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Friday, July 26, 2019

Louise Aronson, MD: a home run on "Elderhood."

Just stop whatever you're doing, buy this book, and read it closely. Lordy, Mercy!
From the Amazon blurb:
As revelatory as Atul Gawande's Being Mortal, physician and award-winning author Louise Aronson's Elderhood is an essential, empathetic look at a vital but often disparaged stage of life.

For more than 5,000 years, "old" has been defined as beginning between the ages of 60 and 70. That means most people alive today will spend more years in elderhood than in childhood, and many will be elders for 40 years or more. Yet at the very moment that humans are living longer than ever before, we've made old age into a disease, a condition to be dreaded, denigrated, neglected, and denied. 

Reminiscent of Oliver Sacks, noted Harvard-trained geriatrician Louise Aronson uses stories from her quarter century of caring for patients, and draws from history, science, literature, popular culture, and her own life to weave a vision of old age that's neither nightmare nor utopian fantasy--a vision full of joy, wonder, frustration, outrage, and hope about aging, medicine, and humanity itself. 

Elderhood is for anyone who is, in the author's own words, "an aging, i.e., still-breathing human being."
This book jumped the line that is my never-ending book queue. I couldn't put it down. I bought my wife her own copy (the "elderhood" topic is about us). I tweeted,
While digital infotech was mentioned only relatively sparely, this jumped out, and is relevant to our original core KHIT topic:
For every hour they spend face-to-face with patients, doctors now spend two to three hours on the electronic medical record, or EMR. They also spend “pajama time” at home at night finishing electronic notes they can’t finish during their long workdays. Many of us lament this. Much less discussed is how technology that has undermined efficiency and the doctor-patient relationship became the national standard. Or why medicine bought electronic record systems from businesses with vastly different priorities from those of clinicians and patients, or why, having seen the harm to clinicians in systems that already adopted that technology, more and more health care organizations followed suit. Instead, we discuss the alarming, increasing rates that doctors get sick, take drugs, get divorced, and leave medicine, and how they commit suicide at rates higher than the general population. We institute programs on wellness and resilience, but don’t change anything fundamental about the priorities and systems that make such programs necessary. We blame the victims.

As a doctor, I use the particular electronic medical record that holds the health information of a majority of Americans. It’s a system designed to facilitate billing, not care. Its greatest asset is that the accounting department can quickly find the information needed to plug into formulas that link activities to charges. To make their jobs easier, we clinicians must provide required data in specific places in interconnected windows that resemble nothing so much as a fun house where doors lead to doors, and mirrors lead to confusion. We are also strongly encouraged to use standardized text, as if my visual disability or cancer surgery or inflammatory arthritis were identical to yours. Or as if one doctor’s take on a particular patient were always identical to another’s. This need to input copious information in particular language and places incentivizes cutting and pasting old notes to make new ones, and erring on the side of leaving things in rather than highlighting what may matter most. Medical notes are now so full of noise and jargon that it’s often impossible to figure out what actually happened during a specific encounter. One night on call, the lab paged me about a dangerously abnormal test result in a cancer patient I don’t know. I read and reread her notes, unable to tell which of the three cancer diagnoses on her chart was active. This is typical. Meanwhile, patients’ illness stories and their doctors’ analyses of those particular experiences, neither of which aid billing, are often altogether absent.

Electronic medical records are not the only contributors to physician burnout, but they are the technological embodiment of the nefarious values driving our health care system. The biggest EMR company apparently dismisses complaints from patients, doctors, and nurses. Our concerns don’t matter, I’ve been told by multiple sources, because we’re not their customers. Medical centers and health systems are, and they just keep on buying the product. In defending their actions, health leaders tout the EMR’s reliability, its accessibility from anywhere, and its usefulness for research and quality improvement. Those are significant benefits. Unmentioned is its often redundant, recycled, and outdated information or its frequent, significant, systematic information gaps with real potential to harm or kill patients. Such flaws would not be tolerated by most businesses or consumers. As anyone who works with data knows: garbage in equals garbage out.

I do not feel sentimental about the days of handwritten patient notes and the illegible, sometimes unsafe, hard-to-find, and practically impossible-to-share records they produced. But I do feel nostalgic for something essential that was lost when they were replaced by electronic record platforms. Heedlessly and unnecessarily, this particular approach to cyberdata collection has desecrated the most precious, meaningful elements of the patient-doctor relationship: the human connection, direct and intimate, laden with subtleties, significance, and respect for each person’s unique feelings and needs. In our brave new world, very little worth is accorded to activities such as spending a clinic visit talking through the impact of a patient’s new diagnosis on her health and life or building the sort of relationship that enables discussion of the real reasons why another patient can’t lose the excess weight causing his diabetes and high blood pressure. The things I most want from my doctors and try hardest to give my patients—things like attentive listening, shared decision-making, and individualized treatment—don’t much matter. In such a system, I am penalized if my patient doesn’t get a colonoscopy, something the EMR and my health center track, but struggle to find a place to document the half hour I spent with her and her daughter discussing why her multiple advanced illnesses and short life expectancy mean that she would likely incur all the risks and inconveniences of that screening test but none of its benefits.

The screen-focused physician is one reason patients complain doctors don’t listen or know them. It’s one reason 81 percent of physicians now say their workload is at capacity or overextended; half would not recommend medicine as a career. It’s not that electronic records are the sole cause of the historically unprecedented disillusionment of doctors today, but they are paradigmatic.

Erosion results in a wound, the worn-away part present like the negative space in a sculpture. When I tried to learn how best to use our new electronic record system, my institution sent me to trainings with a young man who informed my large group of doctors that he hadn’t been trained on what he called “the clinician interface.”

Months later, when I went to the lead doctor in our practice to ask for help because the system-generated notes seemed so worthless that I found myself creating both those required checkbox, robotext records and also narrative notes that captured the important elements of my patient visits, her unspoken words and actions made me feel that she thought my concerns were the time-sucking ramblings of a technologically inept person with an irreparable cognitive deficit and an annoyingly flawed character…

Aronson, Louise. Elderhood (pp. 217-220). Bloomsbury Publishing. Kindle Edition.
Not exactly a new complaint. She's at UCSF, which means she's on Epic. Since I retired, my patient world has been all Epic all the time (they pretty much dominate the SF Bay Area, and as a Kaiser member in Baltimore since June, my chart is now on Epic as well).

While Dr. Aronson cracked on EHRs in a few pointed venting-her-frustrations passages, the book's emphasis delves deeply into her personal story as a child, then a grown daughter / caregiver, her medical education, residency, practice, episode of burnout, and eventually professorship. Particularly moving are her stories of numerous elderly patients. as well as her candid revelations of her personal reactions to now being an "aging" woman.

A truly marvelous read.

From another of my tweets:
"Elderhood." You either die early, or it awaits you. This elegantly written, painfully probing, insightful, humane book should win multiple literary awards.

Interesting post up at THCB: "Doctors will vote with their patients."

The author's book:

...When Donald Trump expressed his cluelessness—“Nobody knew that healthcare could be so complicated”—before a meeting of state governors in February 2017, he was referring to our approach to health insurance, which has been a political piñata whacked by both left and right for decades. But even when we Americans acknowledge the absurdity of our convoluted system of third-party payers, and the pretzel positions our politicians weave into and out of as they try to justify it, reform it, then unreform it, many still find solace in telling themselves, “Well, we still have the best health care in the world.” 

In point of fact, we’re not even close to having the best health care in the world. As legendary Princeton health economist Uwe Reinhardt said, “At international health care conferences, arguing that a certain proposed policy would drive some country’s system closer to the U.S. model usually is the kiss of death.” Our system is marked by extreme variability, a nation of health care haves and have-nots. The fortunate receive services from immensely talented and dedicated physicians, nurses, and other caregivers, and they have access to drugs, devices, and facilities that are the envy of the world. All others struggle just to stay healthy without going broke. Americans spend from 50 percent to 100 percent more on health care as a share of GDP than people in other industrialized countries do, and for all our high expenditure we get collective outcomes that are demonstrably worse. In fact, we get outcomes that are, in general, truly dismal...

Magee, Mike (2019-06-03T23:58:59). Code Blue. Grove Atlantic. Kindle Edition, locations 92-98.
Add one more to the endless reading list. BTW, apropos of the "medical industrial complex"
 Dr. Mike alludes to repeatedly in his book, see "Can medicine be cured?"


My latest snailmail edition of Science arrived the other day. The cover art:

"Glacial Melting." The article is quite technical, but, in plain English, the news is not good.
Ice loss from the world’s glaciers and ice sheets contributes to sea level rise, influences ocean circulation, and affects ecosystem productivity. Ongoing changes in glaciers and ice sheets are driven by submarine melting and iceberg calving from tidewater glacier margins. However, predictions of glacier change largely rest on unconstrained theory for submarine melting. Here, we use repeat multibeam sonar surveys to image a subsurface tidewater glacier face and document a time-variable, three-dimensional geometry linked to melting and calving patterns. Submarine melt rates are high across the entire ice face over both seasons surveyed and increase from spring to summer. The observed melt rates are up to two orders of magnitude greater than predicted by theory, challenging current simulations of ice loss from tidewater glaciers.
Expect the inertial Denialism to continue, though. Right, Donald?

More to come...

Thursday, July 25, 2019

Climate change: What We Know.

apropos, from the always excellent Neurologica Blog:
The Global Warming Consensus

The degree to which there is a scientific consensus in anthropogenic global warming (AGW) remains politically controversial, even though it is not scientifically controversial. Denial of the consensus remains a cornerstone of AGW denial, so let’s examine the science and the arguments used to deny it..
The Anthropocene. Notwithstanding what The Donald thinks. And I use the word "thinks" charitably.

The Risk of Conflict Rises as the World Heats Up
Ignoring the connections between climate and security poses risks for the U.S.

The Trump administration scorns climate science: it has rolled back environmental regulations while promoting fossil fuels, and removed and downplayed mentions of climate change on government websites, among other moves that could weaken efforts to address global warming. It should come as no surprise, then, that the White House also seems to be ignoring—even potentially challenging—research and expert opinions on the connections between climate change and national security…
Yeah. significant, overlapping adversities loom. Read the 2018 IPCC Report.


One of my Facebook friends nails it:
Q: How do you get a Denialist to change his mind on global warming?
A: Claim it causes autism.


Note: TRNN interview transcript at Naked Capitalism.


Two new books on my radar.

See "Environmental racism is bad for your brain."
...One factor that is little considered, even by academics who rail against racist stereotypes, is pollution and its impact on the brain. Research shows that contamination from cars, planes, power plants, factories and landfills is eroding the bodies and minds of black and brown Americans. Two new books call attention to this invisible crisis...
The Upstream.


Ran across this outfit:

DeSmog launched in January 2006 and quickly became the world’s number one source for accurate, fact based information regarding global warming misinformation campaigns...
Well, we''ll see if those self-kudos are warranted.

More to come... #AnthropoceneDenial #

Wednesday, July 24, 2019

More on Medicare Advantage, and other news

Recall that Cheryl and I are now enrolled in Medicare Advantage via Kaiser-Permanente here in Baltimore.

Interesting caveats. Too early for us to tell yet. By year's end I'll have firmer views.


Intriguing article at Vox:
The science of regrettable decisions
A doctor explains how our brains can trick us into making bad choices — and how to fight back.
By Robert Pearl

As Full House actress Lori Loughlin and her husband await their next court date, they stand accused of paying a $500,000 bribe to get their daughters into the University of Southern California as crew team recruits. Their defense is said to rest on the belief that they were making a perfectly legal donation to the university and its athletic teams (their children never rowed a competitive race in their lives).

Legal strategies and moral considerations aside, this strange behavior has left many observers wondering, “What were they thinking?” Surely, Loughlin and her family must have considered someone at the university would audit the admissions records or realize the coach’s high-profile recruits had never rowed a boat.

We may never know exactly what Loughlin and her family were thinking. But as a physician who has studied how perception alters behavior, I believe that to understand what compelled them to do something so foolish, a more relevant question would be, “What were they perceiving?”

Understanding the science of regrettable decisions
Several years ago, I joined forces with my colleague George York, a respected neurologist affiliated with the University of California Davis, to understand why smart people make foolish choices in politics, sports, relationships, and everyday life. Together, we combed through the latest brain-scanning studies and decades of psychological literature.

We compared the scientific findings with an endless array of news stories and firsthand accounts of real people doing remarkably irrational things: We examined the court testimony of a cop who, despite graduating top five in his academy, mistook his gun for a Taser and killed an innocent man. We dug through the career wreckage of a once-rising politician who, despite knowing the risks, used his work phone to send sexually explicit messages. And we found dozens of studies confirming that doctors, the people we trust to keep us safe from disease, fail to wash their hands one out of every three times they enter a hospital room, a mistake that kills thousands of patients each year.

When we read about famous people ruining their lives or hear about normal people becoming famous for public follies, we shake our heads in wonder. We tell ourselves we’d never do anything like that.

But science tells us that we would, far more often than we’d like to believe…
Read all of it. "Science."

I riffed on Twitter: apropos, Kathryn Schulz noted "there is no first-person present-tense phrasing of the word 'wrong'." No one thinks or says "I am wrong."

Great book.

On deck, another awesome book, also of topical relevance:

The thoughts that come out of our minds can make us seem out of our minds. 

Some of our most potent ideas reach beyond reason, received wisdom, and common sense. They lurk at chthonic levels, emerging from scientifically inaccessible, rationally unfathomable recesses. Bad memories distort them. So do warped understanding, maddening experience, magical fantasies, and sheer delusion. The history of ideas is patched with crazy paving. Is there a straight way through it – a single story that allows for all the tensions and contradictions and yet makes sense? 

The effort to find one is worthwhile because ideas are the starting point of everything else in history. They shape the world we inhabit. Outside our control, impersonal forces set limits to what we can do: evolution, climate, heredity, chaos, the random mutations of microbes, the seismic convulsions of the Earth. But they cannot stop us reimagining our world and labouring to realize what we imagine. Ideas are more robust than anything organic. You can blast, burn, and bury thinkers, but their thoughts endure. 

To understand our present and unlock possible futures, we need true accounts of what we think and of how and why we think it: the cognitive processes that trigger the reimaginings we call ideas; the individuals, schools, traditions, and networks that transmit them; the external influences from culture and nature that colour, condition, and tweak them...

Fernández-Armesto, Felipe (2019-07-01T23:58:59). Out of Our Minds. University of California Press. Kindle Edition, location 198.
One more quick excerpt:
"In the pages that follow I intend to argue that evolution has endowed us with superabundant powers of anticipation, and relatively feeble memories; that imagination issues from the collision of those two faculties; that our fertility in producing ideas is a consequence; and that our ideas, in turn, are the sources of our mutable, volatile history as a species." (location 365)
I am reminded of this cool book I've heretofore studied and cited.


More to come...

Monday, July 22, 2019

In Pain

 The Washington Post is all over the scandalous opioid public and personal health emergency of late. See "The Opioid Files" series.

Recall my earlier review (scroll down in linked page) of Beth Macy's riveting book "Dopesick?"

My latest snailmail issue of Science Magazine just arrived. I always look right away to the book reviews for stuff of relevance and interest. Found this, "The ethics of opioids" (paywalled):
Imagine having your foot pinned between a moving van and a motorcycle and subsequently undergoing five surgeries to restore function to your mangled limb over a 1-month period. In order to endure the debilitating pain, you are prescribed high doses of opioid analgesics, only to discover that your care team has no exit strategy. Feeling abandoned by the medical establishment, you decide to subject yourself to a process of aggressive self-tapering and subsequently experience a gruesome withdrawal. Travis Rieder tells such a story—his story—in his new book, In Pain: A Bioethicist's Personal Struggle with Opioids. As an academic bioethicist, Rieder provides a philosophical lens to his lived experiences…
The Amazon blurb:
A bioethicist’s eloquent and riveting memoir of opioid dependence and withdrawal—a harrowing personal reckoning and clarion call for change not only for government but medicine itself, revealing the lack of crucial resources and structures to handle this insidious nationwide epidemic.

Travis Rieder’s terrifying journey down the rabbit hole of opioid dependence began with a motorcycle accident in 2015. Enduring half a dozen surgeries, the drugs he received were both miraculous and essential to his recovery. But his most profound suffering came several months later when he went into acute opioid withdrawal while following his physician’s orders. Over the course of four excruciating weeks, Rieder learned what it means to be “dope sick”—the physical and mental agony caused by opioid dependence. Clueless how to manage his opioid taper, Travis’s doctors suggested he go back on the drugs and try again later. Yet returning to pills out of fear of withdrawal is one route to full-blown addiction. Instead, Rieder continued the painful process of weaning himself.

Rieder’s experience exposes a dark secret of American pain management: a healthcare system so conflicted about opioids, and so inept at managing them, that the crisis currently facing us is both unsurprising and inevitable. As he recounts his story, Rieder provides a fascinating look at the history of these drugs first invented in the 1800s, changing attitudes about pain management over the following decades, and the implementation of the pain scale at the beginning of the twenty-first century. He explores both the science of addiction and the systemic and cultural barriers we must overcome if we are to address the problem effectively in the contemporary American healthcare system.

In Pain is not only a gripping personal account of dependence, but a groundbreaking exploration of the intractable causes of America’s opioid problem and their implications for resolving the crisis. Rieder makes clear that the opioid crisis exists against a backdrop of real, debilitating pain—and that anyone can fall victim to this epidemic.
I've not (yet) bought it, being buried in several others at the moment and probing my usual overload of periodicals and 'net news. Amazon should be paying me to read all these books, given the hundreds I've cited, reviewed and linked on this blog.

I feel very lucky that I got through my open heart surgery last August with minimal need for and consumption of opioids.

Interesting, Travis is here, at Hopkins. Lotta talent in this town.

“This country prescribes too many opioids. People need to take some aspirin sometimes.” —former Trump Attorney General Jeff Sessions
Well, okeee-dokeee then...


Read an interesting piece in my New Yorker this morning.
Does Extinction Rebellion Have the Solution to the Climate Crisis?

...The campaign describes itself as a “self-organizing system,” but it is also the brainchild of a small group of experienced British radical activists. One of its founders is Roger Hallam, a fifty-three-year-old organic farmer from Wales, who is also a postgraduate student of theories of social change. Another is Gail Bradbrook, a longtime anti-fracking and tax-avoidance campaigner, who has a Ph.D. in molecular biophysics. Bradbrook and Hallam met in person for the first time in early 2017, not long after Bradbrook returned from a psychedelic retreat in Costa Rica, where she took ayahuasca, iboga, and kambo, in search of some clarity in her work. Bradbrook had been involved in the Occupy movement and campaigns around peak oil, but they failed to take off. “I was just sort of, like, fed up with failure,” she told me. “I was willing to just try anything, really.” Together, Bradbrook and Hallam sketched the outlines of Extinction Rebellion. In April, 2018, the strategy of conducting a peaceful, mass campaign of civil disobedience—Bradbrook and Hallam speak about converting a critical mass of 3.5 per cent of the British population, more than two million people—was formally approved at a meeting of about fifteen activists at Bradbrook’s house in Stroud, a market town in the Cotswolds with a strong ecological scene. Last summer, the first X.R. campaigners toured more than a hundred village halls and community centers, urging people to accept that the natural world is in a state of emergency. The group’s first demand—“Tell the truth”—is in many ways its greatest...
So, I keyword-searched around, and eventually found and watched this Gail Bradbrook YouTube.

About 50 minutes. Very interesting, very topically commendable--notwithstanding among one of the worst video presentations I've seen. An Anti-TED Talk.

Extinction Rebellion now has boots-on-the-ground chapters all around the world. They're here in Baltimore, and down the road in DC.

Count me in where it comes to the science of our Climate Emergency. See here as well for a recent local view. We also might usefully reflect on what POTUS thinks.
"Tell the truth."
A Frase "Quadrant IV" draws nigh.


Saw this entire 2016 documentary on Maryland Public Television the other evening. This is the trailer for "Company Town" (SF Bay Area, that is).

Having covered the SF/Silicon Valley health infotech space for a number of years, and having lived in San Francisco in the late 1960's and in the East Bay from 2013 til we moved to Baltimore a few months back, I watched with rapt interest. Haven't yet been able to locate the full film.

More to come...

Friday, July 19, 2019

Baltimore: The Real News Network

Nice logo.

Last weekend Cheryl and I were traversing downtown Baltimore on our way to Pigtown when I saw a large sign on the side of a building. Turns out "The Real News Network (TRNN)" is located here (as well as in Toronto). That had escaped me.

I'd been aware of them online for quite a while, given my daily news surfing stops at the Naked Capitalism blog, which routinely features their videos, replete with interview transcripts.

I dig their Mission Statement:
The Real News Network (TRNN) produces independent, verifiable, fact-based journalism that engages ordinary people in solving the critical problems of our times. As legendary journalist Ida B. Wells said, “The people must know before they can act, and there is no educator to compare with the press.”
We examine the underlying causes of the chronic problems, and investigate and report on effective solutions and models for change. We don’t just cover people in high office or limit news to the partisan horse race for power. People who fight for human rights and work for solutions are newsmakers. We believe that real change will be driven by the people who need it most.
While we report on and investigate all important issues of social and economic concern, we consider the climate change crisis an existential threat. In all of our programming and journalism, the impact of environmental degradation and the climate crisis, especially on marginalized people, and the urgency of finding solutions will be front and center. 
Our motto is “The Future Depends on Knowing.”...
"We consider the climate change crisis an existential threat."
I am so with you on that call-out point. See, e.g., here, and here.

One of TRNN's numerous topical areas is that of health.

Yeah. I've been hip to Wendell Potter for a long time.

"Environment" topics?

More and more, I am going to focus on our accruing environmental crises (note plural)--from a pubic health perspective and more. Shaving another 30 seconds off a clinical EHR SOAP Note patient encounter workflow won't mean diddley if we allow our world to turn into a cheesy 'The Day After Tomorrow" disaster flick.
"We examine the underlying causes of the chronic problems, and investigate and report on effective solutions and models for change."
No small tasks. I'll certainly be watching.


Wendell Potter's initiative.
"Tarbell is pioneering journalism that informs, galvanizes and changes America.We take a unique approach to coverage of money in policy, not just politics.

We uncover how powerful people and companies use their influence to shape a system that works for them, not you. We highlight solutions to pressing problems. Our fiercely independent, unbiased news inspires our members in all 50 U.S. states to take action.We understand there are stories that matter to all Americans.

believe there’s journalism that can inspire people to see how much we agree. We know people want actionable, evidence-based solutions..."
The foregoing brings back to mind this cool book I reviewed in 2017:


The Tech Oligarchs Are Going to Destroy Democracy — Unless We Stop Them
Once, the big tech firms embodied American exceptionalism and aspiration. Today, they are strangling these ideals. Government: do something.
Joel Kotkin, for Daily Beast Inside

Congressional posturing about tech firms may have quieted for the moment, but the existential crisis that these firms are creating remains as now unchecked. Even faced with opposition on both sides of the aisle, the oligarchs—those five tech giants that now constitute the world’s five most wealthiest companies—continue to rapidly consolidate economic, cultural, and, inevitably, political power on a scale not seen for over a century.

This tiny sliver of humanity, with their relatively small cadre of engineers, data scientists, and marketers, represent a challenge to democracy, competitive capitalism, and the future of the middle class. Given their virtual monopoly status, a laissez faire approach will likely result in more consolidation; only government action of some kind can stop them now. Current concerns are large enough now that both the Trump administration and many Democrats oppose Facebook’s bid to issue its own currency. That’s a hopeful first step.

Historian Jeffrey Winters defines oligarchy as being based on “extreme concentrations” or power and wealth. Whether in ancient Athens or Rome, or contemporary New York or London, this overclass tends to be “unusually resistant to radical dispersions of power.” In our time, the ascendant tech oligarchy, as a recent World Bank Study suggests, have exploited “natural monopolies”—roughly 80- to 90-percent control of most key digital markets —that adhere to web-based business, and have served to further widen class divides not only in the United States but around the world.

The imperative for all oligarchies is to preserve their power. Once the media lights are off, and the posturing is done, the oligarchs can continue  playing a clever double game, making common cause with the defenders of capital and pouring money into the welcoming arms of the conservative think tanks…

 It might seem strange to think that the slick, urbane, and well-educated oligarchs as a greater threat to our future freedom than the blathering apostle of “fake news.” But despite his crude statements, it’s not Donald Trump curbing free speech and consigning even the mildly dissident into digital exile. If he loses next year, Trump will leave office as the bizarre leader of a peasant rebellion, but we could be living with the oligarchs information empire for decades…

…Long after Trump has retreated to his world of golf links and gold-plated faucets, an embarrassment at best, oligarchs like Jeff Bezos, Marc Benioff, and Lauren Jobs, widow of the late Steve Jobs, will have gained ownership over the nation’s fading traditional media.

But the main vehicle for oligarchical wealth comes from the exploitation of personal data, what Alibaba founder Jack Ma calls the “electricity of the 21st century.” These “super platforms,” as one analyst noted, “now operate as “digital gatekeepers” lording over “e-monopsonies” that aim to monitor our lives in ways even the snoop-crazy Chinese would admire. Firms like Facebook and Google seek to ferret out “psychographic” profiles as part of their core business.

We are already headed toward a world controlled by these super-snoopers. With their enormous financial resources and control of the key digital channels, they are positioned to dominate older industries like entertainment, education, and retail, as well as those of the future: autonomous cars, space-exploring drones, and most critically artificial intelligence…

In its earlier iteration, Silicon Valley was a uniquely egalitarian place where outsiders made success and working people had decent incomes. Today, Wired magazine's Antonio Garcia Martinez has labeled Silicon Valley as ‘feudalism with better marketing.” Despite enormous wealth, tech-driven cities like San Francisco and increasingly Seattle have become dysfunctional places, with massive homeless populations and a shrinking middle class. The urban website CityLab has described the Bay Area as “a region of segregated innovation,” where the rich wax, the middle class wanes, and the poor live in increasingly unshakeable poverty…

Once, the tech moguls legitimately could be sold as exemplars of American exceptionalism. But now, if unrestrained, the moguls are likely to be its assassins. Once, it was wise to let them work their magic unimpeded. But now, if we do this, we will create a society that is profoundly hierarchical, uncompetitive, and undemocratic. They need to be stopped, and now, or the world of tomorrow will not be a place we would like our children to inherit.

(Paywalled. Fairly long read. Subscribe. It's worth it.) 
AAAS proposes a "Science of Deliberation" as crucial for functional "democracy."

Assumes that we all want democracy (participatory or representative). Enthusiasts of technocracy, "epistocracy," "libertarianism" (please), aristocracy, autocracy, oligarchy, monarchy, etc., might well (and do) differ. And, in that regard in the wake of "Citizens United," "one person, one vote" is fast becoming "one dollar, one vote" in the U.S.

Let us not forget this, either:

Anything come to mind?

More to come...

Wednesday, July 17, 2019

Define "health"

Excellent article at STATnews:
It's time to change the definition of 'health'

The WHO defines health as a state of “complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The Centers for Disease Control and Prevention, along with a range of WHO partners, endorses this definition...

A definition of “complete” health as the absence of disease leaves little space for people with chronic diseases and for managing them in new ways. Together, the increasing numbers of Americans over age 65 (currently 51 million) and even over age 85 (currently 6.5 million), with more than 617 million over age 65 worldwide, along with transformations in disease definitions and treatment, amplify the dissonance between the experience of living long and the definition of health...
Read all of it.

When I signed on to Kaiser-Permanente (Medicare Advantage) in June after our move to Baltimore, I self-rated my "health" as only "fair" on their intake form forced-choice Likert scale question. It's way more complicated than that. But, I do know one thing; were we still under pre-Obamacare "medical underwriting," people like me would be declared "uninsurable" irrespective of our rank-ordered self-assessments.
My "health," like that of many people close to my age (I would speculate) comprises a multidimensional distribution exuding highs and lows and averages along various axes. Given the stresses of the past few years (my 2015 prostate cancer dx and tx; losing a second daughter to cancer; my 2018 open heart SAVR px; our fractious April 2019 transcontinental move), I continue to ail a bit physically. But, I have never been more intellectually and socially engaged notwithstanding. Cognitively, I have to keep on being a (post-mid) "life-long unlearner." Socially, I have to give, give back.
I'll be adding this STATnews item to my list of "definitions" in need of closer scrutiny. 
Q: "What's the definition of a 'well person'?"
A: "A patient who has been inadequately worked up."

Recently at THCB: 
Landmark Results Achieved in Aging and Chronic Disease: Danish Group Extends Disease-free Life by 8 Years

New Scientific Breakthroughs Can Provide a Longer Healthier Life
Twenty-one years of follow-up comparing usual care with a protocol-driven team-based intervention in diabetes proved that healthy life in humans can be prolonged by 8 years. These results were achieved at a lower per patient per year cost. Aging researchers have been confident that we will soon be able to prolong healthy life. This landmark study shows this ambitious goal can be achieved now with lifestyle intervention and a few highly effective proven medications. These medications interfere with the core molecular biology that causes chronic disease and aging. These same medications will likely produce similar results in patients with congestive heart failure, chronic kidney disease, arterial disease, history of heart attack, hypertension, and angina. Simple medical interventions can extend healthy lifespan today.

Better Chronic Disease Management Can Improve Health and Lower Costs
90% of health care costs come from chronic diseases and aging which are both related. The same biochemistry that causes aging causes chronic disease. Eating processed food, gaining weight, smoking cigarettes, and sitting on the couch accelerate aging and chronic condition development. Those activities switch on genes that should be quiet. Eating real food, avoiding cigarettes, activity, lisinopril, losartan, atorvastatin, metformin, (and spironolactone) are now proven to extend healthy life by 8 years in patients who are at high risk of health catastrophes and early death! These medications all cost $4 a month except for atorvastatin which is $9 a month. The benefits continue even when best practice treatment stops probably because these treatments block signaling from dangerous genes that are inappropriately and persistently turned on…
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Cited it here (scroll down).


It's hot in Baltimore this week.

apropos, see KHN's "Climate Grief."

I know it bums me out.

More to come...