Big Med: Megaproviders and the High Cost of Healthcare in America

Big Med: Megaproviders and the High Cost of Healthcare in America by David Dranove & Lawton Burns argues that the source of most of the high healthcare costs in America can be attributed to megaprovider healthcare systems. These are also known as Integrated Delivery Networks (IDN).  'Megaproviders' refers to large, integrated hospital-based systems which own and operate multiple healthcare facilities ranging from inpatient to outpatient need. As of this book written in 2020, US health spending approached nearly 18% of GDP. Translated to hospital systems, these entities, although viewed largely as beneficent, are huge companies. “About 52% of every dollar spent on health care goes directly to hospitals and doctors,” (p4). According to the authors, there are several issues related to megaproviders: on the administrative side, many administrators are business people, not doctors, creating a cultural incongruence between those who run the institution; anti-trust practice struggles with how to define a market appropriately; on the political side, megaproviders are seen as trusted healthcare providers in a community- not exploitative businesses, like Pharma and insurers are perceived.

When hospitals, physicians, and insurers integrated in response to the never-realized Clinton Health Plan, it was a race to become big. Megaproviders, aka IDNs, typically included the four components:

• Horizontal mergers with other hospitals, especially community “feeder” institutions
• Primary care and specialty physician practices
• Freestanding outpatient and/or diagnostic facilities
• Therapy and/or home health care services
• Long term care facilities
• PLUS sometimes their own insurance

Many physicians were intrigued by this model because of the appeal of a fixed base salary at a hospital. However, where this model fails catastrophically, is the megaprovider administration’s lack of coordination with individual care providers, resulting in a “power of the [physician] pen” that disregards cost of administration for each service. The thesis of the book is this: “Physicians authorized or influenced most hospital spending; if they were not attuned to cost containment or quality improvement, hospitals would have a hard time satisfying the dictates of managed care. IDNs could not profit from [insurance plans] without reducing health spending, [which required] changing the profligate ways” physicians were rewarded for fee-for-service medicine ([69). Physicians control about “85% of all healthcare spending, either directly or indirectly,” (p64)

As hospitals acquired practices, they offered physicians annualized salaries. Hospitals grew and grew in the name of integrated care. But, anyone who has been to a hospital knows that they do not typically receive coordinated and holistic care evaluations. Administratively, meaningful change in care provision is impossible without provider buy-in (p148). An example of what coordinated care could look like is, within an IDN, the insurer requiring lower copays for prescription drugs prescribed to prevent more expensive medical care (p212), but that does not happen often. From a business perspective, the hospitals offered salaries they could not pay without increasing patient volume, incentivizing myopic care, longer hospital stays, and other billable expenses to be paid by payers. Furthermore, total reimbursement to hospitals for the same service as an independent physician is far higher, due to the payment formula (114). 

Additionally, the authors contend that a big part of high healthcare costs is due to the monopolistic behavior of hospitals. Thus, authors suggest, and federal agencies have pursued anti-trust law to prevent monopolies in healthcare. The authors provide two main goals to drop healthcare costs: 1) Maintain at least three competing value chains 2) One value chain should consist mostly of independent providers (p235). The authors assert that “competition should promote experimentation, but that doing so requires…independent providers” (p231). 

Big Med poses a challenging idea that the doctors and hospitals people think of as 'their' doctor or hospital likely has a much bigger role in that person's healthcare cost than they expected. They suggest leveraging basic economics to ensure lower healthcare costs. Overall this was a pretty good book. It took me a bit of catching up on healthcare policy, but I learned a lot. Thanks to my friend, Melissa, for the recommendation!

Not related to the book topic is an interesting theme, though influenced by the backgrounds of the authors as first-hand accountants of megaprovider cost and academics: I didn’t fully appreciate how intertwined academia is with everyday life. Without academic reports and papers providing the basis for new healthcare models and a review of antitrust, major providers would not be broken up and costs would remain high. 

Miscellaneous definitions:

• There are two main ways to look at care provider payments. Fee-for-service payments refer to payments made for a specific service, such as MRIs, bloodwork, etc, and are most common. Value-based care refers to payment for outcomes of the patient and can include overall health, patience experience, etc.  
• Preferred Provider Organization (PPO): allow use by enrollees in and out-of-network without referrals. 
• Accountable Care Organizations (ACO): a group of healthcare providers that provide coordinated care between specialties. 
• Health Maintenance Organizations (HMO): care only by in-network providers who have contracted with the HMO. This care is typically local and focused on prevention and wellness. 
• There are a number of different entities represented in the healthcare ecosystem. Payers are the entities which pay for the service. This is typically a commercial insurance company, government provider, or employer, or patient. Then there are also full risk contracts, which can refer to value-based care, as it transfers the full risk of patient care to the provider from the insurer. This was referred to often throughout the book. 

Adult Children of Emotionally Immature Parents by Lindsay Gibson

Adult Children of Emotionally Immature Parents by Lindsay Gibson is a self-help therapy book, which isn't my typical pick, but it was good. The book focuses on the developmental impacts of emotionally immature parents and, essentially, destigmatizes this experience and encourages the reader to change or remove expectations of their loved ones that will never be met. 

The book emphasizes that, although emotional interactions with parents, particularly as a child, should be about the child, many times they're not. This can lead to people feeling emotionally lonely (p26). The author asserts that "mutual emotional responsiveness is the single most essential ingredient in human relationships," (p39). 

Miscellaneous:

- The author says that sometimes, emotionally unaware people cannot control their emotions. An example of why this could be the case is that, instead of having a parents "squelch their distress, they never experienced the natural rhythm of a crying episode and how it winds down," (p76). 

- "Internalizers may feel emotionally nurtured as they resonate with the beauty of nature or art," (p175). 

- "How do you define a successful person?..I guess, first of all, you get rid of 'success'- and then you see who you are as a person," (p215).

- "Explicitly say what you feel or want and enjoy that act of self-expression, but release any need for the other person to hear you or change," (p235).

- "You may not ever have the kind of relationship you want with [your loved ones], but you can make each interaction with them more satisfying for you," (p270). "You're likely to find that your relationship with [your loved ones] becomes more tolerable as you relinquish the need for their emotional acceptance," (p275). 

- "Compromise doesn't mean mutual sacrifice; it means a mutual balancing of desires," (p287). 

Questions I found interesting: 

"What are you glad nobody knows about you? How would you describe the social role you try to play? How do you hope others see you? Which of your personality traits do you try to cover up?" (p200).

The Art of Power by Nancy Pelosi

 It has been way too long since I've finished a book, jeez!

The Art of Power by Nancy Pelosi was kind of a political practitioner's handbook following the timeline of Nancy Pelosi's big moments of her career. There were so many nuggets of political wisdom, in fact, that I'll actually list them all below:

• Know your votes; "a successful [person] must never be surprised by anything. You must know what all the possibilities are, all of the time," (p39, p46)
• "Where we can find our common ground...we shall seek it...Where we cannot find that common ground, we must stand our ground," (42)
• Do not delay on controversial items- "Everyone with an agenda will chip away at your delayed decision," (p47). 
• The thinking that informs and supports a [person's] intuition must be strategic and respected it. That is why..it is absolutely vital to maintain a constant level of member contact - you need to know what your members are thinking," (p47). 
• "As with a kaleidoscope, the coalition that works in one design is not necessarily replicated in another combination," (p48). In other words, you may find strange bedfellows in one policy fight, and those same individuals your opposition in another. Further, "We don't want to weaken or dismiss anyone for one position they may hold- because they may be vital to the overall design of another issue and another important vote- and soon," (p50).
• A quote from a survivor of Tianenmen Square, "if we had fought our struggle with violence, we would not have as many friends as we do now," (p140).
• In Washington, the unwritten rule is that the leader who hosts the meeting controls the agenda," (p151). It is also protocol, in a meeting with the president, for the president to open the meeting then recognize the Speaker of the House for comments," (p166). 
• Demonstrating the power of institutional knowledge and knowing the rules of the game, "[late Senator] Harry Reid demonstrated his highly regarded effectiveness by requiring all senators to remain in their seats while the votes were cast," (p173).
• In a bind, "according to the rules of Congress, passing a budget bill would enable us to use a process called reconciliation-which lowers the number of votes needed to pass a measure in the Senate from sixty to fifty-one," (p192).
• "When members are asked to make what is for them a difficult vote, they need to know that the bill will be signed," (p239).
• "Leadership means never being content with history, when you can and must make progress," (p303).

Some hope despite the state of US politics, what saved the Affordable Care Act after Trump was elected in 2016 was outside mobilization. Hopefully we can make that happen again. 

Good book- would recommend, but mostly for those working in politics. 

The Quartet: Orchestrating the Second American Revolution, 1783-1789

 The Quartet: Orchestrating the Second American Revolution, 1783-1789 by Joseph J Ellis explains the inner workings of "the room where it happened" and, specifically, how Washington, Hamilton, Jay, and Madison with the critical support of Goveurneur Morris and Robert Morris (unrelated) transformed the path of a politically sensitive nascent America. 

To set the stage for the time period, there was no sense of "America"; democracy meant mob rule until about 1830; capitalism had never appeared until the mid nineteenth century. The colonies would not pay for the Continental Army, forcing the government into debt. Our Continental Army was fighting the British without shoes or coats. The America we know today was, structurally, nothing like the one we know today. After the American Revolution, there was such intense scrutiny on Britain and its government that, after the war, the colonies were largely uninterested in supporting a new version of Britain, aka, federal government. The initial document holding America together was the Articles of Confederation, lacking any central anchor for the 13 colonies. Washington, Hamilton, Jay, Madison, Morris G. and Morris R. saw through the war's debt that, unless the colonies came together under some type of central government, there would be no America. 

In terms of personal reflections, it was interesting to read this book after finishing Imagined Communities which explored nationalist movements, indeed highlighting America's. To think of these men as nationalists is a funny framework; nationalism was a critical mechanism to making America work at all. In other countries, nationalism tended to be a dividing force between the colonizers and the colonized. 

Additionally, in today's context, the book is extremely relevant: "the confederation model nearly lost the war. And if it persisted in its current form, [George Washington] believed that it would lose the peace," (p24). The idea of giving too much control to the states creates a decentralization of unity and power which, for a country of our size, is not sustainable. 

There were two primary political takeaways from this book: 1) Having a plan first will always benefit the plan creator by default 2) Compromise will last. 

Miscellaneous:

In persuading Robert Morris to take over the finances of the US, Ben Franklin wrote that his decisions and character would be villified: "[Critics] resembling those little dirty stinking insects that attack us only in the dark, disturbing our repose, molesting and wounding us while our sweat and blood is contributing to their subsistence," (p37). This comment stuck out to me as so intense. I feel like we always look back at history and its figures as wise or benevolent, but they're just human!

I'd never heard of Robert Morris, but truly his initial financial plan is the one we ended up adopting; Hamilton was his protege (p43). 

The trend before the revolution of northern conspiracy and north vs. south sectionalism is persistent today and I can't help but wonder why (p89). Clearly there is a long standing perception that the north does not understand and thus should not control the south, but how can this trend continue for hundreds of years?

Robert Morris, a name we're never taught, is the one who changed the constitution to say "We the People of the United States" instead of listing each colony, one of most consequential edits in American history (p151). 

Madison wrote the Bill of Rights, and, at the time, it was just a way to appease the south. He did not want to include it in the Constitution, and the south also felt like it was disingenuous. But today, it is clearly one of the most significant documents of that time (p206). 

The documents rested on "two time-bound truths of the time: namely, that any legitimate government must rest on a popular foundation, and that popular majorities cannot be trusted responsibly, a paradox that has aged remarkably well," (p218). 

Thanks, Jeremy, for finding this book. We read it before a trip to Philadelphia and it set the stage perfectly. 

Imagined Communities: Reflections on the Origin and Spread of Nationalism by Benedict Anderson

Imagined Communities: Reflections on the Origin and Spread of Nationalism by Benedict Anderson is a comprehensive examination of nationalism as a phenomenon. Nationalism is a relatively new phenomenon, emerging from the New World, though that is hard to imagine with its current ubiquity.  Nationalism began with religious empires, popularization of languages and vernaculars, then strengthened and spread with colonialism.

The author breaks the book down by nationalism's evolution, which is how I'll break down this summary, too. 

Nationalism, in theory

Off the bat, several important distinctions exist around nationalism: it is a common feeling that arises within a group of people which defines community; it is not a theory of government or economics like capitalism, communism, fascism, etc. Nationalism is an imagined connectedness with others based on shared qualities of a culture relative to the difference of another group, likely within their own societies. For example, one knew that they were "French" because their neighboring society didn't speak or write French or practice Catholicism; they were "German." The author goes so far as to do a literary analysis showing a transition in a news publication from "a destitute vagrant..." to "our young man..." indicating a novel shared ownership over all parts of society, (p48). Additionally, language and its sentimentality, became a key part of nation-building: "through...language, encountered at the mother's knee and parted with only at the grave, pasts are restored, fellowships are imagined, and futures dreamed," (p204). 

Additionally, it is often connected to statehood, but is not exclusive. Within today's more globalized society, these two distinctions are critical to be able to parse out nationalism as a cultural phenomenon and to fully understand this book and its framework.

Furthermore, the author identifies three paradoxes which define nationalism: "(1) The objective modernity of nations to the historian's eye vs. their subjective antiquity in the eyes of nationalists. (2) The formal universality of nationality as a sociocultural concept - in the modern world everyone can, should, will 'have' a nationality, as he or she 'has' a gender- vs. the irremediable particularity of its concrete manifestations, such that, by definition, 'Greek' nationality is sui generis. (3) The 'political' power of nationalisms vs. their philosophical poverty and incoherence." (p19). 

Creation & growth of nationalism, in the context of colonialism

There are a couple of things that accelerate the creation of a 'nation': literacy, which allowed widespread information and arousal of popular support (p112); models of other nations, which led to an easily replicable national movement (p114); and, once again, relativity. When one group in a place saw other groups in that same place build a nation, there was an anticipatory fear of marginalization (p138). 

Nationalism as a movement also grows for a couple of reasons, some of which are fabricated by those promoting it: legitimacy through historical claim, and the idea that a nation is "interestless," and so, it "can ask for sacrifices," (p194). These factors of shared values and an inherent trust that those who were within a community also created mutual fears and an informal social contract of sacrifice for members of a shared society. 

By the time this shared willingness of sacrifice was established, identities within places also became more obvious. There were several institutions, specific to colonies, which accelerated the spread and strength of nationalistic movements: colonial schools, the census, the map, and the museum. By institutionalizing and defining the geography of a place, forcing people to identify themselves as a specific group, and providing a centralized place of shared heritage for the oppressed group, colonial governments strengthened vernacular nationalism. Further, colonial schools were a function of official nationalism by providing a government curriculum, but it was also a meeting place for individuals who were higher classes and from different places. The official colonialism of institutions in turn catalyzed the growth of vernacular nationalism. 

Types of nationalism

Additionally, Anderson distinguishes vernacular nationalism from official nationalism: "official nationalism was typically a response on the part of threatened dynastic and aristocratic groups - upper classes - to popular vernacular nationalism,"  (p200). What's interesting about this dynamic is that the two nationalisms were effectively movements responding to each other; colonized folks finding an identity in response to the racism & mistreatment they experienced from the colonizers and the natives who supported the colonizers. 

A sticking point of the book was that nationalism was a positive feedback loop. Once it started across the glove in America, people realized they could also have a nation-state, which in turn mentally solved concerns of marginalization both by colonizers and other countries. Now, its everywhere. 

Overall, I felt like I needed a bit more background on nationalism & political theory to fully appreciate the book, but I think I learned a lot from this book. Thanks, Jeremy, for the recommendation. 

Miscellaneous:

Tupac Shakur named himself after Tupac Amaru, a Uruguayan revolutionary patriot considered one of the last great indigenous rebels. 

Empire of the Summer Moon: Quanah Parker and the Rise and Fall of the Comanches by S.C. Gwynne

Empire of the Summer Moon: Quanah Parker and the Rise and Fall of the Comanches by SC Gwynne was an overall informative book about the Comanches. The book centered around a narrative about Quanah Parker, a half native, half white Comanche who became the unofficial, then official leader of the Comanches.  Quanah Parker was a Quahadi, the only band of any tribe in North America that had never signed a treaty with the white man (Loc 5662). The book begins in 1706, which is when white settlers first wrote about Comanche encounters on the Texas frontier.

 The area ruled by the Comanches was known as Comancheria, stretching from the Caprock Escarpment in Texas to parts of Colorado holding at its peak nearly 200 million acres (Loc 4564). Comancheria was ruled by 5 bands, with estimated population at its highest of 20,000. The five bands were Yamparika, who were south of the Arkansas River, Kotsoteka, who mainly inhabited the Canadian River valley in present-day Oklahoma and the Texas Panhandle, the Penateka the largest band who inhabited large parts of Texas, the Nokoni, who occupied between north Texas and present-day Oklahoma, and the Quahadis, who lived in northwest Texas near the Colorado, Brazos, and Red rivers (Loc 1028). The book largely focuses on the Peneteka and Quahadis. Between 1871 and 1876, the bison of the plains were slaughtered and made nearly extinct, ultimately leading to the demise of all plains native americans. 

My biggest critique of the book was its offensive pro-settler bent. The author associates 'civilization' with agrarian societies (Loc 670), even referring to the agrarian tribes as the "Five Civilized Tribes - Creek, Choctaw, Cherokee, Chickasaw, and Seminole" (Loc 4126). However, Comanches significantly held up America's Manifest Destiny for almost two centuries which, to me, means they couldn't have been 'uncivilized.' Additionally, Gwynne says "the Comanches had a limited vocabulary...a trait common to primitive peoples," then proceeds to describe the depth of vocabulary for horses (Loc 731). These comments felt unnecessary and narrow-minded. Comanches spoke a different language; why would they have a large English vocabulary when they didn't trade or interact with English-speaking settlers? 

Further, when the tribes met with the Americans for treaties and had their speeches translated, the white participants were "astounded," (Loc 4495). The author describes the culture clash as "settlers from the culture of Aristotle..DaVinci..and Newton [with] aboriginal horsemen," calling the Comanches "pre-moral, pre-Christian, and low-barbarian...savage, filthy, inordinately fond of alcohol," and said that their practices "horrified the civilized.." (Loc971). All that, and yet, the Comanches resisted American settlement for over 170 years (Loc 90). Gwynne even goes so far as to say directly: "The pathetic little half-naked folks still constituted the greatest light cavalry on earth; no more than a handful of American or Texan soldiers were yet a match for them" Loc (1841), often describing Comanche war plans as "tactically quite brilliant," (Loc 2004). This theme of the book was frankly upsetting and contradictory: the author says they're uncivilized, yet both of Spain's greatest military defeats in the New World came from Comanches (Loc 1279).

Miscellaneous:

I loved the movie Spirit growing up and, after reading about the taming and riding style of Comanches, now realize it was a Comanche tribe being depicted. 

I've slept in the Caprock Canyon and visited Palo Duro Canyon, the last stronghold of Comanche civilization, but there was no trace of that history there. Further, the man who killed Quanah Parker's father, making him an orphan at age 12, bought Palo Duro Canyon.

Beautiful, tragic quote from Chief Ten Bears as a treaty: "I was born under the prairie, where the wind blew free and there was nothing to break the light of the sun. I was born where there were no enclosures and everything drew a free breath" (Loc 4512). 

After moving to the reservation, Quanah Parker actually starred in one of the first westerns ever in 1908, the Bank Robbery. Quanah can be seen around 24:00.

Finally, the Comanche people took up peyote in the mid-nineteenth century (Loc 6158). 

Thanks to my friend Jake C for the recommendation.  

Neither Snow Nor Rain: A History of the United States Postal Service

Neither Snow Nor Rain: A History of the United States Postal Service by Devin Leonard is an engaging, character-driven chronology of the USPS as we Americans know it today, from its initial start when were a colony to the zip code. 

There wasn't too much to call out in this book, but the main theme I took away is the sheer significance of the logistical management of the USPS, as well as the power and novelty of the USPS when it began. Because I've grown up with the USPS, I never thought of it as an entity that could wield political and social power. When it first began, understandably so, people were concerned it would be a tool used by the government to deteriorate the hard-fought rights won in the War of Independence. 

Good book to finish the week of July 4th! Thanks, Carla, for the recommendation.  

Apricots on the Nile by Colette Roussant

Apricots on the Nile by Colette Roussant was a memoir about life in Egypt during World War II as a French child. This book was very short and mostly personal, so I'll keep this blog short. I really liked the style of writing - it was nostalgic and romantic of Egyptian life. Plus, it came with recipes that I'm excited to try to recreate. 

I found this book while searching for books about countries in Africa, and I'm glad I did. 

America’s First Cuisines by Sophie Coe

 America’s First Cuisines by Sophie Coe is a survey of the foods, plants, and dishes eaten by Maya, Aztec, and Inca people. The author is diligent in her caution of information, as most of the information comes from Spanish missionaries. 

By far the biggest achievement by these empires was the nixtamalization of maize, which significantly improved the nutritional value of it (p161). 

The book outlined general food stuffs first, then cuisines and preparations by Aztec, Maya, and Inca. Unfortunately, there was less information available about the Maya. The author also encountered quite a few documents which misnamed or mistranslated information, so sometimes the actual food eaten at a banquet could have been incorrect (p173). 

There are several cultural differences between the US today and the Americas pre-Columbus. Namely, we don’t have a staple food, like maize; we eat far more meat in general; we have notions of required parts of a meal for it to be complete, where Native Americans often ate tortillas dipped in chile sauce- no meat, a few greens maybe. Furthermore, the Native Americans of today-USA seemed to be small tribes. The Native Americans of Maya, Inca, and Aztec ruled tremendous empires.  

Miscellaneous facts: 

Potatoes date back to 8000 BC in Peru (p37). 

Wild peanuts and almonds were used for peanut or almond milk (p57). 

The famous triad of the “three sisters,” beans, squash, and corn, actually didn’t exist. If anything, it would have been maize, beans, and chile, but Europeans viewed chile as a condiment, although it functioned as a dietary cornerstone (p60). 

Montezuma was actually called Motecuhzoma (p107). 

There was a prevailing belief that life was a “ceaseless search for balance and moderation,” (p117). 

It took 200 years for Mayan civilization to fall (p177). 

One of the more remarkable facts about the Inca was how controlled the government was. They tightly accounted for food in storehouses, distributing it meticulously. It was only after Europeans conquered the Inca that people died of hunger in Cuzco (p293). 

Overall, this was a good, kind of dry but interesting content book. Thanks, Jeremy for the recommendation. 

On Salt: A World History by Mark Kurlansky

 Salt: A World History by Mark Kurlansky examines many civilizations from a variety of time periods through the lens of their salt usage to highlight the role salt has played in human history. This included the Indian Independence Movement by Ghandi, the impact of salt loss for the South in the Civil War, Primarily, it was preservative until the 1900s. Ancient civilizations used salt to preserve their foods, pay their solders, and build up their economies through trade. There were a lot of fun facts in this book, so I've included them below. My big complaint for this book is that I found it to be extremely Eurocentric and Sinocentric. I think it largely comes from a lack of documentation in Africa and Latin America, but the author also took liberties to call colonizers "visionary," as opposed to just describing what they did and the impact. Additionally, I found myself wanting more details, so maybe I'm just a depth person more than a breadth person, which isn't the fault of the author.

Fun facts:

Venice built its wealth on salt trading and in AD 600, used landfill to extend the mainland closer to the islands of modern-day Venice (p84). 

Horses worked salt mines in Germany, and some spent their entire lives below ground (p166). 

In 1830, the Wieliczka Salt Mine Band was formed and played in the mine, due to the acoustics (p167). 

The ketchup we know today came from an eighteenth century English anchovy sauce (p183). 

When early American colonizers hunted, they would leave a red herring on the trail to confuse wolves, creating the expression we know today as "red herring," (p211). 

Slavery was used for salt production (p245). 

Cajuns were originally French refugees who fled Nova Scotia after it fell to the British in the eighteenth century and moved to Louisiana (p269). 

Relating this book back to the MLK biography, a key difference in Ghandi's movement for Indian independence was that it was never about Ghandi, it was about the movement. The American civil rights movement became about MLK as much as civil rights.

The word "pastrami" comes up from "pastra," the Romania verb "to preserve," (p389). 

Overall, this book was solid, not my favorite.

On Salt, Fat, Acid, Heat by Samin Nosrat

 Salt, Fat, Acid, Heat by Samin Nosrat was a fantastic book defying the definition of "cookbook." Nosrat creates an engaging narrative around cooking and starts at the basics: Salt, Fat, Acid, Heat. Nosrat makes several key points: 

• Salt from within and without
• Layer types of salt, fat, acid, and even heat (think twice-baked croissants, or boiled then baked potatoes)
• Taste as you go!

If we think of salt, fat, and acid in terms of what it does to flavor: salt enhances, fat carries, and acid balances (p168). 

Salt

I had a couple paradigm shifts around salt as a result of this book, namely rethinking it from seasoning to mineral. It holds a role far more important than I ever realized: "Salt has a greater impact on flavour than any other ingredient...this is why it makes sense to measure salts by weight rather than by volume," (p.36, 37). Cooking is truly a chemistry lab, "salt also unlocks many aromatic compounds in foods, making more readily available," (p42). Further, osmosis, diffusion, and time are salt's main modes of change.  With time, salt dissolves protein strands into a gel, which allows those proteins to retain water better as they cook, keeping things moist (p48). That being said, one has to think about the time, because too much time with salt will draw excessive water out and make things rubbery. 

A tip on beans that I need to keep: "Add a palmful of salt, and a generous pinch of bicarbonate of soda, which will tip the pH of the pot towards alkilinity and help coax even more tenderness from the beans," (p366). 

Fat

Fat does a lot for a meal- it can act as a main ingredient, seasoning, or cooking medium (p84). Also, I had no idea that the term "shortening" comes from a reference to the fact that fat inhibits gluten strand production (p121). 

Acid

First things first, we, the laypeople of the kitchen, can think of acid as salt's "alter ego" (p136). It is an integral part of our favorite meals, and comes in all sorts of ways including wine while a sauce cooks, lemon or lime squeezed at the last second, or in parmesan cheese. Anything with a tang is acidic. Where salt affects both texture and flavor, acid is mostly a flavor add but can trigger chemical reactions, like ceviche. Or, for the perfect poached eggs, add a splash of vinegar, which will coagulate the egg whites (p148). 

Heat

The heat section of the book focuses on sweating, browning, and time. Browning produces flavor through the Maillard reaction, and it's important to be intentional about our onions, for example - do we want them delicate (sweat) or acidic and sweet (caramelized) (p226). The question we all ask: "am I frying things right?" is answered by Nosrat: "The key to getting a crips, golden-brown crust is to encourage that steam to escape as quickly as possible," (p230). Further, don't just think about heat as the outside of a food, think about heat level for even cooking, too. 

I absolutely loved this book, rather unexpectedly. Life is short. Why not eat good food?

Highly recommend this book. It even has cooking practice lessons and recipes at the end!

Madam Secretary by Thomas Blood

This will be a short review, but Madam Secretary by Thomas Blood was a fabulous biography of Madeleine Albright, US UN Envoy and first female US Secretary of State. The book was fun and inspiring to read. It had several nuggets of political wisdom; my primary takeaway is that what drove Madeleine Albright's rapid rise in her career was the personality and virtue of her as a person. People loved to be around her; she was committed to herself, her career, her friends, and her family. She's quoted as saying "the more power and influence one has, the more one can do to help people," (p9). 

Thanks so much, Audrey, for recommending this book. It was a great read!

How the Word is Passed by Clint Smith

How the Word is Passed by Clint Smith carried the reader with Smith as he examined black history in America, starting with slavery. Growing up in the South, Smith knew racism, and knew that the streets he played on as a kid were named for slaveholders and racists, but never gave it much thought. The paradigm shift this book gave me is so many Americans view black history as starting in chains; but it doesn't. On the journey to trace back roots of black history, Smith visits Monticello, the Whitney Plantation, Angola Prison in Louisiana, a confederate grave in Virginia, Galveston Island, New York City, and Goree Island in Senegal. The biggest takeaway I got from this book was that black history did not begin with chains (p220). 

I want to end this review with a quote from a Monticello tour guide which encapsulates my concept of our country: "I believe in the idea of America. I don't believe that this country was perfect. I don't believe it is perfect. I don't believe it's going to be perfect. I believe that the journey to make this a better place is worth the effort and that the United States, if you conceive it not so much as a place to be in but an idea to believe in, it is worth fighting for." (p51). 

Miscellaneous:

• "Oppression is never about humanity or lack thereof. It is, and always has been, about power," (p79). 
• "Just because something is difficult to accept doesn't mean you should refuse to accept it," (p192). 
• In spending the day in the Black History Museum in DC with Smith's grandparents with "the hand that beat them and the laws that said it was okay," (p319). 
• "At some point it is no longer a question of whether we can learn this history but whether we have the collective will to reckon with it,"(p320). 

Thanks, Emily, for the recommendation.

King: A Life by Jonathan Eig

King: A Life by Jonathan Eig was an illuminating biography of one of the most recognizable social leaders of the century, Martin Luther King Jr. The prevailing themes I got from this book were 1) how obsessed the FBI was with MLK Jr 2) The impact of the Vietnam War on MLK's and the Civil Rights Movement's momentum 3) Humanizing MLK, and also understanding his failures

I was staggered by J Edgar Hoover's obsession with Martin Luther King Jr. He bugged all of MLK Jr's hotels, homes, friends apartments, etc., in an effort to somehow prove he was communist, although nothing in the hundreds of pages of memos suggested that. Further, the FBI compiled a tape of recordings of MLK's sexual affairs and black mailed it to him, writing a letter "composed to suggest that its author was a disaffected Black man" (p458). While the FBI listened to MLK's entire life, they shopped the story of MLK's sex scandals around to every major newspaper; none of them accepted (p468). 

MLK Jr had a number of critical failures: he was a serial womanizer, maintaining years-long affairs with multiple women at the same time; he did not elevate women to leadership, despite their roles as organizer, founders, and backend leaders. 

Also interesting is the importance of Christianity in society at this time. It seems that Christianity was explicitly viewed as positive; it was the antithesis of sin, communism, etc., in a way that I didn't realize (p523). I also didn't realize how international this was; MLK Jr. received a Nobel Peace Prize and traveled internationally; Thich Nhat Hanh published a letter to him (p562). 

Further, my favorite speech of all time is the last 2:35 of "I Have Been to the Mountaintop," by Martin Luther King Jr. I had no idea that, leading up to that point on the night of his death was years of political and social decline in popularity and influence. 

Miscellaneous quotes:

Upon hearing that MLK Jr. had been shot, J. Edgar Hoover said "I hope the son of a bitch doesn't die. If he does, they'll make a martyr out of him," (p656). 

"[MLK Jr.] loved books before he could read, took comfort in their...promise of conversations to come" (p36).

On the value of changing laws, "The law may not be able to make a man love me, but it can keep him from lynching me," (p294). 

He referred to segregation as "the Negro's burden and America's shame," (p304). 

MLK, at a march: "I believe in my heart that the murderers [of three organizers, two white] are somewhere around me at this moment." "You're damn right," said Deputy Sheriff."