Separation, Alignment, and Cohesion

The Lake Murray Purple Martin Sanctuary on Doolittle Island is the largest roosting site for purple martins in America. I remember traveling by boat one summer evening to watch as flocks of thousands of birds formed animated clouds above their nesting grounds. Innumerable individuals appeared to be traveling as a unit, then suddenly a small group would break the pattern followed by the entire flock rapidly flowing in a new direction. These patterns repeated and merged in a mesmerizing display, giving the impression that the flock was not a collection of individuals but a single pulsating mind.

Of course this appearance of intelligence and purpose is an illusion. It’s an emergent phenomenon called flocking behavior—and it’s not unique to birds. Other organisms exhibit analogous behavior, from schools of fish to lumbering herds of ungulates. And despite the resulting complexity created by flocking, the basic rules are quite simple. It’s like a computer algorithm where simple lines of code, when iterated, produce complex and aesthetically pleasing fractals.

Computer models can easily mimic the appearance of flocking with only three simple rules: (1) Keep consistent separation from your closest neighbors, (2) align yourself in the general direction of the group, and (3) maintain cohesion by moving toward the average position of those around you. Separation, alignment, and cohesion—it’s that simple.

As beautiful and orderly as flocking behavior appears, there is a darker side. After all, at its root is mindless instinct. Inattention to danger and a blind focus on following others can lead to innumerable deaths when flocks fly into buildings, or when stampeding herds trample the slow and weak.

Separation, alignment, and cohesion. Sadly, human society at large is not immune from these instincts. Witness the long history of popular delusions, financial bubbles, and destructive political movements cheered on by demagogues. Viewed through the lens of history, these human phenomena appear as incomprehensible as schooling fish who foolishly swim into the mouth of a predator.

Speaking of incomprehensible, if you have a progressive inclination, the recent election probably seems as unfathomable as a panicked flock of martins. In these final weeks of 2016, it is impossible to predict what effect the election results will have on health care policy. But if you take politicians at their word, the Affordable Care Act is as good as dead. Immediate repeal, repeal and delay, repeal and replace—the operative word here is repeal, and the results could be disastrous for many of our patients.

This is a shocking reversal of fortunes for the healthcare reform movement. Over the past 8 years an unlikely alliance of advocates came together to support the adoption of the Affordable Care Act, and to continue defending it from a series of court challenges. Consumer groups, business groups, and nearly every medical professional society, including our own AAFP, supported and fought for the ACA.

Even the AMA, long an opponent of “socialized medicine” continues to support the goal of “ensuring that every American has access to affordable high quality health care coverage” (H-165.841). It also supports a system of “tax credits inversely related to income or other subsidies to obtain health care coverage” and “using the tax structure to achieve compliance” (H-165.848), which is a pretty good summary of how Obamacare works.

Being aware of these stated goals, I was shocked to see the AMA announce its enthusiastic endorsement of Dr. Tom Price for Secretary of Health and Human Services. Dr. Price, a congressman and retired orthopedic surgeon from Georgia, has long been a leader in the movement to repeal Obamacare. He has also expressed a desire to privatize Medicare and turn Medicaid into a block grant program while eliminating the expansion under the ACA.

These positions are in direct opposition to recent AMA advocacy, and precipitated an angry backlash from many AMA members. Dr. Patricia Harris, the AMA Board Chair justified the endorsement based on three factors: (1) He's a doctor, (2) he supports medical liability reform, and (3) he's a good listener.

Harris further justified the endorsement by comparing it to the nomination of C. Everett Koop as Surgeon General during the Reagan administration. Koop, whose well-known anti-abortion views prompted opposition from many physicians, is now remembered fondly as a physician who put science before politics in fighting the tobacco industry, and is hailed as a role model for addressing the incipient AIDS epidemic. But the nomination of Price is very different. Koop was an apolitical figure who held a position of advocacy. Price is an ideologue, far outside of the mainstream, who will soon control a trillion dollar federal agency with independent authority to set health care regulations.

Why would the AMA abandon its principles and support a nominee for HHS Secretary who wants to unravel 50 years of progress toward universal coverage? The most likely explanation is that they’re making sure physicians don’t get separated from the new center of power. And they want to align with the new administration while maintaining cohesion within their own organization. Separation, alignment, cohesion—it’s the dark side of the flocking instinct again.

Fortunately, everyone isn’t flocking. Our own Academy’s response to the nomination was measured and polite, simply congratulating Dr. Price on the honor of the nomination while pledging to continue working to improve the health of the nation.

Others have been more forceful, including the American Congress of Obstetricians and Gynecologists who offered their organization as a resource while calling out the congressman for his history of supporting legislation that threatened women’s access to reproductive health services. The American College of Physicians issued a simple and wise “no comment.”

I fear we are all caught up in a headlong rush to unravel the foundations of our healthcare system without a clear vision of where it will lead us, or a decent regard for those who get trampled on the way.

The Scottish poet and journalist Charles Mackay noted, "Men, it has been well said, think in herds; it will be seen that they go mad in herds, while they only recover their senses slowly, and one by one."

Flocking may be natural, but men and women can rise above their darker instincts. We and our institutions, like this Academy, can be guided by evidence and reason. All it takes to turn the herd away from disaster—and to keep bending the arc of history toward justice—is for a small number of individuals to rise above the compulsion to follow their neighbors into oblivion.

This article was published in South Carolina Family Physician.