The biggest question in my research about areas such as support for primary
care, family medicine, admissions changes based on birth to admissions
status, and admissions of those socially and geographically and
chronologically different is not so much about difference and diversity.

It appears to be a matter of direction of change.

Measures now during the regressive phase are likely to be negative.
Measures during more progressive times are likely to be better.

I liked what Jim Collins did when researching Good to Great. It was not
enough to do well as a corporation, the corporation had to do well with
leadership changes. Successful corporations were more than just charismatic
leaders, they were about multiple changes. Those not likely to be on board
were moved out and momentum was established with more and more joining up.
One of my favorite thoughts is having a maximum of $200,000 for CEOs. The
rest of the rewards would be placed in escrow, millions even. The rewards
would be paid based on future performance in 10 years. If the company was
doing well, the CEO could collect, regardless of current situation. If the
company did poorly, the compensation was diverted to taking care of those
displaced by poor management decisions.

The Great Depression - enough said

In the desperate times of 1944 even capitalists had to admit that this best
system was widely abused and concessions were made regarding the most
damaging areas such as pure speculation. Bretton Woods was crafted to
reduce these abuses in the future that favored more and more wealth in the
hands of those with wealth sheerly on the basis of having wealth.

In 1947 Dorothy Sayers crafted a document "Lost Tools of Learning"
lamenting the changes in the way children were educated and dated the
changes back to medieval times. Post WWII involved a lot of reflections on
why the nations became so limited in their abilities to be aware of
situations in other nations that were likely to impact them. Dialogue and
rhetoric and methods of learning were more important than cramming in
subject matter. Cramming in subject matter, testing to the test, and class
divisions based on test scores dominate our times.

In the 1950s the most observant media critics such as Edward R. Murrow
began to realize that the nation's media was no longer as focused on truth.
This did not mean that the focus was deception. It was more focused on
marketing, market share, the dramatic, and worse. This is a process that
has continued today. To watch Dan Rather used as a media critic is......
In any case, be prepared for more and more trivia and less and less truth.
Journalism in black and white with little emphasis on complexity or shades
of gray sets up any nation for mistakes in all policies. Complete contrasts
shape conflict. Dialogue and rhetoric shape understanding and solutions.
Fewer in the nation even bother to study major issues, or vote. Candidates
are far less important than what they project and character is a rarity.
Seems that children taught no, have a shot at character. When politicians
take a tough stand and say no appropriately, they are defeated. Mark White
was governor of Texas. He proposed "No Pass, No Play." To play sports you
had to pass your courses. Molly Ivans, the long term editor of Texas
Monthly, credited this with his defeat. Bill Clements bought his way into
office, then there was Ann Richards, then George Bush. Who fits with the
words of Mirabeau Lamar, 3rd President of the Republic of Texas.
"Cultivated mind is the guardian genius of Democracy, and while guided and
controlled by virtue, the noblest attribute of man, it is the only dictator
that freemen acknowledge, and the only security which freemen desire." This
was a quote etched in concrete on my middle school in Texas City Texas and
I return periodically to review this landmark and my ability to measure up.

In the 1960s and 1970s the nation was moving a very different direction
with much greater emphasis on education, distributions of education, and
distributions of opportunity. Some of this was certainly the result of
Sputnik, Civil Rights, and leadership as reflected in Kennedy's Man to the
Moon speech, which was actually much more than about space.
http://www.unmc.edu/Community/ruralmeded/kennedy_and_crisis.htm    The
nation had clear direction in a positive way. It had to do something as the
market forces that shaped education, income distribution, and opportunity
were not capable of the kind of across the nation public response that was
required to make the nation efficient and effective in business, health, or
education areas. The nation used Sputnik and various threats in positive
ways, to boost emphasis on education. Education degrees maximized in the
1960s and 1970s.

This era also planted seeds that would grow into challenges regarding birth
control, women's health, women's rights, changing family roles, etc. The
nation has not found a suitable substitute for devoted nurturing moms. With
the decline of the most important and earliest nurturing experiences from
birth to the first few years of life, it is not a surprise that teens and
adults are less secure in any surroundings. Should moms be required to stay
at home? That is not the question. The question is, who will nurture
children so well that they will become efficient and effective children,
teens, and adults. This does not have to be a mom, but it needs to be
someone. If this is not addressed, then child development is a backup.
Child development and top level day care also favors lower and middle
income peoples who are trying to invest themselves in a future.

Other nations have made stellar choices to deal with at least some of the
consequences of these changes.
http://www.usnews.com/usnews/news/articles/070318/26intro.htm   Norway
focuses on children, parents, and the first year of life by supporting a
year off for parents at 80% pay and resumption of their job. Books in
American point out the severe penalties for women who take time off for
children, return to a lesser job, often lose the security of a husband and
father, and are much worse off. Finland comes closest to No Child Left
Behind. In America, NCLB funding can be diverted to improved science and
math in high school, that will be used by the 30% highest status (or those
who will be) rather than the earliest or preschool years. Those who are
influential and only thinking of their children fail to see that what their
children really need are lower and middle income children who are more
competitive, who will drive their own children to better excellence and
more awareness. The current situation only divides those most likely to be
leaders from the lower and middle income populations that they most
desperately need to understand to be able to lead well.

Relationships are the fabric of nations and security and efficient and
effective societies - parent child, teacher-student-parent, doctor-patient
being some of the most important along with public security and housing and
nutrition.   Lower and middle income peoples have a relationship with upper
status, and this relationship and information exchange is about nurses,
public servants, school teachers, and family physicians and all who arise
from lower and middle income populations and return to serve these
populations. America has devalued these service oriented and people
oriented occupations and the communication lines are down. These are also
the infrastructure that most encounters diverse, different, and
disadvantaged populations. It is their window to their impressions of their
existence and hope for the future and for their children. This is another
reason why so many who do survive lower and middle income marginal
education and opportunity become nurses, school teachers, family
physicians, policy, counselors, etc.

About 1971 the various economic and financial changes going on were
solidified in rejection of Bretton Woods under Nixon (from Morris Berman,
Dark Ages America).  this means that over 1 trillion dollars a year now
changes hands with no goods or services exchanged, over $20 a barrel of oil
is speculation.

Food, commodities, you name it, involves speculation that raises prices.
Speculation requires a costly bureaucracy that also rarely keeps up with
corruption.

All of these changes make in more and more difficult for those without to
do well, and reward those who have much already. Land and property in the
highest property value areas and professional degree separates those that
have no land, no wealth, less education, and no professional degree.

Enough for areas that require multiple books. What is important is that
nations focus on the basics, for it is their only hope to return to
sustainable civilization. Parent-child, child development-child-parent,
teacher-student-parent. Nations with these basics have market driven
capitalism that is superior, efficient, and effective. Nations that fail in
these basics have markets that drive nations apart with income, education,
professional degree, and opportunity increasingly shifted to the highest
status who sense gathering problems and hold on to their resources even
more and enact more policies that enforce this concentration, a sound
decision from their perspective right up until the "greatest generation"
soon becomes the last. Nations really have no choice other than to
continually focus on the youngest generations. Denial of this reality is a
most disturbing sign of the times.

Robert C. Bowman, M.D.
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