Flight Behavior by Barbara Kingsolver

I masterful example of how difficult it can be to explain climate change to non-scientists. Ultimately before you tell anyone anything, you have to ask and listen, that's what this book reminded me of. The story was almost secondary. It was more an exploration of the very real disconnect between two very different realities, that of the scientists and that of rural and conservative America.

Small is Beautiful: A Study of Economics as if People Mattered by E. F. Schumacher (1974)

I. The Problem of Production
We are "inclined to treat as valueless everything that we have not made ourselves" (11). Schumacher blames even Marx for falling into this trap in the labor theory of value.  Fossil fuels, "the tolerance margins of nature", and "the human substance" are the three categories of capital that Schumacher claims we "cheerfully treat as income" (16).

II. Peace and Permanence
Economic growth has "no discernible limit, and must necessarily run into decisive bottlenecks when viewed from the point of view of the environmental sciences" (23). Rather than growth, the central concept of wisdom within economics should be permanence. "The cultivation and expansion of needs is the antithesis of wisdom. It is also the antithesis of freedom and peace" (26). "Every machine that helps every individual has a place but there should be no place for machines that concentrate power in a few hands and turn the masses into mere machine minders, if indeed they do no make them unemployed" (28).

Small scale operations are less likely to be harmful to the natural environment. People will take better care of their land than anonymous companies that imagine the whole universe "is their legitimate quarry" (29).

III. The Role of Economics
The verdict of "uneconomic" kills many activities that should proceed. Fascinating history about the birth of the discipline of economics, and how many predicted that its separation from social philosophy. Sure enough, economics alone has moved into the center of public concern. Economic growth, expansion, performance have become an obsession of all modern societies. Activities branded as "uneconomic" are questioned about their right to even exist. The judgement of economics is "extremely fragmentary; out of the large number of aspects which in real life have been seen and judged together before a decision can be taken, economics supplies only one--whether a thing yields a money profit to those who undertake it or not" (35). The fragmentary nature gives undue weight to the short term over the long term, and is based on a definition of cost which excludes all 'free goods' or environmental capital (36). "If economic thinking pervades the whole of society, even simple non-economic values like beauty, health, or cleanliness can survive only if they prove to be 'economic'" (37).

IV. Buddhist Economics
   Modern Western economics views labor as a necessary evil, simply a cost, to be reduced to a minimum if not eliminated. This view of economics also claims that work is a disutility for the worker, a sacrifice of leisure and comfort, and wages are a compensation for the sacrifice.
   The Buddhist point of view gives work at least 3 functions; a way to utilize faculties, a way to enable teamwork through common task, and a way to bring goods and services needed for a becoming existence (45). Work and leisure are complementary and cannot be separated without "destroying the joy of work and the bliss of nature".

V. A Question of Size
Rural to cities move explained. Those who have nothing to sell but labor remain in weakest bargaining position. Schumacher argues for "production by the masses rather than for the masses" (61).

VI. The Greatest Resouce -- Education
Humanities provides 6 main ideas that fail to overcome economic values because they lead to "an abyss of nothingness" (74).

1. evolution
2. competition
3. class struggles are based on economics
4. Freud
5. relativism
6. positivism which denies the possibility of objective knowledge about meaning and purpose of any kind.

Education is breaking down due to a lack of metaphysical training. There is no thought about the levels of being. We have abandoned the cardinal vurtues, the seven deadly sins, but "what new ideas have taken their place?" (83). How can one think about virtue, love, and temperance with the above 6 ideas?

VII. The Proper Use of Land
Agriculture should keep man in touch with living nature, humanize and ennoble man's wider habitat, and bring forth food and other materials which are needed for becoming life. Modern economics recognizes only the latter.

VIII. Resources for Industry
IX. Nuclear Energy -- Salvation or Damnation
X. Technology with a Human Face
The goal is to have enough time to make a good job out of any work, to enjoy oneself, to produce real quality, even to make things beautiful.
Schumacher calls for the use of "intermediate technology". Accessible, more advanced than primitive.

XI. Development
A dynamic approach is required because an economic approach fails to recognize the value of abandoning efficiency and maximal profits in favor of meaningful and human work.

XII. Social and Economic Problems Calling for the Development of Intermediate Technology

XIII. Two Million Villages
XIV. The Problem of Unemployment in India
What is education for? The specialization of tasks (and sacrifice in humanness of work that that implies) means that a college education requires 150 years of peasant work to supply. What what do the peasants get back for it? Therefore Schumacher's essential questions are: "is education to be a passport to privilege or is it something which people take upon themselves almost like a monastic vow, a sacred obligation to serve the people?" (173). "Can we establish an ideology that issists that the educated have taken upon themselves an obligation and have not simply acquired a passport to privilege" (173)? The presence or absence of this ideology affects the content of education. If the former view is taken, then education focuses on village life, manual labor, social justice, etc. But the latter suggests that you need electricity, cement, and steel before we can do anything at all.

XV. A Machine to Foretell the Future
A theoretical warning to not mix up events and acts, future and past, certain and uncertain. Predictions vs forecasts. Forecast vs feasibility study.

XVI. Towards a Theory of Large-Scale Organization
Achieve smallness within large organizations.

XVII. Socialism
Pure market economics are "an institutionalization of individualism and non-responsibility" (213).
Ownership is not a decisive question. "There is no case for public ownership if the objectives to be pursued by nationalized industry are to be just as narrow, just as limited as those of capitalist production: profitability and nothing else" (217).

XVIII. Ownership
XIX. New Patterns of Ownership
Middle road between privatization and capitalism. Points out that people hate being taxed and thus fight against public expenditure. "The need for public expenditure should thus be recognized in the structure of ownership of the means of production" (229).

"All the educational, medical, and research institutions in any society bestow incalculable benefits upon private enterprise -- benefits for which private enterprise does not pay directly as a matter of course, but only indirectly by way of taxes, which are resisted, resented, campaigned against, and often skilfully avoided...It is illogical that payments for benefits obtained by private enterprise from the infrastructure cannot be exacted by the public authorities by direct participation in profits but only after private appropriation of profits has taken place. Private enterprise claims that its profits are being earned by its own efforts, and that a substantial part of them is then taxed away by public authorities. This is not a correct reflection of the truth. A large part of the costs of private enterprise has been borne by the public authorities -- because they pay for the infrastructure" (229)

Schumacher goes on to propose three spectrum on which decisions could be made
Freedom--Totalitarianism
Market Economy -- Planning
Private ownership -- Collectivized ownership
In the simplest interpretation, this gives 8 combinations.

He suggests a middle road on all three spectrums. First that the 'public hand' should receive 1/2 of distributed profits of large-scale private enterprise by means of 50% ownership of the equity of such enterprises" (239). Public shares wouldn't have voting rights normally, but woul dhave the right to information and observation.


Epilogue
The idea of economy, work, and technology that sustains "the human substance" continuously reappears in this book. Work that takes away any hint of humanity, becoming a merely mechanical activity, turns the worker himself into "a perversion of a free being" (29). The "humanization" of work would lower GDP, decrease profits, and decrease the way that the current "standard of living" is calculated. Schumacher argues that the calculation leaves out key factors that would be wise to include.

Wisdom is also thrown around quite casually, with what seems to me a lack of theoretical and philosophical underpinning. Schumacher suggests that we need a revision of the ends which economic means are meant to serve.

Remedy and Reaction by Paul Starr (2011)

Part I reviews some of the origins of healthcare reform referencing a lot of the work that Starr did in his previous work. Again the beauty of his language extends into the titles and subtitles of his chapters which I will outline with comments here.

• Stumbling toward Comprehensive Reform
• political deadlock
• the American path to health insurance
• Frustrated ambitions, liberal and conservative
• the shaping of the Clinton health plan (Starr was part of the Clinton's huge team of experts, and has fascinating inside information.
• getting to no
• the rise of a reform consensus 2006-2008
• Romney and MA model
• toward minimally invasive reform
• making 2008 a healthcare election
• Obama and the rollercoaster to reform
• why healthcare reform passed and climate legislation didn't

The Affordable Care Act as Public Philosophy 

 This was the part of the book that really forced me to think. Previous sections were interesting and enlightening, but this analysis of legislation within the paradigms of some philosophical ideas really sparkled. 

Overall, Starr contends that the goal of the ACA was to align one major institution (healthcare) so that it agrees more closely with principles of justice and efficiency. Starr presents the ACA's provisions as they bear upon central problems of public philosophy.

fairness and equality
Rights versus obligations of individuals and states. For states, the question is whether healthcare is a service that the community has an obligation to provide (like basic education). If it is, then the principle of "actuarial fairness" should be abandon. Rather than each person paying for what they use, the cost of care should be spread over the healthy and sick evenly "to avoid imposing burdens on the sick that effectively bar them from access to medical care" (242). Starr invites consideration of the European ideal of "solidarity". He is careful to delineate that the "moral interest in ensuring care for the sick does not require shared responsibility for services such as cosmetic surgery or amenities such as private hospital rooms" (242). 

Starr notes that we do have one federal right to health care, The Emergency Medical Treatment and Active Labor Act but that this is funded by shifting costs to insured patients, "a hidden transfer that the American public has apparently preferred to being openly taxed for the same purpose" (242). The ACA "attempts to extend shared responsibility without entirely banishing actuarial fairness, and it makes the health insurance system more inclusive without flattening its tiered and unequal structure" (243). In an unregulated insurance market, the liability equals 11:1 between a 60yo and a 20yo American. That means older adults would pay 11 times as much for insurance. A pure "community rating" insurance would charge these people the same amount. The ACA limits differences in rates to a 3:1 ratio. Ironically the increased burden falls largely on the poor and middle class who are under 400% (this is where subsidies stop) of the poverty line because those over this level buy insurance independently and most get it through employers, few of which ask older workers to pay more than younger workers for insurance. 

While libertarians cringe at the young paying for the old, shared responsibility can be described as "enlightened self-interest" as those young workers will almost inevitably be old soon enough. 

Subsidies were clarified as a way to make insurance premiums a scaled percentage of income, so that premiums are 3-4% of income for the working poor, and up to 9% of income for those at 400% of poverty level. They're calculated based on second lowest priced silver plan in each area.

The levels are also explained clearly:
   Bronze covers 60% of healthcare costs
   Silver covers 70%
   Gold covers 80%
   Platinum covers 90%

responsibility and freedom
Conservatives support freedom while liberals support equality? Starr argues that a conservatives are using a "shriveled conception of freedom"  that fails to recognize that "health itself is a matter of personal freedom" (247). He reminds libertarians that "there are no rights without a government to protect them" and that "freedom is impossible without the framework of law that the state upholds". Starr recognizes that conservatives fear "arbitrary and capricious" government power, but reminds them that these same interests should motivate them to be concerned about private power, such as that of an insurance company. A law that wields government power in order to reduce arbitrary and unreasonable private powers "may also increase individual freedom". 

federalism and finance
   The subsidiarity principle has solid rationale for keeping decisions at no higher level of government than is necessary. "History complicates theory". Leaving healthcare to the states would mean "denying access to medical care and insurance" for "millions of the poor and near-poor in the South and Southwest" (253). 
   Financing is complicated.

health and the public household
   Health insurance as insurance against unexpected costs or as prepayment for medical services? If you believe the former, than moral hazard is a big deal, and people should pay out of pocket for ordinary expenses. The prepayment model  conceives that limiting coverate to catastrophic costs "creates perverse incentives favoring technologically intensive services to the neglect of primary care and prevention" (259). 
   The ACA supports new nonprofit Patient Centered Outcomes Research Institute to compare clinical effectiveness. "But the law bars use of the findings as mandates or guidelines for coverage or payment" (263). If the Independent Payment Advisory Board gets struck down by the supreme court there will be trouble, because "if we cannot say no to paying for services that are clinically ineffective, we will surely have no choice but to limit services that are clinically valuable" (263).  

The Peculiar Struggle
"Other democracies long ago resolved whether they have an obligation to provide care for the sick and protection against medical costs" (279).  

"If the special interests were arrayed on one side and the suffering masses on the other, the conflict would fit easily into a familiar populist picture of the world. But though the health insurers, drug companies, and other interests profit from the health system, they are not alone responsible for maintaining it. The bias against change also comes from members of the protected public. No other major democracy created a financing system that provides the biggest tax breaks to the people with the best private insurance; no other major democracy established a separate program for the elderly. A variety of other programs protect particular groups. These partial measures have become major obstacles to the efforts to control costs and to extend protection to the uninsured. The resistance to reform didn't arise because Americans were such determined individualists that they rejected all government help; much of the resistance has come from members of an entitled majority with a privileged position in the public-subsidy system. The potency of these entitlements lies in the psychology of self-exemption they instill; the beneficiaries do not understand themselves as benefiting from government assistance or as sharing a common condition with the excluded. The tax subsidies are nearly invisible to those who receive them; Medicare invites the elderly to believe that they have earned its benefits, whereas other claimants have not. Morally armed, they can reject helping others in need as a matter of high principle; after all, Americans shouldn't look to the government for help" (280).

The Social Transformation of American Medicine by Paul Starr (1982)

Should be required reading for all student physicians. Absolutely brilliant historical account of the beginnings of the profession and industry of healthcare in the United States.

Key ideas outlined in Starr's chapter titles and subtitles that I might be able to describe to you if you asked include;

• professional sovereignty
• the market and professional autonomy
• legitimate complexity
• origins of medical sectarianism
• explained origin of homeopathy, eclectics, and orthodox
• reconstitution of the hospital
• Hill Burton Act
• public health vs private practice
• capitalism and the doctors
• professional resistance to corporate control
• the struggle for healthcare reform
• why America lagged
• The New Deal
• Socialized medicine and the Cold War
• health insurance origins
• the birth of the blues
• private social security
• focus on research
• how the medical center gained power
• 1970-1974
• contradictions of accommodation
• generalization of rights
• conservative assimilation of reform
• 1975-1980
• generalization of doubt
• liberal impasse
• The coming of the corporation

And that's where he leaves off in this masterful work. 

The Spirit Catches You and You Fall Down by Anne Fadiman

I'm re-reading this book for my social and behavioral determinants of health course as part of my MPH coursework this year.

This story has innumerable examples of how culture affects the psychology and behavior of the parents and community of one sick Hmong child.

• beliefs about what causes sickness
• epilepsy is when the soul flees the body, or is stolen.
• causes concern but also pride
• medication was causing sickness
• can't give medicine forever
• beliefs about what cures sickness
• treat the soul and the body
• ceremonies
• rituals
• Western medicine seen as disrespectful
• finite amount of blood (but repeated blood tests)
• can't take out organs without messing up next life
• misconceptions about what the doctors were trying to do lead to fear
• the rituals required for being and then for un-being (living and dying)
• attaching the soul to the body
• burying the placenta under the home

The behaviors and beliefs of the US medical community are painfully illuminated by this collision

• Epilepsy has a natural cause just as other diseases have
• not asking the family what they thought was causing the seizures
• The shamanistic rituals might be harmful
• not allowing Hmong mothers to take home their placentas
• cutting off spirit strings for fear that they were fomites
• Westerners hold all of the medical knowledge
• medicine not as exchange, but as gift
• Communication is not as important as are objective laboratory results
• little effort to secure translators
• 5-month delay between medical presentation and diagnosis of epilepsy
• translating just language instead of having a "cultural broker" (95)
• Failure to understand why dilantin was not being given at home, and resorting to CPS to intervene.
• Viewed taboos against blood tests, spinal taps, surgery, anesthesia and autopsies as "self-defeating ignorance" (61).
• Episiostomies one decade but not the next
• Inability to compromise, to give up the "medically optimal" treatment in exchange for one that was more acceptable to the family (257).
• Not a single word in Lia's entire medical chart "dealt with the Lees' perception of their daughter's illness" (259).

The political, social, and economic determinants of this Hmong family's situation include:

• The long history of genocide attempts by the Chinese and other groups.
• "they would rather flee, fight, or die than surrender"
• The Hmong fight against French colonialism in 
• The Hmong alignment with US interests against the socialist Pathet Lao party throughout the Laotian civil war, and then when the US and Hmong were defeated and the Vientiane government fell in 1975, yet another attempted genocide of the Hmong.
• The Lees' time in a Thailand refugee camp Ban Vinai.
• Immigration and placement in Merced, CA.
• Racism, misunderstanding
• Each side expected the other to be grateful.
• US success measured in economic terms

The medical system of the US

• No payment for cognitive work or time spent with interpreters
• Practice is responsible for paying for interpreter
• "Evidence based"
• Little training in cultural medicine
• little training in cognitive errors. "If it had been a brand-new kid walking off the street, I guarantee you Neil would have done a septic workup and he would have caught it. But this was Lia. No one at MCMC woul have noticed anything but her seiaure. Lia was her seizures" (256). 
• The idea of "compliance" (261) "implies moral hegemony". 

What have I learned from this book? What questions remain?

• Arther Kleinman's cross-cultural medicine questions (260).
• What do you call the problem?
• What do you think caused the problem?
• Why do you think it started when it did?
• What do you think the sickness does? How does it work?
• How severe is the sickness? Will it have a short or long course?
• What kind of treatment do you think the patient should receive? What are the most important results you hope she receives from this treatment?
• What are the chief problems that this sickness has caused?
• What do you fear most about the sickness?
• Model of mediation instead of coercion. Negotiate with another Hmong or a medical anthropologist. Compromise must come from both sides.
• "If you can't see that your own culture has its own set of interests, emotions, and biases, how can you expect to deal successfully with someone else's culture?" (261)
• Mindfulness of my own emotions and reactions can improve my ability to be a healer. 
• Which is more important? Life or Soul? (277)

Thinking Fast and Slow by Daniel Kahneman

Two selves

• remembering self constructed by system 2 but still have duration neglect and peak-end rule following. This was demonstrated with the cold hand test.
• experiencing self is in the moment, used to create the U-index of unpleasantness.

Econs and Humans

• Econs act rationally always, they read small print, and calculate the value of two bets.
• Humans are not well described by the rational agent model. Noto to say they are irrational, but they often need help to make more accurate judgments and decisions especially considering that they have system 1 and system 2 thinking giving them conflicting answers.
• The failure of humans to act rationally leads to libertarian paternalism which is based on the idea that "freedom has a cost, which is borne by individuals who make bad choices, and by a society that feels obligated to help them." Protecting individuals against their mistakes is not controversial if you realize that humans do not follow the laws of economics.

Two systems

• System 1 is prone to heuristics, meaning it generates answers to related questions to the one actually asked. System 1 does not realize when the information it is using to make decisions is unreliable or sparse. What you see is all there is, intensity matching, associative coherence, anchoring, nonregressive predictions, overconfidence, and many others.
• System 2 is who we think we are, articulating judgments, making choices, but it often endorses or rationalizes ideas and feelings that were generated by system 1. System 2 is prone to narrow framing. You can get system 2 to kick in by getting outside observers to introduce doubt into your decisions. Checklists, reference-class forecasting, and premortems. 

The Stranger by Albert Camus

Something connects these books written once WWII had begun, all within the context of WWI, pure dystopia.

Camus here paints a picture of a man who may be autistic or perhaps just disillusioned. There is excruciating detail of the protagonist's downfall reminiscent of Crime and Punishment.