Lessons from Cairo

I think most of us would be hard-pressed not to be inspired by the moral power of the crowds in people in Egypt as they throw off a form of government that they find repressive. But, it is about the US reaction to all this to which I turn today. It is the subject of New York Times columns by David Brooks and Nicholas D. Kristof.

Both authors noted the ham-handed manner in which the United States deals with authoritarian regimes and with popular movements for freedom.

Brooks notes,

The . . . thing we’ve learned is that the United States usually gets everything wrong.

Policy makers always underestimate the power of the bottom-up quest for dignity, so they are slow to understand what is happening.

Then their instinct is to comfort the fellow members of the club of those in power.

Then, desperately recalibrating in an effort to keep up with events, they inevitably make a series of subtle distinctions no one else heeds.

Kristof says,

Yet one thing nags at me. These pro-democracy protesters say overwhelmingly that America is on the side of President Mubarak and not with them. They feel that way partly because American policy statements seem so nervous, so carefully calculated.

The upshot is that this pro-democracy movement, full of courage and idealism and speaking the language of 1776, wasn’t inspired by us. No, the Egyptians said they feel inspired by Tunisia — and a bit stymied by America.

Everywhere I go, Egyptians insist to me that Americans shouldn’t perceive their movement as a threat. And I find it sad that Egyptians are lecturing Americans on the virtues of democracy.

Brooks provided a broader context for all of this:

I wonder if sometime around 50 years ago a great mental tide began to sweep across the world. Before the tide, people saw themselves in certain fixed places in the social order. They accepted opinions from trusted authorities.

As the tide swept through, they began to see themselves differently. They felt they should express their own views, and these views deserved respect. They mentally bumped themselves up to first class and had a different set of expectations of how they should be treated. Treatment that had once seemed normal now felt like an insult. They began to march for responsive government and democracy.

You will excuse me if I draw the connection to health care. I hope you don't think it inapposite.

I do not think that it has been a fifty year trend in health care, but a more recent one. Patients and families have decided that they should be equal partners in the process of diagnosis and treatment. They believe that they have a right to the information that can represent life or death, health or suffering. As Brooks would put it, "treatment that once seemed normal now feels like a insult." Opinions from trusted authorities no longer carry the weight they used to. Questions are being asked. Answers are being demanded.

A few weeks ago, author Charles Kenney asked the question, Isn't there a compelling -- perhaps even overriding -- moral component to transparency?

I responded,

The answer, of course, is yes. Doctors and others pledge to do no harm. How can you be sure you are living by that oath if you are unwilling to acknowledge how well you are actually doing the job? As scientists, how can you test to see if you are making improvements in evidence-based care if you cannot validate the "prior" against which you are testing a new hypothesis? At the most personal, ethical level, how can you be sure you are doing the best for people who have entrusted their lives to you if you are not willing to be open on these matters?

But transparency threatens the status quo. In the medical world, status quo confers power, influence, prestige, and money on those who have had a reputational advantage. A close friend and colleague put it this way:

Transparency in self-interested institutions who are making fortunes by deluding themselves and the public that they and only they know what the community wants and needs is a very dangerous concept.

The agents of change in this battle will be the same people who are turning things over in Egypt. Normal people who have experienced pain and suffering, or even just disrespect, in the health care system are starting to find their voice. Like the US in the international arena, the powers that be in the government and their agents, having been captured by the powerful forces of the medical and hospital profession, are slow to react and are protective of the status quo.

Policy makers always underestimate the power of the bottom-up quest for dignity, so they are slow to understand what is happening.

Then their instinct is to comfort the fellow members of the club of those in power.

Then, desperately recalibrating in an effort to keep up with events, they inevitably make a series of subtle distinctions no one else heeds.