Backpacking

Just returned after four days in Sequoia National Park. We hiked out of Mineral King over Franklin Pass, to Forester Lake. Then we turned around and came back.
It's beautiful out there and being around all those peaks and clear cold lakes rubs off on my physical sense of well being. The fact that I'm looking way up at those snowy crags, then a few hours later climbing over them, contributes to the feeling of hale puissance. Franklin Pass is like that. You climb 3000 vertical feet from the trail head to Franklin Lake, then another 1500 feet up what looks like an impassible granite face. It's a narrow trail carved into the slope - a few inches of level ground in a vertical world. When we got to the top we lost the trail under snow and as I was looking for the route over the top, I found myself staring down into thin air - and granite hundreds of feet below.
So is it just the proximity to death that makes me feel so alive? (A note to the mother in law potentially reading this: we were never in any danger, any time you are up high and look down you get that thrill). Perhaps that's part of it, but I contend that there's more than that. Here we are up where it's hard to get enough oxygen, sleeping in what amounts to stress positions all night, getting sunburned and carrying packs over ankle-twisting trails and the net result is feeling healthier and stronger? It doesn't make sense. I think it has something to do with pushing the body. We spend so much time coddling ourselves with orthopedic comfort chairs, and medical treatments for every little ailment - and in the long run we end up getting worse. Perhaps a better solution would be to go out and get bruised, scratched and sunburnt.

Photo by pab_lo49 - yes neither of us brought a camera.

Native American Ecology

Just finished reading 1491, by Charles Mann which has been on my bookshelf for a long time. I was most interested in the third section - on ecology. Mann proposes that the fabled abundance of wildlife that early setters saw (the birds that darkened the sky, the herds that shook the ground) was not a result of careful management by the Indians to maximize the fertility of the land, but rather a symptom of an ecosystem reeling - unbalanced by invasive species. (That turn of phrase is not an implication of the Europeans - microbes played the starring role, as usual). The idea is that millions of Indians had controlled the fauna to protect widespread agriculture. When Old World microbes decimated the Indians, the animal populations boomed.

Oddly, I find this idea tremendously heartening. To understand why you have to know my old frame of reference: Ten million people throughout the Americas = and beautiful, bountiful land. Anything more than that and we are compromising, or really, doing injury. By this figure we are screwed (we have 300 million in the US alone, and each of us has a footprint many times larger than a 15th century American). 1491 gives me hope that we don't have to make a grim choice between people and nature (meaning: either culling ourselves or creating a form of nature so degraded that no one would want to live in it). Mann's descriptions of high density populations in the Amazon rainforest terrifies some environmentalists. That sort of thing could convince people that those lands should be populated again. And why not? If we can populate them in a way that improves the soil (as the last "urban" inhabitants did) I'm all for it. I'm for preserving the pleasure humans take in nature, I don't need to preserve nature empty of humans. If push comes to shove I'd be more than happy to have farms in the ANWR and a city in Yosemite Valley - to spread human warrens through every corner of the earth - if we could do it in such a way that preserved the qualities of those places that give us joy.

Natural birth

For a couple months now I've been sitting on what I think is a huge story, trying to figure out a way that I could frame it for a national magazine. Other journalists are catching on now (there will probably be a story in the LA Times in a few weeks or so - and I'm going to do a story for KALW) so I'm going to break the news here.
Since 1997 the chances of dying in childbirth have doubled in California. When health officials working with the state showed these graphs to a group of obstetricians there were shocked gasps from the audience. New York's numbers are similar and there's enough evidence to convince me that this is a national trend. The usual suspects (older, sicker, fatter, poorer women) only account for a small part of the increase in California. No one has pinned down the root cause of the rest yet. But investigators say there's one obvious place to start looking. What else has changed significantly in childbirth? We're now delivering almost a third of kids by Cesarean. Cesareans are pretty safe as major surgeries go - but if you look at the long term risks (rather than just the immediate risks) they become less appealing. If you have another baby after a Cesarean (and especially after multiples) you have a chance of developing an abnormal placenta attachment like placenta accreta. The placenta can grow through the old C-section scar and send blood-seeking tentacles out into the organs. OB's say they are seeing an epidemic of these conditions - 8 to 10 times the number from a decade ago. They are hugely dangerous - and if they don't kill they can cause severe damage (often requiring hysterectomy). For every woman that dies there are 50 that suffer debilitating injury.
There's pretty good evidence that too much birth tech is hurting women. However - there are some very influential people (at the National Quality Forum and Berwick's Institute for Healthcare Improvement) who are working on this. In the next decade I suspect we will see a sea change in the way that this country does birth. Even conservative OBGYNs (those in the know) have been telling me that low tech, high touch is the wave of the future. They don't care that they sound like hippie midwifes. Natural - it seems - is the new high tech.
Photo/rkimpeljr

Can tech end poverty?

Today I had a fascinating talk with someone who spends a lot of time thinking about how to get technology to the poor that will actually be useful to them (she's on the board of a fairly prestigious institution and therefore has to speak carefully in public so she asked me not to use her name casually).
I'm still digesting this, but our topic was basically: can technology help the poor?
Her answer: Yes, but it's tricky.
And it's tricky in some interesting ways.

The main problem is that - when it comes to tech - the market doesn't work for the poor in the way we normally think it should. Ideally, things start off with an innovator seeing some need, developing a product and marketing it. And then it competes with all the other products, and if it really does help the poor, they buy it. So the poor, the people who understand best what technology they need have a hand in drawing it in. But, my source says, it never works out that way. Instead of a pull from the poor, products must be pushed by the rich. Problem #1 There's almost never competition between technologies - at best you have one alternative to the traditional single choice. This is because the only people who are in the business of developing expensive technology for the poor are governments and charitable organizations. They are not going to pay all the development costs to get a competing vaccine out there if someone else has developed a perfectly good one. Problem #2: If you are really poor you can't afford risk. Experimenting with new things doesn't make sense when the a failed experiment means the death of a family member. Problem #3: Market surveys don't work. My source says that attempts at asking subsistence farmers what they need have failed. People focused on staving off hunger are not in a position to imagine how technology might improve their life, but they are often good at figuring out what you want to hear and telling you exactly that.

If all this is true, it means that any attempt to bring technology to the aid of the poor is paternalistic. That's kind of a bad word, and for good reason: Sometimes when we tell the poor what they should do we end up making things worse. But there are many cases where the Pater of paternalism has proved to be a wise and loving father. Spend enough time on the ground working with people and tinkering with the technology and you can make a difference.

I left that initial conversation with the feeling that the whole enterprise of trying to develop good technology and push it to the poor is incredibly sticky. First - there are the difficult Kipling overtones. Second - whenever you are successful at introducing a new technology you are taking a bit of control away from the non-human world and bestowing it upon humanity. (You could define technology as that which gives humans more control) The question is, which humans seize that control and wield it for themselves? Hopefully it's the people you are trying to help. But what if it's the corporation manufacturing the product? There is a real danger of inadvertently furthering corporate colonialism. If the devil is in the details, so is the answer. I hope to learn the details of some examples that have worked.

More Berwick!

I just can't get enough of him. I know it's incredibly nerdy to get all gushy over a guy who specializes in health care systems analysis and improvement. But think for a second - here's a guy buried to the hip in jargon and numbers of his field, and he's still able to bring to it the perspective of the everyman (not to mention communicate with the everyman). Plus, he's doing some great thinking about technology.

In "Taming the Technology Beast" (JAMA - subscription req), he starts by riffing on a paper showing that RFID tags in hospitals can mess up the pump on your IV. Not cool. So ban them from the premises? Maybe not quite. He's arguing that we should "tame" technology rather than shun it. Okay sure. How does that work? Well here Berwick gets into the tall grass a little with acronyms like FMEA and SHEL (That's software, hardware, environment, and liveware ie people if you were interested). But I think his most important point boils down to this: In complex systems like health care (or ecology) you can't predict the subtle chain of reactions that may lead to dire but remote consequences, even with the best analysis. What you can do is keep tuning up the system and correcting problems as they materialize. "Design in isolation is risky" he says.

What emerges sounds an awful lot like Aldo Leopold's intelligent tinkering. You introduce a little at a time. Watch it closely - adjust - and keep watching and adjusting. Interesting to consider how this can apply for, say, agriculture. Is there an intelligent way to integrate genetically engineered crops into ecosystems? What about our big haphazard experiments with microbiology known as confined animal feeding operations? In these, we are essentially designing new microbes - in isolation from cities. And in the cities, we are designing a new kind of microbial gut ecosystem in people. When those two ecosystems bleed into each other the results tend to neither intelligent - nor incremental.

One other comment from Berwick:

Nuclear power, military operations and weaponry, aviation, rail transport, space programs, and many more high-hazard endeavors have for decades enlisted the attention of scientists of safety, and most of those fields have a far better track record of taming the technology beast than health care yet does.

My question is why? Why is health care allowed to get away with using technology willy nilly regardless of harms when Boeing is not?

Unnatural medicine

A lot of people don't like hospitals. They are sterile, unbeautiful, they are a place where you might die. Most of all they are radically abstracted from the natural world in which the individual has agency. They are a kind of bureaucratic sleep-away camp, where the needs of the organization trump the desires of the individual. Health care visionary Dr. Don Berwick, had a nice article about this in which he makes the case that patients should be in charge. He gives agruments for the ways he thinks it will improve medicine, but in the end he confesses that his extreme views stem from his fear of being a patient:

Last month, a close friend called a clinic for her mammogram report and was told, “You have to come here; we don’t give that information out on the telephone.”
She said, “It’s OK, you can tell me.”
They said, “No, we can’t do that.”Of course, they “can” do that. They choose not to, and their choice trumps hers: period.
That’s what scares me: to be made helpless before my time, to be made ignorant when I want to know, to be made to sit when I wish to stand, to be alone when I need to hold my wife’s hand, to eat what I do not wish to eat, to be named what I do not wish to be named to be told when I wish to be asked to be awoken when I wish to sleep.

Got to love a guy who is able to put dialogue into a scientific journal.

The uses of nature

Psychologist Paul Bloom had a piece in the New York Times Magazine that neatly captures the essence of what I'm trying to get at with this blog. He gives the argument against the Heidi Hypothesis:

No sane person would give up antibi­otics and anesthesia, farming and the written word. Our constructed environments shield us from heat and cold and protect us from predators. We have access to food and drink and drugs that have been devised to stimulate our nervous systems in magnificent ways. We sleep in soft beds and have immediate access to virtual experiences from pornography to classical symphonies. If a family of hunter-gatherers were dropped into this life, they would think of it as a literal heaven.

And then provides evidence that it's correct:

Many studies show that even a limited dose of nature, like a chance to look at the outside world through a window, is good for your health. Hospitalized patients heal more quickly; prisoners get sick less often. Being in the wild re­duces stress; spending time with a pet enhances the lives of everyone from autistic children to Alzheimer’s patients. The author Richard Louv argues that modern children suffer from “nature-deficit disorder” because they have been shut out from the physical and psychic benefits of unstructured physical contact with the natural world.

His conclusion is that we should make a cold-blooded, utilitarian assessment of nature - and figure out what parts make our lives better and what parts we can do without. (Should the Endangered Species Act protect the smallpox virus?) He has no problem eventually replacing nature with technology as long as we do it in a way that improves human happiness.