Friday, December 23, 2011

Stopping Keystone XL is the Best Policy for Energy Security.

Like a crazed heroin addict suffering through withdrawal, America is frantically tapping on its antecubital vein in eager anticipation of the next fix. Of course, Keystone XL hasn't been presented in this way. They say it's a bid for energy security, and that it will reduce our dependence on Venezuelan or Iranian oil. Lets just call it what it really is: giving more heroin to the addict. Building Keystone XL will be proof that America isn't ready to find help to get over its oil addiction, and it will be proof that we don't care about energy security, nor do we care about future generations.

Oil is traded on a global market, so any suggestion that Keystone XL is going to stick it to the Saudis by allowing America to import Canadian oil instead is absolutely ridiculous. In fact, the only way that Keystone XL will impact OPEC at all is if it significantly increased the global supply for oil - which it won't. The pipeline will bring in another 900,000 barrels per day. Considering that global production is about 85 MILLION barrels per day, excuse me, but whoop-de-fucking-do.

In fact, if I was OPEC I would WANT the Keystone XL project to come on-line. OPEC produces 30 million barrels per day and they are under intense international pressure to keep up unsustainable levels of production. They are using methods of oil extraction, because they are in such a rush, that will cause their wells to dry up more rapidly than they would if they could take things out a bit slower. Keystone XL will take the pressure off of OPEC. OPEC can just drop its own production by 900,000 barrels per day, global supply remains the same, the price doesn't budge, and OPEC sacrifices a tiny bit of income now for higher-endurance production in the future.

American politicians always harp about two things: energy security, and watching after our children. What could be more secure than leaving a giant untapped oil field in North America? What would be a better gift to leave our children? The truth is, global oil production right now is quite stable, and our economy is starting to turn around. We don't NEED the oil that Keystone XL would deliver right now, but it would allow us to continue our addiction. What if someday there is a world war of a geologic catastrophe? What if oil flies over 300 dollar per barrel, threatening even access to our military and basic civilian functions? Having a giant reserve in Canada waiting for us is the ULTIMATE energy security. It is a giant piggy-bank that our children could break in a dire emergency.

Even if Keystone XL went straight to American oil markets (it won't), and even if it could all be used for any purpose (it can't), it would only satiate 4.5% of American demand for oil. Another way to achieve energy security, which would be exactly equivalent to making Keystone XL, is to DECREASE our oil consumption by 4.5%. We can (actually, will be forced to whether we like it or not) build an economy that is less reliant on oil. Currently our development is a model of inefficiency. Our cities sprawl ever outward, fueled by cheap gasoline. Government continues to subsidize roads and highways, to connect every random distant suburb to its nearby strip-mall. Why not encourage more dense urban development? Why not push our cities to rely more on the foot, the bike, light rail, or trains - and away from the car? Why not encourage Americans to carpool more?

Well the real answer is this: we don't need to encourage any of these things because the market will do it for us. As long as oil prices remain high, we will begin to shift to a post-petroleum economy. Again, this is an inevitable transition. It makes no sense to me to delay that shift when world oil production is so stable right now. It makes no sense to raid a secure deposit of resources that our children may have a vital need for in the future because we want low-hanging fruit now.

On Traveling, Surgery Residency, and the Intensity of Experience

In his recent book "Thinking, Fast and Slow", Daniel Kahneman expands upon an interesting concept. He describes two ways that human beings perceive reality: the experience of the present and the remembrance of the past. He calls them our "experiencing selves" and "remembering selves" and shows that they often fail to come to a consensus, as illustrated by a beautiful experiment with absurd results:

Participants are subjected to two forms of torture. In one form, the participant's hand is immersed in painfully cold water for 60 seconds. In the other, the hand is immersed in the same painfully cold water also for 60 seconds, at which point the water is warmed 1 degree Celsius and the participant must now endure 30 more seconds of slightly less painfully cold water, for a total of 90 seconds.

If I was going through this torture, at the end of 60 seconds I would obviously prefer to just take my hand out of the water instead of endure another 30 seconds of still very cold water! And most people, if given that option at the time, would do the same. Remarkably, if the participants are later asked which form of torture they prefer, they actually choose the 60 + 30 instead of just the 60. They are voluntarily willing to subject themselves needlessly to an additional 30 seconds of pain!

Why does this happen? Kahneman explains that while the duration and aggregate of an experience might matter to our experiencing selves, those details are easily glossed over by our remembering selves. In fact, our remembering selves focus disproportionately on the beginning, end, lows, and highs of an experience. Another question is posed by Kahneman: would you bother to go somewhere on a vacation if you would have complete amnesia of the entire trip? I'm not sure I would. At that point, relaxation is the only thing that matters (and maybe sun exposure). I might opt for Florida instead of the Bahamas or somewhere more exotic, if I was going to go anywhere at all.

The conflict between our experiencing and remembering selves was an interesting subject for me to read, because it neatly explains a paradoxical trend I had noticed: I remember some situations as being better than I know they actually were at the time (if I am thinking of the sum of the entire experience in aggregate). For example, one of my favorite semesters as an undergraduate was the spring of my junior year, but I also know with certainty that I was insanely busy, studied harder than I ever had, and went out very infrequently. I remember my social life being significantly better than average that semester, which I know empirically is not actually true (I even went to bed early on my 21st birthday because I had a physics test the next week, to the chagrin of my roommates at the time).

In light of Kahneman's book, it makes perfect sense. I didn't go out as frequently, but when I did, it was a much more intense experience. Going out after two weeks studying is just a different feeling than going out for the fourth night in a row. In fact, I remember having significantly MORE fun in medical school than I did in undergrad. Frequency matters less than intensity of experience.

I've noticed this paradox about traveling as well. Traveling is by definition not a relaxing experience (that would be vacationing). Right before medical school I went on a 6 week trip through Europe with some friends. It was a mad rush, to fit in as much as possible, stopping at places sometimes for only 1-2 days before moving on. The trip was exhausting, I remember thinking on more than one occasion. Yet, my remembering self recalls more easily the positive experiences - which were many, and noteworthy, and easily forgets the baseline exhaustion of the grind of intense traveling. This phenomenon can be explained graphically, with the spikes representing the intensity of experiences while the baseline is the quality of life day-to-day. When traveling, there is an obvious sacrifice of short term conveniences, habits, and luxuries for the opportunity to have heightened experiences:

I chose to go into surgery, which as a career has a reputation of being brutal. The long hours and the daily grind mean that I know my experiencing (present) self is, while maybe not completely miserable, certainly wishing I had chosen a more relaxing life. There is a conflict, because when my remembering self recalls the last six months, it think it has been one of the best times of my life. My experiencing self thinks surgery residency is tough and often painful, but my remembering self thinks its great and not so bad. I remember the interesting surgical cases, complex patients, and funny stories - not the long hours.

Like is the case when traveling, I've sacrificed my experiencing self for the sake of the remembering self, in this instance the sacrifice being ample sleep, free time, etc. I am compensated by doing really neat things on occasion. Finally, recall the anecdote from my junior year in undergrad: in residency, when I do get time off, its much more high impact. The fact that I only get every other weekend off on average is more than compensated by the fact that each weekend has 2-3 times the impact that they used to.

I suppose this is something to think about, whether traveling or choosing a career path. Perhaps the difference maker for me is that I am too willing to make decisions based on the preferences of my remembering self. Still, for a person choosing whether or not go to into medical school, or whether or not to go into surgery, "long hours" is something I am glad I never put too much weight on (because hours are essentially forgotten by the remembering self). Like a person who subject themselves to 30 seconds of needless pain in Kahneman's torture experiment, I would choose surgery residency all over again, even if my experiencing self would prefer a more laid back profession. Absurd results, indeed.

Tuesday, December 06, 2011

How Doctors Die

Loved this.

Its a shame that Sarah Palin so completely poisoned the well with her "death panel" comments. A conversation about how we should approach patients at the end of life is something that this nation badly needs.

Sunday, November 06, 2011

The rebirth of my contempt for the left

The Nation writes a sob-story about some idiot who went $ 35,000 in debt in order to secure a degree in puppetry. This apparently is to highlight the injustice that Occupy Wall Street is fighting again, and no, they aren't joking.

One of the consequences of electing a somewhat moderate, consensus-building Democrat like Obama is that the fringe elements on the left have taken a backseat in the last several years. The only visible extremists in the national discourse have been on the right, but I think this will change a lot in the coming months with OWS.

Hat-tip to Tyler Cowen. He has another great post on the problem with American graduates. Yes, more people are attending college. The numbers of students graduating w/ degrees in math, science, computing, and engineering has not budged one iota since 1985.

Tuesday, October 25, 2011

Why I am bullish on America in one simple picture

Its demography, the X-factor that everyone always seems to forget when looking at the past and the future:

France was a dominant world power in part because it used to be the third most populous nation on earth (after China and India). Its population growth stagnated in the 19th and 20th centuries and it was overtaken by Germany, among others. Europe as a whole used to count for 20%+ of the world population, now they are barely 5%. Fears in 1989 were that Japan would overtake America economically. But the Japanese population growth stopped, and reversed, while Americas steamed ahead (we've added another 50 million people, IE, the entirety of England, while Japan has added essentially none). Or think of historical antagonists. In 1900 Britain had 40 million people to Iran's 7 million. Today, Britain has 60 million to Iran's 70.

Anyone who thinks China is destined to overtake America has not learned the lessons of demography. We Americans right now are haggling over debts and austerity, but at the end of the day, we're going to add another 150 million people by the year 2050, which is almost a 50% increase. China is going to start shrinking in population. Their ratio of workers to retirees will dramatically worsen, while ours will stay about the same (hence the oft repeated phrase that "China will get old before it gets rich").

If it was up to me we would encourage this even more, instead of turning into a xenophobic cocoon. A huge advantage that we still have is that most people would rather immigrate to the United States instead of China. Why not open our doors to skilled or driven foreigners from around the world? Every immigrant is a taxpayer. Immigrants are hard workers. They start business, and since they often have big families, they buy houses. Every immigrant is another ambassador to their home country, increasing the soft power of America around the world.

To an America with 500 million people, the debts of today are entirely manageable (assuming we can slow the growth of the debt to some extent). In contrast, the crushing burden of supporting retirees with the waning of the demographic dividend that China is now experiencing is a recipe for stagnation or worse.

America will probably be the second largest economy in the world by mid century. Rather than China that overtakes us, my bet is that it will be India. By 2050 demographers are projecting population growth of another 400 million people on the subcontinent.

Tuesday, October 11, 2011

on PSA screening

The US Preventive Service Task Force (USPSTF) recently recommended that primary care physicians not screen men for prostate cancer. The question I have is, why were primary care physicians ever screening for prostate cancer with PSA levels in the first place if it hasn't been proven to be effective at reducing mortality?

And what of the contentious debate? I don't think anybody is saying don't screen for prostate cancer. There is an appropriate context in which to do it: a randomized, controlled clinical trial. Outside of research, it is ethically and economically* inappropriate to advocate for treatments that have no proven benefit. Am I missing something?

*I suspect that economics will increasingly play a major role in our clinical decision making. We might as well embrace it now and do the leg work early. We need to stop doing things that don't help so there is money to keep doing the things that do help. Physicians have the ability to trim the excess fat from our health care system with a scalpel. If we wait for the government to do it for us, its going to be with a guillotine.

Monday, October 10, 2011

Djerejian on Occupy Wall Street

Christmas for me only comes a few times per year. I found the insights into the behind-the-scenes strategy and tactics of the parties in play to be particularly interesting.

Friday, October 07, 2011

What's wrong with this picture?

This patient has situs inversus. It is a mistake in embryogenesis where the major organs in the body end up in a mirror-image position from where they should be.

On medical images, the right is on the left and the left is on the right. So what you see in this chest x-ray is a heart that extends to the patient's right side. It is normally the opposite, of course.

Tuesday, October 04, 2011

Little America.

Just when I started to think we bottomed out in the "reprehensible reactionary regressive politiking" department:  a new immigration law in Alabama:

"School superintendents and principals across the state confirm that attendance of Hispanic children has dropped noticeably since the word went out that school officials are now required to check the immigration status of newly enrolled students and their parents."

So small.

Monday, October 03, 2011

Republicans and taxes: winning the battle, losing the war.

From one of my favorite economists:

I've said this before:  the problem with the sort of scorched-earth policy that the GOP has been operating with is that in absence of reform, big government wins by default.  The current crop of GOP leaders took power and could have cut all sorts of deals to drastically reduce the size of the government.  They've taken advantage of precisely zero of those opportunities (its already obvious that the debt ceiling deal won't result in any actual spending cuts).

Sunday, October 02, 2011

The Economist on Palestinian Statehood

"In truth, Israel will be safer when a proper Palestinian state has been consolidated. That is a point that too few Israelis and their American supporters appreciate. This newspaper has argued steadfastly for the right of Israel to exist. We abhor the creeping delegitimisation and demonisation of Israel. But we also believe that the Palestinians deserve a state of their own. These two beliefs are entirely compatible. By his intransigence, Mr Netanyahu has played into the hands of those who would destroy Israel. In blocking any Palestinian aspirations at the UN, America is helping extremists on both sides."

Apparently all it takes to be a NYT Columnist is a poorly considered opinion

This was such a weak article:

NYT: Is junk food really cheaper?

The column starts off with an argument that fast food is actually more expensive than natural food. As proof, the author picks an anecdote completely out of thin air. In his hypothetical case, for a family of four, fast food is more expensive than healthy food. Take that, statisticians! He goes on to make the really insightful point that there are lots of things people could do to live cheaper - like drink water instead of soft drinks. He then goes on to talk a lot about how the problem here is really cultural: people are lazy, and don't like to cook. His solutions include changing said culture. The column ends with a complete 180, culminating in vague references to statist political solutions to curb consumption of processed food.

The only useful thing he does is bring up the analogy with the anti-smoking campaign. Consider for a second: what would you say if, instead of taxing cigarettes to $ 8.00 per pack where they are now, the government was subsidizing them to $ 1.50 per pack? And then imagine some jackass wrote a NYT column about how we just have a crisis of culture and that the OBVIOUS solution was for people to just get some willpower and quit smoking. Never mind stopping government hand-outs to tobacco companies (in this hypothetical case).

This is the reality of the nation that we live in: the government essentially pays people to eat fast food and drink soda. That is the 100% truth. We can talk about culture, paternalism, and lots of other things but it really comes down to incentives. Whether or not fast food is cheaper than natural food is really irrelevant - thanks to subsidies, fast food is cheaper than it would otherwise be. Period. People would consume less processed food it it was appropriately priced. Food industry subsidies are an example of big-government corporate socialism at its worst.

Once we all agree that we shouldn't be paying people to eat unhealthy food, we can wade into the area of whether or not we should tax unhealthy food. I think reasonable people can BEGIN to disagree on that point. That being said, taxes have to come from somewhere. Why not tax things that we shouldn't be doing (smoking, eating unhealthy food) instead of taxing things that we should be doing (working hard / income taxation)? Especially when people expect the government to pay for their health care at the end of life, its not unreasonable for that government to try to discourage the most unhealthy behaviors. Whatever; like I said, taxing fast food is an issue we can debate; that we subsidize fast food is not a point for debate - its a travesty.

Medical images blogging

Kid comes in w/ abdominal pain and bilious emesis. Whats going on?

Wednesday, September 21, 2011

Americans, death, and the health care system

This short commentary touches on one of the major problems that we have in the health care system: unrealistic expectations. Really, having great expectations is something that is almost quintessentially American. We generally aren't good at waiting for things or taking "no" for an answer. Health care is no different.

I sometimes get the impression that patients think we (physicians) can do just about anything for them, reverse any condition, and make them feel like brand new. In clinic, if you tell a patient that their condition may not improve, or that there isn't much we can do to help them, they almost always look at you like you're crazy. People tend to have very unrealistic expectations as to what we are capable of.

This especially becomes obvious at the end of life. As patients get closer and closer to death, some people still refuse to believe that we can't completely reverse everything. Even if you tell them as much, its almost as if they don't understand what they are being told. Their baseline perception of the world can be very mixed-up too. To some people, withdrawing care, IE letting the natural course of things proceed, is tantamount to killing the patient. Ceaseless medical intervention for some people is the natural course of things.

Its really very bizarre to me sometimes. Especially compared to other industrialized nations, America is a very religious place. Many if not most Americans profess strong belief in God. And yet, the inability of many people to accept death as a natural course of things, as a legitimate outcome, is just something I still never ceased to be amazed by. South Park made fun of the Terry Schiavo case years ago, but they also were on point in their underlying message. In that case, the Republicans were screaming that we were playing God by removing the feeding tube. Well, no - actually, we were playing God when we put the feeding tube in.

End of life care is enormously expensive. Arranging panels to help patients decide what their end-of-life objectives were was one of Obamacare's greatest pushes. It had the potential to save money AND to improve patient's quality of life (I don't consider prolongued and pointless hospital stays to be improvements in quality of life). Unfortunately, the idea was demagogued to death by members of the opposition political party. Very frustrating, but its something we need to start thinking about as a nation.

Wednesday, September 07, 2011

Herein lies the problem [with our health care system]

A forthcoming study shows that stents put into narrowed arteries in the brain actually increase the risk of stroke.  They are also enormously expensive.  Now that they are proven to not work, we will save money and make patients healthier by not implanting them in the first place.  Check out this quote from the NYT article about the study:
"Quite frankly, the results were a surprise," said Dr. Joseph Broderick, chairman of the department of neurology at the University of Cincinnati College of Medicine.  Without the study, he said, there was no doubt that the stents would have become even more widely used and that the willingness to conduct such a clinical trial would have waned. "Once things get into practice, the genie is out of the bottle, and it is very hard to put it back," Dr. Broderick said.

Herein lies a major problem with our health care system:  Its hard to put the genie back in the bottle.  It shouldn't be!  I have no doubt that there are tons of things that physicians do to patients, expensive things that have never been rigorously studied, that actually hurt patients more than help.  Very few physicians have the courage (or the funding) to look for them.

To be fair, docs aren't the only cause of this problem.  I am not sure we are completely protected (legally) if we want to carry out some of these studies.  Also in America we have a very demanding culture of consumption.  People always want their doctors to "do something!"  to fix their ailments.  A classic example are patients with viral infections who insist on antibiotics.  The physicians finally just get sick of hearing about it, stop fighting, and write the script.  And now we have antibiotic resistance.

If we can't even talk patients out of antibiotics for a cold, are we going to be able convince them to forego a surgery or some other major treatment that has been standard of care for decades for the sake of proving that it actually helps?

Thursday, August 25, 2011

Transplant surgery: quote of the day

From a recent study:
"We find that an organ allocation policy giving priority on waiting lists to those who previously registered as donors has a significant positive impact on registration."
This seems like a no-brainer to me.   
Link to the study:

Americans are pre-revolutionary

“Americans’ lack of confidence in their leadership is so fervent that they are now ‘pre-revolutionary,’ according to pollster Pat Caddell… A new Rasmussen poll shows that just 17 per cent of Americans believe that the U.S. government has the consent of the governed, an all time low. This dovetails with a record low for Congress’ approval rating, which stands at a paltry 6 per cent, while 46 per cent of Americans think most members of Congress are corrupt, with just 29% believing otherwise.”

The author goes on to talk about the possibility of black swan events which could disrupt the American republic in unforeseen ways. Rick Perry talked about succession previously. Who knows, maybe he is right. Dividing The Union in two might allow some of the inter-party hatred to be swept away enough so that things could be accomplished.

Thursday, August 18, 2011

We have a winner!

This is an awesome article:
This needs to happen in the USA!  More efficient nation, lower taxes, less oil money for terrorists.

Monday, August 08, 2011

Obama and the Debt Ceiling

I do have to say that I am fairly taken aback by the remarkable lack of strategic planning that went into Obama's approach to the debt ceiling battle.  As I said before, he was in a position from which he could have easily won a confontation with Republicans and probably humiliated them in the process.  Their bargaining position was very weak, and their hubris *should* have left them quite exposed.
The idea that Obama wouldn't have wanted to win a battle is crazy, too.  I can appreciate value of a strategic retreat, which is what I figured the capitulation over the Bush-era tax cuts was.  At some point though if Obama wants to advance any of his political goals at all, he will need to stop and reverse the GOP momentum.  This was his opportunity, and he totally blew it.
Such an obvious demonstration of incompetence, apathy, or perhaps both explains quite a lot.

Wednesday, August 03, 2011

Too good to not post: costly gas = thinner people

We can save ourselves money, reduce funding for terrorists, help the environment, reduce the debt, AND make Americans healthier.

Naturally, this has no chance of passing through the US Congress.

Saturday, July 30, 2011

Are we winning the war on drugs?

Check out this Washington Post article:

"In Sonora state, Mexico’s military said Saturday that troops seized five metric tons of marijuana near the U.S. border in Puerto Penasco, a beach city popular with visitors from Arizona."

When the drug cartels are moving their shipments aliquots of 5 metric tons, its a good sign that they aren't really having trouble bypassing our border and/or law enforcement counter measures.

What a waste of effort.

Tuesday, July 26, 2011

Time to see if I was right

Over 3 months ago, I posted my predictions for the debt ceiling battle over the horizon. Well, judgment day is here. A recap of two essential points:

1. Republican intransigence was, and continues to be, unwarranted. The Republicans were always holding a weak hand, although it actually shocks me that apparently none of them figured this out. When they approached this debt ceiling issue as a battle, they set themselves up for defeat. At this very moment, the pressure is relentlessly building. The House is being inundated with angry phone calls from constituents. The IMF and credit agencies are warning of a downgrade and economic calamity. Obama is taking to the bully pulpit nightly to (rightly) berate the GOP for being uncompromising. And at the end of the day, the Tea Party isn't playing chicken with Obama. Rather, Boehner and powerful GOP backers are playing chicken with the 41 most liberal members of the senate, led by recently re-elected Harry Reid.

2. This in particular turned out to be true:

I absolutely believe that if Republicans put partisan battles aside, Democrats would join them and real progress on spending could be made. There are tons of low-hanging fruits that could be plucked to get real reductions in government spending.

Obama was offering Republicans a bill that cut the debt by FOUR TRILLION DOLLARS. It was something like 85% spending cuts, including cuts to entitlements. 85% is a very historically fair figure when looking at austerity situations. Democrats were furious at Obama for making such an offer, but luckily the GOP bailed them out by refusing Obama's deal. The Economist, a right-of-center newspaper, had a few good editorials about what a great deal the GOP passed up.

At this moment there is what, a week left before D-Day? I think the Democrats have the advantage at this moment. The Republicans WILL jump, but it remains to be seen whether the Democrats get scared and jump first.

Monday, July 18, 2011

Fact of the day: lung cancer

Something like 80% of lung cancers can be linked to smoking. However, only 15% of heavy smokers will develop lung cancer. 86% of those people will be dead within 5 years of diagnosis. I actually am shocked at how low that number is, though. That most people, fully 85% of them, could smoke a pack per day for decades and not get cancer is remarkable. It is a testament to how resilient the human body is.

So should you play the odds and smoke? There are only two games that I enjoy at the casino: Texas Holdem Poker and craps. If you're a smoker, your odds of getting cancer are the same as your opponent catching his open-ended straight draw on the river...or the same as tossing 7 and crapping out. Those things sure seem like they happen more than they do, and that's only when there is a little money on the line.

Thursday, June 30, 2011

Why I love oncology

This applies to medicine as a whole, but in particular to oncology.  A lot of people "question my sanity" when I tell them that I want to be in a field like oncology.  "Wouldn't it be depressing to be treating cancer patients all of the time, especially when ones that you become close with ultimately have unsuccessful treatments?"

It is all about how one looks at things.  For starters, maybe cancer as a disease is a depressing thing but oncology as a specialty is amazing.  Before 1950 or so, all cancers had the same prognosis:  zero, give or take a few hundredths of a percent.  Now, we save people all of the time.  Colon cancer can be resected and cured with surgery and chemo.  Testicular cancer has a 95% survival rate when only a few decades ago it was 5%.  Many pediatric leukemias we can treat with some efficacy.  For cancers we can't cure, we can certainly make the remaining life better.  In oncology, is it isn't about who you lose - its about who you don't.  Those are the cases where, after, you can look Mother Nature in the eyes and say "we beat you."

The other thing about oncology, although this applies to other fields as well (for example, transplant surgery, which I am on right now), is the effect it has on me as a person.  Its so easy to go home at night and be tired and think, "I want to do nothing", or "I am too tired to go on a run."  Then you remember the stage IV cancer patient who is bed-ridden and beyond cure, without long to live.  Or you might remember the young guy who is stuck in the ICU.  He already had a liver transplant once to save his life, but his immune system has systematically destroyed it despite our best efforts.  Each day we see the new numbers, each day more abnormal, as the liver functions less and less. 

Remember those things and all of the sudden, you have the energy to go for a run or to go out and socialize - because you can.  Because you are so aware that someday, you won't be able to.  Think forward - many of us will be in that very position some day.  What would we give for the chance to come back and be 28 and be healthy enough to do those things?  If that time comes for me, I will smile when it does, because I will know I did.  With the right perspective, oncology is an incredibly uplifting discipline.

Wednesday, June 29, 2011

Reason as a weapon

A recent NYT article about reason summarized viewers responses as thus:

"Reason Seen More as Weapon than Path to Truth".

The NYT went on to describe the title: "a description, that implied that reason is not, as we generally think,  directed to attaining truth, but rather to winning arguments."

I recently heard a quote by some physician which has become one of my all-time favorites. Roughly, it is:  "Humans are forced to choose between truth and certainty. We can have one, or the other, but we cannot have both." 

A person who would prefer certainty over truth would definitely perceive reason to be a weapon. If such a person were interested in 'truth' in the first place, then 'certainty' would not have been their priority all along. To be interested in truth is to be interested in reason. To be interested in certainty is to be indifferent at best, or hostile at worst, to reason.

This is why so many religious people are hostile to science these days (actually the cause is more a product of manipulative religious leaders creating a false enemy to inflate their own sense of importance, but I digress). When people are told that the theory of evolution undermines their religious beliefs (it shouldn't), they are instinctively hostile to the logic and reason of the theory.  To let any of it in would be to suspend their certainty about how the world was created. 

Another interesting thing about this quote (that we can have truth or certainty but not both) is that it is reflected in the physical world by the Heisenberg Uncertainty Principle.  The principle states that we may know the position of a subatomic particle, or we may know the momentum of the particle, but we can never know both.

As for me, I always choose truth over certainty.  I am 100% certain of that.  Or am I?

Monday, June 27, 2011

On Surgery, etc.: The Part-Time Doctor

I thought this was a good read: a surgeon explains what he thinks makes a good doc. 

On Surgery, etc.: The Part-Time Doctor

Friday, June 24, 2011

Cancer in transplant patients

I meant to include this in the previous post but forgot.

Another interesting thing is that being on immune suppression drugs after having an organ transplant drastically raises the chances of developing some (but not all) cancers.  In particular, we see the sort of cancers that are a product of chronic viral infection and genomic irritation.  Squamous cell carcinomas of the skin are a big one.  Women can get these in their cervix from HPV; immune suppression makes everyone all the more vulnerable to HPV.  Other viruses, like Epstein-Barr that healthy people will clear without a problem, will fester in the body and provoke the development of lymphomas and the like.

The fact that some cancers appear in light of a weakened immune system but not others is a useful demonstration of the fact that we really don't know what causes cancer in every case.  Sometimes it seems environmental; enough radiation and anyone will get cancer; smoking cigarettes can cause lung cancer too.  Cancer can be caused by infection:  transplant patients get lymphomas and squamous cell carcinoma; AIDs patients get characteristic neoplasia (cancer) as well.  Genetic deficiency of appropriate anti-cancer genes (BRCA mutation, hereditary adenopolyposis coli, other familial cancers) can be a cause.  Maybe bad luck has something to do with it too.

Wednesday, June 22, 2011

The yin and yang of immunology

One of the tricky things about cancers is that they have figured out how to evade the police force of the body, the immune system.  The immune system should destroy cancer cells, and yet obviously it doesn't always.  How exactly cancer cells figure out how to evade the immune system is something that is being extensively studied.  The goal of cancer immunotherapy is to re-train the body's immune system to target and destroy cancer.  The best model for this is melanoma, a lethal form of skin cancer.  Right now, the best option to treat metastatic melanoma in humans is essentially to infuse patients with IL-2 (the immune equivalent of cocaine-laced red bull) and hope for the best.  With IL-2, the body's immune system changes from a local sheriff and his deputies to a full-fledged SWAT team.  The immune-swat team still isn't sure what it is hunting for, but it ends up killing a lot, including the cancer if the patient is fortunate.  (Giving the swat team specific cancerous targets is the ultimate goal.)

Transplantation immunology is precisely the opposite.  Instead of encouraging the immune system to attack the tissue in question, we are doing everything in our power to hold the immune system back.  This can be accomplished by drugs which prevent lymphocytes (immune cells) from replicating, block signaling and stimulation, or just kill the lymphocytes outright.  Obviously, if the police force is eliminated then a lot of criminals will end up running around; transplant patients are chronically dealing with infections (especially viruses like CMV, HSV, and EBV).  Despite these immune-destroying efforts, chronic rejection of transplanted organs by poorly understood mechanisms seems almost inevitable.  In humanity's defense, huge strides have been made in dealing with acute transplant rejections, which occur through better understood mechanisms.

It is really interesting if one thinks about it:  cancer cells have figured out how to avoid immune destruction, and so the answer to better transplantation immunology is potentially right in front of us and we just can't see it.  Another interesting scenario is this:  if we took a kidney from a child and transplanted it into the child's mother, the mother would reject the kidney unless appropriate immunosuppressive drugs were given (as in any other case).  How then did that child manage to survive in the mother's womb in the first place?  Why did the mother's immune system not immediately attack the fetus and destroy it?

The answer is lots of theory backed by some evidence, much of it conflicting.  This is the same state of affairs as most other things in medicine.  Humility makes a whole lot of sense. 

Monday, June 20, 2011

A way to cut everyone on the liver waiting list

Kidney transplantation, as it compares to liver transplantation, strikes me as a much lower stress affair. For starters, there are more kidneys than there are livers available for transplant (although this is somewhat negated by the fact that more people need kidneys than livers). More importantly, we can keep people alive who have no kidney function via dialysis. This affords time to search for an organ that is a really good match for the recipient. A good match minimizes immune differences (we focus on major antigens like ABO and HLA) and results in a longer lifespan of the graft (transplanted organ).

People with serious liver failure really cannot be kept alive without a transplant. The kidneys and the liver both perform a similar function: filtering toxins from the blood (among other things). Kidneys filter out substances that are ionic or polar; the liver deals with things that are not polar, or fat-soluble. Its been fairly easy for humans to develop a device that can separate ionic substances (dialysis machines) but not so easy to develop an artificial liver.

Anyhow, we can figure out in advance who will need a liver transplant and start looking for an organ for them before time runs out. The way this is accomplished is through a system (MELD) which accounts for a bunch of different factors, including some labs that assess liver and kidney function, as well as time spent waiting. The system works so that people who are closest to the end of their liver function get pushed up on the list.

One of the things that can happen with any organ transplant is a hyper-acute rejection. When this happens, the body's immune system launches an immediate attack on the new organ and the vessels end up getting clotted off and blocked. The only solution to this disaster is to remove and discard the transplanted organ. If this happens to a patient who is receiving a kidney transplant, that is bad, but at least the patient can leave and go back on dialysis. What happens if it happens to a liver transplant patient? There is no substitute.

Turns out, what happens is the patient gets moved to #1 on the national registry for livers. A new liver will be procured from somewhere in the country and delivered to the hospital within a matter of hours.

Wednesday, June 01, 2011

The Republican Yacht

I'm honestly completely baffled by the GOP's approach to trying to reform Medicare via the debt ceiling vote.  Their strategy has zero chance of working.  Even if the GOP could get it through both houses of congress, which they can't, Obama is not going to sign a bill which repeals the ACA or Medicare just like that.

So the GOP is trying this crazy strategy, which can't work, and they are going to get politically wrecked for it anyway for even trying it.  The only way this makes sense to me is if this isn't a strategy at all.  The Republican Party is like a rudderless yacht with a hundred captains all insisting it remain at full throttle despite lack of steering. 

As a continuation of a recent post about the intent of the founders, I really question whether we live in a republic anymore.  In a republic, the representatives are supposed to be principled but also pragmatic, willing to compromise to get most of what they want even if they lose some, and above all work to secure the future of the nation as a whole.  Our representatives don't do that.  They cater to every fickle inclination of their constituents and refuse to compromise on anything at all.  It really is a form of direct democracy.

Wednesday, May 25, 2011

The intent of the founders: representing the people while avoiding gridlock

I've always been a moderate person who believes, contrary to Herman Cain, that the problem with America isn't too much compromise, but rather a lack of compromise. My vision of a smoothly functioning American government is when civil and well-informed representatives of the people converge on Washington, hash out their differences, and produce well intentioned legislation based on the best possible compromises. The goal is to give everyone some of what they want, nobody all of what they want, and always to move America forward.

Some people have intimated, from time to time, that it is fundamentally anti-democratic that I might wish that the representatives decide among themselves what the important issues would be and deal with them accordingly. And I fully admit that I believe that representatives should prioritize their constituents' interests, and even ignore some of them. Some would claim this position reeks of elitism, and that the truly democratic model is to elect representatives who follow their constituents' short-term inclinations to the letter.

If my view is wrong, why did the founders make America a republic? If the founders wanted direct democracy, they would have written into our constitution a form of direct democracy: but they didn't. I believe the founders understood that most Americans have better things to do than worry about politics, or alternatively, don't have the information access or facilities to really grasp the complexities anyway. Elitist? Sure, I'll cede that. But the founders counted on the people electing competent representatives who would follow the spirit of their constituents as best they could within the context of the federal government of a very large and diverse nation.

I've been trying to figure out what exactly is wrong with our political system, and it seems to me that we really almost have moved to a form of direct democracy. Especially with the advent of rapid communications, information technology, massive advertising budgets, messages matter. A hundred years ago, a well meaning representative could sacrifice some of his constituents' priorities in order to gain a compromise that was essential for the nation or one that advanced his voters' interests in other ways.

These days, its different. When a representative insults that small fraction of his support, he gets crucified for it. This is particularly true among the GOP today, which is more a consequence of them being the out-of-power party than anything else. Any one Republican who has bucked any one interest has paid a price. Mitch Daniels saw what most credible economists see: we cant balance the budget without some revenue increases. So why not a VAT? And yet, in today's GOP, proposing a tax of any sort is sacrilegious. Dick Lugar recognized a good START treaty with Russia and supported it along with all of the top military brass, and he was rewarded with a primary. I don't see any way that John Boehner makes it out of the 2012 election with a job. He will vote to increase the debt ceiling, and he will get primaried because of it.

In essence, the rapidity of the response to politics has moved us into an era of what is essentially direct democracy. And unfortunately, the American people don't always know exactly what they want. We want the government to keep its miserable hands off of our Medicare. We want to cut spending, but not cut medicare, social security, or defense. We think that cutting foreign aid to Pakistan will balance our budget. Direct democracy was most obvious in California, where the people consistently vote themselves more services but then refuse to increase taxes to pay for them. The founders knew that there needed to be a competent crew manning the rigging of the ship that we call America. Just let the passengers run things and there is chaos.

Many try to argue that this sad state of affairs is the fault of a misleading media or lying politicians, but I don't buy that. Politicians have always lied, and the media has always been biased. The single biggest thing that has changed is that politicians are now held in an environment where they are unable to make any sacrifices in the name of compromise whatsoever. It is this inability which has led to the intractable gridlock that we now see, and probably will continue to see, for some time. Until American politicians again act as the founders intended them to act, as representatives of a great republic rather than as mere puppets of fickle and conflicted constituents, this ship will continue to drift aimlessly at sea.

Tuesday, May 24, 2011

America as the no-vacation nation

Most Americans have no idea how much more vacation that people in other Western economies get each year. Which is fine, because there are lots of trade-offs here. Germans for example get six weeks of paid vacation every year, but the German economy is crumbling even as we speak.

Saturday, May 21, 2011

Guess who else thinks Netanyahu is being ridiculous?

Former Israeli Prime Minister and current defense minister Ehud Barak. From Haaretz.

Friday, May 20, 2011

The Failure of Netanyahu

A good analysis from TPM:
For years the top generals in the IDF have agreed that Israel can handle withdrawing to the 1967 borders in military terms. But PM Netanyahu says that's impossible because those borders are not defensible. It's an amazing level of denial, intransigence and self-destructiveness on display today -- something the pre-statehood and early statehood Zionist leadership was seldom so vulnerable to.

I agree with Gadi Taub who said recently that while peace is the ideal the highest priority for both peoples right now is partition. Netanyahu's position makes that impossible. The 1967 lines are the only practical and politically conceivable basis for such a division -- with mutually agreed upon swaps of territory along those lines. Netanyahu's plan is simply to withdraw from areas of dense population within the West Bank. In fact, I think that overstates the case. I don't think Netanyahu has a plan beyond holding his coalition together and himself in the prime ministership. The rejectionists' 'plan' is simply to hold on for as long as possible and play for time.

The man is a fool at so many levels. But there's no denying that he speaks for a very large chunk of the Israeli electorate.

Bibi called the 1967 borders indefensible. Of course, Israel successfully defended those borders in 1967, and again in 1973. Meanwhile Israel has seen a foe become a friend (Jordan), its arch-foe become a non-factor (Egypt), another arch foe (Saddam's Iraq) irrevocably weakened, and an Arab world in general more concerned about a threat from Iran than from Israel. In other words, Israel's geopolitical position is far stronger now than it was forty years ago, when it was able to decisively defend the 1967 borders on two separate occasions.

When one stops to think about the threats Israel faces, it becomes even more ridiculous. There is no conventional threat to Israel. Iran has rockets, not a ground army with thousands of tanks like Egypt had in the 60's. The greatest threat to Israel is terrorism from WMDs or delegitimization. Occupying the West Bank makes Israel more vulnerable to those dangers, not less.

I used to hold Binyamin Netanyahu in such high regard, but he has proved himself to be incredibly short sighted. I wrote another post about his missed opportunities just a few months ago. Very disappointing.

Thursday, May 19, 2011

Does Obama hate Israel?

Here are some quotes from Obama's speech that pertain to Israel.
"Antagonism towards Israel became the only acceptable outlet for political expression [in repressive Middle Eastern nations]."

This is implicitly a defense of Israel. There is no doubt that in general the people in the Middle East don't like Israel. The question is why. Pro-Israeli people believe that is because Israel has been used relentlessly as a scapegoat by autocratic dictators to focus their peoples' anger elsewhere. Anti-Israeli people believe it is Israeli policies that create the resentment among its neighbors. Obviously there is an element of truth to both, but extremists tend to believe one or the other. I believe it is primarily the former, and apparently so does Obama, which is implicitly a pro-Israeli stance.

"Standing up for Israel's security...we will continue to do these things."

That doesn't sound very anti-Semitic to me.

"Efforts to delegitimize Israel will end in failure."

Opponents of Israel are pursuing a strategy that results in the destruction of Israel not by military means, but by political and economic means. This is what Obama means by "delegitimize". The strategy in a nutshell is to isolate Israel in the same way that South Africa was isolated because of apartheid. Obama is aware of this strategy, which means he no doubt thinks like I do: that Israel shouldn't play right into the hands of the people who are using it. This means striking a balance between deterrence and use of force, and it means not deliberately provoking Muslims for no reason (IE expanding settlements).

"Symbolic actions in September won't create an independent state."

In September, the PA is going to submit to the UN assembly a vote that would create a Palestinian state. I'm not sure how the rules of the UN work so I'm not sure if they can legally do this or not. I'm not sure if the US can even veto this. We couldn't stop the PRC from taking the ROC's seat in the security council in the 1970's so we may not be able to stop this. It would be a major blow to Israel if it happens. It is a part of the delegitimization strategy that anti-Israeli activists have been pursuing.

"Palestinian leaders will not achieve peace or prosperity if Hamas insists on a path of violence and rejection...Palestinians will never realize their independence by denying Israel's right to exist."

Obama reaffirms that Hamas must renounce violence, recognize Israel's right to exist, and honor previous agreements. This is all very standard stuff.

"Our committment to Israel's security is unshakable, and we will stand against attempts to single it out for criticism in international forums."

In other words, the US has and will veto UN resolutions that condemn Israel for this or that while allowing other nations to perpetrate far worse crimes with no mention.

"Israel must be able to defend itself, by itself, against any threat."

IE the US will continue to support the Israeli military.

"[Palestine should be a] sovereign, non-militarized state."

One of the sticky parts of establishing a Palestinian state is whether or not it gets to develop a military. Obviously the Israelis might be uncomfortable with that. Obama here is coming down squarely on Israel's side of the issue.


There is lots of room for criticism over how Obama approached the Israeli-Palestinian question. The speech was decidedly unambitious and did not budge the status quo even a single iota. Everything in the speech was very standard, widely accepted stuff. Everyone* agrees that peace will come with a two-state solution. Everyone* agrees that the 1967 boundaries are the basis for the future borders. Everyone* agrees that Israel isn't going to take down their West Bank settlements, and so land-swaps are necessary. On the issues that people aren't sure about, such as over the status of Jerusalem or right-of-return for Palestinians, Obama just punted.

What there isn't any room for is criticism that Obama is anti-Israeli. And yet, the only thing I see plastered all over the front page of Fox News is precisely that. This is being echoed all over the conservative blogosphere. And you know what? I get it. I get why the Republicans are jumping all over this big lie. Their attempt at following through to the promises they made in the 2010 elections have been absolutely pathetic. They have been outfoxed by Obama and the Democrats at every turn. Boehner's 38 billion in "cuts" actually ended up increasing the deficit by 3 billion. Paul Ryan has been thrown under the bus by half of his party. The GOP will vote for the debt ceiling increase, but they will only get token cuts for it IF Obama is feeling generous. The GOP presidential candidates are all awful, save one or two who probably can't win a primary.

So like I said, I get it. We're going to hear over the next few weeks how Obama is a vicious anti-Semite, which fits in perfectly with accusation that Obama is also a secret anti-colonialist Muslim America-hater. Netanyahu is of course going to play along, just as a spoiled child will manipulate their divorced parents, and will cement himself in history as one of the most short-sighted Israeli leaders ever. But yea, anything to distract from the train wreck that has been the GOP agenda; I can't say I blame them for wanting something else to talk about. Whether or not there is any truth to what they are saying is irrelevant.

*When I say "everyone", what I mean is "reasonable people who we might listen to". There are lots of people who don't agree on a two-state solution, 1967 boundaries as a basis for that, and land swaps. These people are unreasonable, and should all be ignored. This includes, but is not limited to: Hamas and Islamic extremists, the international far-left extremists, ultra-right wing orthodox Jewish settlers in Israel, ultra-right wing evangelical Christians in the US. To name a few. None of these groups think there should be a compromise, just endless war until their side wins and the other side is dead.

Tuesday, May 17, 2011

Impressions from East Africa: historical development, communities, and finances

Imagine Tanzania in the year 1900. This is a land that is 50% larger than the state of Texas, supporting a population of maybe 3 million. There was no infrastructure, no centralized government, and really, no history of a centralized government. Contrast that to Qing China, the Manchurian dynasty which ruled China up to modern times. Qing China in 1900 was arguably still one of the great powers of the world even if it was quickly falling apart. Back then, the population of China was several hundreds of millions. There was a history of civilization going back four millennia and certainly a tradition of strong centralized government, despite the fact that China is so geographically large.

One of the things required to create a modern nation state and the appropriate institutions is a sufficient population density in the surrounding area. China apparently hit that necessary population density thousands of years ago, but we should remember that Tanzania was nowhere near that threshold even one hundred years ago. A great book that expounds on this topic is "Guns, Germs, and Steel" for anyone interested. Despite these great contrasts, GDP per person in China and Tanzania 30 years ago was not so different. The take-home point is this: strong economic and political development doesn't just happen by default. It can get hindered by any number of things.

Think back to Tanzania in 1900: sparsely populated, inaccessible, every community for themselves. These communities, like other small communities throughout history, would need to be close knit. Vertical ties may involve patronage from a chief or leader who has surplus resources. That leader can distribute those resources to neighbors and subordinates in order to strengthen ties and bonds between them. Horizontal ties would involve relationships between friends, relatives, and neighbors who are on equal footing. In a small self-sufficient society, it is all about hedging risk. Sometimes one family has a good hunt, or a good harvest. Another family may fail to find an animal, or will have crops which get killed by fungus. Obviously, if neighbors are willing to readily share everything they have, the risk gets hedged throughout the community as a whole and everyone is better off.

In a century, the population of Tanzania has increased by 10-fold or more. It has been thrown into the modern world, and expected to develop sound Western institutions of government. Are these aforementioned cultural survival traits just going to disappear in a single human lifetime? Vertical ties of patronage in 1900 are manifested in the modern world as endemic corruption. Horizontal ties between neighbors manifest as a lack of savings. Let me expound on this last point. When we were in Kenya, one Westerner was telling me that if any person makes money or has a big payday, they immediately go out and spend it on all of their friends at the bar or restaurant. An employee of this person didn't want to keep her money at her house. She was afraid a friend or family would ask for it, and she would be obligated to give it away. These two examples help illustrate a source of serious economic problems. Without savings, there can be no investment. Without investment, there is no productivity growth.

I do appreciate that this dynamic is a testament to the strength of the community in Tanzania and Kenya, which is a wonderful thing. I've figured out that it is a big part of the attraction that Colleen feels to east Africa. Really, it is the same for me. The palpable sense of community is something we just don't have in the West anymore for the most part, and its something one can never perceive from photos of Africa. One has to be there to feel that pulse. Not to denigrate my own culture, because I love the West and I think it is the pinnacle of human existence: but this resource-sharing dynamic in east Africa is more instinctively "normal", in the sense that humans are hard-wired to operate that way. Sharing of resources in small, close-knit communities has been the norm throughout human history.

The communal spirit is what enabled clans and small groups of people to survive, because everyone is hedging their successes and failures on their close relatives. Only with the advent of larger towns and cities using national currencies have people in the West in particular moved away from this. There is still an intense attraction to what they have in east Africa, because I believe our brains were designed to function in small communities like they have (and we used to have) instead of the relatively lonely and unfriendly places in which we live in the West. In fact I've read psychological studies which suggest that 150 people is the ideal community size for Homo sapiens; we can keep tabs on and socially interact with that many people.

The move from small self-sufficient community groups to larger cities and towns in the West occurred over an extended period of hundreds of years. This gradual transition allowed for the culture to adjust slowly. We were able to develop a norm of anti-corruption (even though it still happens everywhere). Since everyone was participating in government we began to think in terms of nation or kingdom instead of tribe or clan. Notice in places where political participation was forbidden by some group or another (Jews in Europe, African Americans in the USA) there remained into modern times sort of "tribal" (us versus them) schisms that we see in the news all the time in east Africa and are oh so shocked by. Tribal tendencies, xenophobia, racism - we are talking about the same thing. Barack Obama, show us your birth certificate!

Anyway. If I had one point to this post, I guess it would be this: many people look at the lack of economic development in Africa and think "what has gone wrong?" My reaction is completely different: How could they be anywhere else? There has been so much change in such a short amount of time in east Africa, there is just no way it could have happened smoothly. In east Africa we've been expecting them to make the sort of adjustments in 100 years that in the West we made over the last 700 and in China they made over the last 4,000. This isn't even adding in the complicated history of colonialism, the effect instability of neighbors has on local development, and the effect of poor government economic policies. I don't even need to think about colonialism to not be surprised by the current political and economic position in east Africa. Yet only 30 years ago China was every bit as poor as Tanzania. 70 years ago Italy still had endemic malaria, a high birth rate, and extremely high infant mortality. I don't know how the current situation could make anyone pessimistic about the future of Africa, because to me it makes perfect sense that Africans are where they are now given from where they have come.

Its all about where they are going, and I think the future is promising. Maybe I'm too optimistic, but its never smart to bet against humanity. Topic for another post.

Monday, May 09, 2011

Humans evolved to be persistence hunters

An interesting article about how humans evolved to be runners is found here. Anthropologists have recently started coming to the conclusion that humans relied on persistence hunting in ancient times.

Persistence hunting is just what it sounds like. A human runs down a prey animal on foot over an incredibly far distance in the middle of a hot day, only catching the animal when the prey is too heat exhausted to run any more. Humans can pull this off because we run on two legs, which is more efficient over long distances. We stand upright, and so expose less surface area to the sun. The sun only touches the top of our head and shoulders; in prey animals, the whole back is exposed.

Humans also have no hair, and have sweat glands over our entire body. Both of these things allow us to efficiently cool ourselves even in the hottest weather. In fact, military experiments demonstrated that humans can withstand 400 degree heat for an hour easily IF they have enough water and the air is dry - that is how efficient our sweating is. In the prehistoric human, intelligence allowed the use of containers to carry water on these persistence hunts. Empty ostrich eggs were the Nalgene bottles of 100,000 years ago.

I had read about persistence hunting before going to Africa. When we were driving through Kenya, and I felt the intense heat and appreciated the lack of water, I thought to myself "oh, that makes sense." You see, the Kenyan sun and heat isn't a liability for the humans - its an advantage. The dry hot weather and lack of water exposes the vulnerability of the prey animals: they can't cool themselves in such weather as well as humans can. In a temperate or wet climate, persistence hunting would never work.

Still not convinced that persistence hunting can work? Check out you tube video. Humans still persistence hunt today. Wouldn't that be a fun thing to do. Screw training for a marathon. I'm going to train for a persistence hunt.

Saturday, May 07, 2011

Osama Bin Laden and the US economy

A few posts below, I wrote why I wasn't quite celebrating the death of Bin Laden:

Now there is all of this jubilation that bin Laden is dead, we got our revenge, fine. We're still fighting a war in Afghanistan, we haven't made much progress, and we're almost bankrupt as a nation. That was OBL's entire strategy. He knew he couldn't beat the United States in a conventional war, and he didn't try. His plan was to draw us in and bleed us with a thousand pin-pricks. Are we playing his game or our game? Did we play right into his hands? I'd be more willing to celebrate if OBL's strategy had failed.

Washington Post columnist Ezra Klein writes more about Bin Laden's war against the US economy. He reaches the same conclusion that I did. How could one not come to that conclusion? Pre-9/11 the US economy was running surpluses with a minuscule debt relative to GDP. We were arguably the first hyper-power in history. Now, when the dollar starts to fall, I'm reading WSJ articles about how this is almost certainly not the start of a collapse of American currency and its economy...certainly not, right? We're at the point where we have to reassure ourselves that an economic collapse is not imminent.

Should we exit Afghanistan with dignity?

Really, the book "Nixon and Kissinger" should be required reading as the discussion about ending the war in Afghanistan starts to pick up. We should stay and fight in Afghanistan if we think our interests are at stake and we think we can win the war (however defined). By contrast, we should leave Afghanistan if our interests are no longer at stake, or if we don't believe there is a reasonable strategy through which a victory could be accomplished, given human and financial considerations. In other words, if we "win" by sacrificing thousands of soldiers' lives and trillions of dollars for meager gains, we didn't really win. We just lost in a different way.

What we should not do is stay and fight in Afghanistan so that we can "exit with dignity". That is exactly what Richard Nixon did in Vietnam. Nixon sacrificed the lives of thousands of US troops in a war that he knew we weren't going to win, and a war that he was actively terminating, because he did not want a stain on his honor (and we all know how important Nixonian honor turned out to be). We ended up losing Vietnam without dignity anyway, as the world quickly saw what a farce the face-saving agreement with the communists was. Remember helicopters evacuating the US embassy in Saigon?

The long term consequences of the US withdrawing from Vietnam without dignity were precisely nil. Nobody doubted our strength in the long-term, even if morale was sapped a bit in the short term. I would argue that morale would have been less damaged in Vietnam had we ended the war sooner and saved thousands of lives, though. Furthermore, from the perspective of credible military deterrence, America would be more feared by non-state Al Qaeda types if they believed we could get involved in effective short-term military operations without always settling down for a decade-long war.

The reason I brought this up was because I saw some candidates at the Fox News GOP Presidential Debate say that we should make sure we exit Afghanistan with dignity. The suggestion that the lives of US soldiers are worth less than such petty superficiality is nothing less than reprehensible. Any politician who places priority on such nonsense should send their sons to execute the last face-saving operations of the failing war. The politician who puffs their chest out and talks a tough game about "honor" and "dignity" when sending other peoples' children to fight and die is the worst sort of politician there is. I wish Americans could see through that garbage.

Friday, May 06, 2011

Supermarkets aren't like schools

An interesting thought experiment. The most obvious flaw in it is that while people have to eat, they don't necessarily have to be educated. Not every child is born into a family with parents who, in a free market, would devote lots of resources (time, money) to ensure their children are educated.

The whole voucher for private school concept does not seem unreasonable to me as an alternative. However, the notion that we can just stop taxing people to fund education on some level is ludicrous. A free market in education will only work in families with parents who care.

I'm not willing to withhold opportunities to children who made the mistake of not being born into a family that values education. And if that means the rest of society has to pay to educate those children, I'm OK with that. An educated society is to the benefit of everyone in that society.

Thursday, May 05, 2011

Military Dogs: coolest animals ever?

From a recent NYT Article:

Last year, the Seals bought four waterproof tactical vests for their dogs that featured infrared and night-vision cameras so that handlers — holding a three-inch monitor from as far as 1,000 yards away — could immediately see what the dogs were seeing. The vests, which come in coyote tan and camouflage, let handlers communicate with the dogs with a speaker, and the four together cost more than $86,000. Navy Seal teams have trained to parachute from great heights and deploy out of helicopters with dogs

John Yoo and Bin Laden

"Former government lawyer John Yoo taking credit on behalf of the Bush  administration for Sunday's strike against Osama bin Laden is like Edward John Smith, the captain of the Titanic, taking credit for the results of the 1998 Academy Awards," - Andrew Cohen.

Tuesday, May 03, 2011

Killing Osama Bin Laden

I guess its good in that it satiates our desire for vengence, but killing OBL isn't going to change a ton in the "war on terror".  Take Iraq.  We captured Saddam, but the war only got worse.  It wasn't until we changed our strategy that we made progress.  That Saddam was in jail and subsequently executed really didn't make much of a difference in the course of the war.  Maybe it was an important step...maybe not.
So now there is all of this jubilation that bin Laden is dead, we got our revenge, fine.  We're still fighting a war in Afghanistan, we haven't made much progress, and we're almost bankrupt as a nation.  That was OBL's entire strategy.  He knew he couldn't beat the United States in a conventional war, and he didn't try.  His plan was to draw us in and bleed us with a thousand pin-pricks.  Are we playing his game or our game?  Did we play right into his hands? 
I'd be more willing to celebrate if OBL's strategy had failed.

Saturday, April 30, 2011

Impressions from East Africa: food

I can tell you what I haven't seen in Africa yet:  not a single American fast food chain.  This isnt to say that they don't have any similar things.  I guess there are a few local fast food type places in Nairobi, although I didn't see them.  Also, lots of restaurants serve fried potatoes ("chips" they call them, as in Britain, instead of "French fries").

I haven't been able to really nail down a specific culinary style since I've been here, but the food is very tasty.  Cooked spinach seems to be common and that is one of my favorites.  Rice is standard at every meal.  Lentils and potatoes make frequent appearances.  At Saids house, his wife (Mama Kay) made a spicy red dish with meat and sauce that was excellent over rice.  Because of the amazing weather here, produce is outstanding and fruit is amazing.   Oddly, they don't seem to eat much salad despite all of the fresh vegetables.  I haven't seen anyone growing lettuce.  Actually, I only had my first salad of the trip at Dr Hansen's house, our 7th day in Africa.

When touring the hospital a couple days ago, Dr Hansen was saying how he almost never sees precocious puberty in children in Africa.  As for my own observations, I have seen very few under-nourished children since being here, but also I don't think I've seen a single over-weight child, let alone an obese one.

We were talking about the precocious puberty that we see in the states the other day.  It seems, anecdotally, more common in the African American community, and I bet there are stats to back that up.  It definitely affects Americans of all types, though.  Being here has pretty clearly demonstrated that it has nothing to do with being of African ancestry*, so it must be something about being of African ancestry in America.  Well, African Americans are more likely to be of lower socioeconomic status, and quality of diet decreases with socioeconomic status.

So what is it about the American diet that causes precocious puberty?  One culprit could be the antibiotics and growth hormones we pump in our food.  As Colleen pointed out, a chicken breast in Africa is much smaller than an American chicken breast.  Here, the chickens just wander around the fields all day eating bugs.  In America, chickens are manufactured.  Their breasts are so big they sometimes can't even walk.  Alternatively, the precocious puberty could just as easily be related to the number of calories American children get, and from where.  Simply over eating might encourage premature development.

There are a lot of claims about what American food is doing to American children.  Its hard to figure out what is hype and what is real.  Seeing a place like Tanzania provides a helpful contrast.   The food is mostly locally grown.  The cows and goats actually eat grass instead of growth hormone-infused corn.  The chickens are essentially feral.  The food is home cooked, and not from chain restaurants.  It becomes much easier to see what American food is doing to American children.

Obviously, American food has been negatively influencing American adults, too.  I had put on 10-15 pounds over the last year that was just not going away; I wouldn't be surprised if half of it was gone when I get home, if not all of it (my weight easily fluctuated).  Dr Hansen has lost forty pounds since being here.  So if anyone is struggling with their weight, just move here.  I've heard that McDonalds wants to expand onto this continent.  They should do Africans a favor, and not.  There are enough challenges here to deal with already.  The last thing Africa needs is an obesity epidemic driven by American government-subsidized industrially processed food.

Tuesday, April 26, 2011

Impressions from Tanzania, Part I

Warning:  I am writing about things that I really know very little about.  Anyone who has seen my political blog knows I do that all the time.  Well, believe it or not, I didn't come all the way over here so I could write about the weather, and about what I did all day.  My main objective is to get at least a superficial feel for the culture and the challenges that east Africans face.

One of the shocking things about being here is that you initially don't feel like you can just casually walk among some of the "poverty" that I've seen here.  Some of the dwellings that are here would not be out of place in the set of the movie "District 9".  Not only do we casually walk through these areas, nobody seems to care.  Its not like the music stops, the DJ screeches the record, and everyone stares at us (and this is Colleen and I without Said escorting us).  The people are usually indifferent, sometimes curious, but never shocked/insulted/hostile at our presence.  I wondered before coming here if I would feel unsafe at all, but I really haven't, except for when traveling in crazy packed buses.  By the way, I don't have any pictures from when walking through places like this because I don't want to offend anyone by blatantly taking pictures of them.

The reason I put the word poverty in quotes above is because these people are extremely poor by Western standards but they don't act like we are led to believe that poor people act.  I'm not sure why there is such a gulf between distant perception and reality in this regard.  I can't have been the only American with that impression, because I would confidently say that I am less easily influenced by others, and more skeptical in general, than most Americans. 

The image we have of the third world from American television sets is a bunch of people sitting around with blank looks on their faces.  In contrast, these people in Tanzania move like they are on a schedule.  Everyone has a livelihood.  Brick-making is a big one.  Younger boys are constantly filling wooden wheel barrels full of rocks and then pulling them to the brick makers.  Lots of people are working the fields.  Machine and mechanic work is common.  Carpentry and construction is too.  Maybe the most common are merchants; it seems like every other person has a shop of some sort, or is selling stuff at market.

So there is an extremely intensive economy here, and it is surprising how intensive it is, given my preconceived notions, which I feel foolish for even having at all.  It isn't a productive economy of course, at least not by our standards.  It takes investment in capital to increase productivity.  China only 30 years ago was a hugely unproductive economy, but now look where it is, thanks to investment and good government policies for business.  The real challenge is to figure out a way to get the technical know-how and the capital in so that the people can take off.  Obviously.

Colleen's friend Mary, who runs the school for special needs children, is a perfect example.  She was an entrepreneur who had a vision and a dream of a school, but no money to buy land or build it.  Colleen provided the initial catalytic boost and Mary has ran with the project, taking it beyond the level that any one person, whether it be the richest Westerner or the most motivated Tanzanian, could have on their own.  When it comes down to it, Colleen didn't buy land or build a school.  Anyone with money can do that.  Colleen invested in a Tanzanian, and Mary turned that investment into something great for her people.  This is an incredibly important distinction that must frequently be lost on people, especially western philanthropists.

Anyway, there is lots more to write about, but I'll stop there.  The concluding theme to this post is that the people of Tanzania are far more wealthy than I ever imagined; as an American it is easy to forget that wealth means more than assets and cash on hand minus liabilities.

By the way, the rest of my travel posts can be found here.

Monday, April 18, 2011

The Ethanol Gridlock, and Orwellian Obama

The Economist had a good article a few weeks ago highlighting an anomaly: a case of "conservatives" like Grover Norquist (Americans for Tax Reform) defending big government. Every year, the United States spends billions of dollars to prop up the local ethanol industry with subsidies. At the same time, we impose a tariff on imported ethanol. The imported ethanol would mostly come from our Brazilian friends, who produce ethanol from sugarcane. In fact, Brazilian ethanol is at least 4 times more efficient than our corn-based stuff. That is why local ethanol producers need both help, in the form of subsidies, and hindrances on the competition, in the form of tariffs, to stay competitive at all.

These policies make Americans worse off in general, because we have to pay more for our ethanol (although that cost is hidden among government spending as a whole). Furthermore, corn prices are going up to never before seen levels, since we're converting so much of it to ethanol. The consequence has been devastating to people around the world, especially in nations poorer than our own. This is classic big government at its worst, and yet some of its most staunch defenders are conservatives. That such a no-brainer issue has been such a challenge to deal with is a discouraging foreshadowing of the spending battles to come. Big props to Republican Tom Coburn for fighting back against pseudo conservatives like Norquist, and trying to get this wasteful spending eliminated.

Ethanol subsidies are a form of tax expenditure, and eliminating these would save the federal government literally hundreds of billions of dollars. President Obama mentioned this as a goal in his budget speech the other night. Obama used the phrase "spending reductions in the tax code", in other words, reducing tax expenditures. Jon Stewart was making fun of Obama for using what he thought was Orwellian language to mask a call for tax increases in general, but Stewart misinterpreted what Obama was saying. Tax expenditures are just government spending by another name. Faux conservatives will try to obfuscate this point. They will accuse President Obama of trying to raise taxes, but he is really trying to eliminate big government subsidies. He is going to need all the help he can get, especially from honest Republicans like Tom Coburn.

Monday, April 11, 2011

The Republican Debt Ceiling Bluff

Last fall, Obama compromised with Republicans to extend the Bush tax cuts for another two years. He was roundly criticized by the left for caving in to Republican demands. I actually thought Obama got a great deal when you consider how weak his negotiating position really was. An outcome of failed compromise was more tolerable to the GOP than it was to Obama, for various reasons, so he really couldn't force their hand on anything. Obama recognized his weak bargaining position, and took what he could get. It may not have been satisfying but it was the right move.

Fast forward to several weeks from now, when Republicans will apparently be "demanding fundamental changes in policy on health care, the environment, abortion rights and more, as the price of their support for raising the debt ceiling." This is code for Republican intent to defund planned parenthood and strip the EPA of regulatory authority. Contentious issues, no doubt, but they are also issues that don't really affect government spending. They are a partisan distraction.

In the coming battle over the debt ceiling, I don't think Republicans realize how weak their bargaining position actually will be. The fundamental problem for the GOP is that they control one house of congress, but not the other. Since they control the House, it is absolutely a foregone conclusion that the House GOP will, at some point, vote to raise the debt ceiling. Concessions by democrats or no, forcing the US government to default would be most intolerable to the GOP's powerful backers. Obama himself is shielded from the process because any bill will have to make it through the Democrat-controlled senate; a bill with lots of partisan riders won't pass. Even if the GOP managed to buy off some of the few remaining centrist democrats, there will be at least 41 liberal Democrats who would filibuster an intolerable GOP-sponsored bill.

In the context of failed negotiations, the end-game is this: the GOP-led house passes a bill with severe cuts and partisan riders while the Democrat-led senate passes a modest bill with a few token spending cuts. At that point it is a game of chicken to see who jumps first. Who fears a US government default more, the Republican Party or the 41 most liberal Democrats in the senate? Is it plausible that banks, corporations, and other business interests will tolerate a US government default over a petty battle about say planned parenthood? As the default deadline approached, the Republicans would be forced to pass the senate bill by overwhelming pressure from their powerful backers.

Conservatives, now more than ever, need to start looking for the pragmatic voices in the Republican Party to lead in these negotiations. I absolutely believe that if Republicans put partisan battles aside, Democrats would join them and real progress on spending could be made. There are tons of low-hanging fruits that could be plucked to get real reductions in government spending. I am not confident that the GOP can yet be led by pragmatists. I anticipate they will insist on continuing to fight distracting partisan battles. If Republicans charge into this looking to win a political fight, they may be dealt a defeat of staggering proportions when the Democrats call their bluff.

Thursday, April 07, 2011

Privatize Medicare?

I applaud Paul Ryan for having the guts to propose a drastic solution to our long term fiscal problem. That being said, I think his plan misses the mark. People have looked at the case of Medicare Advantage as a proxy for the effect of health care costs when using a voucher system. They've found that costs are not controlled in such circumstances. So there is no reason to think that privatizing medicare would actually slow growth in spending.

Remember: it is not medicare that is the problem, it's the fact that health spending is growing faster than the economy as a whole. If you could bring those two into line, medicare would be fine. The other problem with the Ryan plan is that the idea of privatizing medicare will be very politically toxic which will make it almost a non-starter. Any real solution to our fiscal mess needs to be politically viable.

As I've said before, Obama's ACA addresses the problem of access to health care, but does not reform the way we deliver health care. I'd love to see the Republicans and Obama agree to sit down and work on the ACA to include more cost-control measures. Obama would go along with it, no doubt, because with a bipartisan stamp of approval his bill would be implemented, Americans would get universal coverage, and the system would be sustainable. Republicans should go along with it because that is the only real shot we have to "bend the medicare cost-curve".

Yea, I'm still naive.

Wednesday, April 06, 2011

Poor people just lack discipline!

In Arizona, the local GOP has decided to start penalizing poor people for being obese, in an effort to close budget gaps. We certainly do have an obesity epidemic in this country. Perhaps a better way to address the problem is to stop paying people to eat unhealthy food.

Thanks to big government subsidies to meat and corn producers, we essentially pay people to eat meat products, fast food, junk food, and other sorts of other processed garbage. On the surface, removing this distortion looks like a no-brainer: we could reduce the size of government, save money, and reduce obesity rates by letting the free market work its magic. Unfortunately, no conservatives are championing this cause. As it turns out, the food industry is more effective at lobbying than poor Americans. Stopping government hand-outs to food corporations is difficult, but blaming poor people for lacking self control is really easy.

Speaking of self control, our current policies actually make willpower irrelevant in many cases. Increased demand for processed foods also means decreased demand for produce and healthier choices. Consequently, in many poor areas there are urban food deserts, where the only sellers are convenience stores and fast food chains. Unsubsidized produce sellers can't compete with cheap fast food and processed foods. A person in that environment may have the willpower to eat healthy foods, but lack a market. Imagine for a moment being a low-income single mother, trying to raise children in an area with no local grocery stores. It becomes easier to see our agriculture policies contributing to a vicious cycle of unhealthy eating, obesity, and poverty.

What we have right now is a government that is actively encouraging people to make bad decisions. It would literally be no different if the government was handing out free packs of cigarettes, or had heroin dispensers on every street corner. "Hey addict its your fault, get some self control!" Apparently everyone is OK with this status quo, but what about the opposite? What about a government that encourages people to make good decisions? We could strip the subsidies from meat and corn and place them on fresh produce and other healthy choices. Alas, that is a political non-starter, because that would be socialism!

At any rate, I would be OK with the truly 'conservative' solution: strip the subsides, shrink the government, and let the free market work.

Monday, March 28, 2011

Can we afford to intervene in Libya?

I made a pie chart on Microsoft Excel to answer this important question. The main problem that I ran into is that the cost of the intervention in Libya is so tiny that it isn't really possible to accurately represent it graphically. On my chart, spending on Libya is only represented by a line, instead of a slice. It's still overstated, because pixels are pretty thick.

I guess the take home point here is that, while there may be a lot of reasons we should not intervene in Libya, cost really isn't one of them.

Friday, March 25, 2011

Is Obama Consistent on War?

A lot of people have been surprised that Obama was willing to launch military strikes on Libya. They should not be. When accepting his Nobel Peace Prize in Norway, Obama gave a long speech discussing issues of war and peace. After reviewing the speech, it is very clear that Obama's actions in Libya are entirely consistent with the principles he laid out in his speech. I've included some relevant sections:

Obama: "We must begin by acknowledging the hard truth: We will not eradicate violent conflict in our lifetimes. There will be times when nations -- acting individually or in concert -- will find the use of force not only necessary but morally justified.

Evil does exist in the world. A non-violent movement could not have halted Hitler's armies. Negotiations cannot convince al Qaeda's leaders to lay down their arms. To say that force may sometimes be necessary is not a call to cynicism -- it is a recognition of history; the imperfections of man and the limits of reason."

Historians will look back on 2011 as an enormously important year in world history. The spread of non-violent revolutions throughout the Arab world has been remarkable and unpredictable. Gaddafi was the first despot to resort to heavy military force to crush the civilian protesters. If left unchecked, that precedent could easily break this wave of revolution, as subsequent despots would be more willing to crush their rebellions with military force. Obama spoke of times when force is necessary and morally justified; if not in Libya, then when?

Obama: "In many countries there is a deep ambivalence about military action today, no matter what the cause. And at times, this is joined by a reflexive suspicion of America, the world's sole military superpower...[but] the instruments of war do have a role to play in preserving peace."

Indeed, there is a deep ambivalence toward military action even among many American citizens today. We must remember that history is a guide, not a blueprint. It is easy to make the mistake of over-learning the lessons of history. A useful example: WW-1 started in part because the belligerents were very nationalistic and almost eager to go to war. The world realized what a costly and pointless endeavor the war was after the fact. In response, France and Britain moved too far in the other direction. In the 1930s the West refused to consider military force, having learned the lessons of WW-1, while Hitler rearmed Germany.

Similarly, is tempting after the excesses and mistakes of the Bush years to swear off foreign adventures. We must recognize that the alternative to the unilateral, preemptive, and costly exploits of the Bush administration is not swearing off foreign intervention altogether. Rather, the alternative is to adopt approaches that are multilateral, based on existing threats, and modest.

Obama: "I believe that all nations -- strong and weak alike -- must adhere to standards that govern the use of force. I -- like any head of state -- reserve the right to act unilaterally if necessary to defend my nation. Nevertheless, I am convinced that adhering to standards, international standards, strengthens those who do, and isolates and weakens those who don't.

Furthermore, America -- in fact, no nation -- can insist that others follow the rules of the road if we refuse to follow them ourselves. For when we don't, our actions appear arbitrary and undercut the legitimacy of future interventions, no matter how justified.

And this becomes particularly important when the purpose of military action extends beyond self-defense or the defense of one nation against an aggressor. More and more, we all confront difficult questions about how to prevent the slaughter of civilians by their own government, or to stop a civil war whose violence and suffering can engulf an entire region.

I believe that force can be justified on humanitarian grounds, as it was in the Balkans, or in other places that have been scarred by war. Inaction tears at our conscience and can lead to more costly intervention later. That's why all responsible nations must embrace the role that militaries with a clear mandate can play to keep the peace."

It is clear that Obama reserves unilateral military action for direct threats to the United States. Libya poses almost no direct threat to the US, and this is why Obama did not unilaterally impose a no-fly zone earlier in the conflict. Also relevant for the Libyan situation: Obama questions how to protect civilians from their own governments, answering that force can be justified in those situations. He cites the Balkans as an example, which has many obvious parallels to Libya.

Obama: "America's commitment to global security will never waver. But in a world in which threats are more diffuse, and missions more complex, America cannot act alone. America alone cannot secure the peace...Peace requires responsibility. Peace entails sacrifice. That's why NATO continues to be indispensable. That's why we must strengthen U.N. and regional peacekeeping, and not leave the task to a few countries."

After a decade of mostly Anglo-led war in Afghanistan and Iraq, many people have questioned the relevance of even NATO, with the relevance of the UN been thrown to the wayside a long time ago. The way Obama has prosecuted the effort in Libya has served to re-legitimize both NATO and the United Nations. If we can prove that a multilateral approach to world problems can work, we open the door for stronger efforts in the future. This has obvious benefits of taking the focus away from America.

Obama: "...within America, there has long been a tension between those who describe themselves as realists or idealists -- a tension that suggests a stark choice between the narrow pursuit of interests or an endless campaign to impose our values around the world...There's no simple formula here. But we must try as best we can to balance isolation and engagement, pressure and incentives, so that human rights and dignity are advanced over time.

The state of discourse in the United States reflects this false choice. The neoconservative Bush-era camp would have us embark on endless campaigns to impose our values around the world. These people balk at the prospect of multilateral action, and considered any international support to be little more than a bonus. Alternatively, with the rise of the Tea Party, there is a new isolationist camp that seems to believe we should never intervene anywhere. These people are over-reacting to the failures of the Bush administration.

We do not need to fall into this trap. The proper reaction to Bush's foreign policy failures is not an absence of foreign policy. It is a balanced foreign policy, one that cannot be reduced to a simple formula. It may call for interventions in some areas but not others. People may be frustrated by a president who allows himself to see the world in shades of grey. Viewing the world in black-and-white has the satisfaction of purity, I will admit. The real historical lesson of the Bush era is that falling into a position of ideological inflexibility leads to disaster; that is one mistake Obama has yet to make.