Interludes & Reflections

Like many others, I was wrong in expecting that the election would lead to a Romney victory or a close result. The Obama campaign built a successful coalition in almost every single battleground state. While Mr. Romney won handily among independents, he did not build a winning coalition.  Since Nov. 7, I have focused on understanding why, speaking with citizens of many political persuasions and many walks of life.

First, let me share several observations.  First, it’s hard to beat something with nothing.  Mr. Obama’s record and spoken priorities show what he would do in a second term: while the prescription of higher taxes, regulation, and staying the course is unappetizing to many, it is a path. Although Mr. Romney towards the end came up with a 5 point plan, most people never really had a handle on what he would do or how his measures would help.  He likely did not go into specifics out of caution not to antagonize voters, but that was not a good thing for a candidate already thought of as a flip-flopper or slippery.  Gov. Romney reminded me of Kerry vs. Bush in 2004, where a flip-flopper from Massachusetts was running with the principal message that the incumbent is doing a bad job on the issue of the day.

Second, Mr. Romney did not run an inclusive campaign.  His primary opponents did not unite behind him, which goes a long way to explain why his vote total this year was less than Mr. McCain’s in 2008. And while Mr. Obama ran a negative campaign and Mr. Romney had to respond in kind, there was not a sense of positive vision offered by Mr. Romney.  The Republican party periodically had vile outbursts that were antagonistic to women and Hispanics, and Mr. Romney was never able to counter or dissociate himself from those elements of his party. One of the most striking things about the election results was that Asian-Americans broke 3 to 1 for Mr. Obama.  In my own friend circles, Asian-Americans tend to be professionals with good jobs, not on welfare, and fully understanding of the higher taxes that will hit them under Mr. Obama.  Further, quite a few of them are social conservatives as well. Nonetheless they vote for Mr. Obama because they felt that Republicans had an uncomfortable proportion of irresponsible firebrands who were tribalistic in their antipathy and xenophobia.   While I am sure Mr. Romney personally does not espouse the views of Messrs. Akin, Mourdock, Broun, he really hurt himself by not distancing himself from that segment of the party strongly or early enough. 

Third, Mr. Romney was not the right candidate to take on Mr. Obama on health care or foreign policy. He alternated between ineffectual attacks or blurring the differences between them.  His tendency to try to figure out what an audience wants to hear and then saying it is not unusual among politicians; in this case, it backfired, as he came across as Obama-lite.  With a reputation for having the backbone of a jellyfish when it comes to convictions, this was probably the last straw. 

Of course, I should not put everything on Mr. Romney.  The Republicans failed in the ground game and wasted a lot of money in ineffectual ads when they should have been party-building in both traditional and new ways.  The party never lent its enthusiastic support to the campaign and egregious statements of a few of its members cost Mr. Romney dearly. 

Enough with the post-mortem. What to do? Although I count myself as a classical liberal, sadly the Democratic party has largely left those principles behind, and the country badly needs a constructive conservative counterbalance.  Let’s start with some ideas on core areas of jobs, economics, energy health, education, environment, and foreign policy.

1.       Jobs:  Current policies discourage employers from creating jobs and workers from taking them.  For example, payroll taxes (employer and employee Social Security and Medicare contributions) cost about 16% on top of salaries upto $108,000, and health insurance often tacks on an additional 15% or more.  Meanwhile, extended unemployment benefits, traditional welfare, food stamps, disability, and housing benefits have become $450 billion of incentives not to work.  Medicaid is another substantial benefit to not working.  We need to reverse many interlocking parts here and realign them to craft a pro-jobs , pro-growth set of policies:

·         Remove the caps on payroll taxes while cutting the total payroll tax rate to 10% (equally distributed between employer and employee)

·         Let employees see how much health insurance costs and let them have the option of using employer-based health funds (along with their own money) to buy private insurance, Medicare, Medicaid, or have higher take-home pay.  This would be part of a larger health care overhaul (see below).

·         Make the criteria for unemployment and disability benefits far more stringent with stronger verification of assets/income and real disability status to forestall abuse

·         Tie food stamps, housing benefits, and traditional welfare to work or public/civil service (e.g., infrastructure projects). 

The focus here is on increasing jobs and stable employment, growing the pie and creating wealth for the long term, and shifting the argument away from how to slice up a dwindling pie.

2.       Economics:  Taxes should serve 2 purposes: discourage “bad” activities and reflect a return on investment to the government for state programs which serve the public good.  They should not serve for one person to take advantage of another’s productivity, and everyone should pay a fair share across the board. When you tax something, you get less of it. As we tax work and investment and far higher rates than consumption or stock market gambling, we have a lot more consumption and stock manipulation than we do work or investment, hence the staggering levels of public and private debt which will slowly but surely strangle our economy and future prospects. My plan can be called the 10-10-10 plan:

• ·         Let’s cut taxes on income, saving, and long-term investment (defined as >5 years) to 10%. Remove all deductions except for charity and children. Let’s tighten up the charitable deductions to only organizations that don’t engage in political campaigns and make the child deduction a deduction (not credit) upto $30,000 per child.  
• ·         Let’s eliminate corporate income taxes but also eliminate corporate welfare and subsidies (such as for sugar, corn, and oil companies). 
• ·         Let’s add taxes on sales and imports of 10% (produce and non-processed groceries exempted).  This could be paired with foreign policy to reduce or waive these duties when appropriate on a most-favored nation status basis.
• ·         Let’s also add taxes of 10% on exotic financial transactions (credit default swaps, collateralized debt obligations, derivatives, etc.) and tax short-term investments at 26% (decreasing steadily with each year of investment to 10% after 5 years of holding). 
• ·         End federal incentives to take on debt (e.g., home mortgages, student loans). For the truly needy or meritorious, provide increased grants in the spirit of a hand-up, not hand-out, e.g., scholarships for programs of study that increase long-term economic potential (e.g., science, technology, engineering, business, math, law, health care, English)
• ·         Let’s raise taxes on alcohol, tobacco, processed foods, high-fructose corn syrup, trans-fats, and marijuana (where it’s been legalized) and start increasing federal gas taxes by a penny a month, indefinitely.
• ·         Let’s add a 10% tax on lobbying and campaign political ads for corporations, organizations, or entities that don’t pay any taxes.  This is not a speech issue, but rather organizations/entities that don’t pay income taxes (and hence don’t vote) should not seek to influence tax policy, or at least should pay a toll to do so.  Just as there should be taxation without representation, I do not feel there should be representation without taxation.
• ·         On the entitlement side, Social Security and Medicare were initiated were longevity was far less than today.  We should increase retirement age slowly but steadily, perhaps 1 year every 5 years.  Benefits should be means-tested for both these programs as well, while increased opportunities for private retirement and private health accounts (with some matching government contributions) should be developed for younger Americans. 

As a package, these measures will remove the distortions in our market and rebalance our economy towards work and productive long-term investment and away from consumption, destructive behaviors, stock market gambling, and rent-seeking behavior through the tax code.  Further, the measures in points 1 and 2 would repatriate and attract capital and jobs from overseas.  Very importantly, all of the above should be accompanied by transparency in budgeting – each American should receive an easy-to-understand budget and balance sheet each year reflecting what tax dollars are being used for and what the future liabilities are for our nation. Further, both houses of Congress (on penalty of sequestered pay) should be required to pass a budget each year.

3.       Energy: Our goals here should be maximizing energy independence, reducing environmental harm, and increasing our economy’s efficiency in using energy.  Crafting a policy geared to these objectives will take time and thoughtfulness but is doable.  While we should remove obstacles to oil and gas exploration, fossil fuel exploration and use has externalities (adverse impacts) that should be accounted for – e.g., the need for overseas military expeditions to keep the Persian Gulf secure, pollution in the air and sea, etc. The best way to account for such externalities is a carbon tax, and I have proposed a gas tax that increases a penny each month to promote a gradual efficiency over time and reduced dependence on fossil fuels.  With respect to renewable sources, the government should engage in subsidies to specific companies but rather offer prizes for specific objectives (efficiency in energy conversion, storage, or transportability) and increase research funding for such objectives.

4.       Health: I have described my ideas for health care reform previously (get rid of the employer health coverage tax benefit to make it an even playing field for individuals, promote transparency in costing, enable cross-state competition, and tort reform). Some of the key problems facing us in health care include lack of incentives for doctors and patients to prevent and save for chronic disease, and lack of discussion regarding costs of end-of-life care. To address these, let’s:

• ·         Change incentives for primary care practice to encourage more physicians to enter it and focus reimbursement of primary care on keeping patients healthy as opposed to fee-for-service. Physicians could help here by starting a “guild fund” donating 1% of income to ensure medical students would graduate with minimal or no debt, in exchange for new graduates committing to a minimum 2-4 year program of primary care service in underserved areas. 
• ·         Start a health information card for each person as a portable electronic record and get rid of the onerous EMR requirements but have prizes for interoperability and reductions in errors
• ·         Health savings accounts where federal dollars would match individual savings (to be used for medical expenses over time and every decade, a distribution could be taken as a reward for savings). Over time, this would get insurance companies, government bureaucrats, and lawyers out of the doctor-patient relationship, and let doctors work directly for patients rather than for third-party regulations, documentation, or mindless box-checkers.
• ·         Allow basic health insurance plans that cover just catastrophic events
• ·         Increase costs to egregious adverse behaviors (e.g., driving drunk, not vaccinating one’s children, etc.) while incentivizing good behaviors (e.g., by reducing premiums for keeping a healthy weight, quitting smoking, etc.)
• ·         Give pharmacists the ability substitute in-class (not just same chemical) generic drugs for specific indications unless the doctor specifically wants a brand, and the chance for individuals to buy into Medicare, Medicaid, or private insurance if they so please.  
• ·         Make the patent protection clock for drugs/devices start from FDA approval as that is when they can be marketed. This would allow drug companies a longer period of time to recoup their R&D costs and reduce the immediate price pressures that occur after approval.
• ·         Let patients know that the longer they wait to buy into health insurance, the higher their premiums would be (much like Australia’s health coverage system or America’s life insurance policies).  Also, for specialists, let there be a free market in services.
• ·         Increase research funding for optimizing patient care and translational/innovative programs geared for bringing new treatments forward.

5.       Education: Curricular and teacher standards need to be improved.  Set national standards for English, history, math, and science based on the achievement tests sponsored by the College Board and Advanced Placement exams sponsored by ETS. This will redirect education towards teaching of content and actual knowledge.  Increase teacher salaries by offering starting salaries of $80,000 or $100,000 or more for teachers with a bachelor’s in the subject they are teaching (education should no longer be a major but a module of pedagogy); perhaps there should be certification-level exams based on GRE or Achievement Tests for subjects teachers desire to teach. Tie raises to performance (as measured by student improvement over the course of each year).  Let parents have choice, and let education dollars follow the student. Further, disconnect education funding from local property taxes – let each student get the same number of dollars from state/federal level income/sales/property taxes.  Promote physical  and vocational education again in schools.  Increase funding for gifted and talented education.  Increase funding for research and development at the university level and for business-academic partnerships in innovation. Last but not least, move towards a stakeholder society by giving every citizen on their 20^th birthday either $20,000 for college, professional, or trade school (contingent on good grades in a viable program of study at an accredited school), $20,000 for starting a business (contingent on a credible business plan), or $10,000 for a long-term savings/investment account (not withdrawable before age 40)

6.       Environment: Some of this I discussed above in energy but the key concept has to be accounting for externalities. Taxes on air, water, and land pollution should account for damage done by energy, mining, corporate, and individual use.  Companies which take on catastrophic risk should have appropriately sized insurance (e.g., deepwater drilling, nuclear plants).   A key element of environmental policy should be to focus on preservation of the global commons – reefs, rainforests, wildlife preserves and ecologic diversity. This is ultimately best done not only through multilateral agreements and pollution taxes but on spreading property rights through the Third World (see Hernando de Soto’s seminal work), and on pricing water, electricity, and gas use appropriately. 

7.       Foreign Policy: What would an alternative foreign policy look like?  To start with, our priorities should be to promote freedom,  economic growth, broad-based human and societal empowerment, liberal democracy, human rights, and free trade around the world while helping our friends and weakening our enemies.  The Millenium Challenge started by George Bush should be expanded – this program directed foreign aid to countries striving for good governance; we should also expedite free trade agreements to reward good governance and ensuring freedom and empowerment for peoples around the world. We should not be enslaved by pessimism and withdraw from tough places around the world. Rather we should ally with fortify, and make robust and muscular alliances with true democracies whenever possible. This requires a strong military with sensible long-term defense spending. And some tough questions need to be posed. Did we hand or are we in the process of handing Egypt, Libya, or Iraq to forces that are inimical to the US? Are we about to do the same in Syria or Afghanistan?  Why did we abandon the green revolution groups in Iran? How will we maintain military supremacy in the air, oceans, sea lanes, and pivotal regions?  Do we have the capacity to maintain our treaty commitments to our friends around the world? How will we minimize and shield against nuclear and missile proliferation? These are difficult questions but they need to be asked and cogent strategies formulated.

While this is not a comprehensive plan, hopefully they form the cornerstones for a new Republican policy strategy.  I should take a moment to comment on social issues.  While I do not view this as important as priorities in a national election context as the above, for a lot of people they are.  And unfortunately both sides define themselves and demonize the other on the basis of what they are against: Democrats are against guns, tobacco, oil, religious influence, restrictions on abortion or marijuana, while Republicans are against abortion, gay marriage, gun control, etc. Anathema and caricature have dumbed down our political discourse.

On the hot button issues of abortion, gay marriage, gun control, immigration, etc., I think Republicans can do a lot more to  be inclusive while yet upholding their principles.  For abortion, almost everyone has charged emotions about this.  In my case, I was strongly pro-choice for many years because a classmate confided her horrible circumstances when we were in high school. Over the years, things became grayer, as I came to realize that the right to a chance at life probably should outweigh the right to convenience in many cases. But in any case, Republicans should convey an understanding of how traumatic and challenging such a situation could be for any particular woman, and guarantee access to it in situations of rape, incest, and threat to a mother’s life, and increase support for prenatal, postnatal, and adoption services. While firmly making the argument that an unborn child has more than zero moral value, stay away from idiocies like mandated transvaginal ultrasounds, call out extremist Democrats when they would ban support for viable infants born after abortion, and leave any other debates on restrictions to the democratic process in states.

On gay marriage, again, many of us, myself included, have personal friends who are gay and we want them to be happy. Is gay marriage a civil right issue, and should it be called “marriage equality’?   The Supreme Court will rule on that in the coming months, but unlike interracial marriage in the 1960s or before, there is not an issue of criminalization – the landmark Loving vs. Virginia case arose from an arrest and prison sentence for the “felony” of interracial marriage.  Freedom from criminalization is not what gay marriage advocates are seeking; rather, what is being sought is a societal seal of approval in the form of a marriage license, and by definition, a license is a privilege, not a right.  Many, perhaps most states, will legalize gay marriage – that is the province of the voters’ wisdom.  No matter what, Republicans should and need to impart a concern for the happiness of couples who don’t happen to be straight by guaranteeing rights on inheritance, hospital access, health proxy, etc. and leave decisions on tax benefits, nature of marriage, civil unions, or domestic partnerships, etc. to states. At the same time, firm lines against polygamy or adult incest should be drawn.  

On gun control, honor and respect the second amendment while closing the gun-show loophole, requiring all gun owners to take background checks, safety, and usage classes comparable to what is required of concealed weapons permit holders in most states.  Acknowledge the risks of guns, but also discuss how many unreported times concealed weapons holders stop crime, yet are often occurrences.

 On immigration, acknowledge the tremendous contribution of immigrants to America and that almost all of us have an immigrant heritage.  At the same time, craft an immigration policy that values skills and education and limits family reunification to immediate family members and minimizes taxpayer benefits to immigrants until 5 or 10 years after becoming citizens. Enforce current laws and seal off areas of illegal entry, and then explore earned amnesty 5 years after a secure border is ensured. Regulate the process of entry to make it fair to all countries without discriminating on the basis of geography, while bringing employers and universities into a system where they bid for the right to hire immigrants.

 On the critical area of reconciling science and faith , understand and appreciate that science and faith do not have to contradict each other and be reasonable about what is taught in what context.   Why not have a conversation premised on the beautiful concept that God could have created evolution? Why not come to a common sense position that faith and reason are like a pair of shoes – you can get farther with both than just one?

Essentially, I hope the Republican Party re-energizes to helping America achieve equality of opportunity, whereas the Democrats have chosen to focus on equality of outcome. To do that, we need a sound platform that restores our country’s financial health, sparks economic growth, creates jobs (while maintaining a safety net that gives a hand-up not a hand-out), and invests in the future (education, health, energy, environment), while maintaining our standing in the world.  I hope the above may serve as a road-map for forward-thinking Republicans and Democrats to right the ship of state, focus on and meet the major challenges facing America, and minimize the tribalization and polarization of our people.  

In 2008 we made history. Now it's time to build a future: Romney for President

I’m proud to be a classical liberal. I’ve been a liberal since I was a child, espousing civil rights, environmental protection, fiscal prudence, energy independence, gun control, educational uplift, stands against military dictatorships, etc.  I’ve never voted for a Republican for President.  Guess there’s a first for everything.  After thorough consideration and much discussion, I must, reluctantly but forcefully, endorse Mitt Romney for President. Let me first make a disclaimer, then lay out my long-held reservations about Governor Romney, the case against re-electing President Obama,and then explain how and why the case against Romney is overcome by the case for him .

Disclaimers: My decision is greatly influenced by my views on Obamacare, which I think is detrimental to patients, physicians, and American medicine.  Therefore, I am sure that biases my decision. At the same time, I endorsed Mr. Obama in 2008. Hence, I believe that my choice is based more on what I think is good for the country than what is good for me.

The Case against Romney: I started out this campaign season joining the effort for Jon Huntsman, but unfortunately Mr. Huntsman’s candidacy never gained sufficient traction or resources.  Gov. Romney’s candidacy was never attractive as he is an intellectual chameleon: he supported abortion, gay marriage, and gun control (and of course the template for Obamacare) in Massachusetts, but is against them now. Now, politicians notoriously tack with the wind, but nonetheless I would like to know, at least a little bit, what and who I am voting for.   He can often have a tin ear, and his record as Governor was, at best mediocre (47^th in jobs creation).  An equally important thing to consider is the potential that a Romney presidency could enhance the power of the fringe elements in the Republican party – the supporters of Todd Akin, and Congressman Broun, who calls evolution, call embryology and the Big Bang theory “lies from the pit of hell”, and assorted crackpots. But there are crazies and nutcases on the other side as well.  

The Case Against Obama

The reader no doubt will ask why I do not discuss the case for Mr. Obama. Quite simply, he himself has not made one: he has not laid out a second-term agenda. “More of the same” is just not much of a case. Certainly, the President has had significant achievements. The killing of Osama bin Laden certainly should garner him much credit – both Mr. Bush and John McCain endorsed treating the Pakistani government as an ally (McCain attacked Obama in 2008 for saying he would bomb in Pakistan if necessary), coddling the Pakistanis’ duplicity. Mr. Obama has been much more clear-eyed when it comes to Pakistan, and that is no mean achievement after decades of American wrong-headedness. Further, “flipping” Burma from being a Chinese satellite to a path of democracy, deepening an alliance with Australia, weakening Iran’s currency and gasoline supplies, and mending relations with certain European nations have been good things.  However, “leading from behind” in doing little to help guide the Arab Spring or help the people of Syria, weakening our strategic protection of and relationships with Eastern Europe (Poland, Czech Republic). It makes no sense why we should intervene against governments in Egypt and Libya in 2010-2011 when we had no basic fight with them, while we abandon the citizens of Iran in 2009 and the people of Syria in the last 2 years to governments that are far more brutal and actively opposed to our interests. Essentially, the message that has been communicated to governments around the world is that if you are our enemy, you have our green light to do whatever you want to your people, but if you are our friend, watch out as we may very well throw you under the bus. In summary, on foreign policy, we have a mixed bag. 

But the key argument against Mr. Obama is domestic policy.  Obamacare I have argued against previously, and I think it is bad for patients and doctors, and incredibly bad for the federal budget.  The piece d’resistance of this administration's failure is jobs.   Mr. Obama’s administration borrowed and spent >$800 billion in a stimulus bill, predicated on the premise that this spending would reduce unemployment to 5.4% by now. By his own standard, he has failed.  Even worse than the headline unemployment rate, the civilian labor-force participation rate has declined from 65.7% in Jan. 2009  to 63.6% today, the worst record on encouraging work of any Presidency since data has been kept, in large part because current policy (both for employers and individuals) taxes jobs and discourages job creation. Further, when Mr. Obama ran for office, he lambasted President Bush for a horrible fiscal situation, calling the national debt run up by Mr. Bush “unpatriotic”. Mr. Bush added $5 trillion in his 8 years to the national debt.  Mr. Obama hit the accelerator, adding $5.3 trillion in less than 4 years. For the first time since World War II, this has made our national debt larger than our GDP!  And for what? The economy remains in the tank, and Mr. Obama has made no credible budget for years (nor has the Democratic Senate), and his budget projects more trillion-dollar deficits in years to come.  Mr. Obama came in and rather than focusing on the economy, he got 2 pieces of legislation – Obamacare, and the stimulus, and neither of them was intended to, nor has, helped the economy.  The stimulus was a bailout of unions and states, not a jobs program, not investment in infrastructure, or long-term R&D, or improving education quality.  

Furthermore, what is evolving is a growing nationalization of various sectors of the economy – finance, medicine, automotive, real estate, etc.  Is that a good thing? What has always distinguished America from Europe is that nationally (and in most states), are biggest cities are not our capitals – there is a separation of government not only from church but from the cathedrals of finance and power. Yet Washington DC is one of the few booming areas in the countrynow, due to increasing concentration not only of power but revenue streams (which will only increase in a second Obama administration).  The increasing incestuousness of government with industry has resulted in not just Solyndra and A123 (spectacular failures of misallocated capital) but regulation creep that strangles new competitors.  Government should focus on monopoly/oligopoly-busting and leveling the playing field, not increasing bureaucratic complexity that favors only big companies with armies of lawyers or individuals/companies with the right politicians’ ear.    Four years is proof enough that Mr. Obama is not, and likely never will be, focused on growing the pie, but on achieving his vision of social justice through central planning. 

The standard defense by Mr. Obama's defenders (and himself) on his dismal economic record is that he inherited a bad situation. Leaving aside that it is unseemly to whine about a bad hand for 4 years and that it is customary for Presidents to take blame or credit for the economy on their watch (as well as their own metrics for success), let's examine Mr. Obama's performance against those of Presidents FDR, Reagan, and Clinton, who also inherited bad economies.  Mr. Obama received an unemployment rate of 7.8% in Jan. 2009, which is where it is in Sept. 2012; civil labor-force participation rate fell from 65.7% to 63.5% in that period. Mr. Clinton received an unemployment rate of 7.3% in Jan. 1993 and brought it down to 5.2% by Sept. 1996, while increasing labor-force participation from 66.2% to 66.9%. Mr. Reagan was greeted by 7.5% unemployment in Jan. 1981 which he brought down to 7.3% in Sept. 1984, while increasing labor-force participation from 63.9% to 64.4%.   FDR brought the unemployment rate down from 25% in 1933 to 14.3% by the end of his first term.  By any standard, Mr. Obama has failed, and should not chalk up his failure to his predecessor.

Last but not least, a little-discussed topic in this election has been respect for rule of law.   I find it quite disturbing that the US bombed Libya without any congressional authorization, that the Dept. of Justice smuggled weapons into Mexico without that country's knowledge (Fast and Furious), that President Obama has unilaterally and selectively waived enforcement of laws in immigration, welfare policy, and even Obamacare, and that he has authorized what can only be characterized asassassination of a US citizen on foreign soil.  Say what you will about President Bush, he did get congressional approval for military actions overseas and never assassinated US citizens.  In a second term, without reelection, one would imagine that Mr. Obama would only feel even more unbridled by matters of law. Indeed, the history of second terms (Nixon; Reagan; Clinton) is not reassuring on this score. 

The Case For Romney:

As I mentioned at the outset, I am not a big fan of Mr. Romney. But I do have confidence that he will enact pro-growth policies and be more fiscally responsible than Mr. Obama.  I think he will focus on jobs, open up energy from Canada, promote free trade, and move towards a tax code that is more fair for everyone. I think the Republicans will repeal Obamacare and its hideous regulations and hidden taxes (which besides its impact on medicine, are a major drag on economic growth) and move towards useful entitlement reform.   Could I be wrong? Sure. But in this particular case and this particular time, I really think that the current path is very wrong. And what Mr. Romney is offering is an economic prescription that, at least in theory, is pro-growth. 

Conclusion

The President has repeatedly contrasted the Clinton years vs. the Bush years, strenuously trying to tie himself to Bill Clinton’s aura and Mr. Romney to George Bush. But the truth of the matter is that in 2012, neither Bill Clinton nor George Bush are running for President. In 2008, the country was not better than it was in 2000, and we changed direction. In 2012, the country is not better than it was in 2008. The question is in 2016, will we better off with a Romney Presidency or 4 more years of the current course; I believe Mr. Romney offers more hope for credible and useful change. In 2008, Americans made history by electing President Obama.  In 2012, it’s now time to build a future, and I believe the best choice this year is Mitt Romney. 

When do US citizens forfeit their rights?

The US government killed Anwar Al-Awlaki today. This was a premeditated liquidation – Al-Awlaki, a US born citizen turned leader of Al Qaeda of Arabian peninsula, was put on a list for targeted killing last year. I do not mourn for this man – he was a traitor and a terrorist and got what was coming to him. Some people and some ideas in this world, especially the radical Islamic fundamentalists, should be wiped out.

And yet. What was done today, while a significant tactical victory, sets a horrible and dangerous precedent. The US President just ordered and the US military executed an assassination of a US citizen in a foreign country with whom we are not at war. Granted, this man was a bad guy and an enemy of the state, and a threat to America. Yet this killing was not done during the course of a battle nor was any judicial process or congressional oversight involved in the targeting of this US citizen. Citizenship means something. The USA is distinguished from most other nations in how it treats its own citizens. In my humble opinion, how this killing was done is comparable to how Russia killed Alexander Litvinenko in London a few years ago – a targeted assassination of their own citizen who they considered an enemy of the state in a foreign country. It is a very dangerous concept that should not be legitimized.

The justifications given for this killing ring hollow. Some cite the case of Herbert Hans Haupt, a US citizen turned Nazi saboteur who was executed after infiltrating America in 1942. Yet Haupt received a military tribunal hearing prior to his sentence. Some state that a court considered al-Awlaki’s father’s challenge to the placement of his son on the hit list and that the court duly rejected the father’s plea as he had no standing and that the son was free to seek the protection of the court; would you return to a court of a nation whose President has put you on a hit list? This same court said that the government requires a warrant to tap Americans overseas, but extrajudicial killings of Americans are beyond judicial review; such a statement is patently absurd. Others state the 2001 Authorization to Use Military Force gives the President authority to use all necessary force to destroy Al Qaeda and its affiliates, and that the Article II investiture of the Commander-in-Chief powers (including powers to suppress armed insurrection) in the Presidency is beyond question. Yet this a short road to carte blanche murder – do we want to invest one man with the power to designate US citizens at will as enemies of the state as part of the war on Al Qaeda?

With the one caveat that I am not privy to any knowledge of Al-Awlaki’s imminent threat capabilities, I would think that the right way of handling this case would have been to long ago try al-Awlaki in absentia for treason with appropriate counsel for his defense and strip him of his citizenship if conviction resulted. We certainly had the time; this guy was placed on the President's kill list over a year ago. Treason is something we don’t try anymore, and I don’t understand why.

This is qualitatively different than Guantanamo, waterboarding, or collateral damage. Constitutional rights do not extend to foreign citizens (lawful enemy combatants are entitled to Geneva protections, and unlawful enemy combatants aren't; they should receive basic human rights and, like pirates, fall under enemies of humanity rules). But US citizens do not forfeit their rights against the US government when they go abroad. They would forfeit in active combat with the US military, or upon conviction of a crime (and treason is certainly a crime). Law enforcement and the military have the right to self-defense. But the US government doesn't get to do what it wants to a US citizen and throw out the Bill of Rights when it's inconvenient. The President is not an elected king. US citizens at a minimum have the negative rights (what the government should not do to them) enumerated by the Constitution and the Bill of Rights; they are not forfeited by being abroad. They are forfeited by treachery which is established by due process - the American Communists Julius & Ethel Rosenberg were executed after a trial, not by assassination.

The Obama administration has set all kinds of dangerous precedents this year – going to war with Libya without any congressional debate comes to mind. Then it was the Bureau of Alcohol, Tobacco, and Firearms (which reports to the Attorney General) distributing guns to Mexican drug cartels. Now it’s assassination of a US citizen. This goes against the Declaration of Independence, the Constitution, and the Fifth Amendment. This is unbridled executive arrogance. This is wrong. Something wicked this way comes.

Sight for the Sightless

I just got back from an intense week serving on a medical mission through the Sight for the Sightless Initiatve based at KK Eye Institute in Pune, India. This was a very different experience from any of my ORBIS missions or my Zambia mission in many respects. India is fascinating from a medical perspective in that it has first-rate physicians with some centers comparable to those of America but the population has masses of patients who have the health status of Africans. The country is in transition, with medical personnel & infrastructure highly capable yet simply overwhelmed by the sheer number of those in need, as well as hobbled by a lack of top notch equipment, instruments, and supplies.

For background, there are likely 20 million patients with at least one blind eye from cataract in India and about 8 million with corneal blindness. There are only 13,000 ophthalmologists in India, as opposed to 18,000 ophthalmologists in the US (which has only a quarter of the population). From a corneal perspective, donor tissue is much less available in India (unfortunately there is not as yet a well-developed culture of donation on passing away). So my objectives for the week were to do both service in terms of medical and surgical treatment of cornea and complex cataract conditions and skills transfer in advanced techniques and technology.

It was a physically grueling and emotionally exhausting week. With lectures, clinic, and surgery, we got done pretty much at 8 or 9pm each day (starting each day at 8am). Business dinners on future planning and needs followed, so I pretty much was going on 5 hrs of sleep each day. The most poignant moment was clinic on the first day during which we saw about 20 kids from the local blind school. For most of these children, I was a decade late and a dollar short. While I am a bit of a dinosaur in medicine (having finished medical school before the Internet and residency before cell phone), I was confronted by even more ancient demons this past week: children who had scarred corneas following measles infection when they were infants, children with wrecked eyes from Vitamin A deficiency. There are few things more heart-wrenching than telling child after child there is nothing we can do. There were 3 children who we thought we could help so we proceeded with transplantation later in the week.

Over the next several days, we performed (3 of these were children, the rest adults):
• An artificial cornea on a child who had lost one eye, and had a badly scarred cornea (barely able to see motion) in the remaining eye that was not a candidate for a standard transplant
• A combined cornea transplant with cataract extraction
• A partial thickness cornea transplant of the front of the cornea
• Two partial thickness transplants of the back of the cornea (one combined with cataract removal)
• A full thickness cornea transplant
• Several hard cataract cases and some amniotic membrane procedures

By comparison, I usually do 1-2 transplants a month in the US. These were all challenging cases given the complexity of the tissue damage on the eyes and the circumstances of available and (unavailable) equipment. But the best part (in addition to fixing the conditions and hopefully helping the patients) was teaching. I spent a lot of one on one time at the Institute with a very talented surgeon, Dr. Kapoor, and it was very rewarding to see her rapid progress over the course of the week mastering the techniques of chopping cataracts and picking up key elements of cornea transplantation. We also did some live surgery teaching the surgical maneuvers of some complex cataracts and the artificial cornea to a group of local ophthalmologists, and there were several excellent interactive small group sessions, surgeon-to-surgeon.

There were some funny moments during the trip. The hospital had arranged a press conference noting the complex cases being done that week and highlighting the need for corneal donation. During this, one of the reporters, whose first name was Nozia, came up to me and introduced herself as “Hi, my name is nausea.” It was all I could do to not burst out laughing and think of where else that joke could go. Then there were the episodes in the OR with the cotton buds with extra lint (which are a pain during eye surgery) which I nicknamed after the host and MC for live surgery, Ashiyana Nariani, who in turn promised to send me Q-tips for Christmas. Later on, I was trying to tell the patient to look down in broken Hindi, "Kali Baga Baba"; I apparently was not understandable and told Ashiyana my Hindi was worse than hers, and she told me I was actually speaking in Marathi (which I don't know either :( ). And then there was the ophthalmologist attending the live surgery and lecture workshop who requested to share his experience and promptly proceeded to regaling the audience with his life story, including the name of his childhood neighborhood street.

All in all, it was a fantastic trip. It was enabled by several groups and people to whom I owe great thanks and appreciation. The leadership of KK Eye Institute (Renu Wadhwa – CEO, who helped make things possible) and the international NGO Sight for the Sightless (founded by Dr. Ashiyana Nariani), the clinic and operative staff of the local hospital (especially Dr. Kapoor, Mr. Rohit, Ms. Madhu, Sister Pradhan, and Mr. Sachin), my mentor Dr. Claes Dohlman (the inventor of the artificial cornea who donated one for this trip), Sameera Farazdaghi of Tissue Bank International and Kelby Koop of Utah Lions Eye Bank, and my home team from Utah who organized things on this end: Jackie Simonis, Chandler Crane, and Tina Szarek.

I hope my fellow ophthalmologists and those interested in vision care will join the fight against needless blindness by contributing their time to service and teaching and making a difference where both short and long-term impact can be made. I also hope that developing societies as they develop focus resources on preventing needless blindness through awareness, encouraging eye donation, fighting diseases like the measles and malnutrition. Saving and restoring vision is probably one of the most important and cost effective things we in health care and societies as a whole can do. Especially for children, who are all too often neglected in the developing world.

Below is the text of my remarks to the 2011 medical school inductees of the University of Utah Alpha Omega Alpha medical honor society delivered March 29 at Alumni Hall:

Thank you very much for a warm introduction and thank you to the students of AOA for the invitation to speak. It is my deep honor to spend this evening with you too, and to share my thoughts with the AOA Inductees of the University of Utah for 2011.

First, my hearty congratulations. After 20+ years of grueling study and work and school, college and med school, long hours in the hospital, and countless tests and trials, you are now recognized as the cream of your class, and more importantly, you are almost ready to start paying off your student loans!

But seriously, as you commence a new phase, it would be very nice to have a crystal ball. I don’t have one, but let me to take some time with you to do 3 things: caution you, counsel you, and challenge you.

Caution

Here are 4 notes of caution I’d like to strike. First, you are entering your profession in a time of treacherous shoals for medicine and for America. Fundamental insolvency of Social Security, Medicare, many states, and the federal government are real risks that are going to affect each of us in countless ways. All will lead to cost-cutting strategies premised on increased compliance enforcement, electronic medical records, and expanding scope of practice of non-physicians, each of which are daggers aimed at the heart of current clinical practice.

Second, the exponential growth of knowledge, medicines, technology, and media will strain your memory banks, stretch your attention, and overload your bandwidth. The ability to read, write, think, and ponder coherently and patiently is becoming increasingly rare and will be more prized as idea and vision become elusive with the fragmentation of thought and consideration.

Third, be conscious of the demons of desire and despair, and master them so they not disturb your peace yet still employ them to effect positive change.

Fourth, avoid the twin seductive sirens of greed and self-righteousness; humility is the best antidote to both.

Counsel

Next, let me share some words of counsel. Although I am not much older than you – at 33, I may be younger than some of you, yet in medicine I am a dinosaur! I went to med school before there was Internet and finished 2 residencies before cell phones. So while my knowledge is probably obsolete, I hope my experience and battle scars may be of some use to you as you hone your own judgment; good judgment is an asset that will keep you out of trouble, help you take necessary and good risks, and evaluate opportunity vs. hazard. Contrary to what you may have heard, it is vital to NOT be non-judgmental. The hard part of judgment is, as Mark Twain said, “Good judgment comes from experience; experience, well, that comes from bad judgment.”

Of all the skills and qualities you have and will need to foster, focus on cultivating three in particular: good listening, equanimity, and nimbleness.

Good listening is the foundation for almost every facet of your professional career: building bonds with your patients, learning from your colleagues and mentors, being there for your staff and residents, and so much more. Any search for truth must begin with the words “I don’t know” and a willingness to listen and learn from others. When you don’t listen, you wind up in a bubble which leads to stupid decisions. You fail to appreciate the other person, where they’re coming from, and the importance of their perspective and thoughts; you lose the ability to put yourself in their shoes. You deny yourself a lot of important insight, and screw things up more. Being a good listener is something one has to work at, consciously. And it’s the basis of what patients are looking for. Doctors care about diagnosis; you need to be a good listener for that. Patients care about prognosis – and you need to understand the patient’s needs, perspectives, and values to truly be their guide and champion in their time of duress, which is what they really value you for and what they think makes you a good doctor or not, more than your competence, knowledge, or skill (all of those are assumed).

Equanimity is what Sir William Osler deemed the first among virtues for the physician: no matter the situation, mental calmness affords clarity and steadfastness. The Bible, in Ecclesiastes, states, “The race is not always to the swift, nor the battle to the strong, neither yet bread to the wise, nor favor to men of skill; but time and chance overtaketh them all.” One of the Geeta’s core precepts is encapsulated in this verse from Lord Krishna to Arjuna in a moment of doubt and despair, “You must perform the right action, but you are not entitled to the fruits of action. Let no desire of the fruits be your motive, and yet be not attached to inaction.” I first read this 11 years ago when I was a senior resident, and wrestled with the concept for a long time. It finally dawned that what it means is that in a crisis, you must focus on doing your best to do what is right, but be detached from the outcome. It helped me be a better surgeon by helping me concentrate in the moment during a case.

There’s a great book I urge you all to read, “How Doctors Think” by Dr. Jerome Groopman. It guides doctors and patients on a journey of what kinds of errors doctors can make and why and how to avoid and mitigate them; his discussions on different types of “cognitive traps” are illuminating. As a surgeon, I realized long ago how important it is to minimize mistakes and how it is even more important how you to react to mistakes. Panic and despair make you lose your mental equilibrium and you make further decisions which stack up and aggregate and make the situation worse. Sometimes no matter what you do, the outcome will not be good or what you want but you do the best you can anyway. As Dr. Groopman emphasizes in his book, lowering your emotional temperature in a tough situation is key to slowing down your thought, enhancing your perception and analysis, and thus permitting clarity to dispel clouded thinking. Pressing for a solution when none is apparent can be the worst course of action. “Picking up a scalpel and cutting can be just the wrong thing” when you don’t see the whole picture. The good surgeon is not defined by technical dexterity or superior hand-eye coordination, but by sound decision-making and judgment that enable clarity and effectiveness in the operating room. Understanding issues and realizing what intervention can and can’t remedy takes a while to learn in a surgical career. Groopman, an oncologist, relates one of his mentor’s quips, “Don’t just do something, stand there” as he counsels against the impulse to jump in and do things. It’s awfully hard to do that as a surgeon. We by nature are gamblers, risk-takers who have to have confidence (perhaps arrogance) in what we do. Especially because inaction is also a decision, and can sometimes be harder to correct than a wrong decision. It all depends on context.

Equanimity is also about righting yourself in hard times. If the present is dim & bitter, and the future seems cold & barren, it is tempting to forfeit hope and forget that your life is an integral thread in the universe’s tapestry. Remember: it could always be worse, and if it can’t, then it can only get better! Be grateful for your blessings – health, home, friends, faith. Cultivate equanimity with literature – Frost, Kipling, Max Ehrmann, and Osler. Foster also your hobbies – hiking, photography, meditation, or yoga. And while others can take away so much from you – your money, job, reputation, even people you love – be thankful for the things which can’t be taken away: personal honor, what you’ve learned, and the satisfaction of service.

Nimbleness encapsulates several qualities – resilience, courage, flexibility, versatility. Pandora released the world’s evils from her notorious box but the last thing that came out was hope. While sometimes memory and even hope can feel like a prison, in truth they are the roots of change. George Bernard Shaw said, “The reasonable man tries to adapt to the world; the unreasonable man tries to make the world adapt to him. Therefore, all progress depends on the unreasonable man.” Success does lie in effort as much as in result. The need for struggle is not grounds for avoidance. As Bruce Wayne’s father said in Batman Begins, “Why do we fall? So we can learn to pick ourselves up.”

What gives you the strength to do these things is both courage and possessing different skill sets. It is very easy to fall into a rut and never learn anything after residency or fellowship. But medical training does not end when practice starts; indeed, practice is just another phase of training. I urge you to consider developing interests and knowledge in other areas – whether it be business, engineering, genetics, or whatever. The best innovations happen at interfaces. Further, if you are good at just one thing, you are very vulnerable. Always ask yourself – what jobs need to be done in America by Americans? If you become so focused as to know just one thing, could your job be automated, outsourced, or insourced? By being versatile, you can differentiate yourself and lay a foundation for being independent of government or insurance. And you make your mind more open to learning new things in the future the more you experience and learn along the way. Nimbleness – it confers joy, recoverability, the ability to think broadly from other perspectives, the ability to persist and roll with the punches while holding fast to your principles, and the ability to take doubt and use it to find and know faith.

When in doubt here are 4 principles that help cover most things:
• Promises are made to be kept
• Rules are made to be bent
• Records are made to be broken
• Schedules are made to be changed

With your finances, exercise caution and think of any financial mistake you make as tuition. Think ahead – fail to plan, and you plan to fail. When you must make a choice that is hard, ask yourself 3 questions: Is it good for the patient? Is it good for the profession? And if the answer to both is yes and only then, ask, is it good for me? Last bit of advice –till now, your time has been judged worthless by others. From now on, the value of your time will grow – so guard it jealously from fools and irritants yet be generous with it to your family, your trainees, and community.

Challenges

So I have sounded caution and offered counsel. Let me now throw down some challenges to you. First challenge is to get involved. For too long, physicians have been objects in health care battles. Learn about the issues and see if you can effect change. Perhaps some of these may capture your interest: tort reform, tax deduction for charity care (why can hospitals and sometimes lawyers write off charity work but not physicians), whether accountable care organizations will be anything other than capitation redux with its substituting of payments for services with incentives to do nothing, the Independent Payment Advisory Board impacting physicians in 2014 but exempting hospitals until 2020, forming a guild fund for medical education, encroachment on physician autonomy by hospitals (for example, physicians cannot own hospitals but no one says anything about hospitals owning physicians), and physician extenders (optometrists doing eye surgery, CRNAs replacing anesthesiologists). After all, neither hospitals nor ancillary staff take the Hippocratic Oath.

More importantly, to this point in time and for the next several training years, your path is clear. Landmarks of applications, tests, certifications, and so on are well defined. But once you are done, the road becomes hazy. You have to figure out what you want your own milestones to be. Will your primary goal be the personal maximization of wealth? There is nothing wrong with that, I encourage all of you to be capitalists, and you have a right to make money. But take a moment to consider – what is medicine to you? A job, a career, or a calling? If it’s a job, then you will make a living, and over time, coast with the least amount of effort to make the most amount of money. If that’s what you want, fine, but I hope all of your professors have not spent all this time training body mechanics. If it’s a career, you will set down several goals – papers, rank, awards, practice-building, etc. and hopefully achieve them. But hopefully, medicine is more than just a job or a career to you – I hope it will be your calling, an integral part of how you fulfill yourself as a person. And that is about things that aren’t dollars made or goals achieved, although money and achievement are important to secure. The original meanings of the word doctor are:
- One who makes things better and
- One who teaches

How will you make things better, make a difference? I think it’s about service – doing things beyond the remit of obligation or purview of compensation, things that you are not easily replaced for by someone else. Things like research, teaching, public health, overseas work, public policy. One of the most fulfilling things I do is to work with ORBIS.
Just wanted to show a video... : http://www.youtube.com/watch?v=5RgOow2LUUY

To conclude, I’d like to share a quote, also from Mark Twain, “There are 3 types of people in the world: those who make things happen, those who watch things happen, and those who don’t know what happened.” To be truly worthy to serve the suffering, let’s all try to be of the first kind. Thank you very much.

Reflections

Those of you who are close to me know I have been going through some rough times recently; those of you who aren’t may have inferred that from the previous post. While I will not discuss details or circumstances here, I choose to write this post in the hope that it may help someone somewhere in a tough spot as well as perhaps help me be a better person as well.

Besides events that have happened, the other thing that prompted me to write this was reading “How Doctors Think” by Dr. Jerome Groopman, which made me reflect on how I think and do things. While the book guides doctors and patients on a journey of what kinds of errors doctors can make and why and how to avoid and mitigate them, his discussions on different types of “cognitive traps” are illuminating in a personal sense as well. Recently, I attended a “Night for Sight” event where Neil Beidelman, a guide mountaineer, related the events of “Into Thin Air”: in 1996, 8 climbers on Mount Everest died during a storm. When he talked about how a cascade of decisions, decisions that were a bit off but taken in unbelievably challenging moments, “stacked up in the aggregate” and led to the tragic outcome, that really hit home.

As a surgeon, I realized long ago how important it is to minimize mistakes and how it is even more important how you to react to mistakes. Panic and despair make you lose your mental equilibrium and you make further decisions which “stack up” and make the situation worse. And sometimes no matter what you do, the outcome will not be good or what you want but you do the best you can anyway. I teach these lessons and focus on them in training my residents and students, but probably should have, somewhere along the way, tried to absorb these lessons in my heart as well. As Dr. Groopman emphasizes in his book, lowering your emotional temperature in a tough situation is key to slowing down your thought, enhancing your perception and analysis, and thus permitting clarity to dispel clouded thinking. It’s just really hard to do when it comes to your own life.

Pressing for a solution when none is apparent can be the exact wrong thing to do. “Picking up a scalpel and cutting can be just the wrong thing” when you don’t see the whole picture. The good surgeon is not defined by technical dexterity or superior hand-eye coordination, but by sound decision-making and judgment that enable clarity and effectiveness in the operating room. Understanding issues and realizing what intervention can and can’t remedy takes a while to learn in a surgical career; I guess it takes even longer to learn that in life. Groopman, an oncologist, relates one of his mentor’s quips, “Don’t just do something, stand there” as he counsels against the impulse to jump in and do things. It’s awfully hard to do that as a surgeon, who by nature are gamblers, risk-takers who have to have confidence (perhaps arrogance) in what they do.

Which ties into one of the most essential qualities to being a doctor, indeed a good person: that of being a good listener. When I fall into panic and despair, I’ve realized I sometimes lose the ability to listen. And when you don’t listen, you make even more stupid decisions. You fail to appreciate the other person, where they’re coming from, and the importance of their perspective and thoughts; you lose the ability to put yourself in their shoes. You deny yourself a lot of important insight, and screw things up more. Being a good listener is something one has to work at, consciously, and something I can get better at.

I wonder a lot about “what ifs” and “if onlys”. It is, I suppose, the natural thing to do after bad things happen. But there is no rewind button on the VCR of life, no matter how ashamed I am of all my mistakes or tears I have caused. Theodore Roosevelt provides a little solace:
"It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat."
Falling short and the gnawing sense of not being good enough are awful things, but it is better to have loved and lost, to have tried and failed, than to have never loved, never tried at all. Or is it? That doubt can be banished only by the knowledge of all the good that I experienced, which outweighs whatever pain I am now left with.

The ancients provide some guidance. The Bible, in Ecclesiastes, states, “The race is not always to the swift, nor the battle to the strong, neither yet bread to the wise, nor favor to men of skill; but time and chance overtake them all.” One of the Geeta’s core precepts is encapsulated in this verse from Lord Krishna to Arjuna in a moment of doubt and despair, “You must perform the right action, but you are not entitled to the fruits of action. Let no desire of the fruits be your motive, and yet be not attached to inaction.” I first read this 11 years ago when I was a senior resident, and wrestled with the concept for a long time. It finally dawned that what it means is that in a crisis, you must focus on doing your best to do what is right, but be detached from the outcome. It helped me be a better surgeon by helping me concentrate in the moment during a case. How much harder it is to accept on a personal level…

When you feel useless, the present is dim & bitter, and the future seems cold & barren, it is tempting to forfeit hope. Yet one (I) must remain grateful for life’s blessings – health, a life in the US as opposed to suffering in the Middle East or Africa, a good career where I can still make a difference, wonderful friends who are good listeners and care. And while others or the world can take away so much from you – your money, job, reputation, even people you love – be thankful for what can’t be taken away: personal honor, what you’ve learned, and service.

Pandora released the world’s evils from her notorious box but the last thing that came out was hope. While sometimes memory and even hope can feel like a prison, in truth they are the roots of change. Why you may ask? As for memory, Mark Twain said, “Good judgment comes from experience; experience, well, that comes from bad judgment.”

And, as for hope, George Bernard Shaw said, “The reasonable man tries to adapt to the world; the unreasonable man tries to make the world adapt to him. Therefore, all progress depends on the unreasonable man.” Perhaps success does lie in effort as much as in result. And the need for struggle is not grounds for avoidance.

As Bruce Wayne’s father said in Batman Begins, “Why do we fall? So we can learn to pick ourselves up.” All I can do now is take a long look in the mirror, make some changes to try to be the best person I can be, and hope for the best. I’ll try to start as I head off tomorrow from Salt Lake to Australia.

Selections from the Rubaiyat
Omar Khayyam was one of the finest poets of any age. I used to console myself with the thought that things could always be worse, and if they couldn't, then they could only get better. I used to believe with that to all things there is a reason and a season. But perhaps those were just illusions, and maybe Khayyam was right about everything. It sure feels that way sometimes. Here are what I think are the most resonant stanzas from his Rubaiyat:

Heaven’s wheel gained nothing from my coming
Nor did my going augment its dignity
Nor did my ears hear from anyone
Why I had to come and why I went

If my coming here were my will, I would not have come,
Also, if my departure were my will, how should I go?
Nothing could be better in this ruined lodging,
Than not to have come, not to be, not to go

Since all a man gets in this place of two doors
Is only a heart of sorrow and the giving up of life,
He who never lived a moment is happy
That man is at peace whose mother never bore him

As the stars have no increase but sorrow,
They restore nothing without taking away again;
If the unborn could know what we
Suffer from the universe, they would not come at all

Since all that is leaves us empty-handed
The only return from all that is, loss and ruin,
See what I’ve got from the world, nothing;
The fruit of my life’s work? Nothing:
I am the light of the party, but when I sit down, I am nothing

Suffering ennobles a man,
Enduring the oyster-shell’s prison makes a pearl of a water-drop
How long will you live, or run after Being or Non-Being?
A life so dogged by sorrow
Is best spent in sleep or drunkenness

My back is bent by time
All my affairs go awry
In this hole and corner of transience long you will seek
This borrowed moment, and never find it

Nobody has mastered the wheel of the universe
Life is never glutted feeding on men
You boast it has not eaten you
Don’t speak too soon, it’s early yet, it will

The skies’ vault brings flower out of the earth
Only to crush them and consign them to earth again;
If the clouds took up dust as they do water,
They would rain till Doomsday the blood of those who loved

I am not free one single day from bondage to the world
Get not one breath of joy from all my existence;
I have served a long apprenticeship to Time
Since in this halting-place there is no justice
And there will be nothing but empty air in the hand, I’m off!

Since a man’s gain in this salt marsh
Is nothing but misery till life’s uprooting
He who leaves this world soon is happy of heart
And he who never entered it at peace

Were I to find fruit on the branch of hope
I’d find the end of my life’s thread there
How much longer must I be in existence’s narrow straits?
If only I could find the door to oblivion.

I never would have come, had I been asked,
I would as life go, if I were asked,
And, to be short, I would annihilate
All coming, being, going, were I asked!