When Apple launched the smartphone revolution in 2007 they made a significant error in naming it, choosing to call it the “iPhone“.  This moniker labeled the device as a phone first and foremost, and relegated its other functions to secondary features.  As any smartphone owner can attest, the telephony features of these devices are truly incidental to their vast capabilities.  These devices serve as nothing less than virtual windows which look out simultaneously onto every corner of the world, peering into every country, every library, every movie theater, and every resource.  The fact that they can also make telephone calls is almost gauche.

Just as a child bored in school may stare wistfully out of their classroom window, so too will a smartphone user turn to their virtual “world window” for an escape when faced with even the mere suggestion of boredom.  As long as anything anywhere in the world is more interesting than what they are doing (and when is that not true?), the temptation to be virtually transported to that activity may prove irresistible.  Teacher droning on?  A good time to look at movie reviews for the flick you want to see.  Conversation take a dull turn?  Let’s join a facebook friend on their Hawaiian vacation instead.  In addition, smartphones provide instant access to references which we may have otherwise ignored.  The annoying feeling one gets when they can’t recognize an actor on TV would probably go unnoticed, but with a smartphone in hand it can be remedied immediately.  The congenial debate with a friend over meaningless historical trivia can be solved immediately, to absolutely nobody’s lasting benefit.  The examples, and the possibilities, are truly endless.

This kind of power and access can be detrimental however.  Numerous scientific studies have warned us of the deleterious effects of being too “plugged in.”  Instant access to all of the world’s data causes us to place unreasonably high expectations on ourselves and others for accuracy, speed, and connectivity.  Such expectations can lead to dangerously high stress levels, deterioration of interpersonal relationships, and eventually a total dependence on the information stream.

Smartphone addiction is the end result of such pressures.  The user not only feels the need to continually access the information stream, but eventually considers it essential to existence, wondering how he or she ever lived without it.  One crucial point of this relationship is that while the addict may consider this access “necessary,” he or she may not actually enjoy it; in fact craving of the object may actually be linked to simultaneous feelings of repulsion for it.   To speak candidly, I fall into the latter group.  I occassionally resent being tethered to my smartphone, but until recently found no way to actually divorce myself from it, while upholding the responsibilities I have to my patients.

Everyone must deal with this issue in a method particular to their own circumstance.  Given my need to constantly maintain a certain minimum degree of connection, this continues to be especially difficult for me.  One solution I have found is simply turning off cellular data and wifi when I come home, effectively transforming my smartphone into a “dumbphone” capable of phone calls and texts (allowing my patients access to me), while not allowing me to look out of my virtual window.  Of course, the power is mine to turn data back on with a few swipes.  I have found that the time it takes to make those swipes, however, allows me the requisite time to reflect on the relative importance of what I am doing, and prevents me from absentmindedly accessing my information feed.  In those precious moments, I can ask myself the questions my Sensei taught us in order to bring about focus in martial arts training, “Where am I? What am I doing? Is it real?”  When it comes to my smartphone, most often the answers are not encouraging.

Another solution I hope to implement soon is the addition of a “smart watch”.  Perhaps it is an addict’s delusion to believe that a device designed to increase connectivity can actually be used to decrease it.  I am hopeful, however, that by allowing me to screen phone calls and text messages without ever touching my phone, I will be less tempted to access the other features of my phone every time it rings or dings (which unfortunately is quite often), or to immediately respond to every communication.

I have resigned myself to always having an increased level of connectivity due to my chosen profession; a day has not gone by in the last seven years when I have not been in touch with patients, the hospital or the office.  However, the novelty of the capability of our current devices has worn off to the point where we, as a society and as individuals, need to make serious decisions about curtailing our use of these technologies in order to preserve the operation of the most powerful computer we own–our minds.

The meeting was an opportunity to reconnect with old friends, and to learn a lot about the state of the art in cardiology, as well as explore some of the current challenges.

Too much of a good thing?

The cardiology community has anxiously been awaiting JNC-8 and ATP-4 for some time now.  These expert consensus statements  will serve as updates to our guidelines on the treatment of high blood pressure and high cholesterol, respectively.  Nobody knows yet (except the writers) what the recommendations will be, but certain themes are beginning to emerge.

One of the themes that I saw emerging quickly was the idea of “overtreatment”.  While the well intentioned writers of previous guidelines recommended very strict control of blood pressure, for example, a plethora of recent data has suggested that lower may not necessarily be better.  In fact, there is now a preponderance of data suggesting a “J shaped curve” for blood pressure control in cardiac risk reduction; meaning that as blood pressure goes lower than a certain “sweet spot”, cardiac risk may actually increase.  This may be especially true in the elderly.  There are many theoretical reasons to have believed in this relationship, but the interesting findings is to show that we begin to see it even at “normal” readings.

Ends don’t always justify the means

Similarly, cholesterol control has often focused on getting bad cholesterol (or “LDL”) down by any means necessary.  The most effective method of doing so has always been HMG-CoA reductase inhibitors (“statins”), but many adjunctive therapies exist that also lower LDL.  The problem is that while these therapies lower LDL, they have not been shown in any large-scale way to significantly reduce cardiovascular risk.

These meetings held particularly bad news for Niacin, a popular B vitamin, which failed in its second consecutive large-scale clinical trial to have benefit.  CETP inhibitors, another promising new therapy, fared no better (so far) though they simultaneously lower LDL and raise HDL (good cholesterol).  Combine these findings with the findings that statins benefit even those with low cholesterol levels who have had heart attacks, and you have fairly convincing evidence that statins reduce risk over and above their ability to lower cholesterol.  Thus, I believe the newer recommendations should focus on statin therapy rather than LDL reduction, with the addition of adjunct cholesterol medications only in cases where statin therapy is impossible or insufficient.  For those concerned about adverse consequences of statins, it has been conclusively shown that for most people on statins the benefits clearly and massively outweigh the risks.  In addition, newer therapies to counteract the muscle aches with statins are showing more and more promise.

Another reason that LDL lowering may not track risk is that we are focusing on the wrong endpoint.  Most cholesterol particles contribute to the deposition of cholesterol in artery walls, with the notable exception of HDL.  Thus, measuring LDL is only measuring a subset of these harmful  particles.  I am hopeful we will see a shift in our guidelines towards increased recognition of “non-HDL cholesterol” as a primary goal of treatment, so we can be sure to address risk at every possible level.

The future is now

The past two decades have seen tremendous changes to healthcare delivery and economics.  While it is convenient to blame “Obamacare” for many of these changes, the fact is that there is plenty of blame to go around for both political parties, from SGR adjustments, to Medicares C and D, to the PPACA.  The upshot of all of these changes is the attempt to achieve substantial cost savings to Medicare by cutting physician reimbursement–this is a rare area of agreement for both political parties.  Physicians have long warned that this would lead to future reductions in physician accessibility, and that future has now arrived.

The same story was heard and overheard time and again at this conference.  Physicians leaving medicine to pursue other careers.  Physicians leaving insurance based practice to go to “concierge” or cash practices.  Physicians fretting over making ends meet in the era of unfunded mandates and regulations combined with almost continuous cuts to reimbursement.

I think much of the public doesn’t realize that the average physician in practice is basically a government employee.  We work for no money upfront and then petition the government or another agency to please pay us whatever it thinks our work (already completed) was worth.  As most private insurances are pegged to Medicare rates, however, every cut in government spending translates into a direct cut in our reimbursement.  At the same time, mandates such as electronic health records and insurance pre-authorization for every activity increase our bottom line significantly.  This is not a model for a successful business, and is the main reason that  more and more doctors are abandoning the field completely (one of the best doctors I trained with is now in the fashion business).  Many of those that stay are forced to cut overhead by cutting accessibility or services offered, or worse yet forced into gimmicky side businesses and unnecessary testing.

It has now gotten to the point that the most popular seminars and symposia at this conference were not so much about medicine as about business–cutting costs in an era of declining reimbursement.  It is an unfortunate truth that many of the most promising innovative technologies and treatments at this conference may never become available because of an economic climate which deters access, innovation, deliberation, or collaboration.  We can only hope that going forward, our legislators are able to wriggle free of the iron grip of the insurance and hospital lobby, and recognize the engine that makes health care run, the physicians.

Last July, in the wake of the Aurora theater massacre, I contended that the uproar over gun rights it had provoked was misplaced and that the important national conversation should be about mental health care. While that truly is an important national conversation, the events in Newtown, Connecticut have served to sharpen the focus on a discussion over gun rights which is overdue and sorely needed.

The President immediately engaged this issue, culminating in his signing a myriad of executive orders proposed by his blue-ribbon gun control panel. Now, action on those orders and “legislative suggestions” will be hotly debated in Congress over opposition from the gunmakers lobby (in the guise of the NRA) and a debate over the second amendment.

The Second Amendment

The second amendment to the constitution states:

A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.

Any reading of this text must be enjoined with a sense of historical perspective. This amendment was written for a fledgling nation with no standing army whose peoples had just succeeded in armed insurrection against their government. In that situation, to disarm the people would have been akin to disarming the state, leaving it totally defenseless.

Today, in the face of history’s largest professional standing army and state controlled national guard troops, this point is moot. For those who are so distrustful of our government that they would like to reserve the right of armed insurrection, I would remind them that it is no longer the romantic ideal it was in post-colonial America. Today, we simply refer to it as treason.

But there is a clearer and more important point here that overshadows the others. The first three words of the second amendment read “A well regulated…” Even our founding fathers realized that if we are to codify a right to bear arms into our constitution we must allow and even mandate the regulation of these firearms. Even for those who oppose gun control legislation on the basis of literal interpretation of the bill of rights, and persist in the near diefication of our founding fathers and consecration of our constitution, the need for firearm regulation could not be more plainly spelled out.

Slippery Slopes

Another argument against gun control legislation stems from the fear that such regulation would start us down a slippery slope towards the prohibition of privately owned firearms. However, I believe this argument is short sighted.

If the goal is safe and legal gun ownership (as it should be) there is no better tool to achieve this than regulation of gun ownership. Licensure and background checking, biometric devices and trigger locks do not infringe on an individual’s right to keep or bear arms—they enhance those rights. By weeding out criminals as well as those without requisite training in gun safety, such regulation would remove any remaining social stigmata towards legal gun ownership and allow law enforcement to better track and confiscate those weapons likely to be used to harm others.

In my state of California, we require drivers safety courses, licensure, and insurance before someone can operate a motor vehicle—a tool designed to transport but with the ability to kill. Yet, none of these things are required for ownership of a gun—a tool designed with the express intent to kill.

Slippery slopes can also slant both ways.  Many opposed to gun control legislation advocate for arming teachers as a tactic to combat school shootings.  Such fortification of our schools would simply shunt our societal vulnerabilities to other venues such as malls, movie theaters, and even churches.  Eventually, we will end up in a heavily armed society, where each citizen will be virtually expected to carry a firearm simply to avoid victimization. Such a society would make us no safer, and would simply serve to verify the adage that “an eye for an eye makes the whole world blind”.  That is a slope I am deathly afraid of sliding down.

Rights and Regulation

The existence of a right does not preclude its regulation. Freedom of speech is regulated to exclude libel, slander, and speech inciting public harm or violence. Freedom of expression does not allow for violence towards others, and freedom of religion does not tolerate human sacrifice.

Guns are designed expressly to kill.  Though they are (and should forever remain) legal, this plain truth demands that they be regulated with a commensurate degree of severity.  Certain fundamental protections must be put in place as the violence in our society escalates. Licensure for gun ownership must exist and be requisite on gun safety training and background checks. When a gun license is administered to an address where a child resides, there must be a stipulation for a locked ammunition cabinet and a separate trigger lock. Consideration should be given to requiring gun owners to show proof of insurance in order to provide a financial disincentive to irresponsible use. And finally, those firearm accessories designed specifically to promote the indiscriminate killing of human beings, such as armor piercing bullets and high capacity magazines, should be banned except by an exceptional licensure mechanism.

Since the horrendous attacks of 9/11, our nation has struggled with a fundamental balance of civil liberties and societal security.  The current discussion is merely an extension of the same question.  None of these measures as I described would infringe on a law abiding citizen’s ability to keep or bear arms. Critics will also argue that none of these would have prevented Columbine, Aurora, or Newtown. But I’m not interested in how we could have prevented the last massacre. I’m interested in preventing the next one.

]]> http://aamerj.wordpress.com/2013/01/20/license-to-kill/feed/ 6 ajamali52 gun-constitution-2 http://aamerj.wordpress.com/2012/12/05/behind-the-veil/ http://aamerj.wordpress.com/2012/12/05/behind-the-veil/#comments Thu, 06 Dec 2012 01:58:05 +0000 Aamer Jamali http://aamerj.wordpress.com/?p=155 ]]>  

(not actually my wife)

Recently, my wife of fourteen years informed me of her decision to start wearing a rida most of the time.  For those who don’t know, a rida is an Islamic garment of modesty, consisting of a long skirt and an upper “pardi” which covers the head, hair, torso, and arms while leaving the face open.  It’s an issue that I know she has been struggling with for quite some time, and one that is complicated by tremendous peer pressure from both sides of the issue.

Her husband hasn’t helped too much either.  In fact, I have made no bones about my opposition to this decision throughout the years.  Personally, I am not yet comfortable with overt displays of Islamic culture in the United States due to significant pervasive Islamophobia in our society.  My personal experience is rife with acquaintances who delude themselves into thinking that their garment and/or grooming choices have not held them back in any way from advancement professionally or personally.  I also remain steadfastly opposed to choices dictated by guilt or a misplaced optimism about acceptance in society.  Further, and perhaps just as important, I feel my wife’s choice will significantly hamper the outdoor lifestyle we have grown to love in Southern California–wither our rough and tumble hikes, sojourns to the beach, or Christmas break ski trips?

In the end however, I hearken back to my first sentence.  My wife informed me.  The decision was entirely hers (and then some).  I did make the effort to ensure that she is not motivated by guilt, nor bowing to the ever-present peer pressure (wasn’t that supposed to disappear after high school?).  She is clearly attuned to the limitations these choices will impose on her professionally and socially.  It is just that she simply, remarkably, does not care.  She has decided that pursuing her acceptance of herself is much more important than seeking the acceptance of the myriad of people of varying importance in her life.  She has even decided that her comfort level with her choices is more important than my comfort level with them.  While this last point upset me considerably at first, it is emblematic of a supreme self-confidence that I cannot help but admire.    It displays a confidence in who she is, what she wants, and how strong our relationship is that I can only marvel at.

For those in the United States who continue to insist on portraying Islamic headcoverings as evidence the subjugation of women, I wish they could be privy to our conversations–A muslim woman arguing to wear a veil against a man pleading for her to dress less traditionally.  This is not the Islam the media loves to portray, but the real Islam practiced by real people.

There is a saying “guns don’t kill people, people kill people.”  An analogous comment could easily be made about the objectification of women– “clothes don’t objectify women, society objectifies women”.  A woman parading around in a bikini on a beach is at just as much risk for being wrongfully treated as a sex object (one to be lusted after and ogled) as a woman wearing a hijab (one to be owned and subjugated).  Just as a woman’s swimsuit can be seen as anything from a piece of athletic apparel to a tool for sexual objectification; so too can a hijab vary from a willful choice to a tool for subjugation (as it is too often portrayed and used).  In the end, it is up to us as a society how we treat women regardless of how they dress.  Just as it is crass, rude, and wrong to say a woman “deserved” sexual misconduct because of her titillating clothing, it would be equally wrong to imply a woman “deserved” to be treated as a second-class citizen (or worse yet, pitied) because of her Islamic dress.  The fact is, a woman has a right to be treated with the appropriate respect for her character, not for her fashion choices.

In the case of my wife, her choice to wear a rida is the polar opposite of an act of subjugation or domestication.  It is an act of supreme self-confidence and pride in her culture, a recognition of her priorities, and a challenge to the rest of society (and to her husband) to show her the dignity she knows she deserves.  It is not an act of defeat, it is an act of victory.  Because I know this, I cannot help but respect and support her decision, though I continue to disagree with it.  After all, this independence, confidence, and intelligence is what has always been what is most alluring about her–not her fashion choices one way or the other.

The Economy.  This topic is incredibly complex and is wrought with dueling statistics and expert panels.  Even the most ignorant of the myriad experts on either side know much more than me on this topic, so I will not deign to try to judge among them.  However, I believe that Mr. Romney’s plan for the economy relies entirely too much on trust.  Trust that the economy will grow at an accelerated rate to help him afford his tax cuts.  Trust that “job creators” will reinvest  their tax savings to hire more workers, rather than cash in profits or take them overseas.  And finally, trust that we will forget that the “Reagan Recovery” he so hopes to emulate led to one of the largest explosions of the national debt in history.  Mr. Obama inherited an economy in free fall, which arguably hit its nadir about six months into his presidency.  To expect us to be completely recovered in only three years is to defy the cyclical nature of history.

Foreign Policy.  Mr. Obama’s foreign policy can seem at first glance to be somewhat muddled and haphazard.  However, I believe this stems from the inherent complexities of international relations in our interconnected world.  I much prefer Mr. Obama’s painstaking deliberation to treat each situation uniquely as well as his wholehearted attempts at multilateralism to Mr. Romney’s one-size-fits-all, with-us-or-against-us approach.  Mr. Romney’s attempts to attack Mr. Obama for being “soft” in Iran or Syria leave no room for him to maneuver except to embroil the United States in more foreign wars which we cannot afford.  Further, while it is vitally important for us to have an unquestioned staunch ally in a volatile region like the Middle East, that is no excuse to equate Israel’s national interests with our own.  While they often do align, and mutual protection is a foundation for our alliance, our national interests must be our own, and must be the President’s focus at all times.

Health Care.  It actually matters very little who becomes President in this regard.  The fact is that Medicare is an extremely expensive entitlement program our nation can no longer afford.  For political reasons, neither side is willing to directly cut benefits to voters, and both sides have pledged to save money.  This must necessarily result in reduced reimbursement to healthcare providers–and subsequently to indirect reductions in benefits through more providers dropping Medicare patients, rationing of care, or the market producing less or lower quality physicians.  The one alternative solution, sweeping malpractice tort reform, has unfortunately not made it to the conversation during this cycle.

Civil Rights.   Mr. Obama has been no saint on civil rights, from failing to close Guantanamo to quietly continuing warrantless wiretapping and other surveillance.  However, the Republicans have squandered the Muslim vote for a generation through a replay of their Southern Strategy.  By systematically demonizing Muslims at the party level, they have made it impossible for us to vote for them.  Michelle Malkin (who advocates placing all Muslims in internment camps) may be a fringe player in the Republican party, but Michelle Bachmann (who advocates a Muslim witch hunt to root out Muslims in the federal government), Herman Cain (who would apply a Muslim litmus test prior to hiring anyone), Newt Gingrich (who compares Muslims to Nazis), and Tom Tancredo (who advocates bombing Mecca and Medina) are most certainly not–in fact, all of them ran for president under the Republican banner.  Add to that the right’s insistence of propagating the Obama crypto-Muslim story as a slur and you have a veritable definition of Islamophobia.  Even the current nominee, Mr. Romney, said in a debate he would not consider a qualified Muslim for a cabinet level post since Muslims do not constitute a large enough proportion of the population to justify it–a reasoning that should also exclude a Mormon from becoming president.  Hiring or not hiring someone based on their religion is a violation of their civil rights and fundamental American principles, and no American (Muslim or otherwise) should allow such violations to creep into governing philosophy.

Leadership. This is perhaps the toughest to judge, and the toughest to quantify.  However, certain anecdotes truly cement this in Mr. Obama’s favor.  First is the decision to green-light the mission to kill Osama Bin Laden.  While in retrospect it seems like an easy decision, prospectively it is much muddier.  There are a myriad of ways this mission could have gone disastrously wrong.  Imagine being engaged in Pakistani airspace by fighter jets we had sold them.  Or storming the compound and mistakenly killing innocent women and children only to find intelligence about Osama’s whereabouts were wrong.  Or having Osama escape, and chasing him through a sovereign country’s streets only to have our strikeforce overcome by a violent mob of Pakistanis.  Almost any alternate scenario would have been an international embarrassment or worse, and would have led to a premature end to Mr. Obama’s political career.  Yes, it is easy for Mr. Romney to say in retrospect he would have done the same thing now that the outcome is known.  It takes leadership and courage to proceed with an uncertain outcome.

Another major test of leadership came this summer, when Mr. Biden unwittingly dragged his boss into the fray of gay marriage.  Mr. Obama was already fully engaged in a re-election campaign which he knew very well would be a fight for the center-ground of the electorate.  Yet, he used the opportunity to state his own personal viewpoint (which risked alienating many middle ground voters) without pandering or massaging it, and without forcing its acceptance by others.  Mr. Romney, by contrast, has shown time and again that he is unwilling or unable to stand up to even the fringes of his party, as evidenced by his newfound criticism of Planned Parenthood–an organization that he found worthy of charitable contribution just a few short years ago.  I simply cannot and will not cede the right to appoint lifetime Supreme Court Justices to someone who has shown a remarkable inability to withstand political pressure.

Mr. Obama has not been a perfect president by any means.  He has not been the president I imagined he would be nor, I venture, the president he imagined he would be.  However, he has certainly made considerable progress amid formidable challenges and united opposition.  Mr. Romney, by contrast, has revealed himself as weak-willed and short-sighted.  On November 6th, I will proudly vote to give Mr. Obama the second term he has earned.

Thus, a very astute question on the scope of federal government (should it have a role in setting gas prices) turns into a discussion on clean coal, simply because the word “energy” was mentioned in the question.  Or a potentially explosive discussion on interagency communication breakdown (as evidenced by requests for security funding for embassies) turns into a sparring over word-choice regarding terrorism.   The candidates end up not so much debating as giving dueling mini-speeches–an unfortunate microcosm of our current political discourse where the two sides talk at each other rather than to each other.

In the midst of all of this, facts and figures which are often totally contradictory get bandied about with reckless abandon,  making it so that drilling on federal lands can both increase and decrease over the same time period (depending on the metric and comparators used).  It is a testament to the degraded quality of our collective political discourse that the most accurate statement out of either campaign on strategy was when Romney’s campaign stated they would not let their campaign be “run by a bunch of fact-checkers.”  I believe that for better or for worse (for worse, in my opinion), they got that point exactly right.  In politics, perception is reality, the rest is just facts.  A bell once rung can be silenced, but never unrung.  Thus, Republicans can fact-check Obama’s Libya comments all they want, and even if the President is proven completely wrong, it will at best only serve as feeble damage control for the GOP.

For too long have we let the candidates and the campaigns police themselves for truth and veracity.  They have obviously proven inept or unwilling to do so.  It is time for us to step in and (gasp!) hold our candidates responsible for their statements in real time.  I would propose that the easiest and most universal venue for doing so is the Commission on Presidential Debates.  The debates currently start with a coin toss– a simple and mostly fair method to determine who goes first and one shared with many professional sports.  Perhaps we can borrow other rules from pro-sports to make the debate more meaningful, useful, and truthful.

For the sake of human nature, please take a moment to imagine President Obama in a football helmet dousing himself with gatorade, then flexing and screaming.  Got it? Good.  Now that you’ve got it out of your system, let’s get serious.

Here are some specific suggestions:

1) Challenge flags.  Each candidate can choose three opportunities in the debate to interrupt his opponent for a real time fact check by an unbiased panel of fact checkers.  If the challenger loses the first two, however, the third is rescinded.  This introduces an impetus for truth as well as an eye for strategy (something I’d like our commander in chief to have)

2) Play clock.  The great lesson of Watergate was that the President is not above the law.  Why, then, should they be above the rules?  If a candidate is given two minutes to answer, they should be held to that rule.  The mic for both candidate should be cut immediately after their allotted time for speaking is over.  A president should be able to handle pressure calmly, prioritize quickly, and communicate effectively and succinctly.  This handles all of those attributes.

3) Time outs.  The executive branch of government is more than just a person.  It is an entire team of individuals charged with keeping the legislature and judiciary in check.  For every major decision, we expect the president to confer with his chief advisors.  And yet, during the debates a candidate is all alone.  Between topics, would it be so bad for each candidate to choose  to huddle with his advisors to discuss general strategy and pertinent points to make/avoid, etc? In the end, the candidate on the stage would maintain final control over each decision, just as we expect a governing president to.

4) The Blitz.  President Obama effectively criticized Senator McCain in 2008 for suspending his campaign to solve the economic crisis by claiming a president “should be able to walk and chew gum at the same time”.  There is no point in the debate where a candidate’s mettle is truly tested.  No truly stressful point in a debate where a president must perform under unexpected pressure.   This could come in any of a myriad of forms, each with its own challenges.  Would the candidate be forced to speak over loud microphone feedback?  With a time-clock that is inexplicably draining in double-time?  Answer two disparate questions at once, or be posed with a second question halfway through answering the first?  Nobody could foresee some of the historical events of the past decade.  It would be imminently reasonable to expect a president to deal with unforeseen challenges.

I know this analogy is prone to lampooning.  But these approaches are used in professional sports simply because they work in an enterprise where fairness and accountability are the keystones of the entire business model.  Shouldn’t we expect at least as much from our presidential candidates?

(Hat tip to my friend Ali Yusufaly for the general inspiration for this post.)

Does any of us really believe that this will change after the 2012 election?  It is unrealistic to think (just as it was in 2008) that we will magically rally around our president and our congress to tackle the major issues of our time.  Given the likely divided nature of our government, and the definitely divided nature of the electorate, the American public can look forward to more fiddling while Rome burns even under the term of the next president.

It is a common theme in presidential politics that first term presidents often “pivot” to the political center in order to buff their chances for re-election, while second-term presidents are “unleashed” from those concerns to return to their idealogical base.

However, Mr. Romney has made too many promises and sold too much of his political capital to the far right of his party to credibly govern as a compromising moderate if he wins.  During his first term, President Romney would need to burnish his credentials as a bona fide conservative in order to convince his base (who is luke warm on him currently) that he is not deserving of a primary challenge.  While President Romney would no doubt vanquish such a challenge, it would be the ultimate pyrrhic victory and likely fatally wound his re-election campaign.  Thus, shortly after election we can realistically expect a lurch to the right from President Romney, which would likely worsen gridlock (without a senate supermajority) and increase the shrill tones of partisan debate.

President Obama, for all of his soaring rhetoric, has not shown a tremendous aptitude for bipartisan leadership and unification of the electorate.  While there may be many reasons for this, it is safe to say that a fair portion of the blame can be laid at his own feet.  As an “unleashed” lame duck president, the right wing warns, he would be free to turn sharply to the left and lead as the unabashed liberal that he inclines to be.  This would also serve (with a Republican house) to worsen gridlock and partisanship.

Lest we get too depressed, there is a glimmer of hope in these scenarios, and it comes from the unlikeliest of sources–President Clinton.  In 2008, it was clear that President Bill Clinton was smarting from the rough and tumble primary contest between his wife Hillary and Mr. Obama.  He was scarce on the campaign trail, and reticent with his endorsements.  In 2012, however, President Clinton gave a tremendous speech at the Democrat’s convention, and has been full-throated in his endorsement of the current president.  It is widely assumed that he is playing nice within the party to help ease Hillary’s (unopposed?) march to the Democratic nomination in 2016.  It is conceivable, and even likely, that in exchange for the badly needed enthusiastic endorsement, President Obama has agreed to throw the full weight of his personality, and his office, behind Hillary’s presumed run in 2016.

President Clinton’s endorsement of Obama has held real value in this cycle.  And in return, President Obama will need to give Hillary something of real value back.  In a very real sense, then, he will not be able to lead as the unleashed liberal that he is, taunting Republicans with brinksmanship at every turn.  Such a term would be considered a failure, and a failed President’s endorsement and party would hold no value.  In that situation all he could deliver to Hillary was his base, a consituency she arguably is more comfortable with than he is.  He will be forced, for her sake and due to promises made, to govern and lead through unification and compromise, in order to win over the middle ground of American politics, the independent voter.

There is good reason to believe that Mr. Romney’s first term would be reminiscent of an “unleashed” second-term president, whereas Mr. Obama’s second term would be more reminiscent of an accountable first-term president.  Given the choice, I prefer a president who feels accountable and motivated to move to the middle any day.

Mr. Romney’s waffling positions on social issues are famous by now, from his support for abortion rights (and his charitable contributions to Planned Parenthood) to his vehemently pro-life stance.  Likewise, his support for gay marriage has shifted to a vehement opposition.  His shifting positions on policy are also gaining more and more attention.  As governor of Massachusetts, he advocated and argued for an individual health care insurance mandate, one he now argues is unconstitutional.  At various times, he has come out both for and against a path to citizenship for illegal immigrants.

To many, these shifting policy stands disqualify Mr. Romney for the presidency.  In my view, they represent an asset which may uniquely qualify him for the job.

The Presidency of the United States, as it is conceived and expected, requires almost superhuman capabilities.  The President, after all, is not a king nor a dictator imposing his whims or his views on the people.  He is an elected executive who ideally represents a “first among equals” among citizens; meant solely to provide checks and balances to the legislature, and to speed along the beaureaucratic process.  Importantly, the president is elected to represent the people.  Not just the people of his home district (like a congressman), or the people of his state (like a senator), or the people of his party (like a chairperson) but the entire citizenry of the United States–equally responsible for considering the welfare of the coalminer in West Virginia, the Sierra Club member in California, and yes, the casino magnate in Las Vegas.

We rightfully demand principled leadership from our most prominent representative.  However, we do not often reflect upon what principles we are demanding.  Principled leadership is extremely important–when it comes to the principles which we all share.   Defense against common enemies, shared prosperity, freedom and liberty, and many others explicit and tacitly implied in the constitution.  If Mr. Romney is elected, and is pressured to pursue a militantly pro-life agenda (just using this issue as an example), he is doing a disservice to a large segment of his own constituents who are equally vehemently pro-choice; and thus not doing his job to represent the American people as a whole.  He was not elected to be the President of the Republican Party, after all, but to be the President of the United States of America (even of those who didn’t vote for him).

Many of the issues a president must confront deal with less constitutionally clear decisions. In these cases,  flexibility, an open mind, and the ability to see all sides of an issue are paramount.  Misplaced rigidity leads to a hyperpartisan atmosphere, disenfranchisement, gridlock, resentment, and eventually political instability.  On those issues where legitimate disagreement exists (and it always will) regarding an interpretation of our core values (eg: does abortion violate a right to life, or does banning it violate a right to freedom?), a president must have the ability to carefully weigh all opinions and all listen to all parties, and only then reach a conclusion which he will be responsible for communicating to his constituents.

A candidate who has spent his life cultivating and defending a single world view on social or economic issues will have a considerably harder time considering the rights, welfare, and arguments of all of his constituents than one who has spent time on both sides of an issue.  Mr. Romney’s colorful history, to me, means that he has carefully considered all sides of an issue, and at various times in his life convinced himself of the merits of each side of an argument.  It means that he recognizes that a single approach is not appropriate in every situation, and that complex issues have complex answers.  Even if it just represents politically expedient pandering, it belies the understanding that his constituency has diverse and disparate interests.

There are many reasons I may not vote for Mr. Romney, but his flip-flopping will not be one of them.

This didn’t actually happen (that I know of).  But I hope for the reader to take a moment and reflect on how they reacted to the above paragraph, and compare it to the paragraph below:

On July 20th, shortly after midnight, a 24 year old neuroscientist opened fire in a crowded theater.  Twelve people were killed, and scores of others were injured.

A very different reaction to that news, I would think.  Unfortunately, however, the second event did occur, and many innocent lives were lost as a result.

The reaction to the first paragraph is usually a feeling of remorse, and a reflection on the fragility and randomness of life and death; accompanied by a feeling of sympathy for all the victims (including the driver).  However, feelings about the second paragraph are more often going to be dominated by anger, blame, and sympathies for the victims (exclusive of the shooter).  Therein lies a major key to understanding this human tragedy.

In our society, mental and psychiatric illness is not treated in the same vein (no pun intended),or with the same degree of respect, as physical illness.  Despite countless years of research indicating the physiologic basis for psychiatric disease, the basic feeling remains that somehow the person suffering from the illness, whether it be depression, psychosis, neurosis, or any other manifestation, is to blame to some degree.

Gun control advocates have been quick to blame lax gun laws for the shooting, and they have been anxious to use this shooting to restart a national discussion about gun control.  I don’t disagree with them, or with the premise that our gun control laws are too lax in this country.  Unfortunately, while they are addressing an important issue, they are missing the true root of the problem.  The fact is that this man suffered from a severe psychiatric illness which hijacked his actions.  And the sad fact is that even if guns were illegal, his illness would have demanded of him that he either find a way to obtain them, or use whatever weapons were at his disposal (such as tear gas and explosives–which he did use) to wreak the havoc that he did.

Assuming news reports are correct, the man, James Holmes, considered himself to be the “Joker” from the second Batman film–a character who sees himself charged with a mission to expose society’s ills through the institution of anarchy.  The shooter’s methods, like the Joker’s, were deliberate, highly organized, and intelligent.  I am not a psychiatrist, but these characteristics are highly consistent with psychosis, likely schizophrenia.  It is unclear whether this was ever even diagnosed, much less treated.  In fact, when the suspect’s mother was called, her first words were “you have the right person.”  This intimates that the family was potentially aware of these tendencies, even if they were in denial.

I would contend that Mr. Holmes’ psychiatric disease was allowed to progress to this homicidal conclusion precisely due to our inability as a society to deal with it as a true medical illness.  The taboos associated with psychiatric disease of all variants are so strong and pervasive that patients are often unwilling to seek treatment, families remain in denial, and proper precautions and treatment are not undertaken.  Imagine the reaction among his peer circle or his employers if he told them he was taking medications to control schizophrenia, and compare that to the reaction they would have if he told them he was taking high blood pressure medication.  These social mores are a strong disincentive to seek treatment; and a lack of treatment is what leads so many psychiatric patients to end up at the end stage of their disease–gravely disabled, a danger to themselves, or a danger to others.  The end stage manifestations then reinforce the social taboo, and the vicious cycle continues.

What happened in Colorado is inexcusable, and I am not suggesting a lack of culpability on the part of the shooter by any means.  However, if we are to use this tragedy as a springboard to a social discussion, let’s make sure that we at least have the correct discussion.   I believe that as a society, we should grieve for all the victims of this heinous, preventable strategy, including for the young man whose brain was hijacked by a relentless disease.

Why do I Fast?

Every year around this time, as I begin preparations for Ramadaan in my personal and professional lives, I am asked that perennial question: “Why do you fast?” I am asked this by colleagus, friends, peers, and even myself. Of course, fasting is only one of the many manifestations of the rituals of Ramadaan, but as the most dramatic, it often attracts the most attention. Having observed the Ramadaan fast for twenty five consecutive years, I have answered this question every year multiple times. Each year, however, I find my answer to be slightly different than the year before, perhaps a testament to my changing attitudes, maturity, and station in life.

Having asked and answered this question many times myself, I have also heard a myriad of different answers. On the one hand, there have been complicated discussions on how the fast serves as a nexus between body and soul, an intensely physical act of the body which is meant to affect the health of the soul. On the other hand, there is the simple “because it says so in the Quran”. There was even once an interesting analysis on the importance of periodic depletion of hepatic glycogen stores. However, none of these answers can encompass all aspects of the fast. Just like every facet of a diamond reflects a different color leading to its brilliance and beauty, so too does every facet of the fast play an important role in understanding its importance.

Over the years of asking and answering the question, certain themes have emerged which serve to illustrate the importance of the fast in terms and ideas which are universal and easily understood regardless of culture, education, or religious affiliation.

A real, true, feeling of accomplishment.

The month of Shaaban (the month before Ramadaan), usually passes in a fog. Ramadaan looms in the near future and is coming forever closer. Thirty days of fasting and prayer, during the Los Angeles summer at that– it seems impossible. When I describe it to my friends, it seems impossible even to me. When I lie in bed at night, it seems impossible. As I make my preparations, it seems impossible. And it may prove to be this year, but I doubt it. After all, I have been doing this for 25 years consecutively and it has not been impossible yet. Somehow, one day at a time, I make it through. When Eid comes, I reflect upon the last month and inevitably wonder how I could have done it–it immediately seems impossible again. A challenge of this magnitude, requiring this degree of discipline and sacrifice, and met consistently by most of the community makes other wordly challenges pale in comparison. What can really seem more difficult than the fasts of Ramadaan? With that feeling on Eid, there is a real confidence that I can accomplish whatever I set my mind to. That my success at a task is only limited by the priority I give it.

The priority I give it.

Those people who can fast easily try to tell me that fasting does not affect their daily lives. That they can go on and do anything they would do if they were not fasting. Some even try to convince me that they can accomplish more, because they feel lighter, or have more time. I hope that’s true for them… But it is surely not true for me. During my Ramadaan fast, I have to constantly make choices. I have a limited amount of energy and strength, and I have to continually evaluate my every action to make sure it is something worth my energy expenditure. Or, is it so important that it is worth missing a fast to accomplish? The fast of Ramadaan forces me to prioritize each and every one of my actions with respect to each other, and with respect to the fast itself.

One of my passions is training in the Martial Arts, a week without a training session and I feel a true sense that I am missing something. And yet, is it more important to me than my faith? On any regular day, riding the endorphin high of a great workout, I might wonder. But Ramadaan crystallizes the answer that was within me all along, as I realize that missing a day of fasting just so I can train is incomprehensible. Most of us in the Western world are faced with a very real decision during Ramadaan about how much time to take off from work/school. And the answer is different for each individual. But within that answer lies each individual’s personal priorities, laid bare for them to reflect upon… and isn’t that one of the major advantages of Ramadaan–reflection?

Reflection.

What is it about the hungry state that makes me more pensive? Perhaps, denied of the energy I normally possess, and forced to budget my strength continuously, I turn inwards. The power of reflection is a potent side effect of the Ramadaan fast, if not one of its main intended effects. With every hunger pang or dry swallow, I am reminded that I am Muslim. Not only that I am Muslim, but that I afford this part of my identity a very high priority in my life, whether I normally realize it or not. It seems that the fast serves to throw one’s internal spiritual landscape into sharp relief, to be examined with painful veracity.

Fasting makes me realize that I believe in a hereafter, in a world view greater than Earthly pleasures. Mankind rules this earth. Uses resources freely, hunts to extinction, and dominates his environment and all living things. That is a simple fact. But who will control such a creature? And how? By reminding him continually that we don’t need all of the resources that we use. We don’t need to eat quite as much as we do, or hunt until there is no more. That the hunger pangs we feel for 1/12th of our lives are felt by others for their whole lives. That the world is not our pleasure palace, to spend our days doing whatever feels good at the time and moving on. This constraint on our basic bodily function, self imposed, reminds us continually that it is not all about the “here” and the “now”. Just as the confidence imbued by Ramadaan carries throughout the year, so too does this basic humility.

What’s the purpose of the fast? Perhaps it is meant to be different for everyone, like a Rorschach ink test for the soul. And perhaps it is meant to change over time, as one’s outlook on their faith and their place in it changes. But what is definitely true is that the Ramadan fast holds the potential for spiritual growth for everyone, regardless of age, culture, or level of education. And it also helps deplete hepatic glycogen stores.