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Sunday, November 24, 2013

When Will Health Care Ever Cost Less?

The answer is, when you reduce the amount and degree of care provided. It's an answer nobody wants to hear but it's true.

On this year's Veteran's Day, a talk show on NPR mentioned the treatment of war-caused PTSD in veterans. A caller asked why PTSD is so common among veterans of modern wars but was not nearly as common back in WWII or before. The experts and/or insiders of course corrected them that back then the same post-combat neuroses was not diagnosed as PTSD but rather was called other names, such as shell shock. Most of the sufferers were not treated, because the medical community didn't know how. So many of them treated themselves with alcohol and psychoactive drugs, and died premature deaths.

Fifteen years ago when I was in school, managed care and preventive care was all the rage. The argument was that if you give people health care before they get very sick, they would live longer and healthier lives, and the cost of health care for a population would go down or at least not continue to go up. The reality of the next decade and half has proved them wrong.

The logical flaw in the managed care premise is obvious: If people live longer and healthier, they would only get sick later, but they would get sick and eventually die anyway. Why would they need less health care in totality?

One might argue that if a person lives longer and healthier and delays the inevitable aging and illness leading to death, he could work longer and produce more in his life. I would argue, however, that the longer he works, the more disposable income he has to spend on treating his illness and delaying his death. How would that reduce the cost of health care?

Spend some time with old people and it will become abundantly clear. The demand for health care is a bottomless pit, because the thirst for life and fear of death is boundless. It is usually limited only by what medical science and technology can offer at the time. Before an elixir is invented to extend people's lifespan to 70 years, people did not spend money on it and died at 69. After the elixir is invented people spend their money to buy another year of life. The same can be said for any other treatment. Before there was penicillin, where would people with infection spend their money on? Before there was methotrexate and paclitaxel, where would people with cancer spend their money on? Not on health care. Once the treatments become available, how can you not spend money on them?

Very occasionally, spending money on one treatment can save you money on alternative treatments. For example, spending on Prozac has saved a lot of cost on psychotherapy. But such cases of saving are uncommon. Most of time, medical advances are like urban sprawl --- build it and people will come. As long as you have a few more years of life or less pain to sell, people will buy it, if they can afford it.

Built on good intentions, the third-party payers of health care only make the cost balloon. Socially it is a sensible philosophy to want to give most people access to most life prolongation technologies. Psychologically, it removes the financial measurement out of individual person's calculation. How much are you willing to pay to prolong your life for another month? If you have a billion dollars, you may be willing to pay a few hundred million. If you have a hundred dollars, you may be willing to pay fifty, saving the rest for a last meal. If you have none and need your parents or children to cough up their life savings, you might spend nothing and choose to give up the last month of your life.

However, once this contemplation is taken out of individual's consideration and put in the hands of an insurance company or the national payer, I bet everyone feels the urge to want to spend "as much as possible" to prolong one's life. It's no longer your own money you spend on the care you need and want. Everyone wants the longest life money can buy.

If I were to devise a system that can truly stem the escalating cost of health care, I would use the collective money pool (as all medical insurance, be it public or private) to take care a set of treatments that have a finite amount of cost. Beyond that, you or your guardians decide how much you want to spend to prolong your life. If you get pneumonia, the system pays for your antibiotic treatment. If your pneumonia turns into sepsis and spending a hundred thousand dollars may save your life, you or your family will have to decide if you can and want to spend the money on that. Such a system assumes that life has a price. Above that price, the system will not pay for life.

This proposal sounds horrible, I know. Life has a price. Shudder. It also highlights the gross inequality between people --- If you have more money, you can afford to live longer. If you don't, you get the basic but less care and therefore shorter life, most likely. However, in another sense, the system is quite equal. It assumes that, to the system, a rich man's life is worth the same as a poor man's. The system spends the same amount on each person. And, because this system does not endlessly escalate, it is able to sustain itself and ensures the largest number of people get at least basic care. The rest is left to the random draw of luck, be it your wealth or your genes, and your own choice.

Friday, November 22, 2013

Fatal Attraction

A person, often but not always a woman, has a romantic liaison with someone, but then changes her mind or loses interest. The jilted lover is so obsessed and/or angry at the end of the affair that he stalks her and kills her. The plot is used often in murder thrillers. Underneath the obvious condemnation of the perpetrator is a faint suggestion of blame that the victim somehow brought it on herself. If she had not slept with the wrong man, if she had kept her eyes open and nose clean, if she had read him correctly ... she would not have provoked his murderous obsession.

Such things obvious do happen, including some high-profile cases, but I wonder how often they really occur. Of all the people I have met and known in my life, no one behaved obsessively and possessively toward their partner, nor were they trapped in a relationship with an obsessive and possessive partner. What's it like to believe, with conviction, that your life will be destroyed if she leaves you? It must be a frightening feeling. It's not realistic of course, but it's a possibility in rare circumstances. Does it happen to only a rare person, or could potentially happen to most people if the "right person came along"? 

Sunday, November 17, 2013

David and Goliath


No wonder he's put in so many disclaimers throughout the book --- He's not advocating for adversity. He does not condone an unhappy childhood with parental loss. He does not think it's a good thing to be born with dyslexia. Reading the character sketches in this book, it is easy to feel incredulous and misled. You can't possibly claim that it's better not to be able to read than to be able to read! Indeed he doesn't, but then the stories of successful businessmen with dyslexia are so compelling. He can explain (citing a Canadian psychiatrist) why people of London did not succumb to the bombings in WW2, but one could argue that this was only because the bombs were not big enough, as the nuclear bombs dropped on Hiroshima and Nagasaki (intentional civilian targets) achieved the psychological effect German conventional bombs couldn't. A lot has to do with a lot of other factors.

Gladwell is the first to admit that these success stories are irreproducible. The vast majority of people are crushed by adversity, but a few special ones rise up and become better, tougher, more fearless, and more resilient. Who can argue with that? In the end the ideas are not so subversive, so revolutionary, so earth-shaking --- perhaps because Gladwell himself had a very normal and happy childhood. Just because a selected or gifted few become better through pain and suffering, doesn't mean the vast majority are not crushed.

Still it makes me feel a little bit good. Even if most of the messages in any Gladwell book cannot be adopted in life, they tickle my brain like bubbly drink with a hint of sweetness. Actually there is at least one usable message in the book --- If the rules of the game are stacked against you, don't play by the rules. Change the game. This sounds suspiciously like the quote from Mad Men: "If you don't like what they say, change the conversation." In politics as in advertising, this is an old trick in psychology known as "framing." Basically, reality is neither good nor bad, the only difference is in one's psychological framing, and any frame can be reframed. This is basically what Gladwell does so well --- he changes the frame all the time until your brain is tingling all over.

Saturday, November 9, 2013

楼兰(更多)

楼兰里的短篇小说,越看越让我心惊肉跳。井上靖在其中的写作手法是我从未见过别人采用的。简单概括之就是:远镜头 --> 特写 --> 远镜头。长镜拍的是宏观景象,如俯视大漠,然后zoom in到大漠上的一黑点:可能是一个人骑一匹骆驼跋涉,马上就要渴死了。然后再zoom out到俯视大漠镜头,显示出一个渴死的人和骆驼多么微不足道。只不过他这个长短镜头的标度,既是空间,更是时间。长镜拍的是几百年乃至几千年的历史,突然zoom in到微小的个人命运,乃至一个人生命中的那一瞬转折点,然后突然zoom out,将个人弃之不理,刷一下跳过几百年。个人之渺小,人生之短暂,跟历史大漠的强烈反差,冲击想象力有限的大脑。比这效果更强烈的作品我是没有见过。The mind is too feeble to handle the vastness of space and time.  真有点吃勿消的感觉,按照眼下流行的说法就是细思恐极。

Friday, November 8, 2013

The Bull Running Story (continued)

"Before the start of the bull run, they made an announcement on the PA --- in Spanish of course --- that there would be two gun shots: One at seven fifty nine, one minute before the bulls are let out; and one at exactly eight, when the bulls are let out. So, on the first gun shot, we were still standing around, loosening our joints, preparing to run, and joking around. Then the second gun shot. After a little while we saw this swarm of people just ... rushed down the street, and we ran.


"It was a little ridiculous. The street was all cobblestone with broken stones here and there, and wet with vomit and trash all over the place --- because of all the drinking and partying the night before. You could barely run on the street by yourself, without the bull or the crowd. But I didn't get to think about it. The crowd came and I just got swept up in it."

"The whole route was 800 meters, in the middle of it was a turn on a street corner called 'dead man's turn.' The bulls are all muscle and weight, but they can't, you know, change directions easily. I saw a bunch of people get crushed into the wall by the bulls. When we got to the end where the bulls were supposed to go into the ring, I saw these people in front of me all laid down on the ground. I was totally dazed and could barely think, so I just stood there, not knowing it was actually pretty dangerous. Someone pulled me aside, like, 'What are you doing?' Then they explained to me that the bulls would just jump over the people lying on the ground, maybe someone would get kicked in the head.

"I had never been in the war but I imagine that's as close as you would get to fighting in the war. I'll never forget it.

"Afterwards we went to have breakfast. I was so hungry and ate a lot."

He told the whole story without stutter or pause, the memory apparently etched in his mind. Perhaps he'd told the same story a number of times before. His date made almost no remark on this narrative, however, either to one-up him or to make any philosophical observations; she didn't even show any signs of being especially impressed by such masculine pursuits. She just went on with her own pursuits --- diet and personal training.

I wondered whether this was a commonplace occurrence on dates. How many time does he have to tell the story before his date would give a more relevant response? Does he notice or care? Does it matter?

Thursday, November 7, 2013

楼兰(井上靖)

很早以前只读过第一篇,但对书中描绘的画面印象极深。重读发现一点也不奇怪,文字完全是电影式的,画面感极强,且声画并茂,难怪。

井上靖文字极简,寥寥几句,信息量超大,冲击力又强,短短一篇故事便看得我晕头转向。还得慢慢地啃,啃完了一口慢慢地消化。

中国古代笔记小说里常常有极简的叙述,一个你死我活的故事三言两语交代完事儿。井上的短篇至少与之形似。但中国古代笔记小说从来不写人物性格心理之类,而井上的小说里的人物心理大大的有,只是草灰蛇线地写,令人无限遐思。

Wednesday, November 6, 2013

A First Date

They were the only ones sitting at the bar. Around they were straggles of diners on the Wednesday evening. He was quite tall with gym-honed muscles. Curly dark hair and olive skin. High cheekbones. In the dim lighting the face could be anywhere between 35 and 45. She had straight hair, dyed blond, and was meticulously made up and accessorized. She was wearing a creamy thin sweater, beige pencil skirt, and tall tan boots, all of which emphasized her well-toned slim shape. She was professionally tanned, in November, from face to legs.

She said she got married with someone she met in second year of college. He asked how long she was married. "Five years," she replied. "Divorced by 27." Then she claimed that the years from 28 to 30 were really good. He said early marriage was not in his family tradition. His father married late. He always saw himself walking the same road. "If you asked me in my twenties where I'd be when I'm forty, I'd have told you I would be single, enjoying life," he said with a smile, bearing his white and slightly misaligned teeth.

He went on to recount the story of he and friends participating in the bull running in Spain. "It was seven in the morning and I was sleepy, wet, and hungover." They got drunk the night before upon arriving in Pamplona. "People all around us were chatting and joking. There was an old guy in his 60s. Steve said look, if he can do it we can too." When the bulls charged down the cobblestone alleys, he was swept up in the crowd.

"It was the most exciting thing, by far, I have ever done in my life," he said. "After it was over we went to have breakfast. Steve asked me if I wanted a drink but I didn't."

She didn't come up any story to match his. Instead she went on with her diet and personal training regimens. Her diet "really works" and cured her of cravings for starch. "The first two weeks can be tough, but now I don't even miss bread any more," she said. She had a raspy, strong voice that projected all the way to the front door. He was almost as loud.

He started to chime in with some workout tips, but not too enthusiastically. At one point the bartender, a guy with beard, younger and stockier than the date, inserted himself into the discussion about various physical training and dieting methodologies. Neither the man nor the woman seemed to be bothered by his intrusion into their conversation, so that for a moment it looked like three buddies chatting over drinks. The man had his face turned to the woman, but his arms were firmly placed on the bar table, drawing a line between her body and his. She, on the other hand, turned her entire body toward him.

On our way out of the restaurant I said to S, "He may not refuse to shag her, but I don't think they'll go farther than that."

Tuesday, November 5, 2013

The Social Stability Pill (cont.)

The pill that has brought peace and stability to the world is now a problem. In country after country, economy has collapsed because of unmotivated young people who have lost interest in not only procreation but also consumption. A deep and pervasive laziness has permeated society. Besides eating, sleeping, taking the pill, people at all ages are content with little material goods, small living quarters, and online diversions. The pill disarms the competitive urges and no one wants to bother with keeping up with the Joneses any more. GDPs continue to plummet along with birth rates.

Under the protests of older people who now have to keep working until they die to financially support themselves, governments finally move to ban the use of the orgasm pill in anyone pre-menopause, which means men are not allowed access to the pill until they are in their seventies. However, thanks to black markets and illegal trades, the pill is still circulating. People are used to the minimalist lifestyle. Natural instincts recovery very slowly. Even off the pill, most behave as if they were still on it. Birth rates, although no longer near zero, hover around 1.

Cities are abandoned. Productions are halted. Populations dwindled.

Just when civilizations lay in the happy ruin and hope is dimming, a tribe of Polynesians sail out of their island and spread rapidly across the world. Isolated from the rest of the world, they have not been exposed to the orgasm pill and therefore remain "barbaric" with all their sexual instinct intact. They meet little resistance on their way to conquer the entire world. They fight, kill, and breed as humans did before the orgasm pill was invented. Humanity enters a new era.

New Biography on Duke



Serendipity is at work lately. I just borrowed a book yesterday that's a compilation of jokes and anecdotes jazz musicians told each other. Today I heard an interview on the radio with the author of a new Duke Ellington biography.

One of the stories Teachout told was this. Ellington had a scar on his left cheek, which could not be seen on stage (because the pianist always sits with the right side of his face to the audience) and was rarely photographed, but the scar is visible on the cover of his book (above). How did he get the scar?

At 19 Ellington married his high school sweetheart Edna Thompson. In the late 1920s, when he was a big success at the Cotton Club in Harlem, Edna and their son Mercer came up from Washington to live with him. One day in 1927 or 28, when Ellington and Edna were in bed together, without warning, Edna pulled out a razor and said, "I know what you've been up to and I'm going spoil the pretty looks" (or something to that effect) and slashed his left cheek. Ellington, who was 28 or 29 at the time, ran out of the house. Edna left New York and went back to DC. They separated but he didn't divorce her.

I gasped when I heard it. Very rarely do you get a dramatic moment in life that illuminates two persons so thoroughly and deeply.

Duke Ellington was a relentless womanizer and had countless affairs with women all his life. Edna's revenge obviously was not effective in stopping him. Jazz pianist Marian McFarland said he had so much sex appeal that it was (almost?) frightening. He was also enigmatic to men and women alike and ultimately unknowable. 

Monday, November 4, 2013

A Hypothetical Solution for Stability (short fiction)

By 2050, stability has become the number 1 priority of the domestic policy for the Chinese government, now that international military conflicts are no longer a major concern. Expenditure on recruiting, feeding, housing, and training millions of young men in the armed forces will have to be cut. But where else would these young men go? There are shortages of jobs, housing, and especially young women of the same age for them to marry. The gender imbalance is already causing social problems and skyrocketing crimes, flooding the general population with millions of young men would be disastrous.

The unspoken fear, of course, goes deeper. Ruling a country with massive number of young men with no way to relieve their sexual frustration will be akin to sitting on a bomb with a short fuse. A charming cult leader, an underground religion, an innocuous social campaign, any excuse, could lead to the throne blowing up under their butts. The only possible solution, starting a large-scale war with another country, is not viable.

What to do? What to do? One day the minister of interior comes into the central committee with a brilliant invention that has come from the health department: An orgasm pill with effects every bit as satisfactory as a real thing and, in most cases, far better than masturbation. It acts on the central nervous system only, but induces the same physiological response, short term and long term. Side effects are few and minor. It does not affect one's reproductive functions at all.

The first recipients on which the pill is tested, of course, are male prisoners. Almost immediately, their aggression dropped. They become unusually relaxed and pleasant in social interactions. Violent outbursts disappear. Everyone walks around with a sprint in their steps and a smile on his lips. Next the pill is tested on female prisoners. The same. Then it is tested in adolescent boys' reform schools, where the most dramatic effect is seen. The boys do not necessarily become smarter or more social, but they no longer get into fights. The pill seems to kill not only their aggression but also their competitive urges. No one seems to care much if he is the top dog in the herd.

The dream of social stability has finally come true, the central committee rejoices. All ten members of the committee vote to approve the plan to release the orgasm pill to the public across the country, except on military bases. At first, they are worried that not everyone is willing to take the pill and those who refuse the pill will be too violent for the rest. In reality it never happens. People of all ages love the pill and the more people take it the more it is sought after. Among the pill's fans are not only young men who cannot find a date but also middle-aged couples who no longer find each other desirable, middle-aged men who don't have enough money to court young women, and women who are too busy making a living to find a husband. The pill is cheaper than buying sex from prostitutes and poses no health or legal risk whatsoever. It is perfect. Within six months, violent crimes are reduced to near zero. Society has never been so stable and peaceful. Happiness is in the air from the Black Dragon River to the Hong Kong harbor.

Other countries take note. Crime-ridden big cities and war-torn countries offer to pay astronomical amounts of money for the formula of the orgasm pill. The cost of policing goes down sharply. Men and women throughout the world finally get the best sex they can hope for and they don't even have to lift a finger to get it. Paradise.

Then, naturally, people begin to lose interest in real sex. Traditional mating rituals are just too much trouble! Why bother when you can get satisfied any time you like? Soon enough, Judeochristian church leaderships begin to get worried and scrambled to find scripture to ban the pill. Some countries ban the pill regardless. Sure enough, the unrelieved young men, who are no longer interested in getting it the old fashioned way, begin to riot and overthrow some of these regimes. In other places the pill floods black market. Now the pill has solved even the problem of overpopulation, and along with it the problems of pollution, water shortage, food shortage, and housing crises.

(To be continued...)

Sunday, November 3, 2013

Autumn in the Woods

Seneca Creek Park, Maryland
Even when the wind was too light to be felt, the rustling never stopped above, the trees making music. Then there was the crunching of dried leaves and pine cones under foot. No birds though, probably all gone to warmer places. On the lake shore, tiny waves broke on the boat house's wooden launch pad, the ripples quieter than a whisper. The boating season was over and all the rental boats had been stowed away, the kiosk shut and empty. On the playground children were jumping up and down recycled old tires and laughing and screaming on swings.

The air was filled with the fragrance of broken leaves and pine needles and dimming sunlight, and the shimmering afternoon lake.

Saturday, November 2, 2013

Kate Shugak 侦探系列


最近开始看 Dana Stabenow 的阿拉斯加女侦探 Kate Shugak 系列。情节其实并不怎么悬疑,设局也毫不复杂,看点是跟现代都市环境截然相反的生活方式,交通不便的野外生存的社会状态,石油工业和原住民和酒民的文化。女主角是有 Aleut 血统的本地人,独自住在森林里,砍树修路赶熊样样拿手,并参与原住民社区的家长里短邻里纷争,兼破案追捕凶手,英明神武,但细节跟真的似的。照她的说法,阿拉斯加有很多移民,都是因为在大陆上受不了“正常的”生活方式或者社会氛围而逃到阿拉斯加森林,“远离喧嚣的人群”。看 Stabenow 的描述,闹得我都要产生去阿拉斯加看看风景的念头,但是她描写的棕熊吃人的段落又让我心惊肉跳。

Another Restaurant Experience

After escaping from the long line of cars waiting to get into the Great Falls Park on a beautiful and sunny Saturday, we decided to try a new Szechuan restaurant in Maryland about which I heard a lot of good things a couple of months ago. Apparently it is a new addition in the fiercely competitive Chinese restaurant market in Rockville. My hairdresser highly recommended the taste, and S is a spicy food aficionado.

Tucked in an obscure little strip mall next to some car dealerships, the restaurant is fairly small and plain, but clean and pleasant. No tablecloth, but there is a bar.

We ordered two dishes: Fried eel and fish head tofu pot. "Are they spicy?" S asked eagerly. "Yes," the waiter assured us. By then I noticed at least half a dozen items on the plastic menu had been blacked out, which is rather unusual for a new restaurant and led me to wonder if the menu had been too ambitious to begin with.

The waiter came back with water and said, "Sorry we don't have the fish head. We can't seem to get the kind of fish with big heads."

It happens. I shrugged and ordered a different fish dish on the menu.

The eel came out in about 15 minutes. It was fine, nothing extraordinary but nothing to complain about. Just then two young men at the table next to ours started a discussion with the waiter.

"We've eaten everything else," said one. "It's been almost an hour. Where's the stir fried greens?"

The waiter said something I couldn't hear since he had his back to me.

"But we're done here. Can't you cancel the order?"

The waiter said something else and walked away. A pretty young waitress came over and said something to the two young men. Again I couldn't hear her words but could hear her girly, whiny voice with a hint of flirtation. After some song and dance, she seemed to persuade them to acquiesce. Within a few minutes she came out with a plate of stir-fried bok choy. The two men sighed and began to pick at it.

I looked around and saw that the place was only half full. Did the waiter neglect to write down the order? Did the chef forget to cook it? It wouldn't have taken more than 5 minutes to cook this.

We finished the eel. The fish was still unavailable. We waited. I got impatient and waved the pretty waitress over.

"We have another dish," I said.

"I know you have another dish," she said with the same whiny voice. "The kitchen's still working on it."

I almost said in reply, "That's the wrong response, honey. You should pretend to rush back into the kitchen and bark at the chef, and then rush back and tell me it's almost done." But I held my tongue and watched her saunter back to the bar area and chat with the boss.

The boss was middle-aged, square-faced Chinese man with a vague southeastern accent. Not a Szechuan accent. He stood behind the bar counter idly with an eye on the dining room, not doing anything in particular. A couple of other waiters were hanging around nearby with nothing particular to do.

We waited some more. I asked the waiter about the fish. He assured us it was coming. Another ten minutes later it finally came. As the waitress set it down on the table I asked, "Is the kitchen short handed?"

She shook her head, "No, but this dish is particularly time consuming."

I almost said in reply, "Yes, just like the stir-fried boy choy." But again I held my tongue and shrugged.

Much to my surprise the fish was excellent. The fish was covered with a brown sauce that contained fermented soybean paste, dry red pepper flakes, and minced meat and Shiitake mushroom. It was delicious. Though not as fiery as S would like, he was also highly satisfied with it and cleaned up the last bit.

I had a hushed discussion with him about the dilemma of such a restaurant. Is this a case of a very slow master chef? Or a lack of cooks in the kitchen to do all the menial jobs like chopping up scallions and garlic and ginger? Or poor management in every link of the chain that makes up running an efficient operation? It would be perfect, I said to S, if the chef got poached by another restaurant managed by someone who really knows what he's doing.

Good food, bad service, poor management. Ah what do you do? I don't know if we will come back, but S seems to like it well enough so we just might, if the restaurant survives. 

Petyr Baelish of Sichuan: Echoes of the 3 Kingdoms

Sometimes my mind makes unexpected associations. A few days ago I was talking to a couple of friends, who are of Sichuan (or Szechuan) ances...

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