Mr. Thabani Zuma is a professional nurse who works in the Ethembeni HIV Treatment Clinic in a small hospital, tucked away deep in the heart of Zululand, the epicenter of the HIV epidemic in South Africa. The remote location, harsh living conditions, and bad roads make it difficult to recruit doctors here, so nurses-the backbone of the health services-must carry the load. But traditional nursing education has not prepared them to prescribe and dispense the powerful, lifesaving antiretroviral treatment drugs. So the South African Government in collaboration with international aid agencies now offers courses to prepare nurses for this expanded role. Mr. Zuma attended this program and achieved 96% on the certifying examination, the highest score in the class. He seems like a good candidate for the nurse mentor course we will sponsor, and I invite him to tea to see if he is interested.

Mr. Zuma is a tall, slim thirty-four year old Zulu man. He is dressed in his nurse uniform-blue slacks and sweater, white shirt, and the maroon, military-style epaulets that nurses in this part of the world wear to signify their status. When he speaks, his sentences are punctuated with laughter and his whole face lights up and dances. We chat a bit and I ask him what led him into nursing. He tells me his story.

Mr. Zuma was born during apartheid in a black township in Durban, South Africa. His father worked as a security guard in an industrial part of town. When he was two, the family “had to move” thirty eight kilometers away to Fredville. He is not sure why.

He attended primary school in Fredville and then won a scholarship for a boarding school back in Durban. After he graduated, the company that had sponsored him encouraged him to study mechanical engineering. He had really wanted to study medicine, but there was no money for that, so he agreed to enroll in the engineering course. He graduated in 1999 and was awarded the National Diploma.

“But then it went all black-I couldn’t get a job. When I went for interviews they said, ‘No, we’ll call you back’, and then they never called back. When I went for other interviews at other companies, they’d say, ‘No, you are overqualified for the post that was advertised.’”

Mr. Zuma knew he had to do something. He had eight people to support. No one at home was working and by then he had fathered a daughter.

“I couldn’t get a job-yes-but the job that was available to me was driving a taxi.”

My mouth must have dropped. When I hear the word “taxi driver,” I picture a reckless guy slouched behind the wheel of a beat up van, his arm hanging out the window-not the intelligent young nurse sitting across the table from me. Taxi drivers on the continent are a law unto their own. They disregard the rules of the road, cut in front of you at will, and stop in the middle of the road to drop off or pick up passengers. Many taxis are unsafe and become death traps for the people crammed inside. Mention the word “taxi driver” to the ordinary motorist and you will get a mouthful of vitriol. Yet these 16-seater minibuses are the source of transport for over half the population. I asked him what it was like to drive a taxi.

“A nightmare. You know how taxi drivers are. When I tell people the story now, they ask, ‘How did you get out of being a taxi driver and start doing something constructive?’ Because you get stuck there. You get quick cash-good money depending on how fast you drive and how many people you squash in.” We laugh.

“Honestly-good cash-I wouldn’t lie.”

Mr. Zuma worked as a taxi driver for four years. But he wanted more than good cash, and he continued to look for other opportunities. During those years he took vocational courses and earned certificates in baking, in entrepreneurship, in catering. Still no job.

Then one day he received a recruitment letter in the mail.

“The Department of Health was looking for people who wanted to do nursing. I thought with nursing I may be able to do one or two things I wanted to do. I had wanted to be a doctor. Nursing was a part of it. I wanted to help people. I put in my application and-Walla!-this was it-they said I must start.”

Mr. Zuma had an excellent high school record and was accepted into the College of Nursing at Grey’s Hospital and awarded a stipend. With this income he could help his family as well as cover his own expenses. During the apartheid years hospitals were segregated by race, and Grey’s had catered only for whites. But by 2003 apartheid was nearly dead, and the hospital served everyone.

“Nursing school-it was difficult! Anatomy and Physiology was my nightmare.”

But he made it through.

“My area of interest was the operating theatre. I could see doctors opening people and doing things-I would have loved being a surgeon.”

When Mr. Zuma graduated in 2007, he applied for a position at Ethembeni Clinic because one of his relatives was employed here.

“It used to be nurses just take care of sick people, follow doctor’s orders. But here most of the things we do ourselves. This clinic is different from working in the wards. What we do we are accountable for.”

In the years that followed, Mr. Zuma became quite the expert in HIV care and treatment. When the nurses have a problem, he is the one they call. When he himself has a problem or a question, he gets in touch with one of the doctors in his network or phones the 24 hour hotline for HIV clinicians.

“If I am not sure of what I am doing, I am putting that life in danger. I should ask.”

Mr. Zuma has been carrying a heavy load of responsibility in this remote area for over four years. During the week, he stays in the Nurses’ Residence in one of the few en suite rooms. But he spends weekends at home.

“I like being at home. Every Friday afternoon I drive two and a half hours to Fredville. And every Monday morning I leave my house at four in the morning and arrive at the clinic by seven.

“I love what I’m doing right now. I must tell you. I really like ART’s [antiretroviral therapy]. I can see progress. That’s the main thing. You see the client today. When you see the client three months down the line, you see progress. That’s lovely. You say, at least I’ve done something that helped this client. That keeps me here. I’m happy.”

“Do you think you’re going to stay?”

“Well, I’ve never seen myself in the office, sitting there in front of the computer, because I love people. Right now I’m doing the one year course on Primary Health Care. They teach us the steps to take to properly diagnose the patients, not just to treat. Let me tell you one story.

“The other day after I had been at my course, a client came in. I looked at him and said I wonder what is wrong with him. I examined him and he had hepatomegaly, an enlarged liver. I never used to do that, diagnose patients myself.”

“The passion that you’ve got-it goes a long way. With me it’s the passion.”

I tell him that we would like to prepare him as a mentor for other nurses. He agrees.
“Whenever I am exposed to new information, I would love to share. Afternoons, when it is quiet, I bring people together-lay counselors, caregivers, and others-and say, let me teach you about one big word that I know.”

Mr. Zuma also sees patients in the outreach clinics. People in the area are poor and transport, including taxi service to the hospital, is limited and costly. So the nurses go out to the community and treat patients in thatched huts, under trees, or in churches.

“I feel for this area. Here they see the difference you are making in their lives. When you go out, people come to thank you with a bucket of potatoes or cabbages, spinaches. Just the appreciation makes you want to do more. It’s one lovely area. I won’t lie to you.”

We finish our tea and get ready to go back to the clinic. The weekend is almost here and Mr. Zuma will start on his long drive home to Fredville.

“My aunt has got taxis,” he tells me. “When a driver needs to go somewhere on Saturdays and asks me nicely, I drive. There’s no harm in that. Like I told you, for me, people are all the same.

“Sometimes the people tease me, ‘Oh, today we’re got a doctor driver.’

“And I say to them. No, I’m trying to push you people to see that when you are here, it doesn’t mean the end of the world, and when you are up there, it doesn’t mean you can’t mix with people down here. With me everyone is the same. I am driving with you.”

I will never again look at a taxi driver slouched behind the wheel, arm hanging out the window, without thinking of Mr. Zuma. I will always wonder…

When I told our hospital vice president I was making home visits with the residents, he gave me a polite smile that said “how quaint.” He then told us how the hospital was developing important new things like a joint replacement program, with concierge service and wood paneled patient rooms. They’re recruiting orthopedists. Like most hospital administrators, consultants keep him well informed on health care reform and other emerging trends. Home visits by family physicians are not part of the conversation. This is curious because of all the talk in health policy circles about the “Patient-Centered Medical Home” as a means to improve quality and decrease cost. In the latest set of standards for the Patient-Centered Medical Home developed by the National Center for Quality Assurance, there is no mention of the patient’s home as a locus of care. There is, however, a great deal about information technology. Information technology is a major concern of our national health policy experts.

The idea of physicians going to patients’ homes calls up nostalgic Norman Rockwell images of a simpler time. For the past two generations home health services have been the province of visiting nurses and other health care workers, not physicians. It’s simply economics. Medicare pays home health agencies enough to make it worth their while, but the overhead of a physician office is so great that making home visits is a money loser. And inconvenient. It’s possible to have a practice that entails only home visits, and a few physicians have done it. But most doctors who still go to patients’ homes squeeze in visits before or after office hours. It’s easy to see why it’s not popular.

I made my first home visits as a family medicine resident in Brooklyn. It didn’t take long to realize I could learn more about my patients in five minutes of a house call than a year’s worth of visits to the office. You see the family photos, the clutter, the pill bottles, the pets, the family dynamics all laid out in front of you. Like one visit to an elderly couple in Flatbush to check on the husband’s diabetic foot ulcer. He was a retired cab driver with Alzheimer’s disease who had finally stopped driving after he ran over the curb and smacked into a street sign. We went over instructions for wound care and then witnessed a shouting match between his wife and their adult son. When I went to say good-bye to the husband I found him washing his feet in the toilet bowl.

Our home visits are not house calls. We only get paid for seeing patients who meet criteria for being “home bound.” Insurance won’t pay for us to visit a child with fever. Still, there are plenty of frail elderly or patients with long-term disabling illnesses who qualify. When we added a required home care rotation to our residency training program we had a few simple goals-to learn more about our community, to see the different types of settings where our patients live (not just houses and apartments, but assisted living facilities, group homes, etc.), to assess their social support and the safety of the home environment, and to learn more about the role of other health care professionals in providing care in the home. In addition to making visits to their own patients, residents go out with home care and hospice nurses, physical therapists and advanced practice nurses. These other health care professionals seem happy to have a physician join in.

Our family medicine program is in a fairly typical small American city. It has a university, some large employers-a middle class and blue-collar community with its share of new immigrants, poverty, mental illness, drugs, and homelessness. If there’s anything that has emerged from our visits, it’s the awareness of how so many of our patients and families-even those we would call middle class-struggle to get by, each in their own way. When they come to the office we hear it in their voices but we don’t see it. The home care nurses know. We visit an 89-year-old woman in a moderate-sized Cape on a quiet suburban-like street. This is not the ghetto. The paint is peeling and old cars are parked in the driveway and the front lawn. Our patient walks from room to room holding on to furniture to keep from falling. The rooms are too cluttered for her to pass through with her walker. She’s taking medicine that makes her a bleeding risk if she falls and injures herself. Her bed is downstairs in the living room. Her daughter sleeps on a mattress on the floor next to her. Her three adult sons have the three bedrooms upstairs. There are family photos everywhere-filling the walls and cabinets, propped up on the backs of sofas, left on chairs. Her calcium tablets expired a year ago. Her out-of-pocket medication cost is $150.00 a month.

A mental health patient is morbidly obese from her anti-psychotic medication. She chain-smokes and uses home oxygen. Dust is everywhere and the room smells of cat urine. She is taking courses at the community college, transported to class by the Red Cross. She says she doesn’t want to live but hasn’t given up yet. When she needs a knee replacement she’ll get a wood paneled hospital room for a few days, maybe a few more if she has complications. At another home a daughter is taking care of her elderly demented mother and her deaf 90-year-old father-in-law between shifts at the family owned restaurant. She serves us Chinese food she brought from work. We see an elderly Italian-speaking man whose son, a local police officer trained for the SWAT team, comes over to translate. It takes fifteen minutes just to go over his medication. His wife serves us Italian Christmas pastries. It’s easy to gain a few pounds doing home visits. An overweight 84-year-old woman with bad arthritis lives alone. She has a walker but has fallen twice in the past several months. The firemen come and pick her up. Her house had structural damage from the heavy snow this past winter, but the insurance company is refusing to cover repairs. The resident sees why it takes her an hour in the winter to get from her house to a car to the office a mile away.

I’m impressed by how well the residents know their patients and their families, and how well liked they are in return. The patients are amazed and appreciative that their doctor is actually coming to their home, just like in the old days. In fact they have trouble believing it. If the system supported them, these young physicians would be happy to make home visits a regular part of their practice. Maybe then our patients wouldn’t have to go to the emergency department or be hospitalized quite so often. Maybe their lives would be a little more manageable. Maybe then we’d really be doing patient-centered care.

By Eva Sage Gordon

Sisyphus: Thanks for joining us Dr. Fretwell. I’ll begin with the most basic question: What is PACE?

Dr. Fretwell: It stands for Program for All-inclusive Care of the Elderly. The PACE programs began 30 years ago. They offer an alternative model to nursing home placement for frail older adults. But the exciting thing, in these times of conflict over health care funding, is a new way to pay for elder care.

Older individuals are often placed in institutions. Sometimes they are unhappy there, and often the costs are a real burden. PACE uses day care center that integrates social services, rehabilitative services, and medical care into a single organization. Its focus is to keep people in the community for as long as possible.

S: How is the funding different from traditional care?

MF: Each PACE program receives a fixed monthly payment and must provide all heath and social services from this. Physicians and others who work with the clients focus on health maintenance and improvement, rather than waiting to respond to illness.

The majority of funding comes from Medicaid and Medicare dollars, so this program aims to serve those who are elderly and poor. This structuring of financial incentives is innovative for the U.S. health care system.

S: You work with the North Carolina PACE program. What can you tell us about the beginnings of PACE in N.C.?

MF: The first PACE program in North Carolina opened in Wilmington in 2008. It has grown to four more sites across the state. Eight additional communities have PACE programs in development.

S: What kind of treatment options do PACE participants have? Who decides what is best for each person?

MF: The PACE program cares for individuals with both psychosocial and medical frailties. The participants and their caregivers become part of an interdisciplinary health care team which, on enrollment to the program and every six months afterwards, reviews a standard set of functional areas (nutrition, emotion, mobility are some of the domains) and the individual’s diagnoses and medications.

This process leads to a Plan of Care. Its goal is to maximize wellness for the participant and minimize stress for family caretakers.

S: What role do diet and exercise play in the care and maintenance of PACE patient health? What options are available on that front?

MF: Every participant exercises daily at the center, either individually with the Physical Therapist, or in balance and strengthening groups, or by riding an exercise bike for 30 minutes a day. Nutrition is part of the plan. In addition, participants have the opportunity for individual and group sessions to help them address emotional issues and patterns.

S: Where do doctor visits and other treatments take place? Is travel involved? Is there a shuttle system offered?

MF: The participant’s primary nursing and physician care are provided in the day center. Primary care nurses work there, communicating with the primary care physician, specialists, families, and with nursing aides who deliver care in the home.

PACE provides daily transportation to the day center and to appointments with specialists. With complex consultations, the primary care RN will accompany them.

S: How might this program interact with government health care spending changes brought by the health care legislation passed last year?

MF: Several themes have emerged from the legislation. The Centers for Medicare and Medicaid have focused on improving quality, reducing costs, and thinking in terms of serving populations rather than fee for services to an individual.

They have also proposed new ways of organizing and reimbursing providers that create accountability and reduce fragmentation as the means of improving care and reducing cost.

Creating Medical or Health Homes that have primary care at the center is currently being facilitated by grants to states from the federal government. PACE programs represent one end of the spectrum of providers who are already embodying these concepts; The Mayo Clinic model of multispecialist/hospital care represents the other end. In the Mayo Clinic Model, large numbers of primary care and specialists are on salary at the Clinic, providing care to a large population. The Clinic receives a fixed reimbursement for an episode of illness and is accountable to Medicare for the outcome.

S: How might the program expand? How much expansion would be good?

MF: PACE programs currently serve 21,000 Medicaid/Medicare funded individuals in 71 sites across the United States. Each site serves between 100-400 people. The Medicaid and Medicare offices would like for us to serve millions more of these “dual eligible” people because they represent a rapidly growing segment and expensive group of patients under the current “fee for service” system.

Much of the success of the PACE program depends on moving participants and their caretakers to a prevention, wellness, home and community based care system from a highly specialized, illness and hospitalization and nursing home placement system.

Our current system of care-fee for service-rewards physicians and hospitals by volume of care delivered, not by quality of outcomes. Patients and families are insulated from the cost of care.

To engage families and patients in moving from illness treatment to prevention and wellness, there must be trust between them and their physicians and other providers. I place trust and empathic relationships at the center of a successful PACE program. Patients and families must focus on wellness, including exercise, nutrition, and addressing emotional and behavioral patterns. This may require a change in their thinking and behavior, just as it does in health care professionals.

Currently, the goal for our PACE programs is to serve 150 participants, using one physician and one nurse practitioner and four primary care nurses. This is the number of individuals cared for in the average nursing home. Expanding centers beyond this size may impair communication and the intimacy required for trust and social support.

Increasing the number of PACE programs (rather than increasing the number of nursing home beds in a community), and linking smaller centers throughout a state by their funding and standard approaches to measuring patient outcomes, may be a better model for expanding the numbers of frail older individuals the program can serve.

S: And finally, why do you advocate for PACE, rather than other frail patient care models? Do you see any way that PACE could be improved?

MF: I advocate for PACE because it is the first health care program model that aligns the incentives for innovation, shared responsibility, high quality and individually appropriate care for everyone involved. Most exciting is the innovation that comes from working from a fixed reimbursement per month, allowing us to create a budgeting process for setting goals and reaching them.

After 30 years in practice, I have found a new source of intellectual challenge: how to help caregivers become more responsible yet less stressed. I, as a physician of frail older adults, have often struggled with difficult, dysfunctional families, but never have I been so motivated to actually get at the root cause of the problems and help families solve them. Part of the problem is that, as a physician, I didn’t have the psychological and social resources available to me. The PACE interdisciplinary team program supports both the physician and families in providing better care.

How to improve PACE? I would like to see less regulation by the state and federal governments. Time spent fulfilling regulatory documentation is time not spent seeing participants. We are at a level of sophistication with assessment measures that we should be able to provide financial statements and outcome reports to fulfill regulatory requirements. Electronic health records should facilitate this process. The direct and quantitative link between an individual’s level of function and the cost of care sustains the motivation toward optimizing each participant’s physical, emotional and cognitive function.

All of this leads me to close with a final statement: the organizing principles of a care system of high quality and sustainable cost are: aligned financial incentives, trusting relationships, and the goal of optimizing the psychosocial and physical function of older individuals and their caregivers. Thank you for this opportunity to share my thoughts on this topic.

S: Thank you, Dr. Fretwell.

Eva Sage Gordon is co-author of The Everything Guide to Writing Children’s Books, 2^nd edition, published by Adams Media in 2011. During 2010-11 she has taught high school in Spain and worked on her MFA in Creative Writing degree at Spalding University.

There is hunger in Florence, Alabama.

You wouldn’t think so to drive through this pretty little town with its thriving downtown and well-kept historic neighborhoods. At night when the restaurants are buzzing, it’s hard to find a homeless person on the street.

Florence does not have the kind of grocery store where union labor stocks the shelves with freshly made sushi and baby watermelons straight from a Chilean summer. For the last two decades I have shopped at a neighborhood grocery store where snuff and chewing tobacco are prominently displayed and where the hourly-wage workers know nothing about ‘bargaining power.’ Organic milk-or organic anything, for that matter-is not available at this store.

The reason I have shopped here for the past twenty-three years is because it is close to where I live and WalMart has closed down anything else that resembled competition. I have never lived in a subdivision nor do I ever intend to. People from the “section 8 houses” (government subsidized) walk to this store daily for food and cigarettes. Because it is a small store-easy to get to and easy to walk around in compared to the behemoth Walmart located on the outskirts of town-the elderly like to shop here. College students pop in for cases of the beverage du jour. But mainly it is the grocery store of the working poor. The featured items prominently displayed include a lot of saltines, white bread, canned vegetables, and store-brand boxes of macaroni and cheese and breakfast cereal.

Through the years I have seen a lot of young mothers, usually with their babies in their grocery carts, sorting through envelopes of clipped coupons as they shop, working hard to save a dollar here or there. I have seen fast food workers still in their uniforms in the check-out line with a cart full of the makings for chili or spaghetti. Later in the afternoon, the construction guys come in for a six pack and something to throw on the grill. Very rarely have I been in line behind someone using food stamps or WIC (supplemental nutrition for mothers and infants) cards.

This Tuesday I saw something at this store I had never before seen. It was around 4 P.M. and parents had just picked up children from school. This is a popular time for people to grab a few items before heading home to make dinner. I was there myself for toilet paper, some grapes and a bag of rice, not an entire cart of groceries. As I picked up a basket and headed down the first aisle, a kid, maybe eight years old, in badly fitting glasses, pleaded with his mom to buy a jar of mayonnaise. “But we’re out!” He had picked up the mayonnaise from the sale floor display and held it up to show her the product as he pleaded. “You said!” he accused. He tried another tactic. “It’s on sale.” He held the jar of mayonnaise like a sports trophy above his head before he shifted it down to cradle it in a ‘baby-doll’ position. Whatever the mother said was whispered, but the kid in the glasses put the mayo back on the display and they headed for the checkout, a loaf of sliced bread the only item in her hands.

I don’t think the reason they did not buy that jar of mayonnaise was because it was not organic.

Then on my way to find the toilet paper, I strolled by the meat counter. A man and woman in their thirties with two kids under the age of five held court at the hamburger section. They looked serious. They had obviously been in the store for a while because their cart was already relatively full of bags of potatoes, cans of green beans and corn, some dried beans, and several packs of the brand of hot dogs on sale this week. The dad had bought a can of store-brand grape soda from the cold drink machine, taken a big swig, and then handed it to the little girl, telling her to share it with her brother. When the wife showed him a package of hamburger meat, it was time for a conference. You could tell that they were adding up the cost of what was already in their cart and trying to decide if they could afford the hamburger meat. But what killed me, really killed me, was the pleading look in her eyes as she asked her husband if they could buy it, as she tried to rationalize the expenditure, there at 4 P.M. on a Tuesday afternoon in Florence, Alabama. She would really like to have the hamburger meat for her family, but they must first consult the rest of their grocery list and see if there would be enough money to buy it and the rest of the necessities they would need that week.

My grandfather was an accomplished gardener. By the time I was old enough to ride the school bus to his farm in the afternoons, he had two gardens. One was to supply food for his family. The other was to give vegetables to anyone else who needed food. One of my aunts was outraged by the people who came by to fill up bags with tomatoes, green beans, corn, and onions, people she had labeled as ‘sorry people.’ “They’re just using him,” she would say. “Just too lazy to make a garden for themselves.” My grandfather smiled at her and never said a word as he kept on cutting lettuce and pulling onions and radishes out of the ground and putting them into the trunks or back seats of the cars of anyone who stopped by and asked. My grandfather’s farm was-and this is God’s truth-halfway between Equality and Richville. My brother found the road sign the state of Alabama had bulldozed when they widened the intersection there at my grandfather’s farm. To the left: Equality. To the right: Richville. We were located exactly halfway between the two.

Coosa County is a great poor man’s county. Halfway between the struggle for equality and whatever lay on the other end of the spectrum. When my ancestors gave up owning slaves and moved there, I am not sure they knew what the future held other than hoping it was something more fair than the county from which they had escaped. Happier times, if no longer Richville.
It worries me that we seem to be drifting more and more toward what Jimmy Santiago Baca described in 1977 as “only a few people got all the money in this world, the rest count their pennies to buy bread and butter.” My father came back from WW2 and never told us anything at all except that he had seen a man shoot another man dead over a wheel of cheese. Later we found out that Daddy had been in several major battles, including the Battle of the Bulge, and that he had sat on a snow-covered ‘bench’ in Germany all winter as he ate his provisions only to find in the spring thaw that the ‘bench’ had been a frozen dead mule. We found out that he was wounded twice and one of only two people from his platoon to live through the entire war. But of all the horror he must have seen, of all the unspeakable horror there was in WW2, what he wanted me and my brother to know was this: given the right circumstances of hunger, people will do what they feel they have to do.

Butter or bullets is not a new dilemma, but in the meantime as our country figures out this latest round, maybe it is not the time to rub our gourmet acquisitions in the faces of others. As best-selling novelist Julianna Baggott, who attended Catholic school as a child, wrote in a recent FaceBook post: “Dear food gloaters who upload pics of their (gorgeous) meals: As Sister Mary Bertha would say, ‘Did you bring enough for everyone?’”

Published on the author’s blog, Talking in Accents, at amgarner.blogspot.com/2011/03/halfway.html

The contentious maelstrom around abortions routinely neglects an important aspect, the well-being of those who are pregnant.

I was trained at Los Angeles County Hospital in the mid-1960s. In those days, if you decided to terminate your pregnancy and were well-off, your family flew you to Japan or Sweden. If you were poor, you sought a local abortionist.

Abortion being thoroughly illegal then, there were no professional standards. Abortionists didn’t need a degree, experience, or, for that matter, scruples. They did their work with whatever came to hand–kitchen implements, harsh chemicals, even turkey quills. More often than not, their patients/victims developed bleeding, perforation, and infection. When I was on my Ob-Gyn rotation, we daily saw an average of eight to ten women with these complications. Many were as young as twelve, often hurriedly dropped off at the ER by frightened boyfriends or parties unknown. On the average, one died every day.

Imagine that: your daughter, who still keeps dolls in her bedroom, getting secretly pregnant, mutilated by a backstreet criminal, and shamefully dying alone. If abortion once again is declared illegal we’ll return to those days. As always, the wealthy will find little difficulty terminating pregnancies and the less affluent will risk death while their impregnaters suffer no risk at all.

To say to these young women, “You should have thought of that before…” strikes me not only as inhumanly callous, but actually supportive of the taking of a human life.

Article originally published on Dr Kane’s blog at http://healthcareasthoughpeoplematter.blogspot.com/

Editors, Charles Entrekin and Luke Wallin

Published by Hip Pocket Press
Managing Editor, Charles Entrekin
All work reprinted by permission of authors

SISYPHUS (cursed to roll a huge boulder up a hill, only to watch it roll back down) is a magazine that focuses on contemporary issues surrounding art, culture, and language. SISYPHUS is committed to printing those efforts that attempt to get a stone to the top of the hill.

Sisyphus Fall Issue 2011: Health & Hunger in America

1. The Taxi Driver – Ruth Stark
2. Home Visits – Mike Stehney
3. A New Wellness Model for Elder Care – Marsha Fretwell
4. Halfway Between Equality and Richville – A.M. Garner
5. Overlooked in the Abortion Issue – Jeff Kane

Introduction of new editor Luke Wallin:

Charles Entrekin and I met in 1966 as graduate students in Philosophy, at the University of Alabama. I was taken by his brilliance and his laughter, and recognized that I’d found someone who loved philosophy as I did. We were excited to explore Wittgenstein and Merleau-Ponty, to practice dialectics, and to learn the philosopher’s skills of shredding (the mean skill) and contextualizing (the kind skill).

Charles moved to the West Coast, and I to the East. We followed parallel roads, writing books, teaching, working in business, raising families. In the last few years we’ve intensified sharing our interests in language, culture, and social justice.

In March of 2011 Charles invited me to join him as an editor of Sisyphus, his online magazine. This year I’ve enjoyed working with Charles on our first issue together.

Introduction to the Issue:

The Health and Hunger in America issue contains five articles.

The first piece is by an American nurse working in South Africa. Ruth Stark, who holds a PhD in Health Services and Social Change, brings a perspective that reflects her career with the World Health Organization in Latin America, Asia, and Africa. I’ve read many of her essays, and what lingers with me is the sense of joy-within-frustration, for the doctors, nurses, and other health providers she describes. Their working conditions seem harsh. Yet there is something about their stories that clarifies health care, and all human care. They’re also a point of reference when we consider health and hunger in America.

Ruth’s piece, “The Taxi Driver,” profiles Mr.Thabani Zuma, a nurse in Zululand, South Africa. His work with AIDS education is interesting, but what’s really compelling is his journey to professional status, and the way he treats people now that he has achieved it.

In “Home Visits,” Dr. Mike Stehney shows readers how much a doctor can learn from five minutes of a house call. He also shows resistance by hospitals to such visits. How can a doctor include a home visit in the care of an individual? How can such visits be brought into medical education?

In an interview conducted by Eva Sage Gordon for Sisyphus, Dr. Marsha Fretwell describes a new funding model for the care for elderly patients. The program she directs has its financial incentives backwards-the rewards come from preventive medicine, keeping patients healthy and independent, rather than from reacting to illness events.

A.M. Garner is a writer who notices the whispers that conceal hunger in her town, Florence, Alabama. She shows how the town lies, metaphorically, “Halfway Between Equality and Richville.” This was the literal location of her grandfather’s garden, where he enjoyed giving away fresh vegetables to anyone who asked. Why? This was his secret, and it took her a long time to work it out. What she found is offered like a grace note from a family story, but it also clarifies explosive events on the national stage today.

Dr. Jeff Kane’s article, “Overlooked in the Abortion Issue,” brings startling reports from his practice. Similar to Garner’s perspective on hunger, Kane shows how the well-being of those who are pregnant depends upon competition between rich and poor.

Pakistani Girls’ School

Ah, there goes the blackboard again.
This time the wind of Cobras
has smashed it to smithereens and torn
the pencils from our hands.
The paper we cling to flaps so loudly
the teacher must shout the lesson.

Throw acid in our eyes and we’ll learn Braille
box our ears ‘til they burst and we’ll touch each other’s
mouths and hands to communicate
the anatomy of remedies
language of multiplication
geography of different lives.

Deluge

Even women with PhD’s,
Women who’ve taught at Berkley,
Who’ve got patches of Christmas pines planted
To finance Christmas plans,
Women who travel the country dancing,
And speak 7 languages (4 of them fluently),
Even women who sleep with women instead of men,
Comedians who make a crowd smile
Just by stepping into a room
Can find themselves cowering behind doors
Hoping the locks will hold as a lover rages;
A storming that tears a house apart ‘til it matches an afflicted mind.
Such smart, talented women can find themselves lowering
A daughter who has to pee out the bedroom
Window to the backyard, praying
The whirlwind that used to be a person
Doesn’t come whipping outside after her,
And whisk her away.

Hopes and prayers sometimes work out.

Congratulations
To those who escape the storm’s immediate vicinity
Who keep it permanently at bay
Who concentrate their powers and will it out of state.

For a few individuals, awakening is a sudden occurrence that lasts either a lifetime or for many years. With most of us, awakening is a gradual process, rewarded by the fruits that leaving a trance state offers us on a moment-to-moment basis. An example of such a reward is dreaming less of how great it will be when we get off work, go on vacation or retire, and instead resting in a place within ourselves that feels good right now. In this way, we shift from a polarized state of perceiving our world to a radiant state of perceiving it, without desire or fear.

Often, we don’t know how far we have come along the path of increasing our presence. This is an individual journey, and there is little or nothing against which to compare our personal progress toward increasing closeness to our true self. Still, the dream state of our imaginings lures us away from beholding whatever is before us by offering us mental-emotional spoils. These alluring abilities act as time travel, through desires, where we imagine ourselves to be somewhere other than where we are and in some other time/space. Fear may offer us a heads-up on something that lies in our imagined future, which we are clever enough to prepare ourselves for or escape from. In this way, desire and fear lure and frighten us away from beholding the present moment as it is. It is the task and pleasure of the artist to lure the viewer back to beholding, that is, drinking in whatever is before us with our eyes and our senses. Imagine a person who is crossing the street but is so preoccupied that he does not know that he is crossing a street. There is great danger. Yet, if he is aware that he is crossing the street, and looks at what is taking place, he will be able to cross any street without danger. If we are focused on emotions and past/future realities, we are in danger, simply because we are not paying attention to where we actually are and what is really going on.

Painting and awakening are naturally the same thing. The act of painting lures us into the present moment, which is the doorway to awakening. It is for this reason that many creative individuals find it difficult traveling a prescribed, spiritual path. Being creative means that one has already seen that life is a dream come true, and one wishes to create expressions of one’s own, and to remind others of this amazing possibility. Being creative means that one has already gone through the realization that ‘it is not what we see, but that we see’ that is the miracle. This is what many artists celebrate, and this is also where some artists get their courage to live so near to the edge. Artists who have already seen to the core of Being also see that artistic expression is a wondrous phenomenon that allows us infinite self-expression. In this spirit, we begin to try our hand at Creation itself. We have seen that our awareness is the creative force. This realization haunts us, until expressed.

When we commit to a spiritual path, such as attending a meeting of teachings by an Awakened Master, it is possible for artists to become confused. We are asked to let go of our minds. Yet, to do so implies to artists that we should let go of all of the marvelous ideas that flood our minds with new possibilities. This is a mistaken conclusion that creative people are prone to make. Many artists, when they are in the act of painting, have already discarded the mind that fills us with polarized concepts. The actively creative mind is not polarized. It is the polarized mind that we revert to that we are being asked by spiritual teachers not to identify with and not the creative mind. The mind that a creative person uses during the act of creation is the aspect of mind that expresses this infinite potential that we see everywhere, symbolically or metaphorically, as a painting, a poem, a song, a dance, a play or a story.

In view of this misconception about mind, we try and try to discard our creative mind, but it keeps filling us with visions of things marvelous to paint, write, or express, and we are swept away once more. Artists may see this as a failure because the Masters say to witness and dis-identify with the mind. We fail to see that the great Masters are not talking to those who have already seen this truth. To rise above the polarized mind is the only way there is to become creative. Therefore, creativity is, in and of itself, a spiritual path. One need only shift the perception that comes with the creative process to daily life in order to be on a coherent spiritual path. Creativity can be a celebration of having awakened, and the practice of offering that "awake-ness" to others through our art. As Paul Klee once said, "Paint, painter, paint."

I want to say at the outset that I’m not one of those nutcase skeptics who don’t believe in global warming. I believe it’s happening and it worries me. But I see no need for getting all worked up about limiting our carbon use as proposed by global warming alarmists. We can easily fix the problem with three solutions based on chemistry and mathematics.

Solution I. The buildup of carbon dioxide in the atmosphere has been linked to global warming. This has led to attempts to regulate carbon output. But carbon is not the biggest part of carbon dioxide. Oxygen is. Carbon dioxide is made up of one atom of carbon and two atoms of oxygen. Therefore, oxygen is twice as big a problem as carbon. The Periodic Table of Elements (even though it’s just a theory) claims the atomic weight of carbon is only 12, compared to a whopping 16 for oxygen. Using these data in sophisticated mathematical models shows that carbon makes up 38% by weight of the carbon dioxide molecule. Therefore, oxygen accounts for 100% – 38% = 62% of the global warming problem. So let’s stop trying to fix the wrong problem. We need to focus our attention on reducing atmospheric oxygen. One way to do this is to produce more humans, who will breathe in more oxygen. Another is to cut down more trees, which are putting oxygen into the atmosphere. We’re already doing a pretty good job at these two things, but more effort is needed. I’m optimistic we can do it. I’m not one of those the-world-is-coming-to-an-end kinds of people.

Solution II. The solution to taking care of that 38% of the problem that does come from carbon is ridiculously simple: sequester the extra carbon in human biomass. Humans are 18% carbon by weight. Multiplying that by 155 lbs, the average weight of an adult human, and by the 6.8 billion humans on Earth today = 95 million tons of carbon currently stored in human flesh, blood, and bone. The beauty of this solution is that humans are wildly expanding their numbers, gaining about 75 million people every year. By 2050, it’s estimated we’ll have 2.1 billion more humans, sequestering another 29 million tons of carbon. To make room for all these people, we must convert more natural areas and wilderness into prime human habitat; namely, subdivisions and malls.

But we can do even better. Encouraging the current trend toward obesity would help sequester more carbon per person. About two-thirds of Americans are overweight or obese. If all 305.6 million Americans were overweight, say 20% overweight on average, that would be 281 thousand tons of carbon more. We should ban all known agents of keeping people fit and thin such as diets, yoga, YMCA gyms, bike paths, and sidewalks. Make sure people have to use a car for commuting and shopping. Incidentally, it’s important that dead humans not be cremated. That turns human flesh into carbon dioxide, which defeats the whole purpose. By the simple procedure of injecting deadly toxic formaldehyde into their bodies and placing them in the good clean earth, their carbon will be sequestered eternally. Lastly, a little-understood fact is that short inter-generational times is a great way to increase the size of the human population. Not only should women have more babies, they should start having them at a younger age. Mothers by age 20, grandmothers by 40.

Solution III. The third way to solve the global warming problem has to do with anoxic areas of oceans. Anoxic means water that is devoid of oxygen for fish to breathe through their gills. Extensive anoxic areas exist in places like the bottom of Chesapeake Bay and the dead zone in the Gulf of Mexico. These areas are mostly caused by too much nitrogen from human waste and agriculture, which cause algal blooms, which suck up all the oxygen. Only certain kinds of slimy bacteria can live in these waters; all the fish go belly-up. But we can’t use emotional arguments just because animals are cute and have big doe eyes. We have to use science. Water is H₂O, so anoxic water is simply H₂O – O = H₂, which is the chemical shorthand for hydrogen, a very clean fuel. Let’s pump all this anoxic water (hydrogen) out of the oceans and use it as fuel in our cars and power plants. The more anoxic water we can burn, the healthier our oceans, so we should make cars and trucks that get even fewer miles per gallon of fuel than they do now. To keep this all sustainable, we’ll have to make more anoxic water. That should be easy to do just by making more humans (see Solution # 2). Do you see how everything on Earth is inter-connected?

An important side benefit is that sucking all that anoxic water out of the oceans would solve the problem of a rising sea level. Reversing sea level rise would give us new dry sea floor so we could constantly pack in more people. Right now, two-thirds of the Earth’s surface is ocean (interestingly, that’s exactly the same proportion as that of Americans that are overweight; must be some sort of magic ratio like pi). But we need to turn that proportion around. If humans are the favored species, with dominion over all other beasts, why did we get only one-third of the space and some of that frozen wasteland?

In closing, I’ve shown three ways how science and technology and unrestrained sex and eating can solve the global warming problem, one of the major crises of the day. My ideas are so obvious I’m surprised no one has proposed them before. Now I expect I’ll hear from the skeptics.

Choices in Ecology

Beyond the light of my desk lamp and computer screen, and the hum of my air conditioner, there exists a coastal hardwood swamp of great mystery. Though I live in the old settled East, not far from Providence and Boston, even closer to Fall River and New Bedford, my garden and lawn connect to a greenbelt teeming with wild life. Coyotes cry to the stars at night, hunt the deer in corridors of wet green, and raid sheep farms in town. Foxes visit my deck when it’s late and quiet, delicately feasting on sunflower seeds I’ve spilled for the birds. In daylight, red-tailed hawks float above the treetops, searching for rabbits and songbirds in the dense growth below. Sometimes eagles drift up there as well.

The life surrounding us appears as a matrix of information, presenting some events which fit our expectations, and others which do not. In order to focus on one set of relationships, we must exclude others. An ecological study of coyotes in my county must leave out earthworms; as a biologist friend wades the coastal waters collecting invading crabs, and examines their stomach contents to explore impacts on prey species, she ignores ospreys circling above, and mosquitoes grazing her ear. Choices must be made before the first hypothesis can be tested.

What then gets chosen? How are some species selected and highlighted? Why are others consigned to the background of scientific attention? These are aspects of ecology’s observer problem. We are used to such a concept in physics, where we understand that spatial and temporal measurements are relative to an observer’s position. And we may realize that in anthropology, the attitude of an ethnographer shapes interviewee responses. But we’re so accustomed to viewing familiar scenes of park or garden, or the turns of a local trail, as nature that exists with or without us, that we’re tempted to imagine all nature in such static pictures. What has this tableau to do with us? Wouldn’t it be the same whether we observe it or not? And shouldn’t it be possible to inventory all species present in such an elegant, well-ordered scene?

In their book, Toward a Unified Ecology, Timothy F.H. Allen and Thomas W. Hoekstra discuss what we might call an open secret at the heart of ecology. This is that a human observer determines what is recognized and studied, and in this sense valued. The same person who includes certain animals and plants within a frame of reference necessarily excludes other species from the framework.

In Physics, we recognize that measurements of the position and speed of subatomic particles are relative to the observer’s position. By contrast, Allen and Hoekstra write, “The things we study in ecology seem very real. Nevertheless, ecology is a science and is therefore about observation and measurement more than about nature independent of observation.”¹

Even at the grossest level of decision making, when the ecologist chooses what to study, that act influences the outcome of the investigation. When one chooses to study shrews, there is an implicit decision not to study everything else. In that implicit decision most other things ecological, such as trees, rivers, or ants, are excluded from the data.

Allen and Hoekstra remind us of the story that the entire army of Alexander the Great slept beneath a single Banyan tree. Is this true? It depends upon the observer’s viewpoint: the Banyan extends thin rootlets which touch the ground and begin to thicken and spread roots. Eventually they appear as new trunks. Genetically identical to the original tree, they become either its spatial extensions or an entirely new forest, depending upon one’s perspective. Perhaps for a biologist they would be a single tree, while for the army being sheltered beneath the many trunks and branches, they would be a forest.

These examples show that the concept of the observer’s position includes more than spatiotemporal location. It encompasses interests, needs, and a way of focusing attention. This way implies a cultural matrix, a language, and a community of investigators.

Every project proposed by developers rests upon a framework which includes implicit claims about which species matter. To the timber corporations of the American northwest, pine, fir, and cedar are interesting, while spotted owls are a nuisance. All our activities take place within frames of ecological reference; by attending to how ecologists, developers, planners and others specify these, we may learn to see our role as decision-makers about the ecosystems around us. After all, while local nature is ‘out there’ in an objective sense, frames of ecological reference are the stage sets upon which environmental debates are dramatically enacted. Scale within the framework is determined by grain and extent of the data. Grain determines how small the observed data will be, while extent determines their largest possible size in time and space. Scale in this sense is not about ‘the world out there,’ but is about our measuring conventions. Scientific stories are limited in this way, as are all stories.

Allen and Hoekstra point out that definitions are primary. Before we can discuss change, we must identify static frames of reference within which change occurs. (For example, if we study change for one year on a farm, we must first draw a line at the edge of the farm property, and another at the end of the year, and pretend not to notice what happens outside this zone.) But as the example about shrews, ants, trees, and rivers shows, specifying an ecological frame of reference always leaves much out, and hence is relative to personal/cultural observer positions. These choices of what to focus upon are subjective in the sense that other options exist initially, but once the choices are made the observations which follow are objective.

The Observer Problem in Conservation

Which species claim our attention determines what we see at a given place and time. The knowledge we eventually generate helps determine how others act there, and what environmental policies are adopted. A study of bears might bring hunters; a discovery of rare plants might halt development. If we ignore a species, its uniqueness may be lost in the ethos of change and transformation that grips our time.

Cultural and political interests are involved. Scientists often specialize in organisms which the wider society has blessed with funding: mountain lion, condor, elegant osprey. In these cases beauty and scarcity lead a biologist to describe a place, on a certain day, as the habitat of this creature alone. Selection of a few organisms from a rich matrix is necessary before ecological study can begin.

A parallelism holds in the field of conservation. Whether one looks at planet Earth from a satellite 40 miles high and sees exploding cities eating green space alive, or takes a drive around one’s own town and counts the white ends of plastic pipe (percolation tests for new house sites) it is evident that development continues rapidly. Conservationists can save less territory now because land prices have risen so dramatically. It has become critical to pick one’s battles. Out of the surrounding matrix of environmental problems, upon which shall I focus my energy and time?

Ecology and conservation arise within cultural and political situations. A complex weave of factors brings scientist or conservationist to subject and site. These factors will include society’s long-term interests in educating people one way rather than another, and local, shorter-term urgencies concerning bulldozers, chain saws, and the disappearance of species. Ecologist and conservationist, by professional custom, respond to slowly deteriorating conditions in the informational matrix. (Without this general situation their roles would hardly have arisen at all.) Within this framework, each project they undertake will address limited windows of opportunity for knowledge or protection. In short, they respond to dynamic, unstable situations, in which effective storytelling holds a key to success.

Both ecologist and conservation writer frame particular species within a limited region of time and space for a study. But whereas a scientist contrasts known factors (constants) with unknown ones (variables) in an effort to discover whether a specific relationship exists, a conservationist seeks to preserve or restore a status quo. This does not mean a no-change zone, where evolution is halted, but rather a slow-change zone, where humans interfere minimally with species relations.

Just what choices must be made before a slow-change zone can be responsibly defined? At a fairly abstract level, a common prime directive for conservation work is ‘protect diversity.’ This principle alone does not tell us what to do in a specific situation, because there are different kinds of diversity, and because reasonable people can disagree about strategy and tactics. But in its very generality, the principle ‘protect diversity’ may allow stakeholders in an environmental discussion to proceed toward an agreed goal. This convergence is part of the urgency conservationists feel about the world today; it is also connected to the words ‘conserve,’ ‘conservationist,’ and ‘conservative’: all arise in relation to a valued state of affairs in which diversity is threatened.

Proceeding from this common point, we must ask in any given case whether the best path is ‘hands off’ an ecosystem, or whether we ought to take actions to encourage some species and discourage others. Even small, unobtrusive actions, like filling a bird feeder with seed, or opening the door to release a cat for the day, have dramatic effects when combined with the similar actions of millions of people.

One way of describing this situation is to say that almost every part of the natural world is a landscape for somebody. And landscapes are cultural and political entities as well as ecological ones. As J.B. Jackson has put it, “A landscape is… a space deliberately created to speed up or slow down the process of nature. As Eliade expresses it, it represents man taking upon himself the role of time.”²

If we viewed Earth from the space shuttle we would be frightened by the spreading of cities. From an airplane over the American Midwest, one is amazed by vast fields of cropland — monocultures for food and profit. On foot, walking in parks or even wilderness areas, we respond emotionally to large trees with open vistas beneath — landscapes encouraged for their scale, which is to say our scale. Each approach to Earth reveals humans in control of nature, human time imposed upon, and altering the processes of, evolution.

When we think about what is happening to Earth as a whole, we recognize the need to plan conservation actions with several different timescales in mind. For example, ecologists distinguish three kinds of diversity: alpha, beta, and gamma. Alpha diversity means species diversity within a patch of land; beta diversity indicates diversity between several patches in the same area; gamma diversity indicates diversity on a regional scale, which includes many mosaics of land patches.

Clearly we need to know as much as possible about the gamma-diversity situation of species. Lacking this knowledge we might attempt to maximize diversity within a single patch, which might have reverse effects from the ones desired, because many species, such as deer, grouse, and crows, thrive on diversity within patches, and other species, such as the Florida Scrub Jay, can only thrive in relatively nondiverse plant communities, and then only in small numbers. So even though a patch of earth over which we have influence (like the woods and marsh behind my house) might be a tempting framework for a conservation plan, a wiser perspective would encompass my entire town and the watershed beyond.

Alpha, beta, and gamma diversity are concepts applicable to nature at many scales. Within these, choices must be made regarding grain and extent. Even then, once a region and its critical species are listed, the principle ‘protect diversity’ requires us to imagine different management strategies. In imagining policies for my wetland, differences appear depending whether I advocate for the deer or the coyotes, the rabbits or the foxes. From a logical point of view, an infinite number of perspectives on a single ecosystem are possible. This infinity of choices can seem bewildering, even debilitating. But this is true only if one clings to a simple model of nature and culture, or hopes for a simple metaphor like those which guided our ancestors, such as nature is divine order, nature is an organic creature, and nature is a great machine.

Every choice within ecology and conservation, just as those within development activities, requires creativity. Every action, and every restraint upon action, requires design decisions. This design ultimately includes physical treatment of land, but it begins with the writing process, where old metaphors are analyzed and new ones tried out.

Suppose I wish to make a narrow trail through the easternmost acre of my woods. Here the land is spongy and mossy, and the vegetation is dominated by Shad Blow, Haw, Holly, and shrub-sized bushes and trees growing in thickety profusion. A human can’t walk through most of this, and a deer doesn’t often choose to. If I cut a trail for my own exploring, and to draw the large mammals through, this will favor them but harm species which need shelter from them. Probably the deer, coyotes, foxes, raccoons, opossums, and neighborhood dogs have enough paths from which to invade tangles and swampy patches. In the past few years pheasant, quail, and woodcock have become scarce, and I’m sure members of these species would appreciate (if they could) my not cutting such a path. I reach for a new metaphor like home is foxless, to clarify a woodcock’s interests and to guide my action. Here I combine the connotations of home (the warm modern sense of which only arose in 18th Century Holland³), with ecological knowledge about a specific place.

Consider a habitat which includes ‘edge effects,’ as most do. This is a concept promoted in 1933 by Aldo Leopold as beneficial to wildlife, and widely adopted as a management strategy. Leopold thought junctures of fields and forests, streams and uplands, even trails and thickets, provide advantages to many species. This is true for some, but not for all. By defining ‘wildlife’ as ‘game species,’ managers often rationalized breaking up uniform habitats into diverse patches; more deer and grouse were frequently the predictable and desired result, but lost in this ‘edge effect’ planning were many unnoticed, non-game species.

If one imagines a boundary between habitat types, it may be tempting to think of this line as a ‘real’ feature of nature, but as biologists William S. Alverson, et al, point out, such a line can only be defined by the experiences of particular organisms. Nearness to the line will produce a range of events of varying intensity.

Ecological field studies sometimes record the number of times particular organisms approach such a line. From these data points, an ‘isoacme’ map can be drawn to show average intensities at the same average densities from the line. Such displays are different for each species considered. Perhaps this is a useful way of illustrating how differently each species ‘evaluates’ edge effects in its habitat. This underscores the critical importance of being chosen as a key species for a study. It’s unlikely that creatures omitted from study will have their interests considered in plans resulting from the study.

Species numbers are greater than we are accustomed to thinking. In the 43 year period from 1940-1983, five new bird species were discovered every two years.⁴ New species of mammals are now found at the rate of about five per year. Oceanic exploration for new life forms has just begun, bringing news of new whales and sharks, and deep-sea communities of sulfur- and methane-eating organisms. Biologist Terry Erwin and colleagues, working with associates in the 1970s studying rain forest trees, discovered each individual tree contained huge numbers of anthropod species, the spiders—and each tree contained unique species. Extrapolations from his data have led to estimates that the undiscovered anthropod species on Earth number from five to 30 million.

If we turn to smaller organisms the surprises are even greater. Studies of bacterial DNA in a single gram of beech-forest soil in Norway turned up between four and five thousand species. Examination of a gram of soil from the shallow seas off Norway’s coast revealed an equal number, but virtually all of them were different from those in the forest sample.

These examples remind us that Earth’s biological diversity is largely unknown, and that we miss whole realms of life by operating within many of our ordinary frames of reference. It’s not only beetles and spiders that go extinct through massive rain forest burning — cases we hear about but may find emotionally distant. What about the newly discovered life forms around oceanic vents? Are these impacted by ocean dumping? What of the new bird species discovered every year? Are we destroying their habitats before we see them?

Birds are often omitted from our ecological planning considerations because of their migratory habits. We know that continued suburban development destroys habitats and encourages predatory species like Bluejays, Brown-Headed Cowbirds, and Seagulls. Small, beautiful warblers are often the losers as ‘edge effects’ spread across the planet. Yet birds receive little consideration in many planning decisions, simply because they ‘pass through’ and their relation to a particular site may be difficult to establish.

All this indicates that every choice of an observer’s position is fraught with consequences. And yet without such a choice there can be no observations, data-gathering, theorizing, or planning — for development or research or conservation. Once an ecological frame is chosen, and specified in both extent and grain, a discussion can begin about appropriate goals for this part of the natural world. And eventually diverse goals can find their way into a plan. But plans never spring from a void. They arise in response to threats and opportunities for conservation. Selecting a frame in space, including valued organisms within it, leads directly to concern with time — both the time of evolution past, which produced the place, and the cultural time which affects it now.

The next question is what target event the conservation writer has in mind. Sometimes this will be a vote (in a small community, a congress, a parliament, or another organization); at other times it will be an executive policy decision. Such pivotal moments determine whether ecosystems are protected or lost. Conservation work, like science, requires that a writer frame a region of space-time (extent), specify entities within that region (grain), and point to events projected into the future. For science, the effort is to observe these events; for the conservation writer, to influence them. (This is simplistic, of course: conservation biology as well as conservation writing require both descriptive and prescriptive components.)

The observer problem is a purely formal one: any story must begin with a specification of what is to be talked about, and with exclusions from the discussion. This means that conservation writers, like ecologists, must make choices before they can begin their work. Sometimes these involve ethical and aesthetic commitments, and always they involve practical and cultural commitments.

Choosing Landscape Values

In A Sand County Almanac, Aldo Leopold proposed that we extend ethical thinking and action from fellow human beings to nature. “An ethic, ecologically,” he wrote, “is a limitation on freedom of action in the struggle for existence.” Limiting our activities for the sake of other species, and their habitats, he called “a land ethic.” When Leopold wrote these words they sounded strange, but some sixty years later many people embrace the idea. In our wetlands and woods, in our gardens and ponds, we take pleasure in restraint to protect nature.

The land ethic is widely embraced, as is the land aesthetic — guiding our efforts to promote landscape beauty. Yet these are only the starting points of land protection activities. How do we make practical decisions about when to leave a site completely alone, and when to introduce mowing or planting, for example? And what happens when the needs of different species conflict — how can we choose between them?

Cultural Values

When management strategies like mowing, thinning, and stream-clearing are undertaken for aesthetic goals, one must choose the historical moment whose ‘look’ is sought. Consider two brief cases which illustrate this:

On Cape Cod, state park rangers needed a policy and management plan to protect a new acquisition for the park system. The landscape included fields, woods, and several historic houses. Planners chose the date of origin of a single one of these houses, then sought to make the surrounding landscapes conform to the way they had looked in that period. It wasn’t possible to preserve the landscape aesthetics of all the houses; the attempt to do so would have resulted in a patchwork of views and ecological states lacking coherence. As Elizabeth R. Lehr has pointed out⁶ by selecting a single period for guidance in landscape practices, the rangers achieved a measure of ecological and aesthetic unity. This example shows how historic preservation is subtly entwined with, and often guides, nature conservation.

Consider the Boundary Waters Canoe Area Wilderness in Minnesota. Some areas of this park are maintained so that a canoeist may glide along beneath huge trees with an open understory. To the uninitiated, this experience seems to touch ‘true wilderness.’ But actually management practices have created and sustained the forest in this ‘climax stasis’ condition; it mimics the ecosystem and aesthetics of the historical moment when European fur trappers first contacted the indigenous people of the region. The forest is magnificent, visually satisfying, and offers the visitor a sense of travel back in time to an unspoiled day. Although reserve designers made a good choice in their historic date for landscape practices, their cleverness in erasing subsequent history — power lines and cleared fields, for example — might tempt the visitor to imagine there was no previous history. In other words, the canoeist might believe these park-like forest banks embody a natural ideal which persists indefinitely. In the 18^th Century and before, they were probably shaped by Native Americans through seasonal burning.

When one first embarks on a land conservation project it is tempting to imagine one is saving nature ‘as it ought to be.’ But usually this goal includes an aesthetic component —nature ‘as it ought to look.’ And the first question is: When? Any answer involves cultural history. This, in turn, requires choices: not every moment of past succession, or landscape configuration, can be represented.

An important part of the conservation task is historic preservation; to achieve this consistently, one must choose a date and manage for the ‘correct look of that history.’ Such choices shouldn’t discourage us. They are part of the creative challenge of conservation, and they give us a meaningful role to play in the unfolding of nature.

Natural Values

Some conflicts cannot be evaded. For example, recently Massachusetts land managers had a painful choice between actions to support seagulls or piping plovers. A ‘no action’ policy would support the gulls.

Similarly, in western Massachusetts, managers had to face the fact that domestic dogs were killing numbers of deer. ‘No action’ would have supported the dogs.

With regard to any piece of property one can choose:

1. to make the needs of a single species paramount (e.g., an endangered species);
2. to craft policies which will favor several species, ranked in a particular order;
3. one may attempt what is called ‘integrated management,’ in which one seeks a rough balance of (a limited number of) species needs, without selecting any one of these for special treatment;
4. one may treat a parcel as a baseline in a scientific study, which means it must be left alone, no matter what happens. While this sounds attractive and appeals to our ‘pure wilderness’ desire, in reality it means never compensating for natural events we dislike, such as devastating invasions of exotic species, windstorm damage, and fire.

Just as in the case of cultural values, the stewardship of natural values requires choices.

States of Nature versus Rates of Change

Early in this century ecologists came to believe in the idea of forest succession: that every forest goes through stages until it reaches a grand ‘climax’ state. This idea was applied to all sorts of ecosystems, with the result that each one was believed to have a proper, final, long-lasting, and most favorable stage. It became the goal of conservation to identify and protect such climax states of nature.

Recently ecologists have realized that much of the focus on preserving climax states was really driven by aesthetics, as in the case of the Boundary Waters Canoe Area discussed above. In the real world, climax states change eventually, perhaps in response to hurricanes, fires, earthquakes, volcanoes, diseases, or invasion by exotics; they often shift dynamics, restarting the clock and beginning a new succession, in response to influences like bulldozers and chainsaws.

What this means for conservationists is that we should protect slow rates of change, rather than no change at all. We need an historical account of each parcel including intelligent guesses about where it will trend with, and without, our interventions. Our goal should be wise stewardship of slow rates of change. Toward this understanding, some land trusts have begun to compile histories for the places they protect.

The Grand and the Pretty

In her 1997 book Placing Nature, landscape ecologist Joan Iverson Nausauer discusses the need for conservationists to appeal to aesthetic tastes and principles shared by their audiences. Americans are deeply committed to two distinct ‘looks’ for the natural world, which Nausauer calls ‘grand’ and ‘pretty.’ Grand landscapes feature broad rolling green fields framed in the distance by tall trees. They mimic 18th Century English estates, the sort designed by Humphery Repton and Capability Brown. Such landscapes, beyond the financial reach of most citizens, grace campuses, parks, golf courses, and grounds of the wealthy.

The other ideal, ‘pretty,’ lies within everyone’s grasp. This is the look of a small but carefully tended lawn, garden, or window box. The pursuit of such landscapes often leads to faithful mowing, weed whacking, pruning and raking.

Two common features should be noted about these styles: first, they express care for nature, and signal that their owner is a careful person. We’ve all heard stories about people who ‘let their place go’ — refusing to mow, or make other concessions to a community’s customary look. Despite good intentions, say to provide habitat, in the end such people are regarded much like those who never cut their hair. They lose their place at the table of community conversation about how landscapes should be treated.⁵ In order to have standing to contribute to decisions about landscapes, people must signal, through their treatment of nature, key facts about themselves.

The other common feature of these two styles, grand and pretty, is that they can enhance, or destroy, environmental values. That is to say, neither style is inherently good or evil, from a conservation perspective. To decide whether our gardens, lawns and woodlots, in conforming to these aesthetic ideals, are helping or hurting species, and encouraging a particular balance of nature, requires careful attention to each site.

When we appeal to our neighbors for a certain look for a conserved landscape, we will have deeply-rooted culture on our side if we cast our argument in terms of one of the dominant styles. If we can find a way to combine either, or both, with such practices as leaving some areas entirely alone, audiences will feel more comfortable.

Conclusions

These are some of the kinds of information one needs to form clear and consistent conservation goals, strategies, and management plans. Not to discuss such matters leads to ‘no action,’ which of course is an action — one which supports current trends, whatever they are.

We might approach each parcel in two stages: the first to gather information of these kinds, and the second to discuss and choose goals, strategies, and plans. Ideally, we need information from many sources, such as neighbors of the property, oral histories of the town, stories from hunters and fishers, and so forth. We also need the perspectives of professional ecologists, biologists, landscape planners, and others.

Initially, each stage might be approached thus:

Stage One

1. Describe the place at landscape scale (that is, the way it appears to humans):
   1. Include natural features, such as landform, species, and tree of life information;
   2. Include cultural features, such as agriculture, stone walls and buildings.
2. Give the history of the place.
   1. Include human factors, such as farming uses;
   2. Include non-human factors, such as plant successions;
   3. Describe rates of change for species in the past.
3. Describe conflicts:
   1. Between species;
   2. Between other species and the human species.
4. List possible land stewardship goals, such as:
   1. Management for a certain stage of nature (through annual mowing or flooding, for example);
   2. Management to encourage a particular succession;
   3. Management to encourage a particular rate of succession;
   4. Prioritize goals, such as:
      1. Aesthetics for human pleasure;
      2. Single-species benefit;
      3. Multiple-species benefit in ranked order;
      4. Mixed-species integrated and equal benefit;
      5. ‘No action,’ as part of a scientific baseline study.

Stage Two

1. Discuss the state of our knowledge; decide whether we need additional data, or can make provisional decisions. If we need data, plan for these with a timeline. Project the consequences of no action, and of several practical actions.
2. Choose goals, strategies, and management plans. Set a date at which to revisit these decisions in the light of new data.

All this takes time, and many of us have to make decisions about our landscapes without the rich information we desire. But no matter how much information we have, creative decisions will be necessary. The process which leads to conversations and decisions must begin with a point of view from which a story is told. That point of view selects the grain (smallest units in space and time) and extent (largest units) of the part of nature in question. This is a purely formal requirement of both science and storytelling, and thus of ecology and conservation. Once the domain, or informational grid, of the place is specified, both science and storytelling about cultural values have roles in filling in detail. In order to rationally apply a land ethic or a land aesthetic to a particular place, historic and current patterns of species coexistence there, as well as historic and current patterns of cultural valuations there, must be specified. Much of this information, such as the alpha, beta, and gamma diversity, and the valuations expressed in historic land use patterns, is objective. Yet underlying the entire conversation, from the first description to the last vote, are issues of viewpoint and choice. ‘No action’ is a choice to favor current trends, so it isn’t really no action at all. Writers and other citizens can influence the outcomes of conservation decisions by gathering the science and cultural history of a place, then using appeals to values like the grand, the pretty, and the protection of diversity to influence actions and policies. Opposing cries of “sacred nature” versus “relative values” oversimplify matters. Writing and speaking from within one’s considered point of view, in a manner which celebrates what is there in both natural and cultural senses, can gently persuade others. That is how Henry David Thoreau, John Muir, Marjory Stoneman Douglas, and Rachel Carson changed the world.

This piece is adapted from Luke Wallin’s Conservation Writing: Essays at the Crossroads of Nature and Culture, published in 2006 by the Center for Policy Analysis; to download or order this book please see http://www.lukewallin.com/cwriting.htm. Wallin teaches in Spalding University’s brief-residency Master of Fine Arts in Writing program.

¹ Allen, Timothy F.H., and Hoekstra, Thomas W., Toward a Unified Ecology, NY: Columbia University Press 1993.

² Jackson, J.B., Discovering the Vernacular Landscape, New Haven: Yale University Press 1984.

³ Rybcinski, Withold, Home: A Short History of an Idea, New York: Viking Penguin, 1985.

⁴ Alverson, William S., Walter Kuhlmann, and Donald M. Waller, Wild Forests: Conservation Biology and Public Policy, Chicago: Island Press, 1994.

⁵ Pollan, Michael, Second Nature, New York: Grove Press 2003.

⁶ Private communbication wih the author.