Living Forward and Understanding Backwards

Soren Kierkegaard once said something to the effect that life must be lived forward but can only be understood looking backward.  Since I recently turned 70 it seems like time to do a little looking backwards.  Most of life seems to go by in a hurry.  One minute you are graduating from high school.  The next it's college and a wedding and a trek across the country to start graduate school.  The year is now 1970 and the protests against the Vietnam War are the big story on most campuses.  It was at The Ohio State University in any case. Classes were often dismissed that spring due to the tear gas that permeated the atmosphere making lecture halls un-inhabitable. When I got my draft notice that spring to report to the induction center for processing I had just learned of the combat death of one of my high school friends.  I had been so self absorbed in education and getting ready for a career in Bio Physics that I had not paid nearly enough attention to politics. Especially the politics of protest.  I was late to form opinions about the value of the conflict. I had been raised in a household where General MacArthur was revered as nearly a member of the Heavenly cabinet.  I naively went along with that for a long time.  I eventually came to the conclusion that Ho Chi Minh was more a nationalist than an existential threat to the American way of life.  As always the issues were complex but it often goes unnoticed that Ho Chi Minh had received help from the OSS and joined in America's fight with Japan in the closing months of WWII. Specifically U.S. Army Major Allison Thomas and the deer team from OSS had been tasked with training Vietnamese guerrillas to prevent Japan's rail access into Southern China in 1945 via Vietnam.  Ho Chi Minh had been in contact with the US as early as 1942 and the original "read" on his politics was that he was primarily motivated by the goal of a Vietnam independent from France.  Only after the war did his communist politics trouble the US government. The swirling alliances in South East Asia during the war are difficult to understand from our point of view in the early 21st century. A simple acknowledgment of Vietnam's independence in 1946 would have saved a ton of treasure and  many thousands of lives.  The Cold War mentality of the day saw Communism as a world wide conspiracy orchestrated out of Moscow.  The failure to recognize the aspirations of a country that wanted to be free of it's colonial overlords as a bid for freedom and not a call for slavery by the puppet masters in the USSR was a tragedy paid for in blood by at least 58,200 US soldiers, 200,000 South Vietnamese soldiers, and nearly 2 million civilians.  In addition South Korea who also sent soldiers to the conflict, lost over 4,000 and Thailand and Australia lost hundreds each.
In any case at the time I did not feel I could support the war and joined the protest movement. Since I was not willing to fight in a war I did not believe in, I had a choice to make.  I could either become a draft dodger and leave the US, or I could seek a deferment to continue my education.  I chose the latter.  Since no deferments were being given to graduate students in Physics in 1970 only two options were available.  Deferments were being given for students in Divinity Schools and Medical Schools.  Since medicine had been an early career option, strongly recommended by my father, I chose that path.  Applications were sent quickly and interviews by telephone followed.  My undergraduate course work had included all of the pre-med course work and I had for reasons unclear to me at the time taken the MedCat exam the previous year along with the GRE exams in both Biology and Physics. The scores for. the MCAT were still valid in the spring of 1970. I got sympathetic hearings from several medical school admissions deans and was finally accepted by Loma Linda University Medical School for the Class of 1973B.  The B was because this class was being accelerated and would finish only 3 months later than the A class of 1973 which had started nearly a year earlier.  I found out about the acceptance by telephone on a Thursday in late May of 1970 and had only a few weeks to sell our house, pack up and move across the country from Columbus Ohio to Loma Linda California in order to start classes.  Looking backwards now it seems improbable to have so many things fall into place.  I put up a 3X5 card in the break room of the local Worthington Foods plant in Worthington Ohio with a For Sale note about our house on a Friday afternoon. Sunday we got a phone call and a couple wanted to see the house.  They made a cash offer and we accepted. I dropped out of all my classes and rented a trailer and we packed and drove across the country.  Medical school was a bit of a culture shock since the information being thrown at us came from a fire hose. It was like trying to get a drink with out having your head blown off.   Classes met 6 days a week and there were no breaks to speak of for the next 38 months.  One of our professors made the comment one day that in the years to come we would look back at these days as the best in our life.  We thought he was nuts.  Who could think of the stresses we were under as the best days of our lives?  Survival was the main goal.  Now I think I understand what he meant.  They were great days!  Unfortunately my marriage did not survive the stresses. But that is a subject all it's own.
I graduated on the last Sunday in September on 1973.  I gave the class response to the graduation commencement address as the class president.  The next morning at 6:30 AM  I went on call as a new Intern at the County Hospital.  It was a work oriented program and you definitely learned by watching and then doing.  The old mantra was in place of: watch one, do one, then teach one.  The first time I was asked by a nurse to place an NG tube I missed out on ever seeing one placed before I stepped into the patients room to do my first one.  I knew by observation that the tube went in the nose but the details of how it got into the stomach were a bit vague.  I carefully lubricated the end and started advancing the tube into the external nares of the patient.  I knew something was wrong when the patient started gesticulating wildly and pointing to his mouth.  I kept advancing the tube and suddenly the patient opened his mouth and the tube exploded out of his oral cavity.  I was dismayed and knew enough to cut it off at the nose and pull the remainder out of his mouth.  A passing nurse took pity on me and got another NG tube and showed me how to get the patient swallowing with a glass of water while advancing the tube.  Success finally.  Looking backwards I can see how some additional training before being turned loose would be helpful, but the arrangement did teach you how to become self sufficient quickly.  Limits on working hours were unheard of and 80 hour weeks were the norm.  More reflections will follow after further cogitation.

Could a Vulcan be Tolerant?

Reflexive statements are logically complex.  By reflexive we mean a statement or principle that "acts on itself".  If a statement includes itself within its "room to act", it is reflexive.  It has been pointed out by many that Tolerance is a self-contradictory principle simply because it has this character.  As a principle, it requires we be tolerant of everything, i.e. we do not get to choose where it should be applied and where it can be put on the shelf.  Thus, the tolerant individual cannot speak out against intolerance since that would itself be an intolerant act.  But tolerance should not condone what it sets out to be opposed to.  Logically tolerance necessitates that we allow intolerant people the right to be intolerant. This is the paradox that Karl Popper the Austrian-British philosopher spoke of in 1945 in his book The Open Society and Its Enemies when he said; “If we extend unlimited tolerance even to those who are intolerant, if we are not prepared to defend a tolerant society against the onslaught of the intolerant then the tolerant will be destroyed, and tolerance with them."  As a star trek fan, it seems to me that Vulcans would by definition be incapable of tolerance since it is fundamentally illogical. This is precisely the dilemma the West faces with respect to "Dawa" which is the political agenda of Islam.  (see my previous blog).

But what do we mean when we say the word "Tolerant"? Is it more than an abstract virtue? Most agree that tolerance is a mind set and the practice of "open mindedness". It is patient, lenient, accepting, even forgiving.  It does not mean agreeing, or giving up one’s own views or convictions. Being tolerant is not easy.  It allows us the ability to suffer fools, if not gladly, with a certain patience that looks beyond the moment.  Are there any limits to tolerance?  I would argue that there must be. One cannot be tolerant of evil.  It is illogical in my opinion for example that the LGBTIQ community in its communal acceptance of unlimited immigration for Syrian refugees fails to understand Dawa and that the goal of political Islam is to impose Sharia on the entire world.  They fail to understand that unreformed Islam or radical Islam if you prefer is inherently intolerant of their sexual orientation and not only preaches but practices the death penalty for those living that lifestyle. Is it logical to accept with open arms those who seek to kill you?  I do not know what the solution might look like, but if we allow the spread of intolerance, those of us who cherish tolerance as a virtue, as the "only real test of civilization" are likely to die out, one way or another.  

Dawa, The Ideology behind Islamic Terrorism

An article by Tunku Varadarajan in the Wall Street Journal's Opinion section last weekend caught my attention.  The interview with Ayaan Hirsi Ali, who is identified as "Islam's Most Eloquent Apostate", brings forward the fascinating idea that there is an underlying political ideology behind radical Islams pursuit of jihad.  This ideology she calls Dawa.  It is also in the title of a recent book by Ms Ali, "The Challenge of Dawa".  Any interested reader should read the book for themselves.  Briefly she makes the point that unless an "Anti Dawa" strategy is developed and soon the west may be doomed.  

Ms Ali has previously held that Islam was not capable of reform.  The opinion piece points out that she has now changed her position and feels that it can be reformed but only by those she calls "Mecca Muslims". These are those who hold to the kinder, gentler form of Islam preached by Muhammad before 622. In that year Muhammad left Mecca and migrated to Medina and the religion of Islam took on a much more militant and "unlovely", some would say evil ideological involution.  Islam in Ms Ali's opinion needs to be viewed NOT just as a religion with all the perks that go along with that identification in a free society, BUT as a religion that is inexorably intertwined with a political ideology that has at it's core the conviction that Sharia Law is destined to overthrow all other forms of jurisprudence in the entire world. Dawa is conducted "right under our noses" in her words and aims at the conversion of non Muslims to political Islam.  By pushing more moderate Muslims toward activism it seeks to overthrow the political institutions of the west and establish an Islamic utopia where Sharia is the law of the land everywhere. 

Ms Ali goes on to say that the focus on terrorism is misguided and what we should be focused on is the war of ideas against "Islamism" or political Islam.  Our reverence for freedom of religion should not blind us to the existential danger of Dawa. The current strategy of Jihadi "whack a mole" is destined to fail in her opinion unless we openly confront the danger of Dawa. The philosophy of Dawa insinuates itself into all of the west's "institutions of socialization" including schools, prisons, universities, and political parties. She points out the fundamental incongruity of progressive's push to accept Islamic culture and practice with their acceptance, even championing of agendas such as gay rights.  She unflinchingly points out that Islamists are not just homophobic but that they actively desire and seek to put gay individuals to death. Another area of her expertise that is not pointed out in this essay is her campaign against female genital mutilation which is still actively practiced in many Islamic countries. Her sad story about being on the receiving end of such a barbaric practice is told in her earlier books. This would seem to be enough to put her in the forefront of "women's rights" movements but instead she is shunned and boycotted from many universities. How I wonder can a liberal progressive woman of 2017 not be in favor of eliminating this horrible abuse of a woman's body?

Many will not agree with her position that the religion of Islam is a Trojan Horse that "conceals Islamism the political movement".   Much as the Jihadist's use of mosques to store weapons takes advantage of the West's reluctance to attack a house of worship the religion of Islam escapes censure and regulation because of our constitutional protections of freedom of religion. She fearlessly states,"the agents of Dawa hide behind constitutional protections they themselves would dismantle were they in power."

The natural enemy of Dawa in her opinion is assimilation. She unequivocally states that the agents of Dawa in the west promote "cocooning" of children to keep them from being exposed to ideas contained for example in the Bill of Rights and the United States Constitution, Freedom, women's rights, gay rights, limits on parental influence, etc are all inconsistent with the tenets of Sharia.  

Her proposed solutions will strike many as unreasonable but what about the alternative?     

Insulin Resistance and Diet Myths and half Truths

As I read others blogs and published articles about Insulin resistance a small semantic matter keeps cropping up.  Lets be clear Insulin resistance is the same thing as "carbohydrate tolerance".
  Early warning signs of possible insulin resistance may include:  These are not necessarily specific ie there are other explanations:

• increased  thirst
• more frequent urination
• excessive hunger
• gaining a weight a few pounds here and there and having difficulty losing them
• unexplained drowsiness or feeling tired most of the time, especially after eating
• inability to concentrate
• decreased endurance during physical exertion and exercise
• inflammation with elevated CRP levels and or Sed Rate
• chronic high blood pressure
• low levels of  high-density lipoprotein (HDL, the “good” cholesterol)
• high triglyceride levels
• high fasting glucose levels 
• rising hemaglobin A1c levels

  It is true that any carbohydrate gets turned into glucose in the digestive tract but when high levels of insulin are present in the blood stream (the insulin resistance syndrome) glucose is not absorbed or used by muscle cells.  It goes instead into fat storage.  Thus the saying "it is not just the fat you eat that makes you fat, it is the sugar you eat that makes you fat".  The reasons for why we become Insulin resistant are complex and involve several mechanisms. One is diet as discussed earlier but it is only one of several important factors. A diet that includes high fat intake AND high sugar intake will reliably induce insulin resistance.  ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129661/) Eating a lot of refined or at least high glycemic index carbs will stimulate insulin production and a lifetime of bad eating habits will have consequences including insulin resistance, but that is not the only reason.   Another is genetics.  Since we can't change our parents or our DNA we are stuck with that one.
Another reason that is becoming clearer is stress.  That mechanism is  potentially something we can do something about.  The stress filled life keeps high levels of cortisol, a glucocorticoid, in the blood stream. Interestingly the pathway for making cortisol in the adrenal glands starts with cholesterol.  Cortisol is a control hormone that is responsible for selecting which type of nutrient is used for energy demands of the body. We all learned somewhere that cortisol and epinephrine together are part of the "fight or flight" mechanism.  Thus its production and use has survival value and is responsible for the heroic feats accomplished by people in desperate situations. The details are important.  When confronted with a threat to existence the hormonal cascade begins.  The adrenal glands secrete cortisol and epinephrine(adrenalin) .  Cortisol floods the blood stream with glucose to give muscles the energy for combat or running.  It also inhibits insulin production briefly to prevent glucose from going into fat storage, thus favoring its immediate use for energy.  Cortisol narrows arteries and epinephrine increases heart rate. IF the stress is resolved the hormonal cascade ends and the levels of cortisol and epinephrine return to normal. Cortisol is thus anti insulin in its hormonal effects. http://press.endocrine.org/doi/abs/10.1210/jcem-54-1-131   If stress is not relieved and cortisol levels remain high the adaptive mechanism is for more insulin to be produced to counter the anti-insulin effect. Thus the connection between chronic stress and chronically high insulin levels i.e.  insulin resistance.  That is simplified but generally true. So it seems one important factor in treating insulin resistance is to deal with stress.  Whither it is mental , physical or spiritual, stress reduction by meditation, yoga, exercise, music, hobbies, vacations, or whatever works for you can help to lower cortisol production and thus be helpful in treating insulin resistance.
Sleep deprivation may be another independent ? factor in developing insulin resistance. https://www.ncbi.nlm.nih.gov/pubmed/25248582
The other effects of cortisol on the immune system, the cardiovascular system, even on fertility and ED are discussed at length in the medical literature. The association with the immune system and the role chronic inflammation plays on cardiovascular risk is becoming clearer over time.  The beneficial effect of low dose aspirin on risk of heart attack probably is tied into its well know anti inflammatory properties and its ability to inhibit platelet aggregation around arterial plaques. Recently quantitative measures of C reactive protein (CRP) have been shown to be a fair measure of cardiac risk for MI.   
 One way to learn about your cortisol status is with the Adrenal Stress Index (ASI). The index test has been available since about 1989.   Results can be hard to interpret  but it is available as a home kit. (Available from Amazon for about $175.00)  It is based on saliva so no needles involved.  Usually several samples of saliva are collected at specific times and sent to a lab for analysis. If the test shows higher than generally accepted norms and if repeated studies confirm a concerted program at stress relief would seem to be in order.
Any discussion of the hormonal aspects of obesity, insulin resistance, metabolic syndrome, etc is incomplete with out discussing the effect of thyroid hormones and sex hormones.  but that is a topic for another time     

The Musculoskeletal Time Bomb

For the past few decades Orthopedic Surgery has been the "jewel" of medicine.  The technological advances in Sports Med,  Microsurgery, Spine surgery, Joint Replacement, and  Trauma Care have been astonishing and well documented.  All of that being said, the looming problem in the US and around the world is  higher and growing demand and not enough providers to keep up.  That is the Musculoskeletal Time Bomb.  According to Steven M. Kurtz, PhD, and Kevin L. Ong, PhD by 2030, the demand for primary total hip arthroplasty (THA) is estimated to grow annually from 209,000 to 572,000 and the demand for primary total knee arthroplasty (TKA) is projected to grow from 450,000 to 3.48 million procedures.  The American Academy of Orthopedic Surgery estimates that the demand for joint replacement will double in ten years and that Total Knee replacement demand will grow by 674% and Total Hip replacement demand will go up by 174% by 2030. 
 Two often overlooked factoids are that new surgeons have different lifestyle expectations i.e. they want to work less and spend more time doing other things, in practical terms they want to do fewer cases.  The second factoid is the trend for older surgeons to retire early.  These two trends come at an inopportune time.
How to increase the supply of qualified Orthopedic surgeons to meet the increased demand is going to demand we, as a society, look at new models for educating surgeons.  It will not be easy.  I anticipate one approach will be to further expand the role of mid-level providers to do more of the office work which will allow the surgeon to spend more time in the OR, but that creates its own problems.  Most patients want to meet their surgeon before they go to the operating room, and who can blame them?  
 As our population ages it is expected to drive the demand for Orthopedics up by at least 50% over the next twenty years or so.  The combination of longer expected life spans, the obesity epidemic, and the progress of the population bubble representing the baby boomers combine into what has been called the perfect storm of unmet expectations for MS care.  Demand for specific procedures like total joints will be even higher if Kurtz and Ong are to be believed.
There are a lot of places to look for numbers on population growth but in very rough terms the Medicare population in the US is projected to increase from around 47 million in 2010 to 80 million in 2030.  Social security numbers indicate that the worker/beneficiary ratio will shrink from 3.4 to 2.3.  The potential instability is hard to overlook.
 

Insulin and Obesity

When speaking about  obesity and type 2 Diabetes insulin resistance is the problem.  Elevated blood sugar is the symptom not the cause.  Much of focus in recent years has been on treating the symptom and not the cause.  The world literature on obesity and diabetes is voluminous and often contradictory. But what is known for sure is that calorie restriction i.e. most diets have a failure rate of around 98%. Any one who has tried any of the fad diets of the last 40 years knows this to be true. Giving drugs to increase insulin production when the real  problem is to much insulin is irrational, sort of liking giving alcohol to an alcoholic to treat their addiction.  Two thousand years of medical progress indicates that the best results are obtained when the cause of a disease is elucidated and treated.  Treating symptoms is sometimes the best that we can do, but to only treat symptoms when the cause of disease is known is poor practice.  High insulin levels that result from insulin resistance are usually associated with metabolic syndrome.  The metabolic syndrome is a group of conditions involving excess weight and girth, high blood pressure, and elevated cholesterol and triglycerides. But insulin resistance is also associated with other problems like Type 2 Diabetes, fatty liver and cirrhosis.  
A few biochemical facts are in order.  Glucose and fat are the main sources of energy for the body.   Insulin is a hormone produced by the beta cells in the pancreas. Insulin circulates in the blood and controls many cellular functions foremost of which is the regulation of glucose as energy.  All carbohydrates that we eat are turned into glucose.  The rate this happens is fairly important and is measured by the glycemic index.  Foods with a high glycemic index get turned into glucose quickly and visa versa.  The Zone diet is one which aims to avoid foods with a high glycemic index.  Trying to smooth out insulin release and avoid spikes in insulin  (which is the response to sudden spikes in glucose levels) is also rational. However it may not be the best way to treat insulin resistance. A lot has been written about the paleo diet.  This is also a low carbohydrate higher protein and fat diet.  What is not mentioned often is that the paleo diet was also characterized by frequent periods of low food availability, i.e. fasting.  There is much to be said about fasting.  Dr Jason Fung has been touting the real and measurable benefits of fasting for some time. 
Fasting is an effective way to decrease insulin levels.  It seems clear that food raises insulin and no food should lower it.  The body turns to fat for energy in as little as 24- 36 hours.  Alternate daily fasting has been proposed as a way to increase insulin sensitivity i.e. lower insulin resistance.  Another benefit of fasting is increased growth hormone production.  GH helps preserve muscle mass and increases the bodies use of fat as fuel. Fasting is an overlooked tool for weight loss and the most effective treatment for insulin resistance I am aware of.  It is of historical interest that most of the worlds religions have included fasting as a tool for enlightenment and practiced by the founders.  

Zero Bound: A limit on limts?

The idea of money, the kind you can carry around in your wallet, has served civilization well.  It makes exchange a lot easier than barter for most transactions and seems to be coupled with the idea of "stored value".  After all if you can by frugality save money you are retaining something of value since you can use the unspent money to buy things you want or need at a later time.  Thus the idea of "money" as stored value seems to be intrinsic to its existence.   In the current economic universe, what many have called a "race to the bottom" interest rates have gotten so low that they bump up against the so called zero bound problem.  What is the zero bound?  On line resources like Investopedia suggests the following definition.  The zero bound problem is a limit on monetary policy that occurs when a central bank lowers interest rates to zero and effectively goes to negative rates when the set rate is less than the rate of inflation.  A simple thought experiment demonstrates the problem.  If inflation is 2% and interest rates are say 1% then the effective interest rate is -1%. That is you invest say a thousand dollars at 1% for a year and get $1,010 back But with 2% inflation your purchasing power is only $989.80   You have just hit the zero bound limit.  It is clear that this will limit the actions of a central bank in terms of its choices in stimulating a moribund economy. This has been called a liquidity trap.  The lack of liquidity is caused by hoarding cash which is rational if putting it to work gives you back less purchasing power than if you just held onto the cash.  Japan discovered this in the 90's and more recently the US Fed has been drifting toward it too.  Paul Krugman has argued that the United States is in a liquidity trap now since the monetary base has tripled between 2008 and 2011 and this failed to produce any real effect on US domestic prices or on dollar denominated commodities.  More recently Mario Draghi president of the European Central Bank pushed interests rates below zero to a minus 0.2% in Sept of 2014. Countries like Denmark that peg their currency to the Euro were forced deeper in negative interest rates.  Negative interest rates are punitive to savers since you get less back than you put in.  By the end of the first quarter 2015 about a quarter of all debt issued by Eurozone governments had negative yields. The spiral of competitive devaluations and ever lower rates seems to spread like the flu virus and most of the worlds economies are acting as if a currency war is in progress.  Even China has been lowering interest rates recently. It is unclear that lowering interest rates below zero for a significant period of time will actually stimulate a credit based economy since the incentive is to hold onto cash rather than pay someone to hold it for you.  It could bring about a monetary and fiscal destruction of the banking system and return us all to a barter economy.  Facing retirement in a sub zero interest world is challenging to say the least.  I think I need to get to work on my sandwich board,  Will Operate for Food.

Obamacare Economics

A quick review of the new taxes associated with the  ACA (Now SCOTUS Care) is revealing.  No matter that John Benedict Roberts has now saved Obamacare twice, the law is bad economics as Larry Kudlow points out in a recent editorial.  There is now an extra 0.9 percent Medicare tax on salaries and on self-employment income.  There is a 3.8 percent tax increase on capital gains and dividends.  There is now a cap on healthcare flexible spending accounts and a higher threshold for itemized medical-expense deductions.  And now there is a stiff penalty on employer reimbursements for employer reimbursements use for individual employee health-policy premiums.
The penalties for a business owner for moving from 49 employees to 50 are onerous.  Similarly keeping an employee at 29 hours a week is avoids costs associated with going to 30 hours a week.  The higher percentage of people reported by the Bureau of  Labor Statistics doing part time work is no surprise during this so called recovery.  There is no disputing the low labor-force participation rate, but why should anyone be surprised.  " Obamacare is a tax on full-time work. After-tax, people working part time yield more disposable income than working full time."

Another issue under reported is the fall off in healthy millennial signups.  The risk pool appears to be shrinking which will force insurance companies to raise rates yet again.  According to the consulting firm Avalere many exchanges are raising rates from 20 to 36 percent for 2016.  This is in addition to the higher deductibles hitting the consumer pocket book.  

As a practicing Orthopedic Surgeon and knowing something about health care finance, things are upside down.  More people are coming to caregivers with Medicaid cards but in our state of Illinois payments are delayed and are less than half of the average commercial carrier.  Not surprisingly fewer and fewer Dr's are not taking medicaid.  It won't be long before that is not an option and states will demand all doctors see medicaid.  I predict it will be tied to state license renewal.  

 

The law remains unpopular. " In the latest NBC/Wall Street Journal poll, 65 percent of Americans think Obamacare needs either modifications or a major overhaul, just 8 percent say it is working well, and 25 percent say it should be eliminated."

 http://www.newsmax.com/Finance/LarryKudlow/Obamacare-Economics-Supreme-Court-Taxpayer-bailout/2015/06/26/id/652475/#ixzz3eUcyOiiA
 

Thoughts on the Caliphate and ISIS

I have not found any close associates or friends who were able to answer a question I posed today. The question; "When was the end of the last Caliphate in the Levant?"  The answer by the way is 1924 when Mustafa Kemal Ataturk (the leader of  the 'young Turks') put an end to the Ottoman Empire. This fact was brought to my attention in an article in The Atlantic: What  ISIS Really Wants by Graeme Wood . Although 1924 is  technically correct it leaves out the fact that the Caliphate was largely a toothless tiger for roughly a thousand years before that. The Ottoman empire was on the decline since the 16th century and after aligning itself with Germany in WWI it suffered the ignominy of defeat and dismemberment by the victorious Allies.  The modern states of Syria, Iraq, Saudi Arabia, Jordan etc. were created by fiat out of the rubble of the Ottoman Empire and Turkey was reduced to a much smaller state.
ISIS has proclaimed Abu Bakr al-Baghdadi as Caliph.  It is sad that very few in the west have any idea what this means.  The Caliph is duty bound to institute Sharia law. "In theory, all
Muslims are obliged to immigrate to the territory where the caliph is applying these laws." Without a caliphate most of Sharia is not applicable ie it is in abeyance.  With the caliphate in place the amputation of hands of thieves will resume along with all of the rest of the above horrors.  The prospect of seeing a complete execution of this body of jurisprudence contained is Sharia is about to play out in our living rooms nightly. The West has only had a taste.  The full meal will follow.
The eschatology of ISIS is all about accelerating the Day of Judgement.  The path they follow according to Wood is "the Prophetic methodology."  This means putting some 7th century Islamic teachings into literal actions.  It means following the "prophecy and example of Muhammad, in punctilious detail."   ISIS is a religious millenarian movement that believes that be-headings, crucifixions, slavery, and rape, are proper and necessary to purify a world that has ignored the actual words of the Prophet.  Another quote is appropriate here; " The Islamic State differs from nearly every other current jihadist movement in believing that it is written into God’s script as a central character. It is in this casting that the Islamic State is most boldly distinctive from its predecessors, and clearest in the religious nature of its mission."
Wood's major point I think, and it is an important one, is that ISIS is in fact very Islamic albeit in a medieval literal way.  Those who doubt this are invited to read Dabiq, the official rag of the Islamic State which condones and certifies these horrors as permissible even required  by Sharia and whats more if one objects to the horrors he is denying or mocking the Koran and thus is himself apostate and deserving of death. 

Ideology and Anthropology

It has been said that "every ideology assumes an anthropology".  What this means in a nutshell is that our idea about the nature of man has a controlling influence on our social theories, philosophies,and favored forms of government. If we assume as does a strict materialist that man is without a "divine spark" ie no soul then we may conclude that life has no meaning and our moral choices are arbitrary at best and have no real consequences now or in the future.  If we assume that man is created "in the image of God", we tend to place great value on life, and live as if our moral choices have very real consequences now and in the hereafter.  Bad behavior tends to increase when no one is watching.  Nietzsche's famous observation that God is Dead was more than a theological construct it was an observation that 19th century European society lived as if their was no cosmic judge.  Many feel that he was prophetic in foreseeing the tragic consequences in the 20th century of the rise of Nationalism and the death of man.     
Much has happened in Europe since Dr. Pangloss stated in Voltaire's classic that  "all is for the best" in the "best of all possible worlds."  We have even more reasons to doubt the optimism of Leibniz than had Voltaire, but we still shrink from the outright pessimism of Schopenhauer. The rise of post modernism is one way to deal with the problems of modernity, but it has it's own issues.  The reemergence of radical Islamofascisim  and the conflict with liberal democracy is a radical conflict of world visions. It is politically incorrect to talk of current events as a holy war, but what other explanation exists for the atrocities that are paraded on You Tube, Facebook, and the evening news?  
 Modern political discourse has left us sharply divided along a progressive/liberal/Democratic vs. traditional /conservative/Republican axis.  I discussed in an earlier blog Sowell's book about different visions.  When discourse is limited by our ability to use language that we agree upon it is impossible to change another s views  on any matter of import.  There seems to be no way out of the impasse. 

Visions and Conflict part 3

Visions and Conflict part 3

 

In part two of his essay Sowell applies his ideas of the constrained vs. the unconstrained vision to various topics that frequently cause conflict in social discourse.  

The first topic addressed is EQUALITY.  It should be obvious that equality is viewed differently by those of different visions.  For the constrained view the important issue is PROCESS oriented.  For the unconstrained view the issue is RESULTS.  

Burke, Hayek, and Alexander Hamilton are quoted in support of the constrained vision.  Hamilton's words are apt.  "All men are entitled to a parity of privileges "but he anticipated that economic inequality "would exist as long as liberty existed". That is the rub.  Equal opportunity never guarantees equal outcomes.  When government forces equal outcomes there is a corresponding loss of autonomy and freedom.  Conservatives generally hold the constrained vision, that sees social processes that give equal treatment as fair and just, even when outcomes are NOT equal for any particular group.  In this view the words of Jesus when he comments that "the poor you will have with you always" are taken to imply that we are not able to create a heaven on earth, but must learn to accept and live with maldistributions of economic resources.  How to rationalize this comment with others such as "it is harder for a camel to pass thru the eye of a needle than for a rich man to enter heaven" has kept theologians busy for the last two thousand years.  

Conservatives would generally agree with Hayek that "irremediable inequalities" exist and will frustrate any effort to remove them.  It is the constrained vision that sees man's capability as limited.  The unconstrained vision see's no such fundamental limits and sees results as the only fair and just way to measure equality.  It assumes more intellectual and moral capacity than can be shown to exist. 

 There is a particularly significant quote from Milton Friedman that bears repeating. " A society that puts equality-in the sense of equality of outcome-ahead of freedom will end up with neither equality nor freedom.  The use of force to achieve equality will destroy freedom, and the force, introduced for good purposes, will end up in the hands of people who use it to promote their own interests."  It seems that SCOTUS ignored that wisdom in finding the mandate to purchase health care insurance constitutional.  When you have the force of the IRS, which includes the right to place a citizen in prison,  used to enforce obamacare the possibility of misuse by those in power seems all to real a possibility.

The Unconstrained vision held by most progressives sees no such fundamental limitations in man.  When results are the measure of equality the existing order is seen as unjust.  This drives the progressive to find ways of "redistributing" resources.  The small fact that the only way to do this is to steal from someone else is seen as acceptable. Providing "compensatory advantage" such as reparations or affirmative action is thus a major goal of progressives, and influences all discussions of public social policy. 

A major point made by Sowell is that causation is part of the unconstrained vision.  Some groups have so little BECAUSE other groups have so much.  The rich are seen as taking from the poor.  For this reason alone redistribution is fair.

Neither vision denies the existence of the poor.  It is how society should deal with the problem that brings conflict.  The constrained view is that capitalism and free markets bring about a rising tide that lifts all boats including the poor.  The unconstrained view is that the "ill gotten wealth" of the rich should be taken from them and given i.e. redistributed to the poor.  This is the language of socialism.  Margaret Thatcher famously said once that the biggest problem with socialism is that you eventually run out of other peoples money.  That is the dilemma facing Greece and for that matter Illinois and California.  No better example of the results of the unconstrained vision exist than in the fiscal mess of these two blue progressive states.

 

 

 

 

Physician Shortage Coming

There have been more than 60 reports in the last 10 years which point to a looming shortage of physicians in the US.  Like most problems facing society the reasons are complicated and multifactoral.  Physicians are retiring earlier than in prior years and the demand for health care goes up as does the population.  Complicating things further, the demographics show rapid growth in the older population who historically consume the lion's share of health care services.

The American Association of Medical Colleges states that the overall physician shortage will be about 63,000 by 2015.  30,000 of this shortfall will be in primary care.  Various strategies such as expanding the role of mid-level practitioners have been proposed to deal with this problem but I hear very few trying to address the underlying problem. 

 IMHO one of the biggest problems responsible is the changing  economics of medical practice.  Physician's have historically been small businessmen. They rent or buy space to practice.  They hire people to work for them, and purchase equipment and supplies from vendors.  They buy computers, and pay for consultants, in accounting, legal, insurance, pension benefits, etc.  Any business where costs go up but reimbursement goes down, will eventually fail.  The income the physician took home was what was left over after paying all the bills.  Taxes take another bite and what is left is what you have to take care of your family, and save for a retirement that arrives all to soon.  Many practices have passed the point where there is anything left.  That model is no longer the paradigm most physicians embrace.  For increasing numbers the uncertainty of private practice is not worth the struggle.  Employment is seen as safer and easier.  With this shift comes a different mind set. An employed physician is going to be more influenced by the employers concerns than an independent physician.  The employer's concern is all about saving money.  Patient advocacy can become a secondary concern when ones job is threatened. What this means is that not only is there a shortage of physicians in terms of absolute numbers, there is also a shortage in advocacy.  Which is the greater problem is difficult to ascertain.

The changing landscape in graduate medical education (GME) is also a problem. The majority of the funding of GME in the United States comes from Medicare and Medicaid (together about 83%), dept of Veterans Affairs (10%), Defense Dept and Bureau of Health Professions (6%).    The number of GME positions in the US, has been capped since the "Balanced Budget Act of 1997".  In spite of these caps medical schools are accepting more students but there are no more slots in GME programs.  

Recent proposals by the Joint Select Committee on Deficit Reduction have included a 50% reduction in Indirect Medical Education costs.  The total contribution by Medicare is approximately 9.5 Billion dollars.  Of that 6.5 Billion are Indirect Medical Education costs.  The effect on GME is certain to be further constraints on training all the while the country is facing a physician shortage.  One thing is certain.  The effect of such a reduction will be seen first in jobs.  The proposed cuts will cost about 73,000 jobs.  One can only wonder if members of either political party have the political will to lose that many jobs in the search for a balanced budget.

The American College of Surgeons has proposed several common sense GME reforms.  First is the  recommendation that IME payments be tracked instead of dumped into the general fund of teaching hospitals.  If performance measures and outcomes for each program are tracked it would go a long way to seeing that the public gets the most "bang for the buck".  Secondly GME funding needs to be separated from patient funding streams.  All stakeholders need to be at the table when alternative funding is being discussed.  The stakeholders include Medical Schools, the Biomedical Industry, Patients, Residents, Hospitals with GME programs,Federal and State governments, Private Insurers, and Non GRE hospitals.  In trying to arrive at even a conceptual framework for GME alternative funding, the issues of equity, adequacy, efficiency, accountability and feasibility must be addressed according to a RAND working paper. 

My take on this issue is that somewhere, somehow, all of the stakeholders have to find a way to increase funding for graduate medical education.  The consequences of not acting are not going to be pretty. 

Visions and Conflict part 2

Further thoughts on Sowell's book.
 How we view issues as basic as human "survival and progress" is different depending on which vision we adopt.  "According to the unconstrained vision, the patterned behavior of society is successful, just, and progressive insofar as it reflects the articulated rationality of man in general and of the most intellectually and morally advanced people in particular."
The constrained vision sees a fundamental inability for man, seen either as an individual or a collective society, to achieve success in deliberate, comprehensive central planning.  This vision sees a "moral and intellectual"  insufficiency that frustrates those attempts.  The failure of the USSR's planned  economy is seen as an example.
How should we make judgements about societal processes? What is justice?  Should judgements be made on results? Or on adherence to agreed-upon rules existent prior to the event or process being judged.  How we make those judgements reflects our vision.  If we judge a process by trying to decide if that process is right or good, we probably have an unconstrained vision.  If we judge a process as fair when all the a priori agreed on process characteristics were faithfully adhered to, and ignore the outcomes, we probably have a constrained vision. The results are subordinate to the process and the agreed upon rules of engagement.  
Just as the word "freedom"  means something different to holders of each vision, justice means something different as well.
The unconstrained vision is results oriented. The constrained vision is process oriented.

As I drive to Chicago to visit my daughter and her family I observe the tear down of the high rise "project housing" lying east of the Dan Ryan. Nearly everyone's judgement about the projects is that it represents an abysmal failure of policy.  When they were built, it was with great fanfare and hope that making good housing available cheaply would help those in poverty rise above.  Instead the projects degenerated into a special version of hell on earth.  The reasons have been debated in multiple forums.  My point in bringing it up is that the different visions are on display.  The constrained vision saw the attempt to give cheap or free housing as bound to fail, since it eliminates the personal pride of ownership, etc, etc.  The unconstrained vision saw the removal of an impediment (lack of housing) as something to be fixed with the providing of free apartments.
History has shown which vision was vindicated. 
The application of the analysis of visions as it applies to power, equality, justice, law, economics will take us further into the book.  I am now reading chapter 5.
     

Visions and Conflict

I recently read Thomas Sowell's book titled "A Conflict of Visions".  I admit I was shocked by the outcome of the last election.  It seems inconceivable that a majority of Americans would vote for more of the same economic malaise that the papers report on daily. I have been searching for an explanation that goes deeper than those offered by the talking heads on TV. Sowell's central idea is that what divides the political spectrum is a fundamental difference in visions.  He differentiates visions from interests. Interests are short term while visions "dominate history".  The insight he offers helps explain why persons of good will can come down on opposite sides of almost any policy debate. 
The definition he offers for vision is a "pre-analytic cognitive act". This was the definition originally offered by Joseph Schumpeter in his book "History of Economic Analysis".  This definition is supposed to describe what we emote about an issue before we analyze it systematically.  It precedes theory. It is the teleological backbone of theory.  Visions are about causation and set the "agenda for thought and action."
A theologian friend of mine used to say that "every ideology assumes an anthropology." What he meant was that it is our ideas about the nature of man that directs our formation of theories about society, history, law, justice, and politics.  Sowell is saying much the same thing as he lays out the contrast of the Constrained vs. the Unconstrained vision.
 The constrained vision sees man as intrinsically  flawed with many moral limitation.  One is tempted to resurrect a theological term and call it original sin.  The constrained vision seeks to make the best of a bad situation.  This is the vision of thinkers such as Thomas Hobbes, Edmund Burke, Adam Smith, Alexander Hamilton, James Madison, John Jay, Friedrich A. Hayek, Oliver Wendell Holmes, and  Milton Friedman.
The unconstrained vision sees man as perfectible with no intrinsic moral limitations.  It sees a possible utopia since there is an infinite well of goodness at the heart of man.  This is the vision of thinkers such as William Godwin, Rousseau, Voltaire, Thomas Paine, John Kenneth Galbraith, Ronald Dworkin, Saint-Simon, George Bernard Shaw, and Earl Warren.
With respect to social decisions the "marketplace" is seen as inadequate, even evil by adherents of the unconstrained vision and as the best way to achieve the greatest good for the greatest number of people by those adhering to the constrained vision.  The alternative to the marketplace for the unconstrained vision adherents is a meritocracy where an elite "far seeing" group decides what is best for society.  The fears of those who hold to the constrained vision is that this group of elites can disintegrate into tyranny very quickly.  They would point to the excesses of Stalin, Pol Pot, etc. as historical examples. The adoration of the intellectual elite by the true believers on the unconstrained vision is justified in their view since they and they alone have the articulated rationality to guide society towards the utopian ideal.
The different visions give different value to "experience vs. articulated rationality". This leads naturally to a youth vs. age debate with respect to the value of their respective insights and the attending societal value of each.  The unconstrained vision sees the institutions and existing beliefs of society holding back its progressive agenda.
Epistemology is the study of knowledge.  What it is and how it is acquired. It seems clear that language is key to the acquisition of knowledge because words have meaning.  If we cannot agree on what a word means it seems pointless to pursue knowledge of what that word depicts.  Take the word freedom for example.  The constrained vision interprets the word to mean liberty, equal opportunity and the individuals "pursuit of happiness".  The unconstrained vision can take the word  freedom to mean equal outcomes, the absence of hunger or poverty and a society free of prejudice and conflict.  Clearly trying to understand what freedom means is colored by our underlying vision. Knowledge is seen as widely distributed and broader in definition by those with a constrained vision.  It is not the province of a gifted elite as seen by those with unconstrained vision.     
The labels of conservative and liberal are inadequate in my opinion to describe what Sowell sees as a contrast of visions.  It will take me some time to digest the implications of this essay but I embark on it eagerly.