Healthcare — the Fundamental Choices

One of our fundamental choices about health care has moral and practical dimensions.  The other is purely practical.

Let’s first address the practical issue.  Our  appruoach to health care puts our businesses at a serious and growing competitive disadvantage.  US corporations currently spend $12,591 on average for coverage of a family of four, up 54% since 2005.

Our national health care spending, which was 5% of GDP fifty years ago, is now 17 % of GDP.  It has more than tripled.  Meanwhile, Germany’s spending is two thirds of ours and is growing much less rapidly.

We spend half again as much or more on health care as other advanced economies.  And the gap is growing.  Germany now spends 11% of GDP on health care, only increased from 9% half a century ago.  Japan spends 10%,  Britain 9%.

It’s no coincidence that our health care system is fundamentally different from our competitors’.

Our business leaders say their competitiveness is hobbled by corporate taxes, but while our health care spending has more than tripled in the last half century, corporate taxes that were then 4% of GDP are now half that at about 2%.

It’s true we have industrialized nations’ highest corporate tax rate but many of our great multinational corporations pay little or none.  It’s also true that our high tax rate hurts smaller domestic corporations but that’s much less important than our health care system’s costs.

To remain competitive, we must restructure our health care system.  

The choice with both moral and practical dimensions is whether everyone will have health care, or only those who can pay?  

If only those get health care who can pay, the others will suffer and die.  If we favor this approach we should consider, are we okay with that fact?

If everyone will get health care, there must be some rationing.   If we favor this approach, do we recognize that fact?

It’s misleading to think of health care as a human right.  Nations choose what rights their citizens will have and embody them in laws.  Those laws can and do change.

Our current legal system specifies that, with an exception I’ll get to in a minute, those of us who cannot pay for health care do not get it.  Why is that, and could it change?

It is an article of faith with us that we are rugged individuals who take responsibility for ourselves.  We resist anything we think could make us less responsible.

Another of our articles of faith is that competing organizations motivated by profit always get the best results.

But that could be about to change.  The Medicare for All act has 108 sponsors as of May 13, 2017: https://www.congress.gov/bill/115th-congress/house-bill/676

We would get better results from a unified approach to health care.  We do not, after all, provide for our defense with autonomous, competing armies.  We know that kind of service can only be supplied effectively by our central government.  And we know our government has encouraged, not stifled innovation in that field.

Here are links to what I’ve written before about some important aspects of our approach to health care but if you’re out of time, just skip past them to the conclusion — a single payer system works best.

In http://martinsidwell.com/socially-acceptable-healthcare/ I pointed out that we do currently provide not health care but at least medical treatment to all via the Emergency Medical Treatment and Active Labor Act (EMTALA) passed under President Reagan.  That approach means: “We have in the USA universal access to medical treatment via the most costly system possible.”

Data I posted at:  https://usaturnaround.wordpress.com/2011/09/21/healthcare-from-85000-feet/ show that:  “US health care delivers poorer results at higher cost because it is based on the flawed assumption that market based systems always deliver the best results. While in most cases they do, for health care they do not. The incentives are perverse”.

Exploring our Federal deficit at: https://usaturnaround.wordpress.com/2011/07/11/drivers-of-the-deficit/ I noted that: “more important even than getting rising Federal healthcare spending under control is to get rising health care cost under control.  As noted in previous posts, we spend double what other advanced economies do on healthcare without getting better results.”

Examining national spending and results at: https://usaturnaround.wordpress.com/2011/04/19/overall-us-healthcare/ I pointed out some contributors to our abnormally high costs:  “our obesity rate, the highest of all OECD countries and more than twice as high as the 15% OECD average …  The percentage of our adult population considered obese rose from 13% in 1965 to […] 34% in 2007.  Obesity-related medical spending in the USA doubled […] between 1998 and 2008.”  

Focusing at: https://usaturnaround.wordpress.com/2011/04/17/medicare-and-medicaid/ on Medicare and Medicaid I pointed out that: “The primary cause of increased Medicaid spending is that it now services 16% of all Americans, up from 2% at its inception [while] Medicare now serves 15% of the population, up from 10% in 1966 and the percentage will continue to increase as our population ages … The key fact about Medicare is that an aging population, unhealthy lifestyles and technology advances are driving its costs up 8% annually, much higher than Medicaid.”

The conclusion?  Our need to remain competitive means we must restructure our health care.  Our competitors did that long ago.  They all established a unified system for all their people, they all have much lower costs than ours, and they all get the same or better results.

Our current approach to health care is not exceptional in a good way.

When the government acts as the one health care buyer it has the market power to negotiate the lowest price that is profitable for suppliers.

A competitive health care market benefits consumers only for procedures like breast enhancement where they have enough time to make an informed choice.

To remain competitive we must change our health care system.  We must either stop providing care to many millions more of those who can’t afford it or establish a single buyer to negotiate the lowest profitable price for providing care to the largest pool of consumers, which is both the currently healthy and the sick.

Annual Report

My end-of-year statistics from WordPress are — 7,691 page views this year with last month the most active at 973 views by 600 unique visitors.

I’m intrigued that while 575 of last month’s 973 page views were from the USA, others came from surprisingly diverse places — 57 from the UK, 37 from France, 34 from India, 33 from the United Arab Emirates, 30 from Canada, 20 from Qatar, 17 from Germany, 11 from Egypt, 10 from the Czech Republic and smaller numbers from elsewhere.  In January, 31 were from Brazil.  This month, 17 are from Japan.  Globalization is a thing!

My research for posts about Yemen, Syria, Iraq, Turkey, Kurdistan, the Islamic State, Jordan, Kuwait, Lebanon, Palestine and Egypt was to dispel my own ignorance with the hope that they would also help friends here in the USA.  I’m happy they also found an audience in the Middle East.

What motivated me to start that work was Islamophobic propaganda.  I wrote about that here.

I plan to complete that first round of Middle East research in the new year, post about Israel, more about the Islamic State/ISIS, and ideas for Middle East strategies and about terrorism in the USA.

I intend also to return to why we engage in endless war and ever-increasing arms exportsjingoism, and how we can counter relentless propaganda.

My seven posts about depression stimulated a lot of comment.  I will return to that topic with some recent research about averting depression.

My posts about Nepal and Buddhist practice got me thinking about adding a new area to the site for photo-heavy posts about my treks in Nepal, Sikkim and Tibet.

And I will explore how to make some older posts more visible.  This month there were 238 views of my October 30, 2014 Ignorance, Fear and Imaginary Facts and I have no idea what suddenly made that post so popular.

So, thank you everyone who came here this year!  I am encouraged to continue 🙂

 

Happy Birthday Every Day

I was both born and met my death on April 20, 1970.  It also happened on March 25, 1944 when I separated from my mother’s body.  It is happening again in this very moment.

Our universe is energy, in no way fixed, an endless, glorious play of energy.

None of the universe’s energy is created or destroyed.  It simply changes.   That is the first law of thermodynamics.  All energy is conserved.

Physicists have measured the conservation of energy.  It is absolutely consistent across all space and time.

So, along with everything else, what I think of as “me” disappears and is reborn in every instant.  The waves of energy that appeared as “me” when I typed “in every instant” have already changed shape and direction.

Mostly, we notice only the dramatic changes.  Perhaps for a moment we feel the beauty of a flower.  But we do not recognize that our mind-body is always changing.

All the energy that manifested as “me” when I landed in New York forty five years ago remains in this world even though much of it is no longer part of “me”.  Every wave of energy that encountered “me” changed “me”.  The path of every wave that met “me” was changed by the encounter.

How to sense this fundamental truth?  I think of the weather.

The entire weather system is interconnected.  It has no fixed borders yet it is different everywhere and always changing.  The sun is rising in a clear sky above Brunswick Maine this morning.   Yesterday at this time it was gray, windy and raining.  Rain is falling in other places right now.

Tiny actions like the flap of a butterfly’s wing engage with powerful winds that arise seasonally as the positions of the Earth and Sun change.  So many factors change the flow of energy that we experience as weather.

We humans manifest in the same way as weather, all different, all part of the same system, not remaining exactly the same even for a moment.  And, like the butterfly drying its wings, our every action changes the entire energy flow.

Perhaps some of the energy that now creates the appearance of “me” will later join other waves of energy in a summer monsoon to nourish rice in India.  Perhaps a grandchild of a child waking up now in Brunswick, Maine will enjoy some of that rice.  The play of energy makes anything and everything possible.

Our intellect can’t quite understand how our “self” can be imaginary yet cognizant, imaginary but able to choose how it nudges the energy in which it appears.  I’ve learned not to worry about that.

Intellect is what gives us the opportunity to deploy our kindness intelligently.  Becoming better able to do that is my birthday wish.

Our Eleven American Nations

I was quite startled to learn that our Constitution has a stated aim to protect the “opulent minority.”   I was impressed when I studied our system of government for my citizenship exam.  Now I realized that I didn’t understand the system’s history or implications.

I started with Robert Dahl’s excellent How Democratic is the American Constitution?  Daniel Lazare’s The Frozen Republic opened my eyes wider.   Then I read Colin Woodard’s enormously helpful America Nations – A History of the Eleven Regional Cultures of North America.

Woodard began his career in Eastern Europe when the Soviet Union was collapsing.  He noticed that the boundaries of Hungary, Poland and other nations bore little or no relation to the ethnic and cultural realities.  Groups within those countries had always been rivals and people across borders shared a culture and long history.

That got Woodard thinking about cultural rivalry within our nation.  The South versus the North, the coasts vs the heartland, those grossly simplified divisions don’t explain the reality.  Cultures that came from England, France, Spain, the Netherlands and so on were significantly different and those cultures remain powerfully alive.

Our values and the behavior they motivate are much more those of eleven distinct people than of fifty States, or of an homogenous population with shared values.

Eleven American Nations

What are the implications?

The Constitution’s first words are “We the people of the United States, in order to form a more perfect Union.”  Coming in the recent past from very different cultures with very different values, many of the delegates did not want union but to be left alone.  Those who wanted union had very different ideas about its form.  The great majority of the population was not consulted, certainly not those whose land had recently been invaded.

The Constitution that resulted from all the necessary compromises results in an ongoing contest between only two major parties.

My conclusion before I read Woodard’s research was that since the Republican Party has been taken over by a tiny minority of the most wealthy Americans in alliance with fundamentalist Christians and anarchists, “something-other-than-progressives” must take over the other Party.  But that would result in even more extreme gridlock.

The Democratic Party must not shift to the far left to balance a Republican Party that is moving further and further to the far right.  It must find a position that accommodates the diverse values of a majority of people across all our eleven nations.

Our world is constantly changing, so our policies and programs must, too.  Sometimes a conservative brake on changes will be best, other times major changes will have grown urgently necessary.  And the priorities of neither major party will permanently align with those of any of our eleven nations.

Some of us wage war on “invasive species”, plants, insects, fish, rodents, mammals, any form of life that “does not belong here.”  Some of us reject people who arrived recently and “don’t belong.”  But as the world inevitably changes, life forms inevitably move.

Recent linguistic research indicates that the first people in North America did not come directly from Siberia across the Bering Strait 12,000 years ago.  People from Siberia had been living in Beringia for around 85,000 years.  When the ice melted and their habitat was flooded 12,000 years ago, some came here.  Others went back to Siberia where they perhaps no longer “belonged”.

Those who came here formed into tribes, some peaceful, some making war on each other.  We think of those Native Americans as being decimated by “the white man” as if a single invasive species destroyed them.  In fact, it was a variety of new species, eleven major ones, that set up an entirely new form of government which excluded them.

What we need to do now is figure out how we can use that system of government to better represent the people of the eleven nations who we speak of collectively as “Americans.”

We are not alone in facing this challenge and we have had governments that better represented us all in the past.  We can have such a government again.  We’re in a much better position than, for example, Nepal.  Politicians there continue to wrangle without visible progress over what structure of government could represent all Nepalis, not just the Brahmin elite.

Nepal’s politicians cannot even start to learn how to govern until they choose a structure.  Ours could start governing effectively right now.  We must make them do so.

Protecting the Opulent Against the Majority

A few days ago, billionaire venture capitalist Tom Perkins wrote that the way progressives are starting to treat the super rich reminds him of how the Nazis treated the Jews.  Soon after his letter was published in multi-billionaire Rupert Murdoch’s Wall Street Journal, he had to apologize for his politically incorrect phrasing.   He would have done better to quote James Madison, “Father of the Constitution” and author of the Bill of Rights.

When the Federal Convention of 1787 turned to the question “whether the republican form shall be the basis of our government,” Madison pointed out: “In England, at this day, if elections were open to all classes of people, the property of the landed proprietors would be insecure.  An agrarian law would soon take place.” 

The implication, he continued, is:  “If these observations be just, our government ought to secure the permanent interests of the country against innovation.  Landholders ought to have a share in the government, to support these invaluable interests, and to balance and check the other.  They ought to be so constituted as to protect the minority of the opulent against the majority.”  (emphasis added)

A widely held belief has developed that the US Constitution offers protection for all minorities.  That was not its intent.  Madison’s much more limited aim was to protect the wealthy minority.  Whether or not we like the result, we should recognize that our Constitution is working as intended.

How does it work?  A republic is where power is held by elected representatives whose actions are bound by a Constitution.  People in a republic vote for candidates who promise changes they like.  The risk is that a small majority could make changes with unacceptable negative impact on the rest of the population.  That’s why a Constitution is necessary, to prevent such changes by defining ‘unacceptable.’

I’m thinking about this because I’m reading Noam Chomsky.  His diagnosis of why our government acts as it does, regardless which party is in power, feels spot on.  He shows example after example of actions by our government that benefit the opulent minority and work against the interests of the majority here and throughout the world.

But Chomsky’s proposed solution is misguided.  His central beliefs are that power corrupts and capitalism concentrates wealth, which, based on long first-hand experience and close study of history, are truths I hold to be self-evident.  The question is, would his solution, anarcho-syndicalism, be better?  Could it even work?

Anarcho-syndicalists are socialist libertarians.  Like capitalist libertarians who enjoy President Reagan’s signature joke: “The nine most terrifying words in the English language are: ‘I’m from the government and I’m here to help'” they oppose central power.  The difference is anarcho-syndicalists say the inevitable concentration of wealth by capitalism exploits the majority.

Attractive increases in freedom are promised by both kinds of libertarians.  In real life, however, the system does not scale.  A libertarian (i.e., unregulated) society cannot protect shared resources or universal needs: local societies often manage local resources (e.g., forests) sustainably but resources managed by non-locals are polluted and/or depleted.  And small societies cannot retain freedom: they cannot defend themselves against more powerful exploiters.

It is true that a fundamental problem for large scale enterprises is that central planning cannot work: there’s too much change to comprehend at the center.  An ingenious programmer I once hired was directed to model how many tractors Soviet factories should plan to build.  He tried combinations of many, many factors without success before at last seeing how to produce results that pleased the planners.  How?  By plugging the number of tractors that were going to be built, anyway.

Big businesses fail for the same reason – they lose contact with changes in their market.

Another problem is many things that start small seem destined to grow big but central planners too often fail to identify which are worth the investment.  Small societies with property managed at the local level would make better choices but they lack the necessary resources.  Today’s semiconductor and internet infrastructure, medical technology and etc required enormous investment.

So history tells us that democracies with a constitution tend to be better for people than autocracies, that market-based economies tend to deliver better results than centrally planned ones, and that capitalism seems essential to generate disruptive technology and deploy it on a large scale.

Speaking in Parliament in 1947, not so long after he lost the election following WW2, Winston Churchill famously said: “Democracy is the worst form of government, except for all those other forms that have been tried from time to time.”  The same looks to be true of capitalism in the economic sphere and nation states in the sphere of sovereign entities.  They do all tend to concentrate power and wealth but the alternatives are worse.

So, “if these observations be just,” how can the non-opulent minorities who make up the majority get protection?  Curtailing the inevitable abuses of power is achieved by incremental legislative changes that adapt Constitutional definitions to changes in society.

Because the fundamental structure of the system results in the wealth and power of the opulent minority always nudging the law’s evolution in their favor, other minorities must speak more loudly.

It is healthy that voices are now speaking loudly enough about too-high and rising inequality to be heard by Perkins and others.  It indicates that our system is working as it should.

The Practice of Transformation

First, some background to the epiphany (an experience of sudden and striking realization).  Twenty-odd years ago I joined Dun and Bradstreet’s advanced services division as Director of Program Management.  I was not the only one unfamiliar with what that job might be.  When my business cards came, they identified me as Director of Program Manglement.

There is no better way in such a situation than Steve Jobs’ approach: “When you don’t know where to start, start somewhere.”  I did what needed doing for a complex new service that was being developed in New York and tested and rolled out in country-specific variants all across Europe, then used that experience to establish a methodical software development process.

The first step in the process is a Vision Statement.  Its purpose is to imagine and articulate “how great it will be when.”  Because our mission was to develop and deploy “advanced services”, we had to imagine new ways our customers could do their work to get better results.

Vision Statements imagined people using radically new software to do business in new ways with far more effective results.  We illustrated how pieces of the software might look and got feedback from innovative customers to identify the best ideas.

Then came the Scope Statement.  That’s where, based on our image of “how great it will be when,” we defined what the first software version would and would not do.  Scope transformed an ultimate vision into something we could actually do.  That became the basis for the Project Plan.

So, the Vision Statement harnesses intuition: the Scope Statement employs the intellect.  The Vision Statement is expansive: the Scope Statement is restrictive — that’s where you discipline yourself to say, “No, we don’t have to do that piece yet.”

By the time I took over as General Manager of that division then went on to establish D&B’s global “Technology Strategy, Architecture and Frameworks” I’d realized the same method of harnessing intuition disciplined by intellect was applicable to transformational business strategy.

No transformation is possible if you have no vision of “how great it will be.”  At best you will find only quicker, cheaper ways of doing the same things you always did.

Now the epiphany:  a couple of days ago, I realized Tibetan Buddhism is built on the same foundation.

In a long traditional set of rituals I practice every morning, supplemented by study and reflection later in the day, I imagine becoming deities that flawlessly manifest behavior I want to perfect.  The only difference from business Visions is instead of imagining freedom from business limitations, I imagine freedom from emotional and conceptual habits.

In the same way as Vision Statements include illustrative stories, Tibetan Buddhist texts include tales about exemplary beings.

But unlike the process for product and business transformation, Tibetan Buddhism requires no Scope Statement.  New products and services or business strategies take substantial time and investment which makes rigorous scope management of a stepwise transition essential.

Tibetan Buddhist practice is more like bug-fixing.  All features exist, they’re just buggy.  Because they’re so buggy, it’s hard to imagine all the defects gone, so we visualize deities that reveal in purified form what we cannot see even though it is already there.

How to proceed when there are so many bugs?  The proven method in the business world is “continuous improvement.”  One of its early leaders, W. Edwards Deming, was instrumental in Japan’s mastery of manufacturing.  They summarize his teaching that errors are opportunities for learning to generate improvements as “every defect a treasure”.

Continuous improvement is an unremitting process of noticing defects, rigorously identifying their root causes, and incrementally eliminating those factors.

Tibetan Buddhism is a continuous improvement practice.  My teacher says two to four hours of formal practice every day is necessary for transformation.  Some change seems to be taking place since I upped my own practice to two hours.  But it’s the same as in business, my aim must be to stay alert throughout the day, notice every defect, identify why it happened, and steadfastly uproot its cause.

I was lucky in my business life to get transformative teachings at Harvard Business School and elsewhere.  I am lucky now to get transformative Tibetan Buddhist teachings.  And I’m blessed above all by my parents’ teaching, “I don’t know, let’s work to find out.”

Epiphanies result, if at all, from long hard work whose aim may not even seem to be discovery.  They are surprising because arriving at the realization is unexpected.  The realization itself, however, is immediately recognized to be obvious truth.

It’s not surprising that both transformational Tibetan Buddhism and transformational business strategy use envisioning integrated with continuous improvement.  My surprised feeling was because I hadn’t noticed that before.  It’s lucky that what I learned in business was such good preparation for what I’m doing now.

Doma: My Greatest Gift

Supplementary essay: “Please tell us about a gift, given or received, that was particularly meaningful to you. What was the gift, and why was it meaningful? (150 words max)” Doma & Niran after SLC Graduation

Doma wrote:

Birthday gifts, Christmas surprises and other presents are not what I am thinking of.  My greatest gift is the education my mother gave me.

My mother had no schooling and was married at fifteen.  My father abused her and soon left us.  Since then mom struggled to support us by working as a hotel maid. Somehow, she managed to keep me in a good school.

For Class 11 and 12 mom wanted me to go to Budhanilkantha School (BNKS) because it is one of the best. I was scared because most of its students are from rich families.  What I learned in that world is there is no limit to the future I can create.

My mother’s gift allows me to make a future so much better than her own life:  it has made me what I am, and what I can dream of to become. What an amazing gift!

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Comments by Martin:

I wrote the following comments when Doma was admitted by Randolph College, the first of five excellent colleges.  I explain her decision to accept Hampshire College’s offer on the Doma Ghale page.

The picture is from when Doma graduated from Amrit School in what we call High School sophomore year.  Doma and her mom, Niran, are dressed in Tibetan style because Norkyel, her first education sponsor, had just honored them for Doma’s graduation in the “First Division with Distinction”.

We were thrilled then by what Doma had achieved, which Niran sacrificed so much to make possible.  Our hopes for Doma’s future were high.   Would she be accepted at Budhanilkantha School for Junior and Senior years?

Two years later, our hopes are again high.  Will Doma be able to come to the US for a college education?

There are some differences this time.  Doma is not afraid as she was about Budhanilkantha: she is excited about the far more different world here.  And for Niran, no sacrifice is possible to make US college affordable: one year at a good US college costs the same as two houses where she lives.

Doma may succeed and be accepted but we might fail to establish enough funding.  Nonetheless, I said, Doma and I will, in different aspects of the process, try our utmost.  And we did.

Doma has been accepted with enthusiasm by Randolph College.  Their academic scholarships range from $6K – $20K.  They granted Doma the maximum and will consider her for their Presidential Scholarship which covers all tuition costs.  The gap will be $26K annually if Doma does not get the Presidential Scholarship, $13K if she does, plus her travel and incidental expenses.

Randolph College is a fine institution where Doma would thrive.  She has also applied to 15 other colleges, some of which have substantially larger endowments than Randolph.  One of them could even cover all her costs including two fully paid trips home each year.

But so many factors go into admission decisions: there is no way to predict what choices Doma may have, or their net cost.  What we do know is I would not be able to provide all $30K-ish a Randolph education may cost.

I mention this because if Doma does need more financial aid than I can provide, I will invite everyone to help.  I would establish a dedicated bank account for Doma’s education, set up a Paypal link or equivalent to facilitate donations, and provide accounting and other updates.

April 2014 Update:  Details about the dedicated bank account and a Paypal link to donate to it are now on the Doma Ghale page.   There is also a Paypal link to donate to it on the Donate page.   Details about financial aid, donations and expenses are on the Accounting page.  Other updates are on the News page.

Doma: One Woman to Converse With

Pick one woman in history or fiction to converse with for an hour and explain your choice. What would you talk about? (250 word limit)

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I want to talk with poet and novelist Parijat, whose real name was Bishnu Kumari Waiba. My principal at Amrit School is a low-caste Tamang woman like me who established that school thirty years ago when only high-caste men started schools. She is Parijat’s younger sister.

Parijat’s mother died when she was very young. She was raised by her strict father and grandparents. She said, “I did not get any inspiration from my home and I had to cheat my family to be as I am today.” I want to ask her who did inspire her and how did she develop the courage to overcome family opposition?

Born in Darjeeling in 1937, she came to Kathmandu when she was 17 and earned a BA degree.  She had fallen ill when she was 13, became paralyzed when she was 26, and my principal supported her after that. She says Parijat’s physical weakness never dampened her spirit. How did Parijat do that?

Parijat rebelled against anything that diminished women’s freedom. She wrote to change how people think, she started a women’s literature movement, and she supported many other social causes. Nepal still is among the most unfair societies for women. What would she say I should do now?

Most of all I want to ask Parijat what it was like in those days when the authoritarian regime of the king was at its height. Nepali society still presents obstacles to people like me.  I could learn so much by talking with Parijat.

About Doma

DomaI promised to write more about Doma, the Nepali girl for whose USA college applications so many of you gave such helpful advice. She submitted the last of 16 applications a couple of days ago and just got her first acceptance!

Doma has amazed me in the six years I have been her education sponsor. Her low-caste, very poor background is a great handicap in Nepal, especially for females. She has made extraordinary progress and will go far beyond what she has already achieved.

I met Doma’s mother, Niran, at the Kathmandu hotel where I began visiting in 2003. She had been working there since soon after her husband brought her from her village in the high hills. It was an arranged marriage and she was only 15 when Doma was born. She had no schooling, spoke only Tamang tribal language, and her husband soon abandoned her. The only job she could get was as a hotel maid. She learned Nepali and the hotel owner, Norkyel, helped her get a divorce. Her first few years were extremely difficult, especially because although she earned barely enough for necessities, she was determined to give Doma a good education. Remarriage is not an option for a Nepali woman with a child.

I chatted with Niran each time I visited because by then she had taught herself English. She also speaks Hindi and was learning Tibetan from a book left by a guest. When Nepal’s civil war ended in 2006, the Maoists began unionizing. I was friendly with Norkyel and he told me he had been giving Niran extra money for Doma’s schooling but he must stop. His staff was unionized now, so he must treat everyone the same. He asked if I would like to take over.

My wife had met Niran and was also attracted by her intelligence, humor and good work so I took over and began getting to know Doma. She was very shy. Tamang are close to the low end of the caste structure, her mom had only ever worked as a maid and Doma expected her future would be the same. I told her she could do better and must try because her mother had made great sacrifices to get her an education.

Doma did try, she slowly gained confidence, and her exam results improved. From her usual place in the middle, she reached 6th place, then 3rd. She said she could never do better because the top two students were wealthy and had tutors. The next year she came 2nd. That made a decisive difference. She had succeeded to a degree she hadn’t believed possible. Now she knew she might surprise herself still more.

Doma was 2nd again in 10th grade then transferred to a new school. Norkyel took her to several of the best ones, including Budhanilkantha (BNKS), the traditional choice of Nepal’s kings. Math was her strongest subject but she preferred arts and did not want to go to BNKS because they teach only science. We told her she should try. At last she told me: “I realized I am not a child now, so I should not be stubborn. Everybody says I should do this. Probably they are right.” She did try, and she was accepted.

How would she get on with high-caste kids from wealthy families who live in a way she had never imagined? It took a lot of courage at first, but she did fine. The only problem, she said, was her friends always had to pay for her when they went out from school. The school didn’t let kids out very often so it wasn’t a big problem.

Doma’s 10th grade results had been 85% in English and in the mid-90% range for math and science. In Junior year, she was 10th in her class of 40 with a mix of As and Bs despite having to navigate a very new environment. Then she grew over-confident and greatly over-committed to extracurricular activities. She was also sick during her final exams.

In Senior year, Doma led many cultural programs and did much volunteer work for school clubs. She was also selected for the annual ‘Quanta’ competition at City Montessori School, Lucknow, India. While taking part in the math competition, she led students from other countries in Nepali dance performance.

What Doma discovered about herself and her potential in two intensive years at BNKS is great preparation to overcome challenges she will meet in college and later.

Doma’s Math SAT 2 result is 730. Her spoken English is excellent but even the best Nepali schools do not provide good training in written English. Her best results so far are 89 for TOEFL, 490 for reading SAT and 410 for writing. While we wait for more admission decisions, she will continue to improve her written English and track her progress with more TOEFL tests.

In college, Doma will learn how to succeed with her dream. The Vice-Principal at her school before BNKS told me, “Doma is relentless. If she doesn’t understand something she will keep coming back with questions, more and more questions until she’s certain she does understand.” Her aspiration is to build a business in Nepal to provide good jobs for people like her and good services for customers. Nepal has very weak infrastructure in government, law and utilities. Doma believes that building a business will enable her to make the greatest contribution to transform her country.

Doma choreographed this dance shortly before she graduated from Budhanilkantha. It is, she told me: “Like Sherpa but not exactly. It’s a dance for people who live high in the mountains.” Sherpas and Doma’s Tamang people both came from Tibet long ago. Doma is the shorter of the two girls in red tops who enter from the left. She then dances in the center.

Over the next few weeks I will post some essays Doma wrote as part of her college applications. I’m so lucky to have found someone who is so worthwhile to help.

College for Doma

I`m in Kathmandu helping Doma apply for college next Fall.  I`ve been supporting her education for six years and will tell you her heart-warming life story another time.  Right now, I`m looking for feedback on 15 colleges where I think she should apply.

Doma`s strongest subject is Math – she got 750s in SAT practice classes – she`s almost equally strong in Physics, her comprehension and fluency in English are excellent, she considers her greatest strength to be creativity and she was a popular and effective leader in High School.  Her exam results got her into the school attended by the children of Nepal`s kings.

Doma`s goal is to build a great business in Nepal and she wants to prepare by studying in a US college. It`s an ambitious and important aspiration, especially for a woman.  Nepal is a very poor country where women are greatly disadvantaged: It ranks 121st of 136 nations in gender equality.

I asked Doma: “What must change so Nepalis can make a good future?”  “Better government and successful Nepalis in other countries coming back to build businesses.”  “Maybe you should work in government?  “Other people must do that.  I want to do business.”  So the criteria for colleges where Doma should apply are:

  • Good business program, ideally with a focus for entrepreneurs
  • Diverse majors for other students from whom Doma can learn
  • Preferably within 300 miles of Brunswick, Maine where I live
  • Residential campus
  • Offers sufficient needs- and merit-based financial aid for international students

The most attractive choices look to be Hampshire College, Providence College, Randolph College and NYU Abu Dhabi.  Hampshire was great for my son who is similar to Doma in important ways, it has a program for entrepreneurs and is networked with UMass and three other colleges.  Randolph looks almost equally good but is in Lynchburg, VA.  It`s on my list because, like Hampshire, I have a friend there.  Both colleges are enthusiastic about Doma.  Another friend`s brother teaches at NYU Abu Dhabi and it offers extremely generous financial aid.   Providence has strong business and other schools, offers generous financial aid and its Dominican culture should suit Doma`s Buddhist values.

Not many colleges offer financial aid to international students and among them, only a few offer need-based aid, which Doma will need as well as merit-based aid because her mother can provide none. If Doma is accepted at Hampshire with the maximum aid it has given any international student, the net cost will be $20K plus travel and incidentals, the high end of what may be affordable.  That maximum is 185% of their average grant.  I estimated the maximum for other colleges using a lower multiple, 100% for Providence because their average is so high and 150% for Randolph and most others.  That makes the estimated net $12K for Providence and Randolph.  It could be zero for NYU Abu Dhabi.

The next most appealing set is Elmira College, Fairfield University, Hartwick College, Quinnipiac University and Ramapo College.  All look to have good business schools and diverse other majors, all are within 300 miles of my home, the first four could offer enough aid to bring the net below $10K, Ramapo`s should be below $20K and it`s a popular choice for students from Doma`s High School.

College of St. Rose, New England College, Saint Michael`s College and Albright College are all popular choices for business majors and all offer a range of other majors, but they are less appealing because they have less capacity for financial aid.  Saint Michael`s may be too Catholic. Cornell University offers generous financial aid to international students but its only business major is Hotel Management.  That may be fine because tourism is an important part of Nepal`s economy but it is restrictive.  Worcester Polytechnic Institute grants enormous aid to international students and it has a range of business majors, however its chief focus is engineering, which is one of Doma`s interests but has limited applicability in Nepal.

Those 15 colleges range widely in selectivity but Doma`s potential Math SAT result is substantially above the high end of the requirement for all except Cornell (she should be way above their minimum).  She has done better than required by 9 colleges on SAT Reading and should also do for 5 others.  The requirement for Hampshire, Cornell and WPI is probably beyond her reach within the next two months and the SAT Writing minimum may be out of reach for almost all 15 as it likely is for most students whose native language is not English.  I expect Doma`s TOEFL (English proficiency) result to count for more and, based on her conversational skill, I expect her result will be high.

Do you or your friends know any of the colleges where I don`t have contacts, are there others we should consider, should I change the selection criteria, do you have other feedback?