As an entrepreneur and investor in healthcare startups, I think there is a substantial ethical difference in healthcare than just about any other sector. If you're going to build something, you have a responsibility to human beings that what you're selling works... at least equal or better than what you're trying to replace.

It's wonderful to have dreams of changing healthcare - it's wonderful also to aim at finding the fountain of youth, after all we're still searching for ways to beat senescence and death! But having big dreams is no excuse for not knowing the state of your company.

If the defense can pull off an acquittal for this ex CEO, I will find it a dark day for justice.

For a CEO to not know that their product doesn't work while feverishly trying to build a business for said product, and further, to claim that they are a victim of fraud and manipulation... it beggars belief.

One can rightly argue that their investors were foolish (yes, they were), but if the CEO isn't responsible, who is? This is not kindergarten.

It's been a while since I've answered a question on a blog, but Adam Haverson asked me the following:

Hey man - it's been a long time! We weren't really close at school but you are one of the few people I know who posts thoughtfully on FB & I've enjoyed following you & your conversations with friends. Been meaning to ask you - what is your take on the Berkshire/Morgan/Amazon healthcare initiative? I saw they just appointed a CEO so it must be moving ahead.

Atul Gawande is certainly a respected figure in medical literati; I'm a little surprised by the pick, but there are few forward thinking medical doctors that can do things that the medical community may strongly disagree with - which may be a good reason to pick him. Other major medical systems like Geisinger, Cleveland Clinic, Mayo - that are physician led - were probably mooted, but they picked Gawande.

It's impossible to know precisely what Amazon/JPM/Berkshire will do - and I suspect they can'd know precisely either. Startups by nature change as they develop. That said, given the players: Logistics, finance, investment/insurance - they pull together very interesting domains for one of the thorniest problems in modern technology and business... how do you create a system that has efficient healthcare delivery?

While this is completely out of bounds for a full discussion here (where is a good forum for this?)
Healthcare in a nutshell

Potentially limitless spending
Huge range of cost/impact curves
Opaque and sometimes quixotic price signalling
Incomplete metrics at all levels of care.
Limited vertical integration
Most systems have payor-provider(multiple tiers)-admin tiers - patient (who may not be the decision maker).

Presently, Geisinger and Kaiser are the most well known vertically integrated healthcare systems in the US. By having insurance and provision, they have the potential to better understand where the money goes, and they have an incentive to spend less to get equivalent results - other systems have no such incentives. But, they lack complete data.

By having a complete vertical, including deep, big data analytics that takes into account logistical problems, the potential to have a much more "aware" system of care arises.

That's my bet on where the collaboration is trying to lead. Provide the insurance, the care, track the delivery, outcomes and feed it back into not only your actuarial assessment for premiums, but also the care delivery - the how, when and how much. This allows internal pricing signaling. Why pay for things that don't work?

The only problem with all of these lean-ish models (and our present system, TBH) is that it's inefficient at dealing with new innovative and effective things... That's something that I wish would be addressed more adroitly.

I visited the Yasukuni Shrine today - 靖國神社, and then the museum that basically records much of Japanese military history starting with the Meiji Restoration. I wasn't sure what feelings seeing everything would evoke, but it was a far deeper experience than I'd anticipated. I've read a lot about history - from medieval European, the Great War, World War 2, wars in Africa. And although I've read a fair amount of Chinese history, I haven't really read history from the Japanese perspective.

This was something different, because it put the narrative of colonization in East Asia and the South Pacific in a very different narrative than I'm used to. And perspective in life, is everything.

As the old adage goes, one man's terrorist is another man's freedom fighter. The irony is that neither is fully true, nor fully false. I've always been fascinated by Rashamon, which is the first writing that I'm aware of that depicts the same event from different views. That is the art and subtlety of history. You cannot read history without reading many sides of an event.

What does it mean, really? Walking amidst the artillery, munitions, bombs, manned torpedoes, fighters, models of warships... seeing blades from 600 AD (some really amazing weapons from that era...) as well as the discussions of how WW II is seen by the historians who wrote the passages describing events, from the beginning of Perry's shelling of Japanese ports, to the Cassus Belli that "led" (I use this to emphasize perspective) Japan to modernize, industrialize, militarize and then invade/free the surrounding lands.

The Greater East Asia War is portrayed as Japan pushing to free East and Southeast Asia from Western Colonial influence. The final words in the museum regarding WWII basically suggests that this war for independence from Europe eventually inspired revolutions and revolts in the former colonies and led to independence in E and SE Asia as well as in Africa and the Middle East. The way I remember these events from a Eurocentric read of history sees it differently - but realistically, from the perspective of East Asia, it's not completely a baffling one.

The world, as Japan saw it, was one where the military and industrial technology of Europe had led to global domination. Playing on this stage required a seismic shift of how Japan was run - leading to the dismantling of the Shogunate, and the restoration of Imperial rule. I won't get in to my feelings on governmental systems, suffice it to say that there are many threads of thought here that I can see in Chinese perceptions on military.

It seems that both have realized that military prostration is a non-starter.

War is reality. We can pretend that armed conflict is a thing of the past... but human history is filled with conflict. It is what happens when resources are perceived to be limited. If the story boards are to be believed in the museum, the essential reason why Japan attacked the US was the embargoes on Oil and industrial tools that fed Japanese industry. They claimed 70-80% of the industrial needs were imported... and securing mineral and oil was what led to "expeditions" throughout SE asia and the continent.

It makes me reflect on my feelings when last in Berlin and thinking about the Weimar Republic. Reading about Chiang Kai-Shek from a Japanese perspective was also startling... essentially no mention of Mao was in the museum. These stories we tell - how did Japan see Korea, Vietnam, Thailand, Burma... Manchuria (Or ManchuKuo)? How did they see their own role in the conflict? How did they see Nanjing?

I can see more why Yasukuni incenses many leaders in E Asia.

But I think there are also sentiments here that are sincere. That's the crazy thing about history. A participant in history can be both victor and villain at the same time. Victim and oppressor as well.

There are so many sad stories - stories of sacrifice in that museum. Sacrifice for the ideal of Japan - and they are sincere... They may be stories that disturb other sensibilities, but that doesn't make them incomprehensible.

As any of you that read my writing know, I am quite fond of Japan and Japanese culture. The time here made me realize that as an outside observer, as much as I love Japan, this story is not mine. I'm not in it, and I can't be in it. There is a sense of being swept up in the tide of world events - of being carried along by the sweep of history.

It's powerful stuff.

I'm glad I went.

War isn't gone, and understanding what drives people to war is vital.

I fear we've forgotten all those lessons already...

As 2016 comes to an end, those of you that know my story know that this has been my Annus Horribilis - my most terrible year. But - it is in such straits, in my case deserved, that one sees grace most clearly.

As this year comes to an end, and I hear the clarion call of Jesus calling me forward, I will write an Ebenezer here - a touchstone to come back to and recall in future times of travail.

So here I will share 2 things through which that God said to me: I am. I hear you. I stand with you.

1) Maybe half a year ago, meeting a woman who has been called to serve in the mountains of Appalachia, she has served as a lay minister with and for the Anglican church amongst the poorest of the poor on the mountain-sides - people who trace their ancestry back to mercenaries hired by the british during the American Rebellion. Having communion with her and another brother, having been anointed with oil, I got to really experience God saying, you're done with this. It is a moment I will remember until I die. I've never experienced this sense of inner healing. I understand so much better the sense of desperation that the woman who sought to touch Jesus and receive healing.

2) Calling. In 2009, arriving in Cleveland, I prayed to God to ask if he'd let me build stroke treatment in the Washington DC area. I also prayed to have the opportunity to do this in Asia - someday. For those of you that don't know much about Stroke - it's the world wide number 2 cause of disability, and number 4 cause of death. 15,000,000 per year - it is the number 1 cause of death and disability in China, number 1 cause of disability and 5 cause of death in the US. As near as 25 years ago, we had no effective treatments. Stroke treatment is pretty amazing - it's perhaps one of the only areas we really can see restoring sight to the blind, the ability to walk to the paralyzed, the ability to speak to the mute. To see that restoration, it is witnessing a piece of the divine.

This year, God has seen fit to answer these prayers - and here I've been brought to work on such things - and God has aligned so many meetings and collisions that have opened so many doors - he really has just shown his presence and favour so many times and in so many ways. Yesterday, in the biting cold, we finalized some of the arrangements to start using medevac helicopters to fly surgeons in the region to a hospital that has the equipment to treat stroke but not the personnel. So, God willing, we'll be able to improve access to care for the whole northwest section of Washington.

There are two reasons why stroke matters so much to me. I've seen so many people forever marred by a stroke - people in their 40-s and 50s, ending their careers, altering their personalities. Stroke also disproportionally affects the poor... as if the poor needed more problems. "Feed my sheep," Jesus called to Peter. I may not always have food, but seeing God's heart for people - how can we not work to improve their lives? Both spiritually and materially?

I don't know whether this will lead to much, but God's opened doors to teach, share faith and do this in Asia (Taiwan/HK/China) in the next year... If it comes to fruition, all Glory to God. Feeling God move is such a privilege - I hope to stay here - until death.

So - here I am, writing this Ebenezer to recall God's faithfulness.

We Remember, God. We Remember You.

Edited

おめでとうはやさん！ to my good friend that made his dream come true.

A couple words about Atsushi -

I met Atsushi at Atlanta Japanese Baptist Church about a year before he opened Sushi House Hayakawa. We saw each other from time to time at a Melodyと言うカラオケ屋、where he commented that he finally had the financial backing to start the restaurant.

I'm actually quite intrigued by the way things start - feeling out what works and what doesn't. I remember eating at his place before official opening, sampling the dishes that were common to sushi restaurants around the world, but also of the types that are much more "homey". I actually had いくら飯 (Ikura Meshi) for the first time at his restaurant. So simple and yet, when prepared with the freshest materials, sublime.

Hand picked salts, and high grade 粗油(soy sauce) - his initial weeks had to be financially tough, trying to find a place in a town that at the time sported 居酒屋 that served sushi and a blossoming vietnamese owned high-end clubby-fusion-hipster sushi joint. How would a place aiming for tradition service and artistry fare in the midst of a city not yet acquainted with Jiro dreams of Sushi? How would he stay in the black using the finest ingredients when his competitors were low-balling the market in prices?

I remember him musing that it was hard to compete when other restaurants aimed for margins, when he couldn't bear to skimp on quality.

3 stories about Atsushi Hayakawa:

The first relates to his childhood in 札幌（Sapporo）小さいとき、in his childhood, he grew up with a father who ran a restaurant as well. He served with faultless hospitality, often letting guests eat for free when they were hard on their luck (the original welfare, my friends- not faceless governments, but people who give out of their own pockets to people responsible for saying thanks...). To the point where sometimes his mom would worry that the family would go hungry. This is the example that 父上would give. It's something that shines beautifully in Atsushi's character.

The second relates to his treatment of his friends. My background photo is of an overflowing glass of 日本酒。渡り船 (Wataribune) to be precise. It is a sake that I first had at Haya's place, where he poured it for me, into a small glass, overflowing （溢れている- afureteiru - beautiful word - tears overflowing, water spilling over）. He told me this symbolized the hospitality of the owner - to give bountifully - to spill over with generosity and graciousness.

It's such a beautiful symbol of hospitality - something akin to the korean practice of pan-chan. So different from the transactional nature of much of modern commerce and relationships - but I digress.

Psalm 23:
5 You prepare a table before me
in the presence of my enemies.
You anoint my head with oil;
my cup overflows.
6 Surely your goodness and love will follow me
all the days of my life,
and I will dwell in the house of the Lord
forever.

5 תַּעֲרֹ֬ךְ לְפָנַ֨י׀ שֻׁלְחָ֗ן נֶ֥גֶד צֹרְרָ֑י דִּשַּׁ֖נְתָּ בַשֶּׁ֥מֶן רֹ֝אשִׁ֗י כּוֹסִ֥י רְוָיָֽה׃
6 אַ֤ךְ׀ ט֤וֹב וָחֶ֣סֶד יִ֭רְדְּפוּנִי כָּל־יְמֵ֣י חַיָּ֑י וְשַׁבְתִּ֥י בְּבֵית־יְ֝הוָ֗ה לְאֹ֣רֶךְ יָמִֽים׃

When he poured that first glass of sake for me on that day of days, I recalled this chapter from my youth - indeed, the passage I memorized for my baptism.

It is, in our modern economy, wasteful. Pouring out sake until it pours over. It is an expression of boundless love.

ありがとうございました、早川さん。本当に、ありがとう。

The third story relates to his personal giving.

It's so easy to talk about love and sacrifice. To protest, but not to give. To be an activist, but lack love.

Haya-san has spent many of his vacations, not relaxing, but serving in 被災地 （hisai-chi - disaster zones) stricken by the Tsunami. Giving of his own resources, and more importantly, his time. This is love-writ large, on lives.

So - if you're in Atlanta, and you like traditional sushi, please try out his place... but more importantly, meet a good friend and a self-sacrificing man.

頑張ってください、敦さん！
頑張れ！

Thanksgiving is perhaps one of the "safest" holidays to celebrate. Essentially, everyone should be able to find a reason to be thankful to someone or something. Not everyone would prefer the Judeo-Christian interpretation of the holiday - that we thank God for all He has provided in all things... But for many agnostics and those of other faiths, thanks to a greater power is not so foreign a concept.

But before I get to what I'm thankful for, I wanted to comment and ponder a little more about Immigration.

If we ponder, for a moment, what the question of immigration might have looked like from the perspective of a native american leader in the late 1400's, it was probably a rather theoretical question. The so-called New World from "Old" Europe looked like a pristine land, settled by "savages." From the "First Nations" (Using the Canadian term) perspective, it was a land that they had lived on for centuries if not millennia, with their own customs, habits, beliefs and vision. Could they share this wide, rich land with new comers?

After all, the newcomers brought industry and energy - new technologies and new thinking. They brought trade goods and fashion. Manufactured from abroad - surely this would be good for the local economy, tax base (as it were?), labor markets. New companies started by the "immigrants" could easily create new jobs and bring new money into the local economy. Globalization was at hand, and you'd be a fool to turn away skilled labor...

We all know that this story isn't a story where everyone "benefited" from globalization.

The point of this observation is merely that ideals that we so simply state are good are rarely so simple. One man's immigration is another man's invasion - and these feelings are now present globally, as nations resist changes to their perceived fabrics.

A couple other examples of "not-so-obvious" ideological supremacy: The US holds several myths about its existence and essence. The Manifest Destiny that led to colonization from sea to shining sea may have brought a sense of accomplishment when the west and east were linked by both rail and trade. This sense probably manifests in the need to explore space, trade and technology as well. But lost in the shuffle are the multiple episodes of effective genocide as the entire land was cleansed from the pre-existing people. With the exception of a couple of the remaining large tribes, it was effectively annihilation for many. Wholesale elimination of languages, people and genotypes.

There is some fairly impressive evidence that prior to the English and the Spanish invasions of N and S. America, that other explorers managed to make contact. Now, across the Baring Strait, the likely trek the aboriginal nations made in tundra makes them very impressive explorers indeed. Navajo elders can understand Mandarin Chinese; contact and education likely made through the treasure ships sent by Zheng He in the 1200s. The Viking nations most likely were operational around modern Nova Scotia... I suppose one could argue that it wasn't a given that invasion would occur, rather trade and exchange as evinced by these other encounters between civilizations.

So - conquest has losers, but it doesn't have to be conquest. The US inveighs regularly upon other nations not to use force of arms or to annex nations. The US was built on force of arms and the annexation of nations. The whole louisiana purchase didn't really factor the First Nations that were living there...

What other myths?
Democracy is the best form of government, never mind that we have a functional republican form of government (ish). We'e seen that using a form of government doesn't automatically make it functional. There are many "elections" that simply bring us back to dictatorship. (End of the Weimar Republic, Democratically elected totalitarian regimes, etc.)

Globalization is always good. Regional excellence in a product can allow specialization. Agriculture is better produced in country a and b, so c can focus on energy, and depend on a and b for food. Which works great until you're at war with a and b, and then, you're dead. Interdependence pre-supposes no-war. There are many peaceful nations that learned that peace and environmentalism doesn't work very well at the wrong end of the muzzle of a firearm.

For myself of Chinese extraction, we are the only people group named specifically by US law as not-allowed to Immigrate. (Chinese Exclusion Act). My Japanese friends have the unique role of being enjoying internment. Do these acts comport with our perceived history as a nation of free immigration?

The Jews, Irish and Italians all experienced life in ghettos - and african americans had a deeply traumatic "immigration" experience as well.

Rhetoric and Ideology are lovely, but wisdom requires that we actually see what's going on and understand what the costs and benefits of each decision are, in the short and long term. Moral consequences, in my opinion, are deeply important as well - although no land was conquered through benevolent intervention (Hawaii - we essentially assassinated their monarchs...)

So what, in view of such amazing bloodshed, should we be thankful for?

We can't go back. We can't undo the deaths of millions on this continent or any other. We can't ever make reparations that would erase the death and suffering (Trail of Tears anyone? Smallpox laden blankets for winter?). But one thing that I really believe, as a Christian we should ponder.

We do not suffer nearly as horribly as we ought. For every "good deed" we have done, there are many evils we have wrought. That we remain, not utterly destroyed by some cosmic Karmic, divine retribution, should prompt us to be thankful.

"If you, LORD, kept a record of sins, Lord, who could stand?" Psalm 130:3

אִם־עֲוֹנֹ֥ות תִּשְׁמָר־יָ֑הּ אֲ֝דֹנָ֗י מִ֣י יַעֲמֹֽד׃

In the face of all the ill in the world, and all the injustice we perpetrate individually and as a people, that we live is cause for Thanksgiving.

That's the core of Christian thanksgiving. God's love spares us the devastation we deserve, and gives us love when we do not deserve his favour. We can be forgiven.

While many in the United States may not be thankful for our government or president elect, I think it bears reflection to ask what our nation is now like? What do we deserve? In tension is both mercy and justice. Call injustice when you see it - and yet have room for repentance, change - and in those settings, extend mercy.

That's something we should agree to be thankful for.

Life moves so very quickly. People come in and out of your life. Every ending is a new beginning.

There is a season for every purpose under heaven.

Thank the Lord for his mercy and steadfast love.

Jesus, how I need you.
Without you, I'd fall to pieces
Already dashed to bits,
I'd shatter if you weren't holding me together

You wanted me to love you first,
And I chose to love myself
I chose to treasure the gifts you gave
Instead of your most precious self.

Jesus, how I need you!
Your blood is the only refuge
From the sting of judgment
And the scourge of shame

For sins that I have wrought and blossomed.

And you, my only joy today
Nothing to distract.
When my eyes leave you,
I am utterly lost

Finally, you showed me your face...
Finally, I start to see
How I need you
How I always needed you.

How I always will need you, my Lord...

07.29.2016

I have an affection for the notion of the British Empire. There were dark deeds and there was glory, there was development and there was mismanagement - but the myth - the legend of Great Britain casts a long shadow over the 19th and 20th centuries. As a student and lover of history in English, it is no surprise that the romantic notions of Great Britain's culture, legacy and influence affect me greatly.

I woke up to the realization that Great Britain has voted to leave the EU. What started off as the European Community, a common market, had gradually increased financial heft, cost and integration. My knee jerk reaction to UK leaving the EU is that it was a bad idea. As I reflect further, I really don't know, as the EU has a lot of problems as well. Just as nations can integrate, they can disintegrate. The Roman Empire, Ottoman's, The USSR, Czechoslovakia to name a few. Indeed, a short century and a half ago, the US might have well devolved to a number of smaller nations.

What is striking to me about notions of permanence is that they are misguided. Very little on this planet is "permanent" and nothing should be taken for granted. EU integration has been a theoretical, and Britain has never been fully European. The fallout in the markets is already blistering - but the long term implications are harder to assess though easy to pontificate about.

Will this portend further disintegration of the EU? The EU doesn't have that many financial sources that are relatively cash rich. If it gets to a point where the entire EU is bankrolled by a couple states, and others are receiving cash transfers, will those states that give more be tempted to get out? Will there be tighter integration to better control possible dissolution?

Will the EU experiment come undone?

Oddly enough, my biggest realization is personal. Further integration is neither inexorable nor to be taken for granted.

Man and his works are evanescent.

Worshiping in Japanese

The past weekend I had the occasion to attend a Christmas Sunday service at the Japanese American United Church in New York City. It’s not often that I get to attend service in Japanese, and it was a true pleasure.

Why is that?

As a person of Chinese ancestry, my roots have some passing relationship with Japan – the mainland Chinese relationship with the Isle of Wa is long and undergoes many turns both good and ill. It’s no surprise that there is friction between the peoples, given some of the more conflict filled terms – indeed, it’s hard not to have friction between some of the more prominent nations that abut.

But, growing up in the west, and traveling more often to Hong Kong and Taiwan, I’ve never been very influenced by those memories or events, remembering instead the contributions to art, cuisine, science and industry that Japan has made. I have surrounded myself with much Japanese culture over the years, and feel very comfortable amidst the sound of the language, and the sights and smells of the land. When I hear the speech and the voices, see the body language – it is comfortable and… なつかしい。恨情怯。

In short, I feel comfortable in that milieu.

When one considers what many things make Japan unique, one often escapes the mind of non-Japanese… what other country has enjoyed two atomic weapons? Hiroshima and Nagasaki both suffered nuclear assaults. It is ironic that the US remembers those events without much remorse – and indeed, the memories relate more to the horror of mutually assured destruction with the Soviets, rather than the Enola Gay, and the radioactive waste that Japan suffered.

Of course I remember Nanking (南京) and all the privations that occurred during the war(s) in the far east… but in history, both perpetrator and victim are often one and the same, and no nation is innocent. I won’t go so far as to say there is no such thing as a greater amount of guilt, but in the Lord’s eyes, the people have both guilt and things to glory over.

But it is not merely my fond memories of Japan, nor affection for her people – it is knowing how much the Japanese Christians have suffered over the centuries, and how few are there.

The Lord desires every tribe and tongue to confess him and bow their knees. In a nominally Shinto/Buddhist spiritual mooring, the modern Japanese are typically more akin to functionally agnostic, with many assuming a hazy spiritual stance if at all.

It is in this context that I am so moved.

131 years this little church has stood – changing congregations and pastors. It is in this milieu that I am so very touched, seeing sincere love for Christ, and singing hymns in Japanese and some English as well.

My heart leaped, and my spirit refreshed.

Many years ago, I sought to learn Japanese thinking that perhaps one day I might be called to that island nation. While that day has never come, my affection and longing for the people has never ceased.

I thank the Lord that he’s given me the chance to spend it in worship with these people – seeing the babies, the kids, adults and the grandparents. I was so at home…

So glad!

May the Lord bless Japan, and bring more Japanese to a saving knowledge of His grace, and belief in His gospel.

お神さまの恵。。。

Blood on the Snow

On the flight to HK, I watched a Japanese movie called Blood on the Snow. If you plan to watch it, please do not read on.

The movie is about two men, one a failed bodyguard who was supposed to protect a pro-trade minister during the fall of the bakufu/shogunate and the beginning of the Meiji period and the restoration of “Imperial” rule – and the other a patriotic assassin that was party to the group that slew that minister.

It follows the changes in society that occurred with the end of the shogunate with no small attention to the identity and role that former samurai were to play. While romanticized in some way, it still brought a lot of thought and consideration to the way duty and honour can both strengthen and shackle a person.

The symbol that underpins the story is the camellia that blossoms in the winter, beautiful amidst the snow. The adversity and suffering experienced by the main characters over 13 years after the assassination have left them in emotional limbo – one charged to bring the assassins to justice before he may commit suppuku, and the other waiting for someone to take his neck – waiting for execution.

It is about two men being stuck in the mire of choices made and failures that followed those choices. But one additional nuance, and I know not new or not to the Japanese media – it comments that the person that suffered the most was not the bodyguard, nor the assassin, but rather the bodyguards wife.

While men might suffer in limbo, wracked by their choices and failures – the women that love them might suffer far more, even more helpless to loose the chains that bind the heart and soul in torment.

What’s the lesson here?