Wednesday, October 22, 2014

The Medical Mafia

"Are there really that many men who worry they won't be ready when the moment is right? "

Whenever we're exposed to broadcast television in the United States we are always amazed at how much of it has been paid for – how much of its time has been purchased – by medical-related corporations. If you turn on the evening news, for instance (and back when we were children that was actually how people became informed of world events, astonishingly enough), the advertising is overwhelming dominated by three sectors: cars, phones, and drugs. By and large, advertising is the principal means by which United States culture instills values in its children.

Other than billion-dollar bribes paid to the best elected officials money can buy, is there some compelling reason why drug advertising is not illegal? Are erections lasting longer than 4 hours really so common that we have to be warned about them 80 times every day? Are there really that many men who worry they won't be ready when the moment is right? Pfizer apparently thinks it is worth spending $1.2 billion per year advertising Celebrex to protect its consumers from such horrific conditions.  In contrast, NASA's total cost for the Apollo program that put a man on the Moon was $22.9 billion between 1962 to 1972.

Apart from the Pentagon or NSA budgets, what else do you know that costs as much as pharmaceutical advertising? Big Pharma spent 15 billion on direct mail promotions in 2012, all that junk mail that went directly to your trash without even being opened.  For contrast, the amount the US will spend on school nutrition programs in FY 2014 is 14.8 billion.

If you were a drug company, which do you think would be more important, money for research into new and better therapies for disease or advertising drugs? Given that most drugs being advertised are available only by prescription, the target audience must be doctors, who we must presume should prescribe on the basis of efficacy and safety, not ad hype. Nonetheless, Merck spends 27% of its revenue on advertising and 17.3% on research and development. Pfizer's ratio is even more lopsided, with 33% on advertising and 14.2% on R&D. 

We are (sort of) proud to say that once we came of Medicare age, we now have medical insurance for the first time in our life. Of course the medical safety net in Tennessee, or the USA generally, is not remotely close to say, that of Mexico, Andorra, Cuba, Singapore or Costa Rica.

Take Iceland, for example. Every citizen gets complete, state of the art health care regardless of their contribution to the system. There is no private sector.

In terms of life expectancy, and most other outcomes, the U.S. and European/Asian systems perform about equally well. But the U.S. spends a much larger portion of its GDP to achieve this performance, getting similar results for 1.5 or 2 times the price. The difference could be explained, and often is, by arguing that the US spends more on innovation than other countries, but as we've seen, that is not true. The US spends more on advertising, and on gaming government spending. The real difference that accounts for the greater cost, we would argue, is the criminal element in the system.

According to a report in The New York Times:

The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.
The line at top is the USA; below are all other countries
Mark T. Bertolini, the chief executive of Aetna, earned over $36 million in 2012. Ronald J. Del Mauro, a former president of Barnabas Health, a midsize health system in New Jersey, took home $21.7 million that year.

The World Health Organization declines to rank countries in their World Health Report 2010, but a report from the Commonwealth Fund ranked seven developed countries on their health care performance and the US came dead last. Maybe if it used its annual $2.7 trillion in health care expenditures for something other than television advertising of fertility enhancements, the US might be doing better when Ebola patients appear in a Texas ER than to kick them out for lack of insurance.

In June, sporting a shiny new plastic card giving us some limited access to the paywall-protected system, we showed up at the office of our assigned primary care physician for our first annual physical. We were handed a clipboard with about 3 pages of questions concerning our medical history, prescriptions and any symptoms of disease, which we dutifully filled out and returned. After about an hour's wait, we were weighed, had our blood pressure and temperature taken, and were shown into a small examining room, where we waited another 20 minutes before a Physican's Assistant came to review our questionnaire with us. The process took about 5 minutes, after which we were shown out and done for the year. We had a clean bill of health.

A few months passed and we started receiving bills. It seemed odd to us, because the annual exam is supposed to be free for people of our age, but they were only asking $10 for the "outpatient visit." We declined to pay on principle, knowing our rights, so the dunning notices have now become a regular feature of our mail and are becoming more strident. Some of the bills provided greater detail, so we dug down into the fine print.  

The doctor's office charged our (now federally-required) insurer $318.00 for the 5 minute exam with the Physician's Assistant. The Social Security Administration picked up $157.65 for that because apparently that is what they honestly consider to be the market value of a 5-minute review (!). Apparently the insurance companies have a special relationship with SSA because subsequently they got an "Adjustment" adding another $160.35 write-down from the government. This made the doctor's office whole without costing the insurance company anything apart from the time spent on paperwork and trying to collect our $10 co-pay, a futile effort.

We should note here that SSA deducts $100 per month from our social security check – money withheld from paychecks during our working career – or $1200 per year. They use this $1200 that we are forced to pay them every year to pay the $318 demanded by the doctor's office for our 5-minute annual checkup (actually $157.65), pocketing the remaining $1042.35 that we might otherwise have spent on canned cat food to have enough to eat. This is apart from the annual premiums we are required to pay to a private insurance company under Obamacare.

Our insurance company continues to cut down trees to send us dunning letters demanding $10 for what is supposed to be a free exam and we continue to ignore them. Next June we will spend another 5 minutes with a Physician's Assistant who will once more go over our answers to the questionnaire and charge $318 for her time, or perhaps 15% more, depending on the going rate of inflation in the industry. 

Although her office is billing her time out at $6360 per hour, she is probably making around $20,000 - 30,000 per year, or $10-15 per hour. But the job comes with a good insurance plan.

We use "industry" guardedly. What we are really talking about here is a grossly incompetent criminal syndicate, legally sanctioned. It might be laughable if it weren't killing so many innocent people every year.

Sunday, October 5, 2014

This Changes Nothing — Naomi Klein's Climate Prescription

"A post-capitalist world would not be one of dense cities and jet travel, but it would have a chance of averting climate change if it could rediscover a balance with nature akin to that previous noncapitalist societies maintained for millennia primarily through gift economies and perennial agronomies."

We eagerly picked up a copy of Naomi Klein's latest book, This Changes Everything — Capitalism and Climate Change, the day it was released because we were mesmerized by the word "capitalism." Of course we were interested primarily in climate change, but we already have whole shelves of books devoted to that topic, going back more than 60 years. What we are looking for now are not retread problem statements, no matter how elegantly posed, but viable solutions to the urgent, existential dilemma. When someone mentions as a pivot point something as grand as capitalism, we are immediately drawn, because at last, we think, they are getting to the root of the matter.
"There is no way this can be done without fundamentally changing the American way of life, choking off economic development, and putting large segments of our economy out of business."
— Thomas J. Donahue, President of the US Chamber of Commerce, on ambitious carbon reductions, quoted in This Changes Everything.
Klein's book disappoints. She delves into capitalism only very superficially. She does not undertake the more arduous task that her title suggests — dissecting linkages between exponential-growth driven culture and macroclimate — and then illuminating a transition pathway to a better future, some style of money game antithetical to Monopoly.

Make no mistake — understanding capitalism is key to understanding and reversing climate change. Klein provides neither the understanding of how that has happened nor any practical and promising way to post-modernize the process, such as by a smartphone linked to MazaCoin (trading at $0.000078 as of Sept. 10).  For her, "capitalism" just seems to be synonymous with "corporatism" or "greed." We might have still purchased the book if either of those words had been substituted in the title, but we would have held fewer expectations.

She refers to the books she reads to her child and creates a similar narrative here: good guys (First Nations women leaders, Ken Saro-Wiwa's Movement for the Survival of the Ogoni People, Henry Red Cloud's Solar Warriors, the Rainforest Action Network,, whose activities are "mesmerizing," "heroic," "determined;" while bad guys (Richard Branson, frackers, Fred Krupp, carbon traders, UN negotiators, Nature Conservancy) are "entrenched," "sly," or "rich and powerful." There is even a cliffhanger finish — will our heroes transition to clean energy in time?

Jean Laherrere predicts a very rapid drop in energy after 2017
Missing are any grasp of civilization itself ascending the steps of the guillotine; the inextricable fossil energy embodied in industrial-scaled renewables; or the Ponzi tsunami in sovereign debt and its implication for globalized supply chains. The dumbing down process Al Gore described in The Assault on Reason seems to have struck the left with the same casual brutality as it lobotomized the right. 

What Naomi Klein dispenses best is harangue. Because she is a very gifted writer working with a large research budget, the book sits well on its shelf beside works of similarly gifted writers performing similar harangues. Her prescription is protest — "Blockadia" is the term she coins — and while that may indeed produce results sometimes, especially when resonating with cultural shifts reflected in contemporary music and prose, it may also be catastrophically naïve if the "ask" is too far a reach for mass acceptance, or if the advocates' own lifestyles betray a secret lust for role reversal.

Martin Luther King's grasp of the use and limits of protest provides a modern example of successful "swerve" (in contemporary climate tactician lingo). As described in his famous Letter from A Birmingham Jail, there are a number of essential preconditions for moral protest. Although King does not make the attribution, his checklist is drawn from the voluminous lifetime writings of Mohandas K. Gandhi.

First, purify yourself.

For Gandhi and King, self-purification means, besides purging racial prejudice from your own heart, harboring no anger, while at the same time being prepared to suffer the anger of your opponent. For King, this meant the ability to forgive but not forget; to bounce back again and again, still holding love in your heart. For Gandhi it meant a willingness to take sides with your oppressor — "If anyone attempts to insult or assault your opponent, defend your opponent (non-violently) with your life." (“Some Rules of Satyagraha” Young India (Navajivan) 23 February 1930 (The Collected Works of Mahatma Gandhi vol. 48, p. 340).

Second, negotiate.

King and Gandhi always sought civil remedies through normal channels, and when these failed for illegal and unconscionable reasons, they could then proceed to a final tet-a-tet. They informed authorities in advance of their intentions to resist. They offered themselves for arrest. No protest could proceed before every possible avenue for redress had been followed but inexplicably blocked by the intransigence of authority. This tedious process provided the clear moral high ground in each confrontation.

Klein writes,

"'You have been negotiating all my life.' So said Canadian college student Anjali Appadurai, as she stared down at the assembled government negotiators at the 2011 United Nations climate conference in Durban, South Africa. She was not exaggerating. The world's governments have been negotiating for more than two decades; they began negotiating the year that Anjali, then twenty-one years old, was born. And yet as she pointed out in her memorable speech on the convention floor, delivered on behalf of all assembled young people: 'In that time you've failed to meet pledges, you've missed targets, and you've broken promises.'"

Does this gain sufficient moral high ground to justify laying down one's life to tasers, tanks and microbeams directed from aerial platforms? Not yet.

The UN climate treaty process (UNFCCC), informed by the slowly consensed scientific authority of the IPCC, is not being thwarted so much by covert action in the West Wing and 10 Downing Street or the corporate headquarters of Koch Industries as by the sluggish response of elected or inherited governments to the slow-dawning reality of the scope of this particular problem. As successive governments over 30 years come to grasp its dimensions and what that implies for the fate of business as usual, there is a kind of institutional learning that takes place -- the kind of progress by baby steps that was foreseen by Eleanor Roosevelt when the United Nations was founded. It may seem glacially slow to people from the generations of Klein and Appadurai, raised in the Twitterverse, but slow is not "no." 

Harvard Students at September Climate March in New York
In the tortoise-like process of the UNFCCC, the next major deadline is COP-21 in Paris, December 2015. The recent high level meeting in New York and this December's COP-20 in Lima are intended to set the stage for a treaty. That legally binding treaty should be seen as a Rubicon for the UN process. If it arrests emissions by firm and timely process, "alea iacta est" – the die is cast.  If the river is not crossed, or it does not go far enough fast enough, or the UN farms the crisis out to mercenary corporations, mass civil disobedience is fully justified.

Klein writes:

"By posing climate change as a battle between capitalism and the planet I am not saying anything we don't already know. The battle is already underway but right now capitalism is winning hands down. It wins every time the need for economic growth is used for the excuse for putting off climate action yet again, or for breaking emission reduction commitments already made.…

"Right now the triumph of market logic, with its ethos of domination and fierce competition, is paralyzing almost all serious efforts to respond to climate change…. For any of this to change, a worldview will need to arise to the fore that sees nature, other nations and our own neighbors not as adversaries, but rather as partners in a grand project of mutual reinvention.

"That is a big ask, but it gets bigger. Because of our endless delays, we also have to pull off this massive transformation without delay. The International Energy Agency warns that if we do not get our emissions under control by a rather terrifying 2017, our fossil fuel economy will 'lock in' extremely dangerous warming."

Giving your negotiating partner (in this case the UNFCCC) a deadline is something both King and Gandhi did. If the partner asked for an extension of time for reasonable cause that would be granted. Again and again. The process of negotiation is not complete until the last legal stone has been turned and the final responses are bereft of moral reason.

The third step in preparing successful protest is surrender. For King, this involved bearing Christian witness, as in the case of sending waves of children to face billy clubs, firehoses and attack dogs in order to fill Birmingham's jails to overcapacity.

For Gandhi, surrender meant to "never retaliate to assaults or punishment; but do not submit, out of fear of punishment or assault, to an order given in anger."

As a prisoner, Gandhi observed the same rules of self-discipline as in the outside world. He obeyed prison regulations except those contrary to his own self-respect. He fasted only when his own self-dignity demanded it. Once begun, he expected no respite from a fast. Each was a fast to the death.

Parenthetically, these same rules have been scrupulously followed by the victims of daily ritual of torture ordered by President Barack H. Obama in the Guantanamo Naval Base in Cuba. These striking prisoners, whose numbers are estimated at between 45 and 160 but whose actual numbers are unknown owing to the gag order issued by the Department of Defense and the refusal to allow in UN human rights inspectors, are innocent men. They were innocent when they were abducted from their homes and farm fields in 2002. They were even found innocent in 2009 by the Military Review Panels ordered by federal courts in 2006. And these were kangaroo courts designed to find them guilty. Their court review came partly in response to the 26-day hunger strike in 2005 that ended only when Navy medics joined in a sympathy strike and refused to provide medical assistance to the daily torture feedings. Only then did prison authorities agree to bring the camp into compliance with the Geneva Conventions, something we all still await.

Today's tortured Guantanamo strikers are waterboarded three times per day at the orders of President Obama. It is not as though he gets up in the morning and before he sees Malia and Sasha off to school he says to a military attaché, "Oh, go ahead and torture another 100 or so prisoners at Gitmo, and throw in some women and children prisoners at the black sites in Afghanistan too, just to let them know we mean business." Rather, as a Commander who could simply order their judicially-ordained release with a few words, he remains mute, kisses his daughters' foreheads, and then prepares daily remarks to, say, praise his outgoing Attorney General for his record on civil rights, or condemn some oil-rich Middle Eastern dictator as cruel and anti-democratic.

From whence does moral authority derive?

Every day since early February 2013, each of Obama's victims is given the option of ending their fast and avoiding being waterboarded yet again — more than 1700 times for some, so far — and each day they choose dignity over the orders of their oppressors. They choose to go under the hose rather than sacrifice their regard for what it means to be a human being.

If the Gitmo hunger strike experience tells us anything, it is that protest does not always succeed. Sometimes it only worsens the conditions being protested. As Malcolm Gladwell describes in David and Goliath: Underdogs, Misfits, and the Art of Battling Giants, the Birmingham civil disobedience campaign was going badly for King until a wire photo of a firehosed teen being attacked by a police dog made front page news. Suddenly, nationwide, public wrath was aroused.

The fourth rule for any protest is to have a goal. For Gandhi, it was Indian independence from British rule. For King, it was ending segregation. Both men, of course, wanted much more. These simple goals, while grand enough to be assumed unachievable by most observers at the outset of the protests, were nonetheless below the mark. Among his goals, King wanted to end the War in Vietnam, and wars generally. Gandhi wanted to end religious and ethnic intolerance. They got what they could, and that was quite enough for the time.

Naomi Klein also has large ambitions. Her vision of the future is bright — "the climate movement does not have the option of saying 'no' without also saying 'yes'" to the many forms of solar development. Already solar power in many of its emerging systems is cheaper and quicker for industrial use than fossil and nuclear options, but that finesses the larger point. Is the goal to save industrial civilization? Is the goal to save the religion of consumerism, of growth economics, and thus, capitalism?

The title of the book seems to suggest that capitalism is the problem. Her analysis, however, lacks the thoughtful deliberation of critics like Noam Chomsky, Steve Keen, Chris Hedges or David Korowicz. Capitalism to Klein is a foil; a target for her sharp political invective. To fight this evil scourge she urges us to storm the parapets, take the streets, stand up to the tanks. Capitalism is just her shorthand for evil greedy bastards.

She writes:

"This book is about those radical changes on the social side, as well as on the political, economic and cultural sides. What concerns me is less the mechanics of the transition — the shift from sole rider cars to mass transit, from sprawling exurbs to dense, walkable cities — than the powerful and ideological roadblocks that have so far prevented any of these long understood solutions from taking hold on anything close to the scale required."

That statement deserves some unpacking. Klein is not very concerned about transition modalities other than street protest. She gives short shrift to Transition Towns, Holistic Management or permaculture and makes no mention of ecovillages, complimentary currencies, gift economies or bioregionalism. She sees the connection between capitalism's profit imperative and the disequilibrium of exponential growth (long a standard of permaculture training) but has scant grasp of the carbon cycle civilizational embed since the dawn of agriculture, energy return on invested energy (EROIE), or the abbreviated future-discount factor as a function of human neurobiology. 

Granted, she pays token lip service to Holistic Management and soil carbon, but calls biochar “problematic at scale” and lumps much of regrarianism with geoengineering. She seriously needs to attend the Biodiversity for a Livable Climate conference in Massachusetts next month. 

Consider her failure to grasp the exponential function as applied to human population. After describing her own difficulties in trying to bear a child, she says simply, "Anyone who wants to have a child should be able to." Really? What about a second, or a fifth? Is this a right that humans had before we emerged from the Paleolithic or is it dependent on some modern scheme of ordered liberty, not to mention bioscience? 

Is it not a right that must first, perforce, be grounded in resource availability, on the penalty of starvation for the whole? Would she confer that right on every reindeer on St. Matthew Island, or are we just talking about womens' reproductive rights here?

Self purification requires we examine our own needs and determine which of them is actually required and which is merely more comfortable. Faced with the discomfort of say, 140-degree summer months, and the discomfort of limiting family size to one-half child, as we described in our Post-Petroleum Survival Guide, which is preferable? For how long?

Klein's "mechanics of the transition" are mere Disney models of New Urbanism — dense, walkable cities presumed able to accommodate 12 billion or more people with ample power from renewable energy to carry packs of contented residents up and down 100 floors in air-conditioned elevators with happy, seasonal background music. Exactly how are those cities to be built and maintained after we dispense with profit motive, not to mention the fossil fuels to turn iron into steel and limestone into concrete?

Self-purification as a pre-protest ritual might reveal to Klein that the powerful and ideological roadblocks she attributes to a Goldman Sachs boardroom are affixed firmly within her own worldview. They are entrenched in the premises of cornucopian solar power advocates as deeply as in the Carlyle Group. If she is to exorcise the Kochs and Saudi princes from control of Earth's climate, she will have to first exorcise mechanistic utopian fantasies from her own thinking. Her admiration for indigenous peoples is good, but she needs to be reminded that their sustainability as peoples comes from their diverse cultures' awareness of natural limits and willingness to forego lifestyle choices that did not adhere to those limits.
A post-capitalist world would not be one of dense cities and jet travel, but it would have a chance of averting climate change if it could rediscover a balance with nature akin to that previous noncapitalist societies maintained for millennia primarily through gift economies and perennial agronomies.

In her new book, The Sixth Extinction: An Unnatural History, Elizabeth Kolbert's epiphany, which comes to her in closing chapters, is that the only way we will ever stop the advent of the Anthropocene is to eliminate the anthros, ie: near term human extinction ("NTE"). She delivers this message with an appropriate sense of grief, but after 300 pages of hard evidence it is difficult to rebut her conclusion. We can really only fall back on unreasoning hope, no matter how fantastical, because the indictment is irrefutable.

Kolbert says that the reason we have the climate threat is not because of human follies and foibles but precisely because of our genius. Our undoing is borne of our strongest attributes — all those parts of ourselves we regard as venerable. It is our human ingenuity, creative spark, versatile skills, and power to project the future from past experience that is killing every other lifeform on the planet, and finally, with the unregistered loss of some tiny, unnoticed but critical link in the web of life that supports us, ourselves as well. As long as we, tool-making homo, remain, Earth's fate is sealed and the climate will continue in the general direction of Venus. Once we are gone, recovery may yet be possible for other life forms. Archaelogists may come to know us only as that mysterious, millimeter-thin layer of radioactive plastic in Earth's outer crust.

If this message is disturbing, there may be comfort to be found by turning back to a part of This Changes Everything. In lionizing First Nations, Naomi Klein reminds us that before the Colombian Encounter there were on Turtle Island a race of people who, by and large, had learned to live in harmony with the natural world, not as dominators but as members. Not to be too simplistic, there were also indigenous nations that over-exploited, behaved with cruelty and avarice, and caused extinctions of megafauna. Klein's heroes are the former, the stewards of nature's bounty, who built verdant soils and abundant forests and lived in peace. If there is any hope for us all, it lies there, in that model. Pray we can rediscover it in time.




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