Books

As Jesuit Volunteers, we are placed in communities which suffer under structural violence. Whether they are broken education systems, political systems, healthcare systems, social systems, or economic systems people we work with suffer under systems they have no control over. This is the type of world we live in and the type of world that Suzanne Collins and Graham Greene create in “Mockingjay” and in “The Power and the Glory.” These books resonated with me, not because of how they are written, but because they thrust a knife into my conscience and twist as hard as they can.

What fascinates me about both these books is the fact that I see them both as protest books. In "Mockingjay," Katniss Everdeen is reduced to a figurehead. A bulk of the story revolves around her conflict with being her own agent, but this self-agency is co-opted by both sides of the conflict. Whether as a sacrifice to remind the districts of their weakness or a lightning rod that the rebellion can hang its hopes on, she becomes a pawn in a greater game between political systems. She is no longer a person, but a role that is inhabited. Katniss and the other tributes are sufferers that we as readers get to know rather intimately. But, the reality is that Panem is a world wherein self-agency is reduced to meandering existences of suffering.

Economic inequality reduces people into caricatures of humanity. From the grotesque Capitol to the faceless Districts, we are forced to take a pause in where we are today. How does our life of privilege, with our ability to take a year of our lives to "sacrifice in service," reflect the grotesqueries of the Capitol? How do our day-to-day interactions with our partners and clients, how they sometimes become just a torrent of victims rather than respected individuals, reflect the facelessness of the Districts? Suzanne Collins slides that knife into our consciousness so that we can see our own lives for what they are: privileged consumption.

In "The Power and the Glory," we are introduced to a flawed nameless priest. The bulk of the story revolves around his quest to survive. But, his final acts revolve around answering the call to serve knowing full-well that such service would require his life and would only affect one singular person that did not even embrace his sacrifice. The priest and the sufferer both die nameless and loveless deaths. Both deaths are witnessed by crowds of people that go on about their lives. We have to ask ourselves, how are we all witnesses to suffering in each of our ministries?

The beauty of the story is that compassion grows from a sense of duty and from a sense of suffering. The priest acts only after he has suffered persecution and been witness to it. He himself became a victim and a witness. It brought him closer to a sense of love for all people. How does our year of solidarity and as witnesses affecting us right now? After this year, where will our experiences as guide us? Graham Greene shocks us into realizing that witnesses bear a great responsibility to change the system that has victimized us all.

It maybe flippant to say what I am saying. In all respects, we are afforded the luxury to reflect on suffering as a means to entering a greater conscious morality/spirituality. The suffering that our clients, (I prefer calling them partners) is all too real. I am not trying to reduce such suffering to an academic discussion. But, it would be a disservice to not let their stories shake our worldview. The fictitious characters in “Mockingjay” and “The Power and the Glory” affected me in a visceral manner. Their suffering is fictitious. In a world of self-numbing media consumption, of caricatured human experiences, of narcissistic self-advertisement, we have the ability to bear the stories of this year and learn as witnesses to suffering. What we learn and how we change is entirely up to us.

Healthcare Collapse

For the past few days, weeks, even years, politicians have been battling and debating the victories and the disasters that the Affordable Care Act will bring about. Whether these victories or disasters are fictitious, overblown, or irresponsible is periphery. The fact remains that the debate has divided politics between notions of fiscal responsibility and moral obligation. We're on a fifth day of a governmental shutdown because this complicated question seethes under all these political debates. Although the Act carries funding provisions that should allow for the Act to fund itself, the effectiveness of them can be debated by economists. What I want to discuss is what I believe will be the Affordable Care Act's lasting legacy. I do this without the education in health policy or the experience of healthcare backing my words, but simply with the hopes of a student.

Jen Christensen of CNN wrote an article called "Doctor Shortage, Increased Demand Could Crash the Health Care System." In the article, she argues that the influx of patients that have health insurance will crash the system. Stephen M. Petterson PhD of the Robert Graham Center along with his colleagues notes that "the United States will require nearly 52,000 additional primary care physicians by 2025." Without this increase in physicians, patients who finally have insurance will face another hurdle: finding a healthcare home and provider. As it stands, the uninsured and even the insured use the emergency room as their medical home further straining a system. In the article, Dr. Stanton worries that the Affordable Care Act will further funnel patients to the emergency room. But I ask that should these worries therefore close off affordable health insurance as an option? I say no. Just because we fear that it might ruin the current system as not enough of an argument against the morality of providing care for all. The real discussion is on what should take its place after it crashes as it inevitably will and should.

In response to this fear, the Affordable Care Act has provisions to persuade training physicians to become primary care physicians. There are loan forgiveness and increased wage provisions for primary care physicians that serve in under-served populations. But, I don't believe that this is enough of paradigm shift. Others have pointed to the limitations of medical school slots. Just this spring as I was applying for medical school, I was informed that one of my top choices that I was denied acceptance could simply not cope with the demand. In essence, they only had 140 seats for 10,000 applicants. As per the American Association of Medical Colleges, there are only 141 accredited MD-granting institutes. Assume that an average class is about 140 students then there will be at least 236,880 new MD's by 2025. Is it realistic to hope that more than 20% of them choose primary care? I don't believe so. There seems to be a clear need for an expansion of medical school training. But I still don't think that this is enough of a solution.

The solution I believe in is explained by Celine Gounder in the New Yorker article "The Case for Changing How Doctors Work." Dr. Gounder believes that it is time to reconsider professional roles in healthcare. She poses one question: is 16 years of medical training necessary for a 20 minute patient visit to check vitals and do a medical interview? She believes not. I concur. She notes that " medical assistant[s], who can be trained in as little as a year, or a registered nurse could provide all of these services…[freeing] more time to focus on more complicated problems." This would require an expanded role for nurses, medical assistants, and community/social workers. Many would argue this as a violation of scope of practice guidelines. But, it is time to reconsider these guidelines. Indeed, "the Institute of Medicine has called for dropping regulations that prevent nurses from practicing 'to the full extent of their education and training.'"

Medications can be prescribed by physicians and nurse practitioners. Patient visits can be performed by nurses and medical assistants. Education and outreach can be done by community/social workers. Lewycka and Co published a paper in the Lancet noting how trained volunteers facilitated peer groups that lead to improved mother and child outcomes. Similarly, Aswathy and Co published an article in the Indian Journal of Endocrinal Metabolism about the efficacy of diabetic control through peer support citing evidence from UK and Mexican-American studies. These papers beg the question: are we really suffering a lack of resources or a misuse of resources? Therefore, we need to engage communities, families, and patients. Healthcare professionals need to look at healthcare as a wide communal project rather than a narrow directed chain of command. We need to create a new environment of greater accountability, personal responsibility, and communal investment. The system will collapse; it is up to us to be as open-minded as possible to accommodate such a collapse.