Friday, October 11, 2013

Restorative forces

There is a corollary to yesterday's post on stability. When a stable system is perturbed, forces inherent in the system act to return it to equilibrium. In political systems, these forces are popular reactions against reform. Political systems differ from physical ones, in that the public responses are often delayed as a result of public perception, remoteness of experience, or initial misperception of the scope and purpose of the reform. The forces seeking equilibrium are present and relentless however, and eventually overcome the transient and artificial dispruptions imposed by authorities. This is why dictatorships fall, or stagnate, and why socialist utopias eventually encounter crises between promises and realities.

Thursday, October 10, 2013


An essential characteristic of a stable system is the tendency to return to a state of equilibrium after being disturbed by some influence. This is true not only of physical systems but biological and political ones as well. The baseline or ground state is an inherent property of the system, and determines the response to perturbation.

Societies are highly complex and heterogeneous systems that, if they are to be stable, will have defined baselines in terms of institutions, economics, and social values. It is of course possible for these to evolve over time, but this evolution tends to be a response to environment and a constellation of circumstances rather than a discrete influence. When reformers and idealists seek to alter these fundamental characteristics of a society they often succeed in achieving only a transient and artificial change that cannot persist without the threat and use of force. Such enterprises, even if they initially have popular approval, eventually collapse under the strain of human nature.

It is difficult, almost to the point of impossibility, to "fundamentally change" a society through legislation or political machination. The natural tendency is for politics to eventually reflect the underlying values of the society, rather than to shape them. The fact is it is not possible for politicians of any type, whether they be tyrants, democratically elected legislators and executives, or appointed functionaries to prescribe what people want or what people value.

The forces necessary to fundamentally change a society, that is to change the baseline or ground state at which a society functions in the absence of force or duress, ultimately derive from people's experience and subjective interests. The instincts and subjective experiences that influence how people interact with each other are much more robust and enduring than political policies or ideological ambition.

Wednesday, October 09, 2013

A technological paradox

An article published in the medical literature in 2011 documented a significant increase in the number of pulmonary emboli that were diagnosed since the introduction of sensitive tests for them. The mortality associated with that condition, however, did not improve significantly over the trends that had existed prior to the adoption of more sensitive diagnostic methods. The number of complications associated with therapy of pulmonary embolism did increase in the same manner as the number of diagnoses. The implication of this is that the introduction of sensitive diagnostic technology led to a dramatic increase in the number of cases diagnosed, but that that increase did not have a significant impact on patient outcomes. Pulmonary embolism began to be overdiagnosed, and some patients experienced significant complications from therapy that previously would have been unnecessary.

This circumstance is not limited to pulmonary embolism, nor to a small number of similar conditions. Diagnostic technology has advanced to the point that resolution of diagnostic studies has out-paced our ability to interpret them. We are finding more minute and unanticipated anomalies for which we do not know the significance. As a result, physicians are making diagnoses, often based on incidental findings, and providing treatments where they would not have only a few years ago. The benefits and risks associated with making these diagnoses and treating these patients is unclear. In the case of pulmonary embolism, increase diagnostic sensitivity clearly carries the risk of overdiagnosis, providing treatment where none is required, and causing unnecessary complications.

The tendency to overdiagnosed and over treat arises not only from technological advancement. Fear of litigation, patient expectation, and the proliferation of protocols and algorithms also influences medical decision-making in the direction of more frequent and less efficacious treatment. Paradoxically, while diagnostic technology enables greater detail of unclear significance, the use of protocols and algorithms homogenizes diagnostic data and disregards other clinical information of significance to a particular patient.

These factors contribute to an undesirable praxis in American medicine. The desire to provide diagnostic certainty when there actually is none, to medicalize everyday difficulties and consider them as diseases leads to such excesses as overprescribing antidepressants and stimulant medications, a proliferation of unnecessary procedures for treatment of ill-defined "syndromes," and an explosion in the number of patients claiming disabilities of one type or another. A peculiarity of American medicine is that many diseases and medical conditions are associated with their own interest groups. Diseases have lobbies. It is an undeniable and likely inescapable fact of American medicine that some interests benefit from overdiagnosis and overtreatment, and those interests are active in perpetuating what is fundamentally bad medicine.

This is only one of an innumerable number of factors for which the affordable care act provides no answer.

Tuesday, October 08, 2013

Government healthcare

With all of the angst accompanying the roll out of the Affordable Care Act, the foibles, the unintended consequences, the unanticipated costs; it may be instructive to review the findings of a previous investigation into government run healthcare. These were the findings of a Senat Committee on Indian Affairs investigation into the operation of the Indian Health Service in the Aberdeen Area in 2010:

Among the investigation’s major findings:
• Chronic mismanagement, lack of employee accountability and financial integrity;

• Several service units experienced substantial and recurring diversions of reduced
health care services, due to lack of qualified providers or funds;

• Five IHS hospitals in the Aberdeen Area are at risk of losing their accreditation or
certification from the Centers for Medicare and Medicaid Services (CMS);

• Several facilities have been cited as having health care providers on staff who
lacked proper licensing or credentialing;

• Key senior staff positions remained vacant for long periods of time, contributing to
the lack of proper management;

• Employees with a record of misconduct or poor performance being transferred to
different health facilities within the Indian health system;

• Pharmaceutical audits of narcotics and other controlled substances are not
regularly performed, and three service units within the region have a history of
missing or stolen narcotics.   Source:

Morbid curiosity

There is perhaps an intuitive sense that human life is protected by the odds. It seems reasonable that the risk of cataclysm is sufficiently small to have enabled human beings to thrive for millennia, and expect to do so for many more. Most commonly perceived threats are associated with vanishingly small likelihood of occurrence. A worldwide extinction such as that which befell the dinosaurs is likely rare enough to have been considered a one off. This perception applies to most conventional threats, such as a catastrophic asteroid impact or nuclear calamity. The odds, simply, appear he to be in our favor.

It may however be the case that there are mortal threats lurking in far more likely scenarios. To take one such example, it is reasonable to assume that there is at least one, and likely several amino acid sequences that would code for a pathogen that would be devastating to human life. Imagine, for example if the human immunodeficiency virus had a genetic makeup that would allow it to be passed by casual contact, or to be transmitted with the ease of the common cold. It is possible to conjecture the existence of such a genome and wonder how likely random mutation is to produce it. Is such a peril thirty base pairs away? ten thousand? A million? It is also possible to consider that such a fateful genetic sequence might be the result of human manipulation.

This is not to imply that human beings are necessarily doomed, or that a biological catastrophe will wipe out the species. It is to suggest however that it might not be unreasonable to wonder what the true odds of disaster are, and when luck might run out.

Monday, October 07, 2013

Thursday, October 03, 2013

The limited competence of public institutions

One thing that you learn from coaching or watching football is that not everyone can do everything well. Certain players can do certain things well that other players cannot do at all. The same applies to entire teams. You also learn that not everyone who does something well does so indefinitely. Players age, skills fade, and times change. Likewise, even though someone may do something very well there is always the possibility that someone will come along and do it better. These principles apply not only to sporting contests but in civic life. No one institution does everything better than the others. Institutions that do something well initially may get progressively worse at it as time goes on. Institutions may be so hampered by bureaucracy that they are unable to adapt to changing conditions, or they may assume responsibilities for which they are wholly unsuited.

These principles weigh against the progressive notion that the government should be relied upon for nearly all important endeavors. The fact is that there are some things that charities, and private enterprise do much better than public institutions. There are also things that public institutions may have initially done well that they have increasing difficulty doing competently. There are things that may best be done by government initially that private enterprise, or dedicated nonprofit organizations eventually do better.

The list of things that require public institutions because private or charitable institutions tried and failed is vanishingly short. There are of course some things which, on the whole, are proper objects of public enterprise; these include such things as law-enforcement, management of roads and thoroughfares, and providing fire protection services. Other areas in which public institutions to have a role, but which benefit from the participation of other entities include such things as managing hospitals and education. Scientific research likewise benefits from not being reliant on a single source of support, and undertakings such as space exploration are areas in which public institutions have been largely left behind.

The fallacy that, unless the government does something, it will not get done, or alternatively, that unless the government does something it will not be done well, is detrimental to both progress and to civic life in general. Governments and public institutions are inherently bureaucratic and hence inherently limited. There is no reason for a free and thriving society to inflict such limitations upon itself without good cause.