Friday, April 30, 2010

The Drunkard's Walk: How Randomness Rules Our Lives by Leonard Mlodinow

This is a good book to read conjunction with Gladwell’s Outliers, it touches on some of the same topics, but from a much different perspective. The author is a Professor at Caltech where he teaches students about the science and mathematics of randomness and probabilities. In spite of this Mlodinow produces a book that is only slightly less accessible than that of the more popular Gladwell. One can, if they wish, skim over the descriptions of how our knowledge of these processes evolved over the centuries and still benefit from the examples and conclusions that are presented.

While Gladwell dwells on how particular circumstances can lead to advantageous results for individuals, Mlodinow focuses on how often what we view as cause and effect is really just the result of random processes occurring in very complex systems (the lives of human beings). The two approaches are not unrelated, but they are more complementary than supplementary. Most of Mlodinow’s work looks at the distributed results of a group of essentially equal individuals, such as professional athletes, mutual fund operators, and Hollywood executives, and analyzes and illustrates the role of randomness in their success relative to their peers. By Gladwell’s logic, these people are already successful. He is more concerned with how and why these individuals attained that level of success while others did not. His parameters are things like age, gender, race, education, and wealth, not what we would normally consider random occurrences.

Hopefully it will be found interesting to collect a few of Mladinow’s observations on the effects of randomness and couple them with some of the descriptions of how the human intellect is not wired to deal effectively with random processes.

The author culminates his narrative on randomness and probabilities by describing the "normal accident theory." This is a concept that is ascribed to Yale sociologist Charles Perrow. This concept was developed after studying the Three Mile Island incident where a series of minor issues cascaded into a near disaster (compare this with Gladwell’s description of why we have aircraft accidents). In Mlodinow’s words:

" complex systems (among which I count our lives) we should expect that minor factors we can usually ignore will by chance sometimes cause major incidents.....Called normal accident theory, Perrow’s doctrine describes how that happens—how accidents can occur without clear causes, without those glaring errors and incompetent villains sought by corporate and government commissions. But although normal accident theory is a theory of why, inevitably, things sometimes go wrong, it could also be flipped around to explain why, inevitably, they sometimes go right. For in a complex undertaking, no matter how many times we fail, if we keep trying there is often a good chance we will eventually succeed....The normal accident theory of life shows not that the connection between actions and rewards is random but that random influences are as important as our qualities and actions."

Much of what the author discusses can be thought of and understood in terms of a simple coin tossing experiment (provided you can occasionally think in terms of coins with more than two sides). Instead of a coin with heads or tails for sides, think of one that has a "good" side and a "bad" side. So here we are tooling through life pursuing our goals as best we can while being buffeted by a number of minor but random occurrences ( a long red light that causes us to be late for a meeting for example). These perturbations can have positive or negative effects. What we know about tossing coins is that eventually the numbers of heads and tails will approach the same value. What we don’t usually consider is that while we spend our time tossing this coin there is a considerable probability that we will throw five or ten straight heads or tails. Or consider millions of people tossing coins. There will be a number of people who will experience long strings of good or bad perturbations. Thus are stars born while others are damned to lives of misery and frustration.

The author provides a number of examples where randomness seems an inevitable explanation. Many of the most interesting ones come from the worlds of art and finance. Consider the popularity of a piece of music.

"For their study they recruited 14,341 participants who were asked to listen to, rate, and if they desired, download 48 songs by bands they had not heard of. Some of the participants were allowed to view data on the popularity of each song—that is on how many participants had downloaded it. These participants were divided into eight separate "worlds" and could only see the data on downloads of people in their own world...each world evolved independently. If the deterministic view of the world were true the same songs should have dominated in the eight worlds....But the researchers found exactly the opposite: the popularity of individual songs varied widely among the different worlds....In this experiment, as one song or another by chance got an early edge in downloads, its seeming popularity influenced future shoppers (Tipping Point?). It is a phenomenon well known in the movie industry: movie goers will report liking a movie more when they hear beforehand how good it is."

The deterministic view would have you believe that "experts" study the buying habits and preferences of customers and predict what will be the next hit or best seller. That is, they study the past and try to replicate it. Mlodinow takes great joy in pointing out:

"John Grisham’s manuscript for A Time to Kill was rejected by twenty-six publishers; his second manuscript for The Firm drew interest from publishers only after a bootleg copy circulating in Hollywood drew a $600,000 offer for the movie rights. Dr. Seuss’s first children’s book, And To Think That I Saw It On Mulberry Street, was rejected by twenty-seven publishers. And J. K. Rowling’s first Harry Potter manuscript was rejected by nine."

Sometimes you have to flip that coin many times before you get a desired result. And then there is this quote from a Hollywood executive.

"If I had said yes to all the projects I turned down and no to all the ones I took, it would have worked out about the same."

The statistics of small numbers is especially relevant to the movie industry. The author devotes some space to delineating histories of the success, the lack thereof, and sometimes both success and failure of various film studio executives to support the following statement.

"That means that if each of 10 Hollywood executives tosses 10 coins, although each has an equal chance of being the winner or the loser, in the end there will be winners and losers. In this example, the chances are 2 out of 3 that at least one of the executives will score 8 or more heads or tails."

The unlucky will soon be unemployed while the lucky are lavishly rewarded with money and accolades. If they are really smart they will move on to another position before their luck changes, presumably to a higher position where they can dispose of the poor souls who are visited with a run of bad luck.

Mlodinow also lobs a few randomness examples at the financial industry. He considers the performance of 800 mutual funds over a five year period. He plots the performance of each fund relative to the mean in ascending order so that entry 800 is the highest performer, and the first is the lowest. A smooth curve is obtained by plotting these points with the first 400 being negative and the second 400 being positive. A knowledgeable investor might come up with numerous reasons why any given fund performed as well or as poorly as it did. An amateur investor would certainly have a hard time selecting any fund out of the bottom 400. Mlodinow then plots the performance of these funds against the median for the succeeding five year period, but he maintains each fund at the same location on the axis that they had earned initially. If past performance is a predictor of future performance, or if the performance is a result solely of the acumen of each fund’s manager one would expect a roughly similar curve to appear. Instead, any correlation between past and current performance disappears and one is left with what the author describes as random noise.

"People systematically fail to see the role of chance in the success of ventures and in the success of the equity fund manager....And we unreasonably believe that the mistakes of the past must be consequences of ignorance or incompetence and could have been remedied by further study and improved insight. That’s why, for example, in spring 2007, when the stock of Merrill Lynch was trading around $95 a share, its CEO E. Stanley O’Neal could be celebrated as the risk-taking genius responsible, and in the fall of 2007, after the credit market collapsed, derided as the risk-taking cowboy responsible—and promptly fired. We afford automatic respect to superstar business moguls, politicians, and actors and to anyone flying around in a private jet, as if their accomplishments must reflect unique qualities not shared by those forced to eat commercial-airline food. And we place too much confidence in the overly precise predictions of people—political pundits, financial experts, business consultants—who claim a track record demonstrating expertise."

Mlodinow’s point is that the world is a complicated place and not easily understood even in retrospect. Extrapolating to the future is extremely difficult, even extremely unlikely perhaps. There are undoubtedly people who have an exceptional grasp of a particular situation and can be more accurate than the average person, but how does one decide who that person is if, generally, results are consistent with randomness. Mlodinow’s advice:

"It is more reliable to judge people by analyzing their abilities than by glancing at the scoreboard. Or as Bernoulli put it, ‘One should not appraise human action on the basis of its results’."

Trusting that someone who was correct one, two or three times will be correct the next time may not be a defendable strategy.

The author discuses the difficulties people have dealing with situations where random variables are in play.

"We often employ intuitive processes when we make assessments and choices in uncertain situations. Those processes no doubt carried an evolutionary advantage when we had to decide whether a saber-toothed tiger was smiling because it was fat and happy or because it was famished and saw us as its next meal. But the modern world has a different balance, and today those intuitive processes come with drawbacks. When we use our habitual ways of thinking to deal with today’s tigers, we can be led to decisions that are less than optimal or even incongruous.....The greatest challenge in understanding the role of randomness in life is that although the basic principles of randomness arise from everyday logic, many of the consequences that follow from those principles prove counterintuitive....The mechanisms by which people analyze situations involving chance are an intricate product of evolutionary factors, brain structure, personal experience, knowledge, and emotion. In fact, the human response to uncertainty is so complex that sometimes different structures within the brain come to different conclusions and apparently fight it out to determine which one will dominate."

Mlodinow lists three types of situations where people get in trouble. Two of these are evolution driven, the third is a result of either not understanding the situation or not understanding how probabilities work, or both.

Naive Realism

The author describes "naive realism" as the belief that things are what they seem. He provides an interesting example from the life of a scientist named Daniel Kahneman. At the time Kahneman was a psychology professor. He was given the task of lecturing a class of flight instructors on the latest knowledge related to behavior modification and how it might be applied to flight training. Studies with animals had taught him that positive reinforcement was the best way to produce results. The flight instructors all protested that their experience contradicted this claim. They had concluded that if you yell at someone for performing poorly they will likely do better the next time while complimenting them for a good performance usually means they will generally do worse the next time. Kahneman pondered over this at length and eventually came up with an explanation that changed his career path and he eventually ended up with a Nobel Prize in economics for his studies on how and why people make the decisions they do.

"The student pilots all had a certain personal ability to fly fighter planes. Raising their skill level involved many factors and required extensive practice, so although their skill was slowly improving through flight training, the change wouldn’t be noticeable from one maneuver to the next. Any especially good or especially poor performance was thus mostly a matter of luck. So if a pilot made an exceptionally good landing—one far above his normal level of performance—then the odds would be good that he would perform closer to his norm—that is, worse—the next day. And if the instructor had praised him, it would appear that the praise had done no good. But if a pilot made an exceptionally bad landing—running the plane off the runway and into a vat of corn chowder in the base cafeteria—then the odds would be good that the next day he would perform closer to his norm—that is, better. And if his instructor had a habit of screaming ‘you clumsy ape’ when a student performed poorly, it would appear that his criticism did some good. In this way an apparent pattern would emerge.....the instructors in Kahneman’s had concluded from such experiences that their screaming was a powerful educational tool. In reality it made no difference at all."

There is a related issue that complicates our reasoning and leads us to deduce false patterns. Mlodinow refers to this as the "availability bias." This bias leads to emphasizing excessively memories that are most vivid and accessible in our past and deducing patterns that in fact do not exist.

"How probable is it that of the five lines at the grocery-store checkout you will choose the one that takes the longest. Unless you’ve been cursed by a practitioner of the black arts, the answer is around 1 in 5. So why, when you look back, do you get the feeling that you have a supernatural knack for choosing the longest line? Because you have more important things to focus on when things go right, but it makes an impression when the lady in front of you with a single item in her cart decides to argue about why her chicken is priced at $1.50 a pound when she is certain the sign at the meat counter said $1.49."

Need For Certainty

People seem to be wired to search for some organization or pattern in their observations even if the events are completely random. There is presumably some evolutionary advantage to this approach, but it can now lead to incorrect conclusions. Mlodinow dwells on how we come to view both successful and unsuccessful people and how we feel a need to explain success or failure as resulting from superior attributes or critical defects.

"Obviously it can be a mistake to assign brilliance in proportion to wealth. We cannot see a person’s potential, only his or her results, so we often misjudge people by thinking that the results must reflect the person."

It is not surprising to be told that we tend to assume that successful people have some innate qualities that justify and explain their success. What is surprising, and somewhat troubling, is that studies show that we will employ the same approach to people who would be described as failures. In their case we feel a need to justify their fate by assuming what befell them was due to some fault of their own. In viewing a homeless person we will tend to assume that person has some defect that put him in that situation.

"On an emotional level many people resist the idea that random influences are important even if, on an intellectual level, they understand that they are. If people underestimate the role of chance in the careers of moguls, do they also downplay its role in the lives of the least successful? In the 1960s that question inspired the social psychologist Melvin Lerner to look into society’s negative attitudes toward the poor. Realizing that ‘few people would engage in extended activity if they believed that there were a random connection between what they did and the rewards they received,’ Lerner concluded that ‘for the sake of their own sanity,’ people overestimate the degree to which ability can be inferred from success."

Lerner conducted controlled experiments in which a group of people observed one of their members undergo what appeared to be a painful electrical shock whenever the person failed at a learning exercise. The person was a plant who acted out the role but this was unknown to the remaining observers.

"At first, as expected, most of the observers reported being extremely upset by their peer’s unjust suffering. But as the experiment continued, their sympathy for the victim began to erode. Eventually the observers, powerless to help, instead began to denigrate the victim. The more the victim suffered, the lower their opinion of her became. As Lerner had predicted, the observers had a need to understand the situation in terms of cause and effect....We unfortunately seem to be unconsciously biased against those in society who come out on the bottom."

Misunderstanding And Malfeasance

There are several relatively minor and harmless mistakes people make when faced with random processes. The most familiar is the "gambler’s fallacy." The standard example involves someone playing a slot machine and losing steadily. The assumption is often made that after so many losing attempts the odds are building up in favor of winning. In fact, the odds of winning in the future are exactly what they were when the person sat down in the first place. Another tendency is for people to put too much belief in things learned from small numbers of events. In sports there is often a seven game series to determine the best team. If the two teams are equally capable then they have an equal chance of winning. If one team is in fact better and more likely to win a given game:

"...there is a sizeable chance that the inferior team will be crowned champion. For instance if one team is good enough to warrant beating another in 55% of its games, the weaker team will nevertheless win a 7-game series about 4 times out of 10. And if the superior team could be expected to beat its opponent, on average, 2 out of each 3 times they meet, the inferior team will still win a 7-game series about once every 5 matchups."

The choice of seven games is more one of practicality than an attempt to attain a statistically significant result.

The more interesting examples are those where statistics are misused and the consequences are significant. Consider this case of doctors trying to interpret statistical results of mammograms.

"For instance, in studies in Germany and the United States, researchers asked physicians to estimate the probability that an asymptomatic woman between the ages of 40 and 50 who has a positive mammogram actually has cancer if 7 percent of mammograms show cancer when there is none. In addition, the doctors were told that the actual incidence was about 0.8 percent and the false negative rate about 10 percent. Putting that all together one can use Bayes methods to determine that a positive mammogram is due to cancer in only about 9 percent of cases. In the German group, however, one-third of the physicians concluded that the probability was about 90 percent, and the median estimate was 70 percent. In the American group, 95 out of 100 physicians estimated the probability to be around 75 percent."

This example is interesting and frightening in many ways. If out of a 1000 women in a high-risk age group, 8 will have cancer and 70 will be told they might have cancer when there is none, is it any wonder that physicians are beginning to question the efficacy of frequent mammograms in lower risk groups? And how many of these 70 women were told they had a 75% chance of having breast cancer instead of a 9% chance? We already knew they had lethal penmanship skills, but given their inability to comprehend simple arithmetic, how comforting is it to consider how much trust we put in these doctors?

Mlodinow’s examples from the legal profession are even more troubling because they arise not so much from incompetence as from an attempt to deceive. He refers to what he calls the "prosecutor’s fallacy" because statistics are often used to mislead jurors in legal cases. The first example concerns DNA testing.

"DNA experts regularly testify that the odds of a random person’s (DNA) matching that of the crime sample is less than 1 in 1 million or 1 in 1 billion. With these odds one could hardly blame the jury for thinking, throw away the key."

The author then describes the case of a jury that was so impressed with these statistics that they convicted a man for a crime even though he had eleven witnesses who placed him in another state at the time of the crime. He served 4 years (out of 3100 years) before a follow-up test indicated that the first test was in error. Was this a case of a 1 in 1 billion occurrence or a case of the jury being misled by a convenient misapplication of statistics?

"But there is another statistic that is often not presented to the jury, one having to do with the fact that labs make errors......Estimates of the error rate due to human causes vary, but many experts put it at around 1 percent. However, since the error rate of many labs has never been measured, courts often do not allow testimony on this overall statistic. Even if courts did allow testimony regarding false positives, how would jurors assess it? Most jurors assume that given the two types of error—the 1 in 1 billion accidental match and the 1 in 100 lab-error match—the overall error rate must be somewhere in between, say 1 in 500 million, which is still for most jurors beyond a reasonable doubt. But employing the laws of probability we find a much different answer.....that is, the odds are 1 in 100. Given both possible causes, therefore, we should ignore the fancy expert testimony about the odds of accidental matches and focus instead on the much higher laboratory error rate—the very data that courts often do not allow attorneys to present!"

Finally there is a most famous misapplication of probabilities and statistics from the O. J. Simpson trial.

"The renowned attorney and Harvard Law School professor Alan Dershowitz also successfully used the prosecutor’s fallacy—to help defend O.J. Simpson in his trial for the murder of Simpson’s ex-wife, Nicole Brown Simpson, and a male companion.....The prosecution made a decision to focus the opening of their case on O.J.’s propensity toward violence against Nicole....As they put it ‘a slap is a prelude to homicide.’ The defense attorneys used this strategy as a launchpad for their accusations of duplicity, arguing that the prosecution had spent two weeks trying to mislead the jury and that the evidence that O.J. had battered Nicole on previous occasions meant nothing. Here is Dershowitz’s reasoning: 4 million women are battered annually by husbands and boyfriends in the United States, yet in 1992, according to the FBI Uniform Crime Reports, a total of 1,432, or 1 in 2,500 were killed by their husbands or boyfriends. Therefore, the defense retorted, few men who slap or beat their domestic partners go on to murder them. True? Yes. Convincing? Yes. Relevant? No. The relevant number is not the probability that a man who batters his wife will go on to kill her (1 in 2,500), but rather the probability that a battered wife who was murdered was murdered by her abuser. According to the Uniform Crime Reports for the United States and Its Possessions in 1993, the probability that Dershowitz (or the prosecution) should have reported was this one: of all the battered women murdered in the United States in 1993, some 90 percent were killed by their abuser. That statistic was not mentioned at the trial....Dershowitz may have felt justified in misleading the jury because in his words ‘the courtroom oath—"to tell the truth, the whole truth, and nothing but the truth" —is applicable only to witnesses. Defense attorneys, prosecutors, and judges don’t take this oath.....indeed it is fair to say that the American justice system is built on a foundation of not telling the whole truth’."

Destiny Disrupted: A History of the World Through Islamic Eyes by Tamim Ansary

This is one of the most informative, stimulating and relevant books that you will encounter. It provides us with a thorough history of the religious and cultural evolution of what might be called the "Muslim world" from the time of the prophet Mohammed to the present day. The author provides sufficient detail to grasp the complexity of this history without deadening the senses. His writing style is clear and easy to follow, and the occasional flashes of humor add to the enjoyment. The story he tells fills in many gaps in our knowledge of Islam and its history but, perhaps, the author’s most important contribution is to stop the narrative at various points and remind us that at that time the state of the world looked quite different depending on whether it was seen through Muslim eyes or Western eyes. This combination of increased knowledge and improved understanding should allow the reader to produce better informed opinions on topics ranging from freedom of religion to the war in Afghanistan. Some of the particularly interesting topics discussed by the author are presented below.

The Success of Islam as a Religion

Islam began in the seventh century with one man in the Arabian Peninsula who claimed he was God’s messenger. Within 100 years it had overwhelmed the Byzantine and Sassanid Empires and its religious and political reach extended from Spain, across northern Africa, throughout the Middle East and into western Asia. What was it about Islam that made it so successful? According to the author it was a combination of a number of factors.

It of course starts with Mohammed, his character, and his message. Mohammed established what are called the five pillars of Islam. All one had to do to become a Muslim was to attest that there is only one God and Mohammed is his messenger, perform a certain prayer ritual five times each day, give a certain fraction of one’s wealth to the poor each year, fast from dawn to dusk during the month of Ramadan each year, make a pilgrimage to Mecca at least once in a lifetime, if possible.

The author points out that, at least on the face of it, this is more a prescription for how to live your life rather than a complicated or demanding belief system. The goal of these requirements was to provide a more perfect community of believers. Islam was a path to a better social system. This concept of society must have been attractive to the peoples who encountered it, easing the acceptance of the new religion.

The military successes seem to have benefited from a convergence of factors. The Muslims had on their side the fervor of recent converts, the lure of plunder from conquered lands, and surprisingly adept military leaders. The timing of the Islamic emergence was also favorable. It came at a time when the surrounding empires were in decline. The Muslims were surprised by their military success. It inspired in them even greater religious fervor for surely it proved that God was on their side. They even formulated a justification for the militant spread of Islam.

"...the idea that the world was divided into the mutually exclusive realms of Dar al-Islam and Dar al-Harb, ‘the realm of peace’ and ‘the realm of war.’ This schema depicted Islam as an oasis of brotherhood and peace surrounded by a universe of chaos and hatred. Anything one did to expand Dar al-Islam constituted action in the cause of peace, even fighting and bloodshed, because it shrank the realm of war."

Surely a major factor in the successful spread of Islam was the wisdom and relative benevolence with which they ruled the conquered peoples.

"Omar’s treatment of Jerusalem set the pattern for elations between Muslims and the people they conquered. Christians found that under Muslim rule they would be subject to a special poll tax called the jizya. That was the bad news. The good news: the jizya would generally be less than the taxes they had been paying to their Byzantine overlords—who did interfere with their religious practices.....The idea of lower taxes and greater religious freedom struck Christians as a pretty good deal, and so Muslims faced little or no local resistance in former Byzantine territory. In fact, Jews and Christians sometimes joined them in fighting the Byzantines."

"Conquest led the surge but conquest was kept separate from conversion. There was no ‘conversion by the sword.’ Muslims insisted on holding political power but not on their subjects being Muslims."

This description may come as a surprise to those used to hearing the current shouts of "death to the infidels." The history of Islam is complex and one needs a book such as this to lead one from these beginnings to the state of the Islamic world today.

Islam and Fundamentalism

One must understand the origins and the history of the Muslim peoples in order to appreciate the tendency towards what we would call fundamentalism: an unswerving dependence on revelation to determine all aspects of a believer’s life. Consider the path of Christianity. Christ was on the public scene for a few years and never had a large following. His sayings are transmitted to our times through translations from multiple languages by authors of unknown identity with unknowable accuracy. The Catholic branch of Christianity resolves uncertainty by allowing the Pope to provide the appropriate interpretation of Christ’s intentions, thereby avoiding the threat posed by ambiguity. The Protestant branch has bifurcated. One path views the Christian Bible as a generally correct guide to what they should believe and how they should live their lives, but it is viewed as a vehicle subject to interpretation. Only the Fundamentalist Protestant path tends toward a view of the Bible as the literal truth, an attitude that is much in the same spirit as the Muslim community and its acceptance of the Qur’an.

Mohammed was a known religious figure for about 20 years. As the messenger from God he defined Islam as a religion. However, he was also a political and social leader.

"Once Mohammed became the leader of Medina, people came to him for guidance and judgments about every sort of life question, big or little: how to discipline to wash one’s hands...what to consider fair in a contract...what should be done with a thief...the list goes on. Questions that in many other communities would be decided by a phalanx of separate specialists, such as judges, legislators, political leaders, doctors, teachers, generals, and others, were all in the Prophet’s bailiwick here."

Mohammed preached that not only was he God’s messenger, he was God’s last messenger. There would be no further revelations. When Mohammed died, his successors had to decide what to do. They had become used to depending on the word of the Prophet on all matters. It was decided that it was necessary to continue along that path.

"Unlike older religions—such as Judaism, Buddhism, Hinduism, even Christianity—Muslims began to collect, memorize, recite, and preserve their history as soon as it happened, and they didn’t just preserve it but embedded each anecdote in a nest of sources, naming witnesses to each event and listing all persons who transmitted the account down through time to the one who first wrote it down, references that function like the chain of custody validating a piece of evidence in a court case."

Given that Mohammed is God’s messenger and that his preaching and sayings are assumed to be documented, one is left with little wiggle room. Islam is inherently a religion of fundamentalism. All questions are to be referenced to a pronouncement of the Prophet. That, of course, becomes harder to do as the world evolves and new circumstances appear. The next step was to attempt to decide what the Prophet would have decided by looking for analogous situations to apply, but that becomes more uncertain and subject to interpretation. The result is that one ends up with factions that passionately believe they are following the revealed truth but arriving at different conclusions. The situation becomes explosive when one factors in a decision by Mohammed’s immediate successor.

"But Abu Bakr responded to the crisis by declaring secession to be treason. The Prophet had said ‘No compulsion in religion,’ and Abu Bakr did not deny that principle. People were free to accept or reject Islam as they pleased; but once they were in, he asserted, they were in for good. In response to a political crisis, Abu Bakr established a religious principle that haunts Islam to this day—the equation of apostasy with treason."

This provides some explanation for why Sunnis and Shiites get along better with Christians and Jews than with each other.

To understand how this relatively benign religion developed the radical strains that bedevil the world today requires some knowledge of Muslim history. This the author provides. To make a long story short, the Muslim world suffered two major classes of catastrophe. The first might be referred to as invasions by barbarians. The first wave consisted of Turks moving down from their ancestral homelands (the central Asian steppes north of Iran and Afghanistan).

"Rude Turks came trickling south in ever growing numbers: tough warriors, newly converted to Islam and brutal in their simplistic fanaticism. Accustomed to plunder as a way of life, they ruined cities and laid waste to crops. The highways grew unsafe, small-time banditry became rife, trade declined, poverty spread. Turkish mamluks fought bitterly with Turkish nomads—it was Turks in power everywhere."

The actions of the ruling Turks would help induce the next wave of assaults.

"At this time the Muslim world knew as little of Western Europe as Europeans later knew about the African interior. To Muslims, everything between Byzantium and Andalusia was a more or less primeval forest inhabited by men so primitive that they still ate pig flesh. When Muslims said ‘Christians,’ they meant the Byzantine church or the various smaller churches operating in Muslim controlled territory. They knew that an advanced civilization had once flourished further west: a person could still make out traces of it in Italy and parts of the Mediterranean coast, which Muslims regularly raided; but it had crumbled during the Time of Ignorance, before Islam entered the world, and was now little more than a memory."

"Then the Seljuk Turks wrested control of Palestine away from the tolerant Fatimids and the indolent Abbasids. As new converts, these Turks tended towards zealotry. They weren’t zealous about sobriety, modesty, charity, and the like, but they ceded second place to none when it came to expressing chauvinistic disdain toward followers of other religions, especially those from faraway and more primitive lands...Christian pilgrims began to find themselves treated rather shabbily in the Holy Lands. It wasn’t that they were beaten, tortured or killed—nothing like that. It was more that they were subjected to constant little humiliations and harassments designed to make them feel second-class."

Reports of such treatment made their way back west and contributed to the notion of a crusade to regain control of the Holy Lands. The result was about 200 years of sporadic, but bloody battles that further disturbed the Muslim regions and pushed them yet further from their goal of the ideal society.

"Some modern-day Islamic radicals (and a smattering of Western pundits) describe the crusades as a great clash of civilizations foreshadowing the troubles of today. They trace the roots of modern Muslim rage to that era and those events. But reports from the Arab side don’t show Muslims of the time thinking this way, at least at the start. No one seemed to cast the wars as an epic struggle between Islam and Christendom—that was the story line the Crusaders saw. Instead of a clash between two civilizations, Muslims saw simply a calamity falling upon...civilization. For when they looked at the Franj (crusaders), they saw no evidence of civilization."

Eventually the crusades petered out and a far worse tragedy befell the Muslim world. This time the invaders were the Mongols coming from the east under the leadership of Genghis Khan.

"Then he marched on Khorasan and Persia, and here the Mongols attempted genocide. No other word really seems appropriate.....When the Arab geographer Yaqut al-Hamawi wrote a description of western Iran, northern Afghanistan, and the republics north of the Oxus River a few years before the Mongol invasion, he described a fertile, flourishing province. A few years after the invasion, it was a desert. It still is."

This sequence of disasters provoked a theological crisis in the Muslim world.

"The crisis was rooted in the fact that Muslim theologians and scholars, and indeed Muslims in general, had long felt that Islam’s military successes proved its revelations true. Well, if victory meant revelations were true, what did defeat mean?....Another major Muslim historian speculated that the coming of the Mongols portended the end of the world. According to yet another, the Mongol victories showed that God had abandoned Muslims."

It was at this point that the first hints of what we would today identify as "radical Islamic fundamentalism" began to emerge. The thoughts taking root were that these tragedies did not indicate any failure in their religion, but in their practice of the religion. The defeats could be blamed on the Muslims themselves for having drifted away from the practice of "true Islam." The meaning of the word "jihad" also began to acquire a new meaning. The author said the word is most directly translated with the meaning of "struggle," and in the early days of Islam it was associated with the struggle of the religion to survive and spread. Now the word was beginning to be used to include armed struggle against enemies of Islam, a category that included non-Muslims, heretics, apostates and schismatics. According to Ansary, this world-view did not take hold initially but never died away either. It was left to ferment across several hundred more years of Muslim humiliation.

The second catastrophe that befell the Muslim world was the economic and technical domination by the Western nations that yet continues. The invasion in this case was not military but economic. The invaders were merchants, flush with money, looking to buy and sell things. This influx of cash into the relatively simple and, by Western standards, backward economies of the Muslim nations caused severe dislocations to which the local citizens were not able to effectively respond. The net result was that the individual regions became beholden to that Western wealth, and subservient to those who controlled it. The exact path to subservience, or colonization, was different in different regions. The author’s description of the effect on India is representative.

"Around 1600, three gigantic national versions of that first corporation were created in Europe: they were the British, the Dutch, and the French ‘East India Companies.’... Each was chartered by its national government, and in each case the government in question gave its company a national monopoly on doing business with the Islamic east. The actual entities jockeying for advantage in Persia, India, and Southeast Asia, then, were these corporations."

"In Bengal, where the British elbowed out all other Europeans, the East India Company pretty much destroyed the Bengali crafts industry, but hardly noticed itself doing so. It was simply buying up lots of raw material at very good prices. People found more profit in selling raw material to the British than in using those materials to make their own goods. As the native economy went bust, indigenous Bengalis became ever more dependent on the British and finally subservient to them....The East India Company enshrined itself as the Bengali government’s ‘advisors’ nothing more. For the sake of efficiency, the company decided to go ahead and collect taxes on behalf of the Moghul government. And again, for efficiency’s sake, they decided to go ahead and spend the money themselves, directly, locally: what was the point of sending it to the capital and having it come back again? Oh, and henceforth the company’s private army would take care of security and maintain law and order. But the company insisted that it was not now governing Bengal: it was just providing needed services for a fee."

The effects of this invasion (colonization) were more subtle than those produced by the Mongols but just as severe and deadly in the long run.

"In practice, this meant the (powerless) "government" was responsible for solving all problems while the (powerful) company was entitled to reap all benefits but disavowed any responsibility for the welfare of the people; after all, it was not the government. Rapacious company officials bled Bengal dry, but those who complained were referred to ‘the government.’ The plundering of the province resulted in a famine that killed about a third of the population in just two years—we’re talking about an estimated 10 million people here."

The entire Muslim world was invaded/colonized in similar fashion. It was generally not until after World War II that this hold was broken. The Muslim world was then left to reform itself along boundaries drawn by the Western governments. This is itself an interesting story, but the point of this discussion was to demonstrate how the groundwork had been laid for a surge in radical Muslim fundamentalism.

The Muslim theological response to all this history was either to demand that Muslims must "shut out Western influence and restore Islam to its pristine, original form," or to demand that Islam be modified or reinterpreted to allow Muslims to better engage in the modern world. The latter approach became the effective winner in the sense that most countries ended up with governments intent on bringing their people to a state where they could compete with the Western countries. The fundamentalist strain persisted, however, and continued to gain adherents.

Wahhabism is the most familiar of the radical fundamentalist movements. It originated with Abdul Wahhab, an Arabian, born around 1703. He preached religious revival through restoration of Islam in its original state.

"...the local ruler Mohammed ibn Saud welcomed him warmly. Ibn Saud was a minor tribal chieftain with very big ambitions: to ‘unite’ the Arabian Peninsula. By ‘unite,’ of course, he meant ‘conquer.’ In the single-minded preacher Abdul Wahhab he saw just the ally he needed; Wahhab saw the same when he looked at ibn Saud. The two men made a pact. The chieftain agreed to recognize Wahhab as the top religious authority of the Muslim community and do all he could to implement his vision; the preacher, for his part, agreed to recognize ibn Saud as the political head of the Muslim community, its amir, and to instruct his followers to fight for him....The pact produced fruit. Over the next few decades, these two men ‘united’ all the bedouin tribes of the Arabian Peninsula under Saudi-Wahhabi rule."

This tie between the Saudi family and this extreme fundamentalism continued. In fact, the definition of Wahhabism today owes as much to Saudi implementation as to Wahhab’s preaching. The prime change to Islamic theology, according to Wahhabism, is the specification of jihad, the struggle to defeat the enemies of Islam, as a fundamental obligation of a Muslim.

"And who were the enemies of Islam?...According to Wahhab’s doctrines those who did not believe in Islam were, of course, potential enemies but not the most crucial offenders. If they agreed to live peacefully under Muslim rule, they could be tolerated. The enemies of real concern were slackards, apostates, hypocrites, and innovators."

Thus, what was originally a tolerant religion had, in this manifestation, morphed into an intolerant and potentially violent form. The tie to the Saudi family continues to this day. Saudi Arabia is the font for Wahhabism. It has allowed the country’s immense oil income to be used to support the spread of this form of Islam. A millennium of defeat and humiliation helps produce enough converts to make it a force in the world today.

This book leaves one optimistic about the eventual reciprocal accommodation of Western and Islamic-dominated governments. However, the followers of Wahhabism may not reside in a universe where such accommodation is possible. For example, if the Taliban in Afghanistan are truly Wahhabists, then they have to look around and see that Pakistan, Iran, Turkmenistan, and Uzbekistan must be the next to go.

The Role of Women in Islamic Societies

The author points out that the role of women provides the most striking example of incompatibility between the societies of the Islamic world and that of the West. He revisits this issue several times as Islam evolves. It would appear that the practice of restricting women’s rights and role in society developed gradually over time and is more a result of cultural and traditional imperatives rather than religious edict. In the time of Mohammed the Arabian culture did not accord women the same rights as men, but they were allowed to participate broadly in society, including running businesses, participating in religious discussions and even going to war. Education was compulsory for both boys and girls. The early religious leaders did dictate that men and women should be separated during prayer in order to avoid sexual distractions. One could foresee this attitude evolving into an ever more restricted role for women. In addition, the Muslims encountered societies in which it was popular for wealthy men to keep their women hidden from view as a mark of their prestige. This practice apparently was gradually adopted by Islamic men for much the same reason.

Ansary seems to view this issue as an unfortunate idiosyncrasy of Islam rather than a tragedy of epic proportions.

"Well meaning folk on both sides believe that no human beings should be oppressed. This is not to deny that women suffer grievously from oppressive laws in many Muslim countries. It is only to say that the principle on which Muslims stand is not the "right" to oppress women. Rather, what the Muslim world has reified over the course of history is the idea that society should be divided into a men’s and a women’s realm and that the point of connection between the two should be in the private arena, so that sexuality can be eliminated as a factor in the public life of the community."

The author quotes a fellow named Ghazali, who is described as an influential early Muslim scholar, in order to indicate what these separate "realms" came to mean. A woman should


"remain in the inner sanctum of her house and tend to her spinning; she should not enter or exit excessively; she should speak infrequently with her neighbors and visit them only when the situation requires it; she should safeguard her husband in his absence and in his presence; she should seek his pleasure in all affairs...She should not leave his home without his permission: if she goes out with his permission, she should conceal herself in worn out clothes....being careful that no stranger hear her voice or recognize her personally....She ready at all times for (her husband) to enjoy her whenever he wishes."

This does not look like a sincere attempt to manage sexuality in society. This appears more like male chauvinism gone berserk. The two realms described are those of master and slave. The whole notion that "separate but equal" can be made to work is inconsistent with everything we learn from history. A recent news broadcast pointed out that the major cause of death for women between the ages of 19 and 44, world wide, was violence inflicted by men. This, of course, includes civil wars, genocides, and other catastrophes. However, this report also pointed out that violence against women is endemic in some societies and stated that 80% of women in Afghanistan are victims of domestic violence. The source for this claim was not given but, knowing how prevalent domestic violence is in open societies where women are allowed to display their bruises and broken bones, one would have to be a little suspicious of men who want to hide their women from view.

Islam: Science and Scholarship

It is not news that the renaissance era in Europe was nurtured by a reacquaintence with the classic works of Greece and Rome that had been lost to Europeans but salvaged and preserved by the Muslims. Nor is it news that while Europe was going through its dark age, Muslim scholars were making great advances in learning and science. What was surprising was that the author seems to imply that this spurt of learning and research was really theological in nature, and was thus ultimately constrained in what was capable of being learned.

"Muslims were the first intellectuals ever in a position to make direct comparisons between, say Greek and Indian mathematics, or Greek and Indian medicine, or Persian and Chinese cosmologies, or the metaphysics of various cultures. They set to work exploring how these ancient ideas fit in with each other and with the Islamic revelations, how spirituality related to reason, and how heaven and earth could be drawn into a single schema that explained the entire universe."

The author provides two reasons why this quest for knowledge eventually expired. The first is the fundamental conflict between a society based entirely on revelation and unbiased scientific inquiry. The second is the havoc caused by the several catastrophes visited upon Muslim lands.

Islam, Jews and Israel

Ansary provides needed background on this age-old interaction.

"Both the Arabs and Jews were Semitic and traced their descent to Abraham (and through him to Adam). The Arabs saw themselves as the line descended from Abraham’s son Ishmael and his second wife, Hagar. The stories commonly associated with the Old Testament—Adam and Eve, Cain and Abel, Noah and his ark, Joseph and Egypt, Moses and the pharaoh, and the rest of them—were part of Arab tradition too. Although most of the Arabs were pagan polytheists at this point (the time of Mohammed) and the Jews had remained resolutely monotheistic, the two groups were more or less indistinguishable in terms of culture and lifestyle: the Jews of this era spoke Arabic, and their tribal structure resembled that of the Arabs."

"Mohammed considered himself a descendent of Abraham and knew all about Abraham’s uncompromising monotheism. Indeed, Mohammed didn’t think he was preaching something new; he believed he was renewing what Abraham (and countless other prophets) had said...."

Throughout the history presented here there is little indication that Jews and Muslims would have difficulty living side-by-side. That began to change in the 20th century when world-wide political turmoil was at its peak and the Jews began to seriously consider the possibility of reestablishing a homeland in Palestine.

"The new European immigrants did not seize land by force; they bought the land they settled; but they bought it mostly from absentee landlords, so they ended up living among landless peasants who felt doubly dispossessed by the aliens crowding in among them. What happened just before and during World War II in Palestine resembled what happened earlier in Algeria when French immigrants bought up much of the land and planted a parallel economy there, rendering the original inhabitants irrelevant. By 1945 the Jewish population of Palestine almost equaled the Arab population. If one were to translate that influx of newcomers to the American context, it would be as if 150 million refugees flooded in within a decade. How could that not lead to turmoil?"

"In the context of the European narrative, the Jews were victims. In the context of the Arab narrative, they were colonizers with much the same attitudes toward the indigenous population as their fellow Europeans.....Arabs who saw the Zionist project as European colonialism in thin disguise were not inventing a fantasy out of whole cloth: Zionists saw the project that way too, or at least represented it as such to the imperialist powers whose support they needed....The seminal Zionist Theodor Herzl wrote that a Jewish state in Palestine would ‘form a portion of the rampart of Europe against Asia, an outpost of civilization as opposed to barbarism.’ In 1914, Chaim Weitzman wrote a letter to the Manchester Guardian stating that if a Jewish settlement could be established in Palestine ‘we could have in twenty to thirty years a million Jews out there....They could develop the country, bring back civilization to it and form a very effective guard for the Suez Canal.’"

The detailed history of what followed is complex and not actually the subject of the author. His interests are in conveying how all this played out in the Muslim psyche.

"Most Arabs had no stake in the actual issue: the birth of Israel would not strip an Iraqi farmer of his land or keep some Moroccan shopkeeper from prospering in his business—yet most Arabs and indeed most Muslims could wax passionate about who got Palestine. Why? Because the emergence of Israel had emblematic meaning for them. It meant that Arabs (and Muslims generally) had no power, that imperialists could take any part of their territory, and that no one outside the Muslim world would side with them against a patent injustice. The existence of Israel signified European dominance over Muslims, Arab and non-Arab, and over the people of Asia and Africa generally. That’s how it looked from almost any point between the Indus and Istanbul."

This book introduced many historical and cultural topics that would be interesting to pursue further. So many books, so little time!

Thursday, April 29, 2010

The Healing of America by T. R. Reid

This review was written just prior to the passage of the health care bill. Its relevance has not diminished.

This was one of the most interesting and relevant books I have encountered in some time. The author makes two valuable contributions to the discussion of health care issues in the USA. The first is to emphasize that any formulation of a health care strategy must evolve from the answer to this most basic of questions: can society allow a person to die because they do not have the funds to purchase health insurance? Health care is thus posed as a moral issue. The second contribution is to travel the world investigating how other countries have developed systems of care and to report back on the strengths and weaknesses of the various approaches. After having read this book, one will have plenty of ammunition to throw the next time the words "we have the best health care system in the world" are uttered. If you hear: "we don’t want to do things like France/Germany/England/Canada/Switzerland/Japan/Taiwan" you will be ready to pounce.

In the author’s words:

"But the primary issue for any health care system is a moral one. If we want to fix American health care, we first have to answer a basic question: should we guarantee medical treatment to everyone who needs it, or should we let Americans.....die from a lack of access to health care?....Beyond this general ignorance about the fate of the uninsured, Americans have never really carried on an ethical debate about health care as a right—that is about which inequalities we are willing to tolerate."

Mr. Reid performs a valuable service by reminding us that there is a moral obligation at issue here. While he is persistent in damning the current state of affairs, he lets general citizens off perhaps a little too lightly. He criticizes the Clinton approach as being focused on health care as an economic issue, implying that this was a major reason for failure. He refers to polls which indicate that when presented with the abstract question: "Do you think that everyone has a right to medical care when they get sick"?—a significant majority answer: "yes". He then implies that people would be more in favor of a universal health system if they only understood the implications of not having one. One could just as compellingly argue that people fully understand the implications and have chosen to pursue their own, narrow self-interest. It is useful to evaluate the response of the various demographic groups to the current legislative activities providing the opportunity (threat?) of universal health coverage. There is a narrative that says the administration began by focusing on the need to provide health coverage for the uninsured, a moral issue, but that did not sell well with most people and they had to switch to an approach that essentially answers the question "What’s in it for me?" If this interpretation is correct, it says something rather disturbing about our society. For example, who better understands the need for access to good health care than senior citizens? Yet the unsubstantiated hint that seniors might get a little less in order that those with nothing might get a little bit more sent them running to the barricades. These people might be ignorant when it comes to the details of what is being discussed in Washington, but they know full well that many people without health care are going to die. Shared sacrifice seems to become popular in this country only when it comes with a healthy tax deduction.

Another disturbing aberration demonstrated in the current health care arguments concerns the role of religion. Bismarck described his development of social services, including universal health care in Germany as "a program of applied Christianity." In our country it is the secular segments of our society that are leading the charge towards universal coverage. It seems that the more loudly one proclaims one’s Christian credentials the more likely that person is to be against health care reform. We can’t even do Christianity right anymore.

The author uses a clever ploy to introduce us to health care in other countries. He approaches each country both as an investigative reporter and as a patient. Mr. Reid has a shoulder that was seriously injured many years prior. He is suffering increasing pain and disability from this injury as he grows older. His US doctor has recommended what is essentially a shoulder replacement, a very expensive and somewhat risky procedure. The process of acquiring appointments and the recommendations he receives from the various doctors in other countries would make an interesting story in itself. His approach allows him to interleave the expected statistics and facts with personal stories from the perspectives of both the patient and the health care provider. This strategy yields accounts that are exceptionally readable as well as informative.

The author begins by providing a short summary of the various health care strategies that are available for study.

The Bismarck Model (Germany, Japan, France, Belgium, Switzerland)

This model uses private health insurance plans, usually financed jointly by employers and employees through payroll deduction. The unemployed or those unable or no longer working have these insurance premiums paid by the government. These plans cover everyone and they do not make a profit. Tight regulation of medical services and fees provided the necessary cost control.

The Beveridge Model (Great Britain, Italy, Spain, most of Scandinavia)

In this system health care is provided and financed by the government through tax payments. There are no medical bills. Medical treatment is considered a public service similar to fire or police services. Many, but not all, hospitals and clinics are owned by the government. Most, but not all, doctors are also government employees. Cost is controlled because the government, as single payer, controls what doctors can do and what they can charge.

The National Health Insurance Model (Canada, South Korea, Taiwan)

This system combines elements of the Bismarck and Beveridge models. The providers of health care are private, but the payer is a government-run insurance program that everyone pays into.

The Out-Of-Pocket Model ( countries too poor to provide a national health service)

The rich get medical care and the poor stay sick or die.

The author points out that the US has aspects of all of these models in its convoluted system.

"For most working people under sixty-five we’re Germany or France or Japan."

"For Native Americans, military personnel, and veterans, we’re Britain or Cuba"

"For those over sixty-five we’re Canada."

"For the 45 million uninsured Americans we’re Cambodia, Burkino Faso, or rural India."

Mr. Reid presents a good summary of the shortcomings of the US "system." These facts are not new to anyone who has been following these issues over the past year. His greatest contribution is to shed light on how the systems in other countries actually work. He devotes chapters to the state of health care in France, Germany, Japan, the United Kingdom, and Canada in order to survey all the established models in practice. He finds that all systems work in the sense that they provide an adequate level of care for the entire population. However, each has its own peculiarities and the occasional drawback. He also visits India as a means of discussing areas where out-of-pocket payments dominate. Presented below are some of his more interesting observations and conclusions.


The author first describes this concept in the context of France, but he encounters it in all the developed countries he visits. This term refers to the notion that citizens feel they must stick together to help one another in time of need. The fruit of this concept is the determination to provide health care coverage for every person, no matter how rich or how poor. This goal has been realized in every "rich" country except the United States. Clearly, we do not yet have a universally recognized goal of health care for all, but even more disturbing is the question of whether or not we even have this concept of solidarité.


Mr. Reid refers often to the table of health expenditure as a function of GDP for the various countries. We lead the pack at 15.3% (2005). France comes in at 11.1% and Japan at 8.0%. The fact that we spend the most and obtain relatively poor results should by now be well known. If we were to provide health coverage for all while maintaining our current cost structure, our percentage of GDP would be even higher. The author describes in detail how each of the countries control costs and what issues arise from each approach. It would appear that every country has similar issues related to the need to control the cost of medical care. For example, France has excellent health care results at much lower expenditure than the US, but the pressure to control costs is perhaps greater. Health care is still an enormous expense for them and increasing expenditures is politically difficult. The tendency is to clamp down on provider fees from doctors, hospitals and vendors. The author was of the opinion that some of the systems had gone too far in controlling fees and they would be better off by increasing their investment somewhat. The lesson for us is that eliminating inefficiencies will not be sufficient. We will not be able to sufficiently control our costs unless we figure out a way to limit the fees charged in our system.


Doctors have strikingly different existences in the countries studied. Under universal health care there were strict limitations on what they could charge for a given procedure. This effectively limited their income to what the author claimed was equivalent to a mid-level corporate executive. In other words they could live comfortably but not get rich. There was some grousing about low salaries by the physicians Reid encountered in his travels, but, as Reid points out, there were also significant benefits to being a doctor in the various systems. Doctors in the US generally have to pay their own college and medical school expenses, often leaving them with an enormous debt to pay off after graduation. There is a tremendous amount of overhead required by our system. Doctors must support accountants, insurance specialists, someone to handle their billing, and must pay for expensive malpractice insurance. Besides practicing medicine they must become small businessmen. They can become wealthy, and perhaps assume they have earned the right to become wealthy, but only by charging their patients enough to cover all that overhead as well as their lofty income. In the other countries the cost of medical school was generally much lower and was often paid for by the government. With well-defined rules on treatment there was not the need to worry about whether given procedures would be covered. Reimbursement for services becomes trivial and rapid. Malpractice insurance was very inexpensive and often paid for by the state. In fact, the author did not indicate that any of the physicians he encountered even considered malpractice suits as something worth thinking about. In other words, doctors could concentrate on being doctors, and the system saved a lot of money.

With respect to medical malpractice, there was an interesting study related by Malcolm Gladwell in his book Blink.

"Believe it or not, the risk of being sued for malpractice has very little to do with how many mistakes a doctor makes. Analyses of malpractice lawsuits show that there are highly skilled doctors who get sued a lot and doctors who make lots of mistakes and never get sued. At the same time, the overwhelming number of people who suffer an injury due to the negligence of a doctor never file a malpractice suit at all. In other words, patients do not file lawsuits because they’ve been harmed by shoddy medical care. Patients file lawsuits because they’ve been harmed by shoddy medical care and something else happens.

What is that something else? It’s how they were treated, on a personal level, by their doctor. What comes up again and again in malpractice cases is that patients say they were rushed or ignored or treated poorly. ‘People just don’t sue doctors they like’ is how Alice Burkin, a leading medical malpractice lawyer, put it."

What a concept! You treat people with respect and you gain respect. Perhaps there is also something to this soliderité notion.

Carte Vitale

The author dedicated this book to General and former President Dwight D. Eisenhower. His reasoning was as follows. Most politicians would be afraid to admit that any other country does anything better than we do. As president, Eisenhower had to sign off on the plans for a new interstate highway system. He was presented with conservative extensions of what was currently in place: two-lane highways that went through the heart of every town. Eisenhower recalled the impressive autobahn system built by the Nazis in Germany consisting of four-lane highways with overpasses and ramped interchanges to avoid intersections. He decided that if the Germans had a better idea there is no reason why we cannot copy it. Reid is suggesting that with so many examples of how to do health care better, wouldn’t it be nice if a politician would stand up and say "We need to do it like the French/Germans/Japanese/British..........."

Carte Vitale seems like a perfect example of a better way to do things, one that we would never be allowed to copy.

"This carte vitale—the "vital card," or the "card of life"—contains the patient’s entire medical record.... Imbedded in the gold metallic square just left of center is a digital record of every doctor visit, referral, injection, operation, X-ray, diagnostic test, prescription, warning, etc., together with a report on how much the doctor billed for each visit and how much was paid, by the insurance funds and by the patient. Everybody in France over the age of fifteen has this card—a child’s medical records are maintained on his mother’s card—and it is the secret weapon that makes French medical care so much more efficient than anything Americans are used to.......But the greatest value of the carte vitale is its impact on the payment of medical bills. Each patient’s green card (carte vitale) knows which sickness fund and which private insurance plan covers that patient. When Dr. Bonnaud finishes a consultation and enters that day’s treatment on the patient’s card, he stretches out the ring finger on his left hand and hits the "transmit" key on his computer. With that single keystroke all billing information—how much the patient owed, how much he paid the doctor as a co-pay, how much each of the insurance plans should pay back to the doctor and the patient—is transmitted to each of the relevant insurance plans. With that single keystroke the billing process is finished. ‘I will be paid,’ Dr. Bonnaud told me, with total confidence, ‘in three days.’ The insurance funds are required to pay him that fast, with no quibbles—and they do"

Preventive Medicine

Much has been said about the efficacy of encouraging early detection of problems and healthy lifestyles. Mr. Reid makes a point about the feedback between universal coverage, or the lack thereof, and preventive medicine that is probably not very obvious.

"In a system where health insurance comes with the job and ends when the job ends, the insurer can expect many customers to terminate coverage in a few years. Insurance experts say the average customer stays with the same plan for less than six years, so an insurance executive with his eye on the bottom line has little financial incentive to pay for long term prevention. American health insurance plans sometimes do cover mammograms and PSA tests and similar preventive measures, but they do it primarily for marketing purposes, to make their plans more attractive to corporate customers.

On occasion, the incentives built into the US health care system are downright perverse. Because awareness of preexisting conditions can lead to higher insurance premiums—or outright denial of coverage—some Americans deliberately avoid physical exams or other medical tests for fear of losing their health insurance."

Compare the passage above with this quote from Tony Blair’s health minister in the UK.

"Almost every person in this country is my patient for life. From the minute the line turns blue on your mother’s pregnancy test until the minute you die, maybe ninety-nine years later, you are my patient. If you become ill it is the job of the NHS to treat you, without regard to cost. So of course I want to prevent you from becoming ill."


One occasionally hears the comments like "this is all too complicated to fix" or "it’s just too hard." To counter such attitudes the author studied and visited Switzerland and Taiwan.

"Most important, both Taiwan and Switzerland had fragmented and expensive health care, similar to the American system—until they launched their reform campaigns. In both countries, payment for medical care was dominated by health insurance plans tied to employment; in both, significant numbers of people were left with no coverage at all. Even with large numbers of people uninsured, both countries were pouring considerable amounts of money into health care. In both Taiwan and Switzerland, as in the United States today, a growing chorus of voices began demanding universal coverage, arguing that every sick person should have access to a doctor.

But at that point the parallels end. The big difference between those two democracies and the United States is that, in Taiwan and Switzerland, the advocates of fundamental health care reform eventually won the day. Both of those nations adopted new health care systems to guarantee that everybody would be covered—and both of them happened to do it in 1994, the same year that the Clinton health care plan was going down in flames."

Shame on us!

The content of this book should have had some impact on the development, and selling, of a national health care approach. It is not clear that it did. Perhaps it appeared too late in the process to alter plans that had already focused on rather limited objectives. Or, perhaps, we are not yet a nation whose people feel united by common purposes. A mere two hundred years may not be long enough to form a stable nation.

Wednesday, April 28, 2010

Born Fighting by Jim Webb

One sees members of Congress marching towards the capital to vote on health care reform. They appear to be marching arm-in-arm. They are surrounded by demonstrators shouting, heckling, racial taunts are heard, a black Congressman is spat upon. What is happening here? Images of the civil rights marches of 50s and 60s are summoned from distant memory. There are no snarling dogs this time, just plenty of snarling white people. A clue? Representatives speak of death threats, of their families being threatened, of rocks being thrown through office windows. On television, recordings of some of the abusive telephone calls are played. Through the cursing and swearing southern accents are clearly heard. Yes, a clue. One recalls the violence associated with the fight for civil rights in the South and asks, incredulously, “Are those people still out there? Has nothing changed in 50 years?” Two days after the vote a poll comes out stating that large numbers of Republicans think that President Obama is a socialist, Muslim, Nazi, non-citizen who may in fact be the anti-Christ. A week later Christian terrorists calling themselves a militia plan on murdering police officers in hopes of triggering an insurrection against the government. This is the twenty-first century. How can people like this still exist? How can a nation function with people like this in it? The Tea Party types—who are they? And why are they the way they are?

The answer may be found in a book by Jim Webb, the Senator from Virginia, who in Born Fighting describes the heritage and dispersion of what he refers to as the Scots-Irish from their roots in Scotland to their migration to northern Ireland and then onto the United States where they mainly settled in the Appalachian regions. We learned from Kevin Philips in his book American Theocracy that the Red States are ethnically dominated by the original settlers of the southern states or by southerners who exited the South after the Civil War. They brought with them their cultural heritage and evangelical religions. These are Webb’s ancestors. He writes of them with affection and claims that they played a great role in determining the attributes of our society. He means that as a compliment. We shall see.

Webb’s thesis is that the Scots-Irish cannot be understood unless one is familiar with their heritage. His description begins in Roman times when Celtic peoples were driven to what is now Scotland and made a stand in defense of their freedom. Their social development, or lack thereof, was determined by the centuries of warfare, by the inhospitable environment they found in Scotland, and by the version of Christianity they adopted.
“...while Scotland’s rough topography made it difficult to conquer, it made it equally difficult to rule.....Not unlike Appalachia, Scotland is a land of difficult water barriers, sharp mountains and deep hollows, soggy moors and rough pastures, and of thin, uncultivable soil that lies like a blanket over wide reaches of granite....the settlements of ancient Scotland grew haphazardly and emphasized a rugged form of survival that had links neither to commerce nor to the developing world. Again we find a cultural evolution and a fundamental lifestyle very much like those that would emerge later in the Appalachian Mountains.”
This is a theme that Webb returns to several times. These people did not pass through the stages of cultural and political development that have been common to most nations. The Scots of interest to us left before Scotland became a stable political entity with renowned universities. By the time they migrated to northern Ireland they had endured many generations of political turmoil at the national level. That and their isolated and harsh environment formed character traits and social responses that Webb argues persist to this day.
“Such turbulence at the center of national government not only empowered the local clan leaders, it also demanded that they be strong, both for their own survival and also for the well being of their extended families. And again a familiar pattern reinforced itself in what would become the Scots-Irish character: the mistrust of central authority, the reliance on strong tribal rather than national leaders, and the willingness to take the law into one’s own hands rather than waiting for a solution to come down from above.”
Of great significance in understanding these people is the development of their religious beliefs. The Scots were the beneficiaries of what Webb describes as the most corrupt version of the Catholic Church to be found anywhere. It seems only natural that they would respond by accepting the most harsh and demanding form of Protestantism based on the teachings of John Calvin.
“But Scotland ‘developed the Calvinistic doctrine that civil government, though regarded as a necessity, was to be recognized only when it was conducted according to the word of God.’ This meant not only that the Kirk would have the power to organize religious power at the local level, but also that Scots had reserved the right to judge their central government according to the standards they themselves would set from below.”
Note that at this point you have a people who have never accepted the notion of allegiance to a central government and have lived with the belief that loyalty is to be extended as far as their local clans and churches. You have a culture whose highest educational goal is to be able to read the Bible.

The lot of the Scots who moved to Ireland to populate the Ulster plantation or colony was not a happy one. To make room for them the English dispossessed the local Irish natives of their land. That and the sectarian hatred between Catholics and Protestants set up a situation that required three centuries to resolve itself into a truce. The English had no respect for either the Scots or the Irish and treated both shabbily. Little was changed in the culture of the Scots during this period.
“In Ireland, the Anglicans of the Church of Ireland and the Catholics who were benefiting from a Jesuit emphasis on education would press the importance of academic learning on their parishioners. The Kirks of the Calvinist Ulster Scots would continue to lecture more about discipline and self reliance than on book-fed philosophy.”
By the beginning of the eighteenth century the Scots were tired of being dominated by the Anglican English and began heading to America.
“Small groups had begun to migrate across the treacherous Atlantic Ocean from the time James II ascended the throne in 1685, scattering themselves from New Hampshire to South Carolina. But after 1715 the migrations assumed a powerful dynamic, growing in intensity and concentrating almost exclusively on the mountainous areas from central Pennsylvania to the Georgia border....From their inception after 1715 until the American revolution, at least 200,000 and as many as 400,000 would leave Ulster for America.”
What is critical to understand about this migration is that the Scots-Irish would continue in a state of isolation from the major cultural, intellectual and economic developments occurring in Europe and the United States.
“Unfortunately, even as they began their second great migration within the span of a century, as a culture the Ulster Scots were missing out, both on the dawning era of educational enlightenment and on the benefits of the Industrial revolution.”
“In America, the settlers of New England and to a lesser extent those Cavalier societies along the southern coast had already created many great universities that survive even to this day. But the Ulster Scots would head into the mountains with few texts other than the Bible in their canvas sacks, beginning a century of educational regression even as others saw the New World as a land of enlightenment.”
Webb attributes the choice of where the Scots-Irish settled to continued discrimination by the English-dominated settlers who had preceded them.
“....I can sense them looking coolly at the pretenses and attempted restrictions placed upon them by yet another branch of an Anglican establishment that they imagined they had left behind in Ulster, a pervasive aristocracy that in America controlled most of the ‘flatlands’ along the colonial coast. They were told they could practice their religion in the mountains even if it was not ‘lawful’ as long as they did not seek to infect the more ordered societies along the coast. And they were expected to reciprocate by both staying in the mountains and keeping the Indians at bay. These memories burned like fire among people who knew, even nearly three centuries ago, that the Eastern Establishment looked down on them, openly demeaning their religion and their cultural ways, and at bottom sought to use them toward its own ends.”
The Scots-Irish therefore ended up in areas where making a living would always be difficult. The wilderness in which they settled was the zone of conflict between the settlers and the native Indians. Life was not only hard, it was dangerous. Webb talks much of the tradition of gun ownership that persists today and attributes it to both the need for guns for hunting and self-defense, and to what he describes as a cultural/genetic readiness to fight.

One can see in this story the seeds of the “Southern” attitudes and culture that we recognize from our experience or our study of history. Senator Webb has provided a narrative in which one can understand how these attitudes developed. To complete the picture one must dwell more on the religious history of these people.
“Organized religion led by strong ministers was the backbone of the communities, for without it (as later decades proved), many would simply regress into the decadence and spiritual emptiness of the wilderness. Just as important, the churches became vital centers of religious, social, and even political activity. From these pulpits, decade after decade, strong men preached about the power of the individual, decried the evil of a government that sought to interpose itself between man and God, and reminded parishioners of the two centuries of discrimination by the Anglican-English aristocracy against their people, a discrimination that in many ways still existed in America.”
The Civil War was, of course, a defining moment for the South and its people. It is in this time period that the history becomes more familiar and more relevant to the present. It is at this point that Webb’s narrative and his people demand more scrutiny than they perhaps can stand. While his story continues to provide insight into and understanding of the Scots-Irish descendents, the individual reader may decide that insight and understanding are not sufficient to foster sympathy or forgiveness.

Webb makes it clear that he believes the southern secession and subsequent Civil War were not driven solely by the desire to protect the institution of slavery. Clearly that is the case. However, our interest here is in moral decisions and how people rationalize their choices. If one views slavery as inherently evil, then judging people who are willing to tolerate slavery for political, economic, social or religious reasons leaves one to conclude they are either dishonest, greedy, bigoted, or perhaps, merely ignorant and uncivilized.

The author depicts his Scots-Irish as being mostly non-slaveholders whose economic situation was little better than that of the slaves. They are described as being dominated politically by politicians and an aristocracy that cared little for them or their welfare. In fact, the institution of slavery was a mechanism for insuring their continued poverty. Yet, when war came, the Scots-Irish formed the core of the Confederate Army. He is quite proud every time his people fight in a war—any war—because they are so willing to fight.
“It might seem odd in these modern times, but the Confederate soldier fought because, on the one hand, in his view he was provoked, intimidated, and ultimately invaded, and, on the other, his leaders had convinced him that this was a war of independence in the same sense as the Revolutionary War. For those who can remove themselves from the slavery issue and examine the traits that characterize the Scots-Irish culture, the unbending ferocity of the Confederate soldier is little more than a continuum. This was not so much a learned response to historical events as it was a cultural approach that had been refined by centuries of similar experiences. The tendency to resist outside aggression was bred deeply into every heart—and still is today.”
Let us consider that statement. Here you have a people who are willing to die to defend a system that has discriminated against them for almost 200 years. They are apparently not interested in the moral issues such as slavery, or historical perspectives. If someone—anyone—tells them an outsider is coming to tell them they have to do something, they are ready to kill or be killed. Webb tries to convince the reader that this is an honorable trait. One can grant Webb that his people are brave and fierce. However, being brave while acting against one’s own self-interest is more appropriately characterized as stupid or ignorant rather than honorable. Willingness to kill irrespective of the justice of the cause is dishonorable at best, not honorable. Being culturally or genetically wired for violent response raises a question as to whether these people are fit to live in a modern society.

The post-War behavior of the Southern whites is something even Webb has a hard time stomaching, although he does manage to put most of the blame on the Yankees.
“Instead of hope, inside the region the South’s leadership was now itself running on resentment and galvanizing the white yeomanry by uniting them against the Yankee on the outside and the black family down the road.... ....The near mandatory hatred of those from the outside, either geographically or ethnically, would result in the stifling of all internal dissent as the postwar leadership unified the body politic to fight the Yankee in the only way the region could—through absolute political unity.”
“This last phenomenon—revenge on the powerless—had no historical precedent among the Scots-Irish, no real basis in the now ancient teachings of the Kirk, and the decades of retaliation against those of African descent would prove to be a monstrous mousetrap that cracked their own necks as well.”
This last quote demands a more thorough look at the religion of the South and the role it played. Webb refers often to the Calvinist origins of the religious beliefs of his people. He refers to it as a harsh form of Protestantism. Calvin created a version of Protestantism that was based on predestination and a literal interpretation of the Bible. His teachings are a perfect example of being able to find anything you want in the Bible if you look hard enough. He chose to base this concept of predestination on a few phrases written by an itinerant preacher who had no direct intersection with Christ, while at the same time ignoring most of the teaching attributed to Christ in the Gospels. According to Calvin everyone’s fate—whether they will go to heaven or hell—was decided by God before the world was formed. What he created was a religion whose members could be smug and arrogant in their confidence that they were God’s select while others—nonbelievers—were doomed and there was nothing they could do about it. Calvin was not above burning alive people he considered heretics. One might assume that if they are going to burn in hell for all eternity anyways, why not start them off a little early. Such a religion could be viewed as inherently intolerant and discriminatory. The preachers of the time certainly had no problem using the Bible to justify the enslavement of Africans. For the author to even hint that this was ever a benign religion that would avoid harming the defenseless is a bit ridiculous given the 300 years of slaughter between the Scots-Irish Calvinists and the Catholics in Ireland. Calvin’s ideas have been moderated over time to make the religion more marketable. Calvin seemed to believe that only he and a rather small fraction of the people would be saved. Who would want to join a religion that says you are probably going to hell no matter what you do? One is reminded of Will Durant’s summation of John Calvin.
“But we shall always find it hard to love the man who darkened the human soul with the most absurd and blasphemous conception of God in all the long and honored history of nonsense.”
The post-war years left the region even more isolated from social and political developments in the rest of the country.
“The level of education fell tragically in these decades. Actual illiteracy increased among the millions. But what was worse was that the state universities ceased in effect to exist for loyal whites in the Thorough period and went for long years thereafter with empty halls and skeleton facilities....If the leadership of the Old South in its palmiest days had been only half-educated even by American standards, the leadership of the land in 1890 would be scarcely better instructed and scarcely less simple in outlook than that of the first generation to emerge from the frontier.”
What Webb has constructed is a history of a people who have lived over a thousand years in relative isolation from the main course of social and economic evolution experienced by the United States and Europe. The South experienced outward migrations over the past two centuries, but it was not until the Second World War that significant numbers of people began to migrate into the region.
“During world War II millions of non-Southerners of all ethnic backgrounds, most of them citizen-soldiers who had been conscripted,....were personally exposed to the twin realities of the South. On the one hand, they were often confronted by an honor-bound but frequently backward white culture that was willing to defend its way of life against all outsiders. On the other, the glaring racial humiliations of segregation were visible for all to see. In many eyes, white poverty was attributed to cultural inferiority rather than the generations of Yankee colonialism that had produced it, while the racial inequities they observed would leave a lasting impression, fueling nationwide support for the desegregation and civil rights efforts that began shortly after the end of World War II.”
Webb decries the racial attitudes developed in his Southern whites, but perhaps is too lenient in trying to blame them on Yankees and carpetbaggers The author seems to be saying that his people are rugged individualists who would never join a worker’s union, but they would band together for the purposes of revenge and discrimination. Webb also comes down hard on civil rights activists. He seems to think everything would have been easier if only the “Yankees” had been astute enough to realize that the vicious, ignorant people they were trying to deal with had a reason for being vicious and ignorant. As if a little sympathy might have helped.
“By working so hard to convert an issue of social injustice designed to eradicate demeaning laws of exclusion into a full blown war against the entire value system of a region, these radical activists terribly misread that region’s basic culture and turned many of the very people who might have worked for racial justice into their most virulent enemies. To provoke and blame disadvantaged whites for the plight of disadvantaged blacks was either naive or politically manipulative. And to expect that the disadvantaged whites would happily assist in revamping the entire social and economic order without attention being paid to their own situation was absurd.”
That statement suggests topics worthy of many books of analysis. However, the purpose of this note is to discuss how a significant section of our population who has lived or been incorporated into the culture that emerges from Webb’s Scots-Irish history might behave in our society. Could the passions and beliefs of the Tea Baggers seem reasonable to those immersed in this culture?

This is an appropriate point to leave a chronological treatment and examine the characteristics that Webb says define the Scots-Irish culture: individualism versus communality, a distrust of authority and educated people, a willingness to fight and wage war, and an intense version of Christianity that informs their political and social views. Consider this statement by the author.
“The great cities of the United States were increasingly filled with Catholics, members of the Orthodox churches and Jews—all professing in one way or another communitarian social values very much at odds with the individualism of the traditional Anglo-Saxon and Anglo-Celtic culture.”
One could define communitarian values as those driven by a sense of group solidarity. Webb seems to be saying—proudly—that his people don’t want any of that solidarity stuff here in their country. Those of us who derive from “foreign” cultures are implied to be the outsiders trying to cause trouble. Here, perhaps, lies the main source of political discord in our country. Roughly half the citizenry seems to believe that a modern nation has to be driven by mutually agreed upon efforts to act in unison for the benefit of all. About twenty-five percent believe that any—or at least any new intrusion of community values on their individual rights is tyranny. The remainder vacillates between the two points of view depending upon circumstances.

If one considers the health care debate, the people pushing for reform were driven by the moral imperative to provide health care to all, while those opposed (read Tea Party types) seem unconcerned about others and focused on what the effects might be on their own situation (“Keep your hands off my health care.”). This latter viewpoint would be consistent with Webb’s description of his people. For avowed Christians they seem to hold rather harsh views on social justice that might be somewhat surprising to those raised on stories of a kind and gentle Jesus who always seemed to healing people and telling everyone to be good to their neighbors. But, in fact, in the realm of health care legislation it is the secular types who are pushing for health care reform while those who profess their Christianity the loudest are generally against it. Recall that the first nation to implement a national health plan was Germany. Bismarck, no sentimental softy, described his development of social services, including universal health care in Germany as “a program of applied Christianity.” So what has happened to Christianity in our country? Consider Kevin Philips’ description of Southern evangelical beliefs in the context of race. While Philips’ comments refer explicitly to issues of race they could easily be applied to other social issues with the same result.
“The SBC’s [Southern Baptist Convention] cultural conservatism is not of the sort that inhibits nonwhite conversion and enlistment. What it does propound, though, is a conservatism of evangelical theology preoccupied with saving souls and dismissive of other designs—whether liberal sociology or government-run-social-welfare programs—to ameliorate the ills of society. The answers, say SBC preachers, lie in the Bible and in coming to Jesus; government social-welfare planning and programs, in this view, only get in the way of individuals’ assumption of personal responsibility and salvation....a compelling case that evangelical beliefs support the status quo when they lead white southerners to insist that persons of both races are masters of their own fates and salvation. White evangelists lopsidedly believe that if blacks do not get ahead, it is because of black culture or lack of initiative, explanations which pivot on individual responsibility. Under evangelical theology, social structures are not the real problem, and government action and involvement are rarely the solution—or so white true believers usually conclude.”
What emerges from this book and others we have read is a picture of a subculture with a unique history, a unique character, and a unique religion. Together they produce an approach to life and governance that is almost completely at odds with trends in all modern nations. If one overlays the attitudes of the Tea Party supporters with those indicated by this generalized picture of the Scots-Irish, there is quite a bit of overlap. It would not be fair to say that this totally explains where the Tea party enthusiasm is coming from, or to say that all Scots-Irish agree with Tea Party goals. What one can say is that it is possible to expect that a significant number of people who have lived in the Scots-Irish culture will emerge with the set of attitudes that most of us find bewildering and occasionally frightening. Governing a nation with these people in it is certainly going to be a challenge.

The subject of the Scots-Irish has come up before in Deer Hunting with Jesus, where we were provided a current snapshot of a community of Scots-Irish descent in Virginia, in American Theocracy where the religious beliefs and their effects on our politics were detailed, and in Outliers where a tendency towards violent response to any kind of slight was attributed to this Scots-Irish heritage. Senator Webb’s book provides a coherent framework in which the Scots-Irish can be viewed and evaluated. This is a highly personal rendering by Webb. He uses his own family and ancestors as examples of the character and history of his people. He is justifiably proud of his family, although it is not clear that they are truly representative of the Scots-Irish as a whole. The book is well-written and easy to follow. Like any good book, it leaves one wanting to pursue further the topics that arose in the reading.
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