Sunday, October 31, 2010

China and Its Border Issues

It would seem that China-watching has become a national pastime. Each day seems to bring a few more articles discussing whatever China’s latest activities are. Waves of punditry sweep over us whenever that giant country makes a move of any kind. I must admit that I have been bitten by the bug. I have begun trying to keep up as much as I can. I am convinced that no one knows what that country is going to do tomorrow, let alone ten years from now. But that doesn’t make the China-watching any less interesting. My amateur investigating has about convinced me that China is a country beset with so many issues that they cannot possibly have a coherent plan to deal with them. When they seem to send out inconsistent and confusing messages, it may be because they actually are confused.

Robert Kaplan wrote a fascinating article titled “China’s Grand Map.” It appeared in the May/June issue of “Foreign Affairs.” He discusses the numerous and complex interactions that occur between China and its many neighbors. He also provides a concise description of what motivates—and presumably explains—China’s actions.
“Moral progress in international affairs is an American goal, not a Chinese one; China's actions abroad are propelled by its need to secure energy, metals, and strategic minerals in order to support the rising living standards of its immense population, which amounts to about one-fifth of the world's total.”

“To accomplish this task, China has built advantageous power relationships both in contiguous territories and in far-flung locales rich in the resources it requires to fuel its growth. Because what drives China abroad has to do with a core national interest—economic survival—China can be defined as an über-realist power. It seeks to develop a sturdy presence throughout the parts of Africa that are well endowed with oil and minerals and wants to secure port access throughout the Indian Ocean and the South China Sea, which connect the hydrocarbon-rich Arab-Persian world to the Chinese seaboard. Having no choice in the matter, Beijing cares little about the type of regime with which it is engaged; it requires stability, not virtue as the West conceives of it. And because some of these regimes -- such as those in Iran, Myanmar (also known as Burma), and Sudan—are benighted and authoritarian, China's worldwide scouring for resources brings it into conflict with the missionary-oriented United States, as well as with countries such as India and Russia, against whose own spheres of influence China is bumping up.”
If you sweep around the boundary of China you will encounter borders with at least thirteen neighbors (the map gets complicated when you get to all the “‘stans”). We will take a tour around this map and discuss the various issues at each border.

China has plenty of options to consider with respect to North Korea with whom it shares a fairly extensive border. China’s main concern is that a stable regime exists across that border. In addition to the nuclear issue, they have to deal with the flux of people crossing over into China looking for refuge, food, or work. Mainly they see North Korea as an underutilized trading partner. China is already South Korea’s biggest trading partner. A healthy North Korea, whether independent or allied with South Korea, would be an economic boon for the Chinese. They would also like to negotiate with them for access to another Pacific port.

Russia and China have a long history of border issues. The situation at the section stretching from Mongolia to North Korea seems destined for some sort of accommodation—hopefully peaceful.
“North of Mongolia and of China's three northeastern provinces lies Russia's Far East region, a numbing vastness twice the size of Europe with a meager and shrinking population. The Russian state expanded its reach into this area during the nineteenth century and the early twentieth century, while China was weak. Now, China is strong, and the Russian government's authority is nowhere as feeble as it is in the eastern third of the country. Just across the border from the roughly seven million Russians who live in the Russian Far East -- a figure that could fall as low as 4.5 million by 2015 -- in the three abutting Chinese provinces, live some 100 million Chinese: the population density is 62 times as great on the Chinese side as on the Russian side. Chinese migrants have been filtering into Russia, settling in large numbers in the city of Chita, north of Mongolia, and elsewhere in the region. Resource acquisition is the principal goal of China's foreign policy everywhere, and Russia's sparsely populated Far East has large reserves of natural gas, oil, timber, diamonds, and gold. ‘Moscow is wary of large numbers of Chinese settlers moving into this region, bringing timber and mining companies in their wake,’ David Blair, a correspondent for London's Daily Telegraph, wrote last summer.”
China has an extremely long border with Mongolia. Like Eastern Russia, it has a very low population density, is relatively wealthy in terms of natural resources, and has rich and abundant grasslands that would be of value to the Chinese. Beijing seems content—for the moment—to dominate Mongolia commercially. In the old days of imperial domains a power such as China might have been expected to just march in and take over. Kaplan sees China’s behavior with respect to Mongolia as a measure of their long-term goals.
“With Tibet, Macao, and Hong Kong already under Beijing's control, China's dealings with Mongolia will be a model for judging the degree to which China harbors imperialist intentions.”
The western province of Xinjiang presents one of China’s most complex situations. Xinjiang is large in area, rich in oil, natural gas, and minerals, and sparsely populated. Historically, its ties to China have been weak. It wasn’t until the Communist took control that the province was definitely and finally made a part of China. The population of Xinjiang is more representative of the Central Asian countries with which it borders: Kazakhstan, Kyrgyzstan, and Tajikistan. The Turkic Uighurs have been uneasy under Chinese rule for some time. They make up 45 percent of Xinjiang’s population. China has been shipping Han Chinese into the region for decades in an attempt to acquire a more manageable population.

Xinjiang also provides a path to the oil and natural gas that are plentiful in the countries to its east. This region plays a major role in Beijing’s efforts to attain sufficient resources to feed its economic machine.
“Beijing's sway in Central Asia takes the form of two soon-to-be-completed major pipelines to Xinjiang: one to carry oil from the Caspian Sea across Kazakhstan, the other to carry natural gas from Turkmenistan across Uzbekistan and Kazakhstan. China's hunger for natural resources also means that Beijing will take substantial risks to secure them. It is mining for copper south of Kabul, in war-torn Afghanistan, and has its eye on the region's iron, gold, uranium, and precious gems (the region has some of the world's last untapped deposits). Beijing hopes to build roads and energy pipelines through Afghanistan and Pakistan as well, linking up its budding Central Asian dominion to ports on the Indian Ocean. China's strategic geography would be enhanced if the United States stabilized Afghanistan.”
Tibet is a second region that rests uneasily under Chinese control.
“Like Xinjiang, Tibet is essential to China's territorial self-conception, and like Xinjiang, it affects China's external relations. The mountainous Tibetan Plateau, rich in copper and iron ore, accounts for much of China's territory. This is why Beijing views with horror the prospect of Tibetan autonomy, let alone independence, and why it is frantically building roads and railroads across the area. Without Tibet, China would be but a rump -- and India would add a northern zone to its subcontinental power base.”
Kaplan makes much of the potential for contention (not necessarily conflict) between China and India. One would hope that with each having so many problems to deal with internally, they would mind their own business.
“To some degree, China and India are indeed destined by geography to be rivals: neighbors with immense populations, rich and venerable cultures, and competing claims over territory (for example, the Indian state of Arunachal Pradesh). The issue of Tibet only exacerbates these problems. India has been hosting the Dalai Lama's government in exile since 1957, and according to Daniel Twining, a senior fellow at the German Marshall Fund, recent Chinese-Indian border tensions ‘may be related to worries in Beijing over the Dalai Lama's succession’: the next Dalai Lama might come from the Tibetan cultural belt that stretches across northern India, Nepal, and Bhutan, presumably making him even more pro-Indian and anti-Chinese.”
Finally we come to the nations of Southeast Asia. China shares borders with Myanmar, Laos, and Vietnam. Its goals seem to be commercial. It sees this region as a market for its manufactured goods and a source of agricultural products and natural resources. One of its thrusts is to obtain a port in the Bay of Bengal.
“China and India are competing to develop the deep-water port of Sittwe, on Myanmar's Indian Ocean seaboard, with both harboring the hope of eventually building gas pipelines running from offshore fields in the Bay of Bengal.”
China has recently inaugurated a free trade arrangement with ASEAN, The Association of Southeast Asian Nations. It was interesting to note that both Russia and the United States were invited by ASEAN to participate at the East Asian Summit starting in 2011. Presumably this move was to counteract the immense presence of China.

This tour around China’s perimeter seems to indicate a country whose intentions are commercial rather than imperial. Kaplan points out that while the Chinese army is huge, it does not seem to have been outfitted in a manner consistent with large-scale continental military actions. Let us hope that is in fact the case. China is in a position where it could wreak havoc far and wide if it chose to, or if it felt threatened and concluded it was necessary.

China would appear to have more problems on its plate already than it is capable of dealing with. The international issues detailed here have to be combined with a raft of economic, environmental and social issues that concurrently require attention. If the country presents an uncertain and inconsistent image, it is probably because they are feeling their way through a horrendous thicket of problems.

Saturday, October 30, 2010

Palestinian Oktoberfest! Can Peace Be Far Behind?

After months of seemingly unending bad political and economic news, it was a sheer delight to find this story about a little brewery that was making a go of it in the unlikeliest of places. Businessweek carried this story titled: In the West Bank, a Palestinian Oktoberfest.

The last Christian enclave in the West Bank is a small town of 1,600 named Taybeh, about 20 miles north of Jerusalem.
“Nadim Khoury returned to Taybeh, his family's ancestral village, after nearly two decades in Boston, even as other Palestinian Christians were abandoning the West Bank. David joined him there in 2000. The brothers and their father sold stocks, a house, and two liquor stores in Massachusetts to come up with the $1.2 million they needed to start Taybeh Brewing. "People thought we had gone completely nuts," says Nadim.”

“There's the disdain that many of his Muslim neighbors have for alcoholic beverages. There are the Israeli checkpoints where beer can spoil as delivery trucks wait for hours under the hot Levantine sun. There's the lack of any outside financing for such an unlikely enterprise. ‘We are running this business against all odds,’ says Khoury, 51....”

“After years of scraping by, the brewery today returns a decent profit and is expanding to meet growing demand. The company has 15 employees, and sales in 2009 topped $1.5 million, with production up 25 percent in the past two years. "We do this due to our shared love of the motherland and making beer," says Nadim, who discovered his passion for brewing three decades ago and went on to study beer production at the University of California at Davis.”
It didn’t hurt that David Khoury was elected mayor of Taybeh in 2005. Nor did it hurt that the name of the town and the brewery, Taybeh, means “delicious” in Arabic.
“As mayor, he has promoted Oktoberfest, the annual autumn celebration of beer culture, to draw tourists to the town—and sell more brew.”

“Over the weekend of Oct. 2, the Taybeh Oktoberfest drew thousands of beer fans to the hilltop town where Jesus is said to have walked. Visitors watched a Brazilian bossa nova band, Palestinian hip-hop performers, and Sri Lankan traditional dancers. The menu featured pita with Labaneh cheese, falafel sandwiches, grilled lamb skewers, and blonde and dark brews from Taybeh....”
They have gone not only national, but international as well.
“About 30 percent of the Khourys' beer is sold in Israel. Although the brothers spend almost nothing on advertising, they have built a thriving market in a handful of pubs and restaurants such as Jerusalem's American Colony Hotel, a watering hole for many diplomats and journalists. David says they would like to find a distributor in Israel to help increase sales. An additional 10 percent of production is shipped overseas, much of it to Japan....”
And now, my here is my favorite part of the story.
“Taybeh beer is getting more popular in pubs in West Bank towns such as Ramallah and Bethlehem—which Nadim says is likely due to growing sales to Muslims. ‘The amount of alcohol we sell in the Palestinian territories,’ he says, ‘cannot be drunk by the Christian population only’."
I am going to take this as a sign of progress, and I will let it cheer me up, at least until I hit the news sources again in the morning. Some cultures could benefit from a little erosion. Perhaps the United Nations should take a fraction of that money they spend, often to little effect, and support Oktoberfests all over the world. Perhaps they could create an international “Share a Brew with an Enemy Day.”

Israel and Its Religious Right

When the word “Jew” is used, does it elicit thoughts of an ethnic group, or thoughts of a member of a religion? This is not a trivial question. It is one that has bedeviled “Jews” since before the formation of Israel as a state.

In 1948 the Zionist leaders, who were mostly planning on a secular homeland for all Jews, made a Faustian bargain with an Orthodox religious group referred to as the “Chief Rabbinate.” Authority for the Chief Rabbinate was first ceded by the British decades before. The net result was that Israel would share governmental and judicial responsibilities with this religious group. This inclusion of a specific religious sect into the fabric of the state would have significant ramifications for any who would call themselves Jews, and, today, may pose an existential threat to the democratic state of Israel. A reference for these issues can be found here.

Not surprisingly, this Chief Rabbinate was given responsibility for interpreting and mandating specific religious functions for religious Jews. What is startling is that the state also gave them responsibility for all marriages and divorces and the authority to decide who was legally a Jew. There are no civil marriages in Israel. If you do not wish an Orthodox marriage, or you do not qualify, you must leave the country to get married. Marriages in other countries are recognized by the state.

This mixture of secular and religious in the governance of the state gives rise to a number of issues that an outsider might consider quaint, or even humorous. The Orthodox religious have their own political party. While not large numerically, within the splintered party landscape of Israeli politics this group can have inordinate influence.

One of the issues being contended by the religious conservatives is whether or not the government’s computer should be allowed to operate on the Sabbath. Another issue revolves around the allowance of a subsidy for religious studies.
“During its six decades of existence Israel has maintained a shaky alliance with its ultra-Orthodox Jewish minority that allowed most religious men to avoid military service, attend separate schools and get paid by the state to study the Bible instead of entering the work force.”

“But this system is coming under new scrutiny, pressured by a series of Supreme Court rulings, an ambitious education minister and the hugely unpopular cost of sustaining a fast-growing ultra-Orthodox population that has few skills for the 21st century and now accounts for one in four Jewish first graders — and growing.”
This is becoming a major issue, with schools and education becoming the focal points.
“Some 245,000 students — about one in every six in Israel — are enrolled in ultra-Orthodox schools from grades 1-12, according to the Education Ministry. The schools, which emphasize religious studies, are essentially run by nonprofit organizations that do not answer to the state, though they receive government funds.”

“Many secular Israelis see the ultra-Orthodox, with their large families, as a financial drain and are growing less willing to subsidize them when half of their men don't work — preferring to study the Torah— and their children are taught little math and science. They warn that if the system continues it could ultimately undermine a country that has become a high-tech powerhouse with vibrant media and culture.”
So much for the quaint. This comingling of the religious and the secular has a dark side also. One serious issue involves the definition of who is a Jew. Only the Orthodox version of Judaism is officially recognized in Israel. That leaves the Conservative and Reform movements in a kind of awkward position. A few months ago there was a law proposed that would extend the power of the Orthodox rabbis to validate, or not, all conversions to Judaism, not just those in Israel. Most practicing Jews in the U.S. are in either Conservative or Reform movements—neither are recognized as valid religions by the Orthodox.
“What's at stake here? For some, Jewish identity comes by straightforward means: a mother who is Jewish. A conversion conducted by an Orthodox rabbi in Israel, or any recognized rabbi outside of Israel. The new bill will render any non-Orthodox conversions invalid.”
In effect, the Orthodox are telling the Jews of the rest of the world that we will take your money, and we will let you fight and die for us, but don’t think of yourselves as being true Jews. This proposed law passed an Israeli committee, bur was eventually killed—for now. A number of letters went out from U.S. Senate offices asking the Israeli Ambassador whether they had lost their minds.

Smug religious fundamentalists are intolerant and intolerable wherever you find them.
“A frequent complaint of Christian clergy in Israel is being spat at by Jews, often haredi yeshiva students. Even Christian ceremonial processions have been alleged to have been spat at, with one incident near the Holy Sepulchre causing a fracas which led to the destruction of the Armenian Archbishop's 17th-century cross. The Anti-Defamation League has called on the chief Rabbis to speak out against the interfaith assaults. One Christian complained that the spitting was ‘almost a daily experience’.”
The most serious ramifications of this religious fundamentalism are in the area of international relations. The world wants to see a two-state solution arrived at in the Israeli-Palestinian negotiations. The religious conservatives want to see Israel’s lands restored to their Biblical boundaries—the ones God promised them. Gadi Taub wrote a column addressing this issue.
“The secular Zionist dream was fundamentally democratic. Its proponents, from Theodor Herzl to David Ben-Gurion, sought to apply the universal right of self-determination to the Jews, to set them free individually and collectively as a nation within a democratic state. (In fact, the Zionist movement had a functioning democratic parliament even before it had a state.)”

“This dream is now seriously threatened by the religious settlers’ movement, Orthodox Jews whose theological version of Zionism is radically different. Although these religious settlers are relatively few — around 130,000 of the total half-a-million settlers — their actions could spell the end of the Israel we have known.”
Taub says these people have religious convictions that are narrowly focused.
“....a single commandment: to settle all the land promised to the ancient Hebrews in the Bible....disciples, energized by a burning messianic fervor, took Israel’s victory in the Six-Day War of 1967 as confirmation of this theology and set out to fulfill its commandment. Religious enthusiasm made the movement subversive in a deep sense — adherents believed they had a divine obligation to build settlements and considered the authority of Israel’s democratic government conditional on its acceptance of what they declared to be God’s politics.”
Taub worries that a democratic Israel cannot survive if these people get their way, because the only way for Israel to rule such an entity would be by establishing an apartheid regime. Actually, there are three other options. One can enslave the Palestinians, one can drive them out, or one can kill them—all methods approved by the Bible.

I fear this will not end well.

Wednesday, October 27, 2010

A Green Trade War?

In global trade you want as much flux of goods across national boundaries as possible, but you have to realize that every export is someone else’s import. The current global situation is characterized by weak demand. Given weak demand, it is important for each country to try to maintain or grow its level of exports. Clearly, there have to be more losers than winners in that competition. Thus there is a tendency for the countries to bend the rules in order to give themselves an advantage. This is a well-known and recognizable phenomenon. Many countries are trying to manipulate their currencies to keep them from rising and making their products less competitive. From this comes the concern about “currency wars.”

Recently the trade of products for the green or clean energy industries has come to the forefront as an issue. Protectionist responses are appearing. A number of countries have argued that China has crossed the line in supporting its green energy industries. There is a nice summary of the situation by Michael Liebreich in Businessweek.
“Now it looks as if the rumblings of discontent are taking a more serious turn. On Sept. 13, Japan complained to the World Trade Organization about Ontario's local-content policy. The same month, the United Steelworkers (USW) in the U.S. filed a 5,800-word submission with the U.S. Trade Representative, citing ‘protectionist and predatory practices utilized by the Chinese to develop their green sector at the expense of production and job creation here in the U.S.’

“How strong a case do these complainants have? China has certainly done more than any other country to establish a leading position in clean energy. It started by creating demand, adopting its first renewable-energy law in 2005 and ensuring that its domestic utilities captured the bulk of the resulting projects. It supplemented this with a raft of industrial policy measures meant to support the development of its supplier base—cheap loans, tariffs on imported wind turbines, aggressive domestic content rules, and so on. Nothing so unusual there: Developed countries that profess allegiance to free trade have resorted to some of the same tricks.”

“Recently, however, the playing field has begun to tilt. So far this year the China Development Bank has offered $32.2 billion in low-interest loans to the country's solar and wind manufacturers. Those outfits haven't yet landed big contracts in Europe or the U.S., but armed with export credits that the West is hard-pressed to match, they're making inroads into emerging markets. And Beijing, which controls most supplies of rare-earth minerals, essential for so many clean-energy technologies, is moving to restrict exports—a worrisome prospect for the industry.”
The U.S. has agreed to allow the United States trade Representative to pursue a 90-day study of the claims submitted by the United Steelworkers concerning China’s trade practices. This could lead to a formal claim to the World Trade Organization for compensation. This would further ratchet up tensions in an already tense world.

The Economic Policy Institute has provided some interesting trade data related to clean energy products.

This chart indicates that while imports from the rest of the world have plummeted in the past few years, our imports from China have continued to grow. In fact, by the end of this calendar year Imports from China will be about equal to imports from all the other countries in the world combined. That seems a little suspicious. The same article pointed out that our import-to-export ratio with China for these goods was greater than ten-to-one—not a healthy situation.

No one can predict where all this tension over trade will lead. Pessimists point out that putting up barriers to protect national industries is what made the Great Depression go worldwide. On the other hand, economies like China’s that depend so much on exports have few options. Any act that causes a decrease in exports comes directly out of their GDP and means layoffs and factory closings. It will take years for their economy to transition to one with more internal demand. Meanwhile they are a giant, but fragile, society. People are already extremely unhappy over economic, social, environmental, and political issues. China does not want any more problems.

The Obama administration seems to be taking a cautious approach to these matters. It is necessary to push back to protect your interests, but with so much at stake, and in such a dynamic environment, caution seems appropriate.

Stay tuned, something interesting will happen!

Tuesday, October 26, 2010

How Do You Value Life? How Do You Apply Cost-Effectiveness to Healthcare?

Many years ago one of the auto companies discovered a defect which in a small number of rear end collisions caused an explosion of the gas tank to occur. The auto executives decided the probability of accident was small and the cost of correcting the problem was large, therefore fixing it was not cost-effective by their reckoning. They received a lot of flack when news of this decision was released. My first reaction at the time was to be outraged that they would place a dollar value on a person’s life. A little aging and some accretion of knowledge taught me that the designers of that car probably made many such safety decisions as they were planning to build that car. In those cases the cost-effectiveness decision could be made implicitly. One could resort to “best current practices” arguments to justify building a car that had a statistical probability of failing and causing death. However, once a flaw is revealed, an explicit decision has to be made—and those are difficult.

There is an article in the New England Journal of Medicine by Peter J. Neumann and Milton C. Weinstein that reminds us that in the area of healthcare, where resources are limited, cost-effectiveness issues come into play. If we are to gain a handle on both costs and effectiveness we will need a means for applying them in an explicit fashion.

We sometimes don’t think of doctors making those decisions, but it happens regularly. If a doctor turns down a patient referral because he thinks the odds are long that the patient will survive, then he has made a cost-effectiveness decision. If he decides to not suggest a type of treatment because the patient may not be able to handle the financial burden, he has made a cost-effectiveness decision. If he decides a treatment might prolong a patient’s life, but the suffering caused would not be worth the potentially added time, he has made a cost effectiveness decision. The doctor has made all these decisions and they were all arbitrary and he did not have to justify them.

The authors point out that
“In 1996, after two years of deliberation, the U.S. Panel on Cost-Effectiveness in Health and Medicine, composed of physicians, health economists, ethicists, and other health policy experts, recommended that cost-effectiveness analyses should use quality-adjusted-life-years (QALYs) as a standard metric for identifying and assigning value to health outcomes.”
QALY is a measure of the duration and quality of life that is expected as the normal result of an applied treatment. Regaining full health would result in a QALY of 1.0 times the life expectancy of the patient. If life after the treatment is characterized by suffering and/or disability the QALY would be a small number, perhaps even a negative number, times the life duration. Many studies are underway to produce the data needed to derive a QALY for the various treatments.

In the U.K. the National Health Service uses the QUALY number for a given treatment on a given patient to explicitly decide whether the treatment will be given. The website for the National Institute for Health and Clinical Excellence (NICE) provides a very clear example of how this is applied.
“Each drug is considered on a case-by-case basis. Generally, however, if a treatment costs more than £20,000-30,000 per QALY, then it would not be considered cost effective.

Patient x has a serious, life-threatening condition.

If he continues receiving standard treatment he will live for 1 year and his quality of life will be 0.4 (0 or below = worst possible health, 1= best possible health)

If he receives the new drug he will live for 1 year 3 months (1.25 years), with a quality of life of 0.6.

The new treatment is compared with standard care in terms of the QALYs gained:

Standard treatment: 1 (year's extra life) x 0.4 = 0.4 QALY

New treatment: 1.25 (1 year, 3 months extra life) x 0.6 = 0.75 QALY

Therefore, the new treatment leads to 0.35 additional QALYs (that is: 0.75 -0.4 QALY = 0.35 QALYs).

The cost of the new drug is assumed to be £10,000, standard treatment costs £3000.

The difference in treatment costs (£7000) is divided by the QALYs gained (0.35) to calculate the cost per QALY. So the new treatment would cost £20,000 per QALY.”

That may not represent a decision mechanism of which you approve, but at least it is a system. It has the advantage of being applied equally to all patients, it relieves doctors of the burden of making difficult and often arbitrary decisions, and it will eliminate costs for procedures of limited utility.

When the issue of cost-effectiveness came up in the recently passed healthcare bill, our legislators took a giant half-step in this direction. Congress directed a Patient-Centered Outcomes Research Institute to perform comparative effectiveness research (to come up with the data to arrive at a QALY). However, they explicitly forbade the use of that data in the mode it is applied by the U.K.

So now we are at least generating useful knowledge, but not allowing it to be used explicitly. Presumably, physicians will continue to be forced to make implicit decisions, but at least in the future they will be better informed.

The QALY path seems to be the only one the experts have managed to come up with. The U.K. approach may not be the best way to go, but something has to be done. It is hard to foresee a time when our legislators would be capable of making a difficult decision in this area, no matter how dire our financial condition.

Monday, October 25, 2010

Doctors Versus Nurses: Let’s Root for the Nurses

This month the Institute of Medicine (IOM) released a study titled: The Future of Nursing: Leading Change, Advancing Health. The report summary included this statement.

“With more than 3 million members, the nursing profession is the largest segment of the nation’s health care workforce. Working on the front lines of patient care, nurses can play a vital role in helping realize the objectives set forth in the 2010 Affordable Care Act, legislation that represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs. A number of barriers prevent nurses from being able to respond effectively to rapidly changing health care settings and an evolving health care system. These barriers need to be overcome to ensure that nurses are well- positioned to lead change and advance health.”
The report indicated the following as its four key messages.
“Nurses should practice to the full extent of their education and training.”

“Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.”

“Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.”

“Effective workforce planning and policy making require better data collection and information infrastructure.”

These messages sound harmless enough until the implications of the report are spelled out. The cover story of the October 11, 2010 edition of “Modern Healthcare” magazine discussed the issues under the title: “Fueling the Turf Battle.” The IOM report is in favor of considerably enhancing the role of nurses in setting policy and in dealing with patients.

One of the interesting results presented by the IOM involved data derived from experiences at the Veterans Affairs Department (VA). In the late 90’s the VA faced a large number of new enrollees.
“In response, the VA moved away from a system of hospital-based acute care and toward community-based delivery emphasizing primary care and chronic-disease management—roles filled by registered nurses and skilled nurse practitioners, the IOM said.”

“The result? Studies showed that higher proportions of veterans received appropriate care relative to comparable Medicare enrollees, and spending per beneficiary rose more slowly—30% cost growth for VA patients between 1999 and 2007, compared with 80% for Medicare beneficiaries over the same period, according to the Congressional Budget Office.”
The message the IOM is sending is that nurses should, with the proper training, be granted considerably more leeway in diagnosing disease, and prescribing medicines and treatment—with little or no physician oversight. This extension of responsibility is not always legally possible at present, depending on state restrictions. The IOM findings and recommendations were not welcomed in all quarters.
“But for skeptics and apathetic readers, the IOM presents this urgent picture: in a time when 32 million more Americans are about to get health insurance, skilled nurses are cheaper than physicians, they are easier to produce in large numbers, and they can prevent costly mistakes and perform with essentially the same rate of errors as doctors once they are established in the workforce.”
The comments on the influx of new patients and the experience of the VA remind one of another area of growing concern. We are becoming an older society. I suspect that the type of care provided by the VA is exactly the right approach for serving our senior citizens. If we can save money and provide better healthcare results, let’s go for it.

Apparently many physicians are not thrilled with the implications of the IOM report. The fear is that the better-organized doctors will lobby state legislatures to keep restrictions on nurses’ responsibilities. Clearly, the doctors were better organized in the past, but I believe nurses are moving towards national unionization and the ability to speak with a single voice. If they aren’t, they should be. I know they are a political force in California. Meg Whitman was foolish enough to make them mad at her.

As for the doctors who are concerned about their incomes and their privileged positions—welcome to the marketplace!

Why Do Economically Disadvantaged Whites Vote Republican?

One of the great mysteries of political life for progressives is why poor white people will year after year vote for politicians who explicitly promise not to do anything to help them. Joe Bageant returns and is once again our tour guide through a depressed and depressing area of Virginia. This material is mostly from the chapter "Republicans by Default" in his book Deer Hunting with Jesus.

He refers to the people in this area as "rednecks." That is a term that requires a definition. Bageant provides a very specific one which will serve to enlighten the reader about the nature of these people. By his definition, a redneck is someone whose life is totally dominated by the need to be working in order to survive. It is not a geographic concept. To be a true redneck, the work has to be manual labor and one has to be born into a family where this need and this work ethic have persisted for generations.
"Life is about work for the American redneck....For all these people work is an obsession and has been for generations...The forebears of today’s rednecks were people for whom not working meant their families would starve. Literally. So the work ethic is burned into their genetic code....In the redneck mind, lazy is the worst thing a person can be—worse than dumb, drunk, or mean, worse than being a liar, and a jailbird or crazy. The absolute worst thing a redneck can say about anyone is: ‘He doesn’t want to work’....By the same logic, educated liberals who have time to read, who in fact read so much that they join book clubs, are suspect."
Bageant uses the Rubbermaid factory, which supplies much of the local employment, and a friend from childhood who he refers to as Tom, as props to illustrate how the system works to propagate this redneck culture.

Rubbermaid is a large company, but not large enough to resist the demands of Walmart. Walmart moves into a region and drives out jobs and lowers wages. They are big enough to be the market in many places. They can demand that producers provide cheaper merchandise or go out of business. The only responses are to produce poorer products, lowering wages, or moving overseas. Walmart doesn’t care how you do it just so it gets done. The "lucky" workers get to keep their jobs, but they have to work harder for less money. This makes them even more dependent on Walmart and its low prices. Most will never realize that by embracing Walmart they have locked themselves into this death spiral towards ever worse living conditions.

Bageant has a son, Tim, who works at the Rubbermaid plant where wages top out at $15 an hour.
"I spent three months living with thirty-four-year-old Tim, who had been pulling rotating shifts at Rubbermaid for five years. What I saw broke my heart. The working-class world of my son’s Rubbermaid friends was so harsh and insecure and barren of the dignity of labor that I damn near cried. Some commuted more than a hundred miles from West Virginia to work, spending four or five hours a day in transit. One vanload of workers commuted almost seven hours a day, taking turns driving while the rest caught what sleep they could.....Most were family men, some older, others barely out of high school, living in mobile homes or modulars. They were decent and quiet men....All seemed worried to death about a possible plant move overseas and about bills, medical bills in particular. Their wives worked, yet they barely kept their heads above water."
Bageant introduces his friend Tom. Here are some Tomisms.
‘America didn’t used to be this way....People have fucked up this country....weirdo university professors, union racketeers, and the rich California ACLU types. People who never worked for a living.’

‘Maybe unions were once valuable, but they have priced American labor completely out of the market. They always want more money for less production....I’m for the common worker. When unions demand a twenty percent pay raise for the same amount of output and prevent management from firing the screw-offs, it raises the cost of everything. It makes it just that much harder for the average worker in a nonunion job to survive.’

‘Life is tough....Suck it in. Don’t take chances. Be conservative and stick with what you know.’
On things like universal health care and education, paid parental leave, unemployment compensation, food stamps....
‘...more damned government giveaways....Luxuries we really don’t need because we used to get along fine without them. If them people really want it, they will get up off their lazy asses and work for it like I do.’
Bageant describes the Tom he grew up with.
"What haunted me as he spoke was this: Tom is every bit as intelligent as I am. He was a better writer than I was in high school and often said back then that his goal in life was to be a writer, painter, musician. Where did those dreams go?"
For Bageant there is an easy answer to the question on where dreams go.
"The same place any such dreams go for children of lower-working-class families. They go out the same door that opportunity for a decent education never walks in through. They vanish along the trails of places like Vietnam or the dusty streets of Iraq. They disappear between high school graduation and the immediate need to earn a living that follows graduation."
He describes a typical week in Tom’s life as consisting of at least a forty-hour shift, with an extra twenty-five hours put in as an independent contractor. Added to that is working to keep house and car functioning and helping relatives who are in even worse shape.
"...but if you spend your days at a soul-numbing repetitious job, your evenings rotating your tires, rewiring your house, or hauling your aging mother a load of firewood....or recovering on the couch from said job while contemplating the late fees on your credit cards, when are you supposed to find the time or wherewithal to grasp the implications of global warming? You are brain dead, so a couple of evenings a week you stop....and pour beer on the dead brain."
Bageant has introduced us to those who become the fodder for the Republican machine. We should remember, the same politicians have been preying on these people for generations. Not too long ago they called themselves conservative Democrats.

It would seem that their fatal flaw, the one that makes them so susceptible to manipulation, is their insistence on individualism and self-reliance. It is a myth of course, but that does not make it any less a dominant factor in their actions. It is a myth that when combined with ignorance can be truly treacherous. It is what convinces them that labor unions are not for them. It is what makes craftsmen acquiesce to being made "independent" contractors rather than employees. "By the way, don’t forget to pay your own taxes and healthcare." If they refuse to band together, they will, as individuals, be at the mercy of well-organized political and financial interests.

Bageant says they become Republicans because Republicans live among them and feed them the messages and morals they want them to learn. The politicians and employers are a team. They both need large numbers of ignorant people to vote or work for them at low wages in order to maintain their power and privilege. Employers and supervisors make it clear where their political sympathies should lie. They are bathed in conservative talk radio at work. If there is no sports on the television, it will be showing Fox News. They are regularly updated on the latest outrages committed by liberal Democrats—usually something having to do with gay pedophiles in decadent California—whether true or not. Bageant says that if you work people as hard as they can be worked, and keep them constantly in fear of losing their wages, they will have neither the time nor the will to sort through and question what they are being told. They will buy the story line if it appears to make sense, and that is as far as they will go.

Bageant titles his chapter: "Republicans by Default." He accuses the Democrats of being completely absent in the battle for the allegiance of these working people.
"There is no good reason why for the past thirty years the uncertainty and dissatisfaction of people like Tom...was automatically snubbed as unenlightened by so many on the left. If the left had identified and dealt with this dissatisfaction early on, if they had counteracted the fallacies the republicans used to explain that dissatisfaction, if they had listened instead stereotyping blue-collar angst as ‘Archie Bunkerism’....and maybe offered some gutsy, comprehensible, and practical solutions, we might have witnessed something better than the Republican syndicate’s lying and looting of the past six years....Rightists tapped into that dissatisfaction by lamenting the loss of community and values and attributing it to the "cultural left’s" feminism and anti racism, the gay movement, and so on. The Republican message, baloney though it is, was accessible to [Tom]. The democrats didn’t have any message at all."
Perhaps Bageant’s sympathies for his people have caused him to lose focus on some rather significant facts. The people feeding the Republican dogma are neighbors and employers and preachers—all part of the community. They were feeding essentially the same lines when they called themselves Democrats. Who should have spread the left’s message—professors from California, or college students who "had never worked a day in their lives?" The message from the left would naturally come from the union organizers. But they had long ago been rejected. How do you help a people who refuse to help themselves? And the image lefties had of his people was not that of Archie Bunker. It remained that of those who thought it was acceptable to kill civil rights workers, and those who thought a club to the head of a union organizer sufficed as a word to the wise.

Bageant is correct in stating that the left should not forget these people. But it is hard to organize people who resist organization. It is hard for a stranger to deliver a message where strangers are immediately distrusted.

I do not have any solutions. Neither does Bageant. We both have many concerns.

Saturday, October 23, 2010

GDP Comparisons and Some Conclusions

Ordinarily I would not find time spent combing through financial data to be very satisfying. This time was different because I actually found some encouraging data, and I got to play with a new toy. The IMF provides a tool here for querying a database on financial data stored by country and by year. I have only looked at the GDP data thus far, but I expect there is more fun to be had.

My interest in GDP was driven by three things. The Obama administration and most economists claim the stimulus funding has saved our economy from a much greater fall in GDP and a much greater increase in unemployment. It would be good to have in hand some data to wave at the evil-doers in the opposition party. The second issue to be addressed is the health of the U.S. economy relative to other countries. It is claimed that the social policies of the European countries impose a penalty in terms of lower economic growth. It would be interesting to quantify that effect. The third issue relates to the economic health of Japan. A number of U.S. economists fear that we will end up with a “lost decade,” such as Japan is said to have suffered. Japan is said to have been in a slow growth mode for an extended period. I would like to learn what has actually occurred, at least in terms of GDP.

The data I will present pertains to the U.S., China, Germany and Japan—Germany is a good “look alike” for the U.S. in the E.U., China is interesting in its own right, and Japan for the reason given.

In reference to whether the economic stimulus helped or not, consider this chart.

 We went into the economic emergency with a growth rate comparable to Japan and Germany and our decline in 2009 was at least two percentage points less than what those countries experienced. I will take that as a win for the stimulus funding. This simple approach seems to be consistent with what economists are claiming.

As a good citizen, I am hoping that the U.S. has been and will continue to perform well economically. Consider these charts.

The U.S. has performed surprisingly well considering all the competition coming from emerging nations like China. The last chart indicates that the U.S. has managed to grow faster than Japan or Germany over the last thirty years. I looked at several European countries and Germany is representative of the community. The U.S. has grown faster than Europe, and it is likely that the European social policies have been a factor. I personally believe the extra growth is not worth the hardships our “everyone-for-themselves” policies impose on our citizens.

Here is one final chart.

If one considers the plot above of GDP growth, one can come to the conclusion that Japan was growing like an emerging country prior to 1990, and subsequently relaxed back to a typical growth pattern of a country with a mature economy. Its growth has been a bit better than that of Germany. Based on this data, if an economic pundit warns again about “becoming Japan,” I will be a lot less concerned.

Thursday, October 21, 2010

China’s Dilemma? What about the U.S.?

There is a short article by George J. Gilboy and Eric Heginbotham titled “China’s Dilemma: Social Change and Political Reform” that can be found on the “Foreign Affairs” website. As the title suggests it discusses all the social pressures that are being activated by China’s changing economy and its changing social structures. The authors point out that the China’s rulers are cognizant of these pressures and respond to them appropriately. The real issue is whether the Chinese Communist Party (CCP) will respond fast enough in order to forestall any significant social unrest. The authors point out that the natives are in fact getting restless.

“The Chinese Academy of Social Sciences (CASS) estimates that incidents of social unrest have risen from about 40,000 in 2001 to “over 90,000” in 2009. CASS also reports that these incidents are becoming larger, more violent, more likely to cross provincial borders, and more diverse in terms of participants and grievances.”

“Increased misappropriation of land, rising income inequality, and corruption are among the most contentious issues for Chinese society. China’s State Development Research Center estimates that from 1996 to 2006, officials and their business cronies illegally seized more than 4,000 square miles of land per year. In that time, 80 million peasants lost their homes. Yu Jianrong, a senior government researcher, has said that land issues represent one of the most serious political crises the CCP faces.”

“China’s wealth gaps have also grown; according to Chinese media, the country’s GINI coefficient, a measure of income inequality, has risen to about 0.47. This level rivals those seen in Latin America, one of the most unequal regions in the world.”

So, the Chinese are worried because their Gini coefficient has risen to 0.47. Guess who also has a Gini coefficient of 0.47? That of the U.S. was calculated to be 0.468 in 2009—and rising.

We are proud of the fact that we have such high income inequality and do not even worry about it. It is a bit troubling that the Chinese seem to have surpassed us in terms of social unrest, and seem to be not far behind in making people homeless, and in corruption. Perhaps we need to enhance our efforts in all these areas if we are to maintain the world leadership we so justly deserve.

Wednesday, October 20, 2010

Lies, Damned Lies, and Medical Science

Lies, Damned Lies, and Medical Science is the title of a very interesting article by David H. Freedman in “The Atlantic.” It is based on an interview with a Greek doctor, John Ioannidis, and some of his associates.

Have you ever picked up the paper in the morning and read about a study that claimed that consuming more of some vitamin or mineral would make you happier and live longer? Have you ever walked away thinking “Didn’t I one time read that too much of that vitamin or mineral is bad for me?” The answer is often “Yes!“ But you needn’t worry the fact that the two studies seem to be inconsistent. The odds are they are both wrong anyway.

The reason Dr. Ioannidis makes such a good interview for the author is because Ioannidis has devoted his career to outing sloppy, biased, corrupt, and incompetent researchers and their studies. He became interested in the problem as a physician-researcher in the early 1990s while at Harvard. His specialty was to be diagnosing rare diseases. Clearly one would have to search hard for solid information on rare diseases. What he discovered in his initial studies was that not only could he not find good data to support his activities, but he could not find data to support many of the treatment decisions that were commonly made by doctors. This realization motivated him to change course.
“He’s what’s known as a meta-researcher, and he’s become one of the world’s foremost experts on the credibility of medical research. He and his team have shown, again and again, and in many different ways, that much of what biomedical researchers conclude in published studies—conclusions that doctors keep in mind when they prescribe antibiotics or blood-pressure medication, or when they advise us to consume more fiber or less meat, or when they recommend surgery for heart disease or back pain—is misleading, exaggerated, and often flat-out wrong. He charges that as much as 90 percent of the published medical information that doctors rely on is flawed. His work has been widely accepted by the medical community; it has been published in the field’s top journals, where it is heavily cited; and he is a big draw at conferences. Given this exposure, and the fact that his work broadly targets everyone else’s work in medicine, as well as everything that physicians do and all the health advice we get, Ioannidis may be one of the most influential scientists alive. Yet for all his influence, he worries that the field of medical research is so pervasively flawed, and so riddled with conflicts of interest, that it might be chronically resistant to change—or even to publicly admitting that there’s a problem.”
Studies of medical effectiveness are extremely complicated and subject not only to misinterpretation, but also to a bias applied by the researchers. Sometimes this bias is unconscious or inadvertent, but, perhaps, sometimes it isn’t.
“....suggested a bigger, underlying dysfunction, and Ioannidis thought he knew what it was. ‘The studies were biased,’ he says. ‘Sometimes they were overtly biased. Sometimes it was difficult to see the bias, but it was there.’ Researchers headed into their studies wanting certain results—and, lo and behold, they were getting them. We think of the scientific process as being objective, rigorous, and even ruthless in separating out what is true from what we merely wish to be true, but in fact it’s easy to manipulate results, even unintentionally or unconsciously. ‘At every step in the process, there is room to distort results, a way to make a stronger claim or to select what is going to be concluded,’ says Ioannidis. ‘There is an intellectual conflict of interest that pressures researchers to find whatever it is that is most likely to get them funded’.”
Ioannidis wanted to convincingly demonstrate to the medical community that the issues he was raising were not isolated examples that he had cherry-picked to prove a point. He wanted to show the community that they had a problem and they had better recognize it.
“He zoomed in on 49 of the most highly regarded research findings in medicine over the previous 13 years, as judged by the science community’s two standard measures: the papers had appeared in the journals most widely cited in research articles, and the 49 articles themselves were the most widely cited articles in these journals. These were articles that helped lead to the widespread popularity of treatments such as the use of hormone-replacement therapy for menopausal women, vitamin E to reduce the risk of heart disease, coronary stents to ward off heart attacks, and daily low-dose aspirin to control blood pressure and prevent heart attacks and strokes. Ioannidis was putting his contentions to the test not against run-of-the-mill research, or even merely well-accepted research, but against the absolute tip of the research pyramid. Of the 49 articles, 45 claimed to have uncovered effective interventions. Thirty-four of these claims had been retested, and 14 of these, or 41 percent, had been convincingly shown to be wrong or significantly exaggerated. If between a third and a half of the most acclaimed research in medicine was proving untrustworthy, the scope and impact of the problem were undeniable. That article was published in the Journal of the American Medical Association.”
What is worse than realizing that much of what you believed about medicine is incorrect? What is worse is the realization that there is not much you can do to correct the situation.
“’Even when the evidence shows that a particular research idea is wrong, if you have thousands of scientists who have invested their careers in it, they’ll continue to publish papers on it,’ he says. ‘It’s like an epidemic, in the sense that they’re infected with these wrong ideas, and they’re spreading it to other researchers through journals’.”

“But even for medicine’s most influential studies, the evidence sometimes remains surprisingly narrow. Of those 45 super-cited studies that Ioannidis focused on, 11 had never been retested. Perhaps worse, Ioannidis found that even when a research error is outed, it typically persists for years or even decades. He looked at three prominent health studies from the 1980s and 1990s that were each later soundly refuted, and discovered that researchers continued to cite the original results as correct more often than as flawed—in one case for at least 12 years after the results were discredited.”
So what is the lesson learned here? Don’t trust your newspaper? Don’t trust your doctor? Of course you shouldn’t trust them! You should have been there long ago! But now you can mistrust them with much more confidence.

Tuesday, October 19, 2010

Aftershock: The Next Economy and America’s Future by Robert B. Reich

Robert Reich’s new book, Aftershock, provides a concise description of the economic and social conditions that he believes caused what he refers to as the Great Recession. These conditions arose both from historical changes and from 30 years of mismanagement of the economy and of society. He suggests a path forward that would correct this mismanagement and get the economy back on a firm footing.

Reich breaks up U.S. economic history into eras. The first would be the pre-Depression period, which he will compare with the period before the Great Recession (1980-2007). The intervening period between World War II and 1980 he refers to as the Great Prosperity. It is this period of prosperity that we need to study in order to understand why the economy drifted into such a weakened and unstable state.

Reich’s explanation for this economic cycle is quite simple. Most economic activity has to come from the majority of the people. This majority will be referred to as the “middle class” for simplicity. If the fraction of the income that goes to the middle class declines, then economic activity will diminish. Accumulating wealth in the hands of the very wealthy is economically inefficient and cannot compensate for the income lost by the middle class. The consumption of the wealthy is much less than that which would have occurred if the income had “trickled down” into the lower wage groups.
“Their savings are hoarded, circulated in a fury of speculation, or, especially these days, invested abroad.”
The growth of income inequality is then the driver for increased speculation, lower consumption and lower investment—clearly an unstable situation. Reich argues, compellingly, that this was the root cause of the Depression and also the Great Recession.

His justification for this thesis lies in his description of the almost universally prosperous post-war decades. Everyone’s wages grew. Unions were strong and they negotiated with managers who considered themselves to be employees also. This was a period of high government spending and high government income. Much of the spending went to reinforcing the social safety net and to building the infrastructure industry needed. Middle class incomes grew and so did the economy. Taxes on the wealthy were high, but they and the middle class thrived.
“The top marginal tax rate during the war ranged from 79 percent to 94 percent. In the 1950s, under President Dwight Eisenhower, whom few would call a radical, it was 91 percent. In 1964, the top rate dropped to 77 percent. It was 77 percent again when Richard Nixon became president. Even after exploiting all possible deductions and credits, the typical high-income taxpayer during the Great Prosperity paid a federal tax of well over 50 percent of his earnings.”
Reich refers to the treatment of the middle class during this period as “the basic bargain.” By this he means that the middle class was guaranteed a proportionate share of economic growth. This balance is necessary to maintain stability in the economy.

A number of factors entered into the breaking of this bargain. Around 1980 the globalization of the economy became a significant factor. About this time automation also became more efficient and more widespread. Both of these developments tended to eliminate jobs and drive workers into lower paying positions. It should have been possible to arrive at a plan to respond in some positive way to this economic evolution.
“....government could have enforced the basic bargain. But it did the opposite. Starting in the late 1970s, and with increasing fervor over the next three decades, it deregulated and privatized. It increased the cost of public higher education, reduced job training, cut public transportation, and allowed bridges, ports and highways to corrode. It shredded safety nets—reducing aid to jobless families with children, and restricting those eligible for unemployment insurance so much that by 2007 only 40 percent of the unemployed were covered. It halved the top income tax rate from the range of 70 to 90 percent that prevailed during the Great Prosperity to 25 to 39 percent; allowed many of the nation’s rich to treat their income as capital gains subject to no more than 15 percent tax; and shrank inheritance taxes that affected only the topmost 1.5 percent of earners. Yet at the same time, America boosted sales and payroll taxes, both of which took a bigger chunk out of the pay of the middle class and the poor than of those who were well-off.”
Reich concludes that the middle class tried to maintain the standard of living to which they felt they were entitled. They did this by putting their wives to work, by working longer hours, and by drawing down savings and borrowing as much as they could. There are limits to all these measures. These limits have been reached.

Reich thinks that the economy can be salvaged. He presents a multipoint plan that he projects would restore the basic bargain—and with no net new costs. The major component of his plan includes a reverse income tax and higher marginal taxes on the wealthy.

Reich would extend the Earned Income Tax Credit (EITC) and put all classes of income on the same tax basis.
“Under my plan, full-time workers earning $20,000 or less....would receive a wage supplement of $15,000. This supplement would decline incrementally up the income scale, to $10,000 for full-time workers earning $30,000; to $5,000 for full-time workers $40,000; and then to zero for full-time workers earning $50,000.”

“The tax rate for full-time workers with incomes between $50,000 and $90,000—whether the source of those incomes are wages, salaries or capital gains—would be cut to 10 percent of earnings. The taxes for people with incomes of between $90,000 and $160,000 would be 20 percent, whatever the income source.”

“I propose that the people in the top 1 percent, with incomes of more than $410,000 pay a marginal tax of 55 percent; those in the top 2 percent, earning over $260,000, pay a marginal tax of 50 percent; and those earning over $160,000, roughly the top 5 percent, pay 40 percent.”

“...under my plan, would raise $600 billion more than our current tax system.”
Reich would also impose a carbon tax, both for environmental and revenue purposes. This would bring in, initially, $210 billion. He states that there would be sufficient funds to cover the income subsidies and the lower tax rate on the middle class—with money left over to recast society.

The author’s numbers indicate just how much society gives up in order to shelter the wealth of a few percent of the population.

I have no problem with what Reich is attempting to do. My only reservation is with his method of redistributing income. If you have a job earning $20,000 a year, your income is actually $35,000. If you work hard and train yourself to get one of those better jobs paying $30,000 per year, your income will increase to $40,000. The system gives away half the incentive to improve one’s self. An employer could look at this situation and tell himself that lowering his employees’ pay $2 per hour is really only lowering it $1. I would expect many employers to employ this logic.

I would be intrigued by schemes which enforce an increase in wages rather than an income subsidy. It might be more popular politically, and it would be healthier psychologically for the workers. Reich’s approach has the advantage of being instantaneously implementable. A wage-based approach would have to be phased in to attain the level of change required without disrupting the economy.

Reich has big plans for what could be done with the remaining funds. They include modifying our unemployment compensation by adding wage insurance and long-term retraining support. He would provide school vouchers to all with the amount based on family income. Similar vouchers would be available to cover early childhood education. He would make tuition free at all public colleges and universities. If a student took out a school loan he would have to repay a fixed fraction of his salary for no more than ten years. Reich would also provide Medicare for all at a huge cost savings. Presumably this last step helps pay for some of the other initiatives.

Except for his plan for school vouchers these are all good progressive proposals. One may agree with them or not, but we all should be struck by the amount of freedom to operate that becomes available if we revert to a more traditional progressive tax code.

I have a hard time seeing much of this happening anytime soon, but it is certain that it will never happen at all if people like Reich aren’t out there beating the drum.

Monday, October 18, 2010

The State of the Bioeconomy

This is based on the book Biology Is Technology by Robert H. Carlson. The author provides an interesting and revealing glimpse into a set of technologies that seem to be exploding in capability. Besides the obvious medical applications, this expansion in skills and knowledge is rapidly being incorporated into novel commercial schemes with some products beginning to appear, and many more just over the horizon.

A 2007 estimate of the size of the biotechnology sector of the U.S. economy was $200-250 billion annually. Growth rates in the various components were in the 10-20% range. While this is not a large fraction of a $14 trillion economy, it is a component that is larger than one might have expected, it is one with enormous growth potential, and it is a technology area in which the U.S. still competes. Carlson provides the following breakdown.
“As of 2007 biotech drugs accounted for about $79 billion in sales worldwide, with about 85% of that in the United States. Genetically modified crops accounted for about $128 billion, with 54% of that in the United States. Industrial applications (including fuels, chemicals, materials, reagents, and services) contributed another $70 billion to $100 billion in the United States, depending on who was counting and how.”
The author divides the pharmaceutical industry into what he refers to as “small molecule” drugs and “biologics.” The small molecule products come from traditional chemistry techniques. The biologics originate with organic molecules. The number provided above only refers to the biologic component of the industry.

The biologic components are becoming more pervasive in the pharmaceutical industry. Much of the testing of drugs now involves characterizing cellular response at a molecular level. Carlson also anticipates that the next generation of drugs will be more focused on catering to an individual’s genetic makeup.
“Approvals of new small molecule drugs have fallen by about 30 percent over the last decade, despite a doubling in R&D spending and increased identification of new candidate drugs.”

“One strategy in the face of declining new-drug approval is to focus on the segment of the population in which drugs have a higher likelihood of being effective, an emerging branch of health-care called ‘personalized medicine.’ This tailoring of treatment to the individual relies on the field of ‘pharmacogenomics.’ which aims to tailor therapies according to an individual’s genetic makeup....Only 25 percent of new drugs are targeted to chronic, ongoing diseases like diabetes or high blood pressure, ‘suggesting the pipeline is shifting toward targeted therapies’.”
Genetically modified (GM) crops are common, but still constitute a small part of the total agricultural industry. They are also controversial—being banned in some regions and embraced in others. GM crops have been successful in producing hardier and more productive versions of plants, but until all the legal and psychological issues are resolved, the industry will not meet its true growth potential.
“As of 2007, 114 million hectares of GM crops had been planted worldwide, on about 9 percent of the worldwide total for cultivated land, with a worldwide value of more than $100 billion. GM acreage has been growing globally at just over 10 percent each year for the last decade, with 54 percent of GM crops planted in the United States; in 2007, among staples worldwide, GM crops accounted for 61 percent of corn, 83 percent of cotton, and 89 percent of soy. In the United States, in 2007, GM crops accounted for 73 percent of corn, 87 percent of cotton, and 91 percent of soy, for a total value to farmers from these three crops alone of about $69 billion alone.”
The agricultural industry is intending to take advantage of new capabilities and keep moving forward.
“While most existing GM crops are modified with a single gene altering a single trait, the next generation will contain multiple genes that through their interactions confer more complex traits. Drought tolerance in cereal crops is one such desired trait.”
Many of the most interesting applications lie in the industrial sector. Currently, much of the focus is on producing efficient biofuels. The author predicts that the nature of that industry will be transformed by technology innovations.
“The fermentation of sugar to produce ethanol and butanol will be short-term solutions. The strategy of improving biofuels-production pathways in existing organisms will rapidly be supplanted by new organisms, modified via metabolic engineering and synthetic biology, that directly convert feedstocks into transportation fuels similar to gasoline. The application of these technologies to industrial biotechnology is already well past academic exploration and into commercialization.”

“Amyris Biotechnologies is pursuing microbial production of biodiesel and a general aviation fuel comparable to Jet-A. The company suggests these fuels will be competitive with fossil fuels at prices as low as $45 a barrel by 2011. Achieving this goal would open up a 3.2 billion gallon-per-year market—the U.S. Air force is planning to replace at least half it petroleum-derived JP-8 with synthetic fuels by 2010.”
The author lists two other applications that serve to illustrate the potential that resides in this technology.
“While transportation fuels are an early target for commercialization of synthetic biology and metabolic engineering, it will eventually be possible to treat biomass or waste material as feedstocks for microbes producing more than just fuels. Dupont and Genencor have constructed an organism that turns starch into propanediol, which is then polymerized in an industrial process into a fiber called Sorona, now successfully competing in the market against petroleum-based plastics. Sorona’s competitive advantage comes from building biology into the production process, resulting in an integrated system that is approximately a factor of 2 more efficient than the industrial process it replaces, while consuming considerably less energy and resulting in lower greenhouse gas emissions.”
In other words, when you are dealing with microbes, processes tend to scale easily.
“A paper published in the spring of 2007 reported the successful construction of a synthetic pathway, consisting of thirteen enzymes, that turns starch directly into hydrogen. This suggests a future fueling infrastructure in which sugar or starch—substances available at any grocery store—go into the tank instead of gasoline, ethanol or any preprocessed fuel. The hypothetical fueling process is very simple: the consumer adds sugar or starch, the enzymes chew on it, and hydrogen gas bubbles out of the soup and is then used in a fuel cell to provide electric power for the car.”
I wouldn’t hold my breath waiting for that vehicle to appear, but an ability to cheaply produce hydrogen in a controlled manner will find applications.

There is much to look forward to. Hopefully it will be exciting new technologies and not the fear of bioterrorism.

Sunday, October 17, 2010

Medical Care Is a System—It Should Be Subject to System Design and Analysis

The famous pilot, Captain Sullenburger, recently lectured some hospital administrators on safety. He compared the changes that had to occur in the airline industry to the changes that need to be made in medical care.

“Thirty plus years ago, before CRM (cockpit resource management), captains could be alternately Gods or cowboys, ruling their cockpits by preference or whim with insufficient consideration of best practices or procedural standardization…And first officers trying to do the right thing would never quite know what to expect. Some captains did not bother with check lists (and it was unclear who was responsible for what).”

“We worked to build a culture of safety that allows us to face an unanticipated dire emergency, suddenly, one for which we had never specifically trained, and saved every life on board…”
He then put the sorry state of medical care into an airline industry context.
“But medical mishaps, on the other hand, happen one by one. But as everyone in this room knows, all too well, the mortality in America’s hospitals from accidents and hospital acquired infections is nearly 200,000 people per year in the U.S., or 548 lives a day, the equivalent of two large passenger jets crashing daily with no survivors….(if that happened in aviation) the airline industry would come to a screeching halt; airplanes would be grounded and airports shut down. There would be Congressional inquiries and companies would go out of business.”
He then points out that most medical errors are the result of system failures. Just as in the aviation industry, safety requires the development of a culture where all participants were viewed as members of a team. A comparison is implied between the cowboy pilots of yesteryear and the doctors of today who choose not to bother with checklists. He goes on to decry the current medical situation where it is assumed that when something goes wrong it is the result of an individual’s error.
“Conventional wisdom often has it that if a nurse makes a mistake, he or she should be terminated, but the vast majority of harmful events are due to system failures not practitioner error. The (health care) leaders are responsible for the maintenance of these support systems, not the caregivers. And the current punitive culture only drives problems underground where they can never be examined or solved.”
Atul Gawande presented the commencement address to last year’s graduating class from the Stanford School of Medicine. He conveyed essentially the same message as Sullenberger, but he expressed it from the perspective of a surgeon.
“The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.”

“Half a century ago, medicine was neither costly nor effective. Since then, however, science has combatted our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we’re struggling. There is no industry in the world with 13,600 different service lines to deliver.”
This leads to the need for a systems-based approach to medical care.
“Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies. The result is that more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities.”

“Like politics, all medicine is local. Medicine requires the successful function of systems—of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively.”

“Having great components is not enough. We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists—but we’ve paid little attention to how to make them fit together well.”
He then, ever so effectively, puts this issue into context.
“Earlier this year, I received a letter from a patient named Duane Smith. He was a thirty-four-year-old assistant grocery-store manager when he had a terrible head-on car collision that left him with a broken leg, a broken pelvis, and a broken arm, two collapsed lungs, and uncontrolled internal bleeding. The members of his hospital’s trauma team went swiftly into action. They stabilized his fractured leg and pelvis. They put tubes in both sides of his chest to reëxpand his lungs. They gave him blood and got him to an operating room fast enough to remove the ruptured spleen that was the source of his bleeding. He required intensive care and three weeks of hospital recovery to get through all this. The clinicians did almost every single thing right. Smith told me that to this day he remains deeply grateful to the people who saved him.”

“But they missed one small step. They forgot to give him the vaccines that every patient who has his spleen removed requires, vaccines against three bacteria that the spleen usually fights off. Maybe the surgeons thought the critical-care doctors were going to give the vaccines, and maybe the critical-care doctors thought the primary-care physician was going to give them, and maybe the primary-care physician thought the surgeons already had. Or maybe they all forgot. Whatever the case, two years later, Duane Smith was on a beach vacation when he picked up an ordinary strep infection. Because he hadn’t had those vaccines, the infection spread rapidly throughout his body. He survived—but it cost him all his fingers and all his toes. It was, as he summed it up in his note, the worst vacation ever.”

“When Duane Smith’s car crashed, he was cared for by good, hardworking people. They had every technology available, but they did not have an actual system of care. And the most damning thing is that no one learned a thing from Duane Smith. For we have since had the exact same story occur in Boston, with an even worse outcome. Indeed, I would bet you that, across this country, we miss the basic, unglamorous step of vaccination in probably half of emergency splenectomy patients.”
Finally, he makes the same point that Sullenberger made.
“Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have—than you have. I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.”
Hopefully, more pervasive use of electronic information technology, combined with a change in attitude similar to what occurred in the airline industry, will provide better and more efficient medical care. Electronic information technology would have caught the vaccination issue with Duane Smith. Let us applaud the Obama administration for emphasizing its need.

Thursday, October 14, 2010

Learning How to Die

Atul Gawande has an excellent article in “The New Yorker” titled Letting Go. In it he tries to answer the question “What should medicine do when it can’t save your life? He tells a long and anecdote-driven tale slowly but inexorably leading himself and the reader to an answer. It is a simple but not an easy answer because it places new responsibilities on both doctors and patients, but Gawande makes the compelling case that it is the right answer.

The author presents the typical situation. A patient is told that they have an inoperable cancer. The issue is not of recovery, it is a question of trying to prolonging life by aggressive therapy. Patients respond differently to sickness and treatment. There is always a statistical distribution of outcomes. A few patients will beat the odds and live much longer than the average patient. Those few patients skew the process towards ever more aggressive treatments. Doctors are only human and, as such, can harbor unreasonable expectations in the same way patients do. Gawande points out that the easiest path for the doctor is to continue to prescribe treatment. It is defensible, generally the patient will agree to it, and there is usually a non-zero chance that it will extend life.

The patients are in a difficult position. They are being asked to make life-or-death decisions on short notice. A combination of hope, fear and even guilt will usually drive them chose the path of continued treatment. They might tell themselves that the doctor will let them know when there is nothing left to do. The problem is that in today’s medicine there is always more that can be done.

What Gawande says is missing from this interaction is the attempt to ascertain exactly what it is that the patients want to get out of the remainder of their lives. Often the patients cannot immediately express their desires. As the author states:
“Arriving at an acceptance of one’s own mortality and a clear understanding of the limits and the possibilities of medicine is a process, not an epiphany.”

“People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this system’s expense. It is how we can build a health-care system that will actually help dying patients achieve what’s most important to them at the end of their lives.”
The doctors must take the time to learn what is truly important to their patients, and then must explain to the patients how the various treatments will affect their ability to live the life they would choose to live in the time they have left. This takes time and skill and it cannot be done in a single session. This process of communication seems particularly important in helping the patients make decisions.

The author refers to a study performed by Aetna. Normally hospice care is only provided to patients after they forego all other treatments. Aetna decided they would let a group of patients have hospice care and their normal treatments concurrently. The results would be compared with a control group only following their regular treatment. Both groups had a life expectancy of less than a year. The results were stunning. Patients benefited greatly from having the hospice service available. Within this group, emergency room visits declined by 50% and the use of hospitals and ICUs dropped by two-thirds. Overall costs dropped by almost a quarter. The ultimate conclusion was that the more personal care they received from the hospice workers improved the patient’s health and well being.
“...they had simply given patients someone experienced and knowledgeable to talk to about their daily needs. And somehow that was enough—just talking.”
Hospice care is concerned with trying to maintain quality of life at the current moment. That means worrying about pain and discomfort and trying to keep the patient alert and active as long as possible. Its goal is to bring the patient peace while nature takes its course.

Gawande describes another study.
“Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer.”
Needless to say, the author has become a fan of hospice care.

So what is to be done? On the patients’ side, they must begin to consider possible responses to these medical decision points before they become necessary. Family and friends should be aware of their thought and desires relating to end-of-life situations. That will make everyone better prepared when the time comes.

Gawande has this to say to doctors and healthcare professionals.
“All-out treatment, we tell the terminally ill, is a train you can get off at any time—just say when. But for most patients and their families this is asking too much. They remain riven by doubt and fear and desperation; some are deluded by a fantasy of what medical science can achieve. But our responsibility, in medicine, is to deal with human beings as they are. People die only once. They have no experience to draw upon. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come—and to escape a warehoused oblivion that few really want.”

Wednesday, October 13, 2010

Religious Extremism—U.S. Style

In the post, The United States: Its “British” Heritage and Its Politics, I briefly described the Scots-Irish immigrants and their history. I pointed out that the descendents of these people form the basis for the Republican party of today. It was made clear that these people could not be properly understood without knowledge of their religious background. This post will take up that subject. I recommend that you read both posts. If you are a visitor from another country and you sometimes wonder why the U.S. cannot get its act together—your question will be answered.

Joe Bageant, author of the excellent book about these Scots-Irish and their lives, Deer Hunting with Jesus, will be our guide. This material comes from a chapter in his book aptly titled “The Covert Kingdom.” We will use the term “fundamentalism” as the general description of this class of religious belief since all forms are based on a literal belief in the words of the Bible.

Bageant was raised in a fundamentalist family. He escaped both the region and the religion of his youth. He returned eventually to the region but not the religion.

In this world, anyone who can convince a person to listen to them can call himself a preacher. If you can get two people to listen to you, you can claim to have a church. If these two people listen to you for more than a week you can claim your own sect.
“Independent fundamentalist churches are theologically wooly places whose belief systems can accommodate just about any interpretation of the Good Book that a ‘Preacher Bob’ or a ‘Pastor Donnie’ can come up with. Members of the clergy arise from within the church ranks and are usually poorly educated, though, like most Americans, they do not see themselves that way. Lack of a broad higher education is a hallmark of fundamentalist ministers and goes completely unremarked by their congregations, in whose eyes a two-year technical school or community college, and especially a seminary of their own, is on a par with any of the vile secular universities. In fact, the ‘Bible colleges’ are better because they don’t teach philosophy, science, the arts, or literature in any form a secular person would recognize.”

“This rejection of ‘fancy learnin’ has been a feature of American fundamentalism since the backwoods-stump church days, and it continues to provide the nation with charismatic literalists whose analytical abilities are minimal.”
These people can no longer be considered harmless eccentrics. There are large numbers of them and they are promoting their ideas politically.
“But taken as a whole, fundamentalists have three things in common: they are whiter than Aunt Nelly’s napkin, and, for the most part, they are working class and have only high school educations.”

“Yet some evangelicals stand apart from the mainstream in one important way: They would scrap the Constitution and institute ‘Biblical Law,’ the rules of the Old Testament, and they take the long view toward the establishment of a theocratic state. Others believe we are rapidly entering the End Times and the fulfillment of the darkest biblical prophesies. Like many of their Scots-Irish ancestors, they see a theocracy of one sort or another as a necessary part of the End Times, and, though few publicly say so, some are not averse to nuclear war in the Middle East, ideally with the help of Israel.”
They see the founding of the modern state of Israel as the initiating event of End Times.
“....the Messiah can return to earth only after an apocalypse in Israel called Armageddon, which a minority of influential fundamentalists are promoting with all their power so that The End can take place. The first requirement was the establishment of the state of Israel. Done. The next is Israel’s occupation of the Middle East as a return of its ‘Biblical lands.’ Which means more wars. Radical Christian conservatives believe that peace cannot ever lead to Christ’s return, and indeed impedes the thousand-year Reign of Christ, and that anyone promoting peace is a tool of Satan. Fundamentalists support any and all wars Middle Eastern....”

“End Times theology, or premillennialism....has many variants. All of them boil down to the idea that history is scripted by God and will soon come to an apocalyptic conclusion according to his plan. Your only hope is to accept Jesus as your personal savior. Then, if you happen to be a member of the Rapturist cult of End Time believers, God will ‘rapture you up’ just as he launches seven years of horror and death upon the earth. An Antichrist will arise, and worldwide war will be the norm. Billions will die.”
Needless to say, such beliefs lead to political conclusions that are not helpful.
“The United Nations is a tool of the Antichrist. America alone must spread the gospel around the world.”

“There is no need to worry about the environment because we are not going to need this earth much longer.”

“Israel is to be defended at all costs and even encouraged to expand, because the Bible declares that Israel must rule all the land from the Nile to the Euphrates in order for End Times prophecy to be fulfilled.”

“God will provide a Christian leader to shepherd the American flock as they become his chosen people to extend the gospel worldwide and rid the earth of evil.”
Fundamentalists have essentially established their own education system. Once homeschooling was a means of avoiding integrated schools, now it is a means of indoctrinating children with conservative ideals, and avoiding contact with people of other beliefs.
“The training of Christian cadres is far more sophisticated than nonfundamentalists realize. By now, most informed people probably know that the homeschoolers have a university network, with dozens of campuses across the nation, each with its own smiling Christian pod people, each school a clone of Jerry Falwell’s Liberty University in Lynchburg, Virginia. But how many outsiders know the depth and specificity of political indoctrination in these schools?”

“For example, Patrick Henry College in Purcellville, Virginia, a college exclusively for Christian homeschoolers, offers programs in strategic government intelligence, law, and foreign policy, all with a strict, Bible-based ‘Christian worldview.’ percent of all internships handed out by the Bush administration went to Patrick Henry students, and many more went to similarly religious rightest colleges.”
If one suspects exaggeration in these statements, they can visit here and get the latest tally on the rapture index.
“It tracks forty-five categories—among them false Christs, plagues, inflation, beast government, and ecumenism—and assigns points to each indicating how predictive of the rapture it is. As I write this, the index stands at 160, perilously close to critical mass, when people like us will be smitten under a sky filled with deliriously happy naked flying Christians.”
As I write this the rapture index stands at 173. I’m afraid to look up.

Still not convinced? A few days after the final vote on the health care bill a poll came out that indicated that 24% of republicans think that Obama “may be the Antichrist.”

Someone is always ready to provide a service and earn a buck. There are many rapture believers who are pet owners. They are concerned about who will take care of their pets after they fly up to heaven. Go here and read about the man who set up a service of atheists who will remain behind and care for the animals for a fee (prepaid).

So cut us some slack—the U.S. has problems.
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