The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
... William Penn's Quaker Colonies
plus medicine, economics and politics ... nearly 4,000 articles in all
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Philadelphia Revelations
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George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.
Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”
After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.
He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.
After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).
A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.
He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.
A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.
The American Medical Association
has several hundred thousand physician members, all of whom consider
themselves important members of their communities, hence important
members of the AMA. "The Association" maintains a large, experienced,
and frequently successful lobbying staff in Washington. It would be
wildly impractical to permit every individual member of the Association
to walk into the Washington office and give orders to the staff. Even
when individual doctors have a very good idea, and the staff members
thoroughly agree with it, it's never safe to assume the professional as
a whole agrees. And in fact, it is always possible to find some doctor
who violently disagrees, no matter what the topic.
So, a couple of centuries of experience led to a system of funneling physician opinion up to the line to the House of Delegates,
and passing it through that narrow neck of the funnel before it is
released to the Washington office as "policy". Sure, a couple of
knuckle-heads can sometimes block a good idea at the narrow neck of the
funnel, just as an occasional Leonidas can save civilization at this
Thermopylae, against a bad idea. Sometimes an idea slides all the way
through on the first try, and sometimes it is necessary to build up a
head of pressure behind it. The fundamental question before the House
of Delegates is not entirely whether a proposition is a good idea or a
bad one; an equally important question is whether it likely reflects
the prevailing viewpoint of the profession.
My first salvo in the campaign to win AMA approval for Medical
Savings Accounts was a letter to Jim Sammons, the Executive Vice
President. He wrote back promptly that he had read the Medical Savings
Account proposal three times, and still didn't understand it. Although
my opinion of him was never quite the same, he did me the favor of
demanding simplicity, to be more quotable. An IRA for Health. An IRA
plus a catastrophic policy. What's good about that? Cheaper. What makes
it cheaper? Compound interest. How does it help poor people? More
people can afford to buy something that's cheaper. Sammons said, ok, I
can live with that.
The letter to the EVP turned out to be a good idea because it
established my claim to ownership. A few months later I arrived in
Chicago with a crisp, brief zinger of an MSA proposal, only to find
that somebody from Louisiana was attending the same meeting with an
almost identical proposal, called CHIP. Mike Smith was president of the
Louisiana Medical Society, and not only had the same idea but
personally had a lot of Louisiana oil money which he freely spent on
professional packaging of his presentation. Mike and I suspiciously
circled each other like two wildcats for a few hours, but we had so
much in common that very shortly we were the best of friends, remaining
so for years until his unfortunate death. He introduced me to his
Southern friends, I introduced him to my Northern ones, and the idea
itself picked up some allies on its own merits. It had a fairly easy
time of it in the House of Delegates. However, it was referred to a
committee for polishing and deeper consideration. Six months later it
had disappointingly picked up quite a lot of unforeseen opposition,
probably after the hospital and insurance executives heard about it. It
took another six months to fight through a wall of specious argument,
but an endorsement of the Medical Savings Account did become a policy of the
AMA and the eager Washington staff was thus free to run with it.
It has remained AMA policy ever since, and the main technical
problem for its main sponsors became one of keeping the idea alive in a
House of Delegates with constantly shifting turnover. The AMA is like
the court system; it doesn't like to keep revisiting an issue that is
settled policy. Too many other members have proposals requesting
attention, so why should we go on reaffirming old matters? However, the
proposal was stalled in Congress, and for the momentum, we needed to keep
beating the drum with variations which somewhat stretched the patience
of the more senior members of the House of Delegates. To them, I
apologize, with gratitude for their tolerance.
But what was the matter with Congress? What was the matter with the
editorial page of the New York Times? I was always uneasy about a protracted debate because reducing the cost of medical care (from the
patient's point of view) was apt to translate into reduced income for
doctors. I was leading a procession of self-employed entrepreneurs into
a proposal to cut their own income for the benefit of the public; how
long could physician enthusiasm be maintained for that? I'm proud to
say the answer is at least twenty-five years.
Even in retrospect, I am a little surprised that even such
sophisticated students of medical economics could remain focused for so
long. They might have come to regard the sponsors of MSA as being on an
ego trip, or else nutty fanatics obsessed with a lost cause. Or they
might have joined the young newcomers in fearing that such determined
opposition at a national level might signify the opponents were somehow
right to oppose it. The arguments advanced by the opponents really
seemed to have very little merit, but perhaps in private, it might be
possible to sympathize with some embarrassing circumstances that
explained the vigor of the resistance without crediting its excuses.
Political debate after all, even in scientific organizations, quite
characteristically wraps venal motives in a cloak of logic and
altruism. I remained fearful for years that the House of Delegates
would shrug its shoulders and let the opponents have their way. That
they never, ever, did so was probably related to medical care being
physician home turf; where you get used to hearing a lot of dumb
arguments, but you don't have to credit them with any merit until merit
is displayed. You can tell doctors a lot of fairy tales about
architecture or investment banking perhaps, but if you talk medicine
with them, you better have your facts.
Whenever my colleagues would privately draw me aside and ask why in
the world a lot of people were so resistant to the MSA, I had to tell
them I was not entirely certain. However, it was notable that three
groups had important things to lose, and would probably fight to
preserve them. The Medical Savings Account threatened the
eighty-year-old pricing preferences between hospitals and insurance
companies. Secondly, it threatened the sixty-year-old preferential
healthcare pricing for members of organized labor. And finally, the
politicians who were so anguished about the uninsured population might
possibly be more interested in preserving the grievance than achieving
its solution.
I can never remember a private conversation of this sort that didn't
satisfy the doctor who asked the question. And I also never met a
representative of health insurance, hospital administration or
organized labor who would admit any truth to it.
We should take the word of his friend and colleague, Daniel Schaviro, that the core of David Bradford's professional career as an economist was his conviction that a very deep wrong existed when two people could earn exactly the same income over their lifetimes but the one who spent every cent immediately would pay less in taxes than the other who carefully saved for his retirement and heirs. Bradford was offended by this message our society was broadcasting.
Working for a time in the U.S. Treasury Department and later as a member of the President's Council of Economic Advisor's, he was able to explore the mechanical workings of tax law well enough to translate moral conviction into a workable proposal for political reform. In 1977 he published "Blueprints for Tax Reform", introducing these practical ideas at the highest level of academic rigor. The impact of his ideas in this paper extended through three presidencies, particularly the present one.
Bradford saw the tax injustice which penalized the Protestant ethic could be corrected in two ways. Either the tax code could shelter individual savings from taxes until they are spent (the IRA), or else convert the income tax into a consumption tax (like VAT). In either case, taxation would take place at the same time as consumption, rather than at the time of earning. Notice the person who saves money to spend later will suffer from both inflation and taxes on taxes on the inflation "gains". The political choice between the two proposed solutions was made by Senator William Roth (R, DE) who sponsored the Individual Retirement Account (IRA) and shepherded it through an intensely political Congress. His was a wise decision, since its voluntary nature made it attractive to politicians, while the French experience with a mandatory Value Added Tax (VAT) created political opportunities to favor certain industries, which politicians were quick to understand.
After twenty-five initially slow years, the eventual popularity of the IRA has now encouraged its extension to Social Security. That's what agitates domestic policy debate at the time of David Bradford's unfortunate death. The IRA model is also the basic concept underlying Health Savings Accounts (HRA), which struggled for many years but have reached their own period of growing acceptance. The Blueprints idea has thus dominated domestic politics for nearly three decades, while its originator remained largely unknown. Far from being a sign of weakness of the idea, it is a proof of the revolutionary nature of this simple concept that it initially provokes public resistance, but also inspires relentless tenacity among those who have taken up its challenge.
David Bradford returned to Princeton from his Washington experience, resting for decades at the quiet center of an Economics department that is not known for its quietude. After a most unfortunate fire at his home, he died of the burns in nearby Philadelphia, which hardly knew him.
Baruch Blumberg may be an octogenarian, but he radiates vigor and good health; his current intellectual interests are invariably on the cutting edge. He currently serves as the president of the American Philosophical Society, was for five years the Master of Balliol College at Oxford, was the Director of Astrobiology at NASA -- all of them after he had won the Nobel Prize in Medicine, and retired from his laboratory. He likes to run and bicycle, with a long history of disconcerting the populace of China, India, and Africa with early morning forays. His undergraduate major was physics, with graduate work in mathematics. He went to medical school at his father's suggestion.
Hepatitis B
The Nobel Prize was awarded for the discovery of the Hepatitis B virus, for which he developed a highly successful vaccine. It has been estimated that there are 375 million people in the world infected with this virus, and it leads in time to liver cancer, the most common form of cancer in Asia. If you set about to stamp out disease and save lives, it's advantageous to do it with an extremely prevalent disease. And then there are some surprising side-benefits. For some reason, women who are infected with Hepatitis B produce a disproportionately large number of male offspring, so that vast immunization programs in Asia are now starting to result in a larger proportion of females in the population. The lack of female children in Asian families has long been attributed to selective abortion, so it's satisfying to see an abatement of that particular slander.
Baruch Blumberg
Blumberg has twice been invited to deliver a lecture to the College of Physicians of Philadelphia. The first was a description of the problems of space travel. The second was a discussion of current trends in medical genetics. It seems that gene mutations only occasionally cause disease directly. The much more important genetic factor in disease affects the ability of some people to resist particular diseases and makes others more likely to be a victim. Hepatitis B? Well, that's so yesterday.
Both political parties in the 2008 election promised to revise healthcare financing and delivery; the nation was restless. It had been restless since a Republican Congress swept Newt Gingrich to Speaker in 1994. It soon swept him back out of power, but its ability to surprise reappeared in 2010 with Republican Senator Scott Brown's election to Edward Kennedy's seat, and then there was the 2012 Republican Congressional landslide, -- but on the other hand there was President Obama's 2012 re-election. One electoral mandate after another, often sending opposite signals. Only a King is allowed to be capricious, nations are described as undecided. When Democrat Barack Obama won his first election in 2008, a concrete proposal was eagerly awaited because it seemed likely to be radical; it disappointed because it merely overpromised. He neglected the iron rule for leadership: underpromise but overdeliver. In order to retain a free hand, the working elements of Obamacare were never concisely stated; in America, that is usually a misjudgment. After enactment, details can no longer escape systematic examination for what they are, and what they omit. We got rid of our King more than two hundred years ago. Capricious behavior is out of fashion. Over-deliver, that's the thing.
Political strategists calculate sweeping changes have the best chance of approval immediately after a new president takes office. But for the Affordable Care Act, that slogan may still have been true but mis-timed; since overly brief sequencing gave interest groups responsible for Obama's election undue influence over the proposal, with an undue sense of mandate from the elections they won. The resulting legislation, the Affordable Care Act, is heavily slanted toward rewarding the base, and the base expected a reward. With its momentum up, organized Labor, blacks and Hispanics displayed impatience about mitigating features the rest of the nation objected to. As Lyndon Johnson once said, the majority of Americans are non-black and non-poor. Political misjudgment increasingly characterizes Obamacare, which at first seemed so smart about politics..
Thousands of pages of uncoordinated proposals had emerged from four congressional committees in 2010, confusing the public about what the basic proposal was, and making it uncomfortably obvious that the congressmen themselves had neither written nor properly digested it. It was announced as a proposal to expand coverage to the whole population, uncharacteristically saving the resulting cost by eliminating waste and overutilization in medical care. That appealed to the public. But without more explanation about how these goals would be achievable, in fact, whether the premises were accurate, the public could not see how to program expansion and cost reduction were consistent, or how these two thousand pages made them so. Universal health insurance was said to be mandated, but in fact, it doesn't say so. What it says is everyone has a choice between insurance and a small tax. Anyone with a pencil knew what to do next.
Furthermore, the public could not see what urgency justified delivering a stack of paper to congressional authorizing committees in the morning and demanding an affirmative vote in the afternoon of the same day. Consequently, the conviction took hold that what was proposed would end up being a massive cut in Medicare benefits to pay for it. Soon after the voluminous bills were released, the Congressional Budget Office (CBO) further undermined trust in the proposal by announcing its assessment that it would add a trillion dollars to health costs in ten years, but still would only extend new insurance to about half of the uninsured population. That didn't sound like universal coverage at no added cost, at all. Furthermore, the CBO had credibility, in fact, was the only credible agency that had actually studied this massive legislation. The President immediately appeared on television, endlessly repeating the promise that the extra cost would not add one dime to the public debt. Therefore, fear of large impending Medicare cuts had to be entirely plausible if you believed anything the man said. The public uproar about an implausible idea thus became general before members of Congress had time to read it or devise soothing explanations; their floundering upset the public even more.
To rescue the deteriorating situation, the President attempted to go directly to the public with weeks of daily speeches. On one Sunday he appeared personally on five television talk shows. Naturally many speeches were ghost-written, containing misstatements or exaggerations, with the result that the harried President next resorted to heated oratory that would have been excessive even on the campaign trail. He was criticized as using rabble-rousing, undignified for a sitting President. Failing into a "trust me" approach, he actually was left with the difficult choice of withdrawing the proposal or being seen to ram it through Congress on a party-line vote. Party-line enactments of controversial legislation tend to justify the opposition party into repealing a controversial law just as soon as they return to power.
With the public bewildered as to what the proposal really was, enacting something certain to be reversed was even more unappealing. The alternative, a humiliating withdrawal of the proposal, seemed intolerable to its strongest supporters in the base. But reversal did not seem unreasonable to independent voters, who had wondered all along why there was such haste. The nation was fighting two international wars, both of them going bad, and was in the deepest economic recession since 1937. What's the hurry with this healthcare thing? It was a reasonable question, and the President did not help himself by darkly accusing opponents of delaying tactics.
* * *
In this analysis, the following three sections address 1) the proposal and its own flaws, particularly the savage strategy for getting enacted. 2) The growing consequences of flaws in health financing which had long pre-existed Obamacare and 3) An improved proposal, not so much radical, as extensive. For a century, conservative proposals of all sorts have been incremental, creating opportunities for mid-course corrections. Often denounced as hesitant and timid, a grand strategy often takes more time than a pitched battle, but usually advances farther and more enduringly.
Headlines in the Wall Street Journal announced collapse of Congressional healthcare reform. In the same edition, a small short article buried in its depths described a possibly major step toward its reform. Martin Feldstein calmly observed, a tax exemption for healthcare insurance of 2.9% really amounts to a wage increase whose elimination might go a long way toward paying for the eighty-year mess Henry J. Kaiser had created. (In fact, it was effectively taxable income of 4%.)
It was all so simple: healthcare extended longevity, created thirty years of new retirement cost. In turn, exempting the premium for healthcare became a tax-exempt increase in wages -- for the 70% of employees getting insurance as a gift. Maybe not at first, but wages adjust to expect it during eighty years. Social Security could not cope with an extra thirty years, so SSA was going broke, while health insurance was actually the main cause of increased longevity.
But notice how unused Health Savings Accounts automatically turn into retirement accounts (IRAs) for Medicare recipients. So if you are lucky and prudent with healthcare, or if you overfund an HSA, unused healthcare money makes a reappearance in retirement funds where it belongs. If you have used up the money, you have probably been sick, and maybe won't need so much for a shortened retirement. Increasingly, expensive healthcare hits the elderly hardest, so there are many years during which compound interest overcomes inflation. At the rate things are going, retirement may become four times as expensive as Medicare, so let's consider that future.
Medicare doesn't save its withholdings, it uses "pay as you go" and spends the money on other things, like battleships. Therefore, to make any use of this windfall, it is necessary to save it, invest it, and use it for retirement. Just doing that much might redirect the other 30% of the withheld tax to its intended purpose. So the economic effect would be considerable, just by stirring around in that corner of it.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
