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The Good Work of Getting What We Need As Patients

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Since recent posts here and here about work in healthcare—discussing burnout among health professionals, concerns about misuse of patient data, and questions about who is policing our rapidly changing health system—I’ve continued to follow developments in the field.  
 
Over the past few weeks, some of you have also shared your troubled reactions about how work in healthcare has been evolving.
 
The net of these developments is that while there are grounds for alarm about the uses of our health data, its proliferation presents some extraordinary opportunities too. Concepts like “precision medicine” become more realistic as the amount and quality of the data improves. More and better data will also help us to live longer and healthier lives. On the other hand, whether AI and other data-related technologies can enable us to improve the quality of the work experience for millions of healthcare professionals is a stubbornly open question.
 
In this last healthcare-related post for a while, there are two, practical rules of thumb that might give us greater sense of control over how our healthcare data is being used, as well as a couple of ways in which more and better health-related information is already producing better patient outcomes.
 
The good work of getting the healthcare that we need as patients (both for ourselves and for others that we’re caring for) requires healthy doses of optimism as well as pessimism, together with understanding as much as we can about when excitement or alarm are warranted.

Two Rules of Thumb To Inhibit Misuse of Our Medical Data

The first rule of thumb involves insisting upon as much transparency as possible around the uses of our medical information. That includes knowing who is using it (beyond the healthcare provider) and minimizing the risks of anyone’s misuse of it.

Unfortunately, more of this burden falls on patients today. As health systems increasingly look to their bottom lines, they may be less incentivized to protect our personal data streams. And even when our interests are aligned, doctors and hospitals may not be able to protect our data adequately. As I wondered here a couple of weeks ago: “Can these providers ‘master the learning curve’ [of big data-related technologies] quickly enough to prevent sophisticated consultants like Google from exploiting us, or will the fox effectively be running the chicken coop going forward?”

An article last weekend in the Wall Street Journal called “Your Medical Data Isn’t As Safe As You Think It Is” raised a couple of additional issues. As patients, we may be lulled into complacency by the fact that much of our data is rendered “anonymous” (or stripped of our personal identifiers) before it is shared in big databases. But as this article describes at length, “de-identified” data in the hands of one of the tech companies can easily be “triangulated” with other data they already have on you to track your medical information back to you. That means they remain able to target you personally in ways you can imagine and some you cannot.

Moreover, even if it remains anonymous, your medical data “in a stranger’s hands” may still come back to haunt you. As one expert in data sharing observed, companies that monetize personal data currently provide very little information about their operations. That means we know some of the risks to us but are in the dark about others. Of the known risks around data dispersal, you may suddenly find yourself paying higher health-related insurance premiums or barred from obtaining any coverage at all:

Google will be in a good position to start selling actuarial tables to insurance companies—like predictions on when a white male in his 40s with certain characteristics might be likely to get sick and expensive. When it comes to life and disability insurance, antidiscrimination laws are weak, he says. ‘That’s what creates the risk of having one entity having a really godlike view of you as a person that can use it against you in ways you wouldn’t even know.’

Our first rule of thumb as customers in the health system is to insist upon transparency around how our providers are sharing our medical information, along with the right to prevent it from being shared if we are concerned about how it is will be used or who will be using it.
 
The second rule of thumb has always existed in healthcare, but may be more important now than ever. You should always be asking: is my medical information going to be used in a way that’s good for me?  If it’s being used solely to maximize Google’s revenues, the answer is clearly “No.” But if your information is headed for a health researcher’s big data set, you should ask some additional questions: “Was someone like me considered as the study was being constructed so the study’s results are likely to be relevant to me?”  “Will I be updated on the findings so my ongoing treatment can benefit from them?” (More questions about informed consent before sharing your medical data were set forth in another article this past week.) 

Of course, understanding “the benefits to you beforehand” can also help you determine whether a test, drug or treatment program is really necessary, that is, if it’s possible to assess the pros and cons with your doctor in the limited time that you have before he or she orders it.
 
With medical practitioners becoming profit (or loss) centers for health systems that operate more like businesses, the good work of protecting yourself and your loved ones from misuse of your data requires both attention and vigilance at a time when you’re likely to be pre-occupied by a range of other issues.

More and Better Data Is a Cause for Excitement Too

There is an outfit called Singularity University that holds an annual conference each year with speakers who discuss recent innovations in a range of fields. Its staff also posts weekly about the most exciting developments in technology on a platform called Singularity Hub. One of its recent posts and one of the speakers at its conference in September highlight why more and better medical data is also a cause for excitement.
 
To understand the promise of today’s medical data gathering, it helps to recall what medical information looked like until very recently. Most patient information stayed in medical offices and was never shared with anyone. When groups of patients were studied, the research results varied widely in quality and were not always reconciled with similar patient studies. Medicine advanced through peer reviewed papers and debates over relatively small datasets in scholarly journals. Big data is upending that system today.
 
For us as patients, the most exciting development is that more high quality data will give us greater control over our own health and longevity. This plays out in (at least) two ways.
 
In the first instance, big data will give each of us “better baselines” than we have today about our current health and future prospects. According to the Singularity Hub post, companies as well as government agencies are already involved in large-scale projects to:

measure baseline physiological factors from thousands of people of different ages, races, genders, and socio-economic backgrounds. The goal is to slowly build a database that paints a comprehensive picture of what a healthy person looks like for a given demographic…These baselines can then be used to develop more personalized treatments, based on a particular patient.

Although it sounds like science fiction, the goal is essentially “to build a digital twin of every patient,” using it in simulations to optimize diagnoses, prevention and treatments. It is one way in which we will have personalized treatment plans that are grounded in far more accurate baseline information than has ever been available before.
 
The second breakthrough will involve changes in what we measure, moving organized medicine from treatment of our illnesses to avoidance of most illnesses altogether and the greater longevity that comes with improved health. As these developments play out, it could become commonplace for more of us to live well beyond a hundred years.
 
At Singularity University’s conference two months ago, Dr. David Karow spoke about the data we should be collecting today to treat a broad spectrum of medical problems in their early stages and increase our life expectancy. He argues that his start-up, Human Longevity Inc., has a role to play in that future.
 
Four years ago, Karow conducted a trial involving nearly 1,200 presumably healthy individuals. In the course of giving them comprehensive medical checkups, he utilized several cutting edge diagnostic technologies. These included whole-genome and microbiome sequencing, various biochemical measurements and advanced imaging. By analyzing the data, his team found a surprisingly large number of early stage tumors, brain aneurysims, and heart disease that could be treated before they produced any lasting consequences. In another 14% of the trial participants, significant, previously undetected conditions that required immediate treatment were discovered. 
 
Karow’s argument is that we’re “not measuring what matters” today and that we should be “hacking longevity” with more pre-sympomatic diagnoses. For example, if testing indicates that you have the risk factors for developing dementia, you can minimize at least some of those risks now “because of third of the risks are modifiable.” 
 
Every start up company needs its evangelists and Karow is selling “a fountain of youth” that “starts with a fountain of data.”  This kind of personal data gathering is expensive today and not widely available but it gestures towards a future where these sorts of “deep testing” may be far more affordable and commonplace. 
 
We need these promises of more personalized and preventative medicine—the hope of a better future—to have the stamina to confront the current risks of our medical data being monetized and misused long before we ever get there. As with so many other things, we need to hold optimism in one hand, pessimism in the other, and the ability to shuttle between them.

This post was adapted from my December 1, 2019 newsletter. When you subscribe, a new newsletter/post will be delivered to your inbox every Sunday morning.

An Unhappy Healthcare System

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It came as no surprise. 

After writing about the growing challenges and responsibilities facing medical professionals and patients last week, I happened upon two posts about the burnout rates for the professionals who are charged with promoting health and healing in the rest of us.

The first was a PBS Newshour segment about the extent of the problem and, more recently, some possible cures. It cited studies from recent years that doctors commit suicide at twice the rate of the general population, that 86 percent of the nurses at one hospital met the criteria for burnout syndrome, that 22 percent had symptoms for post-traumatic stress disorder, and that the PTSD numbers for critical care nurses were comparable to those of war veterans returning from Afghanistan and Iraq. The reporter described what is happening as “a public health crisis.”  In a small ray of hope, providers have also begun to create outlets—like arts programs—so healthcare workers can “process some of the trauma” they are experiencing on a daily basis and begin to recover.

The second post, in Fast Company, discussed the most stressful jobs that are being done by women today, including the category “nurses, psychiatric healthcare provides and home health aides.” It noted that registered nurses are 14-16% more likely to have poor cardiovascular health than the rest of the workforce, “a surprising result” because the job is so physically active and nurses are more knowledgeable about the risk factors for cardiovascular disease than the workforce in general.

Several of you who work in the health care industry wrote to me this week about your experiences at work, which (sadly) mirror these discouraging reports.

The other follow-up development relates to the data that is being gathered from patients by the health care industry. Earlier this week, the Wall Street Journal reported hat Google had struck “a secret deal” with Ascension, one of the nation’s largest hospital systems, to gather and analyze patient data including lab results, doctor diagnoses and hospital records. Called Project Nightingale by Google and “Project Nightmare” by others, the data extraction and analysis “amounts to a complete health history, including patient names and dates of birth.” Having all of our medical information instantly available for analysis in one place is clearly a game changer.

The first alarm bells sounded about Project Nightingale involved the privacy of patient data. (Indeed, the day after its initial report, the Journal reported that the government had launched an investigation into Google’s medical data gathering on the basis of these concerns.) Among the privacy-related questions: will access to a patient’s data be restricted to practitioners who are involved in improving that patient’s outcomes? If this data can be used by others, how will it be used and how is the hospital system ensuring that those uses are consistent with that provider’s privacy policies? The governing statute, the Health Insurance Portability and Accountability Act of 1996, provides only the loosest of restrictions today. (Hospitals can share data with business partners without telling patients as long as the information is used “only to help the covered entity carry out its health care functions.”) 

On the positive side, the aggregation of patient data can facilitate more accurate diagnoses and more effective patient treatment.

Google in this case is using the data in part to design new software, underpinned by advanced artificial intelligence and machine learning that zeroes in on individual patients to suggest changes to their care.

More troubling, given Medicine’s continued drift from “profession” to “business,” is how providers can realize more profits from their patients by prescribing more medications, tests and procedures. How can patients distinguish between what they truly need to promote their healing and what is profit-making by the health care provider? As the Journal story also reports:

Ascension, the second-largest health system in the U.S., aims in part to improve patient care. It also hopes to mine data to identify additional tests that could be necessary or other ways in which the system could generate more revenue from patients, documents show.

How will patients be protected from unnecessary interventions and expense, or, unlike today, be enabled by industry reporting about medical outcomes to protect themselves? As I argued last week, the ethical responsibilities for everyone in healthcare–including for patients–are shifting in real time.
 
Earlier this year, I posted (here, here and here) on a similar Google initiative regarding smart cities. In places like Toronto, the company is helping government to gather and “crunch” data that will allow their cities to operate “smarter” and provide greater benefits for their citizens from the efficiencies that are achieved. As with Project Nightingale, there are privacy concerns that Google is attempting to address. But there are also key differences between this tech giant’s plans for monetizing citizen data in smart cities and its plans for monetizing patient data in the medical system.
 
In healthcare, your most personal information is being taken and used. This data is far more vital to your personal integrity and survival than information about your local traffic patterns or energy usage.

Moreover, in smart cities there are governments and long-established regulatory bodies that can channel citizen concerns back to government and its tech consultants, like Google. Because these interfaces are largely absent in health care, monitoring and enforcement is up to individual patients or hospital-sponsored patients’ rights committees. In other words, if you (as a patient) aren’t “watching the store,” almost no one will be doing so on your behalf.
 
To this sort of concern, Google responds both early and often, “Trust us. We’ve got your interests at heart,” but there are many reasons to be skeptical.  Another Fast Company article that was posted yesterday documented (with a series of links) some of Google’s recent history mishandling user data.

Google has gotten in trouble with European lawmakers for failing to disclose how it collects data and U.S. regulators for sucking up information on children and then advertising to them. The company has exposed the data of some 52 million users thanks to a bug in its Google+ API, a platform that has been shutdown. Even in the field of health, it has already made missteps. In 2017, the U.K.’s Information Commissioner’s Office found the way patient data was shared between the Royal Free Hospital of London and [Google affiliate] DeepMind for a health project to be unlawful. The app involved…has since controversially been moved under the Google Health umbrella. More recently, a lawsuit accused Google, the University of Chicago Medical Center, and the University of Chicago of gross misconduct in handling patient records.

Much of moving forward here depends on trust.

Will health care providers, that suddenly have the profit-making potential of big data, protect us as patients or see us only as revenue generators?

Can these providers “master the learning curve” quickly enough to prevent sophisticated consultants like Google from exploiting us, or will the fox effectively be running the chicken coop going forward?

What will Google and the other data-gatherers do to recover trust that seems to be damaged almost daily wherever their revenues depend upon selling our data to advertisers and others who want to influence us?

Is Google’s business model simply incompatible with the business model that is evolving today in health care?

As the future of medicine gets debated, we all have a say in the matter.

This post was adapted from my November 17, 2019 newsletter. When you subscribe, a new newsletter/post will be delivered to your inbox every Sunday morning.

The Roles of Doctor and Patient Are Changing

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On a train to New York City, I found myself sitting next to a doctor from Johns Hopkins. Mid-career. Confident. As it turned out, he was also from a family of doctors. 

In his career, he said he’d alternated between research and seeing patients and I asked him if he was getting what he’d hoped out of it. He said he had at the beginning, when he could practice more the way his dad had, like taking the time he needed to treat his patients. But more recently, demands from the government and insurance providers were requiring him to spend more and more patient time gathering information and creating medical records about their visits.

It gave him “an awful choice,” he said. “I can either spend much of my patient time looking down at my pad or tablet and taking notes or I can look them in the eye. I went into medicine to establish healing relationships, it’s how I saw my dad practice, but now this beast has to be fed every day.”

“What beast,” I asked. “Because I’ve chosen to keep talking to my patients,” he responded, “I still have to record all their medical information before I forget what we talked about, so almost every night I spend between 9 p.m. and midnight ‘feeding the data beast’  because, of course, my wife and kids get to see me for an hour or so once I get home.”  “The volume of it is grinding me down,” he continued, “but our insurance system requires it. What I looked forward to as a doctor every day is getting harder to come by.”

I’ve noticed this from the other side too. When I go to a specialist or for my regular check-ups I’m faced by my doctor as well as “a record keeper” with a touch screen. I’m always asked whether “I mind” having record keepers there and can always ask them to leave if I want to talk “one-on-one,” but it changes the entire dynamic in the room. Is this visit about me or my medical information?

It’s not whether electronic record keeping is working as intended, or is actually helping to manage medical costs that caught my eye this week. Instead, it’s how the generation and use of patient data is placing more obligations (with fairly profound ethical implications) on the so-called healing arts, and how far those obligations extend beyond data privacy and confidentiality.  Among other things, it got me wondering whether even our best doctors and medical caregivers are treating us as collections of data points instead of “as whole patients” in the grind of it all.  

For centuries, a doctor’s ethical obligations have been set forth in the Hippocratic Oath, with its standards being tailored to current understandings about health and healing.  For example, to reflect our growing environmental awareness, a current version of the Oath widens the focus of care from the individual patient to the health of the community and the planet itself:

I swear to fulfill, to the best of my ability and judgment, this covenant:
 
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
 
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
 
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
 
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
 
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
 
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. 
 
My responsibility [also] includes these related problems, if I am to care adequately for the sick:
 
I will prevent disease whenever I can, for prevention is preferable to cure.
 
I will protect the environment which sustains us, in the knowledge that the continuing health of ourselves and our societies is dependent on a healthy planet.
 
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those [who are] sound of mind and body as well as the infirm.
 
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

In the light of today’s Hippocratic Oath, it was easy to find several of its shadows.

Can our doctors provide “warmth, sympathy and understanding” while they are also filling in the blanks in their paperwork during the few minutes they are allotted to spend with us?  
 
When it comes to my data, how is it being used, who is using it, and how exactly is “my privacy” being protected?
 
Is this data collection primarily designed to make “the business of medicine’” more cost effective and efficient, or does it also promote my health and healing?  
 
What is my responsibility as a patient, not only as a collaborator in my medical outcomes but also regarding  “the multiple lives” of the data I’m providing?
 
In these regards, some food for thought this week came in the form of a new Hippocratic Oath that has been proposed by West Coast doctor Jordan Shlain. I think you’ll agree that in some ways his proposed Oath makes our jobs as patients and our doctors’ (and other medical professionals’) jobs as healers even more fraught than they were already. 
 
Here’s Dr. Shlain’s proposed Oath, with my initial impressions [in brackets] following each of its statements.
 
1. I shall endeavor to understand what matters to the patient and actively engage them in shared decision making. I do not ‘own’ the patient nor their data. I am a trusted custodian.
         
[Instead of doctors doing and patients receiving, the emphasis on joint decision-making shares the health and healing burden more equitably. Unanswered is whether patients should own their medical data.]
 
2. I shall focus on good patient care and experience to make my profits. If I can’t do well by doing good and prove it, I don’t belong in the field of the healing arts.
 
3. I shall be transparent and interoperable. I shall allow my outcomes to be peer-reviewed.
 
[Both 2 and 3 confront “the business of medicine” squarely in the Oath, acknowledging that care should be delivered with greater transparency around a doctor’s outcomes for patients, which the data now allows. As the business of medicine publically proves its worth, patients will become more like shoppers in a marketplace. What this new reality means in terms of accessibility or quality of care is, of course, uncertain.]
 
4. I shall enable my patients the opportunity to opt in and opt out of all data sharing with non-essential medical providers at every instance.
 
[Recognizing a patient’s interest in his/her data, information will need to be disclosed about essential and non-essential users of that data and about each patient’s ability to limit how it is shared.]
 
5. I shall endeavor to change the language I use to make healthcare more understandable; less Latin, less paternal language; I shall cease using acronyms. 
 
6. I shall make all decisions as though the patient was in the room with me and I had to justify my decision to them.
 
7. I shall make technology, including artificial intelligence algorithms that assist clinicians in medical decision-making, peer-reviewable.
 
[As AI and augmented intelligence programs become more common in medicine, protecting proprietary business information should not inhibit validation of the tools a doctor is using to treat us by his or her professional peers.]
 
8. I believe that health is affected by social determinants. I shall incorporate them into my strategy.
 
[This one goes further into the community behind the patient. As Dr. Shlain argues: “Someone’s zip code can tell you more about their health than their genetic code.”]
 
9. I shall deputize everyone in my organization to surface any violations of this oath without penalty. I shall use open-source artificial intelligence as the transparency tool to monitor this oath.
 
[With doctors working until midnight to feed the data beast and stressed about market competition from other practice groups, their willingness to open themselves to these kinds of ethical challenges from within their organizations seems almost utopian, but at the same time, this part of the proposed Oath acknowledges that patient/consumers alone won’t be able to police this rapidly evolving profession.]  
  
Increasing reliance on data collection and algorithm-driven automation is changing the medical profession into a business. It also changes our jobs as patients, Where once we were passive recipients of “the healing arts,” we are now being called upon to become more engaged consumers, with rights to more information about our care and additional options in the marketplace. Moreover, we should be as concerned about the uses of our medical information as we are about how our other personal data is being used (or misused) by Google, Facebook or governmental bodies like the police and IRS. 
 
At the same time that doctors should be anticipating more changes to the Hippocratic Oath, the job of being a patient and the responsibilities that come with it are also becoming more burdensome. It’s not doctor “up here” (with all the responsibility) and patient “down there” (with almost none of it) any more. We’re confronting an uncertain future together now.

This post was adapted from my November 10, 2019 newsletter. When you subscribe, a new newsletter/post will be delivered to your inbox every Sunday morning.

Nostalgia Can Help Us Build a Better Future

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There is a widespread consensus that we’re on the cusp of a workplace revolution that will automate millions of jobs and replace millions of workers. 

Among the many questions is whether these displaced workers will still be able to support themselves because technologies that are on the rise, like augmented and artificial intelligence, will spawn millions of new jobs and a new prosperity.

Those fearing that far more jobs will be eliminated than created have argued for fixes like a universal basic income that would place a minimum financial floor under every adult while ensuring that society doesn’t dissolve into chaos. How this safety net would be paid for and administered has always been far less clear in these proposals.

Others are arguing that the automation revolution will usher in a new era of flourishing, with some new jobs maintaining and safeguarding the new automated systems, and many others that we can’t even imagine yet. However, these new programming and maintainence jobs won’t be plentiful enough to replace the “manual” jobs that will be lost in our offices, factories and transportation systems. Other “replacement jobs” might also be scarce. In a post last January, I cited John Hagel’s argument that most new jobs will bunch towards the innovative, the most highly skilled, what he called “the scaling edge” of the job spectrum.

On the other hand, analysts who have considered the automation revolution at McKinsey Global Institute noted in a July, 2019 report that automation will also produce a burst of productivity and profitability within companies, that employees will be able to work more efficiently and reduce their time working (5-hour days or 4- day work weeks) while gaining more leisure time. With more routine tasks being automated, McKinsey estimates that the growing need to customize products and services for consumers with more time on their hands will create new companies and an avalanche of new jobs to serve them. At the same time, demands for more customization of existing products and services will create new jobs that require “people skills” in offices and on factory floors.  

As we stand here today, it is difficult to know whether we should share Hagel’s concern or McKinsey’s optimism.

Predicting the likely impacts at the beginning of a workplace revolution is hardly an exact science. To the extent that history is a teacher, those with less education, fewer high-level skills and difficulties adapting to changing circumstances will be harmed the most. Far less certain are the impacts on the rest of us, whose education, skill levels and adaptability are greater but who may be less comfortable at the “scaling” edges of our industries.

Then there’s the brighter side. Will we be paid the same (or more) as we are today given the greater efficiency and productivity that automation will provide?  Will we work less but still have enough disposable income to support all of the new companies and workers who eager to serve our leisure time pursuits?  Maybe. 

It is also possible to imagine scenarios where millions of people lose their livelihoods and government programs becomes “the last resort” to maintain living standards. Will vast new bureaucracies administer the social safety nets that will be required? Will the taxes on an increasingly productive business sector (with their slimmed down payrolls) be enough to support these programs? Will those who want to work have sufficient opportunities for re-training to fill the new jobs that are created?  And even more fundamentally, will we be able to accommodate the shift from free enterprise to something that looks a lot more like a welfare state?

While most of us have been dominated by the daily tremors and upheavals in politics, there are also daily tremors and upheavals that are changing how we work and even whether we’ll be able to work for “a livable wage” if we want to.

As I argued recently in The Next Crisis Will Be a Terrible Thing to Waste, the chance to realize your priorities improve significantly during times of disruption as long as you’re clear about your objectives and have done some tactical planning in advance. As you know, I also believe in the confidence that comes with hope OR that you can change things for the better if you believe enough in the future that you’re ready to act on its behalf.

Beyond finding and continuing to do “good work” in this new economy, I listed my key priorities in that post: policies that support thriving workers, families and communities and not just successful companies; jobs that assume greater environmental stewardship as essential to their productivity; and expanding the notion of what it means for a company “to be profitable” for all of its stakeholders.

From this morning’s perspective—and assuming that the future of work holds at least as much opportunity as misfortune—I’ve been not only thinking about those priorities but also about things I miss today that seemed to exist in the past. In other words, a period of rapid change like this is also a time for what Harvard’s Svetlana Boym once called “reflective nostalgia.”  The question is how this singular mindset can fuel our passion for the objectives we want—motivate us to take more risks for the sake of change—in the turbulent days ahead.

Nostalgia isn’t about specific memories. Instead, it’s about a sense of loss, an emptiness today that you feel had once been filled in your life or work.

Unlike the kind of nostalgia that attempts to recreate a lost world from the ruins of the past, reflective nostalgia acknowledges your loss but also the impossibility of your ever recovering that former time. By establishing a healthy distance from an idealized past, reflective nostalgia liberates you to find new ways to gain something that you still need in the very different circumstances of the future that you want.

Because the urge to fill unsatisfied needs is a powerful motivator, I’ve been thinking about needs of mine that once were met, aren’t being met today, but could be satisfied again “if I always keep them in mind” while pursuing my priorities in the future. As you mull over my short list of “nostalgias” and think about yours, please feel free to drop me a line about losses you’d like to recoup in a world that’s on the cusp of reinvention.

MY SHORT LIST OF LOSSES:

– I miss a time when strangers (from marketers to the government) knew less about my susceptabilities and hot buttons. Today, given the on-line breadcrumbs I leave in my wake, strangers can track me, discover dimensions of my life that once were mine alone, and use that information to influence my decisions or just look over my shoulder. Re-building and protecting my private space is at the core of my ability to thrive. 

I want to own my personal data, to sell it or not as I choose, instead of having it taken from me whenever I’m on-line or face a surveillance camera in a public space. I want a right to privacy that’s created by law, shielded from technology and protected by the authorities. The rapid advance of artificial intelligence at work and outside of it gives the creation of this right particular urgency as the world shifts and the boundaries around life and work are re-drawn.

– I miss a time when I didn’t think my organized world would fall apart if my technology failed, my battery went dead, the electricity was cut off or the internet was no longer available. I miss my self-reliance and resent my dependency on machines. 

If I do have “more free time” in the future of work, I’ll push for more tech that I can fix when it breaks down and more resources that can help me to do so. I’ll advocate for more “fail-safe” back-up systems to reduce my vulnerability when my tech goes down. There is also the matter of my autonomy. I need to have greater understanding and control over the limits and possibilities of the tech tools that I use everyday because, to some degree, I am already a prisoner of my incompetence as one recent article puts it.

One possibility is that turning over [more] decisions and actions to an AI assistant creates a “nanny world” that makes us less and less able to act on our own. It’s what one writer has called the ‘Jeeves effect’ after the P.G. Wodehouse butler character who is so capable that Bertie Wooster, his employer, can get by being completely incompetent.

My real-life analogy is this. Even though I’ve had access to a calculator for most of my life, it’s still valuable for me to know how to add, subtract, multiply and divide without one. As tech moves farther beyond my ability to understand it or perform its critical functions manually, I need to maintain (or recover) more of that capability. Related to my first nostalgia, I’d meet this need by actively seeking “a healthier relationship” with my technology in my future jobs.
 
– I remember a time when I was not afraid that my lifestyle and consumption patterns were helping to degrade the world around me faster than the world’s ability to repair itself. At the same time, I know today that my absence of concern during much of my work life had more to do with my ignorance than the maintenance of a truly healthy balance between what nature was giving and humankind (including me) was taking. 

As a result, I need greater confidence that my part in restoring that balance is a core requirement of any jobs that I’ll do in the future. With my sense of loss in mind, I can encourage more sustainable ways to work (and live) to evolve.
 
-Finally, I miss a time when a company’s success included caring for the welfare of workers, families and communities instead of merely its shareholders’ profits, a model that was not uncommon from the end of World War II through the 1970s.  I miss a time, not so long ago, when workers bargained collectively and successfully for their rights and benefits on the job. I miss a time when good jobs with adequate pay and benefits along with safe working conditions were protected by carefully crafted trade protections instead of being easily eliminated as “too expensive” or “inefficient.” 
 
While this post-War period can never be recovered, a leading group of corporate executives (The Business Roundtable) recently committed their companies to serving not only their shareholders but also their other “stakeholders,” including their employees and the communities where they’re located. As millions of jobs are lost to automation and new jobs are created in the disruption that follows, I’ll have multiple opportunities as a part of “this new economy workforce” to challenge companies I work for (and with) to embrace the broader standard of profitability that I miss.

+ + +

Instead of being mired in the past, reflective nostalgia provides the freedom to seek opportunities to fill real needs that have never gone away. With this motivating mindset, the future of work won’t just happen to me. It becomes a set of possibilities that I can actually shape.

This post was adapted from my October 27, 2019 newsletter. When you subscribe, a new newsletter/post will be delivered to your inbox every Sunday morning.

The Work That Our Fragile World Needs Now

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(photo by lyle owerko)

After 9/11, I had a two-part image in my head. 

I recall the strikingly clarity and vividness of that morning as if it were yesterday.  A storm had swept the Northeast the day before, giving rise to a rare meteorological phenomenon known as “severe clear.” I remember looking up while I was walking Rudy and just diving into its photorealism, inhaling everything that was rejuvenating about it. I know where I was standing when it hit me.

But then, like a punishment, the clarity and wonder almost got dashed by the weeks and haunting years that followed, but still I remembered the daybreak that started it all, and how different its offering was.

Maybe because both branded me so powerfully, both have stayed—conjoined in my head—down to this morning. Promise then punishment. Hope then pain.

Has that ever happened to you, where opposites find themselves standing side-by-side and it becomes impossible to forget their inevitability?

That you should never fall for the one because there’s always the other.

As it’s turned out, there was another terrible prophecy in that cerulean blue sky 18 years ago, and it’s two-part disharmony is proving equally indelible. It’s the daily splendor I see outdoors together with all that our failures of stewardship have wrought, as Greenland melts into the sea and hot spots pop up in Rhode Island and now, right across from me, in New Jersey. 

I live in a kind of arboretum that frequently astonishes me with its beauty–whether it’s Rudy or now Wally who lets me stop and look up at it, down and all around at it every morning.

In my mind’s eye, I refuse to harness the promise of “severe clear” or even of more dappled mornings to the degradation that almost daily seems to be marching my way.

When I see the one I no longer want to see the other. But it takes daily acts of faith, hope and love to break them apart. 

A Deeper Future Than Man Can Make On His Own

When I read Robert MacFarlane’s Underland: A Deep Time Journey last summer, I responded to it with notes, markings on the page and, at least twice, with a “Wow” and exclamation point. The book chronicles MacFarlane’s intrepid wanderings through caves, excavations, sink holes, labyrinths, the quietest tunnels of bedrock, and some of the world’s remotest places. I regularly wondered “why” he was seeking out these claustrophobic and often dangerous destinations and his answer always seemed to be: because he was somehow drawn to them.

For more than 15 years now, I have been writing about the relationships between landscape and the human heart. What began as a wish to solve a personal mystery — why I was so drawn to mountains as a young man that I was, at times, ready to die for love of them — has unfolded into a project of deep-mapping.

These “relationships” between landscape and the human heart are richer and more complicated than Nature gives, on the one hand, Man takes or Man destroys, on the other. In ways he couldn’t always explain, MacFarlane was convinced that there was more to it than that, and whatever was calling out to him might be found if he climbed higher, probed deeper and kept better maps. He described his current motivation this way:

Our ‘flat perspectives’ feel increasingly inadequate to the deep worlds we inhabit, and to the deep time legacies we are leaving

With his “why-question” in mind, my first Wow came towards the end of a chapter called “The Understorey (Epping Forest, London)” about the extraordinary subterranean connections that fungi make to unite the trees into the organism of a forest. MacFarlane finds the modern words that we have—our human-centric words–inadequate to describe what the trees and the fungi have accomplished here, so he looks to a Native American language. (“In Potawatami, not only humans, animals and trees are alive, but so too are mountains, boulders, winds and fire.”) Acknowledging the life around them and their almost intentional roles, native language always made humans integral to the world but never at the center of it because all these other intentionalities have their priorities too. If we’re to restore the relationship between landscape and the human heart, we need to look deeper than the language-based understandings we have today.

The real underland of language is not the roots of single words. but rather the soil of grammar and syntax, where habits of speech and therefore also habits of thought settle and interact over long periods of time. Grammar and syntax exert powerful influence on the proceedings of language and its users. They shape the ways we relate to each other and to the living world. Words are world-makers—and language is one of the great geological forces of the Anthropocene [or Age of Man].

As we consider the underland of today’s language amidst the trees of Epping Forest, MacFarlane suggests that we can reshape, with words, the world that we experience into one of interdependence or symbiosis—create what one philosopher has dubbed “the Symbiocene”—instead of furthering a language-driven age that is dominated by human imperatives alone.

Another Wow came towards the end of a harrowing rite of passage. It delivered MacFarlane to an ancient cave on a remote Norwegian island that had been decorated with paintings of people dancing in the fire that had by brought by pilgrims since the dawn of time.

His Norwegian hosts, only too familiar with the environs, ask him why he is so driven to travel there alone in a dangerous, storm-tossed season, but his “reasoning” seems “weak” to explain it, so he doesn’t even try. It’s likely because the pull of a “thin place” like this, where “the borders between worlds or epochs feel at their most fragile,” is deeper than either reason or emotion, buried in heredity, like some instinct to find a better way to survive. And indeed, it’s the very different life force of our ancestors that MacFarlane manages to encounter deep in a cave in Lofotens, Norway.

At first, depleted by the penitential route, he can’t even see the cave paintings. But in his battery’s light:

when I open my eyes and look again, there is—yes, there, there—the flicker of line that is not only of the rock’s making. The line is crossed by another, and joined by a third, and there, there, yes, is a red dancer, scarcely visible but unmistakable, a phantom red dancer leaping on the rock. And there is another, and another, here, a dozen or more of them, spectral still but present now, leaping and dancing on the rock, arms outstretched and legs wide, forms shifting and tensing as I blink.
 
Their red is rough at its edges, fading back into the rock that made it, blurred by water and condensation, and all of these circumstances—the blur, the low light, my exhaustion, my blinks—are what give the figures their life, make them shift shapes on this volatile canvas in which shadow and water and rock and fatigue are all artists together, and for once the old notion of ghosts seems new and true in this space. These figures are ghosts all dancing together, and I am a ghost too, and there is a conviviality to them, to us, to the thousands of years for which they have been dancing here together.

MacFarlane’s story–about risking your safety to see what ancient joy and celebrating life might have looked and even felt like–ends with a modest claim about its significance. He even lets someone else make the necessary comparison.

Shortly after the Nazi death camps were liberated during World War II, the prehistoric cave paintings of Lascaux, France were discovered:  an extraordinary counterpoint about the nature of humanity. Fifteen years later, when an escalating nuclear arms race was foreshadowing a different kind of doom, philosopher George Bataile went down into the Lascaux caves. When he returned to the surface, MacFarlane quotes him as saying: “I am simply struck by the fact that light is being shed on our birth at the very moment when the notion of our death appears to us.”

MacFarlane’s job as a writer is to connect the underland of his instincts and intuitions with his readers’ world.  As we’re pressed each day with the “inevitability” of a dying, unsustainable planet, he shows us that there are deeper ways to envision our future in the language that we use as well as in the ways we can recapture our truer natures beneath the cerulean sky.

It’s embedded within us. We’ve done it before. There are maps that can help us find it.

 A Modern Photo Arc and Additional Irrational Acts

Joel Sartore is a National Geographic photographer who has been documenting the world’s captive animal species. Many of them are on the verge of extinction or are endangered or may soon be. He’s already photographed around 9,000 out of around 12,000 in captivity, and his pictures—which are taken in special sets to highlight each animal’s unique characteristics (a story in itself)—are strikingly beautiful at the same time that they engage us with their plight.

To Santore, the zoos where he takes his pictures are no longer warehouses or curiosity shops but conservation centers providing hopeful bridges from where we are today to where we may be headed. As Sartore recounted in a 2017 interview, by the turn of the next century we could stand to lose half of the earth’s current species and many of his photographs could merely be reminders. Or maybe far more than that.

His project is called the Photo Arc. His photos are featured in a series of books, in magazine articles and on his website. They glow like votive candles.

More than a documentarian, Sartore is also a storyteller with an eye for the funny or moving details that make his critters come alive when he talks about them. (He is the man that you hope will bring out the armadillo to meet your children at the zoo.) But as wonderous as the Photo Arc project—his protecting on film these animals that may soon be lost—it was not nearly as compelling to me as what he and some of his fellow naturalists are also doing right now to sustain the animals that still remain.

As Sartore heralds in his interview, one of these Noahs is Tilo Nadleer, who was an electronics specialist but now runs a primate center in Vietnam. Nadleer noticed that the police who were capturing animal smugglers had nowhere to put the animals they also recovered (baby primates, mostly) so they would euthanize them. It seemed unthinkable, but what could he do? So he took on the job of caring for these orphans himself, eventually building huge enclosures, feeding them with native vegetation from an adjacent national park. Nadleer tried to release them back into the wild but his primates kept getting shot, eaten or captured by smugglers again, so he now has successful breeding colonies, with a big percentage of the world’s population of three or four species. Sartore calls him “a time capsule.”

He started a project that he knew in his lifetime would never be complete. He is buying time for many of these animals, hoping that people will quit shooting them and people will leave the forests intact,

His work is an act of faith, hope and love.
 
Don and Ann Butler’s work at Pheasant Heaven in North Carolina is too. They’re breeding species of pheasant that are extinct in the wild. And then there is Santore himself, call it his second job. He bought land in Nebraska, where he lives, that included “alkaline wetlands and really steep uplands” where a rare breed of bird (long-billed curlews) along with other migrating species, like avocets and sandpipers, happen to breed. “I just wanted to save a little piece,” he said, “to save a little corner, protect something,” not really knowing whether it would make a difference, but feeling that he had to anyway.
 
These aren’t coins in a wishing well, but counter-testimony that Nadleer, the Butlers and Santore are giving (without breast-beating or fanfare) so that their actions are also recorded in the record of degradation and destruction around them. What else could they do? Well, they could do nothing because there is no assurance that their work will even begin to turn the tables. But they’re doing it anyway.
 
As Robert MacFarlane might put it, they’ve chosen to deepen the relationship between landscape and the human heart. And that, just that, might end up making all the difference.

This post was adapted from my October 20, 2019 newsletter. When you subscribe, a new newsletter/post will be delivered to your inbox every Sunday morning.

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