biomedical -- let's call it the "Western" -- conception. This model says that there is a specific bunch of cells that go crazy and grow out of control and which, if left unchecked, will eventually spread throughout the organism and kill it. Does this sound familiar? It's what most U.S. doctors believe at their very core. If you have had any experience with cancer, you have likely either heard it stated explicitly, or else it has been simply assumed in your contacts with the medical system.
I was surprised to learn that, in Traditional Chinese Medicine, or TCM, the conception of cancer is completely different. One might even say it is the opposite. In TCM theory, the problem is an imbalance or disruption in a human being's total system which, if left unchecked, may manifest itself in a specific disease or location. It could manifest as the flu, or as a bi-polar disorder, or as psoriasis. Or it could be a cancerous tumor.
These are two very different ideas. In the Western conception, a "bad" part infects the whole. In the Eastern conception, a weakened whole presents itself as a disease in one or more parts.
The implications of this are quite profound, and not just in some ivory-tower, intellectual way. This health lesson can be extended, as a metaphor, to help us understand how a philosophical bias (or preference, if you like that better) shapes our approach to everyday living.
Cancer As Metaphor
Think of cancer cells as criminals. In the Western conception, cancer cells are "bad guys" who can infect the whole neighborhood/city/country if you don't banish them or kill them. If there are a lot of "bad guys," then you have to do a lot of banishing and killing. And, in fact, that's what we do in the United States. We lock up more people in proportion to our population than any other country in the world, at a rate 6 times that in Canada and China, and 17 times that of Japan.
Similarly, the approach of conventional Western medicine to disease is to remove it or kill it. The three pillars of Western cancer treatment, for example, are surgery, chemotherapy, and radiation. These three approaches banish the cancer cells, in the first case, and kill the cancer cells, in the second and third cases. Exactly like the Western approach to crime and criminals. Banish and kill.
This may not seem too controversial, until one considers the approach of Traditional Chinese Medicine. TCM says that cancer can only grow in an organism that is out of balance, or whose healing system has been compromised in some way. The approach of TCM is not to "kill" the cancer, but rather to make the organism an inhospitable place for cancer to grow and thrive. Based on this theory, TCM believes that one can have cancer for the rest of one's life, but one does not have to die from it.
In modern China, surgery is not rejected outright, but it is understood that, if the body remains out of balance, and the root causes of the cancer are not addressed, surgery and chemotherapy will only be a temporary "fix," and the cancer will return, perhaps stronger and more aggressive than the first time. And this is exactly what has been seen in clinical settings in the West.
Off on the Wrong Track
These two tracks—the "banish and kill" vs. the "come to terms with and coexist"—are analogous to the "tracks" that people may be referring to when they say in public opinion polls that the country is "seriously off on the wrong track." I think most people intuitively understand that there is a larger system that shapes, and is shaped by, our individual lives. Although largely unconscious, I believe that this intuitive understanding of The Great Context causes a profound unease in the hearts of many people—the kind of unease that would move people to say that we are seriously off on the wrong track.
There is a theological or spiritual aspect to this understanding, expressed in a variety of ways, from the Christian "God's plan" to the TCM idea of "universal energy." There are economic and social conceptions, as well. Our dominant economic and social system is so weighted toward an individualistic and fragmented ideology (as I have said, the core of capitalism is individualism and competitiveness) that it becomes very difficult to act on, or even to imagine, the interconnectedness that is a part of everyone's lived experience.
In my partner's battle against breast cancer, we have come to see the need for banishing and killing, in the form of surgery and chemotherapy. But we also are learning, by looking at ideas from different cultures, that a person fighting cancer needs to take steps to re-balance and strengthen their system.
The American "War on Cancer" is based on an attempt to treat each individual case of cancer—to "cure" each one— which is the logical approach of an individualistic culture to a social problem. We see the same approach in all of our "wars:" the War on Crime, the War on Drugs, the War on Terrorism, the War on Anything Seen As "Bad." But cancer is not just something outside of ourselves that can be controlled by killing, any more than drug addiction in Minneapolis can be reduced by sending guns and soldiers to Colombia.
Although we are getting better at treating cancer in America, American women are twice as likely to develop breast cancer now as they were 60 years ago. If we were to take a social approach to the problem of cancer, we would emphasize prevention. This would mean that we would begin to question the larger system—including its environmental, economic, spiritual, and political aspects—that shapes our lives and gives rise to cancer (and drug addiction and crime and other social problems) in the first place.
If my partner does nothing but attempt to banish and kill her cancerous cells, I have no doubt that her cancer will return, in a more dangerous form than before. And if we, as a society, don't take steps to re-balance and strengthen our social and political systems, everything and everyone we banish today will be replaced by two or three who are more of a danger than those we have banished. The only hopeful response to cancer is to begin to help one's body be stronger and more in balance with the Universal, so it can ward off the deadly energy of cancer.
And the only hopeful response to the very real problems facing our communities—from crime to drugs to hunger and poverty—is to work toward the same balance. To get back on "the right track" we will need to move away from our individualistic and competitive system toward a social and cooperative one.