Medicine’s Next Frontier?

I just finished reading a collection of essays by a forester from Hümmel, Germany, outside of Cologne, titled The Hidden Life of Trees.  That could be a good title for a parody, but Peter Wohlleben is an earnest forester with an urgent message. He’s the first to make me believe that trees are social creatures.  And he taught me that much of the interesting life of trees takes place underground.  No wonder it’s hard to believe that trees in forests develop a symbiotic relationship with an elaborate web of fungi through which their roots communicate with the roots of other trees and share nutrients—dubbed the “wood wide web.”  It’s enough to make me think I should throw away my chain saw.

Isn’t it impressive how much time we can spend around trees without understanding one of the most basic aspects of tree life—that they are social creatures that have evolved elaborate ways of depending on each other? We know this about people and animals.  Why should it be different for trees?

This book resonates with another book I’ve been thinking about, the one I’m trying to write.  My working title, The Healer’s Blind Spot, tells you that it too is about the hidden life, in this case the life beneath the turf of our awareness where stress gnaws like a beetle infestation at the roots of our health.  The humble forester spent his career tending to one forest in central Europe, and I’m one clinician who has tended to my group of patients in the Midwest of America.  I too think I have an urgent message for the world about the hidden life.

The National Institutes of Health once declared the 1990’s would be “The Decade of the Brain.”  Before then the brain was beyond the frontier, something few of the best clinicians claimed to understand. Of course it took more than a decade, but now we can see the brain in action and we know the brain, at least the basics of how it works.  The brain was the last major organ to be mapped in detail at multiple levels of understanding, a bit like exploring our last major continent.  In my lifetime before the brain, modern medicine declared the frontier was the heart and then cancer.  In my parent’s generation the frontier was infections, antibiotics, and vaccines.  Imagine life and modern medicine without an understanding of the hidden life of microbes, the heart, cancer, and now the brain.  It’s hard to appreciate what we don’t know until we can see it.

Now that the major organs have been explored, what’s the next frontier for modern medicine?  After mapping the surface of the world, we can only go out or in.  “Out” for medicine could mean exploring out from the individual person to the social and environmental dimensions of health, a bit like exploring our place in the universe of people and environments.  How does group behavior affect individual health through families, teams, institutions, neighborhoods, and prisons?

“In” could mean exploring more deeply the genetics and epigenetics of health and illness, but we’ve already crossed into that frontier.  We’ve mapped the human genome and are starting to understand how it works.  Clones for humans are threatening and a few tantalizing clinical benefits of epigenetics are just beginning to reach the common press.

Another inward frontier that is currently harder to see than genes is the nether world of the stress response system.  This system is the ancient orchestration of our major organ systems that evolved to allow us to respond to challenges in ways that are so quick and automatic that we don’t have to think or be aware of them.  The blink of an eye, the jump in heartbeat, the flinch, the crouch, the sudden sweat—that quick, that automatic.

I saw this frontier with a new clarity a few weeks ago at a conference for psychiatrists in Orlando while attending a talk by Curt LaFrance, MD, about “functional neurologic disorders.”  The term “functional disorders” refers to a group of illnesses or syndromes that cause substantial suffering and disability but don’t fit our current measures and notions of pathology. Every specialty has at least one functional disorder, and they’re usually regarded as the orphans in the specialty’s family of illnesses.  About 5-10% of visits to these specialties are for these functional disorders, so it’s hard for specialists to ignore them, if they’re inclined to.

In neurology it’s psychogenic non-epileptic seizures and functional tremors.  In cardiology it’s atypical chest pain.  In rheumatology it’s fibromyalgia. In gastroenterology it’s irritable bowel syndrome.  In psychiatry it’s somatic symptom disorder.  Most specialists and primary care clinicians regard these disorders as orphans because they don’t fit our trained ways of thinking; they don’t reveal themselves through standard diagnostic measures; and they don’t respond to the traditional and most remunerative treatments so cherished by each specialty.

One of the themes of my book is that most doctors have a blind spot for the role that stress plays in our most common chronic illnesses such as diabetes, heart disease, and obesity.  When LaFrance flashed a slide with a table of the specialties and their functional disorders, I recognized that table as one I’ve seen many times.  But this time I saw it through the lens of this book I’m working on and asked myself what these functional disorders share in common.

The first answer that came to me was treatments.  In spite of these disorders being treated in very different specialties in a variety of ways over the years, they’re all now most effectively treated with various combinations of a) cognitive behavioral therapy, b) graded exercise or physical therapy, c) antidepressant or antianxiety medications, and d) meditation or relaxation techniques.  These are not the usual tools for neurologists, cardiologists, rheumatologists, or gastroenterologists.

The second answer that came to me from the realization that functional disorders respond to a common set of treatments was that these functional disorders share a common mechanism, a chronic dysregulation of the stress response system called autonomic imbalance.  This simply means that for too long their autonomic nervous systems have been overactivated or hyperaroused, with too little time resting or relaxing between activations.  The sympathetic nervous system is too active while the parasympathetic nervous system, which promotes rest and digestion and tissue repair, has not been protective enough.  Like an infestation of the tree’s roots and the fungal web that feeds them, autonomic imbalance destabilizes us at our roots. This condition of autonomic imbalance can be traced to many of our corrosive habits of modern life: ruminations and worry, cheating on sleep, physical inactivity, artificial stimulants, noxious diets, excessive work hours, clinging to unsafe relationships, and social isolation.  If we strain our stress response systems long enough and relentlessly enough, they falter into these disabling syndromes which we euphemistically call “functional disorders,” or diseases that are easier to diagnose, like diabetes, depression, and heart disease.

But most clinicians, even good ones, are not in the habit of thinking about the stress response system.  The stress response is invisible to us in part because we don’t have standard measures for stress in the clinic.  We don’t see the stress response system because most of the stress response occurs deep in the subconscious mind and deep in the organs we can’t see or often feel until we’re in big trouble.  We see and feel the trouble when it’s too late, after the diagnosis of a heart attack or the prescription of insulin for diabetes.

Our current understanding of our bodies and our health is like our current understanding of our global climate.  To explore the deeper oceans of our subconscious mind and our stress response system, we will need new ways of studying them and analyzing what we find.  Detailed monitoring of multiple organ system responses to multiple daily challenges across many people, often called “ecological momentary assessment,” will provide the kind of big data needed to make sense of the mysteries behind how toxic stress makes us ill.  Climate science is a big data challenge.  So is stress science.  Only in the last decade has it become possible to apply these new big data analytic approaches to understand the complexity of the stress response system in your lifespan or mine.

Imagine what that frontier can reveal to us about the hidden costs and benefits to our health of childhood trauma and prayer, unsafe neighborhoods and a belly-laugher joke, an abusive spouse and an easy hug, rush hour road rage and a note of forgiveness or thanks.  Some day these frontier mysteries could become our familiar underworld.  Imagine how it would change medical care if we could see both the crown and the roots.

Making the Human Race Great Again

Before you move to Canada, before you leave me for some place better, have one more think. Please? I found a pair of glasses, so to speak, that will make things look brighter for you and for me and for the human race.

I know it looks bad. Creationism on the rise. Incarceration rates on the rise. Suicide rates on the rise. Global temperatures and drowning seawater on the rise. The gerrymandering that dooms our hopes for a more democratic system. Our cancerous national debt. And we have only ourselves to blame for electing this guy. With all these wrong kinds of rises, it can seem like our world is sinking, or turning backwards. If we’re not careful, we’ll all be running with the lemmings for the cliffs, or Canada.

Look again. Here’s how you see what you’ve never seen before. Count. Count with Steven Pinker. Count big and think big. Pinker shows us how to count and think about the world in his most recent book Enlightenment Now (2018). Through his lenses, when you learn to count as Pinker counts, our world and the human race look different than the one we see on the news. Pinker, a psychology professor at Harvard, has been doing this kind of counting for a while. This is his eleventh book. You may have heard of his eighth book, The Better Angels of our Nature: Why Violence Has Declined (2011). His optimism is well tested.

Look at the big numbers for life expectancy, health, nutrition, wealth, economic inequality (poverty), the environment, war, safety, terrorism, democracy, civil rights, knowledge, quality of life, and happiness. The short version of this book can be seen in a glance at the 75 graphs sprinkled throughout its 453 pages. Here are a few of my favorites:

Life expectancy 1771-2015

Child mortality 1751-2013

Calories 1700-2013

Childhood stunting 1966-2014

Famine deaths 1860-2016

Gross domestic product per capita 1600-2015

Global inequality 1820-2011

Social spending 1880-2016

Income gains 1988-2008

Poverty US 1960-2016

Oil spills 1970-2016

Battle deaths 1946-2016

Death penalty abolitions 1863-2016

Executions US 1780-2016

Hate crimes US 1996-2015

IQ gains 1909-2013


In graph after graph the curves move dramatically in the direction of progress. And it’s hard to fudge these numbers. Our world is improving in almost every way you can look at it, and has been for hundreds of years. The key to this kind of vision is to first ask the questions, then choose long or large enough windows that allow you to see the big picture over time, then gather the data. And keep it simple.

In spite of two horrific world wars, battle deaths declined dramatically in the 20th century and are still dropping. Same with homicide rates and rates of extreme poverty. The trend to progress penetrates every big question Pinker asks about the state of the world. His conclusion is that progress, especially since the 18th century Enlightenment, is a juggernaut that can’t be stopped by our relatively minor failings, such as world wars, tyrannical communism, or the election of a narcissistic throwback. Pinker is sober about the work we have to do on the problems that face us (such as climate change, renewable energy, and the perversions of democracy), but the human race has a good track record for solving thornier problems than these.

If you find yourself thinking our world is turning the wrong way, think again about the issues that in your lifetime were once considered “progressive” or liberal or radical, and now are relatively mainstream. I’m 67 and here’s what my list looks like:

Long hair on men

Mini-skirts and braless tops

Rock music


Opposition to war (peaceniks)

Opposition to the death penalty


Environmental protection


Accommodations for the disabled

Civil rights for minorities, women, animals, gays, immigrants

Small, energy-efficient cars

Energy conservation

Seeking treatment for a psychiatric disorder

Women’s sports

Women in medicine, politics, CEO offices

Interracial marriages

African-Americans in commercials for soap, cars, insurance


What used to be the front edge of progress is now our current standard of living. If you look at the human race through Pinker’s glasses, we’ve done pretty well against steep odds. Survival used to be much harder to achieve. Threats were harder to overcome. The good life we live today was beyond the imaginations of even our grandparents a century ago: freedom from wars between the great powers, dramatic reductions in infectious diseases, steady improvements in health and longevity, widespread increases in wealth and decreases in extreme poverty, free communication across the continents, safe and affordable travel around the globe, unrestricted access to information, the expansion of civil rights to previously unrecognized groups.

Yes, we’ve got our messes to clean up. We have always had our troubles to manage and our problems to solve. Our failings and our apparent about-faces slow this rate of progress, but progress has moved us forward in ways that are dangerously easy to forget. As we raise our standards, we’re troubled now by things we used to overlook or take for granted. Sexual harassment, blatant racial discrimination, lynchings, and public torture were at various times so commonplace that they were not considered illegal or even troubling to most citizens. The recent benefits of peacekeeping forces and poverty reductions and the near eradication of polio and the absence of smallpox don’t dominate the news. These quiet advances escape our fearful attentions in favor of the latest tweet from the White House or the hurricane forecast.

So don’t move to Canada. It’s cold up there. You can count on that. And you can count on the fact that America was never greater than it is today. And in so many ways all over the world the human race is greater now than it has ever been. Let us count the ways. Once you put these glasses on, you can’t take them off.

Love Hunger

On August 5, 1944, my mother kissed her uniformed husband goodbye in the Navy yards of Los Angeles, watched his ship leave for Hawaii, and drove east to Phoenix, where she wrote him a letter that night. The next day she wrote him a second letter in which she described the news of the Hiroshima bomb dropping, wondering what this would mean for his expected assignment. She addressed each letter to him at the Fifth Service Depot, FMF Pacific, a military post office in San Francisco, where letters were sorted by grunts in a warehouse and routed according to the soldier’s assignment. She didn’t know it at the time, but it would be three weeks before he would read her first letter, and longer before she would read his. By then she was home in Cincinnati living with her mother and sister, watching the mailbox with a hunger that ruled the house.

Today most of us can see and talk with anyone we choose anywhere in the world at the tap of a phone screen, even in war zones, for less than the price of those stamps my mother licked for her love letters. We now make social connections with an ease that was unimaginable just a generation ago. We smart phone carriers should be well connected and socially well fed, right?

Not true, says a recent Cigna survey of loneliness in over 20,000 US adults. This study is just the most recent to underscore the paradox that in this age of hyperconnections, loneliness and social isolation remain a major public health problem. Using the UCLA Loneliness Scale to operationalize loneliness, the survey found that 27 percent of respondents reported feeling rarely or never really understood by others. Over 40 percent felt their relationships were sometimes or always not meaningful. One in five felt rarely or never close to people. The age group that reported the highest rates of loneliness was “Generation Z,” age 18-22.

The larger context for this latest survey was set by a 2015 review of 70 of the best studies of the effects of loneliness or social isolation on mortality. The wake-up call from this review is that whether you’re lonely or content to live alone, either one raises your risk of early death by 25-30%–as much as the more traditional risk factors of obesity, smoking, or physical inactivity. The effect of loneliness on mortality hits hardest not on the elderly but on those in middle age.

One of the believers in this loneliness epidemic is Vivek Murthy, MD, whom you may recognize as our former Surgeon General (2014-17). “We live in the most technologically connected age in the history of civilization,” he said recently, following his article in the Harvard Business Review, titled “Work and the Loneliness Epidemic”, “yet rates of loneliness are increasing.” According to one expert, since the 1980’s the percentage of American adults who say they’re lonely has doubled from 20 percent to 40 percent. Murthy attributes this epidemic to our increasing geographic mobility, our growing preferences for texting and email over direct conversation, and the recent shift in work efficiencies and habits that isolate workers from their colleagues.

Can we understand how such apparent progress in social networking could accompany a rise in loneliness with measurably poor consequences for our health? Evolution has not prepared us for these unprecedented levels of self-sufficiency that have come with first world rates of progress. We evolved to function best in small, tight families and tribes, but over the last half-century in developed countries we may have grown efficient and self-reliant to a fault, dispersing ourselves far from our origins. We have isolated ourselves through our houses, our cars, our access to information without talking to anyone, our work spaces, our recent dependence on screens and devices. This efficiency and comfort comes at the unintended expense of direct conversations and eye contact and handshakes and the smells of each other and the daily reminders that we belong to groups that need us.

Is loneliness a reasonable price to pay for our progress? Consider the physical effects of loneliness or social isolation. If we could swim among the undercurrents of the physiology of loneliness, what would we find? Resting heart rates generally go up when we’re alone or lonely, and over the long run high heart rates are hard on the cardiovascular system. We may find stress hormones rise and stay elevated, making us less resilient to hardships. Sleep is less restful, less efficient, meaning we don’t recover well; we lose that bounce. Inflammation levels creep up, infections too, both reflecting a struggling immune system. Self-care goes down. Why not skip that shower? Who needs to brush teeth if no one’s around? Cooking for one is no fun. More errors on the crossword puzzle, more forgetfulness. It matters less when no one else is around. Mental agility and judgment slide. Sometimes that opens the way to consider suicide, which is confined to the isolated, especially when their judgment slides. Almost no one tries to kill himself in the presence of another; the social prohibitions are too great. Pernicious combinations of these physical undercurrents of loneliness pave the pathways to heart disease and diabetes and early death.

So loneliness, like hunger and thirst, is an adaptive signal, if we learn to read it and respond. But the seductions of modern self-sufficiency are hard to resist. A substantial number of us are paying the steep price of loneliness. And yet our resources for combating the seductions of self-sufficiency also have never been greater. If we don’t get smart—smarter than our phones—about feeding our love hunger, our loneliness may do us in early. We don’t have to go to war to understand how writing daily love letters is a good way to survive.

Magnetic Hearts for Our Better Angels

In our church’s recent Palm Sunday passion reading, I read aloud as the Narrator the section before the crucifixion when Judas kisses Jesus: “Then the crowd laid hands on Jesus and arrested him. But one of those who stood near drew his sword and struck the slave of the high priest, cutting off his ear.” Modern day etiquette for heroes would call for Jesus to tend first to the gushing ear wound of the high priest’s sacrificial slave before addressing the crowd. Instead, Jesus chastised the crowd for treating Jesus like a common bandit. But those were the days when slaves donated more than an ear to their masters.

If your faith in human nature, like mine, needs a little resurrecting, read with me Steven Pinker’s The Better Angels of Our Nature (2010) [link]. Try snuggling down at bedtime to his detailed reminders that those were the days when, not only did high priests keep slaves, whose duties included occasionally taking a sword for their masters, but also those were the days of public torture—prolonged and painful and humiliating torture. Common custom both sanctioned and sanctified brutality as a show of high authority in action and a form of entertainment. In the Roman coliseum humans and animals were regularly ripped to shreds to the glee of the audience. Two thousand years ago a stroll up Calvary Hill could promise you the groans of souls and odors of corpses, one after another, nailed to the timbers. In later times saints were publicly martyred on the rack and in the fire. And just four hundred years ago Shakespeare and his fellow Londoners strolled across a London Bridge that was often adorned with the decapitated and rotting heads of the most recently executed, these acceptable and possibly reassuring reminders that an authority, however brutal, was in charge.

If you don’t yet feel resurrected hope for our race, read on. Your nightmares will eventually be rewarded. The subtitle of Pinker’s fascinating 696-page book is Why Violence Has Declined. This book offers the best antidote I’ve found against the popular and gloomy perception that the human race is on a path to self-destruction. What intrigues me most about Pinker is that he’s a psychologist tackling an enormous historical task to answer a compelling question: is violence an essential part of human nature? You might think Yes! after reading about the incessant patterns in almost every culture over thousands of years of warfare, slavery, institutionalized public torture, and massacres in the name of God. But on page after page Pinker makes a persuasive case that we have become dramatically less violent than our ancestors by every measure, and for good reasons.

One aspect of the psychology of violence, one of the “inner demons” that has been outdone by our “better angels” over the millennia, is our capacity to deny another person. If we bother to think at all about that specific other person, we fabricate a fantasy: that scum has no feelings, no story, no loved ones, deserves no respect, and will never mean anything to me. This empathy block is a trick that soldiers in hand-to-hand combat must learn: dehumanize the enemy. Masters do this to their slaves, jailers to their prisoners, natives to their foreigners, dominants to their submissives, perpetrators to their victims. This denial trick allows us to disconnect, dissociate, and remove ourselves from the experience of that other person. If this denial trick seems primitive or callous, think of how we deal with the experiences of animals we don’t know or love, or with that bearded opiate addict who haunts the exit ramp with his cardboard sign, squatting on a milk crate. This capacity to deny and disconnect would not be such an enduring and universal part of human nature if it were not so adaptive.

Two weeks ago I attended a conference in Louisville on the theme of stress and resilience (the annual meeting of the American Psychosomatic Society). This meeting got me thinking about the polar opposite of our capacity to disconnect. Two presenters referred to studies of heart rate variability among couples as the couples talk about tough stuff. What happens to our hearts when we are intimately connected? Heart rate variability is a measure of how much the rhythms of one heart vary with changes, such as breathing in and out, exercise, and psychological stress. Safe intimacy usually improves heart rate variability. Good health requires lots of heart rate variability. And as we age or get sick, our heart rate variability declines.

Imagine what happens to the heart rates of two lovers whispering on a park bench. Or a duet singing harmony. Or a mother and her nursing newborn. Or four old friends sitting around a card table. When the heart rates of two or more people adjust to roughly match their rates and their variations in rates, it’s called entrainment, a concept borrowed from the physics of two systems operating in synchrony. Two hearts beating in synchrony is a harmony of physiologies that may last a few precious moments, or longer. If a hundred members of an army can march in step, could their hearts could march in step too?

How could one heart communicate with another? A recent review of this topic by Rollin McCraty proposes that our hearts communicate through their magnetic fields. If that seems surreal or new agey, consider how herds move and flocks fly in exquisite synchrony. Is the exchange of magnetic heart fields a part of this miracle? Long before we developed words, our ancestors had to sense the states of their human companions. The magnetic fields of our hearts can communicate not just their beats and their variability, but the signature imprints of our feeling states. Patterns of heart rate variability differ from one emotional state to another. My state of gratitude or appreciation traces a different pattern than my anger. And your heart might be able to sense that pattern, if we’re close enough, both physically and emotionally. “Social coherence” is the term for this level of physiologic entrainment.

The company HeartMath, for whom McCraty works, is investing in this science, hoping that with the help of biofeedback about our heart rate variability, we could learn to find each other better in the board room and in the bed room. Whether HeartMath makes a bundle on it or not, the good news is that there’s lots of science out there telling us that we humans have come a long way toward understanding how to connect with people who are not like us. And now we can measure what we have always known, that one heart can magnetically attract and entrain another. And over the millennia our habits of brutality have diminished, while the better angels of our empathy have grown stronger. We still have that capacity to deny and to violate, but we’ve come a long way from slave’s ears and crucifying. “Peace on Earth” sounds to me now less like a line from a Christmas carol and more like a feat of human nature.

Milking Contact from Cows

One Monday morning in 1999 along a country road in the bush of Bungoma County, Kenya, a middle-aged man slowed his walk to watch a woman milking her cow inside the fence of her shamba. He did not know this woman, but this was a familiar sight. And on this morning he saw this milking in a way that opened his eyes.

Wrapped in a head scarf with her kikoi hiked up above her knees, this young mama sat on one overturned bucket while she pressed her head into her cow’s shallow hip cavity and milked into the second bucket. He noticed she had tightened her cow’s tether by wrapping it several times around the fencepost to keep the cow still and close against the fence while she milked. The hide of the cow stretched tight across the hip bones. Even before the milking the udder sagged.

He saw that too soon this young mama finished milking and carried her half-filled bucket across the yard that had been grazed bare except in the corners, and then she disappeared into her house. Next to the house two school-aged children played under the acacia tree where an older mama sat shelling beans and the laundry hung on the line. This was a school day, but these children wore no shoes and no uniforms—they were going nowhere this day. He could find no signs of a man’s things in this yard. Soon the young mama came out of her house and set her milk can on her head—too lightly, he thought. She exchanged a few short words with the woman under the tree, opened the gate, and started down the road toward town.

The middle-aged man, Mr Meshak Maleche, walked on the other way, troubled by this sight. He’d seen variations of this well-worn routine in the months since their move to his wife’s village of Mbakalo. Mr Maleche had recently retired at 55 from his career as a school principal. They had bought an 18-acre farm on the edge of the village, next to the Catholic church and the market. After a career in education, he knew little about the daily realities of farming. He felt like an outsider in this town, a teacher studying what farmers do in their shambas and at the market, wondering what farming might bring into his life.

Yet Maleche knew it was pitiful how light her milk can was. With the weekend and the national holiday it had been at least three days since this woman could have taken her milk to the market. Her can should be full. He thought about what his friend and priest, Father Maruti, had told him yesterday about the women he visits who are too ashamed to come to church. Many are HIV widows. They often run out of money for school fees and can’t sell enough potatoes or milk or beans to buy a dress to wear to church. One cow overgrazing an old shamba can’t feed a small family.

This day Maleche, watching this woman milking her underfed cow, sees in his mind the many other farmers dotting this countryside with their underfed low-yield cows. Maleche has watched these women carry their cans to the market and wait in the sun along with the other women for the good fortune of someone who might choose to buy her milk this day. Some days some mamas sell none. Father Maruti also told him yesterday about dairy cooperatives, how in some places the milk and the profits are shared among the farmers in a way that guarantees a market. “This woman,” he thought, as she walked away under her milk can, “will walk most of an hour to sit most of a day for money she can’t count on. She knows no other way. She just prays. God’s will be done.”

When Maleche told him about his morning walk, Father Maruti said, “They would trust you with their milk money.”

Maleche said, “No. I’m not from this village. They could see I’m no dairy farmer like them. Why should they trust a school teacher from outside with what little they have?”

Father Maruti said, “They will trust you because you have managed the funds for two schools and for many years. I have told them about you. You know the transparent way to do business. You have earned the trust of families in other places. You are the one to show them how to work together, how their poor cows can bring school fees. If you show them how to create a secure market, they will follow.”

Maleche could not sleep at night. He traveled to Nairobi to learn about dairy cooperatives. He read about how it is done in Europe and elsewhere in Africa. He talked to dairy farmers at the market about what they do and what could be done. When they formed the cooperative, instead of naming Maleche the director, they named him the treasurer, because that was the role that would secure the trust of the farmers.

After several months of planning, they began with eight farmers from the church, including several men, who agreed to allow him to pick up their milk cans each day in his lorry, take them to the market, and sell the milk for them. At the end of the first week they were surprised when Maleche showed up at their homes with their milk payments. The payments were as good or better than when they had sold on their own.  By the end of the first month, Maleche had recruited twice as many farmers and had twice as many cans in his lorry most mornings.

As the numbers of farmers and milk cans grew, the cash he had to carry also grew, and that made Maleche nervous. One day he found himself carrying KSh 350,000 home from the market ($3500) in his jacket pockets. He had no safe and no bank account for this milk money, so he hid it in his home. He worried that if anyone knew he was handling this amount of cash for the farmers, he would get robbed on the road. So Maleche told Father Maruti that now he, the priest, would have to make pastoral visits to the homes of these farmers to deliver their monthly milk payments. No one would suspect the priest of carrying cash under his robes, much less dare to rob him.

Soon they opened a bank account in the nearby town Naitiri. As the numbers of farmers in the cooperative grew, they started talking with each other about how to improve their milk yields. Most of the cows produced around 5 liters of milk a day. They used some of the income to buy feed for the most stressed cows, and their milk production increased. They learned to identify the sick cows and to get treatment for some of them, which also increased their yield. More milk for the group meant more money for the members. These farmers now talked to each other in new ways. Some of that money they agreed to spend on efficiencies, such as better milk cans, less wasted milk, access to refrigeration, medicine for infected cows, and healthier feed. Within a few years the average daily milk yield rose to 20 liters a day, four times what it had been.

Word spread. More farmers joined. At the market, Maleche learned about negotiating prices for milk. He started charging a price that allowed the cooperative to pay the farmers KSh 17/liter. That meant that the farmers barely made a dollar a day from their milk, but it was now a reliable dollar, every day. By the end of the month to have a reliable KSh 3000 ($30) was something.

As the quantity of the group’s daily milk supply increased, the quality also improved. He soon found he could sell more and charge more, which meant the farmers were earning 20 and soon KSh 25/liter. From the same cow, farmers were now earning two to three times the income they had been earning on their own. That made it attractive to keep more than one cow active for milking. So the total number of cows in the cooperative grew fast.

Now the Naitiri Dairy Farmers Co-operative Society Ltd, or NADAFA as it is called, pays KSh 35/liter. Coupled with the higher yields per cow, now around 30 liters a day for the most productive ones, this translates into a five to tenfold increase in income for some farmers since the early days of the cooperative. The only thing they had to invest for this big return was their trust in Mr Maleche.

As the cooperative grew, he had to be careful whom he hired to help him. First he needed a driver for a second lorry, and a trustworthy accountant to keep track of the milk coming in and the cash going out. Then he needed a manager to recruit new members, orient them to the procedures, and field their questions. Soon he was managing a team and a growing group of farmers. In some ways it was like managing a faculty and a student body.

Now NADAFA has grown to 8000 members with 47 collection stations in a 40 kilometer radius around Naitiri. A team of over 25 motor bike drivers collects the modern 10 liter milk jugs designed by the Gates Foundation twice a day and delivers them to the central processing station where the milk is measured, tested, pasteurized, and then distributed in a 5,000-liter dairy truck to urban markets in the region. The cooperative can serve as a lending bank for its members. It pays its farmers either directly into bank accounts or by digital M-Pesa accounts, averting the threat of theft and making its records transparent and available to its members for scrutiny. Last year NADAFA began providing veterinarian services to keep the cows healthy and more productive. It sells feed that increases the milk yield. And it trains its farmers to practice smart farming.

One farmer has educated his three children with three cows producing 20 liters a day. The NADAFA payments bringing him KSh 60,000 a month. One cow can educate one child through secondary school.

Now when Maleche walks through the town of Mbakalo, he sees these HIV widows in the tailor’s shop getting a church dress mended; he sees their children walking to school in the required uniforms; and he sees Father Maruti smiling because these women come to church now and they leave donations in the church basket and they sing in his choir. God’s will be done.

That’s a high return on a modest investment for every member. That’s a retired teacher harvesting cooperation from a community of underfed cows. That’s collective wealth created out of collective poverty. That’s Rifkin’s third industrial revolution taking hold in pockets of rural Kenya. And that’s the kind of contact that saves lives.

Stress and Your Social Gradient

How’s your social gradient treating you? This past summer I traded the stress of a full-time job as an academic psychiatrist for the stress of a half-time job as an academic psychiatrist, which allows me to spend my mornings stressing over a book I want to write about stress and illness. By choosing to make this move now I may have dropped a few notches on my social gradient, but maybe not. Maybe this book will save me, someday. I’ve waited most of my working life for the privilege to write each morning, and, so far, most days it’s been fun, the good kind of stress.

My current challenge this month is to figure out how to pack into one chapter the most compelling evidence on how some kinds of chronic stress turn into some of our most common illnesses, such as diabetes, heart disease, obesity, and depression. The timeliness of this issue—and its timelessness—came to me through an NPR piece this month on a recent survey about the effects of racial discrimination on poor health outcomes—not only through big unjust events, such as being passed over for a job or a mortgage, but also through the “little indignities” of disrespect in daily life.

Top on my list for this chapter is a story about two scientists, Robert Sapolsky and Michael Marmot, who have separately and around the same time during the 1990’s captured the same key point about stress and illness: the most powerful determinant of your health and the length of your life is your social rank. It’s true if you’re a human and true if you’re a baboon. (It’s also true if you’re a pig, a rat, or a rhesus monkey.) For you humans, Sapolsky and Marmot tell us, your social rank may be a more powerful determinant of your health than the other common culprits, such as your genes, your income, your education, your family history, or your zip code. And they tell us why. But of course there’s also a catch, which will help you sleep tonight.

Robert Sapolsky is a primate biologist at Stanford University, a short, thickly bearded, long haired professor and self-proclaimed nerd—as a boy he was often chosen last in neighborhood pick-up whiffle ball games because he was uncoordinated and usually had a book in his hand. Sapolsky spent 12 summers in Kenya studying the behavior and biology of baboon troops. He has taught and written extensively about stress and illness, most notably in his entertaining and enlightening book Why Zebras Don’t Get Ulcers (1994, 2004). National Geographic featured Sapolsky and his work in a documentary Stress: A Killer (2008).

Also featured in that documentary is Sir Michael Marmot , a professor of epidemiology and public health at University College London. He is the author of the Whitehall Studies and most recently The Health Gap: The Challenge of an Unequal World (2015). I saw Marmot give a rousing call to action last spring at the annual meeting of the American Psychosomatic Society. He’s a trim, well dressed, eloquent speaker with a refined sense of humor and a hard-earned sense of indignation about social injustices.

In the 1990’s while Sapolsky was collecting blood samples on a baboon troop in the bush and analyzing stress measures in relationship to each animal’s rank in the troop, Marmot was analyzing data on illness and mortality in the Whitehall II Study, a prospective study of British Civil Service workers, each of whom had a well-defined rank within the Civil Service. To their surprise they both found that how long baboons and civil servants live is directly related to where they stand on their social gradients. Lower ranks die younger. And their risk for chronic illness was also related to their social standing. This is more than poverty making the poor sick. This relationship holds true even at the higher ends of the social gradient. The higher your rank, the better your chances of being healthier, even among the top tier. It’s not fair, but it’s true.

I was surprised too. Haven’t we always heard it’s tough at the top? Down lower where fewer people can see you, hold your responsible, or shoot at you, it ought to be safer and healthier, right? Not true, said these two sets of data. Both investigators concluded that the stressful aspect of the lower end of the social gradient is the relative loss of control, resources, and rewards. We’re less in charge of our jobs and our lives. Subservience exposes us to the power plays of those above us in the social gradient. Alpha males, older siblings, clique leaders, bosses, bullies, captains—their influence on our stress response systems can be profound and lasting and sometimes toxic.

If you’re a baboon and you lose your stature to the new alpha male, you’re sunk. You don’t have an out, other than leaving the troop, usually a dangerous move. But if you’re a human, you’re probably thinking right now, I don’t have a “social rank,” or nobody could tell me what it is, not like in the British Civil Service where everyone knows whether your rank is a 13, 5 or 2. The closest thing we have in the US may be our military or the Veterans Administration.

But here’s the catch for most of us humans. Unlike the average baboon, we can choose to belong to several social orders. Most of us don’t have just one rank, and ranks change. In 1994 my boss at the University of Cincinnati demoted me from my role as Vice-Chair for Education in our department. It was a searing humiliation at the time, wrapped in what he later admitted was a form of academic bullying. Though it took a few years, and it made me mighty uncomfortable, that demotion did not quite make me sick. I was lucky and I had resources. I could recover because, though I lost a title and a role, I retained my academic rank and salary and other roles in the department. It was a loose system, not a tight one like the British Civil Service or the VA. And I retained my rank in my family and on my soccer team and in other groups that still thought I was okay, which buffered me against the power plays of my boss. I started writing in earnest. I lost an institutional voice and started working on gaining a written voice, a rank in a separate social order. Baboons should be so lucky.

What does the social gradient have to do with attachments and making contact, the theme of these blogs? One of the most powerful ways we’re attached to others is through our social hierarchies. Think about how much time and emotional energy we spend thinking about the person just above us at work, or the person we answer to, or the person who currently has the most influence on our daily lives. If that’s a nourishing relationship, we thrive, but if that’s a troubling relationship, it’s hard to turn off that kind of worry. It leaks into our sleep, it haunts our daydreams, and it can sap our energy at work and at home. You may feel an intense attachment to and lose a lot of sleep over someone you don’t know very well (where does she live, how many kids, where’d she grow up, why does she wear her hair like that?), just because she currently holds a threatening kind of power over you.

Sapolsky and Marmot remind us that evolution has made most of us acutely sensitive to where we stand in our social gradients. It’s a matter of survival. No wonder it’s stressful when the gradient shifts. No wonder we do better when we have more than one gradient to stand on. No wonder the little indignities of racism or bullying are hard on the heart as well as the soul. Even baboons know that.

Write That Voice

Tell me about Meryl Streep’s voice.  Which of her performed voices do you like best?  Her Julia Child in Julie and Julia, her Polish lover in Sophie’s Choice, her Danish aristocrat in Out of Africa, her Margaret Thatcher in The Iron Lady, or her bullying soprano in Florence Foster Jenkins?  Tell me what magic makes one of her voices so different from the others.  Is it the accent, the range, the pitch, the melody, the register, the body gestures?  It’s hard to say.

And what would Streep say about how to write those voices on the page?  A 2009 You Tube clip, “The Many Voices of Meryl Streep,” collected a selection of her movie voices since 1982.  From the written words alone, can you hear this voice?  “I’m going to try to flip this one over now, which is a rather daring thing to do.  When you flip anything, you’ve just got to have the courage of your convictions….Oooh, that didn’t go very well.”  How much clearer can you hear this voice if you first read that a tall, buxom, middle-aged lady stood behind the stove in her kitchen talking in a droll cultured accent?  With a few hints about the character and the context, it’s easier to “hear” that voice.

You imagine the voice of Sophie Zawistowska as Streep portrayed her in 1982 more clearly if you picture her in her young twenties tilting her head to the side, talking wistfully, smiling upwards at Stingo, the young American man in Brooklyn, saying “When I was little girl, my father, um, typed and I go to sleep to that sound.  It will make me feel, how do you say, secure, secure?”  In Styron’s novel, Sophie’s Choice, he spends few words on the audible sound of her voice, relying solely on the character, context, and the content to carry her voice into our imaginations.

We readers need a few clues beyond the spoken words, but having too many clues kills the effect.  Overwriting a voice leaves little room for the imagination, and the reader’s imagination is more effective at creating a voice than any detailed description.   So what are the essential features that sketch a distinctive voice?

I tried looking on my shelf of how-to-write books that I’ve collected over the last twenty-five years.  Out of 21 books, none had a chapter specifically addressing the writing of voices, but the common theme across the chapters on dialogue is that voice is driven by character.  Begin by knowing the personalities in your story well enough that you can hear them speak in ways that reveal their character.

I tried describing some of Streep’s voices from the 2009 clip.  After several feeble trains of adjectives, I came up with a variation on the game of Celebrities in which one person has to get others to guess the name of a famous person by describing the celebrity’s voice using word clues only.  What makes Hitler’s voice so different from Churchill’s?  Trump’s voice so different from Obama’s?  What makes Stephen Hawking’s voice so mechanical?  We know these voices.  They rattle around in our dreams and our day-dreams.  We recognize familiar voices instantly, but try telling what distinguishes one voice from another.

When I played this game with my wife, Vic gave me 14 clues before I guessed Jack Kennedy.  I gave her six before she guessed Hillary’s voice.  Our son Stu played this game with his wife and her parents.  Their longest run took them through six clues (“melodic and rhythmical, male voice, it’s a singer, upbeat, talks about love, has an accent from a country or a religion”) to get to the correct Bob Dylan, after false stabs at Meryl Streep, John Lennon, Elton John, and Matis Yahu.  Three times they guessed the correct celebrity after just two clues about their voices, and once all it took was one clue: “god-like” for the voice of James Earl Jones.  Those four know each other too well!  How easy or hard is it for you to guess a voice by word clues?

Faces are as complex and distinctive as voices, but easier to describe.   Why are we so inarticulate when it comes to talking about something so essential to our identities as the human voice?  Most of us learn to speak by imitation, not by instruction.  We know voices intuitively.  We learned as infants to recognize and interpret voices long before we learned to speak.  We don’t have to think much about what makes a voice unless we lose it or try to train it to yodel and sing arias.

In case you’re ever afflicted with a stroke in Broca’s speech area or operatic ambitions or the compulsion to be a writer, it’s a useful exercise to think about what it takes to make a voice, and what makes each voice unique.  Most of what we need to make a voice is a clear sense of the character, the context, and the content of their speech.  Imagine how it would change the way you hear Julia Child if, instead of being in her kitchen in Cambridge, Massachusetts, before a WGBH camera in the 1960’s having spent twenty years in France immersed in French cooking schools, Streep’s Julia were delivering those sentences in the back of a bus to an alarmed audience of riders.  Character and content depend on context.

In addition to character, content, and context, it takes anatomy to make a voice.  Does understanding the anatomy of a voice help you write it?  The shapes of the chest, trachea and vocal chords change with adolescence, laryngitis, and screaming.  Julia Child was six feet two.  When a hefty guy has a tiny voice, it’s often surprising, maybe amusing, usually revealing.  The mouth, the pharynx, the nose, and the sinuses are “resonators” for our voices.  If you pinch your nose or fill your sinuses with fluid, you change the pitch and the resonance of your voice.  The tightness or looseness of the soft palate varies with culture and with personality and with emotional tone.  Meryl Streep likely tightened her soft palate a tad for French Lieutenant’s Woman and loosened up plenty for Prairie Home Companion.

An article about our senator in the July 24, 2017, Washington Post begins with these lines: “They could hear him before they could see him — that low, rumbling outboard motor of a voice. It could only be Sen. Sherrod Brown.”  Five paragraphs down Sen. Al Franken (D-Minn) says Brown’s voice sounds “as if he’d been hit in the throat by a hockey puck.”  There’s a lesson here.  When it comes to describing voices, metaphor is more powerful than analytic details.

To sketch distinctive voices on the page, we first have to know our characters so well we can hear them speak.  A voice that reflects gender, age, culture, and physique comes to life when it also changes rhythm, speed, and content with shifts in context and state of mind.  Writing distinct voices works best when the writing comes fast, by intuition, and prods the reader’s imagination.  You can bring a voice to life with a hockey puck.

The Voice of the Heartland

In the winter of 1976 Mark Twain came to Cincinnati’s Music Hall in the form of Hal Holbrooke’s one-man show.  My then-girlfriend and medical school classmate, who knew my fascination with Twain also as my refuge from my insecurities about surviving medical school, arranged for us to usher that evening.  Luck left us with two empty seats in the 10th row, close enough to see his whiskers twitch and the smoke of his pipe curl.

Holbrooke’s Twain shuffled onto a nearly empty stage toward an arm chair and a small table set on a rug to the left of center—as though he were entering his own living room, dressed in his signature white linen suit, in the twilight of his life.  I fell in love that night with the spoken voice of Twain, so true to the voice I’d been hearing as I read—folksy, ambling, disarmingly easy, coming strong from his chest but tinted with the scratch of age and smoking, his pitch rising with excitement.  He meandered from one musing to another like a lowland river, but he made every word count—slow talk hiding fast wit—so we listened close and laughed hard.  Twain created the  voice of the Midwest small town observer with a worldly wit, the compassionate and amused chronicler of the human comedy.  And he had a sharp ear for how we talk.  Holbrooke played both sides of his dialogues.

I loved that voice above other writers until Garrison Keillor stole my heart.  It took a while, but over the past thirty years, how could Twain compete with Keillor’s prolific tales from Lake Wobegon, songwriting, radio drama, newspaper columns, speeches, and novels.  In the year since he stopped hosting “Prairie Home Companion,” I have tried to listen to the show by the same name, but I don’t stay with it.  I understand better now that over the years I was listening to that show for that voice.  The rest was extra.

Last Friday night in our town (May 19) we had “An Evening with Garrison Keillor” at our largest theater, the Aronoff Center.  It was hard to know what to expect—would he bring a crew of musicians?  Would he ad lib or do old favorites from past radio shows?   Would he talk politics and tell us things we don’t know about our home town?  When I looked him up for a preview of the show, all I could find was the St Paul StarTribune’s obituary of his 17-year old grandson who had died earlier that week on Monday, May 15.  The obituary, clearly written in the voice of his grandfather, said nothing about the circumstances of the death and it announced at the end that the visitation in St Paul would be held at 4 pm on Saturday, May 20.  Could the grandfather really be here in Cincinnati entertaining strangers the night before?

The Aronoff, when the lights are on, is a colorful blend of terra cotta walls and cactus green seats and soft amber lighting.  In contrast the stage last night looked stark as we waited for the lights to go down—one stool and a mike stand stood in a single spotlight on the enormous scuffed black stage floor with black curtains in the back.  As the house lights dimmed, Keillor walked out from stage left in his light tan suit, fire engine red tie, and signature red socks and sneakers, looking deep in thought.  The echo of Twain was unmistakable.  He nearly stumbled, as though the floor were sticky or he wasn’t used to these new shoes.  He took the cordless mike, rolled the stand behind him, and launched into an a capella ballad about love and trouble which he then blended into lines from a couple of familiar songs, beckoning us to sing along with him.  When solo, his baritone voice was full,  relaxed and resonant; when we joined him he sang at a lower volume, almost a whisper, and so did we, all 2700 of us, filling the hall with a muted, gentle chorus.

He sat on his stool, chatting as though we were potential chums, disarmingly easy, and he talked about being a misfit as a boy, awkward looking and not among the cool kids.  He got up as if to prove it.  As he moved about the stage, his gait was sometimes awkward and sometimes graceful, but always expressive.  His large hands waved about like a conductor’s, expressive like an actor’s.  He never stayed still for long.  Right from the start he made every word count, so we listened.  He kept the house quiet.

He complained about the way his 17-year old daughter and his 31-year old niece and her boyfriend butcher the English language and use their devices to avoid communication.  “I’m not complaining,” he said.  “It’s just a fact of life I have to live with.”  He talked about being 74 and the intimacies of having his prostate examined by a female urologist.  He mentioned a teenage fan of his radio show who met him in an airport and recited a limerick he’d learned on his show—after all his efforts to write novels and poetry and songs, what this kid had learned from him was a baudy six line limerick.

He told us about being punished by his parents for stealing when he was eight. They sent him to his grandparents farm in Lake Wobegon where he helped Uncle Jim bring the hay in from the fields and store it in the hayloft, until he fell through the trap door onto a cow and into the slop, where a bull with a ring through its wet nose nudged him out to where his uncle could pick him up and take him into the house—an experience he vowed to never forget, the beginning of learning to be a writer by remembering the details of life.

After an hour of talk he sauntered into the audience for what he called a “standing intermission.”  He moved up the aisle about 12 rows and invited us to sing a few lines of a few more songs with him:  Oh Susannah, Swing Low Sweet Chariot, Way Down Upon the Swanee River, Silent Night, John Jacob Jingleheimer Schmidt, and others—he played pastor, choirmaster, and fireside singalong director.

He quoted Twain and Shakespeare and mocked TS Eliot’s J Alfred Prufrock.  He talked of sharing a fraternity with Bob Dylan at the University of Minnesota.  He recited a few of his love poems, both young and recent, and told us a long tale about a first love at age 12 and her recent funeral in Lake Wobegon.  He delivered all this with the apparent spontaneity of inspired conversation, talking in his ambling manner but with a quick and restless wit that moved fast to the next line while we were still laughing at the last one.

This performance went on for two and a half hours, uninterrupted, with no props and no back up band and no notes or script.  Naked talent.  He never lost his audience, never seemed to tire or falter, one voice holding 2700 attentions for over two hours.  Is there anyone else who can write novels and radio drama, do stand up comedy, spin thirty years of tales about an imaginary town, sing gospel baritone in a quartet and solo, lead a chorus of strangers in folk songs, and hold an audience mesmerized by his voice alone for over two hours at age 74?

Twain could be proud of the kid up river who has captured the voice of the heartland.  And Keillor came to our town last night to deliver that voice in spite of the death this week of his grandson.  He never mentioned it.  In show business, that’s courage.

Finding My Voice

The good thing about the hot burn of a bad bout of bronchitis strangling your throat is that it forces you to choose your words carefully.  Flu season could actually be a blessing if it improves the likelihood of my whispering a few precious words to you, or writing instead.  My voice started to desert me Friday evening.  By the third trip to the bathroom in the middle of the night, I knew I’d lost it.  Some noise-making contraption barked wet and hard from a rigid box way down in my boots, but it wasn’t my voice.  A bad bout of bronchitis can make you think hard about what an everyday miracle your voice has been.

My wife left me Saturday morning, so I’ve had plenty of time to think about hard stuff this weekend.  I’m pretty sure her ticket to Albany for that funeral was round trip, so we might talk on Monday, if I find my voice by then.

I have to admit I don’t know much about my voice, or voices in general.  I’ve never taken voice training or read any books about it, and I can’t even tell you whether I sing tenor, bass, or baritone.  In my mid-sixties I’m still surprised by the sound of my own voice when I hear it on my voice mail or in a home video.  Do we ever hear our own voices the way others hear us?

Voices are easy to identify and hard to describe.  Among the thousands of voices we each know, we can usually identify who’s calling on the phone within the first three words.  No two voices are the same on biometric voiceprints.   Have you ever seen your voiceprint?  I can’t imagine what mine looks like, but it probably would not make it any easier to describe my voice to you.

If I could go to the Lost and Found today to retrieve my voice, how would I describe it to the guy at the counter?  “It’s a male, middle-aged, medium-sized voice with a generally fluid cadence and a fair amount of feeling when I’m teaching.  My voice is steady most of the time, spoken from high in my chest, but when I’m rattled it skips and pinches and hesitates and rises up in my throat.”  The guy probably has a hundred of those.  What’s special about mine?

Shouldn’t we linguistically advanced homo sapiens have developed an elaborate convention for describing voices by now?  We associate voices with age, gender, and pitch, but after that it’s all metaphor.  We may talk about the texture (“creamy,” “velvety,” “scratchy”) and the location (“chest,” “nose,” “head”) and the size (“booming,” or “mousey,”) and the range (“sing-song,” or “flat”).  Ask three people to describe the same voice, and you’re likely to get three different descriptions, none of which nails the voice precisely.

Why are voices so distinct?  We each have a different instrument–you have a piccolo and I have an oboe—but more importantly we play it in our own ways.  The distinctiveness of each voice reflects not just the particulars of the anatomical shapes along the 6-9 inch flexible windpipe between our vocal chords and our lips, but also how we move every structure along the way: our tonsils, uvula, soft palate, tongue, cheeks, and nostrils.  Our brain plays our voice and our voice reveals our brain and our soul to our listener.  Is there any more intimate and sophisticated window into our inner selves?  The miracle of your voice can be captured in a voice print and a bar code and by Siri and Alexa, but they couldn’t tell you how they do it.  It’s all pattern recognition by neural networks, and voice recognition requires a precision that defies word description.

Our instinctive talents for voice identification are crucial to our survival, apparently even before we can utter our first cry.  And though we each develop an identifiable voice, don’t we also develop many voices?  You may tolerate my speaking voice, but cringe at my singing voice or not even recognize it as mine.  Good writers, like EB White, can achieve a written “voice” that is quite different from their voice at the breakfast table, but equally genuine and distinctive.  Good actors, like Meryl Streep, can adopt the speaking voices of her characters so convincingly that it’s hard to recognize her own voice—a triumph of empathy as well as vocal dexterity.  The rest of us, and most second-tier actors like Harrison Ford, sound for the most part like ourselves, no matter who we pretend to be.  It’s hard to hide our voices.

I want my voice back, but having a voice is different from raising it.  How do you raise a voice?  That’s a risky process for most of us.  Learning to speak up runs several dangers, including being shut down, ignored, misunderstood, or criticized.  Each culture has its rules about when we speak and when we keep quiet. Not raising your voice is also risky, from the common fate of being misunderstood to the rarer fate of starving.  We all crave to be heard from day one, and our voice is our most sophisticated instrument for human contact.  Losing my voice permanently would rank with losing my sight or hearing.  It would mean the end of much of my work life.

Writing raises my voice.  Rewriting raises it a notch higher, hopefully. So much of good writing depends on finding the effective writing voice.  Our nation’s current political troubles invite me to raise my voice.  Teaching and doing psychotherapy require that I raise my voice.  Much of the work of psychotherapy involves helping people who have figuratively, and sometimes literally, lost their voices to depression or other illnesses such as stroke or multiple sclerosis.  The process of recovering from these conditions can be accompanied by regaining the lost voice—that is, the confidence, the capacity to assert your views where self-doubt and physical fatigue had once robbed you of your natural voice. Sometimes, in the context of early psychological trauma that snuffed out the safety of speaking up, recovering involves discovering in adulthood the permission and the power to raise your voice.  Raising these voices is one of the thrilling outcomes of this therapeutic process.

You can raise your children but you can’t raise their voices, not directly.  They’ll talk the way their peers talk, not the way their parents talk.  Yet parents are the first voice teachers for children, at least by example, and often by directive.  Speak up, shut up, slow down, say it clearly, say it in a nice voice.  We and their teachers can coach them.  What greater playground for finding your voice than high school drama productions, where the changing voices of adolescents can try their vocal and empathic talents on relatively forgiving audiences?

I’m getting my exercise by blowing through about eight sheets of Kleenex an hour now. Tires me out.  Wearing out the bedsheets is tiring too.  Time for a nap.  I’ve strained through a couple of phone calls, enough to convince me I could fool those voice recognition software programs if anybody tried to wiretap me today.

I’ve also watched a cool video of four pairs of vocal chords as their owners sang Kyrie Eleison.  It’s a bizarre and fascinating sight that reminds me how little I know about how we generate the sounds that connect us so intimately through our voices.  Just think what speech pathologists, ear, nose and throat surgeons, opera voice teachers, and theater directors understand about the human voice that the rest of us take for granted.  Maybe one of them can help me get my voice back.  Until then, it’s words on the page that save me.

Welcome to the Revolution!

Actually, welcome to the Third Industrial Revolution.   I woke up to the fact of this revolution on Christmas Eve this year, thanks to a few pages by Jeremy Rifkin, and this realization quickly solved two nagging problems.  It got me out of the doghouse on four Christmas presents, and it gave me an “ahaa!” clarity about what happened in our election on November 8th this year, a gift I’m eager to pass along to you.

If you’re not aware that there’s a revolution going on, you’re in good company.  Nobody I’ve talked to since Christmas Eve is aware of it either.  Yet we all know what Google, Facebook, EBay, Graigslist, AirBnB, ZipCar, Uber, Wikipedia, YouTube, and Amazon have done to shift power from the corporate board room to the solo entrepreneur and to cooperative networks.  You may not find this power shifting threatening, but think of the corporate dynasties that have taken big hits in the last two decades.  Think of most newspapers, record companies, advertising giants, book publishers, postal services all around the world, taxi companies, hotel chains, and the giant retail stores that anchor our big malls and now are selling off their real estate while Amazon hires a larger workforce.

Amazon started out in 1994 as an online bookstore and a platform for solo booksellers, many of whom work out of their homes. In 2007 1.3 million sellers sold products through Amazon.  The traditional capitalist way of doing business is taking hits from upstart start-ups, and power is being distributed outward and laterally in every sector of society.  Some people find that threatening.  In my daily efforts to make sense of our power struggles in the infancy of the Trump regime, I find it both exciting and reassuring to remember that Trump is just a role player—though potentially a dangerous one—in the bigger drama of this Third Industrial Revolution.

Women's March 2017

Washington Park, Cincinnati, 12:30 pm, January 21, 2017

On the day after the inauguration of Donald Trump the streets of 670 cities looked like the scenes of a global revolution.  But this is not a political revolution, at least not at the root, not like 1776 for the colonies, or 1789 for France, or the 1960’s here in the USA.  So it does not really matter which side of the 2016 election you were on.  We’re all living in this revolution whether we like it or not, all over the world.  This is an industrial and economic revolution that is radically changing the way we do business with each other.  This revolution was well on its way before Mr Trump jumped into the scene.  In fact, the accelerating pace of the revolution may be the very reason Mr Trump jumped in now.

Back in 2012 I read Jeremy Rifkin’s book The Third Industrial Revolution.  That book also got me out of the doghouse on four Christmas presents to those same four impressionable sons.  But I didn’t grasp the impact of Rifkin’s announcement of this revolution until the 2016 election whacked me on the head and then I read on Christmas Eve morning the first chapter of Rifkin’s latest book (2014) The Zero Marginal Cost Society: the Internet of Things, the Collaborative Commons, and the Eclipse of Capitalism.

Rifkin tells us that the Third Industrial Revolution is bigger than the First Industrial Revolution, which was ushered in by coal, the steam engine, and the rapid printing press that spawned capitalism and socialism in the early 19th century throughout the western hemisphere.  This current revolution is also bigger than the Second Industrial Revolution, ushered in the early 20th century by the discovery of oil, the invention of the combustion engine and the car, and the wrapping of telephone wires around the world, all of which made possible the emergence of mega-companies like Standard Oil and General Motors.  These two storms of invention in the energy, transportation/manufacturing, and communications sectors revolutionized the way societies did business twice in the last two centuries, all over the world.

Now, in the early 21st century a third storm of inventions is revolutionizing the way we do business with each other.  No wonder those who stand to lose find that threatening.  The browning of America and eight years under our first black president and the recent prospect of our first woman president have spelled the end of the dominance of the white male in our power hierarchies.  No wonder conservative white males came out to vote last November in surprising numbers for a throwback white male billionaire chauvinist real estate tycoon, for a cartoon of the capitalist bully who promotes fear of foreigners and “America First!”   Mr Trump speaks the voice of an old order that won’t go down without a fight.  It is already an ugly fight.  But the fight is not about Mr Trump, though he would like us to think so and we do have to deal with him.  The fight is about how we do business with each other, all over the world.

According to Rifkin, senior lecturer at the Wharton School of Business, University of Pennsylvania, our third revolution began back in the 1990’s with popular access to the internet.  The internet is now nearly free for users, for the first time providing the world with a nearly zero cost medium for communication and business.  The internet has revolutionized communication and commerce more radically and more rapidly for more people around the world in a shorter period of time than the printing press or the telephone did in their day.  We used to pay good money for books, records, fast mail, long distance phone calls, college courses, electric power, and starting a small business.  Now we can buy each of these for nearly nothing.  Facebook was a pipedream just fifteen years ago.  Some people find that threatening.  I find it promising.

Rifkin asserts that a driving force for this Third Industrial Revolution is the rapid escalation of the climate crisis.  If we don’t switch fast to relying more on renewable energy, we face climate disasters, droughts, and famines that will likely decimate agricultural output as we know it.  However, the decline of oil and a rapid rise of renewable energy sources could bring us a shift from the very expensive to the very cheap, from extremely capital intensive drilling and processing and distributing of a finite natural resource by a few enormous corporate dynasties (Standard Oil, Exxon, and Shell) to the reality that soon many of us will be energy producers as well as consumers, or “prosumers.”.  As we adopt solar, wind, and biomass capacities plugged into an energy grid that is owned by none and shared by all—the “Energy Internet,” as Rifkin calls it—power will literally be widely distributed, instead of tightly concentrated in the hands of the power companies.  This shift to renewable energy may happen faster in developing countries through micro-grids in rural areas.  Rifkin spells out how this industrial revolution is changing the way we deliver higher education, finance enterprises, and achieve unprecedented efficiencies in the production and consumption of energy and products through the “Internet of Things.”

This revolution demands new ways of governing to manage forces such as the internet and global climate change that know no national boundaries.  More than ever we need cooperation among cultures and across continents—global networks, not walls between nations, not hostile insults aimed at our partners.  Chapter One of Rifkin’s latest book is titled The Great Paradigm Shift from Market Capitalism to the Collaborative Commons.  He reminds us that before we had big government and big business, just two hundred years ago, we organized ourselves in small villages and towns around the sharing of common resources none of us owned, such as pastureland, our town commons, water, our marketplace, childrearing, and village security in a “commons” model of governance.  Modern big government and big business are not about to go away, but the internet has revived the commons model of governance for the management not just of information but for many of our sharable resources, such as energy, oceans, the atmosphere, education, and the genetic code.

Welcome to the revolution. The rules of the game are changing.  The “commons” model for doing business is challenging the capitalist model.  As industrial revolutions go, this one is moving fast.  But fear and the “forgotten man” are in the White House now, determined to change the game back to what it once was—a fool’s errand.  I find it reassuring to read Rifkin and remember that this revolution is bigger than any one person and more powerful than any political agenda.  Our choice is not whether to join the revolution, but how to join it and guide it.  How do we contain and ease the fears of those who oppose these changes?  Another storm of inventions is already changing us for the better, and for the third time in three centuries.  How do we prevent the reactionary scrapping of recent progress in the Third Industrial Revolution?

Rifkin wrote The Zero Marginal Cost Society in 2014, but for me he spelled out the urgency of the issues that have been magnified by Trump’s election: immigration reform, renewable energy implementation, education reform, political reform to insure fairer representation, women’s rights, healthcare for all, cyber security, embracing the Internet of Things, adopting a collaborative commons approach to governance in certain sectors, and international cooperation on all these fronts.  I sleep better at night knowing we can do these things.  The alternative of ignoring them or opposing them may not be compatible with life, not the life I want to live.