UNC is still a force for good

I have an op-ed in the Raleigh (N.C.) News and Observer today that is reproduced below.

By Donald H. Taylor Jr.

Carolina was the only college to which I applied while a student at Goldsboro High – UNC-Chapel Hill was my dream school.

When I arrived, I was interested mostly in not living with my parents, enjoying newfound freedoms and pretty girls. Four years later, I was passionate about health policy and on my way to graduate school (also at UNC) and a career as a professor.

UNC-Chapel Hill changed my life in ways that were unimaginable the day my parents dropped me off at Winston dorm. That has always been the promise and the reality of Carolina. However, I fear that the difficult budget situation of our state, and the choices that could be made by our General Assembly going forward, could jeopardize the realization of that promise for students in the future.

 I have been deeply embarrassed by what I have read about my alma mater over the past two years. Whatever has happened that is wrong needs to be laid bare, and strong plans made to ensure the same mistakes are not made again. I very much affirm Holden Thorp’s commitment to making things right during his remaining time as chancellor and accept his decision to step down at the end of this academic year.

My biggest fear is that these scandals will be front and center in the minds of the people of North Carolina when the General Assembly has to make the truly difficult budgetary decisions facing our state. It is tragic that the headlines of late have not been of the incredible things that UNC does – both for its students and the state as a whole.

I am fearful that we will essentially “eat the seed corn” instead of making the continued investment necessary to maintain a world-class research university that educates our children while also making discoveries that help the people of North Carolina, the United States and the world.

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It is an expensive endeavor to maintain a research university like Carolina, but it is worth it. Further, given recent budget cuts, the next few years are particularly crucial in maintaining the school’s excellence, and it would be far more expensive to try and rebuild later if we reduce our short-term investments. Our strong university system (all of the campuses) has figured mightily in helping make North Carolina a leader in the South, and it can lead the way to the future.

I would like to say thank you to all the people of North Carolina who have paid taxes to support our state’s great public university system, especially those who themselves did not attend these schools. I join you in expecting that this season of scandal will end, and that the many stories of the good being done by the students and faculty at Carolina will move back to the fore, where they belong.

Donald H. Taylor, Jr., associate professor of public policy at Duke University, holds three degrees from UNC-Chapel Hill. He blogs at www.donaldhtaylorjr.com.

RIP Neil Williams

Neil Williams, Chair of the Board of Trustees of The Duke Endowment died unexpectedly on Sunday Aug. 26, 2012. A memorial service will be held on Thursday Aug. 30 at 11am in Atlanta.

I met and interacted with Mr. Williams in my former role as Director of the Benjamin N. Duke Scholarship, a program that focuses on getting the best and brightest future leaders from North and South Carolina to attend Duke. Mr. Williams grew up in Charlotte and was a Duke grad, so he had great interest and insight into our recruitment goals and challenges as well as our efforts to encourage young leaders. What I most appreciated about Mr. Williams was his direct and frank manner, delivered from a countenance of his love of Duke.

Taking a blog break ~Aug 1

I am leaving tomorrow with my boys (ages 15 and 11) and my dad for a 2 week trip to Sequoia, Kings Canyon and Yosemite National Parks and then some time in San Francisco. Planning to go fairly far off the grid….the blog will pick back up around August 1.

Travelling the rest of the week

so posting may be light after one this afternoon on corporate tax reform.

If You Knew Suzy

The post below appeared on October 24, 2010 in my old blog. We read the book described, If You Knew Suzy last week in my Introduction to the U.S. Health Care System course, and used it as a lens through which to view the entire semester so far. I highly recommend it.

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If You Knew Suzy: A Mother, A Daughter, A Reporter’s Notebook, by Katherine Rosman, Harper, 2010. ISBN#978-0-06-173523-3. Amazon link. Less of a book review and really more of an encouragement to read this book….

If You Knew Suzy is a beautiful book, that is also important. These two attributes don’t often describe the same book for me. By beautiful, I mean that it is well written and tells a story that drew me in, and touched me deeply. If you can read this one and not cry, there is something wrong with you. It is important, because it provides an honest glimpse into the health care system of the United States, or more accurately, into the system of how care is provided to persons who are said to be ‘dying.’ Expectations, hopes, fears and realities are all described as they occur, often in disturbing detail, and with an honesty that I can only describe as ruthless, and appreciated. The book is at the same time funny and irreverent.

This book is worth reading for its beauty alone, but you would then be avoiding the many profound questions raised in this book about the how, where and why of our health care system; especially care provided to persons with advanced life limiting illness. If you bring to the book pre-conceived notions of how people should react when facing their own mortality, or a situation that seems ‘hopeless’ the book provides an important reminder that people are distinct, and don’t fit into neat boxes or roles. At the same time, the individual decisions each of us make affects all of us when it comes to health care decisions, both on the macro level as well as what our choices imply for our family and friends.

I met Katie Rosman in May, 2010, when she came to Duke University’s Institute on Care at the End of Life to give a presentation about her book to a group of providers and advocates for end of life care. This is a round table, blue ribbon type of group that is seeking to advance the research basis of end of life care and to promote better policy. From different perspectives, the participants are mostly interested in improving the quality of life of persons who are suffering.

Into this group, with much experience in the reality of dying and how care is provided just before death, Katie managed to bring a fresh voice, the story of her mother’s death from lung cancer. While her story and this book provides glimpses into the medicalized world of an ICU and interactions with physicians and nurses–some good and some bad–the story of Suzy’s death (Katie’s mother) is told as a part of her life.

The occasion of her mother’s illness and death motivated Katie Rosman to investigate chapters of her mother’s life about which she had not known a great deal. And it seems that in her mother’s death she seems to come to know her mother much better. Intertwined into the story of the decline of her mother’s health and and the families attempts at navigating the health care system are glimpses of Katie’s childhood, her relationship with her sister, father, stepfather, and mother all told to honor the memory of her mother and to preserve it for grand children that will never meet Suzy.

As a person who spends quite a lot of time thinking about policy related to the provision of hospice and palliative care, and who believes that our culture is profoundly bad at having honest and thoughtful discussions about the limits of what medicine can do, there are all sorts of lessons that could be drawn from this book. Bashing off a list of policy changes that I was for before I read the book and claiming the book proves I am right seems inappropriate. I will just leave it where I started: If You Knew Suzy is a beautiful, and important book.

A pharmaceutical story

About 2 years ago, the health insurance that Duke University provides to employees instituted a mandatory policy that you had to use a mail order pharmacy for recurring medicines, or pay a very large penalty (on the order of $100/prescription). So, I switched the one pharmaceutical I take to this service (Fexophenadine 180mg/once per day [generic for Allegra, a seasonal allergy medicine]). I could obtain a 90 day supply of Fexofenadine for $20 via mail order under this year’s benefit structure.

When I went to fill this prescription a few weeks ago, it was denied because Allegra is now available as an over-the-counter medicine. The other day I went and bought a 90 day supply of the medication, but could only find name-brand Allegra. I bought it from Sam’s Club and it cost $32.50, a great deal more than the generic did as a prescription medicine (found OTC Allegra at several other places for a higher price). I did not find generic Fexofenadine 180/mg per day anywhere.

Is this unusual? Was it just Allegra brand name that is available over the counter? Is it typical for the price of newly-over-the-counter meds to be higher than their prescription generic price under insurance? Or does this just mean that Duke has very nice benefits? Obviously the mail order company will receive volume discounts. Will the generic brands also sell over the counter? Can they?

Walking to work

I walked to work today, as I do about once per week.* It takes me around 40 minutes, a nice head-clearing trip. The first 10 minutes are on the shoulder/ditch of a busy road that I wouldn’t let my 10 year old walk along, but I am comfortable doing it (Cornwallis road between Old Erwin and 15-501 in Durham, N.C.). The rest of the walk is on a nice wooded trail and then across Duke’s campus.

The odd thing is that 3 people whom I knew stopped and asked me if I needed a ride today as I walked. This was very nice of them, but it seems to show that purposefully walking to work is largely unimaginable. All of them asked as I was on the busy road, so maybe if there were a proper walking trail or even bike lane it would have seemed more normal. Something is wrong with this story, probably including my reason below for why I don’t walk to work more often.

*the reason I don’t walk to work more often is related to off campus lunch appointments and what I have to do at the end of the day, namely drive numerous carpools to various sporting practices for my three kids just as work is ending. The carpool issue is really the binding constraint.

The economics of barbecue

On Saturday, Ezra Klein tweeted:

ezraklein Heading to north Carolina outer banks. Any recs for barbecue along the way, particularly NC style?

I answered immediately, both with what I understand to be true, but also with a bit of snark:

donaldhtaylorjr .@ezraklein no such thing as ‘NC’ style BBQ. Eastern NC BBQ (vinegar sauce) is awesome; Western NC BBQ (tomato sauce) is tragic

I even offered my opinion that Wilber’s Barbecue in my hometown of Goldsboro, NC serves the best barbecue around in a follow up tweet, though it is around a 4 hour drive from Goldsboro to the Northern Outer Banks, so it was a tip that was not of much practical good to Ezra. Jim Hufford, a great health policy/law blogger chimed in to agree with my assessment that Eastern NC style barbecue (vinegar-based sauce) is superior to that served in the Western (tomato based sauce) part of my fair state. However, he actually really prefers mustard-based barbecue sauce to either vinegar-or-tomato-based sauce, agreeing with Seyward Darby, online editor of the New Republic who got in on the game (she went to Duke and is from Greenville, N.C., also east of I-95), who tweeted in response:

seywarddarby @donaldhtaylorjr tomato done really well can be great — but you can’t go wrong with vinegar. My fave tho is mustard-based, down in florida.

I am not going to try and adjudicate which of these types of barbecue is truly the best, but instead ask, why do many people seem to care so much about barbecue? I believe the answer lies in the economics of pigs, especially in the agrarian South of years past.

I spent my summers starting around age 10 with my grandparents in Snow Hill, N.C., the county seat of Greene county, just up the road from Goldsboro. The main industry in Greene county is agriculture, and I worked harvesting tobacco and tending to pigs on the farm of a cousin each summer until I went to college, while staying with my grandparents.

Almost all big occasions in this community are marked with ‘pig pickins’, events in which whole pigs are cooked slowly (all day) over wood coals, and then individuals ‘pick’ or get what they want from the carcass of the pig after it is finished. Barbecue is a chopped mixture of multiple parts of the pig (tenderloin, ham, shoulder) that one would get in a restaurant. A pig pickin allows for self-serve barbecue. The tradition of the pig pickin is a profound cultural icon in Eastern N.C., held to mark notable events.

I can vividly remember two pig pickins at the home of my grandparents: one to celebrate the wedding of my mom to my step father, and the other to celebrate the life of my grandfather, the afternoon after he was buried. The menu for the two events was exactly the same, but the purpose for the gathering was not. Why the pig pickin?

I think it has to do with the economics of the ‘cull hog.’ A cull hog is a pig that develops a problem that decreases its desirability as it is being ‘topped out’ or grown to a size to take to market to be sold for slaughter (about 180-200 pounds is optimal). When something is wrong with such an animal, such as having an injured foot that would cause a noticeable limp, or having a bulging hernia, it greatly reduces the price that an animal can be sold for at auction. I can remember my grandfather pointing out a hog with a hernia one day when we were loading animals to take to sell at market and saying we would save that one for a pig pickin he was going to hold to celebrate my grandmother’s birthday in a few weeks time. Because the price that could be gotten for such an animal was so low, it made it much easier for people to have large feast celebrations on momentous occasions. And if you raise many pigs, some of them will be such cull hogs, so there will be a steady supply of such cheap animals. And access to such pigs was relatively easy in the past, so many people could get and afford to buy such a pig because the price that could otherwise be obtained for them was so low. Even 30 years ago, there were few people who lived in this general area who didn’t have some connection to a farm, and 100 years ago this would have been even truer. And one 200 pound hog would yield a dressed carcass that weighed ~ 140 pounds that would yield around 45-50 pounds of edible meat, easily feeding 100 people or more. If even 1 in 5 of the 100 attendees brought a side dish or a dessert to share, you had a feast, for a relatively low cost.

Interestingly, Austin wrote yesterday about his move toward vegetarianism, or at least toward a much more sustainable (smaller) level of meat consumption. His notion actually lines up in many ways with an agrarian lifestyle/economy that would hold a pig pickin for a momentous occasion. The health problems associated with meat consumption do not come from attending a pig pickin to celebrate weddings, births or to commemorate loved ones at times of death; the problem is the over-consumption of this food in large quantities as a matter of normal course. Especially for people who sit at desks for their work. In fact, I recall many meals served me by my grandmother that were functionally vegetarian: tomato sandwiches when the garden had many tomatoes, with cucumbers and onions soaked in vinegar, collard greens (cooked with a small bit of pork which is why I say functional vegetarian) and cornbread. Or Chicken stew with a small amount of chicken but large amounts of cooked pastry (flour) and broth, again served with bread. Meat was not consumed in large quantities at every meal because of the cost of eating animals was high, especially ones that could otherwise be sold for money.

I think feelings are so strong about barbecue because feasts around pigs were infused with meaning since they represented shared experiences with loved ones and friends in both good times and bad. So these meals of both celebration and lament, centered around cooking a pig, became culturally meaningful in a way that make me interested in disagreeing with others about the best type of sauce to put on your barbecue. Because these events are important, it makes the way barbecue is prepared and served, important. Even if you are many generations away from a farm, I suspect this is the basic reason that many people have such strong feelings about barbecue.

update: a small amplification

Tom Ricketts-Tar Heel of the Week

The Raleigh (N.C.) News and Observer has named Tom Ricketts, Professor of Health Policy and Management at the UNC School of Public Health, and Director of the Rural Health Research Program and Program on Policy Analysis at the Cecil G. Sheps Center for Health Services Research at UNC, as its Tar Heel of the Week. Tom was named to the Workforce Commission that is held up in Congress that I wrote about a few weeks ago.

I would be nothing without Tom Ricketts, certainly not a tenured Professor at Duke, nor writing on this blog. I owe him a great deal. When I was a sophomore at UNC in 1988, I took a class in Intro to Health Policy that changed the course of my life. It was taught by Tom, while he was still a graduate student. I was a reasonably good student, but one who was a bit unfocused. By the end of that class, I had a growing interest in health policy. Tom then hired me as as a photocopier–I went to the library and copied papers for him, but I also started to read some of them and to ask him questions. He took the time to answer the questions of a 19 year old and to encourage me when I am sure he had better things to do.

After my first year in graduate school in the MPA policy analysis program at UNC, an internship I had fell through, and Tom gave me a job working on a research project evaluating a program designed to expand the supply of OB/GYNs in rural North Carolina. This cemented my career focus and I moved into the Ph.D. program in Health Policy and Management, working with Tom for 4 years until I finished my degree. He was my dissertation chair and would appear at my office with approved chapters saying ‘this no longer depresses me; good work.’  (he didn’t want me to get the big head)

If I had to sum up the way Tom treated me from my Sophomore year all the way through graduate school, it would be that he believed in me before there was evidence that such faith was warranted.

So, in Fall 2011, I will again teach Public Policy 111, Introduction to the U.S. Health Care System at Duke, a survey designed for Freshman and Sophomores. It is easy to forget that the little things are sometimes big things, but I will try and remember. Tom did and does. Thanks Tom.

Spring Break

I am with my wife and 3 kids in Orlando for the week. Despite my best intentions, I have not followed up on several of the comments to my post on Friday about financing medical education. I plan to get back to that topic in the following weeks, and will integrate several of the ideas emailed to me, as well as try and pull in the perspective of those leaving comments (like Tom Ricketts from the UNC School of Public, who was not only my dissertation Chair, but the person who got me interested in health policy as an undergrad at UNC). However, I am not going to do it this week. As my lovely wife (of 19 years!) Martha said today at lunch, “you don’t have anything so clever to say that can’t wait a week.”

Indeed.