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Whatever Happened to Kindness?
Author’s Accepted Manuscript WHATEVER HAPPENED TO KINDNESS? Larry Dossey
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S1550-8307(17)30330-0 http://dx.doi.org/10.1016/j.explore.2017.09.002 JSCH2233
To appear in: Explore: The Journal of Science and Healing Cite this article as: Larry Dossey, WHATEVER HAPPENED TO KINDNESS?, Explore: The Journal of Science and Healing, http://dx.doi.org/10.1016/j.explore.2017.09.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Section Head: EXPLORATIONS
WHATEVER HAPPENED TO KINDNESS? People often ask me what is the most effective technique for transforming their life. It is a little embarrassing that after years and years of research and experimentation, I have to say that the best answer is — just be a little kinder.1 ~ Aldous Huxley • My religion is simple. My religion is kindness. ~ H. H. the 14th Dalai Lama
Basic kindness — the quality of being friendly, generous, considerate, empathic, compassionate — is under attack in healthcare. As I write in early July 2017, the American Medical Association has just sent a letter to the leaders of the US Senate that contains the following statement: “Medicine has long operated under the precept of Primum non nocere, or ‘first, do no harm.’ The draft legislation violates that standard on many levels.” The letter was sent to Senate Majority Leader Mitch McConnell (R-Kentucky) and Senate Minority Leader Chuck Schumer (D-New York). At issue is the Senate bill called the Better Care Reconciliation Act (BCRA), which strives to abolish and replace the Affordable Care Act (ACA) or Obamacare, which Republicans have voted to repeal more than 50 times during the past few years. To many physicians, the proposed BCRA requires not only that they violate their professional oath, it also appears to be a blueprint for a medical apocalypse — a tragic repudiation of empathy, compassion, and kindness toward those in need. The reasons for concern are straightforward. The nonpartisan Congressional Budget Office has determined that around 22 million Americans will lose their healthcare coverage over the next decade if the Senate bill is passed, in order to free up money for tax cuts for the wealthiest Americans.2 The bill would permit individual states to make sweeping changes to insurance market rules, allowing insurers to offer skimpy plans with no basic set of guaranteed benefits, meaning that treatments and medicines for individuals with high-cost ailments would likely be denied. People with pre-existing conditions would probably be placed in high-risk
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pools with larger deductibles and higher out-of-pocket costs than with insurance policies sold under ACA rules. The Senate proposal would undo Medicaid expansion and create deep cuts in Medicaid spending — in spite of the fact that candidate Trump promised at least five times that he would not cut Medicaid.3 Of the 1.4 million elders in nursing homes, 64 percent are recipients of Medicaid; many would be turned out if the Senate bill passes.4 Insurance subsidies would be cut, making private insurance out of reach for many people not eligible for Medicaid.5 Overall, marketplace enrollees would pay on average 74 percent more for a benchmark silver plan in 2020 under the BCRA than under current law. Younger enrollees would see modest increases on average (10 percent for those under age 18; 17 percent for those ages 18 to 34), while average premiums would more than double for enrollees ages 55 to 64.6 Polls show that only 17 percent of Americans approve of the pending Senate healthcare bill, making it one of the most reviled pieces of social legislation in recent history.7 In spite of this opposition, several Republican senators say the bill does not go far enough in stripping benefits from the needy. More austerity, they say, is required.8 Some Republican senators have responded to citizens’ objections with platitudes. One of the most common is that Americans will have greater “freedom” under the proposed legislation. For 22 million Americans, this means freedom to lose their healthcare. Overwhelming opposition has also erupted from the healthcare world. Among the groups who oppose the Republican plan are: 9 American Medical Association American Hospital Association American Association of Medical Colleges American College of Physicians American Academy of Family Physicians American Academy of Pediatrics National Association of Medicaid Directors American Psychiatric Association Federation of American Hospitals America's Essential Hospitals AARP American Heart Association: "The Senate draft health care bill is literally heartless." American Lung Association: "The healthcare legislation released today falls woefully short of providing healthcare for the 32 million Americans living with lung disease and should be rejected." The National Center on Addiction and Substance Abuse: "Anyone who votes for the Better Care Reconciliation Act of 2017 cannot claim to be committed to ending the opioid epidemic." American Cancer Society Cancer Action Network: “Preliminary analysis of the Senate bill released today shows the proposal could greatly harm millions of cancer patients, survivors and those at risk for the disease." US Conference for Catholic Bishops: "This moment cannot pass without comment. As the USCCB has consistently said, the loss of affordable access for 2
millions of people is simply unacceptable. These are real families who need and deserve health care." A TAX BILL, NOT A HEALTHCARE BILL The Senate’s Better Care Reconciliation Act is a blatant transfer of wealth from those who need it most to those who need it least. “It would be a big mistake to call the legislation … a health care bill. It is, plain and simple, a plan to cut taxes for the wealthy by destroying critical federal programs that help provide health care to tens of millions of people,” observed the editors at the New York Times.10 “Mean,” “cruel,” “evil,” and “hateful” are terms being used by opponents of the Senate bill, as it has become clear that harsh punishment will be inflicted on the poor and working classes, including millions of Trump supporters.11 The victims of this austerity will be the poor, elderly, disabled, and the young. Protests are popping up everywhere, including in the hallways of Congress. One journalist wrote, "Police are literally dragging people away, including those who are disabled or in wheelchairs, leaving the hall of the Senate offices streaked with blood. Consider this a portent of the injuries that Americans will suffer if this hateful bill becomes law."12 THE WAR ON HUNGER Recent research shows that many children who do not have enough to eat wind up with diminished capacity to understand and learn. Children don’t have to be starving for this to happen. Even mild undernutrition — the kind most common among poor people in America — can do it.13 ~ Carl Sagan Draconian legislative measures don’t stop with healthcare per se. Plans are also afoot in the President’s proposed budget to slash federal food aid to families of more than six people, the majority of which include young children.14 “This all derives from that old canard that people have more children to get more welfare benefits,” said Craig Gundersen, an agricultural economist at the University of Illinois who for 20 years has studied the Supplemental Nutrition Assistance Program (SNAP). “The amount of money you get for each additional child is not significant. No one is looking at that and saying, ‘I think I’ll have more kids because of it’…. It’s totally inconsistent with the goals of SNAP as an anti-hunger program.” For a family of nine, the new plan would decrease the maximum benefit from about $4.87 to approximately $3.43 per person per day — significantly lower than even the most conservative amount needed to feed a family, says the USDA, who administers SNAP.12
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Irony underlying the proposal to limit food aid to large families is thick. The current administration plans to defund Planned Parenthood, crippling its efforts to help women limit family size. It also supports denying coverage for birth control medications in employers’ health insurance programs, if the employer has a personal religious objection to contraception. These measures promote large family size instead of discouraging it, and are therefore pro-hunger programs in disguise. The President’s budget also proposes to eliminate the minimum SNAP allotment of $16 per month for households with one or two people. Those who receive the SNAP minimum are often low-income seniors with disabilities who have smaller households. According to the Center for Budget Policy Priorities, this change would kick almost two million beneficiaries from the program.12 HUNGER: A CLOSER LOOK I went to bed hungry many nights as a child. It was a Dream that dressed me up when I was ragged, and it was a Dream that filled me up when I was hungry. Now it’s my Dream to see that no child in this world ever goes hungry, certainly not here in America, the most bountiful country in the world. We can do better … we must!15 ~ Dolly Parton In a 2014 essay in Explore I discussed why opposition to federal nutritional assistance is irrational.16 Because of the ferocious current debate about food aid, I’m repeating the main arguments below. Readers familiar with the earlier essay may choose to skip this section. First, some basic facts. Seventy-six percent of households receiving food stamps through SNAP include a child, an elderly person, or a disabled individual. These households receive 83 percent of all SNAP benefits.17,18 Some 45 percent of food stamp recipients are children.19 Still, every night, 17 million children go to bed hungry in the United States.20 This means that no matter how you slice it, the nation’s nutrition assistance program is significantly a program to keep poor children from going hungry. The reason given most frequently for cutting SNAP is cost. Although the program is a lifeline to millions of struggling households that include children, opponents say we can’t afford it.21 Yet the average American household pays $6,000 annually in taxes that wind up subsidizing wealthy corporations who have no need of charity.22 Seen in this context, it is obscene to tell a hungry child that we cannot afford to alleviate her hunger because it costs too much. Corporations don’t go hungry, but people do. It’s obvious that cost is not really the issue here, and that deeper factors are at work. Contrary to the criticism that food stamps are a drain on the economy, many economists consider SNAP one of the most effective forms of economic stimulus. Moody’s Analytics estimates that in a weak economy every dollar increase 4
in SNAP benefits generates about $1.70 in economic activity. Similarly, the Congressional Budget Office rated an increase in SNAP benefits as one of the two most cost-effective of all spending and tax options it examined for boosting growth and jobs in a weak economy.23 Others say nutrition assistance programs should be cut because hordes of people are illegally trafficking in food stamps — collecting free food and selling it, or peddling SNAP cards for cash or ineligible items. In the media, stereotypes dominate this particular objection. There is a steady drumbeat of stories about recipients who spend their benefits on cigarettes, beer, or cosmetics, but there are few reports such as the single mother who figured out how to cut the family’s electricity bills by taking the light bulb out of the refrigerator, and who gives part of the food she obtains from the local food pantry to a homeless woman who is always pleading for help.24 While flagrant examples of abuse can be found in any major governmental (or private) program, the U. S. Department of Agriculture, which administers SNAP, reports that the fraud rate in the program has remained steady at around 1.5 percent, making it one of the least-abused federal programs in existence.25, 26 By comparison, Medicare fraud rates are roughly estimated to be between three and ten percent of expenditures.27 As to defense spending, no one knows how much money is siphoned off by fraud and waste, but experts use words such as “epic” to describe the abuse. Proper accounting methods for defense allocations are acknowledged not to exist. “We [don’t] have the detail … for a lot of it," says one Defense Department insider, which is a delicate way of saying that no one keeps track of where all the money goes.28 It is almost certain that the 1.5 percent attributed to cheating in SNAP is a figure the Pentagon and American taxpayers can only envy. Yet the conservative congressmen who complain loudest about SNAP fraud seldom utter a whiff of objection about the massive lapses in the Pentagon’s accountability. For them, colossal waste and fraud in military spending can be overlooked with a wink and a nod, while minuscule cheating on food stamps for infants, children, the disabled, the elderly, and veterans elicits a display of righteous indignation. We also hear that if the government gives people food, this destroys their incentive to work. Food stamps, these critics claim, create a culture of dependency by rewarding parasitic “moochers and takers.” Food assistance, we’re told, fosters deadbeat, Cadillac-driving welfare queens who prefer making babies to gainful employment. As one of Senator Paul Ryan’s (R-Wisconsin) colleagues described his view, “Paul wants people to dream again….You don’t dream when you’ve got food stamps.”29 Senator Rand Paul (R-Kentucky) agrees, contending that helping people secure food, shelter and other necessities is a “disservice” to the long-term unemployed, as if cutting off food assistance will magically produce a job.30 These hunger-is-good-for-you arguments appear not to care that infants and children are usually involved. In fact, most families receiving food stamps with children are already working:
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[W]hen it comes to families on SNAP with kids, a majority — 55 percent — are bringing home wages, according to USDA.31 The problem is, those wages aren't enough to actually live on…. That jibes with what Feeding America, a network of U.S. food banks, found in 2014 when it issued Hunger in America, a comprehensive report on who uses food pantries and why. It found that 54 percent of the families who turn to pantries to help put food on the table have at least one member working, and that rate was much higher, 71 percent, for households with kids. 32, 33 Why do some individuals respond with kindness and others with callousness when they confront needy, hungry people? Evidence suggests that people differ physically in response to the needy. Princeton University psychologist Susan T. Fiske performed fMRI brain scans on individuals while they were viewing photos of the poor and homeless. Their brains often reacted as if they were seeing things, not people. Her analysis suggests that there may be innate differences in our capacity for kindness, and why Americans often react to poverty not with empathy but revulsion.34, 35 The revulsion is sometimes expressed violently — as when state representative Tom Brower took a radical approach to solving homelessness in Hawaii by roaming city streets, looking for shopping carts that homeless people use to transport their possessions, and destroying them with a sledgehammer.36 Revulsion toward food stamp recipients is often marinated in hypocrisy. In 2013 Congressman Trey Radel (R-Florida) backed a Republican bill that would require food stamp recipients to undergo monthly urine drug testing to prove they were worthy. Shortly thereafter Radel achieved notoriety when he was busted for cocaine possession.37 Psychologist Fiske’s conclusions are supported by readers’ responses to an article on food stamp recipients by columnist Nicholas D. Kristof in the New York Times. One reader responded, “If kids are going hungry, it is because of the parents not upholding their responsibilities.” Another reader agreed: “Why should I have to subsidize someone else’s child? How about personal responsibility? If you procreate, you provide.” Another reader suggested an alternative to food stamps: forcibly taking these children from their parents and putting them in orphanages. It would be difficult to find more unambiguous, full-throated expressions of social Darwinism. Kristof gives a nod to John Rawls, “the brilliant 20th-century philosopher [who] argued for a society that seems fair if we consider it from behind a ‘veil of ignorance’ — meaning we don’t know whether we’ll be born to an investment banker or a teenage mom, in a leafy suburb or a gang-ridden inner city, healthy or disabled, smart or struggling, privileged or disadvantaged. That’s a shrewd analytical tool — and who among us would argue for food stamp cuts if we thought we might be among the hungry children?”38 In their research, economist Hilary W. Hoynes of the University of California at Berkeley and her colleagues Diane W. Schanzenbach and Douglas Almond report, 6
“Our findings indicate that the food stamp program has effects decades after initial exposure. Specifically, access to food stamps in childhood leads to a significant reduction in the incidence of ‘metabolic syndrome’ (obesity, high blood pressure, and diabetes) and, for women, an increase in economic self-sufficiency. Overall, our results suggest substantial internal and external benefits of the safety net that have not previously been quantified.”39 As one observer at the Center on Budget and Policy Priorities noted, “Hoynes and her collaborators have really broadened our understanding of how programs like food stamps not only relieve hardship in the moment but can trigger long-lasting gains in participating children’s later health and education. The implications of the research are considerable. In this long view, such assistance is not only helping struggling families to scrape by, it’s a good investment in the next generation of citizens and workers.”40 In a study from the University of California-San Francisco, researchers found that slashing monthly food stamp programs could cost more than it saves, because of a resulting increase in healthcare costs. The UCSF researchers found that California’s low-income population was more likely to be admitted to the hospital for hypoglycemia, often experienced by diabetic patients who continue to medicate while not eating enough. The risk for admission increased 27 percent in the last week of the month when food runs low, compared to the first week, while they observed no weekly difference among high-income Californians. “This is people going hungry, skipping meals and ending up in the hospital,” lead study author Hilary Seligman said of the low-income patients who may run out of food stamps at the end of each month. “From my perspective as a public health researcher, it’s cheaper to make sure people don’t get hungry than to deal with the far more expensive healthcare costs of not having access to food.”41, 42 THE INFLUENCE OF MEDICATION ON KINDNESS The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.43 ~ Sir William Osler (1849-1919) Acetaminophen is the most common drug ingredient in the US, found in more than 600 medicines. The best-known commercial product is Tylenol, which ranks among the largest-selling health remedies in the world. Before 1975 Tylenol had limited sales because, like prescription drugs, it was advertised mostly to physicians.44 Currently, however, each week about a quarter of American adults, around 50 million people, consume a medicine containing acetaminophen.45 In May 2016 researchers from Ohio State University found that when subjects took acetaminophen ahead of time, they rated the pain and hurt feelings experienced by another individual as not as severe as did the participants who took the placebo. “In the light of these results,” the researchers said, “it is understandable why using Tylenol to reduce your pain may also diminish your ability to feel other people’s pain as well.” Pain and fever, this research suggests, are not the only things
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Tylenol reduces. The research team also plans to study ibuprofen, another common pain reliever, to see if it has similar effects. 46, 47 PHYSICIANS TAKE A STAND Medicine arose out of the primal sympathy of man with man; out of the desire to help those in sorrow, need, and sickness. Our fellow creatures cannot be dealt with as man deals in corn and coal; “the human heart by which we live” must control our professional relations. . . . Nothing will sustain you more potently than the power to recognize in your humdrum routine . . . the true poetry of life, the poetry of the commonplace, of the ordinary man, of the plain toil-worn woman, with their loves and their joys, their sorrows and their griefs.48 ~ Sir William Osler By the time you read this, it is likely that the furor over the repeal or revision of the ACA/ Obamacare will be even more intense. It’s anyone’s guess what the eventual outcome may be. However, judging from the public outcry against the current Republican plans to destroy the ACA to facilitate a transfer of wealth from the most needy Americans to the wealthiest, perhaps a program that increases healthcare rather than diminishes it will eventually prevail. It is encouraging that thousands of US physicians are at the forefront of the movement toward a publicly financed national healthcare program, which would fully cover all Americans and eliminate the profit-driven insurance industry’s stranglehold. Anyone interested in this physician-driven initiative can contact Physicians for a National Health Program, PHNP, at http://www.pnhp.org. PHNP is comprised by some of the nation’s most accomplished physicians at leading US medical schools. David Himmelstein, MD, PHNP spokesman and a professor in the CUNY School of Public Health at Hunter College and lecturer on medicine at Harvard Medical School, says, “Our patients can’t afford care and don’t have access to the care they need, while the system is ever more wasteful, throwing away money on bureaucratic expenses and absurd prices from the drug companies.”49 A 39-member PHNP working group has drafted a proposal that has been endorsed by 2,235 physicians and nearly 200 medical students, “Beyond the Affordable Care Act: A Physicians’ Proposal for Single‐Payer Health Care Reform”: We propose to replace the ACA with a publicly financed National Health Program (NHP) that would fully cover medical care for all Americans, while lowering costs by eliminating the profit‐driven private insurance industry with its massive overhead. Hospitals, nursing homes, and other provider facilities would be nonprofit, and paid global operating budgets rather than fees for each 8
service. Physicians could opt to be paid on a fee‐for‐ service basis, but with fees adjusted to better reward primary care providers, or by salaries in facilities paid by global budgets. The initial increase in government costs would be offset by savings in premiums and out‐ of‐pocket costs, and the rate of medical inflation would slow, freeing up resources for unmet medical and public health needs.50 Support for a publicly financed National Health Program is more widespread than many realize. In May 2016 the Gallup Poll reported that 58 percent of US adults also favor replacing the ACA with a federally funded healthcare system that provides insurance for all Americans.51 KINDNESS IS INNATE People were created to be loved. Things were created to be used. The reason the world is in chaos is because things are being loved and people are being used. ~ Anonymous The best way to prevent people from being used is through the exercise of basic kindness — generosity, compassion, empathy. These qualities have been eclipsed in health care by the craving to convert human illness into enormous profits — loving things more than people. Many advanced nations have transcended this reversal of values. We can, too. In fact, it is our nature to do so. Neuroscience journalist Maia Szalavitz, in her discussion of the origins of empathy, wrote: Although human nature has historically been seen as essentially selfish, recent science suggests that it is not. The capacity for empathy is believed to be innate in most humans, as well as some other species — chimps, for instance, will protest the unfair treatment of others, refusing to accept a treat they have rightfully earned if another chimp doing the same work fails to get the same reward…. The first stirrings of human empathy typically appear in babyhood: newborns cry when hearing another infant’s cry, and studies have shown that children as young as 14 months offer unsolicited help to adults who appear to be struggling to reach something. Babies have also shown distinct preference for adults who help rather than hinder others.52
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GROUND ZERO FOR KINDNESS I expect to pass through this world but once; any good thing therefore that I can do, or any kindness that I can show to any fellow creature, let me do it now; let me not defer or neglect it, for I shall not pass this way again.53 ~ Proverbial saying As I’ve often mentioned in these pages, a growing body of evidence suggests that our consciousness is fundamental, incapable of being reduced to anything more basic. It is nonlocal in nature, infinite in space and time. And if without limits and boundaries, individual consciousness is in some sense united with consciousness everywhere as a universal or One Mind.54, 55 The implications of nonlocal consciousness for kindness are profound. Nonlocal consciousness permits, indeed requires, us to revise the Golden Rule, that great imperative for kindness that exists in all the world’s great religions, from its usual form of “Do unto others as you would have them do unto you” to “Be kind to others because in some sense they are you.” Interconnectedness is, of course, commonplace. There are now more personal mobile devices than people in the world. 56 It is obvious that there is nothing necessarily transformational about connectedness. Indeed, our digital connectedness can be a source of misery and malfeasance, as in identity theft and the hacking of voting systems. But the personal awareness of nonlocal oneness is of a different order than the electronic digital variety. Awareness of our nonlocal interconnectedness is often accompanied by a profound shift in the existential premises on which our life is based, including the way we treat others. As experimental psychologist and consciousness researcher William Braud wrote, “We could, no doubt, treat one another with kindness, understanding, and compassion even if we were not profoundly and intimately interconnected in nontrivial ways. However, having direct knowledge and direct experience of our interconnections can greatly increase our love for one another and enhance our ethical behaviors toward one another.”57 Novelist Henry James was keen on kindness. “Three things in human life are important,” he said. “The first is to be kind; the second is to be kind; and the third is to be kind.” 58 James’s emphasis reminds us that, although large-scale governmental activities we’ve examined such as healthcare and nutritional assistance should always embody kindness, ground zero for kindness remains the countless small actions and choices we make as individuals on a daily basis. As Mother Teresa said, “Not all of us can do great things. But we can do small things with great love.”59 Howard Zinn, the American historian, political scientist, and social activist, understood the virtues of kindness and how they influence how our world gets on. He gets the last word:
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We need hope. …To be hopeful in bad times is not just foolishly romantic. It is based on the fact that human history is a history not only of cruelty, but also of compassion, sacrifice, courage, kindness. What we choose to emphasize in this complex history will determine our lives. If we see only the worst, it destroys our capacity to do something. If we remember those times and places — and there are so many — where people have behaved magnificently, this gives us the energy to act, and at least the possibility of sending this spinning top of a world in a different direction. And if we do act, in however small a way, we don’t have to wait for some grand utopian future. The future is an infinite succession of presents, and to live now as we think human beings should live, in defiance of all that is bad around us, is itself a marvelous victory.60 ~ Larry Dossey, MD Executive Editor REFERENCES Aldous Huxley. Quoted in: Piero Ferrucci. The Power of Kindness: The Unexpected Benefits of Leading a Compassionate Life. New York, NY: Penguin; 2016: 23. 2 Congressional Budget Office. H.R. 1628, Better Care Reconciliation Act of 2017. https://www.cbo.gov/publication/52849. 26 June, 2017. Accessed 8 July, 2017. 3 Yglesias M. 5 times Trump tweeted that he would never cut Medicaid. Vox.com. https://www.vox.com/policy-and-politics/2017/6/23/15862312/trump-medicaid-promise. 23 June, 2017. Accessed 9 July, 2017. 4 Rau J. Medicaid cuts may force retirees out of nursing homes. Nytimes.com. https://www.nytimes.com/2017/06/24/science/medicaid-cutbacks-elderly-nursing-homes.html. June 24, 2017. Accessed 7 July, 2017. 5 Young J. American Medical Association slams Senate GOP health care bill. Huffingtonpost.com. http://www.huffingtonpost.com/entry/american-medical-association-senate-health-carebill_us_59514933e4b02734df2c5070. 26 June, 2017. Accessed 6 July, 2017. 6 Claxton G, Damico A, Levitt L, Cox C. Kaiser Family Foundation. Premiums under the Senate Better Care Reconciliation Act http://www.kff.org/health-reform/issue-brief/premiums-under-the-senatebetter-care-reconciliation-act/. 26 June, 2017. Accessed 9 July, 2017. 7 Taylor J. Just 17 percent of Americans approve of Republican Senate health care bill. http://www.npr.org/2017/06/28/534612954/just-17-percent-of-americans-approve-ofrepublican-senate-health-care-bill. 28 June, 2017. Accessed 8 July, 2017. 8 Sullivan S, Snell K, Eilperin J. Senate GOP’s health plan debuts amid doubts. https://www.washingtonpost.com/powerpost/senate-gop-leaders-set-to-unveil-health-carebill/2017/06/22/56dbe35c-5734-11e7-a204-ad706461fa4f_story.html?utm_term=.cb66b91f15fb. 22 June, 2017. Accessed 8 July, 2017. 9 Stafford D. American Medical Association joins other major groups in opposing Senate health bill. Cnn.com. http://www.cnn.com/2017/06/26/politics/ama-opposes-senate-health-bill/index.html. 26 June, 2017. Accessed 4 July, 2017. 10 The Senate’s unaffordable care act. Editorial. The Senate’s unaffordable care act. Nytimes.com. https://www.nytimes.com/2017/06/23/opinion/senate-obamacare-repeal.html. 23 June, 2017. 1
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Krugman P. Attack of the Republican decepticons. Nytimes.com. https://www.nytimes.com/2017/07/07/opinion/republican-healthcare-obamacare.html. 7 July, 2017. Accessed 7 July, 2017. 12 Cummings W. Usatoday.com. Conservative and liberal spin on the Senate health care bill. https://www.usatoday.com/story/news/politics/onpolitics/2017/06/22/bubble-conservativeliberal-media-reaction-senate-healthcare-bill/103109126/. 26 June, 2017. Accessed 7 July, 2016. 13 Sagan C. Bitsofpositivity.com. http://bitsofpositivity.com/best-hunger-awareness-quotes/. Accessed 9 July, 2017. 14 Dewey C. Washingtonpost.com. Trump’s budget would cut off food for poor people if they have too many kids. https://www.washingtonpost.com/news/wonk/wp/2017/05/23/trumps-budgetwould-penalize-poor-people-for-having-too-many-kids/?utm_term=.1ce9953f1102. 24 May, 2017.Accessed 7 July, 2017. 15 Parton D. Bitsofpositivity.com. http://bitsofpositivity.com/best-hunger-awareness-quotes/. Accessed 9 July, 2017. 16 Dossey L. The lemon juice syndrome and the hunger games. Explore. 2014; 10(3): 137- 145. Explorejournal.com. http://www.explorejournal.com/article/S1550-8307(14)00036-6/abstract. Accessed 7 July, 2017. 17 SNAP (Food Stamps): Facts, Myths and Realities. Feeding America. http://feedingamerica.org/how-we-fight-hunger/programs-and-services/public-assistanceprograms/supplemental-nutrition-assistance-program/snap-myths-realities.aspx. Accessed January 14, 2014. 18 U.S. Department of Agriculture, Food and Nutrition Service. Characteristics of Supplemental Nutrition Assistance Program Households: Fiscal Year 2011. Table A.14. November 2012. http://www.fns.usda.gov/ora/menu/Published/snap/SNAPPartHH.htm 19 Kristof ND. Where is the love? Nytimes.com. http://www.nytimes.com/2013/11/28/opinion/kristof-where-is-the-love.html. November 27, 2013. Accessed November 29, 3013. 20 Hunger in America. Sodexo Foundation. Sodexofoundation.org. http://www.sodexofoundation.org/hunger_us/hunger/america/america.asp. Accessed January 12, 2014. 21 McDonough K. Food pantries struggle to meet rising demand in wake of federal food aid cuts. Salon.com. http://www.salon.com/2013/11/26/food_pantries_struggle_to_meet_rising_demand_in_wake_of_fed eral_food_aid_cuts/. November 26, 2013. Accessed 26, 2013. 22 Hartmann T. Meet America’s biggest welfare queens. http://www.truthout.org/opinion/item/20254-meet-americas-biggest-welfare-queens. Truthout.org. November 27, 2013. Accessed November 27, 3013. 23 Rosenbaum D. SNAP is effective and efficient. Center on Budget and Policy Priorities. http://www.cbpp.org/cms/?fa=view&id=3239 March 11, 2013. Accessed January 14, 2014. 24 Baer K. Washington Post launches sneak attack on food stamp recipients. Povertyandpolicy.com. http://povertyandpolicy.wordpress.com/2013/12/19/washington-post-launches-sneak-attack-onfood-stamp-recipients/. . December 19, 2013. Accessed January 14, 2014. 25 USDA releases new report on trafficking and announces additional measures to improve integrity in the supplemental nutrition assistance program. http://www.fns.usda.gov/pressrelease/2013/fns001213. August 23, 2013. Accessed December 5, 2013. 26 Rosenberg P. GOP debunked on food stamps: Everything they say about SNAP is wrong. Salon.com. http://www.salon.com/2013/12/04/gop_debunked_on_food_stamps_everything_they_say_about_sn ap_is_wrong/. December 4, 2013. Accessed December 5, 2013. 27 Phipps JL. How big is Medicare fraud? Bankrate.com. http://www.bankrate.com/financing/retirement/how-big-is-medicare-fraud/February 21, 2013. Accessed January 15, 2014. 11
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Paltrow SJ. Special Report: the Pentagon’s doctored ledgers conceal epic waste. Reuters.com. http://www.reuters.com/article/2013/11/18/us-usa-pentagon-waste-specialreportidUSBRE9AH0LQ20131118. November 18, 2013. Accessed January 15, 2014. 29 Montgomery L. Paul Ryan, GOP’s budget architect, sets his sights on fighting poverty and winning minds. Washingtonpost.com. http://www.washingtonpost.com/business/economy/paul-ryan-gopsbudget-architect-sets-his-sights-on-fighting-poverty-and-winning-minds/2013/11/18/5c0248884da8-11e3-9890-a1e0997fb0c0_story.html. November 18, 2013. 30 Kilgore E. Rand Paul says unemployment benefits a “disservice” to workers. Alternet.org. http://www.alternet.org/rand-paul-says-unemployment-benefits-disservice-workers. December 9, 2013. Accessed January 14, 2013. 31 USDA. Characteristics of Supplemental Nutrition Assistance Program Households: Fiscal Year 2015 (Summary). https://fns-prod.azureedge.net/sites/default/files/ops/Characteristics2015-Summary.pdf. Accessed 10 July, 2-17. 32 Godoy M, Aubrey A. Trump wants families on food stamps to get jobs. The majority already work. Npr.org. http://www.npr.org/sections/thesalt/2017/05/24/529831472/trump-wants-families-on-food-stampsto-get-jobs-the-majority-already-work. 24 May, 2017. Accessed 10 July, 2017. 33 Feeding America. Hunger in America 2014: Executive Summary. Feedingamerica.org. http://www.feedingamerica.org/hunger-in-america/our-research/hunger-in-america/hia-2014-executivesummary.pdf. Accessed 10 July, 2017. 34 Harris LT, Fiske ST. Dehumanizing the lowest of the low: neur-imaging responses to extreme outgroups. Psychological Science. 2006; 17(10): 847-53. 35 Cikara M, Fiske ST. Stereotypes and schadenfreude: behavioral and physiological markers of pleasure at other's misfortunes." Social Psychological and Personality Science. 2012; 3(1): 63-71. 36 Hawaii Rep. Tom Brower takes a sledgehammer (literally) to homelessness problem. Huffingtonpost.com. http://www.huffingtonpost.com/2013/11/18/tom-browerhawaii_n_4299256.html. November 18, 2013. Accessed November 30, 2013. 37 Poling J. GOP congressman busted for coke possession last month just voted to drug-test food stamp recipients. Slothed.com. http://slothed.com/2013/11/20/gop-congressman-busted-for-cokeposession-last-month-just-voted-to-drug-test-food-stamp-recipients/. November 20, 2013. Accessed January 12, 2014. 38 Kristof ND. Where is the love? Nytimes.com. http://www.nytimes.com/2013/11/28/opinion/kristof-where-is-the-love.html. November 27, 2013. Accessed November 29, 3013. 39 Hoynes HW, Schanzenbach DW, Almond D. Long run impacts of childhood access to the safety net. National Bureau of Economic Research Working Paper No. 18535. Nber.org. http://www.nber.org/papers/w18535. November 2012. Accessed December 5, 2013. 40 Sherman A, Trisi D, Parrott S. Various supports for low-income families reduce poverty and have long-term positive effects on families and children. Center on Budget and Policy Priorities. http://www.cbpp.org/cms/?fa=view&id=3997. July 30, 2013. Accessed January 12, 2014. 41O’Connor L. Study: Increased Healthcare Costs Would Cancel Out Savings From Slashing Food Stamps. Huffingtonpost.com. http://www.huffingtonpost.com/2014/01/08/food-stamp-diabetesstudy_n_4563933.html. Accessed January 9, 2014. 42 Seligman HK, Davis TC, Schillinger D, Wolf MS. Food Insecurity is Associated with Hypoglycemia and Poor Diabetes Self-Management in a Low-Income Sample with Diabetes. J. Health Care Poor Underserved. 2010 November; 21(4): 1227–1233. 43 Osler W. Quoted in: Kurt Kroenke. Polypharmacy: Causes, Consequences, Cure. The American Journal of Medicine. 1985: 79: 149-152. 44 Lippman TW. How Tylenol grew from a little-known drug to the world's largest-selling health product. Washingtonpost.com. https://www.washingtonpost.com/archive/politics/1982/10/02/how-tylenol-grew-from-a-littleknown-drug-to-the-worlds-largest-selling-health-product/5fdfa0f5-445a-4243-91a739aa014658c6/?utm_term=.fc53e96924a2. 2 October, 1982. Accessed 8 July, 2017. 45 Tylenol dosage for adults. Tylenol.com. https://www.tylenol.com/safety-dosing/usage/dosagefor-adults. Accessed 9 July, 2017. 28
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Mischkowski D1, Crocker J2, Way BM. From painkiller to empathy killer: acetaminophen (paracetamol) reduces empathy for pain. Soc Cogn Affect Neurosci. 2016; 11(9):1345-53. DOI: https://doi.org/10.1093/scan/nsw057. 47 Ohio State University. When you take acetaminophen, you don’t feel others’ pain as much. Sciencedaily.com. https://www.sciencedaily.com/releases/2016/05/160510084257.htm. 10 May, 2016. 48 Bryan CS. Caring carefully: Sir William Osler on the issue of competence vs compassion in medicine. BUMC Proceedings. 1999;12:277-284. Baylorhealth.edu. http://www.baylorhealth.edu/Documents/BUMC%20Proceedings/1999%20Vol%2012/No.%204/ 12_%204_%20Bryan.pdf. Accessed 8 July, 2017. 49 Oksman O. 'We need fundamental changes': US doctors call for universal healthcare. https://www.theguardian.com/us-news/2016/may/05/us-doctors-calling-universal-healthcaresystem-affordable-care-act. 5 May, 2016. 50 Gaffney A, Himmelstein DU, Woolhandler S, Angell M, et al. Beyond the Affordable Care Act: A Physicians’ proposal for single‐payer health care reform. Pnhp.org. http://www.pnhp.org/beyond_aca/Physicians_Proposal.pdf. Accessed 9 July, 2017. 51 Newport F. Majority in U.S. Support Idea of Fed-Funded Healthcare System. Gallup.com. http://www.gallup.com/poll/191504/majority-support-idea-fed-funded-healthcaresystem.aspx. 16 May, 2017. Accessed 9 July, 2017. 52 Szalavitz M. How not to raise a bully: the early roots of empathy. Time.com. http://content.time.com/time/health/article/0,8599,1982190,00.html. 17 April, 2010. Accessed 9 July, 2017. 53 Anonymous. Quoted in: Bartlett J. Bartlett’s Familiar Quotations. Sixteenth edition. Justin Kaplan (general ed.).Boston, MA: Little, Brown; 1992: 780. 54 Dossey L. One Mind: How Our Individual Mind Is Part of a Greater Consciousness and Why It Matters. Carlsbad, CA: Hay House; 2013. 55 Dossey L. Nonlocal mind: a (fairly) brief history of the term. Explore. 2015; 11(2): 89-101. DOI: http://dx.doi.org/10.1016/j.explore.2014.12.001. 56 Boren ZD. There are officially more mobile devices than people in the world. Independent.co.u,. http://www.independent.co.uk/life-style/gadgets-and-tech/news/there-are-officially-more-mobile-devicesthan-people-in-the-world-9780518.html. 7 October, 2014. Accessed 11 July, 2017. 57 Braud W. Parapsychology and spirituality: Implications and intimations. Inclusivepsychology.webstarts.com. http://inclusivepsychology.webstarts.com/uploads/ParapsychologyAndSpirituality.pdf. Accessed 10 July, 2017. Also in: ReVision: A Journal of Consciousness and Transformation. 1995; 18(1): 36-43. 58 James H. Quoted in: Robert W. Birch. The Echo of Applause: And the Sound of Poetry. Bloomington, IN: Xlibris Corporation; 2005. 59 Mother Teresa. Quoted in: Goodreads.com. http://www.goodreads.com/quotes/6946-not-all-ofus-can-do-great-things-but-we. Accessed 9 July, 2017. 60 Howard Zinn. The optimism of uncertainty. Utexas.edu.com. http://www.utexas.edu/conferences/africa/ads/871.html. Accessed 7 July, 2017. 46
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S1550-8307(17)30330-0 http://dx.doi.org/10.1016/j.explore.2017.09.002 JSCH2233
To appear in: Explore: The Journal of Science and Healing Cite this article as: Larry Dossey, WHATEVER HAPPENED TO KINDNESS?, Explore: The Journal of Science and Healing, http://dx.doi.org/10.1016/j.explore.2017.09.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Section Head: EXPLORATIONS
WHATEVER HAPPENED TO KINDNESS? People often ask me what is the most effective technique for transforming their life. It is a little embarrassing that after years and years of research and experimentation, I have to say that the best answer is — just be a little kinder.1 ~ Aldous Huxley • My religion is simple. My religion is kindness. ~ H. H. the 14th Dalai Lama
Basic kindness — the quality of being friendly, generous, considerate, empathic, compassionate — is under attack in healthcare. As I write in early July 2017, the American Medical Association has just sent a letter to the leaders of the US Senate that contains the following statement: “Medicine has long operated under the precept of Primum non nocere, or ‘first, do no harm.’ The draft legislation violates that standard on many levels.” The letter was sent to Senate Majority Leader Mitch McConnell (R-Kentucky) and Senate Minority Leader Chuck Schumer (D-New York). At issue is the Senate bill called the Better Care Reconciliation Act (BCRA), which strives to abolish and replace the Affordable Care Act (ACA) or Obamacare, which Republicans have voted to repeal more than 50 times during the past few years. To many physicians, the proposed BCRA requires not only that they violate their professional oath, it also appears to be a blueprint for a medical apocalypse — a tragic repudiation of empathy, compassion, and kindness toward those in need. The reasons for concern are straightforward. The nonpartisan Congressional Budget Office has determined that around 22 million Americans will lose their healthcare coverage over the next decade if the Senate bill is passed, in order to free up money for tax cuts for the wealthiest Americans.2 The bill would permit individual states to make sweeping changes to insurance market rules, allowing insurers to offer skimpy plans with no basic set of guaranteed benefits, meaning that treatments and medicines for individuals with high-cost ailments would likely be denied. People with pre-existing conditions would probably be placed in high-risk
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pools with larger deductibles and higher out-of-pocket costs than with insurance policies sold under ACA rules. The Senate proposal would undo Medicaid expansion and create deep cuts in Medicaid spending — in spite of the fact that candidate Trump promised at least five times that he would not cut Medicaid.3 Of the 1.4 million elders in nursing homes, 64 percent are recipients of Medicaid; many would be turned out if the Senate bill passes.4 Insurance subsidies would be cut, making private insurance out of reach for many people not eligible for Medicaid.5 Overall, marketplace enrollees would pay on average 74 percent more for a benchmark silver plan in 2020 under the BCRA than under current law. Younger enrollees would see modest increases on average (10 percent for those under age 18; 17 percent for those ages 18 to 34), while average premiums would more than double for enrollees ages 55 to 64.6 Polls show that only 17 percent of Americans approve of the pending Senate healthcare bill, making it one of the most reviled pieces of social legislation in recent history.7 In spite of this opposition, several Republican senators say the bill does not go far enough in stripping benefits from the needy. More austerity, they say, is required.8 Some Republican senators have responded to citizens’ objections with platitudes. One of the most common is that Americans will have greater “freedom” under the proposed legislation. For 22 million Americans, this means freedom to lose their healthcare. Overwhelming opposition has also erupted from the healthcare world. Among the groups who oppose the Republican plan are: 9 American Medical Association American Hospital Association American Association of Medical Colleges American College of Physicians American Academy of Family Physicians American Academy of Pediatrics National Association of Medicaid Directors American Psychiatric Association Federation of American Hospitals America's Essential Hospitals AARP American Heart Association: "The Senate draft health care bill is literally heartless." American Lung Association: "The healthcare legislation released today falls woefully short of providing healthcare for the 32 million Americans living with lung disease and should be rejected." The National Center on Addiction and Substance Abuse: "Anyone who votes for the Better Care Reconciliation Act of 2017 cannot claim to be committed to ending the opioid epidemic." American Cancer Society Cancer Action Network: “Preliminary analysis of the Senate bill released today shows the proposal could greatly harm millions of cancer patients, survivors and those at risk for the disease." US Conference for Catholic Bishops: "This moment cannot pass without comment. As the USCCB has consistently said, the loss of affordable access for 2
millions of people is simply unacceptable. These are real families who need and deserve health care." A TAX BILL, NOT A HEALTHCARE BILL The Senate’s Better Care Reconciliation Act is a blatant transfer of wealth from those who need it most to those who need it least. “It would be a big mistake to call the legislation … a health care bill. It is, plain and simple, a plan to cut taxes for the wealthy by destroying critical federal programs that help provide health care to tens of millions of people,” observed the editors at the New York Times.10 “Mean,” “cruel,” “evil,” and “hateful” are terms being used by opponents of the Senate bill, as it has become clear that harsh punishment will be inflicted on the poor and working classes, including millions of Trump supporters.11 The victims of this austerity will be the poor, elderly, disabled, and the young. Protests are popping up everywhere, including in the hallways of Congress. One journalist wrote, "Police are literally dragging people away, including those who are disabled or in wheelchairs, leaving the hall of the Senate offices streaked with blood. Consider this a portent of the injuries that Americans will suffer if this hateful bill becomes law."12 THE WAR ON HUNGER Recent research shows that many children who do not have enough to eat wind up with diminished capacity to understand and learn. Children don’t have to be starving for this to happen. Even mild undernutrition — the kind most common among poor people in America — can do it.13 ~ Carl Sagan Draconian legislative measures don’t stop with healthcare per se. Plans are also afoot in the President’s proposed budget to slash federal food aid to families of more than six people, the majority of which include young children.14 “This all derives from that old canard that people have more children to get more welfare benefits,” said Craig Gundersen, an agricultural economist at the University of Illinois who for 20 years has studied the Supplemental Nutrition Assistance Program (SNAP). “The amount of money you get for each additional child is not significant. No one is looking at that and saying, ‘I think I’ll have more kids because of it’…. It’s totally inconsistent with the goals of SNAP as an anti-hunger program.” For a family of nine, the new plan would decrease the maximum benefit from about $4.87 to approximately $3.43 per person per day — significantly lower than even the most conservative amount needed to feed a family, says the USDA, who administers SNAP.12
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Irony underlying the proposal to limit food aid to large families is thick. The current administration plans to defund Planned Parenthood, crippling its efforts to help women limit family size. It also supports denying coverage for birth control medications in employers’ health insurance programs, if the employer has a personal religious objection to contraception. These measures promote large family size instead of discouraging it, and are therefore pro-hunger programs in disguise. The President’s budget also proposes to eliminate the minimum SNAP allotment of $16 per month for households with one or two people. Those who receive the SNAP minimum are often low-income seniors with disabilities who have smaller households. According to the Center for Budget Policy Priorities, this change would kick almost two million beneficiaries from the program.12 HUNGER: A CLOSER LOOK I went to bed hungry many nights as a child. It was a Dream that dressed me up when I was ragged, and it was a Dream that filled me up when I was hungry. Now it’s my Dream to see that no child in this world ever goes hungry, certainly not here in America, the most bountiful country in the world. We can do better … we must!15 ~ Dolly Parton In a 2014 essay in Explore I discussed why opposition to federal nutritional assistance is irrational.16 Because of the ferocious current debate about food aid, I’m repeating the main arguments below. Readers familiar with the earlier essay may choose to skip this section. First, some basic facts. Seventy-six percent of households receiving food stamps through SNAP include a child, an elderly person, or a disabled individual. These households receive 83 percent of all SNAP benefits.17,18 Some 45 percent of food stamp recipients are children.19 Still, every night, 17 million children go to bed hungry in the United States.20 This means that no matter how you slice it, the nation’s nutrition assistance program is significantly a program to keep poor children from going hungry. The reason given most frequently for cutting SNAP is cost. Although the program is a lifeline to millions of struggling households that include children, opponents say we can’t afford it.21 Yet the average American household pays $6,000 annually in taxes that wind up subsidizing wealthy corporations who have no need of charity.22 Seen in this context, it is obscene to tell a hungry child that we cannot afford to alleviate her hunger because it costs too much. Corporations don’t go hungry, but people do. It’s obvious that cost is not really the issue here, and that deeper factors are at work. Contrary to the criticism that food stamps are a drain on the economy, many economists consider SNAP one of the most effective forms of economic stimulus. Moody’s Analytics estimates that in a weak economy every dollar increase 4
in SNAP benefits generates about $1.70 in economic activity. Similarly, the Congressional Budget Office rated an increase in SNAP benefits as one of the two most cost-effective of all spending and tax options it examined for boosting growth and jobs in a weak economy.23 Others say nutrition assistance programs should be cut because hordes of people are illegally trafficking in food stamps — collecting free food and selling it, or peddling SNAP cards for cash or ineligible items. In the media, stereotypes dominate this particular objection. There is a steady drumbeat of stories about recipients who spend their benefits on cigarettes, beer, or cosmetics, but there are few reports such as the single mother who figured out how to cut the family’s electricity bills by taking the light bulb out of the refrigerator, and who gives part of the food she obtains from the local food pantry to a homeless woman who is always pleading for help.24 While flagrant examples of abuse can be found in any major governmental (or private) program, the U. S. Department of Agriculture, which administers SNAP, reports that the fraud rate in the program has remained steady at around 1.5 percent, making it one of the least-abused federal programs in existence.25, 26 By comparison, Medicare fraud rates are roughly estimated to be between three and ten percent of expenditures.27 As to defense spending, no one knows how much money is siphoned off by fraud and waste, but experts use words such as “epic” to describe the abuse. Proper accounting methods for defense allocations are acknowledged not to exist. “We [don’t] have the detail … for a lot of it," says one Defense Department insider, which is a delicate way of saying that no one keeps track of where all the money goes.28 It is almost certain that the 1.5 percent attributed to cheating in SNAP is a figure the Pentagon and American taxpayers can only envy. Yet the conservative congressmen who complain loudest about SNAP fraud seldom utter a whiff of objection about the massive lapses in the Pentagon’s accountability. For them, colossal waste and fraud in military spending can be overlooked with a wink and a nod, while minuscule cheating on food stamps for infants, children, the disabled, the elderly, and veterans elicits a display of righteous indignation. We also hear that if the government gives people food, this destroys their incentive to work. Food stamps, these critics claim, create a culture of dependency by rewarding parasitic “moochers and takers.” Food assistance, we’re told, fosters deadbeat, Cadillac-driving welfare queens who prefer making babies to gainful employment. As one of Senator Paul Ryan’s (R-Wisconsin) colleagues described his view, “Paul wants people to dream again….You don’t dream when you’ve got food stamps.”29 Senator Rand Paul (R-Kentucky) agrees, contending that helping people secure food, shelter and other necessities is a “disservice” to the long-term unemployed, as if cutting off food assistance will magically produce a job.30 These hunger-is-good-for-you arguments appear not to care that infants and children are usually involved. In fact, most families receiving food stamps with children are already working:
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[W]hen it comes to families on SNAP with kids, a majority — 55 percent — are bringing home wages, according to USDA.31 The problem is, those wages aren't enough to actually live on…. That jibes with what Feeding America, a network of U.S. food banks, found in 2014 when it issued Hunger in America, a comprehensive report on who uses food pantries and why. It found that 54 percent of the families who turn to pantries to help put food on the table have at least one member working, and that rate was much higher, 71 percent, for households with kids. 32, 33 Why do some individuals respond with kindness and others with callousness when they confront needy, hungry people? Evidence suggests that people differ physically in response to the needy. Princeton University psychologist Susan T. Fiske performed fMRI brain scans on individuals while they were viewing photos of the poor and homeless. Their brains often reacted as if they were seeing things, not people. Her analysis suggests that there may be innate differences in our capacity for kindness, and why Americans often react to poverty not with empathy but revulsion.34, 35 The revulsion is sometimes expressed violently — as when state representative Tom Brower took a radical approach to solving homelessness in Hawaii by roaming city streets, looking for shopping carts that homeless people use to transport their possessions, and destroying them with a sledgehammer.36 Revulsion toward food stamp recipients is often marinated in hypocrisy. In 2013 Congressman Trey Radel (R-Florida) backed a Republican bill that would require food stamp recipients to undergo monthly urine drug testing to prove they were worthy. Shortly thereafter Radel achieved notoriety when he was busted for cocaine possession.37 Psychologist Fiske’s conclusions are supported by readers’ responses to an article on food stamp recipients by columnist Nicholas D. Kristof in the New York Times. One reader responded, “If kids are going hungry, it is because of the parents not upholding their responsibilities.” Another reader agreed: “Why should I have to subsidize someone else’s child? How about personal responsibility? If you procreate, you provide.” Another reader suggested an alternative to food stamps: forcibly taking these children from their parents and putting them in orphanages. It would be difficult to find more unambiguous, full-throated expressions of social Darwinism. Kristof gives a nod to John Rawls, “the brilliant 20th-century philosopher [who] argued for a society that seems fair if we consider it from behind a ‘veil of ignorance’ — meaning we don’t know whether we’ll be born to an investment banker or a teenage mom, in a leafy suburb or a gang-ridden inner city, healthy or disabled, smart or struggling, privileged or disadvantaged. That’s a shrewd analytical tool — and who among us would argue for food stamp cuts if we thought we might be among the hungry children?”38 In their research, economist Hilary W. Hoynes of the University of California at Berkeley and her colleagues Diane W. Schanzenbach and Douglas Almond report, 6
“Our findings indicate that the food stamp program has effects decades after initial exposure. Specifically, access to food stamps in childhood leads to a significant reduction in the incidence of ‘metabolic syndrome’ (obesity, high blood pressure, and diabetes) and, for women, an increase in economic self-sufficiency. Overall, our results suggest substantial internal and external benefits of the safety net that have not previously been quantified.”39 As one observer at the Center on Budget and Policy Priorities noted, “Hoynes and her collaborators have really broadened our understanding of how programs like food stamps not only relieve hardship in the moment but can trigger long-lasting gains in participating children’s later health and education. The implications of the research are considerable. In this long view, such assistance is not only helping struggling families to scrape by, it’s a good investment in the next generation of citizens and workers.”40 In a study from the University of California-San Francisco, researchers found that slashing monthly food stamp programs could cost more than it saves, because of a resulting increase in healthcare costs. The UCSF researchers found that California’s low-income population was more likely to be admitted to the hospital for hypoglycemia, often experienced by diabetic patients who continue to medicate while not eating enough. The risk for admission increased 27 percent in the last week of the month when food runs low, compared to the first week, while they observed no weekly difference among high-income Californians. “This is people going hungry, skipping meals and ending up in the hospital,” lead study author Hilary Seligman said of the low-income patients who may run out of food stamps at the end of each month. “From my perspective as a public health researcher, it’s cheaper to make sure people don’t get hungry than to deal with the far more expensive healthcare costs of not having access to food.”41, 42 THE INFLUENCE OF MEDICATION ON KINDNESS The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.43 ~ Sir William Osler (1849-1919) Acetaminophen is the most common drug ingredient in the US, found in more than 600 medicines. The best-known commercial product is Tylenol, which ranks among the largest-selling health remedies in the world. Before 1975 Tylenol had limited sales because, like prescription drugs, it was advertised mostly to physicians.44 Currently, however, each week about a quarter of American adults, around 50 million people, consume a medicine containing acetaminophen.45 In May 2016 researchers from Ohio State University found that when subjects took acetaminophen ahead of time, they rated the pain and hurt feelings experienced by another individual as not as severe as did the participants who took the placebo. “In the light of these results,” the researchers said, “it is understandable why using Tylenol to reduce your pain may also diminish your ability to feel other people’s pain as well.” Pain and fever, this research suggests, are not the only things
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Tylenol reduces. The research team also plans to study ibuprofen, another common pain reliever, to see if it has similar effects. 46, 47 PHYSICIANS TAKE A STAND Medicine arose out of the primal sympathy of man with man; out of the desire to help those in sorrow, need, and sickness. Our fellow creatures cannot be dealt with as man deals in corn and coal; “the human heart by which we live” must control our professional relations. . . . Nothing will sustain you more potently than the power to recognize in your humdrum routine . . . the true poetry of life, the poetry of the commonplace, of the ordinary man, of the plain toil-worn woman, with their loves and their joys, their sorrows and their griefs.48 ~ Sir William Osler By the time you read this, it is likely that the furor over the repeal or revision of the ACA/ Obamacare will be even more intense. It’s anyone’s guess what the eventual outcome may be. However, judging from the public outcry against the current Republican plans to destroy the ACA to facilitate a transfer of wealth from the most needy Americans to the wealthiest, perhaps a program that increases healthcare rather than diminishes it will eventually prevail. It is encouraging that thousands of US physicians are at the forefront of the movement toward a publicly financed national healthcare program, which would fully cover all Americans and eliminate the profit-driven insurance industry’s stranglehold. Anyone interested in this physician-driven initiative can contact Physicians for a National Health Program, PHNP, at http://www.pnhp.org. PHNP is comprised by some of the nation’s most accomplished physicians at leading US medical schools. David Himmelstein, MD, PHNP spokesman and a professor in the CUNY School of Public Health at Hunter College and lecturer on medicine at Harvard Medical School, says, “Our patients can’t afford care and don’t have access to the care they need, while the system is ever more wasteful, throwing away money on bureaucratic expenses and absurd prices from the drug companies.”49 A 39-member PHNP working group has drafted a proposal that has been endorsed by 2,235 physicians and nearly 200 medical students, “Beyond the Affordable Care Act: A Physicians’ Proposal for Single‐Payer Health Care Reform”: We propose to replace the ACA with a publicly financed National Health Program (NHP) that would fully cover medical care for all Americans, while lowering costs by eliminating the profit‐driven private insurance industry with its massive overhead. Hospitals, nursing homes, and other provider facilities would be nonprofit, and paid global operating budgets rather than fees for each 8
service. Physicians could opt to be paid on a fee‐for‐ service basis, but with fees adjusted to better reward primary care providers, or by salaries in facilities paid by global budgets. The initial increase in government costs would be offset by savings in premiums and out‐ of‐pocket costs, and the rate of medical inflation would slow, freeing up resources for unmet medical and public health needs.50 Support for a publicly financed National Health Program is more widespread than many realize. In May 2016 the Gallup Poll reported that 58 percent of US adults also favor replacing the ACA with a federally funded healthcare system that provides insurance for all Americans.51 KINDNESS IS INNATE People were created to be loved. Things were created to be used. The reason the world is in chaos is because things are being loved and people are being used. ~ Anonymous The best way to prevent people from being used is through the exercise of basic kindness — generosity, compassion, empathy. These qualities have been eclipsed in health care by the craving to convert human illness into enormous profits — loving things more than people. Many advanced nations have transcended this reversal of values. We can, too. In fact, it is our nature to do so. Neuroscience journalist Maia Szalavitz, in her discussion of the origins of empathy, wrote: Although human nature has historically been seen as essentially selfish, recent science suggests that it is not. The capacity for empathy is believed to be innate in most humans, as well as some other species — chimps, for instance, will protest the unfair treatment of others, refusing to accept a treat they have rightfully earned if another chimp doing the same work fails to get the same reward…. The first stirrings of human empathy typically appear in babyhood: newborns cry when hearing another infant’s cry, and studies have shown that children as young as 14 months offer unsolicited help to adults who appear to be struggling to reach something. Babies have also shown distinct preference for adults who help rather than hinder others.52
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GROUND ZERO FOR KINDNESS I expect to pass through this world but once; any good thing therefore that I can do, or any kindness that I can show to any fellow creature, let me do it now; let me not defer or neglect it, for I shall not pass this way again.53 ~ Proverbial saying As I’ve often mentioned in these pages, a growing body of evidence suggests that our consciousness is fundamental, incapable of being reduced to anything more basic. It is nonlocal in nature, infinite in space and time. And if without limits and boundaries, individual consciousness is in some sense united with consciousness everywhere as a universal or One Mind.54, 55 The implications of nonlocal consciousness for kindness are profound. Nonlocal consciousness permits, indeed requires, us to revise the Golden Rule, that great imperative for kindness that exists in all the world’s great religions, from its usual form of “Do unto others as you would have them do unto you” to “Be kind to others because in some sense they are you.” Interconnectedness is, of course, commonplace. There are now more personal mobile devices than people in the world. 56 It is obvious that there is nothing necessarily transformational about connectedness. Indeed, our digital connectedness can be a source of misery and malfeasance, as in identity theft and the hacking of voting systems. But the personal awareness of nonlocal oneness is of a different order than the electronic digital variety. Awareness of our nonlocal interconnectedness is often accompanied by a profound shift in the existential premises on which our life is based, including the way we treat others. As experimental psychologist and consciousness researcher William Braud wrote, “We could, no doubt, treat one another with kindness, understanding, and compassion even if we were not profoundly and intimately interconnected in nontrivial ways. However, having direct knowledge and direct experience of our interconnections can greatly increase our love for one another and enhance our ethical behaviors toward one another.”57 Novelist Henry James was keen on kindness. “Three things in human life are important,” he said. “The first is to be kind; the second is to be kind; and the third is to be kind.” 58 James’s emphasis reminds us that, although large-scale governmental activities we’ve examined such as healthcare and nutritional assistance should always embody kindness, ground zero for kindness remains the countless small actions and choices we make as individuals on a daily basis. As Mother Teresa said, “Not all of us can do great things. But we can do small things with great love.”59 Howard Zinn, the American historian, political scientist, and social activist, understood the virtues of kindness and how they influence how our world gets on. He gets the last word:
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We need hope. …To be hopeful in bad times is not just foolishly romantic. It is based on the fact that human history is a history not only of cruelty, but also of compassion, sacrifice, courage, kindness. What we choose to emphasize in this complex history will determine our lives. If we see only the worst, it destroys our capacity to do something. If we remember those times and places — and there are so many — where people have behaved magnificently, this gives us the energy to act, and at least the possibility of sending this spinning top of a world in a different direction. And if we do act, in however small a way, we don’t have to wait for some grand utopian future. The future is an infinite succession of presents, and to live now as we think human beings should live, in defiance of all that is bad around us, is itself a marvelous victory.60 ~ Larry Dossey, MD Executive Editor REFERENCES Aldous Huxley. Quoted in: Piero Ferrucci. The Power of Kindness: The Unexpected Benefits of Leading a Compassionate Life. New York, NY: Penguin; 2016: 23. 2 Congressional Budget Office. H.R. 1628, Better Care Reconciliation Act of 2017. https://www.cbo.gov/publication/52849. 26 June, 2017. Accessed 8 July, 2017. 3 Yglesias M. 5 times Trump tweeted that he would never cut Medicaid. Vox.com. https://www.vox.com/policy-and-politics/2017/6/23/15862312/trump-medicaid-promise. 23 June, 2017. Accessed 9 July, 2017. 4 Rau J. Medicaid cuts may force retirees out of nursing homes. Nytimes.com. https://www.nytimes.com/2017/06/24/science/medicaid-cutbacks-elderly-nursing-homes.html. June 24, 2017. Accessed 7 July, 2017. 5 Young J. American Medical Association slams Senate GOP health care bill. Huffingtonpost.com. http://www.huffingtonpost.com/entry/american-medical-association-senate-health-carebill_us_59514933e4b02734df2c5070. 26 June, 2017. Accessed 6 July, 2017. 6 Claxton G, Damico A, Levitt L, Cox C. Kaiser Family Foundation. Premiums under the Senate Better Care Reconciliation Act http://www.kff.org/health-reform/issue-brief/premiums-under-the-senatebetter-care-reconciliation-act/. 26 June, 2017. Accessed 9 July, 2017. 7 Taylor J. Just 17 percent of Americans approve of Republican Senate health care bill. http://www.npr.org/2017/06/28/534612954/just-17-percent-of-americans-approve-ofrepublican-senate-health-care-bill. 28 June, 2017. Accessed 8 July, 2017. 8 Sullivan S, Snell K, Eilperin J. Senate GOP’s health plan debuts amid doubts. https://www.washingtonpost.com/powerpost/senate-gop-leaders-set-to-unveil-health-carebill/2017/06/22/56dbe35c-5734-11e7-a204-ad706461fa4f_story.html?utm_term=.cb66b91f15fb. 22 June, 2017. Accessed 8 July, 2017. 9 Stafford D. American Medical Association joins other major groups in opposing Senate health bill. Cnn.com. http://www.cnn.com/2017/06/26/politics/ama-opposes-senate-health-bill/index.html. 26 June, 2017. Accessed 4 July, 2017. 10 The Senate’s unaffordable care act. Editorial. The Senate’s unaffordable care act. Nytimes.com. https://www.nytimes.com/2017/06/23/opinion/senate-obamacare-repeal.html. 23 June, 2017. 1
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Krugman P. Attack of the Republican decepticons. Nytimes.com. https://www.nytimes.com/2017/07/07/opinion/republican-healthcare-obamacare.html. 7 July, 2017. Accessed 7 July, 2017. 12 Cummings W. Usatoday.com. Conservative and liberal spin on the Senate health care bill. https://www.usatoday.com/story/news/politics/onpolitics/2017/06/22/bubble-conservativeliberal-media-reaction-senate-healthcare-bill/103109126/. 26 June, 2017. Accessed 7 July, 2016. 13 Sagan C. Bitsofpositivity.com. http://bitsofpositivity.com/best-hunger-awareness-quotes/. Accessed 9 July, 2017. 14 Dewey C. Washingtonpost.com. Trump’s budget would cut off food for poor people if they have too many kids. https://www.washingtonpost.com/news/wonk/wp/2017/05/23/trumps-budgetwould-penalize-poor-people-for-having-too-many-kids/?utm_term=.1ce9953f1102. 24 May, 2017.Accessed 7 July, 2017. 15 Parton D. Bitsofpositivity.com. http://bitsofpositivity.com/best-hunger-awareness-quotes/. Accessed 9 July, 2017. 16 Dossey L. The lemon juice syndrome and the hunger games. Explore. 2014; 10(3): 137- 145. Explorejournal.com. http://www.explorejournal.com/article/S1550-8307(14)00036-6/abstract. Accessed 7 July, 2017. 17 SNAP (Food Stamps): Facts, Myths and Realities. Feeding America. http://feedingamerica.org/how-we-fight-hunger/programs-and-services/public-assistanceprograms/supplemental-nutrition-assistance-program/snap-myths-realities.aspx. Accessed January 14, 2014. 18 U.S. Department of Agriculture, Food and Nutrition Service. Characteristics of Supplemental Nutrition Assistance Program Households: Fiscal Year 2011. Table A.14. November 2012. http://www.fns.usda.gov/ora/menu/Published/snap/SNAPPartHH.htm 19 Kristof ND. Where is the love? Nytimes.com. http://www.nytimes.com/2013/11/28/opinion/kristof-where-is-the-love.html. November 27, 2013. Accessed November 29, 3013. 20 Hunger in America. Sodexo Foundation. Sodexofoundation.org. http://www.sodexofoundation.org/hunger_us/hunger/america/america.asp. Accessed January 12, 2014. 21 McDonough K. Food pantries struggle to meet rising demand in wake of federal food aid cuts. Salon.com. http://www.salon.com/2013/11/26/food_pantries_struggle_to_meet_rising_demand_in_wake_of_fed eral_food_aid_cuts/. November 26, 2013. Accessed 26, 2013. 22 Hartmann T. Meet America’s biggest welfare queens. http://www.truthout.org/opinion/item/20254-meet-americas-biggest-welfare-queens. Truthout.org. November 27, 2013. Accessed November 27, 3013. 23 Rosenbaum D. SNAP is effective and efficient. Center on Budget and Policy Priorities. http://www.cbpp.org/cms/?fa=view&id=3239 March 11, 2013. Accessed January 14, 2014. 24 Baer K. Washington Post launches sneak attack on food stamp recipients. Povertyandpolicy.com. http://povertyandpolicy.wordpress.com/2013/12/19/washington-post-launches-sneak-attack-onfood-stamp-recipients/. . December 19, 2013. Accessed January 14, 2014. 25 USDA releases new report on trafficking and announces additional measures to improve integrity in the supplemental nutrition assistance program. http://www.fns.usda.gov/pressrelease/2013/fns001213. August 23, 2013. Accessed December 5, 2013. 26 Rosenberg P. GOP debunked on food stamps: Everything they say about SNAP is wrong. Salon.com. http://www.salon.com/2013/12/04/gop_debunked_on_food_stamps_everything_they_say_about_sn ap_is_wrong/. December 4, 2013. Accessed December 5, 2013. 27 Phipps JL. How big is Medicare fraud? Bankrate.com. http://www.bankrate.com/financing/retirement/how-big-is-medicare-fraud/February 21, 2013. Accessed January 15, 2014. 11
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Paltrow SJ. Special Report: the Pentagon’s doctored ledgers conceal epic waste. Reuters.com. http://www.reuters.com/article/2013/11/18/us-usa-pentagon-waste-specialreportidUSBRE9AH0LQ20131118. November 18, 2013. Accessed January 15, 2014. 29 Montgomery L. Paul Ryan, GOP’s budget architect, sets his sights on fighting poverty and winning minds. Washingtonpost.com. http://www.washingtonpost.com/business/economy/paul-ryan-gopsbudget-architect-sets-his-sights-on-fighting-poverty-and-winning-minds/2013/11/18/5c0248884da8-11e3-9890-a1e0997fb0c0_story.html. November 18, 2013. 30 Kilgore E. Rand Paul says unemployment benefits a “disservice” to workers. Alternet.org. http://www.alternet.org/rand-paul-says-unemployment-benefits-disservice-workers. December 9, 2013. Accessed January 14, 2013. 31 USDA. Characteristics of Supplemental Nutrition Assistance Program Households: Fiscal Year 2015 (Summary). https://fns-prod.azureedge.net/sites/default/files/ops/Characteristics2015-Summary.pdf. Accessed 10 July, 2-17. 32 Godoy M, Aubrey A. Trump wants families on food stamps to get jobs. The majority already work. Npr.org. http://www.npr.org/sections/thesalt/2017/05/24/529831472/trump-wants-families-on-food-stampsto-get-jobs-the-majority-already-work. 24 May, 2017. Accessed 10 July, 2017. 33 Feeding America. Hunger in America 2014: Executive Summary. Feedingamerica.org. http://www.feedingamerica.org/hunger-in-america/our-research/hunger-in-america/hia-2014-executivesummary.pdf. Accessed 10 July, 2017. 34 Harris LT, Fiske ST. Dehumanizing the lowest of the low: neur-imaging responses to extreme outgroups. Psychological Science. 2006; 17(10): 847-53. 35 Cikara M, Fiske ST. Stereotypes and schadenfreude: behavioral and physiological markers of pleasure at other's misfortunes." Social Psychological and Personality Science. 2012; 3(1): 63-71. 36 Hawaii Rep. Tom Brower takes a sledgehammer (literally) to homelessness problem. Huffingtonpost.com. http://www.huffingtonpost.com/2013/11/18/tom-browerhawaii_n_4299256.html. November 18, 2013. Accessed November 30, 2013. 37 Poling J. GOP congressman busted for coke possession last month just voted to drug-test food stamp recipients. Slothed.com. http://slothed.com/2013/11/20/gop-congressman-busted-for-cokeposession-last-month-just-voted-to-drug-test-food-stamp-recipients/. November 20, 2013. Accessed January 12, 2014. 38 Kristof ND. Where is the love? Nytimes.com. http://www.nytimes.com/2013/11/28/opinion/kristof-where-is-the-love.html. November 27, 2013. Accessed November 29, 3013. 39 Hoynes HW, Schanzenbach DW, Almond D. Long run impacts of childhood access to the safety net. National Bureau of Economic Research Working Paper No. 18535. Nber.org. http://www.nber.org/papers/w18535. November 2012. Accessed December 5, 2013. 40 Sherman A, Trisi D, Parrott S. Various supports for low-income families reduce poverty and have long-term positive effects on families and children. Center on Budget and Policy Priorities. http://www.cbpp.org/cms/?fa=view&id=3997. July 30, 2013. Accessed January 12, 2014. 41O’Connor L. Study: Increased Healthcare Costs Would Cancel Out Savings From Slashing Food Stamps. Huffingtonpost.com. http://www.huffingtonpost.com/2014/01/08/food-stamp-diabetesstudy_n_4563933.html. Accessed January 9, 2014. 42 Seligman HK, Davis TC, Schillinger D, Wolf MS. Food Insecurity is Associated with Hypoglycemia and Poor Diabetes Self-Management in a Low-Income Sample with Diabetes. J. Health Care Poor Underserved. 2010 November; 21(4): 1227–1233. 43 Osler W. Quoted in: Kurt Kroenke. Polypharmacy: Causes, Consequences, Cure. The American Journal of Medicine. 1985: 79: 149-152. 44 Lippman TW. How Tylenol grew from a little-known drug to the world's largest-selling health product. Washingtonpost.com. https://www.washingtonpost.com/archive/politics/1982/10/02/how-tylenol-grew-from-a-littleknown-drug-to-the-worlds-largest-selling-health-product/5fdfa0f5-445a-4243-91a739aa014658c6/?utm_term=.fc53e96924a2. 2 October, 1982. Accessed 8 July, 2017. 45 Tylenol dosage for adults. Tylenol.com. https://www.tylenol.com/safety-dosing/usage/dosagefor-adults. Accessed 9 July, 2017. 28
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Mischkowski D1, Crocker J2, Way BM. From painkiller to empathy killer: acetaminophen (paracetamol) reduces empathy for pain. Soc Cogn Affect Neurosci. 2016; 11(9):1345-53. DOI: https://doi.org/10.1093/scan/nsw057. 47 Ohio State University. When you take acetaminophen, you don’t feel others’ pain as much. Sciencedaily.com. https://www.sciencedaily.com/releases/2016/05/160510084257.htm. 10 May, 2016. 48 Bryan CS. Caring carefully: Sir William Osler on the issue of competence vs compassion in medicine. BUMC Proceedings. 1999;12:277-284. Baylorhealth.edu. http://www.baylorhealth.edu/Documents/BUMC%20Proceedings/1999%20Vol%2012/No.%204/ 12_%204_%20Bryan.pdf. Accessed 8 July, 2017. 49 Oksman O. 'We need fundamental changes': US doctors call for universal healthcare. https://www.theguardian.com/us-news/2016/may/05/us-doctors-calling-universal-healthcaresystem-affordable-care-act. 5 May, 2016. 50 Gaffney A, Himmelstein DU, Woolhandler S, Angell M, et al. Beyond the Affordable Care Act: A Physicians’ proposal for single‐payer health care reform. Pnhp.org. http://www.pnhp.org/beyond_aca/Physicians_Proposal.pdf. Accessed 9 July, 2017. 51 Newport F. Majority in U.S. Support Idea of Fed-Funded Healthcare System. Gallup.com. http://www.gallup.com/poll/191504/majority-support-idea-fed-funded-healthcaresystem.aspx. 16 May, 2017. Accessed 9 July, 2017. 52 Szalavitz M. How not to raise a bully: the early roots of empathy. Time.com. http://content.time.com/time/health/article/0,8599,1982190,00.html. 17 April, 2010. Accessed 9 July, 2017. 53 Anonymous. Quoted in: Bartlett J. Bartlett’s Familiar Quotations. Sixteenth edition. Justin Kaplan (general ed.).Boston, MA: Little, Brown; 1992: 780. 54 Dossey L. One Mind: How Our Individual Mind Is Part of a Greater Consciousness and Why It Matters. Carlsbad, CA: Hay House; 2013. 55 Dossey L. Nonlocal mind: a (fairly) brief history of the term. Explore. 2015; 11(2): 89-101. DOI: http://dx.doi.org/10.1016/j.explore.2014.12.001. 56 Boren ZD. There are officially more mobile devices than people in the world. Independent.co.u,. http://www.independent.co.uk/life-style/gadgets-and-tech/news/there-are-officially-more-mobile-devicesthan-people-in-the-world-9780518.html. 7 October, 2014. Accessed 11 July, 2017. 57 Braud W. Parapsychology and spirituality: Implications and intimations. Inclusivepsychology.webstarts.com. http://inclusivepsychology.webstarts.com/uploads/ParapsychologyAndSpirituality.pdf. Accessed 10 July, 2017. Also in: ReVision: A Journal of Consciousness and Transformation. 1995; 18(1): 36-43. 58 James H. Quoted in: Robert W. Birch. The Echo of Applause: And the Sound of Poetry. Bloomington, IN: Xlibris Corporation; 2005. 59 Mother Teresa. Quoted in: Goodreads.com. http://www.goodreads.com/quotes/6946-not-all-ofus-can-do-great-things-but-we. Accessed 9 July, 2017. 60 Howard Zinn. The optimism of uncertainty. Utexas.edu.com. http://www.utexas.edu/conferences/africa/ads/871.html. Accessed 7 July, 2017. 46
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