Knoxville: Summer of 1915

Eleanor Steber: Soprano
Unlisted pianist

Text: James Agee
Music: Samuel Barber

Part 1.

Part 2.

Unfortunately there isn’t a good place to make a break in this piece but this performance by Eleanor Steber is magnificent. It’s much more intimate than the recording she made with orchestra.

This one is for Echidne who I hope is feeling better soon.

A Month Late, A Birthday Card For Richard Lewontin on His 80th by Anthony McCarthy

If you have an hour and a half to listen closely, this lecture given by Richard Lewontin in December 2007 is wonderful. It’s called Internalism and Externalism In Biology but what he says has implications for all of science and much of politics. Great insights into many of the issues often discussed on this blog are included.

Of particular interest to anyone who tries to use language precisely is his observation that it is impossible to use metaphors, leaving behind their burdens of metaphorical garbage unrelated to what is intended. Just talking about these things is loaded with difficulty. We can drown in those difficulties and the temptation is always to reduce them or to bypass them with pat explanations.

I particularly like the part about the variable and unpredictable growth of cloned plants at various elevations from an experiment done in the 1930s. He doesn’t press the point this far but if such a simply observed and accurately quantified trait like height among genetically identical plants can have such varied and, most importantly, unpredictable expression in different environments*, how can anyone believe that they can find genetic determinants for illusive and transient states such as alleged behaviors in people of varied genetic inheritance and experience? That’s not even asking how could they be reliably discovered and noted.

I’d add the abilities to reason, to apply the feeling of justice, fairness and numerous others to that mix of complicating factors because people can radically change their previous behavior on the basis of these seldom mentioned agents of change. Among the reasons they might be more conveniently left out is that you can’t depend on them being consistently or accurately applied. The practice of not considering them doesn’t mean they aren’t active and important determinants of behavior sometimes.

Note this, I hope verbatim, quote in response to a questioner’s objection to Lewontin’s famous criticism of the baseless stories fashionable in biology and would-be biology today:

The issue to me, as an a priori materialist, is that the fact that I can make up a reasonable story only tells me about the nature of my brain. It doesn’t tell me about the world out there.

A good story that coheres in the mind is no substitute for physical (or historical...) evidence. You would think nothing could be more common ground in any rigorous subject, especially those which have findings about the real world as their stock and trade.

His challenger responded with the often asserted claim that you could experimentally test the assertions of these fables but Lewontin, who is probably in as good a position to know as anyone, points out that it hasn’t been done yet. He doesn’t state that their complexity probably ensures that they never can be. The possibility of this guess being right doesn’t dismiss the possible myriad of other potential explanations - if there was time I’d go into what he says about the possibility of constructing, theoretically, an infinite number of those. All of these created myths are equal in that they are equally unfounded in physical reality. Not necessarily just as a non-materialist, I have the greatest respect for his point of view, complete with reasonably polite rebuttal and full acknowledgment for the contingency in time of his ideas. Contingency is inherent to all of human attempts at understanding, particularly in science but certainly also in other areas of thought. But it becomes a requirement of the greatest importance to acknowledge that contingency in science, for social and political reasons as well as the inherent exigencies of the discipline itself.

If you haven’t ever seen him in action, this bravura performance is a good example of the quality and rigor of his thinking. It probably also shows why he isn’t as famous as his intellectual opponents. He’s habitually honest about the limitations of what we can know.

When you refuse to over-simplify the information you know is included in complex and often untidy reality and when you refuse to pretend to knowledge that is not available in order to attract a more casual audience, many will either be unwilling or unable to understand you. Honest incompleteness is less satisfying than a fictitiously complete synthesis. No matter how clearly you describe it, no matter how honest you are about the limits of what you are asserting, no matter how generously or honestly you acknowledge weaknesses in your preferred viewpoint as well as others. You won’t get a large audience when you don’t satisfy them. But audience satisfaction isn’t supposed to be the goal.

Simplified assertions about reality, simply and, especially, appealingly presented, will get you supporters who are happy to overlook those elisions and even distortions. The convenient omission of the fact that there are rather sizable holes in our knowledge is widely practiced, in many fields. Just So stories are told for the purpose of just getting on with things. The spreading popularity of them is an indication of an intellectual culture in deep trouble. And the motives driving us into the abysmal pit are generally external to the actual subject matter of science, history, law, etc. One suspects a lot of this done for little beyond its catalytic potential to propel professional advancement.

In fields for which reduction to even a relatively high level of synthetic simplicity is destructive of essential precision, a large fan base might well be a sign of dishonesty. Lewontin’s clear-headed discourse probably puts some of these ideas as plainly as they can be put without either distortion or falsification. But they’re probably not ever going to be useful for superficial wire reporting or well-compensated columnage.** It also won’t become the common received knowledge of a large fan base.

* He points out that when you do the analysis that the correlation is actually zero.

* * It’s also not useful to oligarches in search of scientific support for doing what oligarches want to do.

Laurie McClain (by Suzie)

I went to a house concert last night for Laurie McClain, and I'll see her again in concert Sunday in Tampa. She has this weary innocence, this voice, that never fails to move me. My favorite is "I Wanna Be Like You," but I couldn't find a video of it. I like it even better now that I can see her singing to a child. I look forward to listening to her new CD, "Ascend." Others have compared her to Gram Parsons, Dar Williams and Iris Dement.

What do you think of "domestic violence"? (by Suzie)

I posted a short piece about an increase in domestic violence, due to the economy. A couple of you objected to the term. Kali said she would rather people talk about

assault, aggravated assault, homicide ... Use the same terms that are used in other cases. Just because an assault/homicide was committed by a person in the family does not make it any better. Having a separate terminology for attacks where women and children are primary targets just helps in treating these cases as less serious and ghettoizes the cases as being women's issues.

If we want to give specific attention to crimes against women, we can (and do) call it "violence against women". It would be even better to have gender-based crimes accepted/legislated as a hate-crime.

Tinfoil Hattie responded:

I'd also add that using the term "domestic" softens the impact, as "domestic" has meant things like baking cakes and making curtains and making a nice home for your husband and children. You know, it's just "domestic" violence. Not real violence.

Two weeks later, Echidne wrote that this term

serve[s] as shorthand for crimes in which you, the reader, are unlikely to be at risk. If a crime is between 'lovers' or domestic in nature then strangers are safe. But the corollary of this is that putting those labels on a crime makes it somehow less important to report on.

I argued in favor of the term "domestic violence," saying that people in the field try to raise awareness of the mindset and controlling patterns of abusers. I saw advantages in using a specific label. Because I'm no expert, I decided to ask someone in the field: Linda Osmundson, executive director of CASA (Community Action Stops Abuse) in St. Petersburg, Fla. She replied:

The term "domestic violence" was developed to sanitize and degender the work of advocates for battered women. It made it possible for domestic violence to receive government and foundation and donor funding without using the much harsher, much more political terms like battered women. It made it easier for us to talk about with men who largely controlled the funding in the 70's when battered women's programs/shelters first began to open.

Linda considers this discussion important and wants permission to reprint comments in CASA's newsletter, both pro and con for the term "domestic violence." So, in this comment thread, please say whether she can use your comment, and if so, how you'd like to be identified. Thanks for your help!

Friday critter blogging (by Suzie)

Another bitch. This is old Nicky, who likes to de-fuzz tennis balls.         

Today's Harlequin Romance Snippet

This would be a Victorian romance with heaving bosoms, handsome pirates and innocent maidens in whalebone corsets. Here's the crescendo moment:

He looked at her, with green eyes which slowly turned red with desire, the pupils opening and closing like those of a cat. Her corset bones twanged a song of lust, then broke and impaled him against the velvet-covered wall.

Nasty Post VI: What Do You Expect?

The news first told us this:

A U.S. Army soldier convicted of murder in the 2007 killings of four bound and blindfolded Iraqis was sentenced on Thursday to life in prison.

Master Sgt. John Hatley, 40, also will have his rank reduced to private, forfeit all pay and receive a dishonorable discharge, a jury of eight Army officers and noncommissioned officers decided. He has the possibility of parole after serving 20 years.

Today I read about a possible court case against British soldiers:

British soldiers tortured and murdered up to 20 Iraqis in cold blood, the High Court was told yesterday.

It happened after a three-hour gun battle at an Army checkpoint near Basra, a lawyer claimed.

Rabinder Singh said a group of local men were taken prisoner and transported to an Army camp where they were beaten with a rusty tent pole, punched, slammed against walls, denied water, blasted with loud music and forced to strip naked in the presence of a woman – a humiliation for Muslim men.


The next day, he said, only nine were still alive – and 20 corpses were returned to their families. One was teenager Hamid Al-Sweady.

The Army claims the men all died in the initial gun battle, but Hamid's uncle Khuder Al-Sweady and five survivors of the incident yesterday began a court battle in London to win an independent inquiry.

Who knows about that latter case? But my instant reactions to stories like these, and even the torture stories is the headline of this post. Yes, it's nasty of me. But what do you really expect from people who are told to kill, quickly and on orders, who are put under tremendous strain, who are psychologically prepped (long and well) to kill? Do you really expect that every one of those people can simply turn all that off when it's not appropriate?

Of course we must demand that they do. Of course. But given what we now know about the true behavior of those ruling over them, how two-faced is it to treat these lower level killers as somehow shockingly out of line?

All this is part of the costs of war. People are destroyed in more ways than the purely physical, you know, and some of the deaths wars cause take place years after the war has ended. I want us to acknowledge that.

All The Fallen Robins

I've been listening to Leonard Cohen's "The Chelsea Hotel", which is about Janis Joplin. Supposedly the two met at the Chelsea Hotel, she gave him head while the limousines were waiting (we are not told if he gave her head), and she spoke to him so sweetly and so strong. The lyrics deserve several listenings from a feminist: the talk about ugliness and beauty and especially the ending where he muses over not loving her the best, not thinking over every fallen robin, but all this with an odd ambiguity.

Janis Joplin died before this song was written. Her life killed her. She was a robin who fell. But then so many artists fall that way. Still, what was that world like for women, the super-hyper-sexualized world of popular music in those days? Especially for a woman who had the divine fire in her shell of nothing special? Who had the job of multi-tasking as sexual objects, cheerleaders AND the creative geniuses? It must have been extremely hard.

That phrase about 'every fallen robin' stuck with me. I think it would not be applied to men who die of drug overdoses or suicides, because they are not small birds. Or chicks.

Taliban, Again

Secretary of State Hillary Clinton has noted the once-again-growing power of the Taliban:

Pakistan's strategy of trying to appease Taliban militants is showing signs of backfiring, as extremists move within 60 miles of the capital and threaten to spread their influence throughout the country.

Secretary of State Hillary Rodham Clinton warned Wednesday that Pakistan's government is "basically abdicating to the Taliban" by agreeing to let them implement Islamic law in the Swat region last week. Instead of putting down their weapons, as the government had hoped, the insurgents have since moved fighters into the neighboring Buner region, local lawmaker Istiqbal Khan said.

There are two possible ways to interpret the Pakistan government's conciliatory move: Either the militants got what they wanted (a rigidly fundamentalist misogynist theocracy in a small part of Pakistan) or they got what they wanted (a sign that the government is weak and that it will hand over the rest of the country soon enough). So it's a win-win game for the Talibanis.

But not for the people they will try to squash into an impossible mold:

The militants in Buner also are using radio airwaves to broadcast sermons about Islam and have occupied the homes of some prominent landowners, said a police official who insisted on anonymity because he was afraid of retaliation. He said the militants also have warned barbers to stop shaving men's beards and warned stores to stop selling music and movies.

The consequences for women are much more severe than not having access to music or films, however. They are going to be prisoners in their own homes. Or rather, the homes of their owners.

Bring Out The Popcorn

Am I evil for getting enjoyment out of this?:

House Republicans today tried to pummel Secretary of State Hillary Rodham Clinton with questions about the administration's decision to release Justice Department memos permitting tough interrogation techniques of detainees, but she gave no ground.

At one point during Clinton's hearing before the House Foreign Affairs Committee, Rep. Dana Rohrabacher (R-Calif.) cited former vice president Richard Cheney, who has claimed that the administration is suppressing documents that show a more positive picture of the effectiveness of techniques and also that the Bush administration tried to correct problems as they arose.

"It won't surprise you that I don't consider him a particularly reliable source of information," Clinton shot back.

"This" being naturally Hillary Clinton's retort. There's nothing enjoyable about the torture revelations concerning the previous administration.

Hilarious?

This old book about gender roles might make you guffaw:





Here's a snippet from it:





You can see other pages at the link. It made me ask myself why there had to be books about gender roles if they are all based on innate biological gender differences, duh.

Bitches

Media Matters points out that

Sean Hannity decried Perez Hilton's use of "the 'B' word" in reference to Carrie Prejean, saying, "I can't think of anything more vicious, more mean, more insulting, more degrading." But Hannity did not object when Ted Nugent referred to Hillary Clinton as a "worthless bitch."

It's all about context, isn't it? Now this is what I call a bitch:





And this

The Costs Of Health Care. Part III. Keeping Up With The Joneses

Play a little game with me. Imagine the countries of the world as families living in your neighborhood. Some are wealthier than others but all these families get a paycheck (or two) and have expenses they must cover from that paycheck. (The 'paycheck' countries get is called the Gross Domestic Product (GDP), being the value of all production by that country in a particular year, and health care expenses of a country can be expressed as percentages of that GDP.) Here's a picture of the neighborhood (click on it to make it bigger):






Out of each dollar some family takes home, a certain number of cents goes to health care. In the family called the United States, that number of cents was roughly fifteen in 2005*. Yet a family up the street, called the United Kingdom, spent then only eight cents out of those dollars, and the Canadians, round the corner, got by with ten cents. At the same time, a poorer family called India spent a mere pittance of five cents out of each dollar**, but then there were fewer dollars to spend there.

You walk around the whole neighborhood and find out that nobody else spends as much as the Murkan family on health care. Nobody. The U.S. Is Number One!

What's going on here? Most of us can figure out a few possible answers when we replace countries with families.

First, poor families are not going to spend as much on health care, because their smaller incomes must first go to the most essential necessities: food and shelter. Wealthier families can spend more, just as they can spend more on housing and education. Perhaps the United States spends so much simply because it can? A cursory look at a few articles studying this topic tells us that this indeed partly true. It is the affluent countries which spend the higher percentages of their GDPs on health care. But those same articles also tell us that the U.S. is still an outlier: its higher spending cannot be completely explained by its higher income. At least a few of those seventeen cents out of each dollar remain unexplained.

Second, it makes sense that families with more health problems would spend a higher percentage of their incomes on medical care. Could this explain what's going on in the U.S.? This argument has been made many times, most recently by using the U.S. excess obesity rates as the explanation. We are fat! It's Our Fault! Repent!

But obesity doesn't cut it, because this country has been spending proportionately more than other countries for many, many years, including during the era when obesity wasn't the health problem of the day.

What about the age pyramid, then? Perhaps Americans are, on average, older than people in other countries and it's the more expensive care of the elderly which is to blame for the higher health care costs here? But then how do we explain the lower health care costs of Japan, say? Or the European countries who, according to wingnuts here, are refusing to breed just so that they can lumber the system with their high geriatric maintenance costs? In short, having an aging population does mean higher health care costs, but this explanation doesn't tell us why the other aging and affluent neighbors do so much better.

Third, it could be that the U.S. spends more because it gets so much more out its health care system. It's worth it to spend on something like higher quality health care, longer lives, less pain and suffering, right? Just as it may be worth to pay a lot more for a house in a nice, safe neighborhood with good schools and parks and clean air.

This is the most common argument you hear when opponents to Obama's health care policy explain their arguments, though you won't usually hear it in this form but the reverse: If we follow the pattern of those other countries who spend less we will all live under a socialist system (gray walls, clanking tin cans, long lines in cold corridors, military personnel giving you vaginal exams but only every hundred years). You will find an accountant (with dandruff) next to your hospital bed calculating your value of life to see if it's worth to save you, and you might then be allowed to die! Is that what you want?

In any case, some of the arguments about the higher quality of the U.S. health care system are worth examining in more detail. For example, it's certainly true that the medical research in this country is first-class and probably the best in the world, and that the fruits of that research (paid by Americans) will ultimately help people all over the world. But the costs of that medical research cannot explain the higher health care expenditure in the United States in the sense of the direct expenditures being so humongous, though pharmaceutical prices are higher here than elsewhere, and if they were not we might see less research into pharmaceuticals.

It's also true that the quality of medical care in this country can be truly first-class, in some areas and for patients with adequate funding. But not for everyone, and certainly not for those 40-50 million uninsured. Other countries manage to cover everyone for a smaller percentage of their GDPs.

Could it be that this is because they don't have as much advanced technology in medicine, not as much access to imaging machines and scans? Perhaps. But note that it's not access to high-tech diagnostic equipment that we really want. We want good health outcomes, and the two are not necessarily the same thing in every single instance, just as spending more money on particular groups of patients may not always provide higher quality care.

What about general health outcomes? Recent research has compared the treatments patients get for particular conditions in different countries, to see if the U.S. indeed provides superior quality of care. The results suggest that this is the case for some conditions but not for the majority of them, even among the group of life-threatening illnesses.

On a more aggregate level, the United States does not fare well in international comparisons of that cruelest of all health indicators: mortality. Various mortality figures can be seen as reverse overall measures of the outcomes of a country's health care system, especially if we focus on those indicators which are known to be affected by health care. Infant mortality rate is one such measure. Here's a table of data on it:





In 2008 these figures for the U.S., Canada and the U.K. were, respectively, 6.3, 5.1 and 4.9 (expressed as number of deaths in children under one per 1000 live births in a calendar year). Note that a lower figure is desirable in that list, which is bad news for the U.S.***

Similar stories are told when we analyze other measures of mortality or morbidity. But it's always possible to argue that the health care system cannot be seen as solely responsible for the worse health outcomes in the United States. For example, the general life expectancy rate is severely reduced whenever more people die at young ages, and that's exactly what the American excess rates of deaths from traffic accidents and violence cause.

It leaves you a bit breathless, this study of international comparisons. But we need to look at one more possible explanation, the fourth one: Perhaps the American family buys its health care from a different provision system than the other families on the same block, a system which is not based on central price controls or the ability to demand price concessions for bulk purchases? Perhaps it is the relatively market-oriented aspect of the American health care provision that is the fundamental reason for the high health care costs?

After all, no other country is quite as wedded to the idea of swim-or-sink in the wonderful morass of the free health care markets, and neither does any other country offer quite the same profit- or money-making opportunities as the U.S. does. This possibility will be the topic of my next post in this series.


-----
Parts I and II of this series can be found here and here, respectively.
*The latest figure is 17% for the U.S..
**The Indian figures are for 2002.
***The U.S. rate is higher partly because of higher infant mortality rates among the racial minorities who have, on average, lower incomes and less access to medical care. But even the white rates have traditionally been higher than in other comparable countries.

Today's Bad Poetry Hour

Darkness

Musky thighs
murmured sighs
the moon is waxing
try relaxing
inside this burning eye.

You cannot lie
your mouth wont grin
your body's sky
teems in sin.
You always seek
the darkness in the weak

and find the hollow
of your temples filled with sorrow.

Fists

Anger is an art
years in the making.
I am breeding bullets
giving birth to knives.
Daylight breaking.

Taking you apart.

Anger is an art.
Everybody learn to dance.
I am honed to edges,
knowing how to kill -
a lifetime's chance.

Slit getting smart.

Carrie Prejean, Meet Alien. Alien, Meet Carrie Prejean.

Carrie Prejean is the runner-up in this year's Miss U.S. competition and in the news because she stated that a marriage should be between a man and a woman and then "some people" hinted that her statement may have cost her the winner's tiara in the pageant.

The topic of this conversation is a serious one. But the pictures of the person making these religio-sociological statements are of a very made-up woman in high heels, flowing curls and a tiny suit intended to cover sexually taboo areas during aquatic immersions. All this made me ask my friendly Alien what it thought about the topics we humans discuss and the context of those discussions.

It adjusted its spectacles (not needed as it doesn't have eyes as such but it so wants to fit in) and asked me if beauty pageants are like fertility rites. Aren't those who are deemed suitable for participating in such rites the correct experts when discussing who is allowed to mate with whom?

I was left speechless.

Reading Between The Words

I have been reading the news of an arrest in the Craigslist murder, largely because I heard on the radio a reference to the current suspect's alleged misogyny. Here's the bit I was able to find in news:

Many of Markoff's friends and acquaintances found him completely normal, but others picked up on a hostility toward women and African-Americans.

That's not much evidence but who knows. While searching for more information on that I also bumped into lots of contempt towards women and your ordinary garden variety biases. For an example of the latter:

Technology allows women to reach perfect strangers and market sex, massages, lap dances, and other "erotic services." It allowed a killer to lure women to hotel rooms, rob them, and shoot one dead. It also helped police and the public to track down and arrest a suspect.

Take that first sentence, so very innocent and neutral as it might seem. Then rewrite it:

Technology allows men to reach perfect strangers to buy sex, massages, lap dances, and other "erotic services."

Both sentences are equally true, but by selecting the one the article used we turn the flashlight away from the customers of these women (and on the women themselves), except for the odd customer who happens to murder the sellers.

Then there were a few comments in a comments thread attached to an article discussing a purported e-mail to the media from the murder suspect's fiancee. I hasten to add that the comments I have picked are not indicative of the general tone of the comments there, but they are odd enough to tell us something about this society. To understand them you need to know that the suspect, Philip Markoff, is a second-year medical student:

"We expect to marry in August and share a wonderful, meaningful life together."

A true test of love is about to come up: Will she support him through thick and thin, sans a doctor's income - if the allegations stand up?

----

Sorry honey that your perfect little dream world came crashing to an end! marrying a doctor and having a fantasy wedding, at least you know now that you were marrying a pychopath. Let go of the dream and be happy you are alive!

----

Is this what they mean when they say women are attracted to medical doctors? And he isnt even one yet!

What's important to point out is this: Mr. Markoff's fiancee is ALSO a second-year medical student. Yet the assumption is that she is an airhead marrying a doctor for money.

Note that I haven't even addressed the much more seriously misogynistic question about the plight of sex workers and the risks they are subjected to. But then neither do the articles I have come across in this reading between the words.

O Sancta Simplicitas!

She sighs, after kicking through the garage door and after ripping off most of her scales. That statement is appropriate in situations such as...let's say...when you get burned on the pyre for trying to reform a religion which hurt the poor and the poor collect wood for your roasting.

Anyway, there are days when I lose all faith in the ability of humans to use anything past their fingers for figuring things out. This is what set me off:

President Obama called his full Cabinet together for the first time Monday and instructed the department heads to cut enough money from their budgets to set a new tone in Washington.

But the target the president set for the cuts amounts to a fraction of the overall budget, leaving room for critics to question whether the reductions mean much at all.

Obama has asked for $100 million in trims from a budget expected to exceed $3.5 trillion. The Cabinet secretaries have a month and a half to come up with proposed cuts.

"None of these things alone are going to make a difference," Obama conceded, emerging from the Cabinet room. "But cumulatively they would make an extraordinary difference because they start setting a tone."

If they cut "$100 million there, $100 million here," Obama said, "pretty soon, even in Washington, it adds up to real money."

Republicans characterized the target in different terms. A "meager .0025%," said House Minority Leader John A. Boehner (R-Ohio). "Pathetic joke," said Grover Norquist, president of Americans for Tax Reform.

"Let's not forget that at the same time they're looking for millions in savings, the president's budget calls for adding trillions to the debt," said Senate Minority Leader Mitch McConnell (R-Ky.).

According to the White House, federal agencies have already started working to trim fat from their budgets.

It's a thoroughly, gratingly annoying piece of news. First because saving money now is fairly close to suicidal behavior for a government, and, second, because Obama still feels obligated to pretend ('pretend' because the cuts are tiny) that he's going to really starve that beast, the bureaucracy, to a nasty end, even if it's not getting drowned in a bathtub as Grover Norquist would prefer.

Not sure why it's so very hard for politicians not to want to emulate Herbert Hoover. Sure, get rid of waste and inefficiency. But this is NOT the time to discourage consumption. Just go out to a mall and see why that is the wrong moral to draw from this story. Take a ride down the highway and watch the light traffic. Talk to some people and find how many are unemployed, underemployed or waiting for the axe to fall. Ask some shopkeepers how they are doing.

Saving is great. We should all save for the rainy day. But not on the day when the fucking storm has already pulled down the house roof.

Perhaps today is not that day, but neither is it one of those fat days when the sun flows down like yellow butter on both the deserving and the undeserving. Of course the Republicans view most of us as among the undeserving and all expenditure by George Bush as something that Did. Not. Happen. Jeez.

A Medical Nightmare

Or perhaps a medical system nightmare? Kate Michelman (an ex-president of NARAL and a well-known feminist) has written an article for the Nation magazine on what happened to her middle-class family when two health disasters struck, the first one to her uninsured daughter and the second one requiring long-term care for her husband. Do read what she writes. It fleshes out my earlier Morse code post a little.

The Costs of Health Care. Part II: Value For Money

Quite a long time ago I promised to write a series of posts on the costs of the American health care system. I have made several attempts at starting the series but every time I end up writing econo-babble: I stuff too much into one or two posts. This is an attempt to take things from a different angle altogether, by asking a very simple question:

Are we getting value for money in health care?

Think about the possible answers for a while. See how difficult it is? Note that we need to define almost everything in that sentence to really come up with some tentative answers.

First, who are the "we" who are supposed to get value for money? All Americans? All people legally in this country? All people with third-party coverage (insurance or government funding)? People with all possible health conditions? People from all social classes? All races?

Note that a middle-class person with employer-provided family health insurance might be very happy with what she or he is getting. Someone without any insurance at all wouldn't even understand the question. Thus, the answer to the question will depend on how we define that two-letter word "we."

Second, what is the "money" we are talking about? Does that sentence only refer to out-of-pocket costs or to the total expenses that are charged to both the patient and various third-party payers? What if those charges don't actually match the true resource sacrifices to the health care system? This is fairly often the case, after all.

And whose money is this? Is our approach as wide as the whole economy or are we talking only about the private costs to the individuals themselves? These two concepts differ.

Third, what is "value" for money in a field such as health care? This question is an extremely hard one to answer, because the "output" of the health care industry is difficult to quantify and that would be a necessary intermediary step to come up with some measure of value. It's possible to give rough estimates of this output by assuming that good health care would make people live longer and healthier lives. Something like the average life expectancy or the reverse of various mortality figures could then be used as very rough output measures.

But this would assign too much blame for our mortality on the health care system. For example, the U.S. average life expectancy is considerably lowered by car accidents and violence, both causes which are not terribly easy to fix by building better hospitals, say.

The concept of "value" has another hidden dimension, partly embedded in the whole question I pose, and that has to do with the quality of care in general. One way to measure this is by consumer satisfaction. But patients are not always able to judge the quality they receive. Indeed, some aspects of the quality of medical care are not easily measured by even those whose job the development of quality measures is. It is the inherent characteristics of medical care: the uncertainty present in many treatments and the necessary participation of the patient in the process that make quality measurement so difficult.

Fourth, and finally, what is this "health care" we are talking about? Often lumping physicians, medications, hospitals, nurses and nursing homes all together into something called "health care" makes sense. It lets us talk about the big picture. But of course in reality the industry of health care consists of many different occupations and firms, and some of those may be giving some of us excellent (though poorly defined) value for money, while other consumers are getting nothing or rather poor care for their money or someone else's money.

It's time to ask why I posed that question and then went on nitpicking for several paragraphs. The reason can be found in the generally accepted idea that the U.S. health care costs are too high. In what sense are they too high, though? Note that if the total sales of the U.S. car industry were high (sadly, not a realistic example right now) we'd be pleased with how well the industry is doing. That the high sales of the U.S. health care industry are not seen in this light shows us that it's really the "value for money" aspect that we are concerned about, not the absolute size of the expenses themselves. Thus, it's necessary to address that aspect when trying to figure out how to lower the overall costs of health care. And "value for money" makes the study of fairness, access and the efficacy and effectiveness of treatments a necessity in this conversation.

My next post addresses some of those by looking at international comparisons of health care costs.

35 Cents A Word And Hate Mail!

That's a really good price per word, by the way. The column from which this headline was taken is an interesting read, too. A snippet:

The way the envelope was addressed should have been enough to warn me that the letter inside was not amorous in nature.

To the left of the postmarked stamp, in formal but shaky cursive, my new correspondent had written "President, Bitch of the Year Club" immediately beneath my correctly-spelled name. This was unfortunate; there could be no mistake to whom he was referring.

Sent care of the daily newspaper for which I had just written my first weekly column, the envelope had no doubt spawned photocopies that were already circulating widely throughout the newsroom.

..

Inside, the letter itself was unequivocal. In the same painstaking hand, the writer repeated my name in full and charged: You are a dog Faced Slut who likes to run off at the mouth

The random capitalization and complete absence of punctuation enhanced the disarming directness of the message, which continued: I hope some Bull Dyk gives you some B+D so Stick a Sock in it.

mmm.

What caused all that anger was a piece the author, Shari Graydon, wrote about "the peculiar sizing practices of women's clothing manufacturers," a topic we all know makes feelings run high. I guess.

I can't help wondering what Ms. Graydon's feelings would be after a few years as a feminist blogger. Heh. But of course the point she makes is an important one: You need to subtract the cost of the hate mail from that princessly 35 cents per word.

Some Fiction

I found these stories when looking for something else in my archives and thought that you might like them. Well, not really, because one of them ("Pollyanna") requires a childhood abuse trigger warning and nobody ever gets "Bees' Knees." But I like them and I want to have a running start for the week. Here they are:

Pollyanna

Bees' Knees

Confined to the Possible (by Phila)

A conservative commentator named Jay Schalin defends himself against charges that the "common cultural identity" he wants education to impose on American students amounts to indoctrination.

His starting point is that some people are naturally going to fail at life, because they've been given the freedom to do so by a wise and loving God.

[The] vision of equality is frequently in conflict with the real world—people are not equally gifted or inclined. Some are ambitious, others lazy; some are bright or creative, others dull, for reasons beyond our control.

Except, of course, that the reasons are not necessarily beyond our control. We don't have to stigmatize certain people, and poison others with lead and mercury, and punish others for the alleged sins of their parents. And we can also recognize that claiming equality between people who are manifestly unequal is one of the uglier forms of oppression. But all of this would require us to accept that there "should not be justice in the ordinary sense, but 'social justice,'" and Schalin has already identified this as a unreasonable course of action. Since inequality is natural, any attempt to tamper with it is unnatural by definition.

Besides, society has already achieved justice, through the process of natural selection:

Conservatism...does not begin with any such constructed ideal. Perhaps its most important guiding principle is that tradition represents the surviving wisdom of the past—people over time tend to adopt the ideas that enrich them and empower them, and cast off the ones that fail or weaken them. It views modern free society as the result of the grand trial-and-error experiment that is Western civilization, occurring over many centuries—the result of efficiency and justice winning out over the inefficient and divisive.

And that's why black students tend to score lower on tests than white ones, and women tend to earn less than men: "people" adopted ideas that enriched them. And having done so, they defined once and for all the boundaries of what is possible in American society:

It is therefore a philosophy thoroughly grounded in real events and human nature—it is confined to the possible. There is no need to convert or coerce people to believe in a vision that is against their nature—it is about letting people do as they will, knowing that they will generally choose wisely, having the wisdom of past generations to draw upon.

How do you choose "wisely"? Well, avoiding becoming a homosexual is a good first step, since doing as you will in that case will lead to having fewer rights, being persecuted, and so forth. Being a woman, by contrast, is an accident of birth for which you can't necessarily be blamed. But you can make the most of it by drawing on "the wisdom of past generations," and making the choices that time has proven work best for women. In other words, you're free to choose, as long as you make the right choice, and stick to it come what may.

We arrived at our present "natural" levels of inequality through "the grand trial-and-error experiment that is Western civilization." But now that we're here, trial and error must end, lest some "constructed ideal" redefine what counts as human nature and get everyone all confused. In the worst-case scenario, different people might end up being enriched and empowered, which would turn the natural order on its head. The purpose of the past was to get us to this point, and keep us here: "It is...an organic process happening over time—an evolving mindset that adheres to the basic principles despite the changes."

At this point, forming "a common cultural identity" seems primarily to be a matter of stifling complaint. Schalin claims that there are no racial barriers to "American identity," except to the extent that one insists on one's grievances. Racial complaint is answered by the observation that "Jim Crow laws are long over." Does this mean that Jim Crow laws are part of "the wisdom of past generations"? Or does it mean that we're not, in fact, confined to the possible, as defined by the dominant "cultural identity"? Who knows? Who cares? The important thing is that Clarence Thomas is a conservative even though he's black, and Irving Berlin wrote "White Christmas" even though he was a goddamn Jew. Though these men are minorities, they were able to transcend that limitation, and provide a useful service to the people whom nature put in charge. That, in a nutshell, is what forming "a common cultural identity" is all about. It's not indoctrination; it's our birthright.

So we have free will, which we can use to make the right choices, based on what's known to be possible, according to the winners who wrote the history books. And that's why America is unique in giving its citizens "a focus on the future and not the grievances of the past; a feeling of limitless potential...a sense of wonder, innovation and discovery; and the feeling that one is in control of his or her own destiny."

The sky's the limit...as long as you don't step outside the bounds of what's "possible."