Universal Healthcare: Don’t Let a Crisis Go to Waste

We are currently in the midst of dealing with the Covid-19 pandemic.  The social and economic costs have been enormous.  So much so that state and local governments seem to be relaxing measures against the spread of the virus a bit quicker than they should because the cost of those measures is higher than they can bear.  The future is unclear; things could get better quickly, they could get worse quickly, or they could go on indefinitely at the same level.  This seems an appropriate time to consider lessons learned from the crisis and what could be done to emerge from it a better nation; one that is more capable of caring for its population when the next crisis occurs.

Our current healthcare system should be up for serious consideration of an upgrade.  At present, most employed people receive medical insurance from their employer.  If such coverage is not available, then they are on their own to either purchase insurance or, if they have low income, depend on Medicaid.  Unfortunately, Medicaid, while supported by federal funding, is really a state program and each state provides its own eligibility requirements and compensation levels. If one is over the age of 65, Medicare coverage is available to those who have participated in the Social Security Program (almost everyone these days).  This is a true federal program administered efficiently and uniformly across the nation.  The Affordable Care Act (ACA, Obamacare) was put in place to force insurers to provide more complete coverage of necessary treatments and to extend insurance coverage to many more people.  The ACA extends the range of Medicaid to higher income people at the bottom of the spectrum and provides monetary assistance to subsidize healthcare insurance for middle income people.  The program accomplished what it set out to do although Republican legislators were against it from the beginning and have tried to destroy it ever since.  Their main objection seems to be that it was passed by a black Democratic president.  In addition, it was a popular government program that improved the life of the voters, something to which Republicans seem unalterably opposed.  While the ACA helped, it was not very successful in controlling the continual rise in healthcare costs.

This complex system is extremely expensive while at the same time providing poorer health outcomes than the systems in place in other developed nations.  The stakeholders who control healthcare: doctors, hospitals, drug companies and device manufacturers, all have taken care to maximize their profits to the extent possible.  Those profits are sufficient to purchase the allegiance of legislators across the nation.  The stakeholders left out of this process are the patients.

One of the consequences of the pandemic is that tens of millions of people have lost not only their jobs and income, but also their health insurance.  Employer-provided insurance no longer looks quite as advantageous as it once did.  Everyone is currently suffering.  Much of the activity is taking place in emergency rooms and intensive care units.  These are expensive efforts that are likely receiving little in the way of reimbursement.  Most health service providers derive their income from non-emergency activities, many of which are optional, or at least deferable.  Those income streams have declined significantly as people postpone hospital and doctor visits.

Changing this system to make it more efficient and more effective is a big deal.  It would require something drastic to force stakeholders to accept modifications since any progress is likely to mean someone’s profits must take a tumble.  Is the pandemic and its uncertain future capable of creating the momentum necessary for change?  One should certainly hope so.

Progressive Democrats have been pushing for a universal system providing adequate coverage for all.  A major argument against this has been that people are happy with their current employer-provided plans and would not tolerate exchanging them for something else.  The cost of the universal coverage is also considered to be too high, although studies indicate that considerable savings in the nation’s healthcare costs would be achieved.  An analysis of a 2017 version of Bernie Sanders’ Medicare-for-All Plan produced these conclusions.

“Working from the relevant research literature, we estimate that, through implementation of Medicare for All, overall costs of providing full health care coverage to all U.S. residents could fall by about 19 percent in the first year of full operations relative to spending levels under the existing system. The most significant source of cost saving under Medicare for All will be a series of structural changes. These will be in the areas of: 1) administration (9.0 per­cent savings in total system costs); 2) pharmaceutical pricing (5.9 percent savings in system costs); and 3) establishing uniform Medicare rates for hospitals, physicians, and clinics (2.8 percent savings in system costs). We therefore estimate that these three areas of structural change under Medicare for All can achieve, overall, about 17.7 percent in total system cost savings relative to the existing U.S. health care system.”

The addition of service for uninsured and underinsured people is an added cost that brings the net savings down to about 10%.  As the study summary indicates, most advanced countries provide coverage-for-all that produces superior health outcomes than our system at about 40% less cost.  Given that, one should assume that even greater savings can eventually be sought

Other initiatives come and go but they mainly involve incremental changes to the current system.  About two years ago Amazon, Berkshire-Hathaway, and JPMorgan Chase, three respected, big-time employers, decided to form a collaboration to address the intolerable rise in healthcare spending.  They recruited a well-known and respected surgeon/professor/author, Atul Gawande to lead the effort.  Cynthia Koons provided a report on the status of that activity, The Amazon-Berkshire-JPMorgan Health Venture Fails to Disrupt, for Bloomberg Businessweek.

“When Amazon, Berkshire Hathaway, and JPMorgan Chase announced the formation of Haven Healthcare in January 2018 to stem the rise of employer health-care spending, the world expected big results. The mere prospect of Jeff Bezos, Warren Buffett, and Jamie Dimon joining forces so worried investors that the shares of established health insurers and pharmacy benefits managers tumbled on the news.”

“A little more than two years later, those concerns feel like a distant memory. Rather than disrupting health care, Haven finds itself in disarray, with its top two executives departing in the past year and the venture giving few clues as to how it’s going to slow the upward march of health costs in America.”

Of particular interest is the departure of the effort’s leader.

“On May 13, Chief Executive Officer Atul Gawande, a surgeon, Harvard professor, and high-profile expert in the field, resigned abruptly after less than two years in the role to instead become the venture’s chairman and devote his time to efforts related to the Covid-19 pandemic.”

Curiously, Gawande published an article in the March 23, 2020 issue of The New Yorker, Why Americans Are Dying from Despair, essentially saying having healthcare insurance provided by employers was incredibly stupid.  Was this a recent change of opinion?  A reading of his article suggests it might have been.  It seems a viewpoint inconsistent with the goals of Haven Healthcare.

Gawande’s article was focused on discussion of the work of Anne Case and Angus Deaton as presented in their book Deaths of Despair and the Future of Capitalism.  Their work illustrates the highly unusual increase in mortality centered on poorly-educated whites. Several causes for this trend can be identified, including drug and alcohol abuse.  Of interest here is the role healthcare can play in generating “deaths of despair” by diminishing employment opportunities.  Gawande explains.

“The focus of Case and Deaton’s indictment is on the fact that America’s health-care system is peculiarly reliant on employer-provided insurance.”

“As they show, the premiums that employers pay amount to a perverse tax on hiring lower-skilled workers. According to the Kaiser Family Foundation, in 2019 the average family policy cost twenty-one thousand dollars, of which employers typically paid seventy per cent. ‘For a well-paid employee earning a salary of $150,000, the average family policy adds less than 10 percent to the cost of employing the worker,’ Case and Deaton write. ‘For a low-wage worker on half the median wage, it is 60 percent.’ Even as workers’ wages have stagnated or declined, then, the cost to their employers has risen sharply. One recent study shows that, between 1970 and 2016, the earnings that laborers received fell twenty-one per cent. But their total compensation, taken to include the cost of their benefits (in particular, health care), rose sixty-eight per cent. Increases in health-care costs have devoured take-home pay for those below the median income. At the same time, the system practically begs employers to reduce the number of less skilled workers they hire, by outsourcing or automating their positions.”

“In Case and Deaton’s analysis, this makes American health care itself a prime cause of our rising death rates.”

Is it any wonder that Gawande has moved on?  He arrives at this conclusion.

“Instead of preserving a system that discourages employers from hiring, retaining, and developing workers without bachelor’s degrees, we need to make health-care payments proportional to wages—as with tax-based systems like Medicare. Democrats are split over whether our health care should involve a single payer or multiple insurers. But that’s not the crucial issue. In other advanced economies, people pay for health care through wage-based taxes. In some countries, such as Germany and Switzerland, the money pays for non-government insurance; elsewhere, the money pays for Medicare-like government insurance. Both strategies work. Neither undermines the employment prospects of the working class.”

Why are Democrats not taking these facts and running with them?  Why do they let themselves get put on the defensive all the time?  Will they emerge from their funk and push for the necessary healthcare response (initiated gradually, of course)?  Biden seems interested in a lowering of the age for Medicare eligibility to 60.  That would be a good start.

Gawande provides his final thought.

“Because economic policy is inseparable from health-care policy, the unfairness of the health system is inseparable from the unfairness of the economy—an unfairness measured not only in dollars but in deaths. The blighted prospects of the less educated are a public-health crisis, and, as the number of victims mounts, it will be harder to ignore.”

Climate Change: Let Us Not Forget the Microbes

Microbes, or microorganisms too small to be visible to the naked eye, ruled the earth for billions of years.  Larger living structures, macroorganisms, including humans, would evolve from these smaller objects while embedded in a microbe soup.  We and these microbes are thus intimately related and inseparable.  All life on earth is dependent upon a microbe support system.  We humans are making rapid changes to Earth’s ecosystems and trying to predict what the effects of that activity might be on our future.  We spend most of our efforts studying what we can see, while forgetting to learn about changes to this unseen world of microbes.  There is a group, scientistswarning, devoted to educating the public about the various threats we face from our human activities.  They recently released a report on this subject: Scientists’ warning to humanity: microorganisms and climate change. 

“Human activities and their effects on the climate and environment cause unprecedented animal and plant extinctions, cause loss in biodiversity and endanger animal and plant life on Earth. Losses of species, communities and habitats are comparatively well researched, documented and publicized. By contrast, microorganisms are generally not discussed in the context of climate change (particularly the effect of climate change on microorganisms)…simply put, the microbial world constitutes the life support system of the biosphere. Although human effects on microorganisms are less obvious and certainly less characterized, a major concern is that changes in microbial biodiversity and activities will affect the resilience of all other organisms and hence their ability to respond to climate change.”

Before humans arrived on the scene, a carbon cycle existed that determined the sources and sinks of the various greenhouse gases.  These sources and sinks were two very large numbers whose difference could vary significantly.  The climate would respond to whatever balance was attained.  Great variations in climate have been observed over geological times as that balance has shifted.  Since the industrial revolution, we have been disturbing this balance by pumping excess carbon dioxide and methane into the atmosphere.  The climate has responded by getting warmer.  This is easily determined.  What is much less understood is the role microbes are playing—and will play—as more greenhouse gases are pumped into the air.  Microbes, as “the life support system of the biosphere,” control these sources and sinks and thus determine how the Earth responds to climate change.  We understand these microbial processes so little that we cannot predict with certainty exactly how the planet, as a whole, will respond.  What we know is that, thus far, rising temperatures appear to support ever higher temperatures by favoring greenhouse gas sources over sinks.  Rising levels of carbon dioxide can, independently of temperature, affect planetary response as well.

“Although microorganisms are crucial in regulating climate change, they are rarely the focus of climate change studies and are not considered in policy development. Their immense diversity and varied responses to environmental change make determining their role in the ecosystem challenging. In this Consensus Statement, we illustrate the links between microorganisms, macroscopic organisms and climate change, and put humanity on notice that the microscopic majority can no longer be the unseen elephant in the room. Unless we appreciate the importance of microbial processes, we fundamentally limit our understanding of Earth’s biosphere and response to climate change and thus jeopardize efforts to create an environmentally sustainable future.”

Both the oceans and land masses produce complicated microbial behavior contributing to sources and sinks of greenhouse gases.  The ocean, because of its fluid nature and large fraction of the planet’s surface, produces more immediate responses to human (anthropomorphic) changes.  It has been estimated that 90% of marine biomass is microbial, and that the oceans provide about 50% of the planet’s carbon dioxide fixation through photosynthesis.  But increased levels of carbon dioxide in the oceans change the acidity level and thus change many critical processes.  Human caused pollution and the effects of warming are also affecting ocean environments in complex ways that are discussed in the report.

Here, the focus will be on terrestrial processes which are more easily observed.  Controlled experiments are even possible.  Plants and the soil that support them provide most of the Earth’s biomass and are the critical components.  Plants absorb carbon dioxide and release oxygen via photosynthesis.  Soil provides the opposite effect by having microorganisms break down organic materials and release carbon dioxide and/or methane.  Approximately 50% of plant mass will eventually end up as a component of the soil and provide plenty of material for consumption.  In addition, soil has provided long-term storage for organic material that has not been available for consumption in the form of permafrost and peatlands.

“Peat (decomposed plant litter) covers ~3% of the land surface and, due to plant productivity exceeding decomposition, intact peatlands function as a global carbon sink and contain ~30% of global soil carbon. In permafrost, the accumulation of carbon in organic matter (remnants of plants, animals and microorganisms) far exceeds the respiratory losses, creating the largest terrestrial carbon sink. Climate warming of 1.5–2 °C (relative to the global mean surface temperature in 1850–1900) is predicted to reduce permafrost by 28–53% (compared with levels in 1960–1990), thereby making large carbon reservoirs available for microbial respiration and greenhouse gas emissions.”

If we are to be relieved of this seemingly inevitable feedback mechanism for producing ever more greenhouse gas emissions, it will depend on the behavior of microorganisms as temperature and greenhouse gas contributions increase.

“Soils store ~2,000 billion tonnes of organic carbon, which is more than the combined pool of carbon in the atmosphere and vegetation…Soil microorganisms regulate the amount of organic carbon stored in soil and released back to the atmosphere, and indirectly influence carbon storage in plants and soils through provision of macronutrients that regulate productivity…”

Thus far, it appears we will get no relief: greenhouse gas production will elevate temperatures and produce even more greenhouse gases.  Drew Pendergrass provided an article titled Ground Control for Harper’s Magazine that provided some additional insight into the issue of soil response to elevated temperature.

“Natural processes in the soil contribute more than six times as much carbon dioxide to the atmosphere each year than does the burning of fossil fuels. Microbes in the dirt release the gas as they consume dead plants and animals. Before the Industrial Revolution, those emissions were offset by the uptake of carbon by plants, but as global ecosystems react to a sudden shot of carbon dioxide, the balance has been disturbed. Even a slight change in how soils behave would have drastic impacts on the environment.”

Harvard University was granted a section of forest west of Boston.  Since 1907 they have chosen to use it as a research area to study the resident ecosystem.  Of particular interest is the emission of carbon dioxide and methane as the temperature of the soil heats up.  In order to study this phenomenon, they created patches of earth with heating coils in them that would keep the soil five degrees Celsius warmer than control patches so they could compare emissions between the two types.  That experiment is still ongoing. 

The obvious assumption was that higher temperatures would increase microbial activity and lead to greater carbon dioxide emission.  That was what was initially observed.

“Microbes flourish when they are warmer and have more freedom to move around, so Melillo and his colleagues expected the microbes in the heated soil to consume more nutrients and emit more carbon dioxide as a byproduct. They were right. ‘The initial response was, in some ways, exactly what you would expect,’ said David Foster, a silver-haired ecologist who has been the director of Harvard Forest since 1990. ‘If we heat up soils, we’re going to release a ton of carbon dioxide. And that’s going to have this very strong positive feedback’.”

However, things would change after about ten years and it appeared that there was a limit to the amount the microbes could produce.

“It took ten years for the story to change. In 2001, scientists noticed that the soil in the warmed plots had stopped releasing excess carbon dioxide—its greenhouse gas emissions looked just like those of the control plots. When the scientists looked more closely, they found that the microbes, which had been eating quickly in the warmer environment, were now dying off in large numbers because they were out of balance with the rest of the ecosystem. Eventually the pantry emptied, and the microbes starved.”

This potentially good news was merely a pause in the process.  The initial microbial population was suitable for devouring the low hanging fruit, the easily digested carbon compounds.  There remained much more carbon in less easily attacked forms; the microbes merely had to evolve the ability to consume those—something they seem to be quite capable of doing.  By 2008 the heated plots were emitting carbon dioxide at nearly the same rate as when the experiment with elevated temperatures began.  Kristen DeAngelis, a microbiology professor provided the explanation.

“From her experience as a microbiologist, DeAngelis knew that microbes often gain new abilities under stress. She found that the microbes in the warmed plots were better at digesting cellulose, hemicellulose, and lignin—tough, mealy molecules known as “recalcitrant carbon”—than the same species in the control plots. Soils around the world are full of recalcitrant carbon, but scientists had not anticipated that microbes would be able to consume it. The fact that warmed microbes were willing and able to chow down on these molecules was bad news for the climate.”

Pondering these results, Pendergrass inserted these thoughts.

“Recent research suggests that the Amazon rainforest will soon transform from a carbon sink into a carbon source, because of warming and other human-driven change. Farther north, the permafrost is melting. The Arctic tundra contains gobs of easy-to-digest carbon that has been frozen for centuries; once it melts, the microbes there could start a feeding frenzy. Scientists expect that the carbon emitted by thawing land up north will be far worse than anything Melillo observed in his warming experiment.”

Recall that soil emissions of carbon dioxide are already six times higher than that from burning fossil fuels.  What will there be to balance even higher rates?  The fate of the oceans is less certain.  Perhaps they will provide some assistance as our reckless behavior continues.  Unfortunately, like us, terrestrial microbes are only concerned with their immediate needs.

We seem unable or unwilling to change our habits.  The discussion presented here suggests that there could be a point of no return when climate change will continue without our contribution.  What do we do then?  How will it end?

Viruses: A Time to Recall Polio and Its Epidemics

As best can be determined, polio, a viral disease, has been with us at least throughout recorded human history.  The result for some of those infected was varying degrees of paralysis and even death.  Until the beginning of the twentieth century, the virus survived by infecting new additions to the community while the majority had previously developed immunity.  This is the “herd immunity” discussed today.  In this situation the virus is said to be endemic.  Infections would occur but they would not be widespread.  It would take human intercession, in the form improved sanitation and hygiene, to turn polio into one of the most feared pathogens of the modern era.  As we learn over and over again, human actions can have unintended consequences.

Wikipedia provides us with this perspective.

“In children, paralysis due to polio occurs in one in 1000 cases, while in adults, paralysis occurs in one in 75 cases. By 1950, the peak age incidence of paralytic poliomyelitis in the United States had shifted from infants to children aged 5 to 9 years; about one-third of the cases were reported in persons over 15 years of age. Accordingly, the rate of paralysis and death due to polio infection also increased during this time.  In the United States, the 1952 polio epidemic was the worst outbreak in the nation's history, and is credited with heightening parents’ fears of the disease and focusing public awareness on the need for a vaccine. Of the 57,628 cases reported that year 3,145 died and 21,269 were left with mild to disabling paralysis.”

“At its peak in the 1940s and 1950s, polio would paralyze or kill over half a million people worldwide every year.”

The Wikipedia account also included this note attributed Richard Rhodes taken from “A Hole in the World.”

“Polio was a plague. One day you had a headache and an hour later you were paralyzed. How far the virus crept up your spine determined whether you could walk afterward or even breathe. Parents waited fearfully every summer to see if it would strike. One case turned up and then another. The count began to climb. The city closed the swimming pools and we all stayed home, cooped indoors, shunning other children. Summer seemed like winter then.”

Patrick Cockburn was an Irish lad of age six when he was infected during an epidemic in 1956.  He wrote about his experiences with the illness and its effect on his subsequent life in a note in the “Diary” section of the London Review of Books.  The piece was titled The 1956 Polio Epidemic.  Cockburn suffered a degree of paralysis that left him, after several years of physical therapy and some surgery, with a severe limp.  As an adult he was moved to research the disease that had assaulted him and would eventually produce a memoire titled The Broken Boy.

“I started reading about polio, a disease that has probably been around for thousands of years. There is an ancient Egyptian sculpture of a man with a wasted leg, looking very much like my own. Walter Scott was made lame by it as a child. But these were individual cases and it wasn’t until the first half of the 20th century that polio epidemics began to sweep through cities. Before then most people contracted the virus in infancy, when their mother’s antibodies helped them to gain immunity. Long before the Covid-19 pandemic made the phrase ‘herd immunity’ infamous, the pool of people who had polio without knowing it was large enough to prevent epidemics.”

“It was modernity that gave the polio virus its chance: as 19th-century cities acquired clean water supplies and efficient drainage systems, babies were no longer contracting the virus in large enough numbers to provide collective immunity. The most vulnerable populations were in the cities, though some lost protection through geographic isolation…”

“…polio epidemics hit hardest in New York, Melbourne, Copenhagen, Chicago. Disease in such places was assumed to be associated with poverty, dirt and deprivation, but in fact it was the better off in newly built housing who constituted the majority of the victims. An epidemic in New York in 1916 killed 2343 people and crippled many more. Efforts to keep people alive by mechanical means were similar to those in use now against Covid-19: the world’s first ICU unit was established to combat the polio epidemic in Copenhagen in 1952, with two hundred medical students recruited to pump oxygen and air manually into the lungs of patients who could no longer breathe on their own.”

“These epidemics were terrifying because people didn’t understand why children were falling ill when they hadn’t been in contact with any other sufferers. In reality, everybody was infected without knowing it. Various communities, usually immigrants, were scapegoated. In New York in 1916 animals were suspected of spreading the disease and 8000 dogs and 72,000 cats were killed. Many communities made ineffectual efforts to quarantine themselves: towns in Long Island and New Jersey sent out deputy sheriffs armed with shotguns to police the roads and turn back cars containing children under the age of 16.”

It is often said that we should not expect the world to be the same after Covid-19 releases us from its terror.  The polio experience provides a case in point.  Much of the support for polio vaccine development and for aid to those disabled was provided by the March of Dimes.  This charity was funded by small donations from millions of individual citizens, a novel approach then, and collected hundreds of millions of dollars, more than all other charities combined at the time (save for the Red Cross).  The legions of people disabled by the disease would require the development of new techniques for treatment and physical therapy.  Their existence would also inspire the growth of a disability rights movement to generate the legal basis for incorporating the disabled into our society.  Today, one can only guess at the future that lies ahead for us.

Cockburn provides a comment that reminds us that our future plans after Covid-19 should—must—include the assumption that this will happen again.

“In 2005, having come to feel that I had learned as much about the epidemic as I ever would, I published a memoir, The Broken Boy. In the final chapter, I wrote that polio was probably the last in the line of diseases – cholera, typhus, malaria, yellow fever – capable of causing serious epidemics around the world. Polio epidemics had a surprisingly short career: less than seventy years between the end of natural immunity and the widespread use of the Salk vaccine. It was a story with a seemingly happy ending. Few people realised – certainly I didn’t – that if polio epidemics were a product of modernity then the way might be open for other epidemics of equal severity.”

There is a lot of human intervention with unintended consequences involved in the origin of Covid-19 and that of other viral pathogens that have emerged in recent years.  The rapid increase in our population provides greater human densities that are ideal locations for propagating diseases.  We are spreading out and inhabiting locations where humans were once few and far between.  We should not be surprised when we discover new and dangerous viruses lurking therein.  Diseases once easily controlled within local regions are now at risk of wide dissemination by denser and more mobile populations.  We have changed our relationship to animal populations.  Our industrialized treatment of vast herds of animals for our food supply also creates new opportunities for new pathogens to develop that can be transferred to us.  Bats tend to nest in highly dense configurations that invite the transmission of diseases and have been identified as likely sources of the viruses that plague us these days.  But we should realize that our population spread is also limiting the areas acceptable for bat inhabitation altering the communication paths between different bat populations and forcing them to reside in locations physically closer to us and the animals with whom we reside.  Our interest in pursuing exotic food sources has also put us at greater risk.  And we should not forget that our ubiquity puts animals at risk of being infected by pathogens transferred from us.

We are disturbing the world and its ecologies in a major way by our mere presence.  Add to that the impact of our climate change and we can expect diseases unknown to us to migrate along with their hosts as they follow the temperature changes.  Our southern states are already at greater risk as tropical diseases move northward.

We must assume that escaping from Covid-19 is not the end of a story.  The lesson to be learned is that it can happen again, and it might be much worse next time.  The world will never be quite the same again.  Life could be worse, or life could be better.  The choice is ours to make.  Hopefully, wisdom will prevail.

Surveillance States: China and the United States

Whether the US wishes to admit it or not, it is immersed in a critical competition with China that is both technological and political in nature.  China has already demonstrated that it can be the world’s manufacturing center for low-value products, has demonstrated competitiveness in high-value production, and has a plan (Made in China 2025) to become a leader, if not the leader, in major technology areas.  They have the leadership, power, and resources to make things happen.  Meanwhile, the US has no plan, no leadership, and few resources.  In the political arena, China has much to brag about concerning its economic and cultural accomplishments.  It wishes to compare the effectiveness of its political system to the flailing democracies of the US and Europe.  Most recently, the coronavirus pandemic demonstrated that it was capable of isolating and apparently subduing the disease.  Meanwhile, it can sit on the sidelines laughing at the struggles of the US and its leadership as they come as supplicants for the necessary protective equipment and other products they need from China.

John Lanchester provides an interesting look at this competition in an article in the London Review of Books titled Document Number Nine.  China’s leadership is still identified by the title Chinese Communist Party (CCP), but communism is a poor label for its system.  Lanchester provides perspective.

“There’s no off-the-shelf description for China’s political and economic system. ‘Socialism with Chinese characteristics’ is the Chinese Communist Party’s preferred term, but the s-word makes an odd fit with a country that is the world’s most important market for luxury goods, has the second largest number of billionaires, stages the world’s biggest one-day shopping event, ‘Singles’ Day’, and is home to the world’s biggest, fastest-expanding, spendiest, most materially aspirational middle class. Look at the UN’s Human Development Index: after seventy years of communist rule, China’s inequality figures are dramatically worse than those of the UK and even the US. Can we call that ‘socialism’?”

“It’s equally hard to claim China as a triumph of capitalism, given the completeness of state control over most areas of life and the extent of its open interventions in the national economy – capital controls, for instance, are a huge no-no in free-market economics, but are central to the way the CCP runs the biggest economy in the world. This system-with-no-name has been extraordinarily successful, with more than 800 million people raised out of absolute poverty since the 1980s. Growth hasn’t slowed down since the global financial crisis – or, as those cheeky scamps at the CCP tend to call it, the Western financial crisis. While the developed world has been struggling with low to no growth, China has grown by more than six per cent a year and a further eighty million mainly rural citizens have been raised out of absolute poverty since 2012. There is a strong claim that this scale of growth, sustained for such an unprecedented number of people over such a number of years, is the greatest economic achievement in human history.”

Clearly, China is a country to be reckoned with.  Past US postures towards China have clung to the hope that involvement with the international community would lead to China behaving more like the other members of that community.  That has not happened.  In particular, it was assumed that the advent of the internet in China would lead necessarily to liberalization.  It has not.

“The ‘butchers of Beijing’, as Bill Clinton described them in 1992, would be swept away by history. The arrival of the internet made this inevitability seem even more inevitable. ‘Liberty will be spread by cell phone and cable modem,’ Clinton said. ‘We know how much the internet has changed America, and we are already an open society. Imagine how much it could change China’.”

The thrust of Lanchester’s article is to demonstrate how China is using its IT prowess and the internet to gain even greater control over society and over political aspirations.

“Its position is the diametric opposite of the Western received wisdom that the internet is necessarily and in its essence a threat to the authoritarian state. The Chinese government favours the doctrine of ‘cyber-sovereignty’, in which countries have control over their own versions of the internet.”

In 2013 a document referred to as “Document Number Nine,” with the official title of “Communiqué on the Current State of the Ideological Sphere” was leaked.  Lanchester tells us the perpetrator received a seven-year jail sentence and is now under house arrest.

“Document Number Nine warned of ‘the following false ideological trends, positions and activities’: ‘promoting Western constitutional democracy’; ‘promoting “universal values”’; ‘promoting civil society’; ‘promoting neoliberalism’; ‘promoting the West’s idea of journalism, challenging China’s principle that the media and publishing system should be subject to party discipline’; ‘promoting historical nihilism’ (which means contradicting the party’s view of history); ‘questioning Reform and Opening and the socialist nature of socialism with Chinese characteristics’. The paper, which is cogent and clear, takes direct aim at the core values of Western democracy, and explicitly identifies them as the enemies of the party.”

“It sees the internet as a crucial forum for defeating these enemies. The conclusion speaks of the need to ‘conscientiously strengthen management of the ideological battlefield’, and especially to ‘strengthen guidance of public opinion on the internet’ and ‘purify the environment of public opinion on the internet’.”

“Document Number Nine is thought to have been either directly written by, or under the auspices of, President Xi Jinping. It marked a new turn in the history of China, and quite possibly the history of the world: the moment at which a powerful nation-state looked at the entire internet’s direction of travel – towards openness, interconnection, globalisation, the free flow of information – and decided to reverse it.”

The internet came late to China and grew slowly at first, but then exploded as technology, particularly smartphones, spread.  With over 800 million users, the internet has become a busy place.

“The biggest internet companies in China can be seen as knock-offs of American originals, though because China is so big, the Chinese versions are now in many cases larger than their US templates, and as they have grown they have added many distinctive features of their own. Baidu is Google, Alibaba is Amazon (they’re the ones behind ‘Singles’ Day’), Tencent is sort of Facebook plus Netflix…Sina Weibo, usually referred to just as Weibo, is Twitter, which has been blocked in China since 2009. The story of the Chinese internet pivots around Weibo, because it was that company that came closest to embodying the opening up of information that internet advocates see as the main transformational point of the technology.”

“Weibo launched in August 2009 and over the next few years was the site of an unprecedented new freedom for Chinese citizens. People used it to connect and communicate and, increasingly, to complain – about pollution, corruption and government scandals.”

The popularity of Weibo as a mechanism for inserting and spreading criticism of the administration throughout the nation could not be tolerated.  Rules would be installed that would not so much forbid complaining as forbid organizing.

“This​ was the context for Document Number Nine, and it was also the point at which the CCP launched its counterattack. First, the Weibo accounts of prominent critics were ‘harmonised’ – in other words, deleted overnight. Then a conference was called for ‘Big Vs’, people with well-followed verified accounts, analogous to Twitter’s blue tick. At the conference, the newly formed Cyberspace Administration of China reminded the assembled big shots about their ‘social responsibility’ to the ‘interests of the state’ and ‘core socialist values’. Two weeks later, on 23 August 2013, the prominent investor and Weibo activist Charles Xue was arrested. He turned up shortly afterwards in a Chinese Central Television interview from his prison cell, weeping and apologising for his irresponsibility and vanity.”

“Such TV interviews have become a staple feature of the CCP’s internet crackdown, helped by a new law, passed in September 2013, which threatens three years in prison to anyone who shares a rumour that ‘upsets social order’ and is shared five hundred times or clicked on five thousand times. For people with Weibo followings well into the millions, the law effectively banned the posting of anything even potentially controversial…Weibo continues to grow, mind you; it’s just that it’s now the usual entertainment news and celebrity bollocks.”

Besides the expected blocking of any news the party deemed unacceptable, they also developed a cadre of agents who were paid to post information to counter anything that might leak through.

“The party’s new focus on internet censorship was given its first big test by the Umbrella Protests in Hong Kong, which kicked off in September 2014 – the name comes from the fact that protesters used raised umbrellas to ward off tear gas. The protests drew almost no attention in mainland China, thanks to the blocking of news and messages from Hong Kong, and also thanks to the systematic use of counter-propaganda by a new ‘fifty-cent army’ of paid bloggers, trolls and subject-changers (‘fifty-cent’ because that’s the amount allegedly paid per helpful post).”

Censorship is not the main goal of China’s control of the internet.  It is intended to be part of a bigger system of surveillance that would allow the state to track and evaluate the actions of every individual in the country.  This kind of capability is useful in countering an epidemic, but the ultimate intention is to grade citizens according to the social usefulness of their behavior.  The state will provide the appropriate criteria for evaluation.

“Big data and artificial intelligence [AI] are the next big thing in computing. The party’s plans for it, as set out in the State Council’s ‘next generation artificial intelligence development plan’, published in 2017, are the most ambitious of any government in the world. (It’s noteworthy that this paper, which is fully as alarming as Document Number Nine, was freely published by a government press. The CCP is proud of what it has in mind.)”

“When it comes to AI the party really, really isn’t messing around. ‘The widespread use of AI in education, medical care, pensions, environmental protection, urban operations, judicial services and other fields will greatly improve the level of precision in public services, comprehensively enhancing the people’s quality of life.’ Oh, and by the way: ‘AI technologies can accurately sense, forecast, and provide early warning of major situations for infrastructure facilities and social security operations; grasp group cognition and psychological changes in a timely manner ... which will significantly elevate the capability and level of social governance, playing an irreplaceable role in effectively maintaining social stability.’ This is as pure a dream of a totalitarian state as there has ever been – a future in which the state knows everything and anticipates everything, acting on its citizens’ needs before the citizen is aware of having them. It is an autocratic fantasy, a posthumanist dream, hiding in the plain sight of a Chinese government white paper.”

As in the United States, the Chinese willingly give away enormous amounts of data about themselves by using social media.

“For the censorship and control of the Chinese internet, one of the most useful tools is the app WeChat, which is one of the wonders of the internet world. WeChat – a subsidiary of Tencent – is a chat app similar to WhatsApp, but it also incorporates China’s biggest system of payments. Hundreds of millions of people use WeChat to pay for stuff, do their banking, call minicabs, find movies, book appointments, order takeaways and, of course, to communicate with one another, via phone or text or social network. No more than five hundred people are allowed to take part in any one chat – you can communicate with your family and your mates, but not broadcast across the entire platform on a Weibo-like scale.”

“WeChat is WhatsApp plus Uber plus Deliveroo plus Facebook plus online banking, and it is also god’s greatest gift to the Chinese surveillance state, since the authorities have access to all this information.”

The ubiquity of surveillance cameras coupled now with facial recognition and artificial intelligence allows nearly limitless opportunities for intrusion into individuals’ lives.

“The arrival of AI has turned the hundreds of thousands of cameras in our cities from passive recording devices into a connected network offering real-time surveillance and supervision. Add facial recognition to this and we have something new. The cute, customer-friendly side of this is effortless check-in at Chinese airports: the passenger simply stands in front of a camera and is identified, her boarding pass printed, without any action on her part. The slightly less cute version comes, say, in Beijing’s Temple of Heaven, where a machine in the toilet, designed to crack down on excessive use of loo paper, ‘releases 60 cm of paper per face’; you can get more paper but you either need to grow a new face or wait nine minutes. And then there are the uses which aren’t cute at all: a street crossing in Fujian where jaywalkers are identified and have their face, name and address appear on a video screen beside the road; a school in Hangzhou where facial recognition technology monitors students to see when they are bored or distracted (the scanners are also used to pay for food and borrow books from the library); a state surveillance network, Skynet (yes, that’s the same as the evil computer system in the Terminator movies), which is capable of identifying any one of China’s 1.4 billion citizens within a second. Skynet is part of what’s been called the ‘police cloud’, in which police gather and synthesise all the information they can: ‘medical histories, takeaway orders, courier deliveries, supermarket loyalty card numbers, methods of birth control, religious affiliations, online behaviour, flights and train journeys, GPS movement co-ordinates and biometric data, face, voice, fingerprints – plus the DNA of some forty million Chinese people’.”

“This progress in facial recognition and big data is all part of the other development in the Chinese digital world, the social credit system. This is a credit score analogous to those which are run in the West by credit reference agencies such as Experian and Equifax. The complete view of our lives and finances owned by these firms seems largely to escape attention in the West, but it hasn’t escaped the attention of the CCP, which has multiple trials running of social credit systems that build on and expand the existing Western model. The Chinese pilots look not at consumer creditworthiness but at social behaviour, with the criteria for desirable behaviour defined by the party.”

“Put all this together. Imagine a place in which there’s a police post every hundred metres, and tens of thousands of cameras linked to a state-run facial recognition system; where people are forced to have police-owned GPS systems in their cars, and you can buy petrol only after having your face scanned; where all mobile phones have a state app on them to monitor their activity and prevent access to ‘damaging information’; where religious activity is monitored; where the state knows whether you have family and friends abroad, and where the government offers free health clinics as a way of getting your fingerprint and iris scan and samples of your DNA…you don’t need to imagine this place, because it exists: that’s life in Xinjiang for the minority population of Muslim Uighurs.”

Far from becoming more like the rest of the developed world, China is attempting to create a state that is totally new and frighteningly different.  Success will depend on its people being reprogrammed into more compliant citizens.  They are currently practicing this reprogramming initiative on the Uighurs in Xinjiang.  One can imagine China becoming an example for autocrats everywhere, with the software system becoming a product for export.

“The idea that prosperity and the internet would in themselves make the country turn towards democracy has been proved wrong. Instead, China is about to become something new: an AI-powered techno-totalitarian state. The project aims to form not only a new kind of state but a new kind of human being, one who has fully internalised the demands of the state and the completeness of its surveillance and control. That internalisation is the goal: agencies of the state will never need to intervene to correct the citizen’s behaviour, because the citizen has done it for them in advance.”

It is important that we appreciate what is occurring in China because the same technology exists in our country and it is being used for much the same purposes.  The difference is that the developers are private companies who are surveilling the population in hopes of making more money.  Lanchester uses Facebook as his example.

“Much if not all of the technology currently developed in China already exists in the West, in forms that are just as intrusive. The difference is that the technology is almost all in the hands of private companies. AI, big data, facial recognition: Facebook, Google, Amazon, Apple and any number of smaller and emerging companies are deeply invested in these fields. Add what these companies know about you to the colossal amount of data held by the credit reference agencies, and we are as fully open to surveillance in the West as are the citizens of the People’s Republic.”

“There is a touch of bathos to this: the technologies which are being used in China to invent a new form of the totalitarian state are being exploited here to make us click on ads and buy stuff.”

“Do we want facial recognition technology to be in the hands of the least scrupulous technology giant? If we don’t, we’re too late – it already is. Facebook has changed its terms of service over ‘tagging’ people’s photos a couple of times, from opt-out to opt-in, but the gist is that it is too late: Facebook already owns your ‘faceprint’, the algorithmic representation of your face. How much do we think we can trust them with it? Put it like this: Facebook owns a patent on how to recognise patterns of friendship association through identifying the spots of dust on your phone camera – in other words, if two people had their photo taken by the same camera, then those two people probably know each other. That’s important to the company, because the ‘People You May Know’ feature is one of Facebook’s strongest drivers of growth and engagement. Facebook also owns a patent on a system that interprets people’s facial expressions as they walk around a shop looking at the merchandise, and another on a system that recognises shoppers’ faces and assigns them a ‘trust level’ derived from their Facebook profile. The trust level might unlock special deals, if it were positive, but if it were negative – who knows? Why on earth would we trust Facebook?”

If you are pleased that at least your government agencies are not generating all this information about you, you should realize that they don’t have to generate it, they merely have to sweep it up from the people who already have it.

And how high is your level of trust in your government at this point?

COVID-19: A Tale of Two Cities

The Center for Disease Control and Prevention in Atlanta runs a training program called the Epidemic Intelligence Service (EIS).  Those who emerge from this training generally assume roles in health programs at governmental agencies, both national and international.  They refer to themselves as “disease detectives.”  They are intended to be the people one goes to when health threats arise generating a need for investigative efforts and emergency responses.  There is a specific protocol that is recommended when a situation such as presented by COVID-19 arises.  Charles Duhigg tells his readers about that protocol and about two cities/states that made different decisions when the health emergency struck.  His article appeared in The New Yorker as Seattle’s Leaders Let Scientists Take the Lead. New York’s Did Not (as The Pandemic Protocol in the paper version of the magazine).

Duhigg provides this background on the EIS.

“The Epidemic Intelligence Service was founded in 1951, when American troops in Korea began experiencing fevers, aches, vomiting, and fatal hemorrhages. Some three thousand soldiers fell ill, leading military leaders to conclude that Chinese-backed Communists had weaponized bacteria. ‘The planning of appropriate defensive measures must not be delayed,’ an epidemiologist at a new federal agency, the Communicable Disease Center, declared. He proposed a new division, named to evoke the Central Intelligence Agency. But when the first class of E.I.S. officers landed in Korea they found that the fevers were not caused by a crafty enemy. Soldiers, it turned out, had been accidentally consuming rodent feces. In later conflicts, generals were instructed to use thicker food-storage bags and to set more rat traps.”

Despite this humble beginning, those trained in the EIS program would contribute to health-care activities across the globe.

“E.I.S. alumni went on to take powerful health-care jobs across the country. ‘Nearly ninety per cent of E.I.S. graduates embark on public-health careers at the local, state, federal or international level,’ a 2001 study found. Four former C.D.C. directors are E.I.S. alumni; half a dozen graduates have served as the U.S. Surgeon General.”

The protocol developed by the EIS to deal with situations such as COVID-19 calls for a scientist to be the spokesperson for communication with the public.  It is natural for a politician to wish to play that role, but given the nature of our politics, any politician is likely to have a problem gaining the trust of about half the people.  In addition, the instincts of a politician are at odds with what is needed to counter an epidemic.  The traditional role for a politician would be to reassure people that eventually all will be well.  But what is needed is someone to frighten people into action.  A politician will tend to wait until drastic measures can be justified.  The scientist knows that if the need for drastic measures is apparent, then it is already too late.

“Epidemiology is a science of possibilities and persuasion, not of certainties or hard proof. ‘Being approximately right most of the time is better than being precisely right occasionally,’ the Scottish epidemiologist John Cowden wrote, in 2010. ‘You can only be sure when to act in retrospect.’ Epidemiologists must persuade people to upend their lives—to forgo travel and socializing, to submit themselves to blood draws and immunization shots—even when there’s scant evidence that they’re directly at risk.”

“The C.D.C.’s Field Epidemiology Manual, which devotes an entire chapter to communication during a health emergency, indicates that there should be a lead spokesperson whom the public gets to know—familiarity breeds trust. The spokesperson should have a ‘Single Overriding Health Communication Objective, or SOHCO (pronounced sock-O),’ which should be repeated at the beginning and the end of any communication with the public. After the opening SOHCO, the spokesperson should “acknowledge concerns and express understanding of how those affected by the illnesses or injuries are probably feeling.” Such a gesture of empathy establishes common ground with scared and dubious citizens—who, because of their mistrust, can be at the highest risk for transmission. The spokesperson should make special efforts to explain both what is known and what is unknown. Transparency is essential, the field manual says, and officials must ‘not over-reassure or overpromise’.”

At the end of February, political leaders in the Seattle area were made aware that COVID-19 was loose in the area.  Within a few days the lead politician, Dow Constantine, King County Executive, was working with the health experts on how to proceed.  It was agreed that the scientists would take the lead, and that extreme social distancing would be necessary as soon as possible.  But this was before there were any signs that the public could consider in order to feel such a move was necessary.  The trick was to convince people of the seriousness of the situation before the seriousness became obvious.  They began by getting both Microsoft and Amazon, two huge employers in the area, to tell their employees to stay home and work remotely if they could.  They also floated the idea that schools would have to shut down.  This managed to convey the direness of the epidemic and gave people the nudge to begin their individual assessments and to begin to change their habits.  By the time the actual regulations were implemented, and the schools were officially closed, many people had already gone into the shelter-at-home mode on their own.  The Seattle area would experience an initial surge in cases and fatalities due to outbreaks in local nursing homes, but after that brief period, it and Washington state have been effective in keeping the disease from getting out of control.

COVID-19 cases were making an appearance in the New York City area about the same time as near Seattle.  However, the response was quite different.  In New York, the politicians took the lead.  In particular, the Mayor of New York City, Bill de Blasio, and the Governor, Andrew Cuomo, two people who don’t particularly like each other, both tried to be spokespersons communicating with the public.  And both hesitated to send the message that great sacrifices would have to be made.

“In early March, as Dow Constantine was asking Microsoft to close its offices and putting scientists in front of news cameras, de Blasio and New York’s governor, Andrew Cuomo, were giving speeches that deëmphasized the risks of the pandemic, even as the city was announcing its first official cases. De Blasio initially voiced caution, saying that ‘no one should take the coronavirus situation lightly,’ but soon told residents to keep helping the city’s economy. ‘Go on with your lives + get out on the town despite Coronavirus,’ he tweeted on March 2nd—one day after the first COVID-19 diagnosis in New York. He urged people to see a movie at Lincoln Center. On the day that Seattle schools closed, de Blasio said at a press conference that ‘if you are not sick, if you are not in the vulnerable category, you should be going about your life.’ Cuomo, meanwhile, had told reporters that ‘we should relax.’ He said that most infected people would recover with few problems, adding, ‘We don’t even think it’s going to be as bad as it was in other countries’.”

“De Blasio and Cuomo kept bickering. On March 17th, de Blasio told residents to ‘be prepared right now for the possibility of a shelter-in-place order.’ The same day, Cuomo told a reporter, ‘There’s not going to be any “you must stay in your house” rule.’ Cuomo’s staff quietly told reporters that de Blasio was acting ‘psychotic.’ Three days later, though, Cuomo announced an executive order putting the state on ‘pause’—which was essentially indistinguishable from stay-at-home orders issued by cities in Washington State, California, and elsewhere.”

The net result was that New Yorkers began changing their habits later in the process than those in the Seattle area.  It would make a great difference.

“According to data collected by Google from cell phones, nearly a quarter of Seattleites were avoiding their workplaces by March 6th. In New York City, another week passed until an equivalent percentage did the same. Tom Frieden, the former C.D.C. director, has estimated that, if New York had started implementing stay-at-home orders ten days earlier than it did, it might have reduced COVID-19 deaths by fifty to eighty per cent.”

There are reasons why the virus should be more deadly in New York City than near Seattle.  New York is considerably more densely populated and crowding in public transit is more common.  Health experts were well aware of how dangerous the virus could be for New Yorkers.  It’s a shame they didn’t have more influence.

Data on the pandemic can be found at the Worldometers site.  This link provides a state-by-state comparison of case numbers and fatalities.  From there one can link to country comparisons and a range of other data.  At this time in the United States, New York is first in number of COVID-19 cases, while Washington state is eighteenth.  In fact, New York state has experienced more cases than any other country on Earth. Deaths per million of population provides a direct comparison of the fatality levels in the two states.  In Washington it is 114, the number for New York is 1227.

Duhigg also considers Trump’s behavior as the coronavirus scenario plays out.  Luckily, most responsible people have ignored him as much as possible.