David Brooks calls some attention to that Goldhill article. He's saying - look: enough with futzing with the window treatments, we've got to do something about the sinkhole under the corner of the house. I feel the same way, and yet...

There's a tendency for us journalists to crave fundamental change - because it's exciting. And because we like to believe that good ideas can change the world (because that's our stock and trade). History is full of examples though, of big changes leading to big problems. There's more success when the changes are of the tinkering sort - a gradual sort of coevolutionary growth between insurers, government, business and medicine.

The all-natural-Heidi-force in me wants big change of course. It wants a system that doesn't push treatment (and kill hundreds of thousands a year with overtreatment). The inner Heidi applauds Bruce McCall's Shouts an Murmurs:

Did You Know: Human illness adds two trillion dollars annually to America’s gross domestic product. Are you contributing your fair share?

and this brilliant miniature:

Q. & A. of the Month
Q: My current statement lists two hundred and thirty-one charges for “brain surgery,” even though I have had no brain surgery. How can I rectify this?
A: Invalid question. Brain surgery is not covered under your plan.

People think doctors are all-knowing

Just got off a call going over the release of a poll by the Campaign for Effective Patient Care. The biggest takeaway for me was this: 65 percent of people in California think that their medical care is backed up by solid scientific evidence. Of course in reality - as Shannon Brownlee writes in the group's report -

In a landmark 2008 report, the prestigious Institute of Medicine reported that at most half of the care that doctors deliver is evidence-based.

This is important to the health care debate - people have been awful upset about comparative treatment reviews (the extremists think looking at how effective something is and how much it costs will lead to death panels). But at the same time nobody wants care that's not effective - we all want our doctors to know what treatments work and what don't. How to explain this contradiction? Well this poll explains it. People oppose comparative effectiveness research because they (65 percent) think their doctor already knows what's best for them. So a minority that sees this research as cover for a rationing regime is not drowned out by the reasonable majority who should be saying we want to stop spending so much (and being injured by) care that doesn't work.

How health care killed David Goldhill's dad

The Atlantic recently published a great piece of contrarian thinking on health care. David Goldhill points out that all the incentives in our medical system encourage more treatment - and that's making us sicker (plus, it killed his dad, or at least made the end of his life unpleasant).

All of the actors in health care—from doctors to insurers to pharmaceutical companies—work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to the economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing.

So far so good. I'm pretty convinced that we have too much medical treatment and that there are some foundational problems causing that. But Goldhill thinks these problems all come down to one thing: Lack of market pressure. It's an interesting point, but one that I think has some problems. But before I get to his proposal, here's one more interesting critique:

Blog neglected, but plants thriving

So I was on vacation recently - away from the blog - and when I got back all my editors suddenly wanted drafts. The first breaths of the brisk winds of fall, I suppose. In any case I've been doing a lot of writing these days - for which I'm actually paid (rather than the prospective research and navel gazing that feeds this project). So spending a lot of time writing hurts the blog... but it does wonders for the plants that sit in the window to my right - just past the mouse. When I'm sitting there trying to force my brain to figure out a way to make a particularly improbable transition - or how to breath some narrative life in to a sterile series of facts - it sometimes plays tricks on me to get out of the chore. One of my brain's favorite tricks is the classic "OMG what's that!" caper. It usually plays out something like this:

Pregnancy related death

KALW just aired two pieces that I did on the rising rate of pregnancy related deaths and the black-white disparity. You can see a longer post from June. I'm hoping this will get more media attention - it's a particularly troubling example of the broader problem that Atul Gawande and others (and still others) have identified. How does this tie in with Nature? Well when you live in a world we look to science for all the answers, science sometimes ends up providing best-guess answers when it should just be saying - "we don't know enough about that yet."

Romantic? Rational? Or machinist?

Finished Daniel Botkin's book "Discordant Harmonies" last night. It has a lot to offer, but what I'm most interested in is Botkin's perspective on the trajectory of thought on nature. We start out with competing myths: The earth is a divine creation with everything made according to a plan to foster life (Jewish creation story) - versus - The earth is a living organism passing through different stages of life (pagan/animist). And then around the industrial revolution - when people had complex machines available to refer to in their metaphor making, and when Newton's breakthroughs offered a vision of a universe governed by an elegant set of simple rules - a new myth grew and dominated the others: The earth is just an piece of machinery. There are several implications if you think of the world this way. The most important implication (to Botkin) is that the world tends toward a steady state - it should just keep chugging along unless we really screw things up.

Fatted

A series of studies have shown that being "overweight" makes you live longer. Slate has a good wrap up. This is the sort of thing that makes me want to abandon modern medicine and run off to the Alps with Heidi. We adopt this overly simplistic flawed measurement (the body mass index) and build all of this architecture on that foundation (from giving dieting advice to giving pills). And eventually that becomes the only thing visible to us - instead of thinking "hmm, I feel healthy, strong, I still can get to the top of the hill without breathing hard, I'm happy so I must be doing something right" the tendency is to think "the number says I'm fat! the number says I'm fat!"

The Future and its Enemies

Virginia Postrel has posted a chapter from her book by this name - it's a trenchant critique of Bill McKibben's "The End of Nature" and others though she does spend a lot of time beating up McKibben. I learned a couple things from this.

I found this especially interesting:

"As a 19th-century position, romanticism never broke with rationalism: rather, it was rationalism's mirror-image," writes the historian and philosopher of science Stephen Toulmin.

"Descartes exalted a capacity for formal rationality and logical calculation as the supremely 'mental' thing in human nature, at the expense of emotional experience, which is a regrettable by-product of our bodily natures. From Wordsworth or Goethe on, romantic poets and novelists tilted the other way: human life that is ruled by calculative reason alone is scarcely worth living, and nobility attaches to a readiness to surrender to the experience of deep emotions. This is not a position that transcends 17th-century dualism: rather, it accepts dualism, but votes for the opposite side of every dichotomy."

This is my point exactly - that the fight between the techies and the all-naturals is stupid one and that we should stop arguing about it. (So thanks, Virginia, for introducing me to Mr. Toulmin) I think Postrel is proposing the same thing - though she wants to replace reason v. passion with what she calls dynamism. Dynamism sounds basically like libertarianism. Get a lot of minds working creatively on figuring out problems for themselves and then let the market and natural selection do its thing. Rather than trying to predict and control the future, she says, allow the process to take its course.

Hmm. What about cases where we are pretty darn sure of the future? Should we really cut down the last Truffula tree to improve our lives - knowing that we are eating off the plates of our children? Or climate change blah blah blah?

One quarter of new foods are "natural"

Just came across this from Mintel. Apparently the most common way to get you to buy a new food product is for manufacturers to put the word "natural" somewhere on the packaging. That word was used to sell almost a quarter of all new food launches worldwide in 2008, up nine percent from 2007. I the U.S. "natural" is even more powerful - it was on a full third of new launches, up 16 percent from 2007.

I'd now like to make up a new law - Nate's law if you will. I haven't thought about this at all and have no idea if it's really right - but hey, isn't that what blogging is all about?
Nate's law: Whenever a simple gesture toward a concept creates massive sales, it means we must have deep and (crucially) unexamined associations with that concept. ie, it's gotta be universal, and vague.

My explanation for the appeal of natural is that the pendulum swings back and forth between the desire for "natural goodness" (pristine waters blessed by the singing of tree sprites), and mechanical control. (Glaceau manages to have it both ways - check out this brilliant copy: "smartwater is inspired by the way mother nature makes water, known as the hydrologic cycle (you remember the ocean, cloud, raindrop diorama from fifth grade right? Actually, it's how we got our name too (hydro=water/logic=smart)." But then they "one up ma nature with electrolytes.") Anyway - I think we are still swinging toward natural but as we do we are going to see a lot more mixing like this - where products are going both back to the land and back to the lab. With any luck that will lead to confusion and a lot of tough questions about what's actually natural and what's not. Science is going to be prominent in this confusion: Is science natural? any sane smart person is on the side of science right? But as the graf below demonstrates (also from the Mintel presser) science (ie calorie, fortified) easily falls into the role of opposite to nature (ie pure, holistic, genuine).

"In the past, low-fat and low-calorie were the hallmarks of good nutrition and
dieting, but today, that lifestyle seems passé. On top of this, fortified
products are falling out of favor," comments Lynn Dornblaser. "Food and drink
manufacturers today realize that natural and pure have become healthy eating
ideals, as people look for holistic, genuine nutrition they can trust."

Pride weekend

This weekend was Pride in San Francisco. In the morning Dan Choi gave a stirring speech (the three words that got him kicked out of the military, he said, were not "I am gay," but "I love you").

Watching the parade I started thinking about the way that "natural" has been used as a rhetorical bludgeon to fight the sort of celebration of difference that I was seeing. Now that we know there are gay dolphins and gay seagulls we should hear a change of tune from the people who argued that homosexuality was bad because it wasn't natural. But of course we won't. In cases like this the natural claim gets grafted on to support the belief - if something is bad it's unnatural.

Often, I think what we are really saying if we say something is unnatural is that it is foreign to our system of beliefs.

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.

The recession is good for America

I'm starting this off late at night - so the description of what I'm doing here will have to come later. For now I just wanted to mention something that's been bothering me for a while. Every day when I hear the business news it's reporters praying to the gods of finance for growth. There's no questioning whether growth is good - or what type of growth we would want - or even what growth means outside the abstract world of econ numbers.

Of course, like everyone else I want growth that stimulates hiring so people like the guy in interviewed in North Richmond (California) don't lose their homes. But for most of my young life in Nevada City, growth represented cutting down forests and putting up strip malls. It meant destruction of that which was meaningful and beautiful and it's replacement with opportunities to buy. Even from a dispassionate money-is-the-only-object economic standpoint, it never seemed like this was a good idea in the long run. They were building all these Circuit City's and tanning salons - but these were all things that depend on people making money elsewhere for their support. They are luxuries really. The money to feed these retail centers had to come from somewhere and I wasn't seeing the growth of actual useful industry - the creation of new wealth from the land. There was no new mining or timber or farming - we were just shuttling money around from the therapist to the tanning salon, to the record store, to the grocery store. And every time someone bought something real, like food, a little money got siphoned off to the Midwest or China or Peru.

All that is a hastily worded way of saying that I've been a little worried that we are scrambling so hard to get out of this recession that we aren't taking time to solve the problems that got us into it in the first place. I was bothered enough about this that I found an economist who thinks about such things and interviewed him for Crosscurrents (KALW 91.7). I was especially interested to learn about the history of how the belief that economic growth is essential got ingrained in the '50s. You can listen here: Richard Norgaard - he's an interesting guy
Here's his website.