Tuesday, May 7, 2019

Where can I donate my pap smear?

I recently dropped some clothes off at a donation site after a doctor's appointment and found myself thinking - it's too bad I can't donate that unnecessary pap smear and lab work I just got instead.

I kept my thoughts to myself, though. The young man taking my donation looked a little awkward already, no need for me to make the interaction even more so.

Every few months it seems social media, or some other quasi news sites, has some uplifting report to share on how a restaurant or school cafeteria or grocery store found a new way to re-purpose its left over food for those in need. They partner with a food kitchen, or make extra lunches for kids to take home on weekends, or sell ugly looking fruit and veggies at 1/2 price but full flavor. We have thrift stores and antique shops for re-used clothing. You can buy almost anything used online, often for cheaper.

While these efforts don't in of themselves lift anyone out of poverty, change social determinants, or even help long term, they can provide some short term relief, a more reliable source of lower cost necessary goods, involve the community in caring for others, and help us recycle high pollutant items.

But do you know what I can't donate or share or give second hand? My healthcare.

It's easy to understand why. It is not as tangible, it's personalized, it involves so many systems and liabilities that it isn't a simple good to exchange. Even the payment for one office visit requires at least 3 different systems to adjust claims, payments, assessment of services, before the transaction is complete a few weeks later.

We don't exactly have "left over"health care. But we should, or could. What we do have is over used, or poorly used healthcare services which could have been spent more wisely, and I'll even say more justly.

Before moving 3 years ago I had a regular check up which included a pap smear. When I moved and got a new doctor and was newly pregnant, I got another one, just 1 year later. I didn't need one yet by evidence based standards, but they didn't have records from my prior doctor and wanted to have one on file. After I delivered my baby my OB doctor did another one post-partum- that was just their policy, how they've always done things, even though by evidence based guidelines I didn't need another one yet. Then this year, just 1 year later, I changed doctors and got another one. They didn't have records of my last one, despite the fact that I could see the my former doctor's office from the window of the new one.

That makes 4 pap smears in the span of 4 years, in which only 1 was needed based on evidence based guidelines that are agreed upon by all major medical societies. Every 5 years is the standard, as long as you ordered the test correctly, the results were all normal, and there were no other big obvious risk factors.

So that makes 3 pap smears that my doctors ordered out of convenience or habit, but not based on evidence. That makes 3 tests, that each cost about 50$, not including any other office associated fees or time spent, that were not needed. Now, imagine if there were about 1 million women (it is way more than that in reality, 1 million is just an easy number to use) whose doctors decided that they would stick with outdated guidelines and continue to provide once per year pap smears because, it is true, insurance will pay for it. In a year, that would be 50 million unnecessary dollars spent and paid for. In 3 years, 150 million. How many uninsured patients could receive coverage for basic health needs for 150 million? And so, I repeat - where can I donate my unnecessary pap smears?

I could use any other number of examples that demonstrate the waste of healthcare dollars, pap smears just happen to be on my mind - the same labs getting ordered by different doctors who don't share results, prescribing new brand name drugs without evidence that they are any more effective than the old ones, labs or tests ordered out of physician fear or to calm patient fears or out of habit. The list could go on.

I'm certainly not advocating to take away or refuse evidence based and necessary services. And I spend enough time arguing with insurance companies about what is evidence based and necessary to know that they are not the best first line decision makers on those questions. We don't always have perfect evidence, and sometimes it's frustrating when new evidence changes formerly tried and trued methods. But that is the journey that those in healthcare signed up for. To make the best decision today with the evidence published last night.

The very purpose of the field of medicine is to use evidence - ideally from well designed clinical trials, but sometimes just from years of collected experience - to improve the health of others based not on their insurance or race or disease state, but based on their humanity. When we stop using up to date evidence, the result is not neutral. The result is a violation of the very first oath taken as a physician: do no harm.

We typically think of this harm being done to the patient in front of us - an unnecessary lab test they got charged and poked for, radiation exposure from an unnecessary CT scan or complications from a procedure that didn't follow evidence based guidelines. But there is a responsibility to think as well about the millions of other patients that are not in the room at that moment. People whose insurance premiums go up when we over use the healthcare system, leading to a poorer and more under-insured population. People who needed that test or procedure but don't have access to it.

It is the patients who are not yet patients, because they don't have access to the healthcare system, who often are done the most harm when we overuse our healthcare system either as patients or as doctors. They are our patients just as much as anyone who walks into the waiting room with a newly minted insurance card.

We often think of living in excess to be defined by ones clothes or houses or cars or vacations. But if we are to argue that access to healthcare is a right, or that it is at the very least a matter of justice, then we have to accept that misuse of it is not our right and contributes to injustice. As with most matters of rights and justice, we have to look at our own misuses and inconsistencies rather than just demanding policy change and political action, though these are also generally necessary.

Like food, healthcare is not an infinite good springing from some magical well that will never run dry. We have a finite amount of healthcare dollars invested by the government, a finite number of doctors and places for care, and a finite amount of money individuals are able to spend. All those categories could be changed or increased to facilitate improved access, but the truth remains that it healthcare is finite. And just as access to food can nourish or starve, keep alive or kill, so can access to healthcare. Food pantries will not ultimately save the hungry and free clinics will not save the sick. Food can be given and shared and distributed more easily, but healthcare has a secret weapon: evidence. Evidence gives healthcare the power to provide high quality care equally, which is to do justice to the humanity medicine has sworn an oath to not harm, and whenever possible, to embolden with more life.

Monday, November 12, 2018

I Hate Guns

I do, I hate them. I hate them the way I hate cancer, and car accidents. Except, I actually hate them more than that. We have them, and they aren't going anywhere. And since that is the truth I don't have any problem with the 2nd amendment. I disagree with the way it's used and abused these days, but, then, we can all disagree about a lot of things. I understand there's probably a reasonable place for them in the present day, and that their presence in the past is part of what shaped our country's founding, independence, and power. I'm not sure how proud I am of that particular history, but it's the history I have and bearing arms was an important part of it.

All that said, I still hate guns. I find them to be one of the most offensive items in our current society.

I spend years working with patients to improve their health just enough to lengthen their life by a few years. Aside from the rare though gratifying life saving moments I have, the vast majority of medical work is long and slow. It's like long term counselling for your body. No one changes overnight, and the reality of our mortality is ever present. Some medical advances have more impact than others, but even when you look at the big picture - modern medicine has lengthened the average lifespan by about 15-20 years if you go back a couple of hundred years. And it has took trillions of dollars to do so.

A gunshot can steal away a life in seconds. We spend trillions to be able to lengthen lives by a fragment of the amount of life that can be stolen by a bullet. As someone who is charged to do no harm, to improve the number and quality of our days on earth, and who does so at great cost to patients and taxpayers (those are actually the same people, remember?) it is offensive to then also allow weapons to exist so rampantly in the community that can undo countless dollars and hours of effort towards improved life in just seconds. How can we pour words and time and money into healthcare (or education, housing, public safety), while in the same breath sanction those tools which so carelessly and carefully take away life. It is a contradiction at it's core. We cannot serve two masters- either we love life, or we love death. We'll never be perfect at loving life and choosing life, but we love and choose death too much.

Have you ever stuck your hand into a bullet wound? I have. I'll never forget how warm my finger felt, my right pointer finger, when it pushed it's way into the bullet wound hole of young man in the ER in DC. He was shot in the neck. He was probably already dead, but as a med student I foolishly thought maybe if I put my finger in to stop the bleeding it would help. But I was useless. And for once, I wasn't useless just because I was a med student, we were all useless in the ER that night. That was the first bullet wound I touched, but by far was it the last.

The holes bullets make in flesh are remarkably clean because the bullets go through so fast. It is almost hard at first to believe such a small hole can do so much damage except that there is so much blood. But isn't that just the problem? This small machine can do so much harm with so little thought and with so much thought. It's an equal opportunity killer when it comes to forethought, though not equal with who it kills.

I've never seen a toddler killed by accidentally firing a bayonet.

I'd just as well get rid of guns all together. It won't happen, but I think it's the right thing for any society aiming to love life, liberty and happiness. Find a different way to command force and fear and public order. Find a different hobby or sport. It isn't a luxury worth having. It's not that some of us should have them and not others. None of us should have them. Radical, I know. But wrong? They came about as a necessary evil and we got addicted to their ability to command armies and nations, but also friends turned enemies, spouses turned traitors, black bodies, and kids. But, really, is evil necessary? I don't believe so; it isn't what was meant to be, what is meant to be. Evil is laced with good explanations and intentions about culture and context and rights and history. Evil is convenient. But the argument that better or safer life can be achieved through instruments of death was valid once in history, in Jesus, and we are arrogant to think that it is a power we are sanctioned or able to wield.

Also relevant: https://www.bbc.com/news/world-us-canada-46186510

Wednesday, September 5, 2018

Cookies for Communion

For months, maybe even close to a year, Theo has been fascinated by communion time at church. That makes sense - it's dynamic, kinetic - any on-looker can tell there is something different going on. There is walking and pouring and cracker breaking and singing. It is also conveniently right before lunch time, and little growling tummies (and big ones, if we're honest) join in the holy chorus. "I'm hungry," he often whispers, as he squirms in his seat, waiting to be done.

Those growling melodies are a helpful analogy. "Just like your body needs food and water to live and be strong, our souls need Jesus, body and blood, to live also," we often tell him.

Our souls growl, too. It sounds less like a broken garbage disposal (which is my best descriptor for a serious stomach growl) and more like a heavy sigh at the brokenness of the world; the discontentment with life even when things are going pretty well, but especially when they aren't; the longing for better love, even when you know you're loved, but especially when you don't; the disappointment in bodies that fail and relationships that fade; the frustration of always battling the same imperfections; the need for assurance that everything will be alright, will be made right.

Delightfully, Theo has absorbed all of the motions and words that get said as the wine gets poured and bread broken. Months ago I noticed him at the playground, holding up his ritz cracker snack to the sky, reciting, "the body of Christ, broken for you," cracking his salty snack in half, and proceeding to hand it out random kids and pigeons at the park. It was sweet...and salty. I didn't realize what he was doing initially, his words at the time still had a little bit of that toddler lisp left in them. When asked, he replied, "everyone needs some crackers." He doesn't know how right he was. (Apparently he's been doing it at preschool this week too?! Can't wait for our next parent-teacher conference...)

He still has some learning to do about communion. I'll admit it must look a little bizarre without context - some guy up front holds up a cracker like he's worshiping the cracker god, breaks it, then a bunch of adults and some kids go eat one and drink from a germ infested cup and then sit down. We're glad he's got some developing context and age appropriate sense of holiness.

The other night, after dutifully eating a respectable amount of dinner, he earned his chocolate chip cookie dessert. We were cleaning up dishes already as he got his prized treat. Sitting tall in his booster seat, he held it up to the sky, as far as his little 3.8 year old arms would reach, "the body of Christ, broken for you. Take and eat in...Christ died....thanksgiving." His voiced trailed off towards the end in part because he couldn't remember some of the words, and in part because he was really excited to get that cookie into his mouth. It was the holiest of unholy communions.

He finished with a grin. Cookie crumbs on the floor from his less than perfect breaking of it and traces of chocolate around his mouth where his tongue can't reach. "All done!" he proclaimed. All done, indeed. I doubt that the church at large will move towards serving cookies for communion (but really, who would complain about it?!), but what a sweet picture of the grace that is offered. Jesus' body isn't the broccoli your parents make you eat, or the pizza that is delicious but makes you feel bad later. It's the joy of a single chocolate chip cookie, completing a meal, ending a day, satisfying not just hunger, but providing more than enough.

I'm hungry. Everyone needs some crackers. Cookie communion. All done.

Would that our hungry souls mirror this sense of need, community, sweetness, satisfaction.

"Taste and see that the Lord is good." (Ps 34:8) Even as good as a chocolate chip cookie. Maybe, we'll find, even better.

Sunday, August 27, 2017

The Year of the Hurricane

1 year ago this week Theo and I caught the last flight into Tallahassee's airport before Hurricane Hermine. We had planned to leave the following day, but made last minute changes when we saw the weather. Jonathan was already there, camping out in an empty house and getting ready to start teaching.

We had known we'd be moving to Tallahassee for 16 months before moving day actually arrived, and yet the last minute change in plans, the cancelled goodbye dinner planned for the following day, the chaotic hustle to check out of work early, the scramble to get an airport ride and hours on hold with the airline made the move feel sudden. It felt like rushing out of a birthday party because your kid fell and broke his arm, even though you knew you were going to leave just 30 minutes later anyway.

Despite starting off with a dramatic storm and a week without power, the year was less like a storm, and more like an intense sports match. There were notable highs and lows which caused cheers and tears, but the majority of the time was spent in a high power dance between defense and offense. I'm not sure who won or lost, or even really who the opponent was - perhaps my expectations, my past, my future hopes? I definitely did battle with several thousand mosquitoes.

Still, it was a stormy start, and the analogy of "rebuilding life" after a major event, like a hurricane, feels apt. I found myself often torn this year between the desire to rebuild what I used to have and what was familiar, with the reality that those habits and patterns don't all fit into life in a new place. When people talk of rebuilding after a storm, they rarely rebuild the exact same house, in the exact same spot. Their favorite elements remain the same, I would think- perhaps the location, or the style of home, or how big it is. But an exact replication would be, if anything, foolish. A new home should be safer, sturdier. It would be foolish to plan for a new home and keep the faults - the creaky floors or sticky windows or awkwardly shaped kitchen - of the old home. The past should inform the present, but not limit it from growth.

There was nothing so perfect about my life in DC that it warranted replicating so exactly. And yet, I struggled not to replicate it because at least I knew how to live life in that structure. But, just like new wine will rip open old wine skins, a new city and job and space literally did not fit into expectations and daily life strategies that worked well in a different city and season of life. What I needed was not skills in memorization - the repetition of words and concepts that don't change. What I needed was wisdom - the application of skills and concepts learned but applied to a life that is dynamic.

Wisdom has the ability to fully hold the past and present (and sometimes the future) at the same time, to see and know them both, and to act in accordance with that truth and knowledge. Wisdom doesn't rebuild the old, it creates the new. Creation is a lot more work than replication. Better and more fruitful, to be sure, but more work.

I'd like to think that a year after our hurricane, we've got a solid foundation build. There are even some metaphorical walls and decorations up. Still, for better or worse, I get a lot of comfort from moments that remind me of more familiar life patterns - long weekend walks, the diversity of people seen in public spaces, the familiar frustration of healthcare system. They are sweet moments of God saying, "here I am." Because, unlike my wisdom, which is ever-lacking despite feeling like I'm constantly growing, God's wisdom- His ability to be true to past, present, future, and self all at once, and to act accordingly- is not lacking, and is that constant companion calling out, "here I am."

This year was not about starting new, because God is too kind to give us blank slates to work with. It wasn't about re-building the old, because, well, I tried that at first and it didn't work! It was about learning to need and find and grow in the wisdom of a Creator whose constraints are not location and experience and comfort, but rather goodness and truth and beauty.

Sunday, July 16, 2017

Walk Two Moons

“Don't judge a man until you have walked two moons in his moccasins.”― Sharon Creech, Walk Two Moons [adapted from a Native American proverb]. I have fond memories of reading this book as a middle-schooler. The details are long forgotten, but the themes I can still recall.

Last week I got in a fight with my doctor. Ok, so it was really more of a medical disagreement, but it felt like a fight. It had that bitter aftertaste of discontent, like when disagreements reach a conclusion but emotions are still at odds. We disagreed by 7 days about the most accurate due date for baby girl.

It was not your most typical doctor-patient disagreement. I have both the benefit and burden of also caring for prenatal patients, so I'd like to think I know what I'm talking about when it comes to establishing an accurate due date. If the roles had been reversed, and I was the doctor, I would have agreed with myself. I had assumed it was something we would agree on. I don't have a lot of experience with different doctors in this city, but she seemed like a solid choice- I had no reason not to trust her medical knowledge. (though, to be honest, I mostly choose her office because as an OB she worked together with a midwife partner which I appreciate, and because her front desk staff was nice and efficient).

Now, practically speaking, it probably won't matter too much which due date we pick. I will probably go into labor right around those two dates anyway, and the difference of a few days won't change matters. That said, it could matter. It could change when I decide to start my leave, if I would need to be induced, if I need extra (expensive) post-dates testing, or if a baby would be called preterm or post term. It felt like it mattered practically, even if chances are it wouldn't change much either way. It also mattered that we made a decision based on all the best facts, to the extent that we were able to do so.

On her end, she had to trust some of the facts I was telling her. She also was having a bad day- her partner called out with a broken rib and she had to cover clinic and the hospital floor. I know how that goes- I would be stressed and rushed, too. She needed the time to document, emotional energy, and patience, to have this discussion, change her mind, and come to an agreement. She did, in the end, reluctantly agree with me, though perhaps more out of exasperation than conviction. I won, but it didn't feel like winning.

That's a long story simply to reflect on the fact that we become better providers and receivers of goods and services when we experience both sides of that economic coin. I am a better doctor - more patient, a better listener, a better teacher-  when I am also a patient. I am a more gracious and understanding patient because I am also a doctor- long wait times, frustrating insurance problems, last minute schedule changes, I know that's not what any doctor wants (though I also might be more annoying when I refuse to do non-evidence based lab work or tests...).

Depending on our profession, we can't all quite so smoothly experience both sides of the coin. I suspect, though, that making a significant effort to do so would go a long way. Regardless of profession, we all have a chance to do this socially, economically, even racially (to some extent). "What's it like to be you?" we need to first ask, and then endeavor to experience.

That's what incarnation is. It is embodying, en-flesh-ing, the life and world of an "other" out of a desire to know and be with them for the purpose of forming a better, truer, relationship. It reconciles and restores us to one another in ways that we didn't even know we were un-reconciled and broken. It helps bridge power differentials in a way that is mutually beneficial, though perhaps not always mutually comfortable. Rather than changing us to be like someone else, incarnating the life and experience of others makes us all better, fuller, truer selves.

Sunday, May 7, 2017

Healthy Stools

There's been a lot of talk about healthcare, and I'd like to do some defining of terms when it comes to health, medicine, and what it means to be healthy.

Medical care and Health Care are different. This, I believe, is at the root of the problem with our insurance system. That is a blog post for another day. Medical care provides medicine, operations, and concrete solutions to clear diagnoses and problems. The goal of medical care is to make some one who is sick, better. This is important! Health care, I would argue, includes medical care as I've just defined it, but goes on to also focus on preventing medical problems before they arise (good medicine is awesome, but isn't not getting sick even awesomer?!), educating patients on medical concerns that may arise in the future, addressing ones hopes and fears in relation to living, dying, and just getting through daily life with as much purpose, energy, physical and emotional wellness possible. (our insurance system was set up to address medical care, but research and experience have lead the medical community to want to provide health care...but like I said, a blog post for another day).

Our health (and therefore our care of it) comes from 3 different places. I often describe this to patients as a three-legged-stool which, without any one leg, wouldn't be complete.

One leg is made of the health related factors that we are born with; our genetics. In medicine we call these non-modifiable factors. You have no control over them. This includes your genetic predisposition for cancer, or diabetes, or any number of illness. It also includes your race, body type to some extent, and some behavioral tendencies as well. One day these may become more modifiable, though I expect even then, our genes will have a large influence over our health.

One leg is made of health factors that are largely up to us. What you eat, if you smoke, how much you drink, if you exercise, if you wear a seat belt, what type of physical and emotional risks you take...etc. We call these modifiable risk factors. They are aspects of health that can be changed by your actions. Though, it is important to point out that while all of us have choices, for some of us the healthy choices are easier, more obvious, more available. For others, they are options in theory, but in reality much harder to choose, even if desired.

The last leg is made of health factors that happen to you because of your surroundings. They didn't have to happen, and are therefore technically modifiable, but they are also largely out of your control. They are modifiable by someone - your parents, the government, your city officials, those with more power and influence than you, but you yourself can't do much to change them. Some examples might be - having a parent who smokes, causing respiratory harm to a child; a city with high lead content in its water causing lead poisoning; what your school serves for lunch; the safety of your neighborhood.

Health care (care for one's health), I would argue, can be seen in a similar 3 legged stool analogy - if you remove any one leg, the goal of improved health becomes much harder.

One leg is the patient - they can choose to follow medical advice, take medications, alter modifiable risk factors, and be an active participant in getting or staying healthy. We all acknowledge that there is some degree of personal responsibility in the movement towards health. It is important for one's mental and emotional well being to find ways to be in control of one's health.

One leg is the doctor or other health care provider, and her or his specific recommendations and treatments. It's the medical professional's job to explain diagnoses in clear terms, review treatment options, discuss goals of care, and pick a plan going forward that is both evidence based and realistic for the patient.

The final leg is the medical industrial complex - insurance companies, pharmaceutical companies, regulatory organizations. From what medication is covered, to how many doctor visits are allowed in a year, to how many days of rehab you are allotted, to which doctors you can see, to how much your doctor will get paid for the care they provide, these groups have a lot of power.

I like the stool analogy because it demonstrates how reliant each leg is on the other one in order to create a sturdy, safe, reliable system of care. If your genetics are so strong in predisposing you to a certain illness, then sometimes there isn't much medicine or you can do to help change that as much as you'd like. If your environment leaves you with so few reasonably healthy options for food, activity, education, mental well being, it is hard to over power that with pure will power or medical advice. If you put no effort into wanting to improve your health, even the best doctor in the world won't get far in making you healthier. If you are highly motivated, but have a doctor who suggest culturally or economically unrealistic treatments, you feel stuck. If your insurance, or the price of a medication, or even the existence of an approved medication, is out of line with your needs and reality, then even the best health care goals and plans won't help you very much.

Whether we like it or not, these three pieces are woven together to make this system we've created called Health Care. A less than holy trinity. But, as power and influence shifts more to one leg, we become unbalanced. Sometimes this unbalance is non-modifiable (genetics) or very hard to modify (systemic poverty and all its causes), and sometimes it is hard, but slightly more modifiable (policy, law, regulations, encouraging evidence based medicine).

We're all faced with a different set of modifiable and non-modifiable factors that affect our health. But for many, there are aspects of their health which should be modifiable that have become non-modifiable, and this is the greatest task the health care world has to address right now.

PS - extra props if you got and enjoyed the pun in this blog title. :)

Sunday, January 29, 2017

Nazis and Refugees

My ancestors were both Nazis and refugees. So are most of us.

I was born in Germany, and half of my family is German. My grandparents and great grandparents lived in the eastern German countryside, with a few of them also in Berlin. There's not exact information about what they all were doing during WWII, but the evidence generally indicates that some escaped to the countryside to avoid all conflict, and others, though not my direct grandparents, were likely Nazis.

When the war ended, my grandparents were still in eastern Germany. The Berlin contingent experienced the soviet blockade in the 1940s, and moved as far West in the city as they could afford. The eastern Germany group was forced into the Russian labor camps. While they weren't concentration camps, conditions were bad, food was scarce, lives were lost, and my grandmother was raped. They were, somewhat miraculously, released, and returned to eastern Germany to settle down once again. There, my dad was born. When it became apparent that conflict with the Soviets was not going to end, and the Iron Curtain began to fall, they escaped on literally one of the last trains to cross from East to West Germany for the next 30 years. The needed refuge. They lived in Hamburg and Berlin for the rest of their days. There I was born, in West Germany. My baby clothes and toys are marked, "Made in West Germany." **

We moved to the US in the late 80s, after seeing the Berlin wall come down. My father brought me a piece of it - graffiti red and black on one side, and grey concrete on the other.

I loved my German-ness. I enjoyed our few remaining traditions, being able to speak German, getting to travel internationally at a young age. It made me feel unique. Until 6th grade. Our history class did projects on injustices throughout history. At least half of them were about the Holocaust. It took me years to figure out how I could feel ashamed and sorry for something that happened before I was born. I could have gone off-campus to take German as my required foreign language. Instead, I took Spanish.

This (his)story may sound uniquely dramatic, but it's not. Not really.

Most of us have within us, within our families, within our culture or country or religion, stories of being oppressors and being oppressed. Perhaps not to this degree. Nazis, after all, are essentially the gold standard example for oppression, injustice, and hate. They may not be our personal stories, but we carry them with us. We exist, because of and in spite of them. Some of our stories are neater, more obviously lacking of evil and oppression, and perhaps more filled with mercy. Some are messier, making us feel dirty and wishing we could dissociate from that part of our unchangeable identity.

I've thought again and again about how to hold these two identities at the same time. I've wondered, what I would have done, had I been alive back then.

At any given moment, we all hold the ability to enact either hatred or mercy. It's a grace in and of itself that we're able to choose mercy and kindness as often as we do. At times we are the oppressed, the refugee- powerless, alone, vulnerable, the object of oppression. Some face this intensely and physically. At times we are also the oppressor, or at least given a choice of being the oppressor- powerful, safe, able to harm others. Some experience this in large, dramatic ways; all of us experience it in smaller, day to day actions and choices.

Just as my family history holds both evil and escape, hatred and harmony, mercilessness and mercy, so do I. So do we all.

Let us be refugees from our own hate and fear- to flee from evil and darkness, and run with abandon towards goodness and light; to find refuge in something outside of our selves.

** while my family were not refugees when they came to the US, they were relatively well-off immigrants, they were also descendants from one of the largest terror organizations, in modern times. Yet, we had no trouble getting into the US.