What You Should Think About Health Care

September 21, 2009

“Expensive medicines are always good:  if not for the patient, at least for the druggist.”

–Russian proverb

I recall, as a libertarian-minded youngster, becoming upset that media coverage of reforms advocated by Bill and Hillary Clinton referred to “the American health care system.”  I noted a fact as true today as it was then — this nation does not have a systematic approach to health care provision.  It bothered me to think that the implication of a “system” was misleading people into believing there was some sort of problem in need of a solution.

Today I remain concerned about use of the phrase “health care system.”  As a grown man with knowledge of the world that books alone cannot convey, I understand the grotesque inhumanity of American policy as relates to the provision of medical services.  It is a real and grave problem, a problem every other prosperous civilized nation has already solved within its own borders.  Arguments about the precise number of uninsured citizens only distract from the reality that tens of millions of Americans have no practical alternative to emergency medical services.

For some, this means sicknesses and injuries are only addressed in moments of desperation, with inefficient use of precious resources.  For some, this means sicknesses and injuries are endured despite protracted or even lifelong suffering.  According to [warning: PDF link] a recent Harvard study, for around 45,000 people each year, this leads to death.  Effective universal health care policy could save as many American lives as preventing one 9/11-magnitude attack every forty days!

Perhaps it is unfair to compare Republican party leaders with the leaders of Al Qaeda.  Yet the scope of preventable deaths brought about by human choices begs the question — to whom is that comparison unfair?  Are working class families caught in the gap between Medicaid and affluence somehow less innocent than the final occupants of the World Trade Center?  If expense is the real issue, why does solving the much more deadly problem of health care access warrant so much less support than the problem of terrorist attacks?

At a disturbing nexus of ignorance and irony, proponents of universal health care have been cast as villains who pose a threat to the American way of life.  That ignorance stems from some notion that it is unconstitutional for the federal government to see to the general welfare of the American people.  Never mind that the Article 1, Section 8 explicitly provides Congress with that power.  Never mind that the very first sentence of the Constitution articulates that duty as one fundamental purpose of our government.  As with so many other areas of debate, many critics of reform are unwilling to be swayed by even the most obvious facts.

If there has been any betrayal of the American way of life, it has been the institutionalization of political dogma holding that government action impedes private sector solutions.  While political leaders in the opposition party have either failed inexcusably in their duty to be informed or deliberately shirked their duty to serve the public interest, their followers are typically less villainous.  A month or so ago, one well-meaning and apparently patriotic woman shouted out that “the good hearts of the people” should be given a chance to address this problem.

As long as the problem has existed, public goodwill has had unfettered opportunity to provide relief to the sick and downtrodden.  In the early 1990s, it was already clear that philanthropy was inadequate.  In spite of enormous tax breaks for wealthy Americans in the interim, our nation has only seen more and more of our citizens uninsured or underinsured.  The notion that government cannot play a constructive role is repudiated not only by dozens upon dozens of foreign realities, but also by our own increasingly bleak public health reality.

Yet narrow interests remain zealously defended.  Some say that universal access to health care would somehow inhibit the development of new drugs and other medical technologies.  Does our nation lose nothing greater from tens of thousands of deaths (not to mention uncounted lost hours of productivity) brought about by inadequately treated medical conditions?  If medical innovation really suffers somehow from the provision of universal access, how much blood must be spilled in its name?

Yet even that is a false dichotomy.  Several European nations are each home to large thriving medical research enterprises.  Heck, even Cuba, in spite of scant national resources, manages to develop lifesaving new drugs at an impressive pace.  The idea that America, with so much raw wealth and so much intellectual capital, cannot meet the needs of its own people and still outshine the inventiveness of those other nations is a very strange assertion for a self-identified patriot to voice.

If there is any valid criticism of reformers, it would be about their widespread willingness to compromise with a political movement utterly at odds with facts.  In months of high profile public debate, few voices have been raised to ask just what profit-based health insurance actually accomplishes.  In effect, these institutions serve as private sector death panels. Somehow that term has instead achieved cultural resonance based on the fictitious and absurd rationing no public official has ever proposed to end the lives of Americans no one wishes to see dead.

Certainly there are times and places where compromise is in order.  When good faith efforts to get at the facts yield inconclusive results, bold action may be unwise.  Regarding the state of American health care today, it is only efforts made in bad faith that prevent widespread clarity about a national body count caused by a cutthroat economic paradigm applied to health care policy (not to mention monumental losses to productivity suffered by survivors of that same blight.)

Perversely, even as national media outlets are assault by propagandists, they continue to indulge purveyors of misinformation.  Again and again, transparent lies and the unrepentant dissemblers behind them are put on equal footing with provable facts and earnest informed advocates.  As with the disastrous plunge into Iraq, this critical political decision is being shaped by dialogues that equate major league national scoundrels with genuinely wise national leaders.  Yet whatever wisdom exists to promote reform, it seems unable to bring our nation anywhere near the kind of sweeping overhaul that would bring great benefit to each and every other enterprise by way of marginalizing a single parasitic industry.

Neither conservative nor libertarian thinking is without wisdom of its own.  This wisdom becomes folly when it relies on misinformation and hostile emotion.  Every day, more of our own citizens die because this particular folly continues without remedy.  If a few thousand Americans dying in 2001 justify enormous changes to our way of life, on what basis does anyone reject less dramatic change in to prevent the deaths of so many more innocent citizens?

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What You Should Think About Hope

October 13, 2008

“I steer my bark with Hope in my head, leaving Fear astern.  My hopes, indeed, sometimes fail; but not oftener than the forebodings of the gloomy.”

–Thomas Jefferson

Virtually all Americans desire a peaceful and prosperous future for our nation.  I can say this with confidence because virtually all <insert nationality here> people desire a peaceful and prosperous future for <insert nation here>.  This is universal human nature.  Even in time of war, opposing forces are each mobilized by concern for the security of their homeland.

The most insidious sort of combatants, terrorists, can be distinguished by life-changing experiences in parts of the world devastated by constant violence.  Unable to imagine a secure homeland, their desperation drives them to undermine the security of strangers and neighbors alike.  Yet even they harbor the twisted hope that shocking violence could raise awareness and bring an end to the brutal oppression in which their darkest tendencies were forged.

Away from the insanity of a place like Belfast during the Troubles or the Gaza Strip today, hope and malice are less likely to intersect.  From the yokels responsible for the Oklahoma City bombing to the killers who lash out at abortion clinics, our homegrown terrorists have clearly lost all hope.  Consumed and deranged by a potent blend of fear and hatred, they lash out despite having no coherent vision of a better future to follow from those actions.

Responsible civic discourse is always degraded by appeals to fear and hate.  Yet it can be elevated by appeals to hope.  This nation has made many monumental efforts through the decades.  Some, like marginalizing indigenous tribes or organizing the Confederacy, were the product of fearful and hateful rhetoric.  By contrast, hopeful rhetoric has inspired our greatest achievements, from the Internet to the Apollo Program all the way back to the Constitution itself.

As fuzzy and sentimental as this analysis may seem, its strength is revealed by the rarity and weakness of exceptions to it.  Direct your mind to the past.  Did a President’s angry words ever serve as the birth cry of a great national success?  Did any dark chapter in our history begin with earnest appeals to the better angels of our nature?  If those questions are answered in the negative, a clear relationship between hopeful rhetoric and real success in statecraft has been observed.

The present election provides mixed messages from both sides.  The Republican ticket offers hope that there will be more use of domestic fossil fuels, more tax cuts for the wealthiest Americans, and more cold shoulders for foreigners seeking high level diplomacy without preconditions.  Few people seriously believe a surge in fossil fuels can address our economic shortcomings, never mind dealing with serious environmental issues.  Faith in the panacea of tax cuts remains popular, though in the present historical context that can only be characterized as blind faith.

As far as American exceptionalism goes, that point is a blend of hope and fear.  It is all well and good when citizens hope that our nation’s conduct on the world stage is so amazingly wonderful that there are no errors to acknowledge.  It is neither well nor good when citizens hope that our nation’s position in the world is so coercively dominant that there is no need to acknowledge errors as they become apparent.  When the line between patriotism and jingoism is crossed, so too is the line between hope and fear.

By contrast, the Democrats’ chief appeal to fear draws mainly from a reasonable apprehension about continuity in public policy after George W. Bush and Dick Cheney left their mark on world history.  Sure, occasionally there is a low blow about Senator McCain’s aversion to modern information technology (after all, a President should have no shortage of top quality clerical assistance.)  However, the bulk of the attacks go negative on the record and plans of the Republican nominee — not his personality and assorted minor foibles.

With the rest of their enormous media buys and direct communications, Senator Obama’s supporters articulate real hopes.  His health care proposal may not rid the nation of parasitic middlemen, but it does constitute a real effort to address a serious national problem in terms of access to medical goods and services. Few Americans would argue that poor citizens should be allowed to die in the streets due to the costs of treatment.  Yet some legislate and millions vote as if that they hoped for precisely that.  Not since the early 90s has any prominent American leader tried to realign hope with basic human decency in this crucial way.

Elsewhere, Senator Obama’s idealism takes even more noble forms.  His plans for education and science funding would make our workforce more competitive and could bring about a technological renaissance.  Healing damaged international relationships, getting serious about renewable energy sources, providing tax relief for families that have never seen a six figure paycheck — the list of appeals driven by hope and joined by substantive specifics is lengthy.  Heck, the man even hopes to radically transform [warning: PDF link] the national failure that is our policy on broadband infrastructure development.

Perhaps there is no force in the universe that could silence all the fearmongering and hatemongering noise machines in American politics.  Yet that is no reason at all to bend to any particular agenda.  The ultimate tax cut would not address the realities of homelessness, domestic hunger, and preventable loss of human life that occur in our cutthroat economy.  The ultimate drilling initiative would not address the realities of toxic byproducts, industrial emissions, and rising greenhouse gas levels.

Even if political conservatives accomplished goals as stated in this election cycle, unsolved problems growing, some already devastating in scope, would create far more trouble than the most loud-mouthed partisan pundit ever could.  All loyal citizens bear a duty to disregard, dismiss, or dismantle sources of political fear and hate.  Likewise, civic duty calls for heartfelt hopes to be expressed clearly and harmonized with the realities of our times.

Not even a sitting President gets to live in a United States perfectly altered to suit his every whim.  Hope must be tempered with reason if it is ever to bridge the gaps between our noblest dreams and our daily realities.  Fear and hatred repulse reason and hope.  What Machiavelli wrote on the subject has little relevance in an open society with regular peaceful transitions of power.   Perhaps appeals to fear and hatred have a part to play in popularity contests and power struggles.  Yet they can only diminish any civilized leader’s ability to govern effectively over the long term.

Barring one of the greatest surprises in the history of American politics, the contrast will be clear as voters go to the polls on November 4th.  One candidate offers ample thoughtful specifics in a long list of plans to make life better for honest working Americans.  The other adheres to the failed politics of the past while framing precious few appeals without falling back on themes of fear or hatred.  When taking the time to exercise a citizen’s right to vote, think of which future is more desirable — a nation driven forward by hope or a nation frozen in place by fear — then act accordingly.


What You Should Think About Fear

July 1, 2008

“Fear is not the natural state of a civilized people.”

–Aung San Suu Kyi

Senator Joe Lieberman is a fascinating study in missing the point.  I first became aware of this when he embarked on a campaign to censor violence in video games.  Here was a grown man, well-educated, commanding a large capable staff, and placed in a position of moral obligation to be astute on a wide range of issues.  Yet he was convinced of a strong causal link between an entertainment medium and the worst sorts of human behavior.  In joining that misguided crusade, he fell in line with a shameful tradition of cultural conservatives ignoring substance in order to attack music or films or books or even plays.  The same buffoonery has been going on in public squares since the Agora of Athens was established.

Still, this particular Senator never fails to disappoint.  Forget about failing to deliver Florida in the 2000 election (after all, Vice President Gore’s organization bungled Tennessee even worse.)  Senator Lieberman’s misadventures go well beyond an ineffective run for his own Vice Presidency.  Whenever presented with a chance to display some insight into international relations, security issues, and counterterrorism policy; the man displays a natural gift for apparently sincere obliviousness.

Either that, or he is truly a coward.  If this is the case, then he is not merely cowering in fear for himself, but coweing in fear for the entire nation.  After all, less than eight years ago, this great nation was attacked by nineteen men with small knives.  Of course that means we must escalate warfare throughout the Middle East until both Iran and Iraq are merely parking lots for the great shopping malls of Dubai and Saudi Arabia, right?

This is the thing to keep clearly in mind as the security debate unfolds.  Armed only with a clever plan and a few inches of sharpened steel, nineteen men brought the United States of America to tears.  Perhaps because of one subject that is still taboo — the extraordinary weakness that enabled such a modest effort to produce such horrific results — we made a collective choice to fight first and think later.

Thus this choice was made without regard for little matters like target selection, means of engagement, post-invasion planning, etc.  Rather than fight back against those who had bloodied, terrorized, and (dare I say it) shamed us; this nation chose to fight for fighting’s sake.  We did not reform transportation safety to bring about real security upgrades.  We reformed it to satisfy the political desire to make people feel as if action were being taken.  We did not deploy armies to neutralize the actual threat to our safety.  We deployed them to satisfy a convoluted mix of political goals, with greater emphasis on acts that would predictably strengthen Al Qaeda than those that would be likely to weaken or eliminate the group.

For people acquainted with relevant facts, it seems hard to imagine such a stupid response to such an important issue.  In the coarsest levels of political dialogue, many conclude that this is because people like George W. Bush, Dick Cheney, and even Senator Lieberman are all evil men intent on bringing the nation to ruin.  I suppose there is some possibility that apocalyptic delusions of grandeur influence the sitting President’s worldview, and Dick Cheney is disturbingly comfortable in the role of a latter day Darth Vader.  However, I believe that it is nonsense to suggest either of them actually hates America or desires ruin befall our people.

They are simply terrorized.  The goal of the terrorist is to strike fear into the hearts of many people.  Even with the stunningly lethal outcomes of the 9/11 hijackings, American security was not significantly changed.  Rare is the month our driving habits fail to kill more people than died in those terrorist attacks.  A perfectly rational response would be to pursue the perpetrators and their accomplices, implement a sensible transportation safety plan, and go on about routine business.  An understandably irrational response would be to dwell on a mix of anger or sadness for a time, then go forward with the rational response.  Given national leadership that was adequate or better, recent history would have played out along understandable lines.

It did no such thing in large part because a particularly twisted and corrupt subset of politicians happily exploit the fact that fear is power.  Making the absurd leap from Saudi men with boxcutters to an Axis of Evil intent on nuking our homeland was only possible because a traumatized people are vulnerable to the absurd.  It was all made much worse still by political hate media — the sort that continues to draw enormous audiences no matter how profoundly wrong its content has been in the past.  Perhaps there are still some sensible voices on the American political right wing, but they are largely drowned out by other voices that cunningly exploit negative emotions — fear, anger, and hatred — to galvanize resistance against constructive political change.

When Senator John McCain’s campaign recently floated the “we put the nation first, the other candidate puts his left wing agenda ahead of the nation” campaign theme, it seems as if it could only have emerged from a circle of terrorized political advisors.  Like Senator Lieberman, it seems Senator McCain and most of his inner circle are still deathly afraid that the United States of America will prove no match for the next band of fanatics to arm themselves with innocuous tools and a cunning plan.  To hear them speak of strength and experience, to hear them criticize the opposition as weak or soft — the irony that such craven jellyfish would take that tone should be lost on no one.  Alas, it is lost on virtually everyone, including many of their critics.

It would have been a great thing for the world if cooler heads had prevailed in late 2001 and beyond.  Heck, it probably would have been great for the world if cooler heads had taken charge in 2004.  This fall, another opportunity presents itself to let cooler heads prevail.  John McCain may not be more quick-tempered or loud-mouthed than Barack Obama.  However, his continued embrace of bloodshed justified by only the most absurd and implausible of political narratives is a shameful misjudgement that threatens to pile misery atop misery, slaughter atop slaughter, all in one of the most oppressed parts of the modern world.

We should fear terrorists . . . we should fear them even more than we fear lightning strikes, but certainly much less than we fear smog.  All these risks are real, yet they are also all no reason whatsoever for a routine day to be uncomfortable.  The more our behavior reflects a terrorized mindset, the less keenly we will be able to focus efforts on neutralizing actual terrorism.  Even worse, the blundering and slaughtering will continue, perhaps even escalate, while decisions are made based on this terrorized mindset.

It is long past time to overcome this insipid fear, spawned by nineteen suicidal fanatics and nursed into a behemoth by years of carefully calculated political misinformation.  The best security credential anyone could bring to a bid for the Presidency in 2008 is a clear history of opposing misguided military aggression in a climate when such opposition was boldly unpopular.  If we truly want to be strong as a nation, then the time has come for us to show the world no fear.  Endorsing the views and candidacies of leaders still clearly and deeply terrorized by the events of September 11th, 2001 is showing plenty of fear — the very fear by which our true enemies define their own successes.


What You Should Think About Medical News

October 25, 2007

“The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d rather not.”

–Mark Twain

Rarely a day passes without some new proclamation about the nature of a healthy diet. In some households this can produce grumbling about the overconfidence of doctors. Usually medical researchers are not at fault. It just happens that as the story passes through layers of intermediaries, it becomes distorted. Researchers publish with an eye toward being critiqued by peers. Popular medical journals borrow from this and publish with an eye toward keeping professionals up to speed. By the time someone involved with a general media organization decides to do a story about new findings, the emphasis is much more on storytelling than relating the actual findings.

In fairness, this is not just because original medical papers would be unpopular items in daily papers and television newscasts. Most readers would also find raw research uninformative. Competent dutiful science journalists build a bridge between general audiences and the original research. They assess it with expert eyes, then parse it in such a way that their own work is the most accurate and informative retelling their abilities permit. Generating interest with this model involves having some passion for the subject and being exposed to enough research as to have no shortage of genuinely fascinating topics.

I believe the emphasis on cutting corners does even more damage here than crass commercialism. Like a children’s soccer team, reporters in any given niche seem to act as a mob in pursuit of a single thing. After all, why stick your head in academic papers day after day when it is possible to skim somebody else’s report, perhaps glance at another document or two, put it in your own words, and still look like you’ve done the job of a diligent professional? When someone completely fabricates a report (or in Dan Rather’s case, when someone lets one fabrication slip into a report,) the result is scandal. Yet the “do just enough not to get fired” paradigm generates plenty of work that borders on scandalously poor quality.

On the other hand, commercialization is not blameless in all this either. It probably has much to do with a tendency to decontextualize statistics. For many conditions, risk of mortality is less than 1%. If eating a particular food causes a 0.08% chance of mortality to become a 0.17% chance of dying from that same condition, that food is far from toxic. Yet many editors would be much happier to oversee a report claiming “problem food doubles your chance of dying from <insert cause here>” than something like “this food may increase your risk of <insert condition here>.”

A difference like that may seem subtle. Yet a subtle difference in language combined with a dramatic difference in tone can turn a humdrum observation into an alarming report. I dispute the idea that alarming reports make for more popular news than fascinating observations (especially when the alarm is rooted in trivia.) However, I do understand production of fascinating science journalism is hard work, while making people scared of everything but their own shadows can be an easy day at the office.

Medical journalism in mainstream venues is especially problematic because it easily plays into a common misconception — immortality. Sure, everyone on the tall side of puberty should be well aware that death is a human inevitability. Yet how many people really think about it? How many people have come to accept the weight of such a thing? For many young adults, death is something that happens to other people. Even as the years take loved ones from most and provide personal close calls for some, this profound matter is still often left on the fringes of awareness. No doubt this is sensible and healthy — a constant preoccupation with death is generally regarded as one sign of a troubled mind.

Thus, in between the bombastic music and dramatic graphics, an ominous report about how this habit or that diet might have a 2% chance of causing your death is not typically met with the thought, “well, something’s got to do it.” The lack of context transforms new findings that only deserve a little consideration among those intent on a healthy lifestyle into some sort of dramatic threat to which all decent self-loving Americans must be strongly averse.

Of course, basic common sense has some say in the matter too. As legitimate information is transformed into unnecessarily dire warnings, the general public only develops a thicker skin as applied to medical risks. “So what if oil-based paint causes cancer when it seeps into groundwater? Last month ‘they’ said fried chicken could kill you!” goes the final interpretation of a story. The abstract “They” responsible for all expert opinions increasingly fades into background noise.

Commercial media then must strive harder to succeed in efforts to attract audiences through hyperbolic alarmism. The mechanism reinforces itself. This not only wastes people’s time by failing to provide more informative content; it also minimizes the impact of medical expertise when something that truly deserves alarm comes to light. Be it an obesity epidemic, overmedicated children, undermedicated hospice patients, etc. the medical issues of the day that should be a big deal sometimes get lumped in with the noise made about fresh research of trivial consequence.

One way to address this is simply to lose interest in those types of stories. If you go to the media to have an emotional reaction, both broadcasters and publishers offer up no shortage of excellent drama (or reality shows, for the shallow folks.) If you go to the media to become more informed, consider filtering out alarmism even if that means ignoring the majority of “health news” items. Of course, that approach is not for everyone.

In the alternative, get in the habit of digging the facts out of whatever journalistic coverage happens to encase them. Distinguish between research that quantitatively assesses risk and research that manages to establish a mechanism of causation. When practical, try to find out whether reports related to risk factors were normalized or based on raw data.

I would never deny that smoking is an unhealthy habit, but in a broad sample the higher mortality rate of smokers would be significantly attributable to a range of other factors from childhood nutrition history to occupational hazards. Without knowing what efforts have been made to factor out other influences, it is difficult to formulate any context for health risks ranging from the pesticides on apples to the tannins in Zinfandel. If you can get down to the facts without being moved by an emotionally charged presentation, then there is still much that can be learned from medical research . . . even after it percolates through the filters of commercial media.