I should get out more.

Lessons from the contraception controversy.

2012-02-11T14:23:00.001-05:00

1. Nice to see the GOP so concerned with Catholic opinion (seriously). I assume this means they agree that the death penalty should go and that we should extend unemployment benefits.

2. The real story here is how ridiculous it is that health insurance is tied to our jobs. Breaking that link will help with cost control, and will enhance labor market fluidity by encouraging riskier moves on the part of workers. (Health insurance is an anchor keeping talented people at 'safe' jobs instead of going solo, with a new firm, etc.)

3. Obama is unwise for picking a fight with the Catholic Church. He thinks Republicans are stubborn? It took the church 360 years to exonerate Galileo.

4. Catholics themselves need to be more active participants in their church's theology. Family planning is smart, not sinful. It reduces abortions. It results in healthier families and societies. Condoms can prevent disease, reducing the health care burden and suffering. The Catholic Church needs to have a new council to address these issues for the 21st century. Their flock, but not the government, should be pushing for that.

5. Mitt Romney enacted similar regulations in Massachusetts as governor. Enjoy your nominee, Republican Party. You could have had Jon Huntsman but nope he wasn't crazy enough for you. Now you get Obama until 2016.

Questions for Catholic Bishops re: health insurance coverage

2012-02-08T18:48:00.001-05:00

The Bishops believe that Catholic insurance should not cover contraceptives, because they do not want to encourage what they say is sinful behavior. There are many other situations where the church would be encouraging vice by paying for medical treatment. I would be curious to know where the church would come down on a few of these issues:

1. Sexually-transmitted diseases are a consequence of promiscuous sex. If the church treats such conditions, people do not live with the consequences of sinful behavior. This is clear moral hazard which will encourage more vice. However, if left untreated, STDs can be rapidly fatal, hurt unsuspecting spouses in cases of infidelity, cause birth defects and stillbirth of fetuses, and increase the risk of pregnancy.

2. On one hand, the Gardasil vaccine gives our daughters carte blanche to have lots of promiscuous, unprotected sex. On the other hand, it is a simple vaccine that prevents cancer. Its easy to see where the controversy comes from. Reducing the risk of a behavior will certainly encourage said behavior.

3. What to do in cases of cervical cancer caused by HPV? If we treat our daughters every time they develop cancer after having unprotected sex, aren't we just encouraging their sinful behavior?

4. Gluttony is a grievous sin. However, bariatric surgical procedures have been shown to be cost effective at increasing the health and quality of life in morbidly obese people. Should the church be forced to encourage gluttony?

5. Type II diabetes is, like obesity, very often caused by excess consumption. Should the church be forced to cover the costs of medications that control the disease, hence promoting sinful behavior?

6. Many people who smoke will develop lung cancer. For Catholic insurance to pay for treatment would clearly violate the teachings of the bible; see Corinthians:19-20

"Don’t you realize that your body is the temple of the Holy Spirit, who lives in you and was given to you by God? You do not belong to yourself, for God bought you with a high price. So you must honor God with your body."

7. If a person develops a parasite or neurocysticercosis after eating Biblically-forbidden pork products, obviously the church would violate their principles if they paid for treatment.

Why haven't aliens contacted us?

2012-02-07T21:45:00.000-05:00

Some people believe that the lack of outside contact is evidence that complex life does not exist in the universe. As the idea goes, we know that simple life is easy to create (from our own experience). Yet, complex life defined as a civilization at or beyond our level apparently does not exist. If they did, presumably there would be a lot of them, and we would find evidence of them in the frequencies of the cosmos. So some people believe life is easy to start but hard / impossible to develop beyond a stage where we are, the conclusion being something snuffs out the civilization when it is about our age. Maybe nuclear weapons are to blame.

There is a tribe deep in the Amazon jungle in Brazil that has never had contact with humans from the outside. The Brazilian government is actively protecting them from outsiders who are trying to contact them, in fact. If anyone is curious why we haven't been contacted - this is my theory why: we are the equivalent to the uncontacted Brazilian tribe. There probably are millions of intelligent civilizations, and maybe even the supreme among them are protecting our planet from outside signals from others who would interfere. In their mind, we should make our own way. If we succeed then we can join the league of universal civilizations. If we destroy ourselves in the interim, then we weren't a worthy species.

I think Bill Watterson's theory is good too:

98% of Catholic Women

2012-02-07T17:55:00.001-05:00

That is the number that uses some form of contraception.

http://www.guttmacher.org/media/nr/2011/04/13/index.html

98% of Catholic Women are not wrong.

Indiana right-to-work, breaking the Union of the 1%.

2012-02-06T15:50:00.003-05:00

Indiana just passed right-to-work legislation. The standard labor argument (against Mitch Daniels) is that all workers benefit from the actions of a worker's union, so they should all contribute. I'm not sure if that is true. There are some cases of overlap I'm sure, but one of the most important benefits of being in a union is protection from being laid off "unfairly". If a worker declined to pay union fees and didn't join the union, they face that risk. It's a calculation that any individual would need to make - but clearly, if the benefits of unionization are so great, theres no need for a law that forces a worker to join. I am always for greater individual freedom, so I definitely side with Mitch Daniels on this issue. Workers have the right to organize and join unions, but unions shouldn't have the right to force workers to join.

On a somewhat related note, consider what the essence of unionization is: it is undeserved economic influence; economic power at above-market rates. In a union, a collection of individuals organize within the framework of a larger group such that, by virtue of that organization, they become more influential than the sum of their parts. They increase their economic power not by increasing productivity, but by pressing political advantage into economic gain. Obviously, this leads to less efficient labor markets - and many others are hurt in consequence, including non-unionized workers.

Now stop and consider the entrenched financial and corporate elite in this country. The "1%" generally is a very productive group, and in a genuinely free market they would be compensated handsomely for their efforts. However, by virtue of their connections to politicians and their virtual ownership of government in general, the financial and corporate elite have been able to press their advantage. They have built a system from the inside that favors them unfairly. They are no different than factory workers who unionize and demand outrageous or unearned pay.

Wall Street and many entrenched corporations have economic power beyond that which their productivity deserves. Tax-payer bailouts and implicit government backing of too-big-to-fail institutions. A tax code, written by armies of lawyers and voted into being by bought politicians, which is insanely complex and riddled with loopholes that benefit the authors. Entrenched corporations (think: unionized workers) with their lobbyists buy themselves government subsidies and tax breaks; these are advantages that their smaller or newer competitors (think: non-unionized labor) don't enjoy. The power of the financial and corporate elite, like unionized workers in a factory, is greater than the sum of their parts. This is the Union of the 1%.

While Democrats are funded by traditional middle-class unions, Republicans are backed by the union on Wall Street - and as the financial crash in 2007 showed, the latter is more detrimental to the economy. So: want to do some union busting, and make our economy more competitive? Fine. Lets not stop with the middle class unions. We need to end corporate welfare. Simplify the tax code. Break up any company or bank that is implicitly backed by the taxpayers because it is too big to fail. Stop government subsidies and tax breaks to entrenched corporations. End attempts at regulating the internet. Re-write our ridiculous patent laws which have been woven into place by entrenched companies to keep out the competition. THAT is how you revitalize the American economy.

This is what Occupy Wall Street is all about. Americans have gone along with the de-unionization of the middle classes for decades, and the promised gains in living standards have absolutely failed to be realized. Now its time to end the union of Wall Street, of the entrenched interests, of the elites who own Washington.

Catholic Bishops and the Laws of Men

2012-02-05T15:35:00.002-05:00

Imagine a couple has been in a monogamous marriage for over two decades. They have raised four children. They do not wish to have more. They could be worried about having enough money for retirement,
and can't afford to raise more children. In addition, because the couple is getting older, they are worried that they will lack the energy to raise another child. Finally, they worry about the health of the mother and potential child in such a late pregnancy. This couple wishes to remain intimate, and so use contraceptives to prevent another pregnancy.

The vast majority of Catholics agree that the use of contraception, such as in the case described above, is completely reasonable. In 2005, a poll showed that over 90% of Catholics thought using contraception in some circumstances was not a sin. Also important is the central role that contraception plays in preventing great sins: a sure-fire way to prevent abortion is to prevent unwanted pregnancies.

Catholic Bishops stand in stark contrast to their flock. They believe that anyone who uses condoms is a sinner, no matter what. Not content to merely pass their antiquated judgments, the Bishops are now demanding the power to deprive American Catholics the right to purchase condoms & other family planning products with their health insurance.

Growing up a Catholic, I remember a church that tried to serve as a guide. The church gave recommendations and advice to its flock, but never dictats. The recent change is really bizarre to me. What does it say about the Bishops' mindset that they would even try to use legal means, to use man's laws, to restrict the freedoms of their flock? At any rate, the Vatican should not have the right to impose their religious laws on Americans from Europe. Americans have economic freedom, religious freedom, and behavioral freedom that should not be infringed upon by anyone, even Catholic Bishops. I am glad that President Obama stood up for the freedom of Americans in this case and told the Bishops that they can preach, but they cannot rule. Any Catholic who believes that family planning is smart, and that abortion is terrible and should be avoided, should call their Bishop and tell them as much.

The Tragedy of the Komen Foundation

2012-02-03T14:14:00.002-05:00

Public health has taken another blow. They say these things come in threes. We have leading conservative presidential candidates telling people that vaccines cause autism. A conservative senator in Tennessee just told his constituents that it is "virtually impossible" to spread HIV through heterosexual contact. And now, we are politicizing the screening and treatment of breast cancer. I can't stop thinking about the cultural damage here. Has anyone else considered what we just lost as a nation? We disagree on just about everything these days. The notion that breast cancer is a disease worth fighting is one of the few remaining things everybody could agree on. That has now been destroyed; and for what? At the end of the day, this was over $700,000 dollars. To destroy such a cherished and unitary cultural icon for such a petty trifle, for such a cheap political victory. It must take an exceptionally vindictive person to want to make that trade.

At any rate, this was an unforced error of staggering proportions on the part of the Komen Foundation itself. Before this story broke, I suspect that very few people knew that Komen gave money to Planned Parenthood. Even if people knew Komen was providing breast cancer care at Planned Parenthood clinics, what kind of person would possibly care? One would think self-interest alone would have led Komen to stay out of this debate. Now that they have taken sides, its probably too late. If they stand firm and abandon low-income women, they will alienate at least the 75% of Americans who support abortion rights in some form or another. Arguably they will lose more than that, since obviously not everyone who is anti-choice thinks depriving poor women of breast cancer screening is worth a political point. Alternatively, Komen could do the right thing and reverse course. In doing so they would become a perpetual target for religious bullies who are always looking for another battle to fight. Either way, what used to be a non-controversial, unitary force, the fight against breast cancer, will be reduced into another yearly battle in our incessant culture wars.

I do think there is a way out. Komen needs to stand with low-income women and support breast cancer services, and provide concrete data that show that donors' money is being used only for breast services. Conservative women should stand with them when they do - because they should recognize that this isn't worth it, and that there are better and less destructive venues in which to have the abortion fight. People should remember why they supported the Komen Foundation in the first place and leave politics aside for once.

top 5 regrets of the dying

2012-02-02T09:33:00.001-05:00

Interesting article from a palliative care nurse:

http://www.guardian.co.uk/lifeandstyle/2012/feb/01/top-five-regrets-of-the-dying

I anticipate that I will regret not having drank more beer. So I will
pre-emptively fix this problem tonight.

Why do turtles travel across the ocean? And what of the recurrent laryngeal nerve?

2012-01-22T13:11:00.001-05:00

A really magnificant description of an ancient behavior:

"I was told some years ago that the reason why some species of sea turtles migrate all the way across the South Atlantic to lay their eggs on the east coast of South America after mating on the west coast of Africa is that when the behavior started, Gondwanaland was just beginning to break apart (that would be between 130 and 110 million years ago), and these turtles were just swimming across the narrow strait to lay their eggs. Each year the swim was a little longer—maybe an inch or so—but who could notice that? Eventually they were crossing the ocean to lay their eggs, having no idea, of course, why they would do such an extravagant thing.

What is delicious about this example is that it vividly illustrates several important evolutionary themes: the staggering power over millions of years of change so gradual it is essentially unnoticeable, the cluelessness of much animal behavior, even when it is adaptive, and of course the eye-opening perspective that evolution by natural selection can offer to the imagination of the curious naturalist." -Daniel Dennett

In mamillian anatomy there is a similar such detour that seems absurd in the absence of evolution: the recurrent laryngeal nerve. Watch a video about it here:

http://www.youtube.com/watch?v=cO1a1Ek-HD0

The Decline of Islamic Civilization

2012-01-08T11:38:00.001-05:00

An exerpt from "Why the Arabic World Turned Away from Science". When reading about anti-rationalism, its impossible for me to not think about contemporary America.

----------------------------------------------------------

Just as there is no simple explanation for the success of Arabic science, there is no simple explanation for its gradual — not sudden, as al-Afghani claims — demise. The most significant factor was physical and geopolitical. As early as the tenth or eleventh century, the Abbasid empire began to factionalize and fragment due to increased provincial autonomy and frequent uprisings. By 1258, the little that was left of the Abbasid state was swept away by the Mongol invasion. And in Spain, Christians reconquered Córdoba in 1236 and Seville in 1248. But the Islamic turn away from scholarship actually preceded the civilization's geopolitical decline — it can be traced back to the rise of the anti-philosophical Ash'arism school among Sunni Muslims, who comprise the vast majority of the Muslim world.

To understand this anti-rationalist movement, we once again turn our gaze back to the time of the Abbasid caliph al-Mamun. Al-Mamun picked up the pro-science torch lit by the second caliph, al-Mansur, and ran with it. He responded to a crisis of legitimacy by attempting to undermine traditionalist religious scholars while actively sponsoring a doctrine called Mu'tazilism that was deeply influenced by Greek rationalism, particularly Aristotelianism. To this end, he imposed an inquisition, under which those who refused to profess their allegiance to Mu'tazilism were punished by flogging, imprisonment,or beheading. But the caliphs who followed al-Mamun upheld the doctrine with less fervor, and within a few decades, adherence to it became a punishable offense. The backlash against Mu'tazilism was tremendously successful: by 885, a half century after al-Mamun's death, it even became a crime to copy books of philosophy. The beginning of the de-Hellenization of Arabic high culture was underway. By the twelfth or thirteenth century, the influence of Mu'tazilism was nearly completely marginalized. In its place arose the anti-rationalist Ash'ari school whose increasing dominance is linked to the decline of Arabic science.

With the rise of the Ash'arites, the ethos in the Islamic world was increasingly opposed to

original scholarship and any scientific inquiry that did not directly aid in religious regulation of private and public life. While the Mu'tazilites had contended that the Koran was created and so God's purpose for man must be interpreted through reason, the Ash'arites believed the Koran to be coeval with God — and therefore unchallengeable. At the heart of Ash'ari metaphysics is the idea of occasionalism, a doctrine that denies natural causality. Put simply, it suggests natural necessity cannot exist because God's will is completely free. Ash'arites believed that God is the only cause, so that the world is a series of discrete physical events each willed by God. As Maimonides described it in The Guide for the Perplexed, this view sees natural things that appear to be permanent as merely following habit. Heat follows fire and hunger follows lack of food as a matter of habit, not necessity, "just as the king generally rides on horseback through the streets of the city, and is never found departing from this habit; but reason does not find it impossible that he should walk on foot through the place." According to the occasionalist view, tomorrow coldness might follow fire, and satiety might follow lack of food. God wills every single atomic event and God's will is not bound up with reason. This amounts to a denial of the coherence and comprehensibility of the natural world. In his controversial 2006 University of Regensburg address, Pope Benedict XVI described this idea by quoting the philosopher Ibn Hazm (died 1064) as saying, "Were it God's will, we would even have to practice idolatry." It is not difficult to see how this doctrine could lead to dogma and eventually to the end of free inquiry in science and philosophy.

The greatest and most influential voice of the Ash'arites was the medieval theologian Abu Hamid al-Ghazali (also known as Algazel; died 1111). In his book

The Incoherence of the Philosophers, al-Ghazali vigorously attacked philosophy and philosophers — both the Greek philosophers themselves and their followers in the Muslim world (such as al-Farabi and Avicenna). Al-Ghazali was worried that when people become favorably influenced by philosophical arguments, they will also come to trust the philosophers on matters of religion, thus making Muslims less pious. Reason, because it teaches us to discover, question, and innovate, was the enemy; al-Ghazali argued that in assuming necessity in nature, philosophy was incompatible with Islamic teaching, which recognizes that nature is entirely subject to God's will: "Nothing in nature," he wrote, "can act spontaneously and apart from God." While al-Ghazali did defend logic, he did so only to the extent that it could be used to ask theological questions and wielded as a tool to undermine philosophy. Sunnis embraced al-Ghazali as the winner of the debate with the Hellenistic rationalists, and opposition to philosophy gradually ossified, even to the extent that independent inquiry became a tainted enterprise, sometimes to the point of criminality. It is an exaggeration to say, as Steven Weinberg claimed in the Times of London, that after al-Ghazali "there was no more science worth mentioning in Islamic countries"; in some places, especially Central Asia, Arabic work in science continued for some time, and philosophy was still studied somewhat under Shi'ite rule. (In the Sunni world, philosophy turned into mysticism.) But the fact is, Arab contributions to science became increasingly sporadic as the anti-rationalism sank in.

The Ash'ari view has endured to this day. Its most extreme form can be seen in some sects of Islamists. For example, Mohammed Yusuf, the late leader of a group called the Nigerian Taliban, explained why "Western education is a sin" by explaining its view on rain: "We believe it is a creation of God rather than an evaporation caused by the sun that condenses and becomes rain." The Ash'ari view is also evident when Islamic leaders attribute natural disasters to God's vengeance, as they did when they said that the 2010 eruption of Iceland's Eyjafjallajökull volcano was the result of God's anger at immodestly dressed women in Europe. Such inferences sound crazy to Western ears, but given their frequency in the Muslim world, they must sound at least a little less crazy to Muslims. As Robert R. Reilly argues in

The Closing of the Muslim Mind (2010), "the fatal disconnect between the creator and the mind of his creature is the source of Sunni Islam's most profound woes."

http://www.thenewatlantis.com/docLib/20110605_TNA30Ofek.pdf

Stopping Keystone XL is the Best Policy for Energy Security.

2011-12-23T14:46:00.002-05:00

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

2011-12-23T13:49:00.000-05:00

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.

How Doctors Die

2011-12-06T11:23:00.000-05:00

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.

African health worker drain

2011-11-26T19:03:00.001-05:00

Interesting criticism:

http://marginalrevolution.com/marginalrevolution/2011/11/doctors-with-borders.html

The rebirth of my contempt for the left

2011-11-06T11:25:00.000-05:00

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.

Why I am bullish on America in one simple picture

2011-10-25T22:27:00.000-04:00

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.

on PSA screening

2011-10-11T16:21:00.001-04:00

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.

Djerejian on Occupy Wall Street

2011-10-10T15:09:00.003-04:00

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.

What's wrong with this picture?

2011-10-07T13:15:00.002-04:00

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.

Little America.

2011-10-04T11:05:00.001-04:00

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.

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

2011-10-03T14:05:00.001-04:00

From one of my favorite economists:

http://www.nytimes.com/2011/10/02/business/economy/antitax-ideas-could-have-unintended-results.html?_r=1

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).

The Economist on Palestinian Statehood

2011-10-02T18:26:00.000-04:00

"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

2011-10-02T10:59:00.003-04:00

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

2011-10-02T10:28:00.000-04:00

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

Americans, death, and the health care system

2011-09-21T15:01:00.000-04:00

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.

Herein lies the problem [with our health care system]

2011-09-07T14:43:00.001-04:00

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?

http://www.nytimes.com/2011/09/08/health/research/08stent.html?_r=1&hp

Transplant surgery: quote of the day

2011-08-25T11:24:00.001-04:00

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:

http://papers.nber.org/papers/w17324

Americans are pre-revolutionary

2011-08-25T07:50:00.000-04:00

“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.

We have a winner!

2011-08-18T11:56:00.001-04:00

This is an awesome article:

http://www.economist.com/node/18989175

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

Obama and the Debt Ceiling

2011-08-08T21:59:00.001-04:00

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.

Too good to not post: costly gas = thinner people

2011-08-03T14:17:00.001-04:00

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

http://web.hbr.org/email/archive/dailystat.php?date=080111

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

Are we winning the war on drugs?

2011-07-30T22:19:00.000-04:00

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.

Time to see if I was right

2011-07-26T22:05:00.000-04:00

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.

Fact of the day: lung cancer

2011-07-18T20:02:00.001-04:00

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.

Why I love oncology

2011-06-30T22:03:00.000-04:00

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.

Reason as a weapon

2011-06-29T17:07:00.002-04:00

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?

On Surgery, etc.: The Part-Time Doctor

2011-06-27T16:12:00.001-04:00

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

On Surgery, etc.: The Part-Time Doctor

Cancer in transplant patients

2011-06-24T19:18:00.000-04:00

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.

The yin and yang of immunology

2011-06-22T21:47:00.000-04:00

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.

A way to cut everyone on the liver waiting list

2011-06-20T22:01:00.001-04:00

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.

Guess who else thinks Netanyahu is wrong?

2011-06-02T13:32:00.001-04:00

The former head of the Mossad.

http://m.smh.com.au/world/former-mossad-head-advocates-saudi-peace-plan-20110602-1fivf.html?from=smh_sb

The Republican Yacht

2011-06-01T10:36:00.001-04:00

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.

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

2011-05-25T00:57:00.000-04:00

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.

America as the no-vacation nation

2011-05-24T09:08:00.000-04:00

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.

Guess who else thinks Netanyahu is being ridiculous?

2011-05-21T22:05:00.002-04:00

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

The Failure of Netanyahu

2011-05-20T19:29:00.002-04:00

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.
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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.

Does Obama hate Israel?

2011-05-19T17:39:00.001-04:00

Here are some quotes from Obama's speech that pertain to Israel.
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"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.

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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.

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

2011-05-17T11:50:00.002-04:00

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.

Humans evolved to be persistence hunters

2011-05-09T07:18:00.000-04:00

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.

Osama Bin Laden and the US economy

2011-05-07T14:11:00.000-04:00

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?

2011-05-07T08:15:00.000-04:00

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.

Supermarkets aren't like schools

2011-05-06T09:07:00.000-04:00

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.

Military Dogs: coolest animals ever?

2011-05-05T19:55:00.000-04:00

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

2011-05-05T17:51:00.001-04:00

"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.

Killing Osama Bin Laden

2011-05-03T03:45:00.001-04:00

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.

Impressions from East Africa: food

2011-04-30T01:57:00.001-04:00

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.

Impressions from Tanzania, Part I

2011-04-26T04:44:00.001-04:00

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.

The Ethanol Gridlock, and Orwellian Obama

2011-04-18T09:30:00.000-04:00

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.

The Republican Debt Ceiling Bluff

2011-04-11T12:16:00.000-04:00

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.

Privatize Medicare?

2011-04-07T10:16:00.000-04:00

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.

Poor people just lack discipline!

2011-04-06T11:49:00.000-04:00

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.

Can we afford to intervene in Libya?

2011-03-28T20:32:00.000-04:00

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.

Is Obama Consistent on War?

2011-03-25T11:53:00.002-04:00

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.

Intervention in Libya, Intervention in Congo

2011-03-21T09:31:00.001-04:00

A lot of people have questioned why we intervene in Libya and not in places like the Congo, where civil war has resulted in the deaths of millions of people. The answer is that the nature of the threat to civilians in general is completely different. A useful analogy: if you have a gun, you can use it to protect your child from a wolf, but not from disease-carrying mosquitoes.

What is happening in the Congo and in many other failed states is a tragedy, but its very difficult for outsiders to stop the sort of low-tech civil war that goes on in places like that. The only real way to do it is to send massive numbers of US ground troops to impose order, and even then its very difficult and politically risky. There are situations in which it should be done anyway (Rwanda) but its easy to see that building up the political momentum for that kind of a mission might take longer than the conflict lasts.

By contrast, it is very easy for the US to stop civilian deaths if we can focus our efforts on a few targets, IE high-tech military forces like tanks and airplanes. Our military is built to deal with such threats. We can get there really quickly, because we have carriers all over the world. It is also far easier to secure political backing for such sorts of missions, since the risks are far lower.

Anyway, I do think that this effort has a reasonable shot at working. If you break the back of Qaddafi's military forces, and get a stalemate, then its just a war of attrition. If we are serious about getting him out, at that point we just impose an embargo on his oil exports and starve him out. Once his cronies realize the money well has dried up they will turn on him.

It is nice to dream of a world where our interventions are purely based on the gravity of the situation in the affected nation, but the reality is we have to pick our battles. We simply don't have the ground forces or the money to occupy every troubled spot in the world. But we do have an military that is really, really good at blowing up enemy tanks and airplanes. So if those are the weapons that a dictator chooses to use to kill his civilians, why not neutralize them?

In Libya, we send a message to the militaries of autocracies.

2011-03-20T16:54:00.000-04:00

The debate over Obama's actions in Libya have been hopelessly muddled by what happened in two other recent situations: what George W. Bush did in Iraq, and what Bill Clinton let happen in Rwanda. We must remember that there is a middle ground between "send 150,000 troops to occupy and nation build" and "let millions of people get massacred while the world watches". While Obama attempts to find that middle ground, critics are hysterical on both sides with claims that he is doing too much ("just like George Bush!") or not enough.

The truth is, our intervention in Libya is likely to be inconsequential more than anything. Our help may come too late to save the rebels. Even if they do hold out, they may not be able to finish the drive to the capitol to remove Qaddafi. Thats OK though, because the consequences of our intervention are similarly modest. We have a UN resolution and support from the Arab league. We aren't sending ground troops. Meanwhile, the Libyan military poses zero threat to us or our allies around the world. At best, we allow a revolution to drive out a dictator; at worst, our actions won't change anything.

There is another very good reason to intervene that I don't see many people talking about. This is an extremely important time in world history, with more revolutions in the Middle East almost certain to come. Our actions in Libya are very important, as they provide a very stark contrast for other militaries to consider. When a dictator in the future orders his military to attack civilians, what should the military do? They can take the example of the Egyptian military, and ignore their dictator's orders to shoot, thereby winning the adoration of their people, the support of the world, and the favors of America. Alternatively, they can follow the example of Libyan military, which followed Qaddafi's evil orders and ended up a smoldering, flaming wreckage as a consequence.

The threat of force won't deter everyone. For geopolitical reasons, we can't intervene in Iran, Syria, Bahrain, or some other potential hot spots. Still, this season of revolution is certain to be unpredictable. The single most important factor for the success of peaceful revolution is whether or not the military attacks the people. The last thing we want to do is send a message that it is OK for an air force or military to start attacking civilians. We would almost be inviting massacres. Even though it would be nice if some other country could deal with things for once, Obama is doing the right thing.

Congestion Pricing

2011-03-17T07:54:00.002-04:00

We all know from experience that the severity of a 'traffic jam' is not linearly proportional to the number of cars. Instead, a traffic jam almost seems to be a product of a threshold effect. A given highway can handle any number of cars smoothly up to a certain point. Once that point is reached, additional cars rapidly cause the buildup of a traffic jam. Obviously this does not apply to jams caused by accidents or breakdowns, but most traffic jams aren't caused by those things. Most jams are caused by too many vehicles on too small of an artery.

The implication is that if we were to institute congestion pricing and reduce the overall number of cars by 20%, we may not be reducing the severity of the traffic jam by only 20%. The extra cars that don't show up because of congestion pricing may have been what pushed the highway over the traffic threshold had they been present. By getting rid of that extra 20% of the cars, we could potentially get rid of the majority of the traffic slowdown. This is sound policy on so many levels. Liberals and conservatives should all agree on this, but we don't have this policy yet. Too bad.

Moving Beyond the Automobile: Congestion Pricing from Streetfilms on Vimeo.

First Teachers, then Physicians?

2011-03-14T10:34:00.004-04:00

If you view our governmental system as nothing more than a long protracted partisan war, I think the actions of Republicans make a lot of sense. Budgets need to be balanced, so why not make your political enemies foot the bill while letting allies off the hook? Teachers traditionally vote Democratic and their unions are a huge boon to Dem politics, so the GOP has come after them. I worry about this sort of 'trade warfare' as an American and as a future physician. I could be wrong, but my suspicion is that physicians as a group generally vote Republican. What if some hypothetical future extreme Democratic Party comes to power, looks at explosive health costs and deficits, notices that physicians support Republicans, and decide to punish us for it? They could simply block the medicare doc fix, or worse.

I resent the idea that one group should be faced with a disproportionate share of a social burden because they are on the losing side of politics. It is not unreasonable to expect sacrifice from public employees - and it looks like they were prepared to sacrifice in Wisconsin. At the same time, is gutting education spending the best way to secure our nation's long term prosperity? (If it was up to me, we'd cut teacher unions and tenure, but expand benefits and pay such as to make teaching jobs more competitive). There are more millionaires in New Jersey than teachers. There are other forms of public spending, including inefficient subsidies to various industries. There are of course costly entitlements, and the military. These dwarf our education spending in scale.

If Republicans are serious about improving our deficit situation, they need to do more than pay lip service to the notion of shared sacrifice. Focused partisan assaults on a few groups will never be accepted as fair. Any gains will be only temporary, and will simply be undone in the next electoral cycle. To make sustainable changes, changes that are accepted as fair by both political parties and thus not likely to be reversed, Republicans will need to cut government spending in all areas. They may have to injure some political allies in the process. That is the nature of compromise. Without mature leaders who were willing to compromise, our nation wouldn't exist; without them going forward, our nation won't exist.

Holding Our Leaders to a High Standard

2011-03-13T15:34:00.000-04:00

Say what you want about the left, but they hold their leaders to standards that the right can only dream of. What is happening to Bradley Manning pales in comparison to what Bush was authorizing on a regular basis to be done to hundreds of captives we had in Iraq, Afghanistan, and Guantanamo.

And yet, the outrage on the left against Obama is orders of magnitude greater than anything we saw from Republicans against their president. Republicans during the Bush era made apologizing and rationalizing their leader's blunders and excesses into an Olympic sport.

This is something conservatives should learn from the left. The next time your "small government" leaders try to expand entitlements, subsidize business with government money, or go on reckless foreign policy adventures, revolt against them!

This advice might be especially prescient given the situation in the Middle East and the fact that every GOP candidate for president apparently thinks we should have intervened militarily in Libya and Iran to help anti-government forces. Have none of them learned anything over the last decade?

Republicans should repeal Medicare Part D

2011-03-06T16:03:00.001-05:00

Republicans are obsessed with repealing costly health care bills. Why not start with Medicare Part D? This massive unfunded entitlement expansion was passed by the Bush Administration just before the 2004 elections to buy-off the senior vote. Why not repeal it today?

Something George W. Bush got right

2011-03-03T14:09:00.000-05:00

He did a good job, in the aftermath of 9/11, in reminding us that Muslim-Americans are good people and should not be confused with the extremists who attacked us. Its a shame that his supporters seem to have forgotten that.

Imagine that protest was at a synagogue, and its target was Jews. It would be a window into Germany circa 1933.

A republic, if we can keep it.

2011-03-02T19:33:00.001-05:00

It was really only a matter of when this sort of thing would happen rather than if, but Fox News was caught lying about the protests in Wisconsin. In this video, which Fox attributes to the pro-union protests in Madison, we see some violent protesters. Also notice there are palm trees in the background: there is no way this footage was from winter in Wisconsin.

Fox News makes "mistakes" like this all of the time. They may accidentally use the wrong footage to make a Tea Party protest look larger than it is, or they may misquote people, or take things out of context. And this is just when they are reporting, don't even get me started about when their pundits come on and start talking. It is hard to believe Fox is just innocently erring when these mistakes happen, because the change always happens to benefit a right-wing narrative. At any rate, the purpose of this post wasn't to point out a lie that Fox News is trying to sell. Thats old news.

An interesting fact that came up when I was reading about this latest lie was that Fox was recently denied access to Canadian television. Canada has a law in place that prohibits misleading or false information from being propagated from television news stations. A lot of people apparently wish we had a similar sort of law here in the states, but I don't. The most indispensable legal right we have in America is the 1st Amendment. That includes the freedom to lie, if that is the agenda of a person or organization. I want no affronts to the freedom of speech, and furthermore I would not want the government to spend effort deciding what is true and what is not (if that was even possible).

Ben Franklin told us after the constitutional convention that we have been given a Republic, if we can keep it. I am confident that when it comes to lies and propaganda, Americans as a group will see through it and will ultimately marginalize the source. I have written before: Fox News undermines conservatism. The phony debates they have on their network cheapens our discourse. The influence conservatives grant to Fox means that they, not we, decide who our party leaders are. Every time the network lies and gets caught, they hand a recruiting tool to the left.

The onus is on conservatives to demand better from Fox News.

(Another) Oil Bubble

2011-03-02T00:02:00.001-05:00

Oil prices have been rising lately, probably caused by a multitude of factors. As the economic recovery quickens, demand will increase and so price along with it. Adding to the increases are all of the revolutions going on in the Middle East. Concerns are abound about Iran and Saudi Arabia in particular.

An important point that is often lost on people is that oil producers like Iran are in sort of a catch-22. In the event of an actual geopolitical crisis (a war, for example) with a subsequent disruption of oil supplies, the price of oil would indeed skyrocket. But if Iran isn't selling their oil, they don't benefit from that increased price. Thus it is in Iran's interest to increase tensions and concern of a geopolitical crisis without precipitating one. That way, the price of oil goes up and Iran makes a juicy premium on what it would have exported anyway.

Then you think about what would happen if there was actually a disruption: say a conflict in the Strait of Hormouz or a revolution in Saudi Arabia. The price of oil would skyrocket, possibly to close to 200 dollars a barrel. Consider though that both of those nations are heavily dependent on oil to keep their countries running. In the event of a disruption and subsequent price spike, that nation has a huge economic incentive to get their oil back to market ASAP to take advantage of the high prices. I don't care who takes over Saudi Arabia: you factor in the number of barrels they can export every day times a 200 dollar per barrel price, and its obvious that any disruption will be short lived.

Finally, I think its pretty clear that the demand for oil is pretty plastic. Americans waste a ton of fuel. Dressing warmer in the winter and heating homes less could save a lot. Carpooling, taking a bus, or riding a bike would save more. These are all things that we don't do now because gas is only 3 dollars a gallon; they are things we will do if gas hits 5-6 dollars a gallon. Adding to the flexibility of demand for oil is the fact that there *are* substitutes. Natural gas, nuclear power, and coal for example (the latter two could power cars via batteries).

Commodity speculators were almost certainly behind the spike of oil to 140 dollars per barrel that we saw a couple of years ago. A price at that level was not economically sustainable. With all of the aforementioned variables causing uncertainty in the oil market, the speculators no doubt will be at it again. All things being considered, we will almost certainly see another oil bubble soon. I suspect that prices over 130 dollars per barrel are not sustainable over the long term. If I had some financial assets I'd be ready to short anything above that. You'd have to be crazy to not short anything above $ 160 / barrel, which I wouldn't be surprised to see at some point in the next year or two.

Netanyahu Halting Settlements

2011-02-28T22:11:00.000-05:00

The odd thing is that he has really only de-facto halted the settlement construction in the West Bank, and apparently hasn't stopped private expansion. Here is a NY Times article which discusses Netanyahu's recent criticism of fellow right wingers in Israel:

“People don’t understand the reality they are living in,” Mr. Netanyahu was quoted as telling an assembly of Likud ministers and legislators, as well as some leaders of Jewish settler councils from the West Bank, who then passed on the remarks to the Israeli news media.

“If you don’t live in this world, you can ignore everything, and I suggest that you beware in order to protect the existing construction, because that’s what’s on the agenda, not the new construction,” Mr. Netanyahu said.

The really bizarre thing is that Netanyahu is taking flak for not expanding the settlements but he really isn't getting the benefits of an outright ban, which would be an advancement of the peace process and the acclaim of the international community. Some people are quick to suggest that the peace process would fail anyway, so why should Israel bother? The answer is simple: world public opinion. Anyone who doesn't think that matters over the long term is crazy. Turning world opinion against Israel is the main strategy of anti-Israeli extremists. Expanding settlements only plays into their hands.

Grown-up Behavior

2011-02-22T23:49:00.001-05:00

Politicians who are actually interested in doing the business of the people and not just furthering their own ambitions are a lot less exciting. That is a good thing. Mitch Daniels has demonstrated to Hoosiers that he is a capable, mature, and very serious leader. I wish other Republicans would take note. Mitch has proposed a temporary truce on divisive social issues so we can get our economic house in order, for example. That is a great idea, one that will be rejected by self serving politicians who make careers out of plucking the emotional strings of Americans about these social issues. Mitch proposed a consumption tax as an alternative source of revenue and was crucified for it by the right. Here is Mitch Daniels being a leader again, about union stripping measures, and the subsequent Democratic exodus:

"I'm not sending the state police after anybody. I'm not gonna divert a single trooper from their job of protection the Indiana public. I trust that people's consciences will bring them back to work. ... For reasons I've explained more than once I thought there was a better time and place to have this very important and legitimate issue raised."

A better time and place, indeed. Mitch wants to reform and doesn't want petty squabbles to get in the way of that, and that's because he cares about the people of Indiana more than his own ambitions. Make no mistake, this move will get him criticized by national GOP leaders and certainly won't help him in a Republican presidential primary.

Another great Hoosier Republican is Dick Lugar, who committed the heinous crime of supporting Obama's arms control bill with Russia. Nuclear arms control was a major goal on which he partnered with then Sen Obama before 2008. Sen Lugar is another leader who puts people over politics, the penalty for which will be a primary challenge from the state GOP.

National Republicans should be emulating guys like Daniels and Lugar, not marginalizing them. Republicans are not our problem, and Democrats aren't our problem. Rather, our problem is uncompromising extremist jerks on both sides of the aisle who would rather hurt the other side more than help Americans. People, we need less partisanship, not more, but you don't get less partisanship by demanding more ideological purity at the gate.

Banksy!

2011-02-22T14:32:00.000-05:00

I was living in New York City for a couple of months last summer while doing rotations at Memorial Sloan Kettering. One weekend we went to Williamsburg for dinner, which is in Brooklyn, one subway stop past the East River. Williamsburg is still a developing neighborhood, but is a really cool place. If I was going to move to NYC I'd buy a place in Williamsburg if anywhere. Williamsburg is now what the East Village was like 15-20 years ago.

Anyway, we were walking into a tea bar (it was my first time going to a tea bar) and I noticed some graffiti on the brick wall outside. I recognized it as being the work of a famous graffiti artist by the name of Banksy, or at least it was a fantastic imitation. In the drawing, there is a man holding a remote control. He is standing in front of a giraffe with a radio collar around its neck, so the man seems to be controlling the giraffe. The giraffe has a paintbrush in its mouth, which it is using to write the word "vandal" on a high part of the wall. The theme is classic Banksy, although like I said it could be an imitation.

Bizarro Capitalism in Health Care

2011-02-22T10:39:00.001-05:00

Thanks to Tyler Cowen for the link, here is an interesting article where the governor of New Hampshire is basically telling hospitals in his state that they need to stop expanding. A basic principle of macroeconomics is that supply and demand are inversely related. Only in the health care industry, apparently a world of bizarro capitalism, could increasing supply actually increase demand.

In fact, this is not a new phenomenon nor is it a novel observation. Health care resources tend to get concentrated in areas where everyone has access to insurance. The population in those areas tend to get more health care spending than they need, with no demonstrable increase in outcomes at all. Spending elsewhere is suboptimal. The net effect is that distribution of health resources is only tangentially tied to demand, and is certainly inefficient at any rate.

Anyway, sort of related. I got an email from a friend, which is an email that a med student apparently sent to President Obama. The student was on his emergency medicine rotation, which is what I am doing this month, so I figured I'd add it. I end up with a lot of similar sentiments after my shifts in the ED.

----------------------------------------------------------------------------------

Dear Mr. President:

During my shift in the Emergency Room last night, I had the pleasure of evaluating a patient whose smile revealed an expensive shiny gold tooth, whose body was adorned with a wide assortment of elaborate and costly tattoos, who wore a very expensive brand of tennis shoes and who chatted on a new cellular telephone equipped with a popular musical ringtone.

While glancing over her patient chart, I happened to notice t hat her payer status was listed as "Medicaid"! During my examination of her, the patient informed me that she smokes more than one costly pack of cigarettes every day and somehow still has money to buy pretzels and beer.

And, you and our Congress expect me to pay for this woman's health care? I contend that our nation's "health care crisis" is not the result of a shortage of quality hospitals, doctors or nurses. Rather, it is the result of a "crisis of culture", a culture in which it is perfectly acceptable to spend money on luxuries and vices while refusing to take care of one's self or, heaven forbid, purchase health insurance. It is a culture based in the irresponsible credo that "I can do whatever I want to because someone else will always take care of me".

Once you fix this "culture crisis" that rewards irresponsibility and dependency, you'll be amazed at how quickly our nation's health care difficulties will disappear.

Respectfully,

STARNER JONES, MD

Act on a mandate, or squander an opportunity?

2011-02-19T15:02:00.000-05:00

We keep hearing about this "adult conversation" that our politicians are going to have with us, which is code for cutting entitlements. Entitlements of course represent by far the largest chunk of federal spending, and it is growth in those entitlements, especially medicare, that is the cause of the massive budget shortfall predicted in a few decades. I am fully supportive of having this conversation about entitlement cuts, but all we have right now is a budgetary impasse. Republicans have thus far only had the political courage to target non-defense non-entitlement discretionary spending for their cuts, but Obama doesn't agree that we should gut the EPA, ax R&D, and shut down all of the national parks in order to put a band-aid on our hemorrhaging debt problem.

President Obama just released his own budget proposal, and Republicans have been lambasting him for a lack of leadership basically because he didn't propose cutting entitlements. I'm not really sure why Republicans are waiting for Obama to make the first move in proposing those cuts. Didn't Americans elect the GOP because they don't trust Obama on spending? And if Obama is as left wing as some purport him to be, why would he ever go along with, let alone propose, entitlement cuts? At any rate it's pretty obvious that Obama will agree to cuts in entitlements. What the Republicans really want, and the reason for the current impasse, is for Obama to help them avoid the political consequences of proposing and enacting entitlement cuts.

While Republicans are dithering about when or if to make the first move on this huge issue, they might do well to look at recent history. Obama poured virtually all of his political capital into his health care reform bill and he did it when he was fresh in office and most popular. If he had waited it never would have happened. The consequence of passing such a huge bill was he suffered politically in the next election. Republicans are now in a similar position. They were swept into office with a mandate to cut entitlements. If they want to make those cuts, they could do it now. Obama would not stop them. But he isn't going to make it *easier* for them. To expect otherwise is to live in a fantasy land. Republicans didn't make it easier for Obama and the Democrats to enact the long-time dream of universal health coverage, they did the opposite. Thats just politics 101.

As I've said before, there is a difference between electoral victory and legislative victory. The former means nothing without the latter. There will be huge resistance to any entitlement reforms - we are seeing a glimpse of it in Madison Wisconsin. The longer the GOP waits to move, the more time the opposition has to sap their momentum and break their will. Republicans may be squandering their only chance for years to do entitlement reform. The GOP needs to stop waiting around for Obama to give them political cover (he won't) and stop diddling around with the small peas of discretionary spending. The real victory is in medicare and social security, if Republicans have the courage to take it.

Naturally, I'm not optimistic about the Republican Party. I think they'll skirt around the real issues and instead focus on PR stunts like shutting down the federal government while whining that Obama won't let them do anything.

Worse Than CCTV, continued

2011-02-13T12:02:00.001-05:00

Is Fox News worse than China Central Television? When it comes to the Egyptian protests, CCTV is choosing to simply ignore the issue: they are not running any footage or stories of the revolution. Contrast that to Fox News, which is actively cheering for the forces of authoritarianism and repression. Here is Rachel Maddow taking Fox to task for standing squarely on the wrong side of history, on the wrong side of American ideals, on the wrong side of morality.

http://www.politicususa.com/en/rachel-maddow-fox-mubarak

The most confusing thing of all is that, by taking this anti-democracy stance, Fox News is essentially rejecting the Bush administration philosophy towards the mdidle east. That philosphopy, founded by the neocons, was the reason we invaded Iraq and overthrew Saddam. Hell, the war itself was called "Operation Iraqi Freedom". And the march to war in 2003 was supported by Fox News more than any other organization!

Tim Pawlenty's phenomenal idea

2011-02-13T10:58:00.001-05:00

I saw T-Paw on a television show the other day, and he had this proposal: make members of congress do their own taxes. Furthermore, the law would forbid them from using a lawyer or accountant for help - they have to do it themselves! This would give members of congress a taste of the awful tax code that they expect the rest of us to grapple with. Maybe then they'd have more incentive to simplify it.

If it was up to me, I would contract out google to redesign the tax code and develop a system for collecting taxes and distributing returns.

Worse than CCTV?

2011-02-11T03:58:00.009-05:00

A year ago, I had the opportunity to live in China for 5 weeks or so. I had intended to make a comment about CCTV (China Central Television) and its influence on the people...and how those lessons are relevant for the United States. I basically left China with the impression that CCTV was less harmful to the Chinese than Fox News is to the United States. And yes, I am being completely serious.

To be clear: the argument I am making is NOT that CCTV lies or propagandizes less than Fox News. My argument is that CCTV is in net less damaging. In China, everyone knows that CCTV is state run, is biased, and is propaganda. Therefore, it seems like most people there take everything they see on CCTV with a great big grain of salt. Many people might be prone to flat out disbelieve anything the broadcaster says purely because it is on CCTV.

Contrast that to Fox News. While there was a recent poll that demonstrated that Fox was the least trusted name in news, that was mainly by virtue of their large negatives. There is still a huge segment of this nation that actually thinks Fox News is "fair and balanced". Fox is very divisive: the people who watch Fox only trust Fox, and the people who don't watch Fox really tend to distrust it.

Some might argue that Fox is no worse than MSNBC, which is obviously baised to the left. But Fox goes beyond bias. MSNBC is biased to democrats because they will focus on the stupid things republicans do and not focus on the stupid things democrats do. Or they will make arguments to support Democrat ideas and ones critical of Republicans ideas. But the crucial difference between bias and propaganda is that MSNBC rarely is actually dishonest about what they are presenting.

Fox News is different. They do have a routine habit of distorting, of manufacturing and propagating lies, of spreading misinformation generally. In fact, they've done far worse in my eyes: in the 2008 presidential primaries, Ron Paul won the straw poll from the first GOP presidential primary debate. Fox News pundits after sat around and all agreed that Ron Paul actually didn't win the debate, and then later Fox News tried to exclude Ron Paul from the next presidential debate that they were hosting. It was the single most reprehensible display of utter contempt for the American people that I have ever seen from any person, group, or organization.

Anyway, watching this recent clip of routine Fox News BS made me think to write this.

http://www.huffingtonpost.com/video/video_2324.html?1271360625

The last point I will make is that it is my belief that Fox News hurts America not because they hurt the Democratic Party, but because they hurt the Republican Party. Fox News almost is doing Democrats a favor at this point: the young internet-saavy Jon Stewart generation is very aware of the blatant lies and distortion that Fox pulls on a regular basis, even if elderly voters aren't. Anti-Fox sentiment is a rallying cry for the left.

Its the damage that Fox News does to conservative discourse that really hurts America, because we cannot operate as a nation without two viable political parties, and right now we really only have one. Fox News hurts Republicans because they are essentially the king makers. Sarah Palin is a force in American politics right now *because* of Fox News' promotion of her. In fact, the only reason she ever was named VP was because John McCain was stupid enough to let the establishment, of which Fox is a part, hand pick her for him. All of the intellectual hacks that Fox News promotes among the rest of the Republicans who have been named the leadership of the GOP have contributed to the rot of conservatism as a movement, a movement which I predict will prove utterly incapable of capitalizing on the electoral gains yielded by the inevitable backlash to overwhelming Democratic legislative gains seen in Obama's first two years (and a terrible economy).

Conservatives in the past used to be unafraid of taking on the left because they were confident in their principles and understood the ideas behind them with an unashamed intellect. Now they only go in front of friendly journalists like Sean Hannity and hit scripted soft-ball questions. Many conservatives have read "Atlas Shrugged" by Ayn Rand. For anyone who doubts if what I am saying here is true, ask yourself this question: who among today's Fox-anointed Republican leadership would John Galt not be contemptuous of? I can think of only one: Ron Paul. But as Donald Trump said tonight, Paul can't win a general election.

Quick update: I wanted to add some clarification. There are a lot of Republicans who I have a high opinion of. In fact, we have a few of them in Indiana; Mitch Daniels and Richard Lugar in particular have done a great job for our state. Mitch Daniels has a ton of smart ideas, but he has no megaphone with which to talk about them, because Fox is too busy promoting Republicans who obsess over culture war issues, or who are fond of suggesting that Obama is a Muslim. Perfect example: Mitch Daniels wrote an Op-Ed proposing a VAT, and he got crucified for it by the Fox-dominated GOP establishment. Meanwhile, Dick Lugar is facing a major challenge by the Tea Party in the 2012 election. They despise Lugar, and I'll tell you why: he is way too reasonable. He is willing to work with Obama on issues that advance the national interest (securing nuclear materials, START, etc), and that is a crime to many GOP primary voters.

the State of the Republican Party

2011-02-10T14:32:00.001-05:00

Mitch Daniels, the effective governor of Indiana, recently wrote an op-ed. He went into detail about how serious the economic situation of America is, and how important it is that we lay a strong foundation for growth in the future while reducing our debts. I think all Americans agree that these are the most important challenges facing our nation, and that sentiment is why the Republican Party won a landslide election in November. To accomplish these challenges, Daniels proposed that we called a temporary truce on contentious issues like abortion, gay marriage, etc so we can focus on the economy. Leave culture warrior issues for another day.

Since taking the House of Representatives, what have the Republicans focused on? Most of their efforts have been spent redefining what "rape" actually is so they can try to restrict abortion rights for poor women (which is silly anyway, because poor women can still get food stamps or welfare, so money not spent on food and housing can go towards abortions). They've also expended a huge amount of effort trying to put in constitutional amendments to define "marriage" as between a man and a woman. From an economic standpoint, the only thing the GOP has done is promised to cut 32 billion or so in spending this year. That amounts to roughly 0.9 % of our yearly federal budget.

Republicans came to office in November promising to focus on jobs and the economy, to reduce the size of government, to balance the budget. They've done none of these things, and I don't have much hope that they will. They've fallen back on the old battles that the Bush administration focused on while the country melted all around him. My skepticism vis a vis the new libertarian-conservative revival of the Republican Party that we saw last year seems to have been well placed, unfortunately.

The importance of evidence based medicine

2011-02-08T19:32:00.002-05:00

From my inexperienced vantage point, the greatest internal battle going on in the medical profession is the contest between medical dogma and evidence based medicine. Believe it or not, there are quite a few interventions that physicians utilize on a regular basis that have never been proven to actually benefit patients.

If some treatments aren't proven, why are physicians still doing them? Well, lets hypothetically say that obstetricians have been doing "x, y, and z" for premature babies for the last two decades, but there is actually no evidence to support z. Are you going to let your premature child be the first in an experimental group that forgoes treatment z? And what kind of malpractice insurance would a physician have to have in order to conduct that sort of experiment?

A New York Times article about a new breast cancer study touches on this challenge. Its pretty easy to convince someone to try something new that is not proven, but getting them to pass on established treatment options in the name of science is another matter. And yet, the physicians who carried out this study on breast cancer did just that. A quote from the article:

The complications — and the fact that there was no proof that removing the nodes prolonged survival — inspired Dr. Giuliano to compare women with and without axillary dissection. Some doctors objected. They were so sure cancerous nodes had to come out that they said the study was unethical and would endanger women.

As it turns out, the study proved that axillary dissection in some women provide no benefit. This is a win-win-win. The surgeons can be confident they are providing the best care, the patients are not getting unnecessary treatment with lots of complications, and the health care system is not losing thousands of dollars on a procedure that isn't helpful. A very courageous study, and we need more like it. I don't presume to know all of the barriers that prevent more research studies like this from being executed, but we should all be working to break them down.

One Frail Heartbeat from the Presidency

2011-02-08T08:49:00.001-05:00

Here is Sarah Palin on Egypt. Remember: she was almost VP, and is considered a GOP frontrunner for 2012:

"It's a difficult situation. This is that 3am White House phone call and it seems for many of us trying to get that information from our leader in the White House, it, it seems that that call went right to, um, the answering machine. And, uh, nobody yet has, uh, explained to the American public what they know, and surely they know more than the rest of us know, who it is who will be taking the place of Mubarak. And, um, no, not not real enthused about what it is that is being done on a national level from DC in regards to understanding all the situation there in Egypt and, um, in, in these areas that are so volatile right now, because obviously it's not just Egypt but the other countries too where we are seeing uprisings. Uh, we know that now more than ever, we need strength and sound mind there in the White House. We need to know what it is that America stands for, so we know who it is that America will stand with. And, um, we do not have all that information yet."

Israel's Historic Missed Opportunity

2011-02-05T12:18:00.007-05:00

It certainly seemed that the Israelis were in an exceptionally strong position over the last two years compared with the historic average. Israel had waged two wars against its near enemies, Hezbollah in 2006 and Hamas in 2008. Politics aside, these conflicts were undeniably decisive military victories for Israel. In the meantime, we've seen the international community rally further against Iran, and Syria has been quiet as well after being caught red handed building a nuclear reactor and subsequently bombed by Israel. So strong was the Israeli position that we have seen come to light an assortment of embarrassing leaks about the extent to which the PA was willing to make concessions to Israel to advance the peace process.

Of course, one of the great drivers of wars in the Middle East is religious extremism. To Americans, the biggest culprits here are groups like Hamas, who refuse to renounce violence or recognize Israel. Unfortunately, there are Israeli religious extremists, too. The Israeli government has refused to confront the settler movement, who continue to build in East Jerusalem and in the West Bank. If the Israelis want to continue to advance settlements, that is one decision. The consequence of that decision is that the peace process is stopped in its tracks and the international community almost universally condemns Israel for the provocations, with the exception of America.

This is all very frustrating to me. I had enormous amount of respect for Binyamin Netanyahu when he took power. Then Obama was elected, an American president who clearly demonstrated a superior understanding of the conflicts in the region and also one who had unprecedented support from Arabs and Muslims in general, by virtue of not being George Bush, having opposed the Iraq war, having a Muslim father, and having lived in a Muslim country as a boy. In this context, I was extremely optimistic about the prospects for peace. I figured the Israelis would be ready to make a move, because the the best time to compromise is when one is in a strong position, and the Israelis clearly were.

Alas, instead of compromising, Israel squandered its time. Binyamin Netanyahu, for all of his military courage, didn't have the political courage to stand up to these irrational religious extremists in the settler movement. When Obama took office, his first move in the Israeli-Palestinian dispute was to call for restraint from both sides, and specifically asked the Israelis to simply halt new settlement construction. Netanyahu humiliated Obama by refusing until Obama bribed him sufficiently, and even then only yielded a temporary freeze which expired soon thereafter. The peace process was stopped dead in its tracks because a bunch of religious extremists believe that Allah or Yahweh promised them the same land. From our end, Republicans have been encouraging this bad behavior on the Israelis' part not because it was in the best interest of Israel, but so they could contribute to Obama's failure.

In fact, just the other week, Mike Huckabee gave a speech commemorating the completion of a new settlement built illegally in the West Bank. Expanding these settlements into the West Bank does not contribute to Israel's security, it gravely undermines it. Yet to Christian evangelicals in the United States and to the Israeli settler movement, these settlements are justified and necessary from a Biblical perspective. At this point we might pause and ask ourselves if the Old Testament is a good guide for American foreign policy in the Middle East. If anyone actually needs an answer to this question, I would refer them to Deuteronomy 20:17 for God's recommendation for dealing with the Palestinian question.

Last week an earthquake struck the Middle East with the epicenter in Cairo. The greatest Arab ally of Israel, and one of the few with a peace treaty, is going to be overthrown. What will come in Mubarak's place? If the new Egyptian government is at all democratic, it will certainly be a government that is far less friendly than Mubarak towards Israel: a recent poll showed that 3% of Egyptians have a positive attitude towards Israel while 91% have a negative attitude. Egyptian animosity towards Israelis will only worsen when Egyptians find out that Netanyahu's government had been frantically lobbying the Obama administration to stand by Mubarak when the crisis hit. Incidentally, I was reading about how some American Jews are struck by the irony of the Jewish Israeli government working to stifle the freedom of oppressed peoples in the lands of Egypt.

What happens from here on out? I do not believe we will see a return to the days of Nasser, where Egypt is actively warmongering and planning to attack Israel. I suspect Egypt will go the way of Turkey lately; relations with Israel will cool, perhaps to the point of animosity, but mutual alliances with the United States should provide enough glue to prevent a severing of relations or outright military confrontation. Still, it is very difficult to imagine that the Egyptians over the long term will continue to enforce the blockade of Hamas in Gaza, which causes great hardship for the 1.5 million Palestinians in the strip. There is no doubt that Hamas and Hezbollah will be emboldened that by far the most populous and important Arab country may become less friendly to Israel.

Nietzsche once said that true courage is having the strength for an attack on one's convictions. Any hard-headed fool can stubbornly cling to his beliefs, no matter how enormous the evidence to the contrary. George W. Bush ignored for almost 3 years the disastrous reality of Donald Rumsfeld's handling of the War in Iraq, and thousands of American soldiers died because of it. George W. Bush is a coward precisely because he did not have the strength for an attack on his convictions. Binyamin Netanyahu is similarly guilty and has let his people down. In retrospect, we will all come to realize the enormous opportunity to make peace over the last two years that the Israelis had. The Netanyahu government wasted this opportunity because it didn't have the political courage to stand up to their religious extremists in the settler movement. Again and again in history, we see that the easy thing for politicians to do is to beat on the drum of nationalism and to prove their mettle by refusing to compromise. It is much harder to offend some of your own in the name of compromise and advancing their interests.

When it comes to Israel and war, there are two questions: one is whether Israel has the right to keep pounding its enemies, and the other is whether it should keep doing so. The first question: Israel certainly has the right to defend itself. No doubt, it feels good to see Israel teach a terrorist group like Hamas a lesson, especially after Hamas provoked the Israeli response. The second question is harder to answer. Israel beat Hamas, but hundreds of innocents died in the process. The international community almost universally condemned Israel. Relations with Turkey in particular melted down to almost nothing. The most important thing to remember is that pounding Hamas did not actually accomplish anything for Israel. Hamas is still in Gaza, it is as radical as ever, and it is still arming. Israel cannot continue to engage in these wars with non-state actors who don't care how many of their own people die so long as they hurt Israel; it's like playing chicken with someone who is suicidal. Weapons and war can only make Israel safe in the short term; the only thing that can make it safe in the long term is compromise, negotiation, and peace.

China Mega-City of 42 Million People

2011-02-03T10:36:00.003-05:00

Guangdong Province in southern China is the manufacturing heartland of the nation, perhaps like the Chicago-Detroit-Cleveland hub of the United States a few decades ago. China wants to consolidate 9 cities in Guangdong, including the capitol, and merge them into one large mega-city of 42 million people.

When I did an exchange in China last April, I lived in Guangzhou (the capitol) for a month and had the opportunity one weekend to travel to Hong Kong, which is just south of and not included in this proposed mega-city (since Hong Kong is its own special administrative region and not really included in China proper).

The interesting thing about this plan is that this area is already a mega-city. Its not like China is trying to play semantics here for bragging rights. Guangzhou is only about 100 miles from Hong Kong. Furthermore, on the drive (by bus) from Guangzhou to Hong Kong, we passed through the bulk of this proposed mega-city. Between Guangzhou and Shenzen, for example, it's not like we were driving through empty fields and farmland. It was all highly populated. It wasn't as dense as the cities proper, but it was every bit as dense as the bulk of Indianapolis is.

Apparently the impetus to consolidate is to streamline all of the public infrastructure servicing the cities. Under one authority, it is more efficient to organize rail and transit, for example. I am a big fan of China, but I am not as bullish on China as some people in the United States are. Sure, the Chinese economy is going to overtake ours, and relatively soon, but I still think their challenges going forward are larger than a lot of people suggest. That being said, for people who are terrified of China's rise, this is another example of how they are getting a leg-up on us, by smart planning to make their cities and infrastructure more efficient.

There has been a lot of talk lately about how cities and states in the USA are going to all start going bankrupt. Maybe the low population density of American cities has something to do with it? Compare Indianapolis to Amsterdam, which both have about the same population, but Amsterdam is physically only 20% as large as Indy (and Amsterdam feels less crowded for some reason). Which city's infrastructure is more expensive to maintain? The two cities are so different in part to their historic development, but for the last 50 years in America we have guaranteed cheap gas and large abundant roads, whereas in the Netherlands they've taxed gasoline and built public transit with the money. Plus, they have awesome bike lanes which are often physically separated from the roads, leading to things like this: a packed bicycle parking garage next to the central train station.

I don't think it is ever too late to change our development model. The new buzz in Indianapolis is that one of the highways on the upper east side is constantly clogged because the suburb up there is booming. There is so much land in the city proper that is hardly being used, its just a shame these people aren't moving into those areas instead. It seems less efficient to build ever outward when we already aren't using what we have, but I understand schools are a big part of the problem.

The evolution of overconfidence

2011-02-01T22:22:00.003-05:00

In a free market that is influenced by evolved human behavioral overconfidence, there will always be bubbles, and always be spectacular crashes.

Something Americans should be proud of

2011-01-31T14:06:00.001-05:00

Support for Mubarak aside, our military has played a large role in educating and training the Egyptian military. Now as Mubarak is on the verge of collapse, he is almost certainly trying to order the military to crack down. The Egyptian military has refused to turn its guns on the civilians (thus far).

It would be nice if not massacring civilians was a given, but we've seen that very thing happen time and time again in dictatorships. The professionalism of the Egyptian military reflects well on the US military and the excellent job it has done in training the leaders of Egypt's armies.

The real question is whether or not the civilian leadership will successfully push for free and fair elections. My suspicion is that President Obama will do the right thing and reject the installment of another strongman to replace Mubarak. The Egyptian people need to finally have a chance to attempt to build a democracy.

Amazing how quickly things happen

2011-01-29T09:26:00.001-05:00

Mubarak's security forces have withdrawn from the streets and are now surrounding the presidential palace. The army was called in - but is doing nothing, and if anything the soldiers are starting to take part in the protests. The protesters already smell blood metaphorically speaking in the firing of Mubarak's cabinet. They also smell blood literally. When this sort of thing was happening in Iran a couple of years ago, someone pointed out that if the government security forces are going to spill blood, they need to spill a LOT of blood. Only killing a few people just pisses the crowd off even more. Mubarak personally is a more challenging position than the Iranians were though, because Mubarak couldn't just start massacring protesters like the Iranians did without alienating his important Western allies. Its hard for anyone to know, but it seems to me that a threshold of no return has been passed. Now that the security forces are gone, there is nothing to get the crowds off of the streets. At this point I can't see how Mubarak does not fall.

Vice President Fail

2011-01-28T10:55:00.001-05:00

Honest to goodness, what a jackass:

"I would not refer to him [Mubarak] as a dictator."

This brings me back to my go-to axiom of American foreign policy: whatever Joe Biden says, take the exact opposite and that is probably best.

I know that Egypt has been an important American ally, because we have to deal with the world as it is. That means cozying up to some less than scrupulous characters from time to time (actually, on a pretty regular basis). Nevertheless, Mubarak is certainly a dictator, and his policies are almost certainly not good for the Egyptian people. If Biden didn't want to throw Mubarak under the bus outright, he could have just declined to answer the question: "I'm going to let the Egyptians deal with their own internal affairs" would have been a sufficient response.

Egypt has been especially important as it relates to the peace process between Israel and Palestine, but even there its pretty clear that Mubarak is a net negative. This should transcend partisan opinion pretty easily - remember that this was the entire premise of the neoconservative invasion of Iraq. As the neocon story goes, Arabs are angry because they are not free, and so that anger is channeled by their leaders at Israel. If we free the Arabs and give them democracy, they can prosper and the animosity at Israel disappears. I actually subscribe to this sort of thinking, but where neoconservatives and I part ways is whether America should intervene militarily to spread democracy in Arab countries: I didn't think we should in the case of Iraq.

Back to Egypt, I think everyone agrees that Mubarak is a net negative for American policies in the region, but we keep him propped up because we are worried about a worse alternative. Perhaps our worst fear would be a Muslim-brotherhood Hamas-type government taking power, cutting off ties with Israel, talking about war, and generally destabilizing the region. That is a small risk risk if Mubarak goes, but I think we make that outcome MORE likely by blatantly supporting Mubarak, which only increases anti-American sentiment. Maybe we should take a step back and let the Egyptians go their own way, and promise to help and engage them no matter which direction they go. In the short term, they may even move in a direction that we are less than enthusiastic about, but in the longer term we can win them back.

Of course, I don't necessarily think Mubarak is going to fall, but its certainly possible, and we should be thinking about what to do if he does.

Saw this coming from a mile away

2011-01-25T13:46:00.000-05:00

Protests in Egypt, inspired by Tunisia, coordinated with Facebook. I'm not sure how efficiently Arab governments can clamp down on social networking sites on the internet, but it could be a long summer if they can't do it very well. After medical school graduation, I was hoping to backpack through the Middle East. That is looking like it might not be such a good idea anymore. Will play it by ear I guess.

If not kicking it deep is a good strategy in the playoffs, why isn't it a good strategy for the regular season?

2011-01-24T11:05:00.001-05:00

Watching the NFC championship I was reminded of what seems to be a relatively common phenomena in the NFL playoffs: teams are opting to kick the ball low and fast instead of higher and farther. Presumably this is to reduce the chances that the kickoff returner will run it back, but it comes at the cost of letting the receiving team get a slightly better start position.

If this increases the odds of winning a playoff game, why not do it in the regular season?

Should we cut the NIH budget by 44%?

2011-01-22T13:13:00.001-05:00

I was watching an episode of Fareed Zakaria's GPS program the other day, and the thesis of the hour was innovation. One of the points that was made by some titans of business and innovation is the crucial role of government in research funding. Whether we're talking about 60% if not more of cancer research, the internet, the global positioning system, government research money has been behind a lot of the major advances in our society.

The Republicans want to pass budget cuts - and certainly we need them. However, they don't want to touch social security, medicare, or defense. To be politically safe, the GOP is focusing on "discretionary spending". This includes the NIH, the FBI, environmental protection agencies, education, and the list goes on and on.

We're really going to have to think long and hard about our priorities as a nation, because we can't have it all. Do we want to continue to nation build in Afghanistan? Should we continue to accept our role as the world's policeman with a 500 billion dollar military? Should the government continue to pay people to stop working at the young age of 65 (ie, social security). Or, do we want to invest in the future, by putting more money in education, science, and research?

Something tells me that the Chinese won't be cutting their education and research budgets anytime soon. Its OK though. All of the new jobs in the biosciences can be created in China just as easily. Maybe in the future we will import our cancer and other medical treatments from China like we do with toys today. The most intelligent young American scientists will compete to earn a Ph.D. spot in a Chinese laboratory. The top American medical researchers will move their laboratories to China where funding is reliable and easy to get. The pharmaceutical companies might start following the researchers over there.

The research is going to get done. It is just a matter of where.

Our lab paper: CD4 T cell mediated tumor destruction

2011-01-19T07:46:00.000-05:00

I took a year off between my third and fourth years of medical school to do research. Part of my efforts were devoted to a large project, the results of which were published in December 2010. Here is the abstract of our paper in the Journal of Clinical Investigation:

The development of effective cancer immunotherapies has been consistently hampered by several factors, including an inability to instigate long-term effective functional antitumor immunity. This is particularly true for immunotherapies that focus on the adoptive transfer of activated or genetically modified mature CD8+ T cells. In this study, we sought to alter and enhance long-term host immunity by genetically modifying, then transplanting, mouse HSCs. We first cloned a previously identified tumor-reactive HLA-DR4–restricted CD4+ TCR specific for the melanocyte differentiation antigen tyrosinase-related protein 1 (Tyrp1), then constructed both a high-expression lentivirus vector and a TCR-transgenic mouse expressing the genes encoding this TCR. Using these tools, we demonstrated that both mouse and human HSCs established durable, high-efficiency TCR gene transfer following long-term transplantation into lethally irradiated mice transgenic for HLA-DR4. Recipients of genetically modified mouse HSCs developed spontaneous autoimmune vitiligo that was associated with the presence of a Th1-polarized memory effector CD4+ T cell population that expressed the Tyrp1-specific TCR. Most importantly, large numbers of CD4+ T cells expressing the Tyrp1-specific TCR were detected in secondary HLA-DR4–transgenic transplant recipients, and these mice were able to destroy subcutaneously administered melanoma cells without the aid of vaccination, immune modulation, or cytokine administration. These results demonstrate the creation of what we believe to be a novel translational model of durable lentiviral gene transfer that results in long-term effective immunity.

If things work well, I may have another paper out before the end of the year!

The WikiRevolution

2011-01-15T12:11:00.000-05:00

The President of Tunisia fled the nation, and the PM took over, but now he has ceded power too. A lot of people are discussing the role that Wikileaks played in this situation. Obviously there was already a lot of discontent in the nation, but the relevations about the government excesses that were leaked might have pushed things over the edge.

This brings me back to a point that I made about wikileaks a few weeks ago, which is that more access to information for more people is clearly a net gain for the USA. Secrets leaked about the USA may be slightly embarrassing but secrets leaked about autocratic governments can be lethal to those dictators.

Imagine if Julian Assange exposed leaks about everyone - the US, but also Iran, North Korea, Saudi Arabia, etc. Imagine the populations can access that information. What we are seeing in Tunisia is a precursor to what will happen when more people get access to more info, say via wikileaks, and can organize efficiently, by Facebook, Twitter, or whatever. How is that not a huge net win for American values and interests?

Instead of prosecuting Assange, maybe we should be helping him. If the US government wants to bring down the Ayatollahs we shouldn't bother with bombs. We should just develop a version of Twitter that can't be shut down in Iran.

Middle East

2011-01-14T14:56:00.000-05:00

"The historical significance of what happened in Tunisia is huge. This is the first time an Arab dictator is overthrown by a popular uprising. It is too early to speculate whether this will or can spread, but I think one lesson is too obvious: the Arab people has realized that overthrowing a regime is much much easer than they had thought. If the Iranian Revolution had an impact on Arab politics, this will certainly have an impact," - As'ad, at angryarab

The Blamers become the Blamees

2011-01-12T00:35:00.000-05:00

Not a novel perspective, but here is my take: it is no more fair to blame Sarah Palin or the Tea Party for the actions of an assassin who is on an anti-government streak, than it is to blame the Muslim American community for the actions of a few Islamic extremists.

Health care reform, revisited

2011-01-05T09:54:00.001-05:00

A senior medical student clerkship is emergency medicine, and for orientation we had a series of lectures. In one of them, the doc described a tragic case that took place in 1988. There was a migrant worker in Texas who had classic symptoms of meningitis. However, at each hospital the ambulance was turned away because the patient had no health insurance. Ultimately, the patient ended up at U-Texas Southwestern but ended up dying due to the costly delay in treatment. Meningitis is an extremely dangerous condition but is very treatable with the proper antibiotics.

A 60 minutes special exposed the recorded conversations between the ambulance and the hospitals that one after another inquired about the patient's health insurance status before turning the patient away. This led to congressional legislation which dictated that emergency rooms must treat patients regardless of insurance status. In effect, the bill gave all Americans the right to a medical exam and treatment regardless of ability to pay. This mandate was, perhaps not surprisingly, unfunded by the federal government. Almost half of ER patients have no health insurance. Given that (most) hospitals must turn a profit, the 1988 unfunded federal mandate ends up being paid for by patients with health insurance.

To me, the individual mandate of the Obama health care bill stems logically from this 1988 bill. In other words, if the individual mandate is unconstitutional, why isn't the 1988 bill unconstitutional? Republicans are trying to argue that you can't force people to buy something (health insurance). But the 1988 bill did something worse - it forces people to buy something for someone else! We can talk about personal responsibility until we are blue in the face, but at the end of the day, we as a society are not willing to not treat sick patients. That is a good thing, but someone still has to pay for that treatment. Right now, only hospitals and people with insurance are paying. With an individual mandate, even though low income citizens will require help, everyone will have some role in paying for their health insurance.

While Republicans want to repeal the ACA, they are quick to point out that they favor certain parts of the bill - for example, people should not be denied insurance based on pre-existing condition. Tell me though: If I cannot be denied coverage based on pre-existing condition, why would I ever buy health insurance? Why not just wait to see if I get sick, and only buy insurance if I do? If everyone did that, the insurance market would collapse spectacularly. The only way to prevent gaming of the system like that is an individual mandate: you cannot do one without the other.

The ACA deals with access to health care, but the real problem in this country is delivery of health care, which is often expensive and inefficient. If we are to secure the fiscal future of our nation, we need to address these serious challenges - and quickly. More health care reform is needed, not less. Repeal is out of the question, and attempts at such are just posturing. Obama should tell Republicans that if they have a better bill that they want to replace the ACA with, if they have modifications, or additions, he is all ears. Obama should challenge Republicans to put up or shut up.

Are animals capable of making conscious lifestyle choices?

2011-01-04T12:07:00.001-05:00

Homosexuality in nature. This isn't a new discovery, yet it remains that a lot of people don't realize that animals can be gay, too. Which sort of flies in the face of accusations that homosexuality is a choice or is unnatural.

One for the history buffs

2010-12-26T12:45:00.001-05:00

I thought this was really interesting: Germany just finished paying off their WW-1 reparations.

I had been under impression that the reparations were paid off in the 1920's, by hyper inflating the debt away. I had no knowledge of the post WW-2 German government's agreement to assume debts stemming from the Treaty of Versailles.

It is amazing how different the world can become in a span of two generations.

WWMFD?

2010-12-21T12:22:00.001-05:00

I've been on Youtube watching videos of Milton Friedman on this issue or that. They are particularly relevant nowadays since we have a resurgence of anti-government and anti-regulation sentiment in this country. I think all of this is very healthy, and I agree with it completely even if I take issue with the abrasiveness of the methods employed (in other words, I agree with the point of the Tea Party but I take issue with the style and methods).

In this video that I linked, Milton Friedman talks about the folly of consumer protection agencies and how absurd that they can be. He finishes by concluding that we don't need government bureaucrats to protect us from ourselves - that we can be trusted to make the right decisions.

An important point that is missed from people who whole heartedly subscribe to these sorts of views, however, is that government regulations and interventions have distorted the market that Milton Friedman and maybe the Tea Party completely trusts to solve the problems that we face today.

Take obesity. Politicians like Sarah Palin have come out and mocked Michelle Obama for wanting to stop children from drinking soft drinks, and the Republicans in general scoff at the idea that we might impose a tax on soft drinks. But the point that these sorts of people miss is that the government has intervened to subsidize corn farmers and these subsidies have artificially driven down the cost of soft drinks; thus have encouraged overconsumption. The cheapness of fast food is another example, thanks to generous subsidies to meat farmers. I do not believe it would be possible for McDonalds to be so cheap without those price supports - and if a trip to McDonalds cost 2-3 dollars more, people would consume far less fast food.

The government does other things, like imposing tariffs on Brazilian ethanol, which is much cheaper than American ethanol, to protect our market. The government has all sorts of regulation regarding property development, commercial development, that stipulate that they must have so many parking spaces available or be so close to this or that. Furthermore, roads are paid for by government, instead of the costs appropriately going to the drivers of cars. This tangled web of regulations, inappropriate subsidies, and other incentives have distorted the market and seem to have contributed to urban sprawl, over reliance on cars, and a lack of other transportation mechanisms in many cities.

Current disciples of Milton Friedman like Greg Mankiw have written about negative externalities. Mankiw argues that driving cars imposes negative consequences other than having to pay for fuel: roads are more congested, CO2 is released, and geopolitics is far more complicated (we need secure sources of oil). Mankiw is no liberal - he is the former chairman of the council of economic advisors under G.W. Bush. He argues for a gasoline tax to account for these externalities and price gasoline so that the market can respond appropriately.

This is an important lesson for Republicans, libertarians, Tea Partiers, and anyone else who wants to keep "government out of our lives" - government is already in our lives. You cannot rely on the market to solve problems if the market is already distorted. We need to make sure we are removing these imbalances to the market before we start deregulating everything. Until then, I'm going to side with Michelle Obama and encourage government bureaucrats to help prevent our children from drinking so many soft drinks.