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More Than Surviving the Crisis


Street Medicine Conference
Salt Lake City
September 28, 2012

I spoke the following lecture in Salt Lake City, Utah, at the annual conference of the Institute for Street Medicine, an advocacy and support organization by and for professionals who offer health care (broadly defined) to individuals who live on the street.  Rather than serving homeless individuals in institutions, however, these professionals work on the streets themselves in the United States and other nations around the world.

This is my last speech to a professional audience and it brings together the themes of the American political, ecnomic, social, and environmental crises to explore their complex, virtually impenetrable interweaving.  I suggest that given this impentrability, the necessary changes that offer a sane way out will only be possible after a significant breakdown in the current capitalist system.  Several other pieces of my writing The Earth's Immune System, Hope in an Environmental Wasteland, Theology of the Cross, and Moral Lapses and Economics) have explored various facets of this subject but this is, I think, the clearest and most complete presentation I have to offer.

Good morning.  I feel really privileged to speak to you this morning.  The work you do--while maybe unrecognized--is fundamental to a compassionate society. So, thank you for your efforts and the honor of speaking to you.

Right off the bat, I'd like to confess my trepidation in standing here.  I haven't practiced medicine since 1993, so I'm sure I'm a bit out of touch with your daily reality.  I hope it doesn't show too much.

I did practice with impoverished people both in rural northeastern Minnesota and in the inner city of Washington for a total of seventeen years before I called it quits.  In Washington, we had a small clinic, and, in 1985, several of us also started a medical recovery shelter for homeless men called Christ House, where my family and I lived with two other doctors' families for five years.  Then in 1990 we founded Joseph's House, a home and community for homeless men terminally ill with AIDS, where my family and I lived for three years.  But in 1993, I finally realized that medical practice--any kind of medical practice--within the context of my long-standing depression was simply too painful.  So I left.

While I've continued in various other roles at Joseph's House, I've spent much of the last twenty years teaching and writing about American poverty, especially in its relationship to the political and economic crises that beset us.  It's that relationship and its impact on our work that I'd like to talk with you about.   

To begin I'm going to make the assumption that most of you find yourself swamped with more and more patients to care for and fewer and fewer resources to do it with.  That may not be true for all of you since there have been some new initiatives for the homeless in the past several years: the HUD/VA housing program with supportive services for homeless vets.  The Affordable Care Act should increase Medicaid eligibility to more very low-income people.  And the overwhelming cost-effectiveness of the Housing-First initiatives has made a difference for some of you.

On the other hand almost half of all Americans live under 200% of the poverty level. And--in part because of the 1996 Welfare Reform, in part because of the ongoing economic crisis--over 20 million Americans live in "extreme" poverty, defined as less than half the poverty level.  And for six million Americans, the only income is food stamps, equivalent to about 1/3  of the poverty level.  And most of us know that even a full poverty-level income isn't enough to live on with dignity.  The pipeline into homelessness gets more and more crowded.

Even including the Great Depression, our country has never accepted its responsibility for those people persistently impoverished by the nation's social and economic structures.  Since the largely stillborn Great Society programs of the 1960s, we've gradually abandoned the poor with a cruelty that's staggering.  The oppression of the poor seems destined to intensify as public resources dwindle amidst the insatiable desire for wealth and power among the richest and the consumerism and fear among the rest of us.

My own Judeo-Christian tradition (and I think most other religious traditions) makes it clear that nations who abandon the poor will ultimately be judged severely for their sin and hubris.  But you don't need to be a person of faith to understand that the ultimate, real-life consequences of greed and abandonment of the poor can look very much like the kind of divine judgment declared by biblical prophets on their nation.  There are direct links between our neglect of the neediest and the coming crises.[1]

And I want to suggest this morning that these crises--worsening American poverty, increasing inequality, rising environmental devastation, the tightening of political gridlock and so on are not only deeply interrelated but also essentially inevitable given the current structures and driving forces of American society. Somewhat oversimplifying, I'd like to name those forces as  

  • the brand of capitalism that we've chosen (or backed into);
  • American consumerism;
  • the dysfunction of politics;
  • the shift of power to large, publically held corporations; and
  • the media.  

Chart of social structures

I want to make the case that each of these five Powers reinforces, protects and strengthens the others to create an impenetrable web of control that will remain immune to any of the usual attempts to change it significantly … until the breakdown of the social, political and economic order makes the birth of something quite new both possible and inevitable. 

While my argument may initially seem one of despair, I hope to show you that it's not cynical or despairing but ultimately hopeful.  A Chinese proverb says: "The beginning of wisdom is to call things by their right names."  Knowing where we are, why we're here, and what's coming--no matter how dispiriting--is ultimately better than continually bashing our head against the wall in the darkness.

The question then becomes: How do we find hope amidst what seems so bleak?  How do we continue our work with energy and enthusiasm?  Is there a radical hope that doesn't deny the coming tragedies but nevertheless has faith that there is a way through? 

I probably shouldn't put this into your heads, but this next fifteen minutes of my talk--on the economic and political systems--is often where people's eyes start to glaze over and their heads droop.  Too many of us have been brainwashed that economics is too opaque or too complicated or too boring for the non-economist.  But given the economists' dismal track record over the past few years,  I'd suggest that complicated isn't necessarily better.  So I'm going to outline a few basic principles of our capitalist economic system that might help us understand the mess we're in.  Try to hang in there with me. Unless one understands something of the analysis, my contention that the web is impenetrable will seem just too simplistic and exaggerated.

The Web


It's fashionable (and pretty easy, actually) to denounce the excesses and injustice of capitalism, so I won't recite the litany.  The problem, though, is that even the critics have to acknowledge that capitalism has been easily the most powerful engine of economic growth in history. 

So, what's made capitalism such an effective creator of wealth?  Well, among other reasons, the first two basic assumptions harness the powerful motivator of human self-interest.  But maybe more importantly other assumptions of capitalism's theory--profit as the only goal, money as the measure of all value, and a commitment to the laws of supply and demand--boil all economic decisions down to one primary variable, the maximization of profit.  And that organizes a strikingly simple and efficient pricing mechanism that allocates resources, maximizes production, and coordinates desire and availability so effortlessly that it's probably impossible to match in any other system. 

Now, when scarcity was the world's primary economic problem and natural resources seemingly inexhaustible, capitalism--despite its many contradictions--was the best thing going.  But scarcity is no longer the primary economic problem: Distribution of wealth and depletion of natural resources are.  And the overwhelming problems now caused by capitalism are becoming intolerable.

Capitalism, of course, isn't monolithic but comprises different varieties.  So, here I'll simplify to the fundamentals of "free-market capitalism."  Fortunately, because of its devastating impact on humans and the Earth, such unregulated "free-market capitalism" has not and cannot exist in the real world.  Unfortunately, the large, publically held, virtually unregulated, transnational corporations have moved us closer and closer to such raw capitalism … with tragic results.

We often condemn the barons of capitalism for their greed, callous abandonment of the poor and destruction of the environment.  There's plenty of greed and callousness, of course.  But we may not notice that the wages that you can't live on, the jobs that disappear overseas, or the environmental devastation that accompany the wealth-generating power of capitalism are actually built into the system and don't require avaricious, insensitive managers to do their damage.  Ultimately it's not possible to adhere to the basic rules of capitalism without, say, abandoning the poor or damaging the environment. 

I'm certainly not saying that all companies act in destructive ways.  Privately owned companies of any size, but especially smaller and more local companies can and often do work for the common good.  They may build their companies on a foundation that values adequate wages, fair prices, environmental sanity, and honesty but in so doing they break capitalism's fundamental rules that require the single-minded focus on maximal monetary profit.  assumption of maximal efficiency and monetary profit.  But most of these companies can only stay in business because of the loyalty of long-standing clients, the lack of effective competition in a very local market, or the customers who are willing to pay a premium to put their values into practice.  That allows the company to break the free-market rules and still do "well enough."  But notice how little of Main St survives when Wal-Mart moves in and just "follows the rules."

Large publically traded corporations, however, are typically owned by thousands of individual stockholders, virtually all of whom  invest for one purpose: maximal financial returns.  And that means that company management must follow the dog-eat-dog rules of raw capitalism or be eaten by their competitors.  And, unless government intervenes, that means environmental destruction, the lowest possible wages, increasing social inequality and so on. 

Take the problem that even free-market economists acknowledge: the externalization of costs, or in everyday language "getting someone else--usually the rest of us--to pay those costs."  For example, if making widgets creates waste that would cost money to dispose of properly, that cost can be eliminated by dumping the waste into the nearby river.  For the economist, the problem with externalizing costs is that it distorts the market.  For the rest of us, the problem is a polluted river or the public cost of cleaning it up.  But notice, then, that if other companies are to remain competitive and survive, they have to follow the same practice, too … even if the management were to be the good guys who like to fish in the clear rushing waters of that local stream. 

This is all vastly oversimplified, of course.  Cooperatives, companies whose just wages and environmental policies are important to a certain pool of investors, government-owned businesses and others are important exceptions.  But the general truth remains: raw capitalism consistently produces the undesirable results we see.

But this is where it gets interesting.  Not only is capitalism often devastating in itself, but it also reinforces the resiliency of the rest of the system. The economic system is the source of corporate wealth and power.  Free-market capitalism must use its considerable influence to undercut government regulation that might slow growth or reduce consumption.  The power and effectiveness of the economic system to create "stuff" itself convinces consumers that capitalism is the only alternative.  Capitalism’s need for growth requires media advertizing.  All this reinforces the power of the rest of the system.  (Impact of capitalism)


Consumerism is a material attachment to possessions that often manifests as the widespread delusion that--despite considerable research and common sense--more stuff brings greater happiness.  It's a  fundamental cause of the coming crises in that consumption itself not only demands natural resources but also tends to blind people to its negative impact.  But notice the reinforcing of the rest of the system:

  • consumer demand is the ultimate source of the corporations' overwhelming wealth and power;
  • the highest satisfaction of consumer desires requires the greatest possible economic growth, which strengthens capitalism's psychic hold on our economy; 
  • consumerism handcuffs government to policies that stimulate economic growth, destroy the environment, reduce taxes and cut social benefits.  How many political candidates, for instance would get elected if they campaigned on a platform of slowing economic growth and restricting our material standard of living?
  • consumer desire is in a mutually reinforcing relationship with the media, for it's ultimately the consumer's susceptibility to advertizing that makes media profitable. (Impact of consumerism)


In the current economic and social system, government is the only institution remotely capable of modifying capitalism, regulating the corporate system, and reigning in consumerism … and sometimes it manage to.  Regulations do limit the power of corporations.   Progressive taxation and social programs--for instance, Social Security and Medicare--do redistribute income which moderates consumerism and restricts its destructive impact.  Laws do discourage externalization of costs;  and they do limit advertizing.  (Impact of Government)

But these are shadows of the interventions that would be necessary if government were to pierce the web that's keeping us from eradicating poverty.  Other industrialized countries have gone much further with universal health care, higher and more steeply progressive taxes, stronger programs to ameliorate poverty, and so on.  Even in those countries, however, the same web of international forces is beginning to suffocate progressive policy.

Government could be the major ameliorating force.  It's the failure to act appropriately that tightens the web. 

Corporate Power

It would be hard to overemphasize the impact of corporations and their power to reinforce the impermeability of the web.  The history of their rise to power is fascinating.  In the 1700s, in order to increase investment, government chartered corporations, but only those that served a public purpose, subject to regular state review.  By the early 1800s, the corporations’ power had grown so that they could pressure governments to drop that requirement.  Later in the century the Supreme Court gave corporations some of the rights of actual persons--the ability to sue and be sued, due process and equal protection and so on--that gradually increased the enormous power of these entities.  The recent Citizens United decision allowing effectively unlimited corporate contributions to campaigns cemented corporate control over government.  But, of course, corporations aren't people; they're humongous, massively wealthy, immortal, amoral and have as their only goal monetary profit.  But, if they were real persons, would we ever put them in charge of our economy?

We're only just beginning to recognize the staggering power of corporations to control our federal and state governments and the citizenry.  It's not only the unlimited campaign contributions.

  • Much more powerful and effective is the constant political lobbying at every level of government in between elections.
  • The devil is in the details, and corporations are deeply involved in creating the details of regulations that will implement the law.  Since lobbyists are often the only ones who know the details well enough to actually write arcane sections of the regulations, it's not uncommon for their contributions to be incorporated whole cloth into legislation.  And then the lobbyists get busy influencing the regulatory agencies, too.
  • And all of this is repeated at the state and and local level.
  • Corporations have extraordinary power to change even how capitalism works.  Witness the ability of World Trade Organization sanctions to force harsh, free-market policies on even the largest countries.
  • And, of course, the corporations own the media.  The influence is sometimes subtle and sometimes not, but virtually no media source will do an exposé of their corporate advertizers and certainly not on the corporations that own them.
  • It's obvious, even simplistic, but it's the corporations that supply the products that enflame consumerism.

(Impact of Corporations)

The Media

It is hard to overestimate the power of advertizing to create desire, a power profoundly strengthened by individuals' belief that they aren't susceptible to it.  Advertizing created consumerism, and it sustains it.

Media have overwhelming power to change political opinion.  It's not civic responsibility that motivates Boeing or Archer Daniels Midland to sponsor NPR's News Hour.  Climate-change denial exists almost exclusively because of corporate propaganda. 

Media even shapes the economic system (or at least the perception of it).  "Everyone" knows that social programs for the poor distort the free market but no one notices that corporate handouts distort it much more.  And, of course, the media are fundamental to corporate wealth.  In fact, since the media are corporations owned by other corporations, the line between them is blurred at best.  (Impact of Media)

Overall Impact

Little of this, I suspect, is news to most of you.  It's hard to miss or overstate the extraordinary power of the dominant systems.   But it's more: The web of forces is now so interdependent and self-reinforcing that as long as the current system exists, the web will be impenetrable.  Fundamental change is just not gonna happen.  

I realize that such dogmatic pessimism isn't really acceptable within our culture.  We Americans have an unshakeable faith in progress, in our capacity to overcome obstacles.  "Things'll work out," we remind each other.  "Look at the bright side," we say.  Even when things clearly won't work out, even when there is no bright side, it's rude to say so in mixed company. 

(Now, our national commitment to a positive outlook has taken a beating since the turn of the century … with important consequences that I'll turn to in a minute.)

This "official" optimism is thoroughly grounded in the Enlightenment commitment to reason as the primary, or even only, way of knowing.  Reason gives us confidence that ultimately everything is rationally knowable.  This rationalism leads us to science, science gives us technology, technology offers increasing mastery of the natural world, and mastery (we believe) leads to progress, indefinite progress.  "If we don't see the bright side yet, keep working on it."

But in the US the notions of mastery and progress are fed not just by the Enlightenment but also by: 

  • The triumphant colonization of the Americas,
  • the taming of the frontier,
  • wide-spread national industrialization during the 19th and 20th centuries
  • our transformation into the richest and most powerful nation in history, and
  • the growth of an affluent middle class …

  I won’t speak to the obvious oppression caused by these "victories" of the dominant culture, but the victories have reaffirmed our faith in progress and powerfully reinforced our native optimism.  Until the last fifty years, our nation's experience has been that we can accomplish whatever we set our minds to, which is still the only point of view that politicians can put forth. 

We've been understandably proud of our can-do attitude.  We attribute much of our success to our optimism and willingness to forge on against seemingly insuperable odds.  Our intellect and our technology will ultimately solve any problem.  Anything less than a positive outlook is considered "defeatist" or "needlessly depressing."  We shouldn't be "quitters."  Optimism is part of the American creed. 

Hopelessness and Helplessness

So what's the matter with that? 

Well, the problem is that such desperate optimism doesn't prepare us emotionally for real failure.  The US has been confronted with incontrovertible failure over the past generation, and our frequent response has been just to deny it.  The Vietnam conflict went on for years partly because we couldn't believe we were losing.  We've done nothing substantive about global climate change because some deny its existence and others deny the devastation that it will bring to our civilization.  “If only this would happen or someone would do that,” we say, “we could fix things.” 

Some of us here, I imagine, are still hanging on to similar hopes for the amelioration of poverty. 

  • Alleviate homelessness with Housing First or increased Section 8 housing.
  • Raise working class wages by strengthening unions.
  • Salvage Medicare by eliminating excessive treatment. 
  • Eradicate at least the financial aspects of poverty with an adequate safety net.

Those are all good ideas and would probably work … if implemented.  But given the web of forces, they're simply not going to be implemented in any reasonable future. 

But more of us here, I suspect, have recognized this sobering reality.  We know, at least, that our work is a rear-guard action and won't markedly change the system.  We stay with it for many different, important reasons, but when we lose hope that things will get better, enthusiasm is more difficult to find.  If we believe we must fix the system but we can't fix the system, helplessness and hopelessness are almost inevitable.

It's difficult to look around after fifteen years in practice and realize that, actually, things are worse now than when we began.  If not hopeless, at the very least we'll be extraordinarily frustrated with the declining resources available to the very poor. 

OK, so that's the depressing part.  In the last fifteen minutes or so, I want to point a path away from hopelessness even when there's no significant hope for positive change.  But I also want to avoid that common American trap of moving through the despair too quickly.  At the conclusion of most talks like this, the speaker shows the audience the clever solutions to the problems.  But I don't have any tricks up my sleeve.  If we're to find real hope, it won't do for us just to acknowledge our helplessness intellectually and then get on with it. If we don't sink into the reality that things really will get worse no matter what we do, then the real possibilities for hope that do exist will seem thin gruel, indeed.  We won’t be satisfied with what is possible if we aren’t thoroughly convinced that what we’d rather have isn’t possible.

The Earth's Immune System

So let me take what may seem like a diversion.  In his book Blessed Unrest, Paul Hawken describes lecturing in the 1990s about environmental issues.  Afterwards, people would frequently approach him, describe their own work in local projects and he’d take their business cards.  Soon he had thousands of cards.  Wondering what was going on, he started researching such small groups.  While accurate estimates are impossible, he believes that there are well over a million such projects around the world from the vast Sierra Club to a single young person selling local farmers' market produce.  And if we then include social justice groups and indigenous rights groups and add in groups with no official standing, some have estimated perhaps ten million around the world.  And they're spreading inexorably. 

These are not, Hawken stresses, an organized movement.  They come into existence and disappear.  Their goals are often quite different from one another, perhaps even at cross-purposes.  And even their foundational values may seem different: compassion for the poor in one instance, nonviolent distribution of political power in another, care for the earth in a third.  What binds them together is resistance to the destructive values of the dominant culture.  They're part of a global spiritual awakening that longs for inclusion of the stranger, justice for the oppressed, compassion for the suffering and care of the Earth. 

For example, just by walking through the door into Joseph's House--our home for the homeless with terminal illness--you'll sense some of that awakening: a quiet loving presence, compassion for the suffering, inclusion of the excluded.  We're a tiny light radiating love and respect within the darkness of the dominant culture.  We're part of no movement and have no plan to fix anything.  In spite of this, we stay in our work with joy. 

Every year at Joseph's House, three or four or five post-college, full-time volunteers join our staff and, over the course of a year, learn compassionate presence with and respectful care for the destitute dying.  We teach them about the injustice of inner-city poverty.  They develop intimate relationships with those abandoned by the wider society.  And these young people are transformed.  Some join our staff and stay for a year or two, but eventually we send them on--to medical school, law school, or MSW programs--into the world with values and skills out of which something new might be built.

Joseph's House isn't alone.  I would guess that most of you represent this spiritual awareness that's awakening within the belly of the beast.  And at a conference like this, you can  sense the power of your common, alternative values in the midst of the dominant culture, sense the possibility for more.

Hawken subtitles his book How the Largest Movement in the World Came into Being and Why No One Saw It Coming.

Its grass-roots origins, minimal ideology and loose coordination give this non-movement a resilience that no top-down organization could ever have; you can't kill it by co-opting the leadership … because there isn't any.  You can't fight their values because they express the longings of the human heart.  They unite with each other through modern communications technology.  The network constantly grows and renews itself; one organization may disappear because of whatever, but others take its place.  Those that are small with few resources by necessity use their resources efficiently and work with profound dedication.  They go with whatever works and so can adapt to local conditions.  But they're all about humanizing our global society.

Where does that leave us?

This network is not my "secret weapon" that'll fix things and replace the system with something more humane.  The problems aren't that simple; the forces arrayed against change too powerful.

My point is rather that the current system will not survive.  The economic contradictions behind the collapse of 2008 have not been resolved.  Climate change and other environmental issues will worsen inexorably with staggering losses.  As inequality gets worse, American consumerism is more likely to turn ugly than toward a sustainable simplicity.  There's little sign that politics will regain any of its sanity.  The system simply can't continue as it is.  Significant, if unpredictable, disruption is coming. 

So when I've used phrases in this talk like "unless there is significant structural change," I've meant significant structural change; not a well-ordered transition but something closer to collapse.

At that point we reach crisis, a word the Chinese famously write by combining the character for danger with the one for opportunity.  The danger is that the collapse will tear us apart, perhaps leading to political chaos or fascism, perhaps leading to something more terrible that we can't even imagine now. 

The opportunity is that at that point new forms--better forms based on life-giving values--have the possibility to emerge. 

I'm not suggesting that these millions of organizations around the world will transform themselves directly into the institutions that will become the new society.  Rather, they--and you--are creating a milieu: a set of values, structures and ways of operating that embody the values of non-violence, compassion, inclusion, love and others. 

Whatever new structures try to emerge out of the collapse will have spiritually aware people and organizational models for creating life-giving structures.

There's no guarantee, of course.  Depressive that I am, I would guess that the odds favoring a disastrous resolution to the crises are greater than those of a positive one.  But there's also the possibility that you and your work could become one spawning ground for something new, something much better. 

To emphasize again, this isn't a blueprint, a secret plan that I'm pulling out of my pocket at the last minute to save the day.  What I'm trying to say is that your work is not simply providing care to street people, critical as that is.  It's also participation in creating and defining the new values, the new organizing principles, and the new models for a future.  You may be a critical part of that network that may yet lead us toward sanity.

Where that leaves us

Where does that leave us as individuals and organizations?  Should it change anything in our lives?  Does it help us toward hope?  I find it fascinating that such a radical vision for the future may not require anything new of those of us who are already working for peace, justice or environmental sanity.  If our vocation is to serve the poor by providing for those on the street, we're already an important, living demonstration of what society should look like … no matter how few of our patients survive or how long we stay in the work or how little we change the system.  We already play an important role in this vast unorganized movement.  And when the time comes, perhaps we will be the guides, the leaders, the examples for a new kind of society that's not yet visible.  Or our students will be.  Or their students.

We may do nothing differently, but now it can be supported by honest hope for the future.  The world has been very dark before.  But in history, it turns out, change is as common as grass.  There will be something new; the question is what it will look like.  We can have a non-delusional hope that our work is part of the coming light.

Hope isn't the knowledge that things will be this way or that way.  Rather, hope is that which empowers us to forge on through very dark days, knowing that regardless of the final outcome we're in the right place, doing the right thing … on the side of justice, mercy and peace.

I thank you once again for your work and your presence with those who have been abandoned.

[1] Some connections:

1) Rigid class structure leads to the despair of persistent poverty

2) Increasing inequality leads to looser social connection and a host of social ills

3) Poor education leads to fewer trained workers

4) declining taxes leads to lack of money for education, social services, physical infrastructure and protecting the environment

5) increasing private investments in high performing financial instruments leads to greed and the financial crisis that most hurts the poor

6) refusal to take steps toward ameliorating the environment crises leads to suffering most for the poor.