ShrinkWrapped

Reading Tea Leaves

The President gave another speech last night and was neither specific, bipartisan, nor particularly believable.  He is in the same position he was in before the speech, with lots of reason to wonder whether he knows or cares what is in the bills being bandied about and whether or not he understands that a fundamental overhaul of such a complex structure as our Healthcare system should be done with extreme humility and exquisite sensitivity.  I suspect that as he continues to give speeches and as his words lose their resonance, people will increasingly stop hearing what he has to say. He has clearly not learned much from the master politician of our times, though it may be that others have.

Bill Clinton was a wonderful orator.  He may not have given a speech as well as Obama but he could speak extemporaneously with the best of them.  He was far more skilled than Obama in telling people what they wanted to hear.  (Obama's ability to be all things to all people would never have survived a skeptical press.)  There are two other very significant differences between Clinton and Obama that are germane.  Bill Clinton had executive experience by the time he entered the White House and Bill Clinton was much more ideologically flexible than Barack Obama.  If Obama fails it will be primarily because of his lack of experience and his ideological rigidity.

The other Clinton, Hillary, was blindsided by Obama during the campaign.  She assumed the nomination was hers and was out fought, out organized, and out thought, by a more astute politician.  However, Hillary still has the ear of the best politician of our era, and that is why there is good reason to lend credence to rumors that she might resign from her post at State and run for Governor of New York next year.  She has nothing to gain from staying in a flailing administration, whose ideological approach to international affairs is likely to lead to serious problems for American and allied interests.  If she resigns to run for New York Governor, it will be a clear sign that the smart money in the Democratic party is losing confidence in their standard bearer. 

I will refrain from the obvious metaphor of sinking ships and those who flee them.

Offered Without the Need for Comment

From commenter, and occasional guest poster Jimmy J, this is so good it deserves its own post:

As a member of the "mob" that has been protesting porkulus, cap and trade, and Obamacare I take deep umbrage at the insults and invectives hurled at me and my fellow citizens by the elite MSM and the democrat pols.

Unfortunately, I live in the People's Republic of Puget Sound, where conservatives are almost as rare as spotted owls. Our representatives are, for the most part, close observers of the party line as delineated by Nancy and Harry.

In spite of that fact I regularly communicate my views to them. Sometimes I get an answer - usually democrat boilerplate probably written by a staffer. Recently, because of the insults directed at TEA Party citizens by the democrat leadership I sent this missive off to both Senators and my Congressman.

"Dear Senator Murray,

I am a retired 76 year old Navy veteran and airline pilot. I've always been a voter and tried to stay informed about political issues. However, I've never been involved in any kind of protest on the streets........until now! In the last few months I have participated in two TEA Parties and two Healthcare Reform protests. Never did I think I would be involved in such a thing. Let me tell you why I have taken to the streets.
1. I don't feel my elected representatives are listening to their constituents.
2. I don't feel my elected representatives are paying strict attention to the Constitution.
3. I am upset because this Congress is out of control as far as fiscal responsibility goes. You folks are spending too way much money! And it's most all borrowed money! You give drunken sailors a bad name. (I know because I was one once) At least we were spending our own money.
4. You people are passing bills (The stimulus bill, the omnibus budget bill, the Waxman-Markey bill, HR 3200) that you haven't read and were mostly written by special interests. You have become so reckless in your legislative work and fiscal duties that I, and many other good citizens like me, are truly alarmed.
5. We, unlike many of your colleagues, have read HR 3200. (Written in dense, lawyer speak that makes it extremely hard to read and understand.) We have found its provisions at odds with what we want and primarily aimed at producing - over a period of time - a single payer health insurance system run by the government. When we look at single payer systems in Canada, England, and other countries we don't like what we see, which is rationed healthcare based on bureaucratic decrees. We also do not see how HR 3200 reduces healthcare costs. We wonder what is in the various Senate bills. Hopefully, they are easier to understand and do not aim to make our system over in the likeness of Canada. But we are not confident they will be any better than the House bill. These things alarm us!
6. You, your Democrat colleagues, and President Obama seem to be intent on passing this healthcare reform over the objections of a majority of citizens. This is 1/6th of the nation's economy we're talking about. Even Solomon would be hesitant to take on a complex task such as this in a matter of weeks. This gives us pause and does not engender confidence!

I am just one voice, but I have found others who see the actions of Congress much as I do and we have met freely, peacefully, and publicly to petition you, our representatives, to hear our voices. Yet, Speaker Pelosi has called us hired demonstrators, astro-turfers, or even Nazis. We citizens are shocked and insulted that our representatives would be so disdainful of the voluntary and peaceable assembly of citizens. Shame on Speaker Pelosi and others who have deigned to insult us.

Now, let me tell you what I would like to see in healthcare reform.

I urge first that healthcare reform be slowed down so that the Congress can consider implementing incremental reforms such as the following:
1. Pass malpractice tort reform. Some states have done this to good effect. It would make sense to do it nationwide if we want to reduce costs nationwide.
2. Attempt to cut costs, waste, duplication, and fraud in the Medicare and Medicaid programs. If those programs can be reformed and improved it would greatly improve the on-going fiscal picture for our nation.
3. Put into effect a health insurance exchange allowing nationwide sales of insurance to increase competition in healthcare insurance.
4. Implement a tax benefit for individuals who buy their own insurance so they are not necessarily dependent on their employers for health insurance.
5. Make those who cannot afford to buy health insurance eligible for generous tax credits or even inclusion in Medicaid at some premium that they can afford.
6. Develop an insurance pool composed of all health insurers to insure people who can afford insurance but have pre-existing conditions and cannot get insurance. Implement this so they can buy insurance at premiums they can afford.

Let me tell you this. The actions of this Congress have stirred anger and resentment among citizens who much prefer to worry about other things. But you have, by your actions, (enumerated above) stirred us to action. We are in this to the end. November 2010 is fast approaching, and we are working to retire those who don't/won’t listen to the voters."

I am confident that this letter expresses the views of many people who are at the town hall meetings, the TEA Parties, and healthcare protests. It is the pattern of legislative recklessness and fiscal irresponsibility that alarms, yes ALARMS, average citizens. When bills are not read or are written by special interests/lobbyists or are pushed through before the citizentry has a chance to understand and react, it is smacks of authoritarianism that betrays the freedoms we cherish. People like Friedman and other elites really do believe they know what's best for the "little people." I've got a message for him and all those like him, "No. You. Don't!"

Abu Ghraib Revisited

It is an unhappy truism that minor atrocities committed by Americans or Israelis are more heavily weighted than much more egregious atrocities committed by the "Other."  Yaacov Lozowick notes a sadly ignored story coming out of the Iraq we are now leaving; the Iraqis are reverting to form and torture (real torture, not the minor league torment of the American version of Abu Ghraib) is back in fashion:

Navel Gazing, Torture and Other Boring Trivialities

As the Americans leave, the torture ramps up and freedoms are restricted. Americans can claim they owe little to Africans murdering Africans in jungles (see previous post), but the emerging regime in Iraq is emerging from an American intervention, and whether you like it or not, what happens in Iraq impacts on the US (and Europe, and elsewhere). This is where the naval gazing sanctimony and lazy (im)moral refusal to make distinctions between gradations of evil nor act upon them slip from unpleasant intellectual omissions to life-endangering callousness.

Africans torturing, murdering and raping Africans; Iraqis torturing, murdering, and raping Iraqis; (fill in the blank) torturing, murdering, and raping those who look like them; all are non stories if they cannot be used as a weapon against Israel and America.

We Are Living Longer

Threescore and 17.9: Longevity Rises

Death rates are at a record low and life expectancy is at a record high in the United States, according to the latest figures from the Centers for Disease Control and Prevention.

...

Age-adjusted death rates decreased significantly for 8 of the 15 leading causes of death: heart disease, cancer, cerebrovascular disease, accidents, diabetes, influenza, high blood pressure and assaults.

The decreases in death rate held across all races and ethnicities, with black males showing the largest decrease — more than 4 percent. The drop occurred in all age groups except infants under 1 year old, where rates were unchanged.

Those of us who suffer from heart disease and cancer already outlive their counterparts in every other country in the world.  Maybe we should think twice before we completely overhaul a system that is working fairly well, though imperfectly, lest we dis-incentivize those who are currently working so successfully to keep us alive longer every year.

Liberal Elitism: Liberal Fascism?

During the 1960s it was fashionable to decry the Republican (Conservative) elites as out of touch, reactionary, and fascistic.  In reaction, the 60s radicals rejected all presumptions of authority.  In one of those extravagant ironies which the Universe regularly bestows upon us, the Democrat  (liberal) elites are now the ones in authority and it is they who appear to be so often out of touch and reactionary, and as if to offer evidence for Jonah Goldberg's thesis, Tom Friedman today does his best to demonstrate the fascistic impulse at the core of his liberalism:

Our One-Party Democracy

Watching both the health care and climate/energy debates in Congress, it is hard not to draw the following conclusion: There is only one thing worse than one-party autocracy, and that is one-party democracy, which is what we have in America today.

One-party autocracy certainly has its drawbacks. But when it is led by a reasonably enlightened group of people, as China is today, it can also have great advantages. That one party can just impose the politically difficult but critically important policies needed to move a society forward in the 21st century. [Emphasis mine-SW]  It is not an accident that China is committed to overtaking us in electric cars, solar power, energy efficiency, batteries, nuclear power and wind power. China’s leaders understand that in a world of exploding populations and rising emerging-market middle classes, demand for clean power and energy efficiency is going to soar. Beijing wants to make sure that it owns that industry and is ordering the policies to do that, including boosting gasoline prices, from the top down.

Our one-party democracy is worse. The fact is, on both the energy/climate legislation and health care legislation, only the Democrats are really playing. With a few notable exceptions, the Republican Party is standing, arms folded and saying “no.” Many of them just want President Obama to fail. Such a waste. Mr. Obama is not a socialist; he’s a centrist. But if he’s forced to depend entirely on his own party to pass legislation, he will be whipsawed by its different factions.

It takes a special kind of ignorant arrogance to imagine that the Republican intransigence is the major factor in the public's rejection of both Cap-and-Trade and the Healthcare abomination.  Among other things, both pieces of legislation are incredibly complex, incredibly expensive, show no evidence of any awareness of the theory of unintended consequences, and have not even been read, let alone understood, by our politicians, including President Obama (challenged today by Senator DeMint to go line by line through the healthcare legislation; the contest would be as instructive as it is unlikely to ever occur.)  This legislation is a "process disaster" even before any of the actual resulting dislocations that would occur.

Beyond that, in the highlighted section of Friedman's article, we can see his unconscious assumption that the liberal elites know more than the hoi polloi; further that if only our messy Democratic process could be obviated, perhaps by the kind of enlightened dictatorship the Chinese Communists have granted their subjects, we would be able to solve all sorts of complex problems, whose complexity is in almost direct proportion to the fantasized simplicity of the Friedman solutions.  There are many reasons to move beyond oil as the primary engine of the global economy but the still hypothetical Anthropomorphic Global Warming theory is very low on the list.  One of the inadvertently comical aspects of Friedman's article is his lack of awareness that many of the industries China is championing and that Friedman wishes could receive higher subsidies from the government are industries whose competitiveness has been destroyed by the environmentalists and the lawyers, integral components of the liberal elites who he would like to see have more power. 

(Government subsidies, as if following the second law of thermodynamics, always destroy more valuer than they create, as Coyote helpfully illustrates in an example of how government largess with our money supports uneconomic choices by destroying wealth for all, while increasing wealth for the usually already wealthy few.)

The problem for the liberal elites is that they do not understand or countenance the limits of our knowledge.  We do not have nearly as much information as they pretend when it comes to such complex systems as the climate or health care.  (And contra Tom Friedman, there do exist reasonable Republican health plans which seek to change the incentive structure without damaging the entire edifice; of course, if Friedman gets his information from his own newspaper, he would have no way of knowing that.) 

A. Jay Adler is a liberal blogger who attempts to be a reasonable liberal, just as I attempt to be a reasonable libertarian/conservative blogger.  (Which of us is more often successful almost certainly depends on one's political orientation.)  In his post yesterday, he decried the vituperative quality of the Republican attacks on the Obama administration and its policies:

GOP: Gone Off Prozac

What we see now on the right, then, is not without precedent, but to say the present has mirrors in the past is not to say we know the future too. Every time it will be different. One cannot be sanguine about the levels of ill-informed rage, intolerant intimidations masquerading as exercises in democratic debate, the ugly, hateful names, the xenophobia, the racism cloaked in humor and theatrics by media demagogues, the brandishing of guns, the calls of Nazi, socialist – Martian, whatever. The “death panel” lies. The health care concentration camps hysteria. The “C” Street religious megalomania. The birthers (just like the 9/11 truthers) and all the elected officials who would not denounce them. Senator Tom Coburn on Meet the Press refusing to criticize the wearing of guns at a Presidential speech. The anxieties of ordinary people stoked to a fever pitch by cynical pols. And not yet one significant Republican figure willing – however best it might be done – to stand and lead another way.

Once, famously, William Buckley and Barry Goldwater rejected The John Birch Society as an acceptable part of American conservatism. Now the Republican Party is The John Birch Society. It is a raging Id in the guise of a political philosophy, and it needs to be contended with one exercise in reason, smart politics, and human decency at a time.

Either that or the nation is in peril.

I would not only disagree with A. Jay that the Republican party has been especially irrational lately (the "Birthers" have been much more thoroughly marginalized by the Republicans than the "Truthers" have been by the Democrats, as evidenced by the nomination of one to be the "Green Jobs Czar"); in fact most of the conflict at the moment is within the democratic party and between the Democrats and the public, who have not been convinced of the wisdom of the Democratic plans despite the presence in the White House of one of  the most eloquent speech readers of the last 20 years.  If anything I would take A. Jay to task for his descent into the same kinds of ad hominem attacks and exaggerations that he assigns the Republicans. 

Beyond that, however, I would suggest to A. Jay that not only is such intemperance and irrationality not a cause for alarm, but we probably could use more of it.  We all imagine ourselves to be deeply rational creatures understanding our world and our politics in the most rational ways.  Yet our rationality is merely a thin crust that resides unstably atop a cauldron of irrationality that comprises our deepest mental strata.  In one of my first ever posts I suggested that Democracy (and one might use "markets" instead) is the best system because it allows us to "sum our irrationalities" and thereby arrive at the closest approximation of reality.  I do not have a monopoly on reason or rationality and neither does A. Jay (or Tom Friedman, but he makes that obvious biweekly.)  Perhaps A. Jay could accept that after all the noise diminishes, some kernels of reality will persist; insisting upon the alternative of received or assumed knowledge, leads to the incipient authoritarianism of the Tom Friedmans of the world.  A reminder to A. Jay, et al:

"The first man who hurled an insult instead of a stone was the founder of civilization" - Sigmund Freud

France and Healthcare

Courtesy of Dr. Mark J. Perry at Carpe Diem, complete with multi-colored graph (by way of Coyote Blog):

On a PPP basis, all European countries in the graph except the U.K. have per capita GDP below America's poorest state. In other words, if Italy, France, or Germany left the European Union and joined the U.S., they would be the poorest of the U.S. states, and the same would apply to the European Union as a group, and the same would apply to Japan. 

Coyote uses the graph to ask So Why Are We Benchmarking Health Care v. France? and his answer is succinct and perfect:

On a purchasing power parity basis, France, Japan, and Germany would all be the poorest states in the United States, based on per capita GDP.  People on the coasts don’t benchmark their education or health care spending against Mississippi, except perhaps to make the case that Mississippi is spending too little.  So why do they benchmark their spending against Germany or France.  Of course we spend more on health care per capita – we spend more than these countries per capita on everything from TV’s to cars to movie tickets.

Also, get yourself over to Coyote Blog to see his rather brilliant answer to Kevin Drum's assertion of the need for government health care. Using the same chart Kevin does (not the one from Carpe Diem), Coyote pretty much demolishes Drum's argument and answers the question whether our very high level of spending on health care is A Bug or a Feature?

The Significance of the Return of the "Blood Libel"

The first documented instances of Christian blood libel against the Jews occurred in the 12^th century.  It became a model for later iterations of an accusation that was used to direct and intensify anti-Semitism during periods of societal stress.  From wikipedia:

Jews of Norwich were accused of ritual murder after a boy, William of Norwich, was found dead with stab wounds. The legend was turned into a cult, with William acquiring the status of martyr and crowds of pilgrims bringing wealth to the local church. In 1189, the Jewish deputation attending the coronation of Richard the Lionheart was attacked by the crowd. Massacres of Jews at London and York soon followed. On Feb 6 1190, all the Norwich Jews were found slaughtered in their houses, except a few who found refuge in the castle. Jews would later be expelled from all of England in 1290 and not allowed to return until 1655. In 1171, Blois was the site of a blood libel accusation against its Jewish community that led to 31 Jews (by some accounts 40) being burned to death .^[8]>

In general, the blood libel gained prominence only after a long period of slowly intensifying anti-Semitism and was typically the culmination of a campaign of Jew hatred; the blood libel was usually followed by an outbreak of overt, violent aggression against Jews.

In August the Swedish newspaper Aftonbladet printed a modern blood libel.  The story followed a familiar arc, as noted by Barry Rubin:

And this is how anti-Semitism has always worked, going back to the Middle Ages. A Jew is accused of a crime, falsely or otherwise, and all Jews are guilty. A Jew is accused of an illegal commercial transaction, and this justifies accusing the whole Jewish community of systematic murder.

If a Swede, a Muslim, or an African was accused of a crime, would that justify accusing an entire country or people of an even worse crime without evidence?

There’s a popular word for that today:

Racism.

This story is particularly personal for me. One hundred and twenty years ago, one of my ancestors was accused of ritual murder in Dolhinov, Russia, and a mob set out — unsuccessfully — to lynch him. A young Russian boy had been found killed, and my ancestor was accused of having done it using a “Jewish tool” — a barrel stuck through with nails for draining the blood to make matzoh.

Similarly, the Dutch story is an update to the old libels — Jews poisoning wells, worshiping money, and seeking world domination. And the British story is an update of the idea that the Jews pose as victims but are actually criminals equivalent to the worst evil in the world.

Anyone who cannot see the relationship of the historical ritual murder charge to its modern-day version is either not paying attention or is seeking the historical goal of anti-Semites: slandering the Jewish people in order to destroy them.

Further excellent commentary has been offered by Rabbi Abraham Cooper, Carl in Jerusalem, Solomon, Yaacov Lozowick (who in a very brief post manages to demolish any logical basis the story pretends to have), and Elder of Zion (who attempts to illustrate the absurdity of the EU's "balanced" response to the outrageous story.)

I would add to their excellent work that when a society descends into overt anti-Semitism (even as the European elites disguise their Jew hatred from themselves via semi-sophisticated rationalizations) it is a signal of serious societal distress and regression.

When I discussed certain psychological aspects of Arab anti-Semitism in Pity the Poor Anti-Semite, I noted that the anti-Semite unconsciously accepts that he is inferior to the Jew and unable to compete with his hidden inflated sense of the Jews' superiority:

... MEMRI posted excerpts from a Syrian government run newspaper which describes some of the lengths to which the anti-Semite is willing to go to blame the Jews for events:

On January 31, 2006, the Syrian government daily Al-Thawra published an article by columnist Abd Al-Rahman Ghunaym suggesting that Israel created the avian flu virus in order to damage "genes carried only by Arabs." The article further speculates that Israel may have planted the virus in East Asia in order to mislead the world, and that this is why the disease first appeared in that remote region. Another possibility given is that the virus was created to attack "the yellow race - especially in China and Vietnam" which are "rising powers" threatening "American hegemony over the world."

The article has a compendium of other paranoid fantasies about the Jews.  It includes the canard, which unfortunately a significant percentage of the American black population believes, that Jews developed AIDS to kill blacks.  The article ends with this gem, which bears scrutiny:

"Tampering with Arab genes [without affecting] the white race is very difficult. But the Zionists are capable of attempting this [risky] adventure if [they have] a preventive treatment or a [cure for the disease]. Recall that the assassination of Yasser Arafat was carried out by means of biological weapons. The attempt on the life of the fighter [Hamas leader] Khaled Mash'al [likewise] involved a biological [agent] which [is countered by] a secret antidote that only the Zionists possess."

Not only is "tampering with Arab genes [without affecting] the white race ... very difficult", it is not possible (yet) though if it becomes possible, it is almost certain that Jewish scientists will be involved.  However, consider the implications of this idea and other common delusions/fantasies about the Jews.  Jews control international finance; they control governments behind the scenes; they have death rays, control tsunamis, etc.  The list of powers that Jews are supposed to possess are remarkable and incredible; the Jews are supermen!  Meanwhile, the poor Arabs are weak and helpless victims.  [Notice, the alternative, that Jews are a hard working group who value education, would cast the Arab world's manifest failures into an even worse light.] 

Anti-Semitism is the societal equivalent of the paranoid delusions that the impending psychotic uses as a desperate, last ditch effort to maintain his psychological integrity.  (See The Reparative Function of Paranoid Delusions for further explanation of this process.)  If Europe is beginning to countenance the ancient blood libel in "sophisticated", mainstream media, this should alert us that the societal stresses roiling under the surface in Europe may be more significant than recognized. 

It has been apparent for quite some time that much of Europe would be happy to sacrifice Israel in the delusion that such human sacrifice would appease the barbarians in their midst.  Beyond that unhappy recognition, there is an additional, perhaps sadder point: no society that has descended into overt, paranoid anti-Semitism has ever recovered without terrible conflict, blood, and destruction.  The few remaining Jews in Europe may become the first victims of the disorder but they will not be the last.

Semi-Random Data Points

I am with Cassandra on this; if after 8 months in office, the administration still doesn't know why we are in Afghanistan (ie, they have not determined what our goals are from which strategy and tactics should follow) then I would be extremely disturbed to see American men and women remaining at risk without the most strenuous support by their Commander-in-Chief.

Last month a friend who owns a small business confided that his sales were down ~10% but his company is still making a profit because he has cut expenses by 25%.  One area cut was instructive.  The company's unit in California had 40 employees.  The cost of their workman's comp was 3 times more than the total cost of workman's comp for the 115 employees in New York.  He closed the California unit, moving 40 workers to the unemployment line and costing California 40 productive tax payers. 

A woman who has visited Paris regularly for the last 30 years was astounded at how expensive it has gotten.  A continental breakfast of coffee, toast, and a Danish cost $30! 

I have spoken to a fair number of people in the last weeks, most of whom are liberals; I have yet to meet someone who thinks the Healthcare reform ideas being bandied about by Congress having anything to commend them. 

One particular emphasis of Obamacare that is worth comment.  He has made the point that 25% of health care costs derive from treatments in the last year of life.  As Richard Fernandez notes, "hopeless" diagnoses are often incorrect and the existence of a "death pathway" under the aegis of the NIH in Britain creates pressure for a self-fulfilling prophecy to increase death rates.  During my Medical School training I spent a day at a Hospice Care facility which primarily offered palliation and comfort to terminally ill cancer patients.  The Physician who led us on rounds mentioned in passing that almost 10% of their patients actually survived hospice care and went home because they had been misdiagnosed and did not in fact have terminal cancer!  Predicting when a patient is gong to succumb and determining when their quality of life has become so eroded that death has become welcome is not a decision I want the government to make for me or my patients.  And the idea that most patients do not discuss their treatment options in the last year(s) of their life is simply inaccurate.  The problem, from the point of view of Obamacare, is that most people insist on trying all (or almost all) available treatments before accepting that they have passed beyond the possibilities of modern medicine and coming to terms with their impending demise. 

One more health care fiction worth reconsidering; from  Jonathan Gruber in the Boston Globe comes this old chestnut:

In fact, both sides in this debate need each other. Liberals are right that fundamental cost control can only come from the supply side. Consumers are poor and ineffective shoppers in the medical arena. Ultimately, they will do what their doctors tell them to do. So only by providing the proper incentives for providers can we truly control costs.

Arnold Kling nails one side of this meme:

Needlessly to say, I take strong exception to Gruber's "poor and ineffective shoppers" allegation. Instead I would describe consumers as embedded in an institutional environment that takes away their motivation to compare costs with benefits.

Once upon a time in a galaxy far, far away, patients were passive consumers of health care.  They went to their Doctor with a problem and were instructed from on high in a treatment.  Patients can still find themselves passive recipients of health care in urgent or emergency situations, however, there is no excuse for patients taking a passive position in re: their chronic or routine health care.  We have been told for the last 40 years that patients are no longer subordinate to their Doctors and that medical decisions are collaborative efforts.  Patients are expected to get second opinions (and can easily obtain third opinions while educating themselves via the internet.)  When I prescribe a treatment course or medication for a patient I offer them various options and explain why I think one option is preferable to another; the cost of the treatment should be simply one data point they need to consider when determining whether or not they wish to accept my recommendation.  The idea that patients do not have the autonomy, wisdom, or knowledge to determine their own choices is nonsense.  If patients remain "poor and ineffective shoppers in the medical arena", it is their responsibility; certainly the existence of a multi-billion dollar industry in alternative Medicine suggests that a great many Americans, when motivated, do not consider themselves poor and ineffective shoppers in the medical arena."

And just for the record, medical care is not a right.  No one has the "right" to my services without my consent.

Better Living Through Chemistry? Part I

Last week Charles Barber, a Yale Medical School Psychiatrist, wrote a provocative article for Salon.com:

Are we really so miserable?
Antidepressant use has doubled, and anxiety is at a troubling high. Blame TV, Big Pharma -- and possibly yourself

Aug. 26, 2009 | Earlier this month the Archives of General Psychiatry released a much publicized study that one in 10 Americans is now taking antidepressants within the course of a year, making antidepressants the most prescribed kind of medication in the country. The number of Americans on antidepressants doubled between 1996 and 2005, and the number of prescriptions written for these drugs has increased each year between 2005 and 2008. One has to wonder: Are we really that miserable?

Manipulated might be a better word than miserable. If we were to pick one factor that explains the dramatically increased number of selective serotonin reuptake inhibitors (the technical name for drugs like Prozac, Paxil and Zoloft) that now run through our collective bloodstream, it would be direct-to-consumer advertising, otherwise known as television commercials for prescription drugs. An obscure rule change by the FDA in 1997 allowed Big Pharma to advertise its products on TV and bring them into our living rooms, and our daily consciousness. The pharmaceutical companies concentrated on their best-selling “blockbuster” drugs — Lipitor, Claritin, Nexium, Viagra, as well as the psychiatric drugs Prozac, Paxil and Zoloft, and more currently, Effexor and Lexapro — and soon enough these drugs became, quite literally, household names, the celebrities of pharmaceutical agents. Psychiatric drugs featured prominently in these ads because psychiatric drugs are very good sellers, among the best in the industry, for which there is a simple reason: Legitimate psychiatric illnesses are chronic (if episodic), and the legitimate sufferer needs to take the medication for a long time, if not for life.

In his article Dr. Barber focuses on how Big Pharma uses direct to patient advertising to present a rosy picture of how their chemical ministrations can lift our spirits and bring the warmth and light of sunshine back into unhappy lives.  He also offers some anecdotal evidence that the explosion of antidepressant use coincides with one of our periodic upsurges in cultural angst:

But there is something dark and undeniable shifting in our cultural mood, too. Sure, there is manipulation in the advertising and confusion about what constitutes legitimate “serious and persistent mental illness” (a formal term to describe the afflictions of the very small percentage of people who suffer from severe bipolar disorder, major depression or psychotic disorders) as opposed to the far more normative, if often very painful, stressors and issues of living life in the early 21st century. Yet I would also say that misery and — if one were to use a slightly more clinical word, anxiety — are at one of their periodic high points. Arguably we have entered a new age of anxiety, a term associated with the post-World War II era through the 1960s, when the prevailing belief was that the world might blow up at any moment (and on the medication front, Valium was king). Maybe there’s some weird synchronicity that the hottest thing in our present cultural moment, "Mad Men," is set firmly in that era. In any case, I have written widely about mental health and have traveled the country in the last couple of years and, given the nature of my writing, have been sought out by all kinds of troubled souls. I can claim confidently that there is, right now, a high-water mark of worry and suffering on numerous fronts — economic, of course, but also social, with our ever-increasing isolation and Internet-driven loss of human connection and the ongoing trauma of wars and crises that just don’t seem to end.

Dr. Barber overstates the impact of the zeitgeist on anti-depressant use (or, at least, focuses on the wrong aspect of the zeitgeist.)  Since the 1960s, the idea that pharmacological interventions can, and should, solve problems with a minimum of effort, has become deeply ingrained in our culture.  For example, when people are unhappy (and please note, I am not considering Major Depressive Disorders, which exist on a different continuum from unhappiness) their Physicians and insurance companies are far more likely to recommend a pill than an exploratory Psychotherapy.  Pills are cheaper, often work more quickly, and have the added virtue of not requiring the patient to actually make any significant changes in their life.  But although I may take some issue with Dr. Barber's emphasis, he commits a much more egregious omission.  Nowhere in his article does he reflect upon the contribution that organized Psychiatry has made to the medicalization of unhappiness.

Organized Psychiatry is in the process of revising the DSM, the Diagnostic and Statistical Manual which has described the official diagnostic criteria for various Psychiatric illnesses since the 1950s and is currently on its 4th iteration.  The DSM has taken an interesting path.

DSM-I (1952) was heavily influenced by the Psychoanalytic community, which in the 1950s was extremely influential in American Psychiatry.  The DSM-I discussed and described various traditional Psychiatric diagnoses (Neurosis, Schizophrenia, Manic-Depressive Illness) with an attempt to elucidate the etiology of the various conditions.  In other words, the attempt was made to explain what actually caused the symptoms which were causing suffering and suggest treatment approaches for alleviating suffering.  The DSM-II (1968) carried forward the emphasis on etiology while adding a number of additional diagnostic entities and offering support for a more biological emphasis for certain serious disorders.  Nonetheless, it maintained a continuity with the DSM-I's attempt to understand the underlying psychodynamics of behavior and the causation of Psychiatric disorders.  This all changed when the third revision took place in the late 1970s.

By the time the DSM-III task forces were established, it was correctly recognized that the Psychoanalytic understanding of etiology was insufficient to explain serious Psychiatric illness. Two elements became crucial.  First organized Psychiatry, in reaction to the burgeoning use of Psychiatric medications and the relative disconnect between traditional Psychoanalysis and Psychiatry, as well as concerns about viability in an environment of increasing third party compensation, determined to make Psychiatry more clearly a Medical discipline rather than a Psychological discipline.  This led to an over-emphasis on biological (pseudo) explanations for behavior.  As a result the DSM-III was a document that made diagnoses based almost solely on collections of symptoms and symptom complexes (often referred to as the "Chinese Menu" style of diagnosis.)  The unintended consequences of the decision to base Psychiatric diagnosis on symptoms rather than etiology slowly grew and metastasized.

[It must be emphasized that when the DSM-III was being developed, the well meaning Psychiatrists involved failed to recognize that symptoms were not merely biological responses to levels of neurotransmitters.  Just as the Psychoanalysts in the first flush of their success in curing Neurosis with the "talking cure", over-explained all behavior as resulting from conflicts and deficits in the mind while neglecting the brain, the biological Psychiatrists, in their first flush of excitement at managing Psychiatric illnesses with their new Medication, over-explained all symptoms and behavior as being the result of the interplay of neurochemistry in the brain, while neglecting the mind.  Finding the proper balance, when our understanding of the Psyche and the brain remains relatively rudimentary, is a long term task which we have barely begun.]

The unintended consequences of the shift to a symptom based diagnostic manual, an over-emphasis on biological determinism, and the medicalization of unhappiness will be the subject of Part II.

Better Living Through Chemistry: Part II

Better Living Through Chemistry: Part III

Humpty Dumpty and the Burqa

“When I use a word,” Humpty Dumpty said, in a rather scornful tone, “it means just what I choose it to mean—neither more nor less.”

“The question is,” said Alice, “whether you can make words mean so many different things.”

“The question is,” said Humpty Dumpty, “which is to be master—that’s all.”         

Lewis Carroll [Charles Lutwidge Dodgson] (1832–1898), Alice’s Adventures in Wonderland, chapter 6 (1865).

Psychoanalysis concerns itself, above all, on the meaning of language and communication.  We recognize that our language and behavior, despite all their manifest shortcomings, are the best vehicles we know to convey meaning.  Our words and behaviors convey multiple layers of meaning, some intentional and conscious, other meanings unintended and unconscious.  (Can unconscious communications be thought to have intent behind them?  Our unconscious minds often seek expression of ideas that our conscious minds reject yet we do not equate conscious intent with unconscious intent even as the Psychoanalyst attempts to enlarge the realm of conscious awareness.)  Literature and the arts can also be thought of as endeavors which attempt to convey multiple layers of meanings, often much more than the author intends.  These are non-controversial ideas yet in certain areas of current discourse, there is an implicit insistence that Humpty Dumpty's attitude in Alice in Wonderland should be our guide to meaning.

In today's New York Times, Steven Erlanger reports on the controversy in France over the wearing of the Burka, or Niqab:

Burqa Furor Scrambles French Politics

It is a measure of France’s confusion about Islam and its own Muslim citizens that in the political furor here over “banning the burqa,” as the argument goes, the garment at issue is not really the burqa at all, but the niqab.

A burqa is the all-enveloping cloak, often blue, with a woven grill over the eyes, that many Afghan women wear, and it is almost never seen in France. The niqab, often black, leaves the eyes uncovered.

Still, a movement against it that started with a Communist mayor near Lyon has gotten traction within France’s ruling center-right party, which claims to be defending French values, and among many on the left, who say they are defending women’s rights. A parliamentary commission will soon meet to investigate whether to ban the burqa — in other words, any cloak that covers most of the face.

The debate is indicative of the deep ambivalence about social customs among even a small minority of France’s Muslim citizens, and of the signal fear that France’s principles of citizens’ rights, equality and secularism are being undermined.

Erlanger focuses on the French tradition of anticlericism and the perceived threat to French values of such public displays of religious devotion.  He makes one minimal comment about French concerns over the growth of radical Islam (in the 10th paragraph) but manages to do so in way which minimizes the concern, conflating it with base political concerns:

There is a strong suspicion that Mr. Sarkozy, who has supported religious freedom, is playing politics in a time of economic unhappiness and social anxiety. But he also seems to want to restrict more radical and puritanical forms of Islam from gaining further hold here.

Having managed to undermine the argument that Sarkozy et al might have some genuine reason for concerns about "more radical and puritanical forms of Islam", Erlanger then spends the rest of the article offering supportive statements of the Niqab, concentrating on its liberating aspects and its signification of religious piety.  This is disingenuous at best.

Last week, Naomi Wolf penned an ode to the wonders of the burqa; Phyllis Chesler devastates Naomi Wolf's paean to the burqa, and her post should be read in full:

The Burqa: Ultimate Feminist Choice?

Naomi Wolf Discovers That Shrouds Are Sexy

Women in chadors are really feminist ninja warriors. Rather than allow themselves to be gawked at by male strangers, they choose to defeat the “male gaze” by hiding from it in plain view.

...

Well, what can I say? Here’s a few things.

Most Muslim girls and women are not given a choice about wearing the chador, burqa, abaya, niqab, jilbab, or hijab (headscarf), and those who resist are beaten, threatened with death, arrested, caned or lashed, jailed, or honor murdered by their own families. Is Wolfe thoroughly unfamiliar with the news coming out of Afghanistan, Pakistan, Iran, Saudi Arabia, and Sudan on these very subjects? Has she forgotten the tragic, fiery deaths of those schoolgirls in Saudi Arabia who, in trying to flee their burning schoolhouse, were improperly veiled and who were beaten back by the all-powerful Saudi Morality Police?

What Wolf and Erlanger have done in their articles is to strip away and conceal the full panoply of meanings that the burqa, niqab, etc have accrued since the veil (mask) has become adopted as a symbolic representation of Islamist identity (supremacy) and the dedifferentiation of women into objects, ignored or used at will.  It is unclear if, as Phyllis poses the question, the writers are "unfamiliar with the news coming out of Afghanistan, Pakistan, Iran, Saudi Arabia, and Sudan" but I suspect their diffidence has other roots and meanings.  The most prosaic explanations would include the writers' disinclination to question the rationalizations of "the other;" after all, Westerners have no standing to claim understanding or offer criticism of "the other."  As well, it has become conventional wisdom among the commentariat of the left that any criticism of Islamic practices is tantamount to Islamophobia (a phobia for which there exists no particular evidence but which terrifies the legacy media.)  Holding opinions that are at odds with the conventional wisdom of their colleagues is a sure way for a legacy writer to face the opprobrium of their peers; moral courage is not a conspicuous trait of the profession.

On deeper levels, the disinclination to criticize Islam and its most egregious practices emerges from a combination of cowardice and pride.  The starkest example of the combination was seen during the Danish Cartoon controversy, where the vast majority of the legacy media refused to print the images out of fear, yet proclaimed high minded rationalizations (ie, to avoid showing insensitivity to Islam) out of pride.

The burqa, etc, have become powerful symbols conveying unmistakable meaning.  To deny such accrued meaning, for all that it has become de rigeur in our media, is unfortunate and divorced from reality.  One wonders if Erlanger and Wolf would report on a Ku Klux Klan march that the masked marchers were freed by their masks and merely exhibiting their devotion to their Christian faith while avoiding any discussion of the multiple additional meanings of the KKK hoods?  To pose the question is to answer it.