Saturday, May 29, 2021

Human Psychology, Group Psychology, and War Psychology

 We are at a critical juncture in our national history.  When significant social initiatives were called for in the not too distant past, the party in power could expect some level of support from the minority party for needed legislation.  That is no longer the case.  Our two political parties have realigned themselves from diverse entities into feuding tribes.  Each tribe views the other as an existential threat and generally refuses to cooperate.  We essentially are in a second Civil War, with the battles being waged in legislatures and courts.  Attacks by one group on the other’s motives and “stupidities” seem only to intensify the tribal nature of our politics.  Greg Jackson provided an interesting suggestion for unravelling this standoff: a good war could bring us back together.  He presents his thoughts in an article that appeared in Harper’s Magazine: Prayer for a Just War.  His just war would be one waged against climate change.

While a “war on climate change” seems necessary and a good thing, our concern here is with the observations Jackson makes with respect to human behavior during an actual war.  What instructs Jackson is the documentation of war that suggests it can satisfy some fundamental need in humans.  The need seems related not to the violence of war but to the camaraderie, to its purposefulness and its meaningfulness. 

“The blessings of war have been obscured by its horrors, no doubt rightly, but we mustn’t confuse the impulse to war for the impulse to violence. It is instead, as many have documented, the impulse to encompassing meaning: lives of purpose, actions of consequence, excitement, comradeship, and responsibility.”

“In War Is a Force That Gives Us Meaning, the former war correspondent Chris Hedges notes that, for all its destruction and carnage, war ‘can give us what we long for in life.’ It awakens us to the deadness of the everyday, of life without meaningful struggle and thus meaningful triumph. Even those who have experienced war’s brutality firsthand, he notes, often find themselves disillusioned afterward.”

Quoting Hedges.

“Once again they were, as perhaps we all are, alone, no longer bound by that common sense of struggle, no longer given the opportunity to be noble, heroic, no longer sure what life was about or what it meant.” 

Jackson turns to Sebastian Junger for additional support. 

“Sebastian Junger reiterates this point in his book War, in which he chides our culture for lacking the courage to see ‘that one of the most traumatic things about combat is having to give it up.’ Civilian life feels empty by comparison…”

Quoting Junger.

“When men say they miss combat, it’s not that they actually miss getting shot at—you’d have to be deranged—it’s that they miss being in a world where everything is important and nothing is taken for granted. They miss being in a world where human relations are entirely governed by whether you can trust the other person with your life.”

Jackson elaborates.

“Junger wrote War after embedding with soldiers in Afghanistan’s Korengal Valley, one of the war’s deadliest fronts. He talks to soldiers on leave who were desperate to return to the fight. ‘I got to get back there,’ one says. ‘Those are my boys.’ The Army Research Branch has documented cases of wounded soldiers going AWOL to rejoin their units faster, Junger tells us. What keeps drawing ‘sane, good men’ back to combat is not the killing, but ‘the other side of the equation: protecting. The defense of the tribe is an insanely compelling idea, and once you’ve been exposed to it, there’s almost nothing you’d rather do’.”

That final statement about tribalism is rather startling—both for what it suggests about our growing partisan divide, and what it says about our inherent human nature.  Jackson suggests we should consider what the lack of opportunity to provide a compelling contribution to “defense of the tribe” might mean to modern humans. 

“Our fundamental affliction is not the magnitude of our problems but our alienation from their manifest solutions. Our tools have never made us more powerful, yet we seem more powerless than ever to effect change. Our primary way of interacting with the world is through a screen, and our principal avenue to changing anything appears to be typing into or clicking on that screen. We are alienated from the earth, from our hands, and from one another. We appear to be part of an efficient system that has brought ever more and cheaper goods to market, but our skills have become specialized to the point of practical uselessness. Our ability to create and cultivate the goods that we rely on and enjoy has shriveled to almost nothing. There is a maddening abstraction to our reality, a virtuality to all life. We are told that we are hopelessly partisan and polarized—patriotic or traitorous, awake to truth or in thrall to lies—but above all we are separate: from one another despite our mutual dependency and from the material reality on which every aspect of our life depends. We are separate from the actions we might undertake, and undertake together, to solve the tangible problems before us, which do not care what brand name or party affiliation their solutions go by.” 

Combating global warming will need an all-encompassing response which will force us to work together to avoid the ultimate catastrophes that will inevitably ensue from inaction.  We should wish Jackson good luck in propagating that notion—for he is correct.  But our interest here is the intriguing notion that what has been called a tribal response activated by the shared hazards of warfare is a fundamental component of human nature. 

Humans are members of the primate family of which monkeys and apes are our nearest relatives.  Scientists tell us that we once shared an existence with chimpanzees until we broke off from that line and went our own way, up to 6 million years ago. An unknown number of million years previous there must have been a primate ancestor from which all evolved.  Over the millions of years, humans became bipeds, shed most of their body hair, rearranged their bodies via mate selection, presumably to make them more sexually attractive to the other gender, and grew larger brains.  Most assume that we lived in small groups of hunter-gatherers over those millions of years.  We would only become sufficiently numerous and robust to venture out of our African home a few hundreds of thousands of years ago.  We must have begun as just another species in a vast network of predators and prey. As we evolved, so did our enemies, providing an always dangerous environment.  We would have to struggle with food supplies as the climate underwent enormous changes over those millions of years.  Some researchers claim we nearly went extinct—perhaps numerous times.  It is not difficult to make an argument that such a group (or tribe) of humans would require the same tendencies that modern humans only experience in warfare.  Living continuously over millions of years in an environment akin to wartime conditions could make the measures needed for group survival instinctive and inheritable.    

What are the characteristics that a primitive group of hunter-gatherers should develop in order to survive in a threatening environment, and is there any evidence that these characteristics are innate to our nature?  Let us turn to the work of Frans de Waal for some enlightenment.  His most recent effort is titled Mama's Last Hug: Animal Emotions and What They Tell Us about Ourselves.  Emotions were once considered an example of a higher order cognitive response that was available to humans, but largely lacking in other species.  De Waal’s purpose is to convince us that emotions are not only common among animals, but that emotional response has been a part of natural selection since quite early in animal evolution.  Human emotional makeup, and that of a chimp for example, both result from the same evolutionary path that extended many millions of years into the past.

It was once thought that animal behavior was mainly instinctual.  Certain stimuli produce certain responses.  It only takes a few minutes to conclude that such a mechanism is insufficient for the complex environments in which animals live.  Higher order animals had to develop emotions such as fear, joy, disgust, affection, and empathy if they were to survive, particularly in a group or family environment.  The role of emotions is to signal to the conscious part of the brain that something is afoot and action must be considered.  Instinct might lead a small vulnerable ape like ourselves to run when seeing a large leopard nearby, but that could be a fatal mistake.  The emotion of fear tells us a decision on action is required but gives us time to make a conscious decision about which is the best option. 

Perhaps the emotion most important for group function is empathy.  Empathy can be defined as the ability to interpret and share the feelings of another.  What de Vaal wishes to make perfectly clear is that the emotion of empathy is not restricted to humans, and that empathy is a physical phenomenon—our bodies are designed to participate in the process, and its activities often take place subconsciously.  Humans are a social animal.  It appears evolution has decided that social animals are more effective as a society if members have some way of interpreting the emotions other members are experiencing. 

Humans have many facial expressions that convey emotion.  Evolution has provided us with the muscles we can use to produce very nuanced expressions.  A group of humans would be unable to function if its members were unable to recognize each other’s emotions.  It was long thought that this presumed unique complexity was consistent with higher order human intelligence and sociability.  However, chimpanzees have the exact same number of facial muscles and nearly the same muscular topology as humans. 

“When a team of behavioral scientists and anthropologists finally tested the idea by carefully dissecting the faces of two dead chimpanzees, they found the exact same number of mimetic muscles as in the human face—and surprising few differences.  We could have predicted this, of course, because Nikolaas Tulp, the Dutch anatomist immortalized in Rembrandt’s The Anatomy Lesson, had long ago reached a similar conclusion.  In 1641 Tulp was the first to dissect an ape cadaver and found it resembled the human body so closely in its structural details, musculature, organs, and so on, that the species looked like two drops of water.” 

If chimps and early humans were once the same species and after millions of years of evolution the two species possess the same facial musculature for expressing emotion, then that attribute must have come into existence prior to the divergence of the two species—perhaps millions of years before.  And the machinery must have been fundamentally important to each species for it to have survived millions of years of additional natural selection with little or no change. 

Chimps are quite adept at recognizing and responding to emotions expressed by humans.    An example is provided by Nadia Ladygina-Kohts of a pet chimp’s response to the perceived distress of his mistress.

“If I pretend to be crying, close my eyes and weep, Joni immediately stops his play or any other activities, quickly runs over to me, all excited and shagged, from the most remote places in the house, such as the roof or the ceiling of his cage, from where I could not drive him down despite my persistent calls and entreaties.  He hastily runs around me, as if looking for the offender; looking at my face, he tenderly takes my chin in his palm, lightly touches my face with his finger, as though trying to understand what is happening, and turns around, clenching his toes into firm fists.”

Note that the pet chimp assumed the woman was in distress because she was in danger.  Yet he immediately came and acted as if he was ready to protect her from whatever the threat was.  In the past it was generally regarded that natural selection (survival of the fittest) would reward the more selfish option of avoiding any personal danger.  It seems that the opposite has been favored by evolution: survival of the group is the best way to ensure survival of the individual.  If a member of the group is in trouble, animals seem to be programmed to move to the distressed individual not away from potential danger.

“Emotional contagion, as it is known, begins at birth, such as when one baby cries upon hearing another baby cry.  On airplanes and in maternity wards, babies sometimes chorus like frogs.  You might think they cry in reaction to any kind of noise, but studies have shown they respond specifically to the cries of same-age babies.  Girl babies do so more than boy babies.  That the emotional glue of society emerges so early in life reveals its biological nature.  It is a capacity we share with all mammals.”

“Once an infant [chimp] accidently landed on a dominant female, who bit him.  He screamed so incessantly that he was soon surrounded by other infants.  I counted eight of them in the baby pile, all climbing on top of the poor victim, pushing, pulling, and shoving each other aside.  That obviously did little to alleviate the first infant’s fright.  But the monkeys’ response seemed automatic, as if they were just as distraught as the victim and sought to comfort themselves as much as the other.”

“It is as if nature has endowed children and many animals with a simple rule: ‘If you feel another’s pain, get over there and make contact!’  It is good to realize, however, that any theory of strict self-preservation would predict the exact opposite…That mice, monkeys, and many other animals actively seek out those in trouble…proves the fundamental flaw of the sociobiological theories popular in the 1970s and ‘80s.”

Evidence of similar programming is found in humans.

“The early development of this behavior has been studied in our species by filming children in their homes.  The investigator asks an adult family member to pretend to cry or act as if they are in pain, in order to see what the children do.  In the film the children look worried while approaching the distressed adult.  They gently touch, stroke, hug, or kiss the adult.  Girls do so more than boys.  The most important finding was that these responses emerge early in life, before the age of two.  That toddlers already express empathy suggests it is spontaneous, because it is unlikely that anyone has been instructing them how to proceed.

“When people in a neuroimaging experiment were given a choice between a selfish and an altruistic option, most opted for the latter.  They went with the selfish choice only if there were good reasons to avoid cooperation.  Many studies support this view, saying that we tend to be kind and open to others unless something holds us back.”

What we have observed is that evolution has provided animals who live in groups with tools to protect and support the group.  These tools allow an individual to surrender his/her safety in order to assist in protecting the group.  Soldiers are trained to assume that attitude as exhibited by the tales told by Jackson and Unger.  However, that training likely gets a major assist from our evolutionary history.

Jackson realizes that what we know of tribalism is not working in our favor since we have mobilized ourselves into two contending tribes who respond to threats as we expect.  How to make two contending tribes switch to operating as a single tribe to contend with climate change seems too much to hope for at this point.  History tells us that this type of confrontation between tribes often leads to war.  Let us hope we can avoid that.

We should thank Jackson and Junger for raising our awareness of a prosocial tendency observed in warfare that could easily be misunderstood.  Some researchers, particularly male anthropologists, like to describe humans as intrinsically violent creatures.  Nothing in their description of wartime behavior or the discussion of intrinsic characteristics evolution has provided supports that notion.  Go to bed tonight believing we are decent creatures and sleep well.

 

Tuesday, May 18, 2021

To Mask or Not to Mask: Covid and Long Covid

Not too long ago, the CDC was predicting a catastrophe if citizens did not diligently follow the restrictive mask guidelines in place.  Then just last week it pivoted 180 degrees and claimed that fully vaccinated people could go without a mask in everyday situations, both outdoors and indoors.  The announcement seemed to assume, rather naively, that the unvaccinated would continue to wear masks in public.  It also proclaimed loudly that this decision was based entirely on scientific results.  This action no doubt pleased some who were doubtful about mask efficacy and were quite ready to ditch the things and get back to normal.  But to others, conditioned by over a year of cautious behavior and mask reliance, the move seemed precipitous and suspicious.  Was the CDC unduly influenced by political pressures?  These people will have to decide for themselves what they believe to be the proper course of action. 

The suddenness of the CDC action prompted a pair of doctors to meet and discuss the issue and post their concerns under the title CDC says no masks are needed if vaccinated. But there are plenty of reasons to wear them.  The participants were Dr. Gunisha Kaur, physician and human rights researcher, and Dr. Natalia S. Ivascu, cardiac anesthesiologist and intensivist.  Some of their concerns about relying completely on vaccination were the obvious ones.  Being vaccinated does not fully protect you from acquiring the virus.  There is a finite possibility that you can still become infected and infect others

“Firstly, vaccines do not confer 100 percent immunity; vaccines don’t mean that nobody dies from the targeted illness. Differences in the degree of exposure, individual medical problems and viral transformation into variant viruses all affect how much immunity a vaccine provides.”

“An additional crack in the vaccine armor is that we don’t know how long our post-vaccine antibodies will be adequate to stave off sickness. Similarly, we don’t know if current or future variants will penetrate our vaccine protection.”

“Even vaccinated high-risk patients, such as those who are immunocompromised, may always be in danger. We don’t have a lot of safety data for the Covid-19 vaccines in immunocompromised people, and we don’t know if their weakened immune systems can or will mount a response. So if you won’t wear a mask to protect yourself, do it to protect those around you.” 

These doctors also remind us that there is much about this virus and its multiplying number of variants that is not understood.  

“And while the severity will likely be less when someone develops an infection post-vaccine, the long-term implications of even mild or moderate cases of Covid-19 are unknown…” 

What is not unknown is that long-term conditions exist and are disturbingly common.  There is an official name for these effects: Post-Covid Syndrome (PCS).  The more common term is “long covid.”  Infection seems to mostly start through respiration.  But the virus need not stop at the lungs. It appears to find ways to penetrate most parts of the body and often do its worst damage in regions remote from the lungs.  Long covid appears to consist of enduring symptoms that might have little correlation with the intensity or nature of an initial infection, making it a difficult issue with which to deal.  People who survive an encounter with the virus with no significant symptoms could still suffer from long covid.

The British have been accumulating data from their own experiences with long covid.  Their results were summarized in an article in The Economist titled Post-Covid Syndrome.  It opened with this lede.

“Researchers are closing in on long-covid.  The results are alarming.”

The types of symptoms reported are so numerous that it is difficult to categorize them. 

“There are, indeed, many of them. A survey of almost 3,800 people around the world reported 205. A sufferer typically has several at a time, with the most debilitating usually being one of three: severe breathlessness, fatigue or ‘brain fog’.” 

“Britain’s Office for National Statistics (ONS) estimates that 14% of people who have tested positive for covid-19 have symptoms which subsequently linger for more than three months…In more than 90% of those cases the original symptoms were not severe enough to warrant admission to hospital. According to the ONS, in the four weeks from February 6th nearly half a million people in Britain reported they had had long covid for more than six months—and this will not include any of those infected towards the end of 2020 in the country’s second wave.”

“At the time when the ONS collected those data, at least 1.1% of Britain’s population, including 1.5% of working-age adults, reported symptoms dragging on for three months or longer. Multiply that by the hundreds of millions around the world who have been infected at some point by SARS-COV-2, the virus that causes covid-19, and a public-health catastrophe may be in the making. In the short term, it was only right that effort focused on dealing with the acute disease. Today covid-19’s chronic after-effects also need to be considered.”

The incidence of long covid does not seem to be related to comorbidities which should peak in the elderly. 


The symptoms are significant in intensity with about 80% of sufferers saying the condition has limited the ability to perform their work. 

Long covid is actually a misnomer because what has been observed are illnesses that appeared in the short term.  It will be years before we can assess any long-term effects.

Given this discussion, there seem to be a number of good reasons to continue to wear a mask when out in the general public.  Considerably more scientific knowledge is required before absolute safety can be ensured.  If we do not understand what the virus does to our bodies, it is best, for ourselves and others, to avoid any contact with it at all.  For the immediate future, that means wearing a mask in public.

  


Saturday, May 8, 2021

The Costcoization of Healthcare: Shunning Excessive Profits

 Costco is a large retailer with the worldwide reputation of providing low prices for quality goods.  You have to love a place where you can get inexpensive toilet paper plus a great bargain on Dom Perignon.  It operates with a different model than most retailors in that it charges an annual membership fee.  Wikipedia describes its cost philosophy.

“The company’s rule is that no regular item may be marked up more than 14% over cost, and no Kirkland Signature [home brand] item may be marked up more than 15% over cost.  The company runs very lean with overhead costs at about 10% of revenue and profit margins at 2%.  Membership fees…account for 80% of gross margin and 70% of its operating income.”

In other words, Costco’s business plan depends mostly on having growing numbers of satisfied customers willing to pay the $60 or $120 membership fee rather than extracting profits from the sale of merchandise.  Its customers seem to like this approach, saving lots of money on reliable bargains and receiving good service from well-paid workers.

Costco’s business model is effective, but in the retail world it is not revolutionary.  Where such a business model would be a game changer is in the healthcare field.  There the customers are captive and do not have to be satisfied in order to harvest their wealth, and each individual service is priced to produce a profit.  Costco has ventured into healthcare in the past by providing pharmaceuticals under its traditional low-cost policies and making the bargains available even to nonmembers.  A Bloomberg Businessweek article by John Tozzi, Costco Brings Its Low-Price Magic to Employer-Paid Drug Plans, indicates Costco is getting into the pharmacy benefit management game.

“The company best known for its cavernous warehouse stores, where it sells everything from TVs to pallets of paper towels, has become partners with Navitus Health Solutions LLC, a small pharmacy benefit manager based in Madison, Wis., on a strategy that could rewrite the complicated playbook for running prescription plans.”

Pharmacy benefit managers (PBMs) are hired to act as intermediaries between institutional healthcare providers and drug companies in order to negotiate lower drug prices and save the providers money.  These PBMs also have leverage over the drug companies by having control over the list of drugs that are considered “preferred medications.”  If a company’s product does not make that list, then it will lose sales revenue—perhaps a lot.  What the PBMs do is not negotiate the list price of a drug, but the discount price that a given provider will pay for the drug.  The PBMs take a percentage of the discount to the providers as their income and are paid a fee by the care providers.  People not in one of the provider’s plans will end up paying the full list price.  The insightful reader will have already become suspicious about this system.

Consider the perverse set of incentives operating in the negotiation between PBMs and drug companies.  If two companies have equivalent drugs and one is cheaper than the other, the PBM can make more money from dealing with the more expensive product.  The cheaper drug company recognizes this factor and concludes that it is in its best interest to raise the price of its drug to match or even exceed that of the competitor.  This type of competition can easily lead to competitors frequently raising prices in lockstep.

The PBM can use the higher price to provide greater discounts to the healthcare providers.  Consequently, the providers may not be too much bothered by this scam, but this is far from a victimless crime.  We end up with two prices for drugs: the inflated list prices and the negotiated discount prices.  The problem that arises is people without insurance being required to pay the artificially high list price.  People without medical coverage, the least likely to be able to pay, will face the list price.  People with a healthcare plan but with a high deductible will be required to pay the full list price until the deductible is met.  The Medicare system is not allowed to negotiate prices with drug companies so the taxpayers are getting gouged, as well as the elderly who use a lot of medications. 

Navitus, as a PBM, has adopted a business plan similar to that of Costco in which they accept no funds from the drug price negotiations and take only the fees received from its provider clients.  If the model works, healthcare providers, patients, and governments will save money, providing more clients for Navitus. 

“Pharmacy benefit managers, better known as PBMs, traditionally make money by pocketing a portion of the rebates and discounts they negotiate with drugmakers for employers. In contrast, Navitus offers a fee-based model that passes on all the savings it creates to its employer clients. After working with Navitus for years, Costco purchased a minority stake in the closely held company in 2020. Now executives from both companies say the investment will help accelerate their growth at a time when drug costs are increasingly burdening U.S. businesses and consumers. “We believe that the marketplace is really starting to place a value on our particular business model,” says Navitus Chief Executive Officer David Fields.” 

Navitus is now small compared to the major PBMs, but it has acquired a good track record, including managing Costco’s employee health plan with its 300,000 US members. 

“Navitus’s 100% pass-through model saved the retailer millions of dollars on drug costs, according to Costco Chief Financial Officer Richard Galanti, while aligning with a core Costco strategy. ‘We’ve always been known for passing on as much savings as possible directly to our member, to our customer, whether it’s food and sundries or prescriptions,’ he says.”

One way in which this marriage can help is by facilitating access to the low drug prices maintained at Costco pharmacies by more consumers.

“Navitus and Costco are exploring ways to wring further savings out of the prescription supply chain—and drive more business to the 538 pharmacies at U.S. Costco warehouse stores. The companies are testing a plan that makes Costco the preferred pharmacy for one client in California.”

Tozzi warns that the current system may be near a breaking point as mergers of players into more complex entities nearly eliminates any transparency it may have once had.

“In the past several years, PBMs have gotten bigger and more powerful. The three largest processed about 77% of U.S. prescriptions in 2020, according to industry publication Drug Channels. And they’ve been consolidated into larger health-care enterprises—UnitedHealth Group, CVS Health, and Cigna—and integrated with related businesses such as health insurance, medical care, and pharmacies.”

“The consolidation has left some employers looking for alternatives, says Elizabeth Mitchell, CEO of the Purchaser Business Group on Health, a coalition of large employers. ‘The bigger these entities get, and the more integrated, the harder it is in some cases to actually have meaningful accountability, she says. ‘You can’t tease apart where the waste is’.”

 

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