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Amazon, BH, JPMorgan

With 1.2 million employees, Amazon, Berkshire Hathaway, and JP Morgan have decided to venture together into health care for their employees.

Following in the grand tradition of Henry Ford, who set up Henry Ford Hospital in Detroit, these three giants are stepping in too.

They have no illusions about how difficult it will be. But with premiums rising 19% per year, its clear that Congress is doing nothing, and someone has to do something.

“Planning for the new company is being led by Marvelle Sullivan Berchtold, a JPMorgan managing director who was previously head of the Swiss drugmaker Novartis’s mergers and acquisitions strategy; Mr. Combs; and Beth Galetti, a senior vice president at Amazon.”

The article points out that there are others working on this.

“Robert Andrews, chief executive of the Healthcare Transformation Alliance, a group of 46 companies, including Coca-Cola and American Express, that have banded together to lower health care costs.”

“Walmart contracted with groups like the Cleveland Clinic, Mayo and Geisinger, among others, to take care of employees who need organ transplants and heart and spine care.”

“Caterpillar, the construction equipment manufacturer, sets its own rules for drug coverage, which it has said saves it millions of dollars per year, even though it still uses a pharmacy benefit manager to process its claims.”

Suzanne Delbanco, the executive director for the Catalyst for Payment Reform, a nonprofit group that mainly represents employers”

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CREDIT: https://www.nytimes.com/2018/01/30/technology/amazon-berkshire-hathaway-jpmorgan-health-care.html?smid=nytcore-ipad-share&smprod=nytcore-ipad

TECHNOLOGY
Amazon, Berkshire Hathaway and JPMorgan Team Up to Try to Disrupt Health Care

By NICK WINGFIELD, KATIE THOMAS and REED ABELSON
JAN. 30, 2018
SEATTLE — Three corporate behemoths — Amazon, Berkshire Hathaway and JPMorgan Chase — announced on Tuesday that they would form an independent health care company for their employees in the United States.

The alliance was a sign of just how frustrated American businesses are with the state of the nation’s health care system and the rapidly spiraling cost of medical treatment. It also caused further turmoil in an industry reeling from attempts by new players to attack a notoriously inefficient, intractable web of doctors, hospitals, insurers and pharmaceutical companies.
It was unclear how extensively the three partners would overhaul their employees’ existing health coverage — whether they would simply help workers find a local doctor, steer employees to online medical advice or use their muscle to negotiate lower prices for drugs and procedures. While the alliance will apply only to their employees, these corporations are so closely watched that whatever successes they have could become models for other businesses.

Major employers, from Walmart to Caterpillar, have tried for years to tackle the high costs and complexity of health care, and have grown increasingly frustrated as Congress has deadlocked over the issue, leaving many of the thorniest issues to private industry. About 151 million Americans get their health insurance from an employer.
(Why will health care be so difficult for these companies to untangle? Analysis from The Upshot.)
But Tuesday’s announcement landed like a thunderclap — sending stocks for insurers and other major health companies tumbling. Shares of health care companies like UnitedHealth Group and Anthem plunged on Tuesday, dragging down the broader stock market.

That weakness reflects the strength of the new entrants. The partnership brings together Amazon, the online retail giant known for disrupting major industries; Berkshire Hathaway, the holding company led by the billionaire investor Warren E. Buffett; and JPMorgan Chase, the largest bank in the United States by assets.

They are moving into an industry where the lines between traditionally distinct areas, such as pharmacies, insurers and providers, are increasingly blurry. CVS Health’s deal last month to buy the health insurer Aetna for about $69 billion is just one example of the changes underway. Separately, Amazon’s potential entry into the pharmacy business continues to rattle major drug companies and distributors.
(Here’s a look at how the even the threat of Amazon’s entry into an industry can rattle stocks.)

The companies said the initiative, which is in its early stages, would be “free from profit-making incentives and constraints,” but did not specify whether that meant they would create a nonprofit organization. The tax implications were also unclear because so few details were released.
Jamie Dimon, the chief executive of JPMorgan Chase, said in a statement that the effort could eventually be expanded to benefit all Americans.

“The health care system is complex, and we enter into this challenge open-eyed about the degree of difficulty,” Jeff Bezos, Amazon’s founder and chief executive, said in a statement. “Hard as it might be, reducing health care’s burden on the economy while improving outcomes for employees and their families would be worth the effort.”

The announcement touched off a wave of speculation about what the new company might do, especially given Amazon’s extensive reach into the daily lives of Americans — from where they buy their paper towels to what they watch on television. It follows speculation that the company, which recently purchased the grocery chain Whole Foods, might use its stores as locations for pharmacies or clinics.
(We asked health care experts to imagine what the three corporations might do.)

“It could be big,” Ed Kaplan, who negotiates health coverage on behalf of large employers as the national health practice leader for the Segal Group, said of the announcement. “Those are three big players, and I think if they get into health care insurance or the health care coverage space, they are going to make a big impact.”

TAKING ON ‘THE HUNGRY TAPEWORM’
A look at the three companies that announced a joint health care initiative on Tuesday.

Total employees: 1.2 million 
Amazon: 540,000 
Berkshire Hathaway: 367,000
JPMorgan Chase: 252,000.
Individual strengths 
Amazon: logistics and technology
Berkshire Hathaway: insurance
JPMorgan Chase: finance.

Jeff Bezos of Amazon:
“The healthcare system is complex, and we enter into this challenge open-eyed about the degree of difficulty.”
Warren E. Buffett of Berkshire Hathaway:
“The ballooning costs of healthcare act as a hungry tapeworm on the American economy. Our group does not come to this problem with answers. But we also do not accept it as inevitable.”
Jamie Dimon of JPMorgan Chase:
“The three of our companies have extraordinary resources, and our goal is to create solutions that benefit our U.S. employees, their families and, potentially, all Americans.”

But others were less sure, noting that the three companies — which, combined, employ more than one million people — might still hold little sway over the largest insurers and pharmacy benefit managers, who oversee the benefits of tens of millions of Americans.

“This is not news in terms of jumbo employers being frustrated with what they can get through the traditional system,” said Sam Glick of the management consulting firm Oliver Wyman in San Francisco. He played down the notion that the three partners would have more success getting lower prices from hospitals and doctors. “The idea that they could have any sort of negotiation leverage with unit cost is a pretty far stretch.”

Even the three companies don’t seem to be sure of how to shake up health care. People briefed on the plan, who asked for anonymity because the discussions were private, said the executives decided to announce the initiative while still a concept in part so they can begin hiring staff for the new company.

Three people familiar with the partnership said it took shape as Mr. Bezos, Mr. Buffett, and Mr. Dimon, who are friends, discussed the challenges of providing insurance to their employees. They decided their combined access to data about how consumers make choices, along with an understanding of the intricacies of health insurance, would inevitably lead to some kind of new efficiency — whatever it might turn out to be.

“The ballooning costs of health care act as a hungry tapeworm on the American economy,” Mr. Buffett said in the statement. “Our group does not come to this problem with answers. But we also do not accept it as inevitable.”

Over the past several months, the three had met formally — along with Todd Combs, an investment officer at Berkshire Hathaway who is also on JPMorgan’s board — to discuss the idea, according to a person familiar with Mr. Buffett’s thinking.

The three chief executives saw one another at the Alfalfa Club dinner in Washington on Saturday, but by then each had already had dozens of conversations with the small in-house teams they had assembled. The plan was set.

Mr. Buffett’s motivation stems in part from conversations he has had with two people close to him who have been diagnosed with multiple sclerosis, according to the person. Mr. Buffett, the person said, believes the condition of the country’s health care system is a root cause of economic inequality, with wealthier people enjoying better, longer lives because they can afford good coverage As Mr. Buffett himself has aged — he is 87 — the contrast between his moneyed friends and others has grown starker, the person said.

The companies said they would initially focus on using technology to simplify care, but did not elaborate on how they intended to do that or bring down costs. One of the people briefed on the alliance said the new company wouldn’t replace existing health insurers or hospitals.

Planning for the new company is being led by Marvelle Sullivan Berchtold, a JPMorgan managing director who was previously head of the Swiss drugmaker Novartis’s mergers and acquisitions strategy; Mr. Combs; and Beth Galetti, a senior vice president at Amazon.

One potential avenue for the partnership might be an online health care dashboard that connects employees with the closest and best doctor specializing in whatever ailment they select from a drop-down menu. Perhaps the companies would strike deals to offer employee discounts with service providers like medical testing facilities.

“Each of those companies has extensive experience using transformative technology in their own businesses,” said John Sculley, the former chief executive of Apple who is now chairman of a health care start-up, RxAdvance. “I think it’s a great counterweight to what government leadership hasn’t done, which is to focus on how do we make this health care system sustainable.”

How Amazon Rattles Other Companies
The e-commerce giant’s actions – some big, like buying Whole Foods Markets; some smaller, like Amazon meal kits – have led to stock sell-offs for a wide range of businesses.

Erik Gordon, a professor at the University of Michigan’s Ross School of Business, predicted that the companies would attempt to modernize the cumbersome process of doctor appointments by making it more like booking a restaurant reservation on OpenTable, while eliminating the need to regularly fill out paper forms on clipboards.

“I think they will bring the customer-facing, patient-facing thing into your smartphone,” he said.

Amazon has long been mentioned by health care analysts and industry executives as a potential new player in the sector. While the company has remained quiet about its plans, some analysts noted that companies often use their own employees as a testing ground for future initiatives.

The entry of Amazon and its partners adds to the upheaval in an industry where much is changing, from government programs after the overhaul of the tax law to the uncertain future of the Affordable Care Act. All the while, medical costs have persistently been on the rise.

Nationwide, average premiums for family coverage for employees rose to $18,764 last year, an increase of 19 percent since 2012, according to the Kaiser Family Foundation. Workers are increasingly paying a greater share of those costs — they now pay 30 percent of the premium, in addition to high deductibles and growing co-payments.
“Our members’ balance sheets speak for themselves — health care is a growing cost at a time when other costs are either not rising or falling,” said Robert Andrews, chief executive of the Healthcare Transformation Alliance, a group of 46 companies, including Coca-Cola and American Express, that have banded together to lower health care costs.

Other major employers have also sought more direct control over their employees’ health care. Walmart contracted with groups like the Cleveland Clinic, Mayo and Geisinger, among others, to take care of employees who need organ transplants and heart and spine care. Caterpillar, the construction equipment manufacturer, sets its own rules for drug coverage, which it has said saves it millions of dollars per year, even though it still uses a pharmacy benefit manager to process its claims.

Suzanne Delbanco, the executive director for the Catalyst for Payment Reform, a nonprofit group that mainly represents employers, said controlling rising prices is especially hard in markets where a local hospital or medical group dominates. While some have tried to tackle the issue in different ways, like sending employees with heart conditions to a specific group, “it’s piecemeal,” she said.

She added, “There are so many opportunities to do this better.”

The issue is not solely a 21st-century concern: In 1915, Henry Ford became increasingly worried about the quality of health care available to his growing work force in Detroit, so he opened the Henry Ford Hospital. It is still in existence today.

Nick Wingfield reported from Seattle, Katie Thomas from Chicago and Reed Abelson from San Francisco. Michael J. de la Merced contributed reporting from London, and Emily Flitter from New York.

A version of this article appears in print on January 31, 2018, on Page A1 of the New York edition with the headline: 3 Giants Form Health Alliance, Rocking Insurers. Order Reprints| Today’s Paper|Subscribe

Prevention Revisited

The essay below is an argument for the quality of life benefits of prevention. But its conclusions about whether prevention saves money? Those conclusions are depressing.

But I want to consider it. If prevention doesn’t save money, this goes against every intuition I have ever had on the subject.

The source of this essay is worth considering. If you look below, Dr. Aaron just published a book arguing that bad foods are not so bad – in moderation. This is a conclusion I happen to agree with. I agree with “all things in moderation”.
 
For example, a primary conclusion is that insuring people makes them more, rather than less, likely to use the emergency room. But this conclusion is about insurance, not prevention, and speaks to people’s need for convenient access to health care.

Or a second example used: anti-smoking. The essay’s conclusion is outrageous: it says that society will pay more because people who stop smoking will live longer! So, if society wishes to reduce costs, a mass euthanasia program, at, say, age 67, will really do the trick!
 
I publish but do not endorse…..

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CREDIT: Essay in the New York Times

THE NEW HEALTH CARE

The essay below is depressing. But I want to consider it. If prevention doesn’t save money, this goes against every intuition I have ever had on the subject.

I definitely don’t trust the source of this essay, or its conclusions.

For example, a primary conclusion is that insuring people makes them more, rather than less, likely to use the emergency room. But this conclusion is about insurance, not prevention, and speaks to people’s need for convenient access to health care.

Or a second example used: anti-smoking. The essay’s conclusion is outrageous: it says that society will pay more because people who stop smoking will live longer! So, if society wishes to reduce costs, a mass euthanasia program, at, say, age 67, will really do the trick!

I publish but do not in any way endorse…..

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CREDIT: New York Times Essay

THE NEW HEALTH CARE

Preventive Care Saves Money Sorry, It’s Too Good to Be True

Contrary to conventional wisdom, it tends to cost money, but it improves quality of life at a very reasonable price.

By Aaron E. Carroll
Jan. 29, 2018

The idea that spending more on preventive care will reduce overall health care spending is widely believed and often promoted as a reason to support reform. It’s thought that too many people with chronic illnesses wait until they are truly ill before seeking care, often in emergency rooms, where it costs more. It should follow then that treating diseases earlier, or screening for them before they become more serious, would wind up saving money in the long run.
Unfortunately, almost none of this is true.

Let’s begin with emergency rooms, which many people believed would get less use after passage of the Affordable Care Act. The opposite occurred. It’s not just the A.C.A. The Oregon Medicaid Health Insurance experiment, which randomly chose some uninsured people to get Medicaid before the A.C.A. went into effect, also found that insurance led to increased use of emergency medicine. Massachusetts saw the same effect after it introduced a program to increase the number of insured residents.

Emergency room care is not free, after all. People didn’t always choose it because they couldn’t afford to go to a doctor’s office. They often went there because it was more convenient. When we decreased the cost for people to use that care, many used it more.
Wellness programs, based on the idea that we can save money on health care by giving people incentives to be healthy, don’t actually work this way. As my colleague Austin Frakt and I have found from reviewing the research in detail, these programs don’t decrease costs — at least not without being discriminatory.

Accountable care organizations rely on the premise that improving outpatient and preventive care, perhaps with improved management and coordination of services for those with chronic conditions, will save money. But a recent study in Health Affairs showed that care coordination and management initiatives in the outpatient setting haven’t been drivers of savings in the Medicare Shared Savings Program.

There’s little reason to believe that even more preventive care in general is going to save a fortune. A study published in Health Affairs in 2010 looked at 20 proven preventive services, all of them recommended by the United States Preventive Services Task Force. These included immunizations, counseling, and screening for disease. Researchers modeled what would happen if up to 90 percent of these services were used, which is much higher than we currently see.

They found that this probably would have saved about $3.7 billion in 2006. That might sound like a lot, until you realize that this was about 0.2 percent of personal health care spending that year. It’s a pittance — and that was with almost complete compliance with recommendations.

One reason for this is that all prevention is not the same. The task force doesn’t model costs in its calculations; it models effectiveness and a preponderance of benefits and harms. When something works, and its positive effects outweigh its adverse ones, a recommendation is made.

This doesn’t mean it saves money.

In 2009, as part of the Robert Wood Johnson Foundation’s Synthesis Project, Sarah Goodell, Joshua Cohen and Peter Neumann exhaustively explored the evidence. They examined more than 500 peer-reviewed studies that looked at primary (stopping something from happening in the first place) or secondary (stopping something from getting worse) prevention. Of all the interventions they looked at, only two were truly cost-saving: childhood immunizations (a no-brainer) and the counseling of adults on the use of low-dose aspirin. An additional 15 preventive services were cost-effective, meaning that they cost less than $50,000 to $100,000 per quality adjusted life-year gained.

But all of these analyses looked within the health care system only. If we really want to know whether prevention saves money, maybe we should take a wider perspective. Does spending on prevention save the country money over all?

A recent report from the Congressional Budget Office in the New England Journal of Medicine suggests the answer is no. The budget office modeled how a policy to reduce smoking through higher cigarette taxes might affect federal spending. It found that such a tax would cause many people to quit smoking — the desired result. In the short term, less smoking would lead to decreased spending because of reductions in health care spending for those who had smoked.
But in the long run, all of those people living longer would lead to increases in spending in many programs, including health care. The more people who quit smoking, the higher the deficit — even with the increased revenue from taxing cigarettes.

But money doesn’t have to be saved to make something worthwhile. Prevention improves outcomes. It makes people healthier. It improves quality of life. It often does so for a very reasonable price.
There are many good arguments for increasing our focus on prevention. Almost all have to do with improving quality, though, not reducing spending. We would do well to admit that and move forward.
Sometimes good things cost money.

Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine who blogs on health research and policy at The Incidental Economist and makes videos at Healthcare Triage. He is the author of The Bad Food Bible: How and Why to Eat Sinfully.

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CREDIT: https://www.npr.org/sections/thesalt/2017/11/19/564879018/the-bad-food-bible-says-your-eating-might-not-be-so-sinful-after-all

The Bad Food Bible
How and Why to Eat Sinfully
by Aaron, M.D. Carroll and Nina Teicholz
Hardcover, 272 pages

There are some surprises in your book, like milk isn’t as nutritious as some might think?

This is one of those where, if you just look at nature, we’re the only animal that consumes milk outside of the infant period. Now there’s no need for it. Part of that is politics, and the fact that the United States got involved in promoting dairy and the whole dairy industry. But there’s really no good evidence outside of the childhood period that milk is necessary. One of the things that I tried to state in the book, and this is true of all beverages with calories, you should treat them like you treat alcohol. I mean, what else are you going to do with a good chocolate chip cookie? Of course you need a glass of milk with that. That’s like dessert — it’s something you should have because you want it, not because you need it.

Raw eggs often get a bad reputation, particularly when it comes to cookie dough. How bad are they, really?

The raw egg is another one where of course there is a risk. But you have to weigh that against joy again. The truth of the matter is that if you committed to eating raw eggs in cookie dough once a week every week for the rest of your life, you’d almost never come into contact with salmonella. If you did, you’d almost never get sick. If you got sick, you’d almost never notice. Even if you noticed, it would almost never result in something serious. The chance of you actually getting seriously ill is infinitesimal. … The joy of doing those kinds of things with your kids or enjoying the process of baking is much more satisfying and will lead to greater increases in quality of life than the infinitesimal risk that you’re hurting your health in some way.
So, it sounds like there’s a lot of misinformation surrounding what food is bad for us. What’s your eating advice then?

So I think you know, in general, one thing you can do is limit your heavily processed food as much as possible. Nature intended you to get the appley goodness from an apple, not from apple juice. But the more we can do to smile, to cook for ourselves, to know where our food is coming from, to be mindful of it, the better. But we shouldn’t be so panicked and fearful and constantly believing that if we don’t do what we’ve heard from the latest expert, that we’re going to get sick and die. That is just not true.

Of course, we are staring down the barrel of Thanksgiving, which for many of us can be a moment that produces a lot of anxiety, especially food anxiety nowadays. It just feels like it’s all so fraught. I’m evil if I eat meat. I’m bad if I like Diet Coke. Food is loaded.
It’s also really important, it’s one day a year! Your health and your eating habits are not established by one day a year. It’s perfectly fine to enjoy yourself and to live! You need to weigh — in all your health decisions — the benefits and the harms. And too often we only focus on the latter. And included in benefits are joy, and quality of life and happiness. There are times when it’s a perfectly rational decision to allow yourself to be happy and to enjoy yourself. I’m not sort of giving a license for people to eat whatever they want, anytime they want. Yes, the Diet Coke, the pie, these are all processed foods. So you should think about how much you’re eating them in relation to everything else. But on the other hand, a piece of pie on Thanksgiving is not going to erase everything else you’ve done the rest of the year. Thanksgiving is easily my favorite holiday and it’s not just because of the food, but also because of the meal and the fact that you get to enjoy it with family and friends.

I’ve got to ask you, what are you having for Thanksgiving?

As much as I can cram into my body on that day. But, I love turkey, really well-done turkey. I love mashed potatoes, and stuffing and gravy, and I think pie is the greatest dessert that exists, so I’m sure I’ll be having too much of that as well.

Producer Adelina Lancianese contributed to this report.

Homeostasis

One of the smartest guys in the room, Antonio Damasio, give his views about neuroscience and its relationship to pain, pleasure, and feelings. He points out that they all play a giant role in one of life’s most important concepts: homeostasis.

CREDIT: http://nautil.us/issue/56/perspective/antonio-damasio-tells-us-why-pain-is-necessary

Antonio Damasio Tells Us Why Pain Is Necessary
The neuroscientist explains why feelings evolved.

BY KEVIN BERGER
JANUARY 18, 2018

Following Oliver Sacks, Antonio Damasio may be the neuroscientist whose popular books have done the most to inform readers about the biological machinery in our heads, how it generates thoughts and emotions, creates a self to cling to, and a sense of transcendence to escape by. But since he published Descartes’ Error in 1994, Damasio has been concerned that a central thesis in his books, that brains don’t define us, has been muted by research that states how much they do. To Damasio’s dismay, the view of the human brain as a computer, the command center of the body, has become lodged in popular culture.

In his new book, The Strange Order of Things, Damasio, a professor of neuroscience and the director of the Brain and Creativity Institute at the University of Southern California, mounts his boldest argument yet for the egalitarian role of the brain. In “Why Your Biology Runs on Feelings,” another article in this chapter of Nautilus, drawn from his new book, Damasio tells us “mind and brain influence the body proper just as much as the body proper can influence the brain and the mind. They are merely two aspects of the very same being.”

BEYOND SCIENCE: Antonio Damasio, director of the Brain and Creativity Institute at USC, sings the glories of the arts in his new book, The Strange Order of Things: “The sciences alone cannot illuminate the entirety of human experience without the light that comes from art and humanities.”

The Strange Order of Things offers a sharp and uncommon focus on feelings, on how their biological evolution fueled our prosperity as a species, spurred science and medicine, religion and art. “When I look back on Descartes’ Error, it was completely timid compared to what I’m saying now,” Damasio says. He knows his new book may rile believers in the brain as emperor of all. “I was entirely open with my ideas,” he says. “If people don’t like it, they don’t like it. They can criticize it, of course, which is fair, but I want to tell them, because it’s so interesting, this is why you have feelings.”
In this interview with Nautilus, Damasio, in high spirits, explains why feelings deserve a starring role in human culture, what the real problem with consciousness studies are, and why Shakespeare is the finest cognitive scientist of them all.

One thing I like about The Strange Order of Things is it counters the idea that we are just our brains.

Oh, that idea is absolutely wrong.

Not long ago I was watching a PBS series on the brain, in which host and neurologist David Eagleman, referring to our brain, declares, “What we feel, what matters to us, our beliefs and our hopes, everything we are happens in here.”

That’s not the whole story. Of course, we couldn’t have minds with all of their enormous complexity without nervous systems. That goes without saying. But minds are not the result of nervous systems alone. The statement you quote reminds me of Francis Crick, someone whom I admired immensely and was a great friend. Francis was quite opposed to my views on this issue. We would have huge discussions because he was the one who said that everything you are, your thoughts, your feelings, your mental this and that, are nothing but your neurons. This is a big mistake, in my view, because we are mentally and behaviorally far more than our neurons. We cannot have feelings arising from neurons alone. The nervous systems are in constant interaction and cooperation with the rest of the organism. The reason why nervous systems exist in the first place is to assist the rest of the organism. That fact is constantly missed.

The concept of “homeostasis” is critical in your new book. What is homeostasis?

It’s the fundamental property of life that governs everything that living cells do, whether they’re living cells alone, or living cells as part of a tissue or an organ, or a complex system such as ourselves. Most of the time, when people hear the word homeostasis, they think of balance, they think of equilibrium. That is incorrect because if we ever were in “equilibrium,” we would be dead. Thermodynamically, equilibrium means zero thermal differences and death. Equilibrium is the last thing that nature aims for.

The importance of feeling is that it makes you critically aware of what you are doing in moral terms.

What we must have is efficient functioning of a variety of components of an organism. We procure energy so that the organism can be perpetuated, but then we do something very important and almost always missed, which is hoard energy. We need to maintain positive energy balances, something that goes beyond what we need right now because that’s what ensures the future. What’s so beautiful about homeostasis is that it’s not just about sustaining life at the moment, but about having a sort of guarantee that it will continue into the future. Without those positive energy balances, we court death.

What’s a good example of homeostasis?

If you are at the edge of your energy reserves and you’re sick with the flu, you can easily tip over and die. That’s one of the reasons why there’s fat accumulation in our bodies. We need to maintain the possibility of meeting the extra needs that come from stress, in the broad sense of the term. I poetically describe this as a desire for permanence, but it’s not just poetic. I believe it’s reality.

You write homeostasis is maintained in complex creatures like us through a constant interplay of pleasure and pain. Are you giving a biological basis to Freud’s pleasure principle—life is governed by a drive for pleasure and avoidance of pain?

Yes, to a great extent. What’s so interesting is that for most of the existence of life on earth, all organisms have had this effective, automated machinery that operates for the purpose of maintenance and continuation of life. I like to call the organisms that only have that form of regulation, “living automata.” They can fight. They can cooperate. They can segregate. But there’s no evidence that they know that they’re doing so. There’s no evidence of anything we might call a mind. Obviously we have more than automatic regulation. We can control regulation in part, if we wish to. How did that come about?
Very late in the game of life there’s the appearance of nervous systems. Now you have the possibility of mapping the inside and outside world. When you map the inside world, guess what you get? You get feelings. Of necessity, the machinery of life is either in a state of reasonable efficiency or in a state of inefficiency, which is most often the case. Organisms with nervous systems can image these states. And when you start having imagery, you start having minds. Now you begin to have the possibility of responding in a way that you could call “knowledgeable.” That happens when organisms make images. A bad internal state would have been imaged as the first pains, the first malaises, the first sufferings. Now the organism has the possibility of knowingly avoiding whatever caused the pain or prefer a place or a thing or another animal that causes the opposite of that, which is well-being and pleasure.

Why would feelings have evolved?

Feelings triumphed in evolution because they were so helpful to the organisms that first had them. It’s important to understand that nervous systems serve the organism and not the other way around. We do not have brains controlling the entire operation. Brains adjust controls. They are the servants of a living organism. Brains triumphed because they provided something useful: coordination. Once organisms got to the point of being so complex that they had an endocrine system, immune system, circulation, and central metabolism, they needed a device to coordinate all that activity. They needed to have something that would simultaneously act on point A and point Z, across the entire organism, so that the parts would not be working at cross purposes. That’s what nervous systems first achieve: making things run smoothly.

Now, in the process of doing that, over millions of years, we have developed nervous systems that do plenty of other things that do not necessarily result in coordination of the organism’s interior, but happen to be very good at coordinating the internal world in relation to the outside world. This is what the higher reaches of our nervous system, namely the cerebral cortex, does. It gives us the possibilities of perceiving, of memorizing, of reasoning over the knowledge that we memorize, of manipulating all of that and even translating it into language. That is all very beautiful, and it is also homeostatic, in the sense that all of it is convenient to maintain life. It if were not, it would just have been discarded by evolution.

How does your thesis square with the hard problem of consciousness, how the physical tissue in our heads produces immaterial sensations?

Some philosophers of mind will say, “Well, we face this gigantic problem. How does consciousness emerge out of these nerve cells?” Well, it doesn’t. You’re not dealing with the brain alone. You have to think in terms of the whole organism. And you have to think in evolutionary terms.

The critical problem of consciousness is subjectivity. You need to have a “subject.” You can call it an I or a self. Not only are you aware right now that you are listening to my words, which are in the panorama of your consciousness, but you are aware of being alive, you realize that you’re there, you’re ticking. We are so distracted by what is going on around us that we forget sometimes that we are, A-R-E in capitals. But actually you are watching what you are, and so you need to have a mechanism in the brain that allows you to fabricate that part of the mind that is the watcher.
You do that with a number of devices that have to do, for example, with mapping the movements of your eyes, the position of your head, and the musculature of your body. This allows you to literally construct images of yourself making images. And you also have a layer of consciousness that is made by your perception of the outside world; and another layer that is made of appreciating the feelings that are being generated inside of you. Once you have this stack of processes, you have a fighting chance of creating consciousness.

Why do you object to comparing the brain to a computer?

In the early days of neuroscience, one of our mentors was Warren McCulloch. He was a gigantic figure of neuroscience, one of the originators of what is today computational neuroscience. When you go back to the ’40s and ’50s, you find this amazing discovery that neurons can be either active or inactive, in a way that can be described mathematically as zeroes and ones. Combine that with Alan Turing and you get this idea that the brain is like a computer and that it produces minds using that same simple method.

Religions have been one of the great causes of violence throughout history. But you can’t blame Christ for it.

That has been a very useful idea. And true enough, it explains a good part of the complex operations, that our brains produce such as language. Those operations require a lot of precision and are being carried out by cerebral cortex, with enormous detail, and probably in a basic computational mode. All the great successes of artificial intelligence used this idea and have been concerned with high-level reasoning. That is why A.I. has been so successful with games such as chess or Go. They use large memories and powerful reasoning.

Are you saying neural codes or algorithms don’t blend with living systems?

Well, they match very well with things that are high on the scale of the mental operations and behaviors, such as those we require for our conversation. But they don’t match well with the basic systems that organize life, that regulate, for example, the degree of mental energy and excitation or with how you emote and feel. The reason is that the operations of the nervous system responsible for such regulation relies less on synaptic signaling, the one that can be described in terms of zeroes and ones, and far more on non-synaptic messaging, which lends itself less to a rigid all or none operation.
Perhaps more importantly, computers are machines invented by us, made of durable materials. None of those materials has the vulnerability of the cells in our body, all of which are at risk of defective homeostasis, disease, and death. In fact, computers lack most of the characteristics that are key to a living system. A living system is maintained in operation, against all odds, thanks to a complicated mechanism that can fall apart as a result of minimal amounts of malfunction. We are extremely vulnerable creatures. People often forget that. Which is one of the reasons why our culture, or Western cultures in general, are a bit too calm and complacent about the threats to our lives. I think we are becoming less sensitive to the idea that life is what dictates what we should do or not do with ourselves and with others.

What is love for?

To protect, to cause flourishing, to give and receive pleasure, to procreate, to soothe. Endless great uses, as you can see.

How do emotions such as anger or sadness serve homeostasis?

At individual levels, both anger and sadness are protective. Anger lets your adversary know that you mean business and that there may be costs to attacking you. These days anger is an expression of sociopolitical conflicts. It is overused and has largely become ineffectual. Sadness is a prelude to mental hibernation. It lets you retreat and lick your wounds. It lets you plan a strategy of response to the cause of the wounds.

You say feelings spurred the creation of cultures. How so?

Before I started The Strange Order of Things, I was asking friends and colleagues how they thought cultures had begun. Invariably what people said was, “Oh, we’re so smart. We’re so intellectually powerful. We have all this reasoning ability. On top of it all, we have language—and there you are.” To which I say, “Fine, that’s true. How would you invent anything if you were stupid?” You would not. But the issue is to recognize the motive behind what you do. Why is it that you did it in the first place? Why did Moses come down from the mountain with Ten Commandments? Well, the Ten Commandments are representative of homeostasis because they tell you not to kill, not to steal, not to lie, not to do a lot of bad things. It sounds trivial but it’s not. We fail to think about motivation and so we do not factor it into the process of invention. We do not factor in the motives behind science or technology or governance or religion.

How does consciousness emerge out of nerve cells? Well, it doesn’t. You’re not dealing with the brain alone.

And there’s one more thing: The importance of feeling is that it makes you critically aware of what you are doing in moral terms. It forces you to look back and realize that what people were doing historically, at the outset, at the moment of invention of a cultural instrument or a cultural practice, was an attempt to reduce the amount of suffering and to maximize the amount of wellbeing not only for the inventor, but for the community around them. One person alone can invent a painting or a musical composition, but it is not meant for that person alone. And you do not invent a moral system or a government system alone or for yourself alone. It requires a society, a community.

The assertion that intellect is governed by feelings can sound New Age-y. It seems to undermine the powers of reason. How should we understand reason if it’s always motivated by subjective feelings?

Subjective simply means that it has a personal point of view, that it pertains to the self. It is compatible with “objective” facts and with truth. It is not about relativism. The fact that feelings motivate the use of knowledge and reason do not make the knowledge and the reason any less truthful or valid. Feelings are simply a call to action.

If humans formed societies and cultures to avoid suffering and pain, why do we have violence and wars?

Your question is very important. Take developments of political systems. On the face of it, when you look at Marxist ideas, you say, “This is obviously homeostatic.” What Marx and others were trying to do in the 19th century is confront and modify a social arrangement that was not equitable, that had some people suffering too much and some profiting too much. So having a system that produced equality made a lot of sense. In a way that is something that biological systems have been trying to do, quite naturally, for a long time. And when the natural systems do not succeed at improved regulation, guess what? They are weeded out by evolution because they promote illness.
Biological evolution, through genetic selection, eliminates those mechanisms. At the cultural level something comparable occurs. Seen in retrospect, Marxism as applied in Russia resulted in one of the worst tragedies of humankind. But Russian communism was ultimately weeded out by cultural selection. It took around 70 years to do it, but cultural selection did operate in a homeostatic way. It led to the fall of the Berlin Wall and the Soviet empire. It was a homeostatic correction achieved by social means.
The same reasoning applies to religions. For example, we can claim that religions have been one of the great causes of violence throughout history. But you certainly can’t blame Christ for that violence. He preached compassion, and the pardoning of enemies, and love. It does not follow that good recommendations can be implemented correctly and always produce good results. These facts in no way deny the homeostatic intent of religions.

You write, “The increasing knowledge of biology from molecules to systems reinforces the humanist project.” How so?

This knowledge gives us a broader picture of who we are and where we are in the history of life on earth. We had modest beginnings, and we have incorporated an incredible amount of living wisdom that comes from as far down as bacteria. There are characteristics of our personal and cultural behavior that can be found in single-cell organisms or in social insects. They clearly do not have the kind of highly developed brains that we have. In some cases, they don’t have any brain at all. But by analyzing this strange order of developments we are confronted with the spectacle of life processes that are complex and rich in spite of their apparent modesty, so complex and rich that they can deliver the high level of behaviors that we normally, quite pretentiously, attribute only to our great human smarts. We should be far more humble. That’s one of my main messages. In general, connecting cultures to the life process makes apparent a link that we have ignored for far too long.


What would you be if you weren’t a scientist?

When I was an adolescent, I often thought that I might become a philosopher or perhaps a playwright or filmmaker. That’s because I so admired what philosophers and storytellers had found about the human mind. Today when people ask me, “Who’s your most admired cognitive scientist?” I say Shakespeare. He knew it all and knew it with enormous precision. He didn’t have the nice fMRI scanner and electrophysiology techniques we have in our Institute. But he knew human beings. Watch a good performance of Hamlet, King Lear, or Othello. All of our psychology is there, richly analyzed, ready for us to experience and appreciate.

Tribute to Global Progress

Debbie Downers: attention!

The point of this post: global progress on the fronts that really count has been amazing.

There are many sources. But my favorite is Nick Kristof’s column “Why 2017 Was the Best Year in Human History”. The column was the most emailed column of the week. I now see why. It is reprinted below.

“The most important thing happening right now is not a Trump tweet, but children’s lives saved and major gains in health, education and human welfare.”

Let me step back for a minute.

Fareed Zacharia, in his 2008 book The Post-American World, first raised my awareness about global progress. He began to get my head screwed on correctly.

Don’t get me wrong. I have lived in this fishbowl of global progress my entire life. I have been keenly aware of its major events, such as:

The Industrial Revolution
The Triumph of Democracy
The victories of WWI and WWII
The fall of the Berln Wall
The rise of global institutions, e.g. the UN, the WTO, the WHO, the World Bank
The rise of the computing revolution
The rise of the internet
The advent of iPhones
The conquest of infectious disease

But Fareed’s take on world events was spectacular in its optimism. He reminded readers that wars can be massive or small, like skirmishes; that peace can be the norm or war can be the norm; that human suffering can be widespread or isolated; and, most of all, he pointed out that the last fifty years have been, on the whole, spectacularly peaceful, wealth-creating, and welbeing-creating.

I am just like everyone else, though. I need a reminder.

The reminder came to me in Nick Kristof’s column this Sunday.

My favorites:

As recently as the 1960s, a majority of humans:

were illiterate. Now fewer than 15 percent are illiterate;
lived in extreme poverty. Now fewer than 10 percent do.

“In another 15 years, illiteracy and extreme poverty will be mostly gone. After thousands of generations, they are pretty much disappearing on our watch.”

“Just since 1990, the lives of more than 100 million children have been saved by vaccinations, diarrhea treatment, breast-feeding promotion and other simple steps.”

The writing is below, and the data supporting the writing is attached.

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CREDIT: https://ourworldindata.org

CREDIT: https://ourworldindata.org/happiness-and-life-satisfaction/

CREDIT: https://www.nytimes.com/2018/01/06/opinion/sunday/2017-progress-illiteracy-poverty.html?smid=nytcore-ipad-share&smprod=nytcore-ipad

Why 2017 Was the Best Year in Human History

We all know that the world is going to hell. Given the rising risk of nuclear war with North Korea, the paralysis in Congress, warfare in Yemen and Syria, atrocities in Myanmar and a president who may be going cuckoo, you might think 2017 was the worst year ever.

But you’d be wrong. In fact, 2017 was probably the very best year in the long history of humanity.

A smaller share of the world’s people were hungry, impoverished or illiterate than at any time before. A smaller proportion of children died than ever before. The proportion disfigured by leprosy, blinded by diseases like trachoma or suffering from other ailments also fell.

We need some perspective as we watch the circus in Washington, hands over our mouths in horror. We journalists focus on bad news — we cover planes that crash, not those that take off — but the backdrop of global progress may be the most important development in our lifetime.

Every day, the number of people around the world living in extreme poverty (less than about $2 a day) goes down by 217,000, according to calculations by Max Roser, an Oxford University economist who runs a website called Our World in Data. Every day, 325,000 more people gain access to electricity. And 300,000 more gain access to clean drinking water.

Readers often assume that because I cover war, poverty and human rights abuses, I must be gloomy, an Eeyore with a pen. But I’m actually upbeat, because I’ve witnessed transformational change.

As recently as the 1960s, a majority of humans had always been illiterate and lived in extreme poverty. Now fewer than 15 percent are illiterate, and fewer than 10 percent live in extreme poverty. In another 15 years, illiteracy and extreme poverty will be mostly gone. After thousands of generations, they are pretty much disappearing on our watch.

Just since 1990, the lives of more than 100 million children have been saved by vaccinations, diarrhea treatment, breast-feeding promotion and other simple steps.

Steven Pinker, the Harvard psychology professor, explores the gains in a terrific book due out next month, “Enlightenment Now,” in which he recounts the progress across a broad array of metrics, from health to wars, the environment to happiness, equal rights to quality of life. “Intellectuals hate progress,” he writes, referring to the reluctance to acknowledge gains, and I know it feels uncomfortable to highlight progress at a time of global threats. But this pessimism is counterproductive and simply empowers the forces of backwardness.

President Trump rode this gloom to the White House. The idea “Make America Great Again” professes a nostalgia for a lost Eden. But really? If that was, say, the 1950s, the U.S. also had segregation, polio and bans on interracial marriage, gay sex and birth control. Most of the world lived under dictatorships, two-thirds of parents had a child die before age 5, and it was a time of nuclear standoffs, of pea soup smog, of frequent wars, of stifling limits on women and of the worst famine in history.

What moment in history would you prefer to live in?
F. Scott Fitzgerald said the test of a first-rate intelligence is the ability to hold two contradictory thoughts at the same time. I suggest these: The world is registering important progress, but it also faces mortal threats. The first belief should empower us to act on the second.

Granted, this column may feel weird to you. Those of us in the columny gig are always bemoaning this or that, and now I’m saying that life is great? That’s because most of the time, quite rightly, we focus on things going wrong. But it’s also important to step back periodically. Professor Roser notes that there was never a headline saying, “The Industrial Revolution Is Happening,” even though that was the most important news of the last 250 years.

I had a visit the other day from Sultana, a young Afghan woman from the Taliban heartland. She had been forced to drop out of elementary school. But her home had internet, so she taught herself English, then algebra and calculus with the help of the Khan Academy, Coursera and EdX websites. Without leaving her house, she moved on to physics and string theory, wrestled with Kant and read The New York Times on the side, and began emailing a distinguished American astrophysicist, Lawrence M. Krauss.

I wrote about Sultana in 2016, and with the help of Professor Krauss and my readers, she is now studying at Arizona State University, taking graduate classes. She’s a reminder of the aphorism that talent is universal, but opportunity is not. The meaning of global progress is that such talent increasingly can flourish.

So, sure, the world is a dangerous mess; I worry in particular about the risk of a war with North Korea. But I also believe in stepping back once a year or so to take note of genuine progress — just as, a year ago, I wrote that 2016 had been the best year in the history of the world, and a year from now I hope to offer similar good news about 2018. The most important thing happening right now is not a Trump tweet, but children’s lives saved and major gains in health, education and human welfare.

Every other day this year, I promise to tear my hair and weep and scream in outrage at all the things going wrong. But today, let’s not miss what’s going right.

A version of this op-ed appears in print on January 7, 2018, on Page SR9 of the New York edition with the headline: Why 2017 Was the Best Year in History

Fiber’s Role in Diet

In this post, I discuss the role of the microbiome and the role of fiber in supporting a healthy microbiome. A healthy microbiome is related to the amount and diversity of the bacteria found within it.

If I had to summarize, I would say this: new research strongly confirms that high fiber diets are healthy diets. Because of this finding, eat 20-200 grams of fiber daily, by eating nuts, berries, whole grains, beans and vegetables.

The Role of the Microbiome
Bacteria in the gut – the “microbiome” – has been the subject of intense research interest over the last decade.

We now know that a healthy microbiome is essential to health and wellbeing.

On a scientific level, we now know that a healthy biome is one with billions of bacteria, of many kinds.

And specifically, we now know that a healthy biome has a layer of mucus along the walls of the intestine.

“The gut is coated with a layer of mucus, atop which sits a carpet of hundreds of species of bacteria, part of the human microbiome.”

If that mucus layer is thick, it is healthy. If it is thin, it is unhealthy (thin mucus layers have been linked to chronic inflammation). (“Their intestines got smaller, and its mucus layer thinner. As a result, bacteria wound up much closer to the intestinal wall, and that encroachment triggered an immune reaction.”)

The Role of Fiber in Supporting a Healthy Microbiome
“Fiber” refers to ruffage from fruits, vegetables, and beans that is hard to digest. If fiber is hard to digest, why are they so universally hailed as “good for you”?

That’s the subject of two newly-reported experiments.

The answer seems to lie in bacteria in the gut – the “microbiome”. Much has been written about their beneficial role in the body. But now it seems that some bacteria in the gut have an additional role: they digest fiber that human enzymes cannot digest.

So some bacteria thrive in the gut because of the fiber they eat. And, in an important natural chain, apparently there are some bacteria in the gut that that thrive because the waste of the bacteria that eats fiber. An ecosystem of bacteria tracing to fiber!

This speaks to one of the most-discussed subjects in science today: how and why is one microbiome populated with relatively few bacteria numbers and types, and why is another microbiome much more diverse – with many more bacteria and bacteria types?

One study, shown below, reports from Tanzania, after reviewing data from tribes that sustain themselves on high fiber foods. The results, reported in Science, clearly show that an ultra-high fiber diet results in ultra high bacteria counts and diversity.

Other findings suggest that fiber is the food of many bacteria types. Because of this, a diverse, healthy bacterial microbiome is dependent on a fiber-rich diet. (“On a low-fiber diet, they found, the population crashed, shrinking tenfold.”)

Indeed, it may well be true that many types of fibers support many types of bacteria.

Proof of this?

Researchers, including Dr. Gerwitz at Georgia State proved that more fiber seems to be better:

Bad: high, fat, low fiber (“On a low-fiber diet, they found, the population crashed, shrinking tenfold.” “Many common species became rare, and rare species became common.“)

Good: modest fiber
Better: high dose fiber (“Despite a high-fat diet, the mice had healthy populations of bacteria in their guts, their intestines were closer to normal, and they put on less weight.”)

Best: high dose of fiber-feeding bacteria
(“Once bacteria are done harvesting the energy in dietary fiber, they cast off the fragments as waste. That waste — in the form of short-chain fatty acids — is absorbed by intestinal cells, which use it as fuel.”

(“Research suggests that when bacteria break down dietary fiber down into short-chain fatty acids, some of them pass into the bloodstream and travel to other organs, where they act as signals to quiet down the immune system.”)

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This article documents rich-in-fiber foods:

CREDIT: http://www.todaysdietitian.com/newarchives/063008p28.shtml

In recognition of fiber’s benefits, Today’s Dietitian looks at some of the best ways to boost fiber intake,from whole to fortified foods,using data from the USDA National Nutrient Database for Standard Reference.

Top Fiber-Rich Foods
1. Get on the Bran Wagon (Oat bran, All-bran cereal, fiber-one chewy bars, etc)
One simple way to increase fiber intake is to power up on bran. Bran from many grains is very rich in dietary fiber. Oat bran is high in soluble fiber, which has been shown to lower blood cholesterol levels. Wheat, corn, and rice bran are high in insoluble fiber, which helps prevent constipation. Bran can be sprinkled into your favorite foods,from hot cereal and pancakes to muffins and cookies. Many popular high-fiber cereals and bars are also packed with bran.

2. Take a Trip to Bean Town (Limas, Pintos, Lentils, etc)
Beans really are the magical fruit. They are one of the most naturally rich sources of fiber, as well as protein, lysine, vitamins, and minerals, in the plant kingdom. It’s no wonder so many indigenous diets include a bean or two in the mix. Some people experience intestinal gas and discomfort associated with bean intake, so they may be better off slowly introducing beans into their diet. Encourage a variety of beans as an animal protein replacement in stews, side dishes, salads, soups, casseroles, and dips.

3. Go Berry Picking (especially blackberries and raspberries)
Jewel-like berries are in the spotlight due to their antioxidant power, but let’s not forget about their fiber bonus. Berries happen to yield one of the best fiber-per-calorie bargains on the planet. Since berries are packed with tiny seeds, their fiber content is typically higher than that of many fruits. Clients can enjoy berries year-round by making the most of local berries in the summer and eating frozen, preserved, and dried berries during the other seasons. Berries make great toppings for breakfast cereal, yogurt, salads, and desserts.

4. Wholesome Whole Grains (especially barley, oats, brown rice, rye wafers)
One of the easiest ways to up fiber intake is to focus on whole grains. A grain in nature is essentially the entire seed of the plant made up of the bran, germ, and endosperm. Refining the grain removes the germ and the bran; thus, fiber, protein, and other key nutrients are lost. The Whole Grains Council recognizes a variety of grains and defines whole grains or foods made from them as containing “all the essential parts and naturally-occurring nutrients of the entire grain seed. If the grain has been processed, the food product should deliver approximately the same rich balance of nutrients that are found in the original grain seed.â€‌ Have clients choose different whole grains as features in side dishes, pilafs, salads, breads, crackers, snacks, and desserts.

5. Sweet Peas (especially frozen green peas, black eyed peas)
Peas,from fresh green peas to dried peas,are naturally chock full of fiber. In fact, food technologists have been studying pea fiber as a functional food ingredient. Clients can make the most of peas by using fresh or frozen green peas and dried peas in soups, stews, side dishes, casseroles, salads, and dips.

6. Green, the Color of Fiber (Spinach, etc)
Deep green, leafy vegetables are notoriously rich in beta-carotene, vitamins, and minerals, but their fiber content isn’t too shabby either. There are more than 1,000 species of plants with edible leaves, many with similar nutritional attributes, including high-fiber content. While many leafy greens are fabulous tossed in salads, saut ©ing them in olive oil, garlic, lemon, and herbs brings out a rich flavor.

7. Squirrel Away Nuts and Seeds (especially flaxseed and sesame seed)
Go nuts to pack a fiber punch. One ounce of nuts and seeds can provide a hearty contribution to the day’s fiber recommendation, along with a bonus of healthy fats, protein, and phytochemicals. Sprinkling a handful of nuts or seeds over breakfast cereals, yogurt, salads, and desserts is a tasty way to do fiber.

8. Play Squash (especially acorn squash)
Dishing up squash,from summer to winter squash,all year is another way that clients can ratchet up their fiber intake. These nutritious gems are part of the gourd family and contribute a variety of flavors, textures, and colors, as well as fiber, vitamins, minerals, and carotenoids, to the dinner plate. Squash can be turned into soups, stews, side dishes, casseroles, salads, and crudit ©s. Brush squash with olive oil and grill it in the summertime for a healthy, flavorful accompaniment to grilled meats.

9. Brassica or Bust (broccoli, cauliflower, kale, cabbage, and Brussels sprouts)
Brassica vegetables have been studied for their cancer-protective effects associated with high levels of glucosinolates. But these brassy beauties, including broccoli, cauliflower, kale, cabbage, and Brussels sprouts, are also full of fiber. They can be enjoyed in stir-fries, casseroles, soups, and salads and steamed as a side dish.

10. Hot Potatoes
The humble spud, the top vegetable crop in the world, is plump with fiber. Since potatoes are so popular in America, they’re an easy way to help pump up people’s fiber potential. Why stop at Russets? There are numerous potatoes that can provide a rainbow of colors, nutrients, and flavors, and remind clients to eat the skins to reap the greatest fiber rewards. Try adding cooked potatoes with skins to salads, stews, soups, side dishes, stir-fries, and casseroles or simply enjoy baked potatoes more often.

11. Everyday Fruit Basket (especially pears and oranges)
Look no further than everyday fruits to realize your full fiber potential. Many are naturally packed with fiber, as well as other important vitamins and minerals. Maybe the doctor was right when he advised an apple a day, but he could have added pears, oranges, and bananas to the prescription as well. When between fruit seasons, clients can rely on dried fruits to further fortify their diet. Encourage including fruit at breakfast each morning instead of juice; mixing dried fruits into cereals, yogurts, and salads; and reaching for the fruit bowl at snack time. It’s a healthy habit all the way around.

12. Exotic Destinations (especially avocado)
Some of the plants with the highest fiber content in the world may be slightly out of your clients’ comfort zone and, for that matter, time zone. A rainbow of indigenous fruits and vegetables used in cultural food traditions around the globe are very high in fiber. Entice clients to introduce a few new plant foods into their diets to push up the flavor, as well as their fiber, quotient.

13. Fiber Fortification Power
More foods,from juice to yogurt,are including fiber fortification in their ingredient lineup. Such foods may help busy people achieve their fiber goals. As consumer interest in foods with functional benefits, such as digestive health and cardiovascular protection, continues to grow, expect to see an even greater supply of food products promoting fiber content on supermarket shelves.

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This article documents the newly-reported experiments:

CREDIT: NYT Article on Fiber Science

Fiber is Good for You. Now we Know Why

By Carl Zimmer
Jan. 1, 2018
A diet of fiber-rich foods, such as fruits and vegetables, reduces the risk of developing diabetes, heart disease and arthritis. Indeed, the evidence for fiber’s benefits extends beyond any particular ailment: Eating more fiber seems to lower people’s mortality rate, whatever the cause.

That’s why experts are always saying how good dietary fiber is for us. But while the benefits are clear, it’s not so clear why fiber is so great. “It’s an easy question to ask and a hard one to really answer,” said Fredrik Bäckhed, a biologist at the University of Gothenburg in Sweden.

He and other scientists are running experiments that are yielding some important new clues about fiber’s role in human health. Their research indicates that fiber doesn’t deliver many of its benefits directly to our bodies.

Instead, the fiber we eat feeds billions of bacteria in our guts. Keeping them happy means our intestines and immune systems remain in good working order.

In order to digest food, we need to bathe it in enzymes that break down its molecules. Those molecular fragments then pass through the gut wall and are absorbed in our intestines.
But our bodies make a limited range of enzymes, so that we cannot break down many of the tough compounds in plants. The term “dietary fiber” refers to those indigestible molecules.

But they are indigestible only to us. The gut is coated with a layer of mucus, atop which sits a carpet of hundreds of species of bacteria, part of the human microbiome. Some of these microbes carry the enzymes needed to break down various kinds of dietary fiber.

The ability of these bacteria to survive on fiber we can’t digest ourselves has led many experts to wonder if the microbes are somehow involved in the benefits of the fruits-and-vegetables diet. Two detailed studies published recently in the journal Cell Host and Microbe provide compelling evidence that the answer is yes.

In one experiment, Andrew T. Gewirtz of Georgia State University and his colleagues put mice on a low-fiber, high-fat diet. By examining fragments of bacterial DNA in the animals’ feces, the scientists were able to estimate the size of the gut bacterial population in each mouse.

On a low-fiber diet, they found, the population crashed, shrinking tenfold.

Dr. Bäckhed and his colleagues carried out a similar experiment, surveying the microbiome in mice as they were switched from fiber-rich food to a low-fiber diet. “It’s basically what you’d get at McDonald’s,” said Dr. Bäckhed said. “A lot of lard, a lot of sugar, and twenty percent protein.”

The scientists focused on the diversity of species that make up the mouse’s gut microbiome. Shifting the animals to a low-fiber diet had a dramatic effect, they found: Many common species became rare, and rare species became common.

Along with changes to the microbiome, both teams also observed rapid changes to the mice themselves. Their intestines got smaller, and its mucus layer thinner. As a result, bacteria wound up much closer to the intestinal wall, and that encroachment triggered an immune reaction.

After a few days on the low-fiber diet, mouse intestines developed chronic inflammation. After a few weeks, Dr. Gewirtz’s team observed that the mice began to change in other ways, putting on fat, for example, and developing higher blood sugar levels.

Dr. Bäckhed and his colleagues also fed another group of rodents the high-fat menu, along with a modest dose of a type of fiber called inulin. The mucus layer in their guts was healthier than in mice that didn’t get fiber, the scientists found, and intestinal bacteria were kept at a safer distance from their intestinal wall.

Dr. Gewirtz and his colleagues gave inulin to their mice as well, but at a much higher dose. The improvements were even more dramatic: Despite a high-fat diet, the mice had healthy populations of bacteria in their guts, their intestines were closer to normal, and they put on less weight.

Dr. Bäckhed and his colleagues ran one more interesting experiment: They spiked water given to mice on a high-fat diet with a species of fiber-feeding bacteria. The addition changed the mice for the better: Even on a high-fat diet, they produced more mucus in their guts, creating a healthy barrier to keep bacteria from the intestinal walls.

One way that fiber benefits health is by giving us, indirectly, another source of food, Dr. Gewirtz said. Once bacteria are done harvesting the energy in dietary fiber, they cast off the fragments as waste. That waste — in the form of short-chain fatty acids — is absorbed by intestinal cells, which use it as fuel.

But the gut’s microbes do more than just make energy. They also send messages. Intestinal cells rely on chemical signals from the bacteria to work properly, Dr. Gewirtz said. The cells respond to the signals by multiplying and making a healthy supply of mucus. They also release bacteria-killing molecules.
By generating these responses, gut bacteria help maintain a peaceful coexistence with the immune system. They rest atop the gut’s mucus layer at a safe distance from the intestinal wall. Any bacteria that wind up too close get wiped out by antimicrobial poisons.

While some species of gut bacteria feed directly on dietary fiber, they probably support other species that feed on their waste. A number of species in this ecosystem — all of it built on fiber — may be talking to our guts.

Going on a low-fiber diet disturbs this peaceful relationship, the new studies suggest. The species that depend on dietary fiber starve, as do the other species that depend on them. Some species may switch to feeding on the host’s own mucus.

With less fuel, intestinal cells grow more slowly. And without a steady stream of chemical signals from bacteria, the cells slow their production of mucus and bacteria-killing poisons.
As a result, bacteria edge closer to the intestinal wall, and the immune system kicks into high gear.

“The gut is always precariously balanced between trying to contain these organisms and not to overreact,” said Eric C. Martens, a microbiologist at the University of Michigan who was not involved in the new studies. “It could be a tipping point between health and disease.”

Inflammation can help fight infections, but if it becomes chronic, it can harm our bodies. Among other things, chronic inflammation may interfere with how the body uses the calories in food, storing more of it as fat rather than burning it for energy.

Justin L. Sonnenburg, a biologist at Stanford University who was not involved in the new studies, said that a low-fiber diet can cause low-level inflammation not only in the gut, but throughout the body.

His research suggests that when bacteria break down dietary fiber down into short-chain fatty acids, some of them pass into the bloodstream and travel to other organs, where they act as signals to quiet down the immune system.

“You can modulate what’s happening in your lung based on what you’re feeding your microbiome in your gut,” Dr. Sonnenburg said.
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Hannah D. Holscher, a nutrition scientist at the University of Illinois who was not involved in the new studies, said that the results on mice need to be put to the test in humans. But it’s much harder to run such studies on people.

In her own lab, Dr. Holscher acts as a round-the-clock personal chef. She and her colleagues provide volunteers with all their meals for two weeks. She can then give some of her volunteers an extra source of fiber — such as walnuts — and look for changes in both their microbiome and their levels of inflammation.

Dr. Holscher and other researchers hope that they will learn enough about how fiber influences the microbiome to use it as a way to treat disorders. Lowering inflammation with fiber may also help in the treatment of immune disorders such as inflammatory bowel disease.

Fiber may also help reverse obesity. Last month in the American Journal of Clinical Nutrition, Dr. Holscher and her colleagues reviewed a number of trials in which fiber was used to treat obesity. They found that fiber supplements helped obese people to lose about five pounds, on average.
But for those who want to stay healthy, simply adding one kind of fiber to a typical Western diet won’t be a panacea. Giving mice inulin in the new studies only partly restored them to health.

That’s probably because we depend on a number of different kinds of dietary fiber we get from plants. It’s possible that each type of fiber feeds a particular set of bacteria, which send their own important signals to our bodies.

“It points to the boring thing that we all know but no one does,” Dr. Bäckhed said. “If you eat more green veggies and less fries and sweets, you’ll probably be better off in the long term.”

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CREDIT: https://www.npr.org/sections/goatsandsoda/2017/08/24/545631521/is-the-secret-to-a-healthier-microbiome-hidden-in-the-hadza-diet

Is The Secret To A Healthier Microbiome Hidden In The Hadza Diet?

August 24, 20176:11 PM ET
Heard on All Things Considered

MICHAELEEN DOUCLEFF
Twitter

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The words “endangered species” often conjure up images of big exotic creatures. Think elephants, leopards and polar bears.

But there’s another of type of extinction that may be occurring, right now, inside our bodies.

Yes, I’m talking about the microbiome — that collection of bacteria in our intestines that influences everything from metabolism and the immune system to moods and behavior.

For the past few years, scientists around the world have been accumulating evidence that the Western lifestyle is altering our microbiome. Some species of bacteria are even disappearing to undetectable levels.

“Over time we are losing valuable members of our community,” says Justin Sonnenburg, a microbiologist at Stanford University, who has been studying the microbiome for more than a decade.

Now Sonnenburg and his team have evidence for why this microbial die-off is happening — and hints about what we can possibly do to reverse it.

The study, published Thursday in the journal Science, focuses on a group of hunter-gatherers in Tanzania, called Hadza.
Their diet consists almost entirely of food they find in the forest, including wild berries, fiber-rich tubers, honey and wild meat. They basically eat no processed food — or even food that comes from farms.
“They are a very special group of people,” Sonnenburg says. “There are only about 2,200 left and really only about 200 that exclusively adhere to hunting and gathering.”

Sonnenberg and his colleagues analyzed 350 stool samples from Hadza people taken over the course of about a year. They then compared the bacteria found in Hadza with those found in 17 other cultures around the world, including other hunter-gatherer communities in Venezuela and Peru and subsistence farmers in Malawi and Cameroon.

The trend was clear: The further away people’s diets are from a Western diet, the greater the variety of microbes they tend to have in their guts. And that includes bacteria that are missing from American guts.

“So whether it’s people in Africa, Papua New Guinea or South America, communities that live a traditional lifestyle have common gut microbes — ones that we all lack in the industrialized world,” Sonnenburg says.

In a way, the Western diet — low in fiber and high in refined sugars — is basically wiping out species of bacteria from our intestines.

That’s the conclusion Sonnenburg and his team reached after analyzing the Hadza microbiome at one stage of the yearlong study. But when they checked several months later, they uncovered a surprising twist: The composition of the microbiome fluctuated over time, depending on the season and what people were eating. And at one point, the composition started to look surprisingly similar to that of Westerners’ microbiome.

During the dry season, Hadza eat a lot of more meat — kind of like Westerners do. And their microbiome shifted as their diet changed. Some of the bacterial species that had been prevalent disappeared to undetectable levels, similar to what’s been observed in Westerners’ guts.

But then in wet season — when Hadza eat more berries and honey — these missing microbes returned, although the researchers are not really sure what’s in these foods that bring the microbes back.

“I think this finding is really exciting,” says Lawrence David, who studies the microbiome at Duke University. “It suggests the shifts in the microbiome seen in industrialized nations might not be permanent — that they might be reversible by changes in people’s diets.

“The finding supports the idea that the microbiome is plastic, depending on diet,” David adds.

Now the big question is: What’s the key dietary change that could bring the missing microbes back?

Lawrence thinks it could be cutting down on fat. “At a high level, it sounds like that,” he says, “because what changed in the Hadza’s diet was whether or not they were hunting versus foraging for berries or honey,” he says.

But Sonnenburg is placing his bets on another dietary component: fiber — which is a vital food for the microbiome.
“We’re beginning to realize that people who eat more dietary fiber are actually feeding their gut microbiome,”
Sonnenburg says.

Hadza consume a huge amount of fiber because throughout the year, they eat fiber-rich tubers and fruit from baobab trees. These staples give them about 100 to 150 grams of fiber each day. That’s equivalent to the fiber in 50 bowls of Cheerios — and 10 times more than many Americans eat.

“Over the past few years, we’ve come to realize how important this gut community is for our health, and yet we’re eating a low-fiber diet that totally neglects them,” he says. “So we’re essentially starving our microbial selves.”

The Dying Algorithm

CREDIT: NYT Article on the Dying Algorithm

This Cat Sensed Death. What if Computers Could, Too
By Siddhartha Mukherjee
Jan. 3, 2018

Of the many small humiliations heaped on a young oncologist in his final year of fellowship, perhaps this one carried the oddest bite: A 2-year-old black-and-white cat named Oscar was apparently better than most doctors at predicting when a terminally ill patient was about to die. The story appeared, astonishingly, in The New England Journal of Medicine in the summer of 2007. Adopted as a kitten by the medical staff, Oscar reigned over one floor of the Steere House nursing home in Rhode Island. When the cat would sniff the air, crane his neck and curl up next to a man or woman, it was a sure sign of impending demise. The doctors would call the families to come in for their last visit. Over the course of several years, the cat had curled up next to 50 patients. Every one of them died shortly thereafter.
No one knows how the cat acquired his formidable death-sniffing skills. Perhaps Oscar’s nose learned to detect some unique whiff of death — chemicals released by dying cells, say. Perhaps there were other inscrutable signs. I didn’t quite believe it at first, but Oscar’s acumen was corroborated by other physicians who witnessed the prophetic cat in action. As the author of the article wrote: “No one dies on the third floor unless Oscar pays a visit and stays awhile.”
The story carried a particular resonance for me that summer, for I had been treating S., a 32-year-old plumber with esophageal cancer. He had responded well to chemotherapy and radiation, and we had surgically resected his esophagus, leaving no detectable trace of malignancy in his body. One afternoon, a few weeks after his treatment had been completed, I cautiously broached the topic of end-of-life care. We were going for a cure, of course, I told S., but there was always the small possibility of a relapse. He had a young wife and two children, and a mother who had brought him weekly to the chemo suite. Perhaps, I suggested, he might have a frank conversation with his family about his goals?

But S. demurred. He was regaining strength week by week. The conversation was bound to be “a bummah,” as he put it in his distinct Boston accent. His spirits were up. The cancer was out. Why rain on his celebration? I agreed reluctantly; it was unlikely that the cancer would return.

When the relapse appeared, it was a full-on deluge. Two months after he left the hospital, S. returned to see me with sprays of metastasis in his liver, his lungs and, unusually, in his bones. The pain from these lesions was so terrifying that only the highest doses of painkilling drugs would treat it, and S. spent the last weeks of his life in a state bordering on coma, unable to register the presence of his family around his bed. His mother pleaded with me at first to give him more chemo, then accused me of misleading the family about S.’s prognosis. I held my tongue in shame: Doctors, I knew, have an abysmal track record of predicting which of our patients are going to die. Death is our ultimate black box.

In a survey led by researchers at University College London of over 12,000 prognoses of the life span of terminally ill patients, the hits and misses were wide-ranging. Some doctors predicted deaths accurately. Others underestimated death by nearly three months; yet others overestimated it by an equal magnitude. Even within oncology, there were subcultures of the worst offenders: In one story, likely apocryphal, a leukemia doctor was found instilling chemotherapy into the veins of a man whose I.C.U. monitor said that his heart had long since stopped.

But what if an algorithm could predict death? In late 2016 a graduate student named Anand Avati at Stanford’s computer-science department, along with a small team from the medical school, tried to “teach” an algorithm to identify patients who were very likely to die within a defined time window. “The palliative-care team at the hospital had a challenge,” Avati told me. “How could we find patients who are within three to 12 months of dying?” This window was “the sweet spot of palliative care.” A lead time longer than 12 months can strain limited resources unnecessarily, providing too much, too soon; in contrast, if death came less than three months after the prediction, there would be no real preparatory time for dying — too little, too late. Identifying patients in the narrow, optimal time period, Avati knew, would allow doctors to use medical interventions more appropriately and more humanely. And if the algorithm worked, palliative-care teams would be relieved from having to manually scour charts, hunting for those most likely to benefit.

Avati and his team identified about 200,000 patients who could be studied. The patients had all sorts of illnesses — cancer, neurological diseases, heart and kidney failure. The team’s key insight was to use the hospital’s medical records as a proxy time machine. Say a man died in January 2017. What if you scrolled time back to the “sweet spot of palliative care” — the window between January and October 2016 when care would have been most effective? But to find that spot for a given patient, Avati knew, you’d presumably need to collect and analyze medical information before that window. Could you gather information about this man during this prewindow period that would enable a doctor to predict a demise in that three-to-12-month section of time? And what kinds of inputs might teach such an algorithm to make predictions?
Avati drew on medical information that had already been coded by doctors in the hospital: a patient’s diagnosis, the number of scans ordered, the number of days spent in the hospital, the kinds of procedures done, the medical prescriptions written. The information was admittedly limited — no questionnaires, no conversations, no sniffing of chemicals — but it was objective, and standardized across patients.

These inputs were fed into a so-called deep neural network — a kind of software architecture thus named because it’s thought to loosely mimic the way the brain’s neurons are organized. The task of the algorithm was to adjust the weights and strengths of each piece of information in order to generate a probability score that a given patient would die within three to 12 months.

The “dying algorithm,” as we might call it, digested and absorbed information from nearly 160,000 patients to train itself. Once it had ingested all the data, Avati’s team tested it on the remaining 40,000 patients. The algorithm performed surprisingly well. The false-alarm rate was low: Nine out of 10 patients predicted to die within three to 12 months did die within that window. And 95 percent of patients assigned low probabilities by the program survived longer than 12 months. (The data used by this algorithm can be vastly refined in the future. Lab values, scan results, a doctor’s note or a patient’s own assessment can be added to the mix, enhancing the predictive power.)

So what, exactly, did the algorithm “learn” about the process of dying? And what, in turn, can it teach oncologists? Here is the strange rub of such a deep learning system: It learns, but it cannot tell us why it has learned; it assigns probabilities, but it cannot easily express the reasoning behind the assignment. Like a child who learns to ride a bicycle by trial and error and, asked to articulate the rules that enable bicycle riding, simply shrugs her shoulders and sails away, the algorithm looks vacantly at us when we ask, “Why?” It is, like death, another black box.

Still, when you pry the box open to look at individual cases, you see expected and unexpected patterns. One man assigned a score of 0.946 died within a few months, as predicted. He had had bladder and prostate cancer, had undergone 21 scans, had been hospitalized for 60 days — all of which had been picked up by the algorithm as signs of impending death. But a surprising amount of weight was seemingly put on the fact that scans were made of his spine and that a catheter had been used in his spinal cord — features that I and my colleagues might not have recognized as predictors of dying (an M.R.I. of the spinal cord, I later realized, was most likely signaling cancer in the nervous system — a deadly site for metastasis).
It’s hard for me to read about the “dying algorithm” without thinking about my patient S. If a more sophisticated version of such an algorithm had been available, would I have used it in his case? Absolutely. Might that have enabled the end-of-life conversation S. never had with his family? Yes. But I cannot shake some inherent discomfort with the thought that an algorithm might understand patterns of mortality better than most humans. And why, I kept asking myself, would such a program seem so much more acceptable if it had come wrapped in a black-and-white fur box that, rather than emitting probabilistic outputs, curled up next to us with retracted claws?

Siddhartha Mukherjee is the author of “The Emperor of All Maladies: A Biography of Cancer” and, more recently, “The Gene: An Intimate History.”

Scourge of Opioids

CREDIT: https://www.nationalaffairs.com/publications/detail/taking-on-the-scourge-of-opioids

Taking On the Scourge of Opioids

Sally Satel

Summer 2017

On March 1, 2017, Maryland governor Larry Hogan declared a state of emergency. Heroin and fentanyl, a powerful synthetic opioid, had killed 1,468 Maryland residents in the first nine months of 2016, up 62% from the same period in 2015. Speaking at a command center of the Maryland Emergency Management Agency near Baltimore, the governor announced additional funding to strengthen law enforcement, prevention, and treatment services. “The reality is that this threat is rapidly escalating,” Hogan said.

And it is escalating across the country. Florida governor Rick Scott followed Hogan’s lead in May, declaring a public-health emergency after requests for help from local officials across the state. Arizona governor Doug Ducey did the same in June. In Ohio, some coroners have run out of space for the bodies of overdose victims and have to use a mobile, refrigerated morgue. In West Virginia, state burial funds have been exhausted burying overdose victims. Opioid orphans are lucky if their grandparents can raise them; if not, they are at the mercy of foster-care systems that are now overflowing with the children of addicted parents.

An estimated 2.5 million Americans abuse or are addicted to opioids — a class of highly addictive drugs that includes Percocet, Vicodin, OxyContin, and heroin. Most experts believe this is an undercount, and all agree that the casualty rate is unprecedented. At peak years in an earlier heroin epidemic, from 1973 to 1975, there were 1.5 fatalities per 100,000 Americans. In 2015, the rate was 10.4 per 100,000. In West Virginia, ground zero of the crisis, it was over 36 per 100,000. In raw numbers, more than 33,000 individuals died in 2015 — nearly equal to the number of deaths from car crashes and double the number of gun homicides. Meanwhile, the opioid-related fatalities continue to mount, having quadrupled since 1999.

The roots of the crisis can be traced to the early 1990s when physicians began to prescribe opioid painkillers more liberally. In parallel, overdose deaths from painkillers rose until about 2011. Since then, heroin and synthetic opioids have briskly driven opioid-overdose deaths; they now account for over two-thirds of victims. Synthetic opioids, such as fentanyl, are made mainly in China, shipped to Mexico, and trafficked here. Their menace cannot be overstated.

Fentanyl is 50 times as potent as heroin and can kill instantly. People have been found dead with needles dangling from their arms, the syringe barrels still partly full of fentanyl-containing liquid. One fentanyl analog, carfentanil, is a big-game tranquilizer that’s a staggering 5,000 times more powerful than heroin. This spring, “Gray Death,” a combination of heroin, fentanyl, carfentanil, and other synthetics, has pushed the bounds of lethal chemistry even further. The death rate from synthetics has increased by more than 72% over the space of a single year, from 2014 to 2015. They have transformed an already terrible problem into a true public-health emergency.

The nation has weathered drug epidemics before, but the current affliction — a new plague for a new century, in the words of Nicholas Eberstadt — is different. Today, the addicted are not inner-city minorities, though big cities are increasingly reporting problems. Instead, they are overwhelmingly white and rural, though middle- and upper-class individuals are also affected. The jarring visual of the crisis is not an urban “gang banger” but an overdosed mom slumped in the front seat of her car in a Walmart parking lot, toddler in the back.

It’s almost impossible to survey this devastating tableau and not wonder why the nation’s response has been so slow in coming. Jonathan Caulkins, a drug-policy expert at Carnegie Mellon, offers two theories. One is geography. The prescription-opioid wave crashed down earliest in fly-over states, particularly small cities and rural areas, such as West Virginia and Kentucky, without nationally important media markets. Earlier opioid (heroin) epidemics raged in urban centers, such as New York, Baltimore, Chicago, and Los Angeles.

The second of Caulkins’s plausible explanations is the absence of violence that roiled inner cities in the early 1970s, when President Richard Nixon called drug abuse “public enemy number one.” Dealers do not engage in shooting wars or other gang-related activity. As purveyors of heroin established themselves in the U.S., Mexican bosses deliberately avoided inner cities where heroin markets were dominated by violent gangs. Thanks to a “drive-through” business model perfected by traffickers and executed by discreet runners — farm boys from western Mexico looking to make quick money — heroin can be summoned via text message or cell phone and delivered, like pizza, to homes or handed off in car-to-car transactions. Sources of painkillers are low profile as well. Typically pills are obtained (or stolen) from friends or relatives, physicians, or dealers. The “dark web,” too, is a conduit for synthetics.

It’s hard to miss, too, that this time around, the drug crisis is viewed differently. Heroin users today are widely seen as suffering from an illness. And because that illness has a pale complexion, many have asked, “Where was the compassion for black people?” A racial element cannot be denied, but there are other forces at play, namely that Americans are drug-war weary and law enforcement has incarceration fatigue. It also didn’t help that, in the 1970s, officers were only loosely woven into the fabric of the inner-city minority neighborhoods that were hardest hit. Today, in the small towns where so much of the epidemic plays out, the crisis is personal. Police chiefs, officers, and local authorities will likely have at least one relative, friend, or neighbor with an opioid problem.

If there is reason for optimism in the midst of this crisis, it is that national and local politicians and even police are placing emphasis on treatment over punishment. And, without question, the nation needs considerably more funding for treatment; Congress must step up. Yet the much-touted promise of treatment — and particularly of anti-addiction medications — as a panacea has already been proven wrong. Perhaps “we can’t arrest our way out of the problem,” as officials like to say, but nor are we treating our way out of it. This is because many users reject treatment, and, if they accept it, too many drop out. Engaging drug users in treatment has turned out to be one of the biggest challenges of the epidemic — and one that needs serious attention.

The near-term forecast for this American Carnage, as journalist Christopher Caldwell calls it, is grim. What can be done?

ROOTS OF A CRISIS

In the early 1990s, campaigns for improved treatment of pain gained ground. Analgesia for pain associated with cancer and terminal illness was relatively well accepted, but doctors were leery of medicating chronic conditions, such as joint pain, back pain, and neurological conditions, lest patients become addicted. Then in 1995 the American Pain Society recommended that pain be assessed as the “fifth vital sign” along with the standard four (blood pressure, temperature, pulse, and respiratory rate). In 2001 the influential Joint Commission on Accreditation of Healthcare Organizations established standards for pain management. These standards did not mention opioids, per se, but were interpreted by many physicians as encouraging their use.

These developments had a gradual but dramatic effect on the culture of American medicine. Soon, clinicians were giving an entire month’s worth of Percocet or Lortab to patients with only minor injuries or post-surgical pain that required only a few days of opioid analgesia. Compounding the matter, pharmaceutical companies engaged in aggressive marketing to physicians.

The culture of medical practice contributed as well. Faced with draconian time pressures, a doctor who suspected that his patient was taking too many painkillers rarely had time to talk with him about it. Other time-consuming pain treatments, such as physical therapy or behavioral strategies, were, and remain, less likely to be covered by insurers. Abbreviated visits meant shortcuts, like a quick refill that may not have been warranted, while the need for addiction treatment was overlooked. In addition, clinicians were, and still are, held hostage to ubiquitous “patient-satisfaction surveys.” A poor grade mattered because Medicare and Medicaid rely on these assessments to help determine the amount of reimbursement for care. Clearly, too many incentives pushed toward prescribing painkillers, even when it went against a doctor’s better judgment.

The chief risk of liberal prescribing was not so much that the patient would become addicted — though it happens occasionally — but rather that excess medication fed the rivers of pills that were coursing through many neighborhoods. And as more painkillers began circulating, almost all of them prescribed by physicians, more opportunities arose for non-patients to obtain them, abuse them, and die. OxyContin formed a particularly notorious tributary. Available since 1996, this slow-release form of oxycodone was designed to last up to 12 hours (about six to eight hours longer than immediate-release preparations of oxycodone, such as Percocet). A sustained blood level was meant to be a therapeutic advantage for patients with unremitting pain. To achieve long action, each OxyContin tablet was loaded with a large amount of oxycodone.

Packing a large dose into a single pill presented a major unintended consequence. When it was crushed and snorted or dissolved in water and injected, OxyContin gave a clean, predictable, and enjoyable high. By 2000, reports of abuse of OxyContin began to surface in the Rust Belt — a region rife with injured coal miners who were readily prescribed OxyContin, or, as it came to be called, “hillbilly heroin.” Ohio along with Florida became the “pill mill” capitals of the nation. These mills were advertised as “pain clinics,” but were really cash-only businesses set up to sell painkillers in high volume. The mills employed shady physicians who were licensed to prescribe but knew they weren’t treating authentic patients.

Around 2010 to 2011, law enforcement began cracking down on pill mills. In 2010, OxyContin’s maker, Purdue Pharma, reformulated the pill to make it much harder to crush. In parallel, physicians began to re-examine their prescribing practices and to consider non-opioid options for chronic-pain management. More states created prescription registries so that pharmacists and doctors could detect patients who “doctor shopped” for painkillers and even forged prescriptions. (Today, all states except Missouri have such a registry.) Last year, the American Medical Association recommended that pain be removed as a “fifth vital sign” in professional medical standards.

Controlling the sources of prescription pills was completely rational. Sadly, however, it helped set the stage for a new dimension of the opioid epidemic: heroin and synthetic opioids. Heroin — cheaper and more abundant than painkillers — had flowed into the western U.S. since at least the 1990s, but trafficking east of the Mississippi and into the Rust Belt reportedly began to accelerate around the mid-2000s, a transformative episode in the history of domestic drug problems detailed in Sam Quinones’s superb book Dreamland.

The timing was darkly auspicious. As prescription painkillers became harder to get and more expensive, thanks to alterations of the OxyContin tablet, to law-enforcement efforts, and to growing physician enlightenment, a pool of individuals already primed by their experience with prescription opioids moved on to low-cost, relatively pure, and accessible heroin. Indeed, between 2008 and 2010, about three-fourths of people who had used heroin in the past year reported non-medical use of painkillers — likely obtained outside the health-care system — before initiating heroin use.

The progression from pills to heroin was abetted by the nature of addiction itself. As users became increasingly tolerant to painkillers, they needed larger quantities of opioids or more efficient ways to use them in order to achieve the same effect. Moving from oral consumption to injection allowed this. Once a person is already injecting pills, moving to heroin, despite its stigma, doesn’t seem that big a step. The march to heroin is not inexorable, of course. Yet in economically and socially depleted environments where drug use is normalized, heroin is abundant, and treatment is scarce, widespread addiction seems almost inevitable.

The last five years or so have witnessed a massive influx of powder heroin to major cities such as New York, Detroit, and Chicago. From there, traffickers direct shipments to other urban areas, and these supplies are, in turn, distributed further to rural and suburban areas. It is the powdered form of heroin that is laced with synthetics, such as fentanyl. Most victims of synthetic opioids don’t even know they are taking them. Drug traffickers mix the fentanyl with heroin or press it into pill form that they sell as OxyContin.

Yet, there are reports of addicts now knowingly seeking fentanyl as their tolerance to heroin has grown. Whereas heroin requires poppies, which take time to cultivate, synthetics can be made in a lab, so the supply chain can be downsized. And because the synthetics are so strong, small volumes can be trafficked more efficiently and more profitably. What’s more, laboratories can easily stay one step ahead of the Drug Enforcement Administration by modifying fentanyl into analogs that are more potent, less detectable, or both. Synthetics are also far more deadly: In some regions of the country, roughly two-thirds of deaths from opioids can now be traced to heroin, including heroin that medical examiners either suspect or are certain was laced with fentanyl.

THE BASICS

Terminology is important in discussions about drug use. A 2016 Surgeon General report on addiction, “Facing Addiction in America,” defines “misuse” of a substance as consumption that “causes harm to the user and/or to those around them.” Elsewhere, however, the term has been used to refer to consumption for a purpose not consistent with medical or legal guidelines. Thus, misuse would apply equally to the person who takes an extra pill now and then from his own prescribed supply of Percocet to reduce stress as well as to the person who buys it from a dealer and gets high several times a week. The term “abuse” refers to a consistent pattern of use causing harm, but “misuse,” with its protean definitions, has unhelpfully taken its place in many discussions of the current crisis. In the Surgeon General report, the clinical term “substance use disorder” refers to functionally significant impairment caused by substance use. Finally, “addiction,” while not considered a clinical term, denotes a severe form of substance-use disorder — in other words, compulsive use of a substance with difficulty stopping despite negative consequences.

Much of the conventional wisdom surrounding the opioid crisis holds that virtually anyone is at risk for opioid abuse or addiction — say, the average dental patient who receives some Vicodin for a root canal. This is inaccurate, but unsurprising. Exaggerating risk is a common strategy in public-health messaging: The idea is to garner attention and funding by democratizing affliction and universalizing vulnerability. But this kind of glossing is misleading at best, counterproductive at worst. To prevent and ameliorate problems, we need to know who is truly at risk to target resources where they are most needed.

In truth, the vast majority of people prescribed medication for pain do not misuse it, even those given high doses. A new study in the Annals of Surgery, for example, found that almost three-fourths of all opioid painkillers prescribed by surgeons for five common outpatient procedures go unused. In 2014, 81 million people received at least one prescription for an opioid pain reliever, according to a study in the American Journal of Preventive Medicine; yet during the same year, the National Survey on Drug Use and Health reported that only 1.9 million people, approximately 2%, met the criteria for prescription pain-reliever abuse or dependence (a technical term denoting addiction). Those who abuse their prescription opioids are patients who have been prescribed them for over six months and tend to suffer from concomitant psychiatric conditions, usually a mood or anxiety disorder, or have had prior problems with alcohol or drugs.

Notably, the majority of people who develop problems with painkillers are not individuals for whom they have been legitimately prescribed — nor are opioids the first drug they have misused. Such non-patients procure their pills from friends or family, often helping themselves to the amply stocked medicine chests of unsuspecting relatives suffering from cancer or chronic pain. They may scam doctors, forge prescriptions, or doctor shop. The heaviest users are apt to rely on dealers. Some of these individuals make the transition to heroin, but it is a small fraction. (Still, the death toll is striking given the lethality of synthetic opioids.) One study from the Substance Abuse and Mental Health Services Administration found that less than 5% of pill misusers had moved to heroin within five years of first beginning misuse. These painkiller-to-heroin migrators, according to analyses by the Centers for Disease Control and Prevention, also tend to be frequent users of multiple substances, such as benzodiazepines, alcohol, and cocaine. The transition from these other substances to heroin may represent a natural progression for such individuals.

Thus, factors beyond physical pain are most responsible for making individuals vulnerable to problems with opioids. Princeton economists Anne Case and Angus Deaton paint a dreary portrait of the social determinants of addiction in their work on premature demise across the nation. Beginning in the late 1990s, deaths due to alcoholism-related liver disease, suicide, and opioid overdoses began to climb nationwide. These “deaths of despair,” as Case and Deaton call them, strike less-educated whites, both men and women, between the ages of 45 and 54. While the life expectancy of men and women with a college degree continues to grow, it is actually decreasing for their less-educated counterparts. The problems start with poor job opportunities for those without college degrees. Absent employment, people come unmoored. Families unravel, domestic violence escalates, marriages dissolve, parents are alienated from their children, and their children from them.

Opioids are a salve for these communal wounds. Work by Alex Hollingsworth and colleagues found that residents of locales most severely pummeled by the economic downturn were more susceptible to opioids. As county unemployment rates increased by one percentage point, the opioid death rate (per 100,000) rose by almost 4%, and the emergency-room visit rate for opioid overdoses (per 100,000) increased by 7%. It’s no coincidence that many of the states won by Donald Trump — West Virginia, Kentucky, and Ohio, for example — had the highest rates of fatal drug overdoses in 2015.

Of all prime-working-age male labor-force dropouts, nearly half — roughly 7 million men — take pain medication on a daily basis. “In our mind’s eye,” writes Nicholas Eberstadt in a recent issue of Commentary, “we can now picture many millions of un-working men in the prime of life, out of work and not looking for jobs, sitting in front of screens — stoned.” Medicaid, it turns out, financed many of those stoned hours. Of the entire non-working prime-age white male population in 2013, notes Eberstadt, 57% were reportedly collecting disability benefits from one or more government disability programs. Medicaid enabled them to see a doctor and fill their prescriptions for a fraction of the street value: A single 10-milligram Percocet could go for $5 to $10, the co-pay for an entire bottle.

When it comes to beleaguered communities, one has to wonder how much can be done for people whose reserves of optimism and purposefulness have run so low. The challenge is formidable, to be sure, but breaking the cycle of self-destruction through treatment is a critical first step.

TREATMENT OPTIONS

Perhaps surprisingly, the majority of people who become addicted to any drug, including heroin, quit on their own. But for those who cannot stop using by themselves, treatment is critical, and individuals with multiple overdoses and relapses typically need professional help. Experts recommend at least one year of counseling or anti-addiction medication, and often both. General consensus holds that a standard week of “detoxification” is basically useless, if not dangerous — not only is the person extremely likely to resume use, he is at special risk because he will have lost his tolerance and may easily overdose.

Nor is a standard 28-day stay in a residential facility particularly helpful as a sole intervention. In residential settings many patients acquire a false sense of security about their ability to resist drugs. They are, after all, insulated from the stresses and conditioned cues that routinely provoke drug cravings at home and in other familiar environments. This is why residential care must be followed by supervised transition to treatment in an outpatient setting: Users must continue to learn how to cope without drugs in the social and physical milieus they inhabit every day.

Fortunately, medical professionals are armed with a number of good anti-addiction medications to help patients addicted to opioids. The classic treatment is methadone, first introduced as a maintenance therapy in the 1960s. A newer medication approved by the FDA in 2002 for the treatment of opioid addiction is buprenorphine, or “bupe.” It comes, most popularly, as a strip that dissolves under the tongue. The suggested length of treatment with bupe is a minimum of one or two years. Like methadone, bupe is an opioid. Thus, it can prevent withdrawal, blunt cravings, and produce euphoria. Unlike methadone, however, bupe’s chemical structure makes it much less dangerous if taken in excess, thereby prompting Congress to enact a law, the Drug Addiction Treatment Act of 2000, which allows physicians to prescribe it from their offices. Methadone, by contrast, can only be administered in clinics tightly regulated by the Drug Enforcement Administration and the Substance Abuse and Mental Health Services Administration. (I work in such a clinic.)

In addition to methadone or buprenorphine, which have abuse potential of their own, there is extended-release naltrexone. Administered as a monthly injection, naltrexone is an opioid blocker. A person who is “blocked” normally experiences no effect upon taking an opioid drug. Because naltrexone has no abuse potential (hence no street value), it is favored by the criminal-justice system. Jails and prisons are increasingly offering inmates an injection of naltrexone; one dose is given at five weeks before release and another during the week of release with plans for ongoing treatment as an outpatient. Such protection is warranted given the increased risk for death, particularly from drug-related causes, in the early post-release period. For example, one study of inmates released from the Washington State Department of Corrections found a 10-fold greater risk of overdose death within the first two weeks after discharge compared with non-incarcerated state residents of the same age, sex, and race.

Regulatory State and Redistributive State

Will Wilkinson is a great writer, and spells out here two critical aspects of government:

The regulatory state is the aspect of government that protects the public against abuses of private players, protects property rights, and creates well-defined “corridors” that streamline the flows of capitalism and make it work best. It always gets a bad rap, and shouldn’t. The rap is due to the difficulty of enforcing regulations on so many aspects of life.

The redistributive state is the aspect of government that deigns to shift income and wealth from certain players in society to other players. The presumption is always one of fairness, whereby society deems it in the interests of all that certain actors, e.g. veterans or seniors, get preferential distributions of some kind.

He goes on to make a great point. These two states are more independent of one another than might at first be apparent. So it is possible to dislike one and like another.

Personally, I like both. I think both are critical to a well-oiled society with capitalism and property rights as central tenants. My beef will always go to issues of efficiency and effectiveness?

On redistribution, efficiency experts can answer this question: can we dispense with the monthly paperwork and simply direct deposit funds? Medicare now works this way, and the efficiency gains are remarkable.

And on regulation, efficiency experts can answer this question: can private actors certify their compliance with regulation, and then the public actors simple audit from time to time? Many government programs work this way, to the benefit of all.

ON redistribution, effectiveness experts can answer this question: Is the homeless population minimal? Are veterans getting what they need? Are seniors satisfied with how government treats them?

On regulation, effectiveness experts can answer this question: Is the air clean? Is the water clean? Is the mortgage market making food loans that help people buy houses? Are complaints about fraudulent consumer practices low?

CREDIT: VOX Article on Economic Freedom by Will Wilkinson

By Will Wilkinson
Sep 1, 2016

American exceptionalism has been propelled by exceptionally free markets, so it’s tempting to think the United States has a freer economy than Western European countries — particularly those soft-socialist Scandinavian social democracies with punishing tax burdens and lavish, even coddling, welfare states. As late as 2000, the American economy was indeed the freest in the West. But something strange has happened since: Economic freedom in the United States has dropped at an alarming rate.

Meanwhile, a number of big-government welfare states have become at least as robustly capitalist as the United States, and maybe more so. Why? Because big welfare states needed to become better capitalists to afford their socialism. This counterintuitive, even paradoxical dynamic suggests a tantalizing hypothesis: America’s shabby, unpopular safety net is at least partly responsible for capitalism’s flagging fortunes in the Land of the Free. Could it be that Americans aren’t socialist enough to want capitalism to work? It makes more sense than you might think.

America’s falling economic freedom

From 1970 to 2000, the American economy was the freest in the West, lagging behind only Asia’s laissez-faire city-states, Hong Kong and Singapore. The average economic freedom rating of the wealthy developed member countries of the Organization for Economic Cooperation and Development (OECD) has slipped a bit since the turn of the millennium, but not as fast as America’s.
“Nowhere has the reversal of the rising trend in the economic freedom been more evident than in the United States,” write the authors of Fraser Institute’s 2015

Economic Freedom of the World report, noting that “the decline in economic freedom in the United States has been more than three times greater than the average decline found in the OECD.”

The economic freedom of selected countries, 1999 to 2016. Heritage Foundation 2016 Index of Economic Freedom

The Heritage Foundation and the Canadian Fraser Institute each produce an annual index of economic freedom, scoring the world’s countries on four or five main areas, each of which breaks down into a number of subcomponents. The main rubrics include the size of government and tax burdens; protection of property rights and the soundness of the legal system; monetary stability; openness to global trade; and levels of regulation of business, labor, and capital markets. Scores on these areas and subareas are combined to generate an overall economic freedom score.

The rankings reflect right-leaning ideas about what it means for people and economies to be free. Strong labor unions and inequality-reducing redistribution are more likely to hurt than help a country’s score.

So why should you care about some right-wing think tank’s ideologically loaded measure of economic freedom? Because it matters. More economic freedom, so measured, predicts higher rates of economic growth, and higher levels of wealth predict happier, healthier, longer lives. Higher levels of economic freedom are also linked with greater political liberty and civil rights, as well as higher scores on the left-leaning Social Progress Index, which is based on indicators of social justice and human well-being, from nutrition and medical care to tolerance and inclusion.

The authors of the Fraser report estimate that the drop in American economic freedom “could cut the US historic growth rate of 3 percent by half.” The difference between a 1.5 percent and 3 percent growth rate is roughly the difference between the output of the economy tripling rather than octupling in a lifetime. That’s a huge deal.
Over the same period, the economic freedom scores of Canada and Denmark have improved a lot. According to conservative and libertarian definitions of economic freedom, Canadians, who enjoy a socialized health care system, now have more economic freedom than Americans, and Danes, who have one of the world’s most generous welfare states, have just as much.
What the hell’s going on?

The redistributive state and the regulatory state are separable

To make headway on this question, it is crucial to clearly distinguish two conceptually and empirically separable aspects of “big government” — the regulatory state and the redistributive state.

The redistributive state moves money around through taxes and transfer programs. The regulatory state places all sorts of restrictions and requirements on economic life — some necessary, some not. Most Democrats and Republicans assume that lots of regulation and lots of redistribution go hand in hand, so it’s easy to miss that you can have one without the other, and that the relationship between the two is uneasy at best. But you can’t really understand the politics behind America’s declining economic freedom if you fail to distinguish between the regulatory and fiscal aspects of the economic policy.

Standard “supply-side” Republican economic policy thinking says that cuts in tax rates and government spending will unleash latent productive potential in the economy, boosting rates of growth. And indeed, when taxes and government spending are very high, cuts produce gains by returning resources to the private sector. But it’s important to see that questions about government control versus private sector control of economic resources are categorically different from questions about the freedom of markets.

Free markets require the presence of good regulation, which define and protect property rights and facilitate market processes through the consistent application of clear law, and an absence of bad regulation, which interferes with productive economic activity. A government can tax and spend very little — yet still stomp all over markets. Conversely, a government can withdraw lots of money from the economy through taxes, but still totally nail the optimal balance of good and bad regulation.

Whether a country’s market economy is free — open, competitive, and relatively unmolested by government — is more a question of regulation than a question of taxation and redistribution. It’s not primarily about how “big” its government is. Republicans generally do support a less meddlesome regulatory approach, but when they’re in power they tend to be much more persistent about cutting taxes and social welfare spending than they are about reducing economically harmful regulatory frictions.

If you’re as worried about America’s declining economic freedom as I am, this is a serious problem. In recent years, the effect of cutting taxes and spending has been to distribute income upward and leave the least well-off more vulnerable to bad luck, globalization, “disruptive innovation,” and the vagaries of business cycles.
If spending cuts came out of the military’s titanic budget, that would help. But that’s rarely what happens. The least connected constituencies, not the most expensive ones, are the first to get dinged by budget hawks. And further tax cuts are unlikely to boost growth. Lower taxes make government seem cheaper than it really is, which leads voters to ask for more, not less, government spending, driving up the deficit. Increasing the portion of GDP devoted to paying interest on government debt isn’t a growth-enhancing way to return resources to the private sector.

Meanwhile, wages have been flat or declining for millions of Americans for decades. People increasingly believe the economy is “rigged” in favor of the rich. As a sense of economic insecurity mounts, people anxiously cast about for answers.

Easing the grip of the regulatory state is a good answer. But in the United States, its close association with “free market” supply-side efforts to produce growth by slashing the redistributive state has made it an unattractive answer, even with Republican voters. That’s at least part of the reason the GOP wound up nominating a candidate who, in addition to promising not to cut entitlement spending, openly favors protectionist trade policy, giant infrastructure projects, and huge subsidies to domestic manufacturing and energy production. Donald Trump’s economic policy is the worst of all possible worlds.

This is doubly ironic, and doubly depressing, once you recognize that the sort of big redistributive state supply-siders fight is not necessarily the enemy of economic freedom. On the contrary, high levels of social welfare spending can actually drive political demand for growth-promoting reform of the regulatory state. That’s the lesson of Canada and Denmark’s march up those free economy rankings.

The welfare state isn’t a free lunch, but it is a cheap date

Economic theory tells you that big government ought to hurt economic growth. High levels of taxation reduce the incentive to work, and redistribution is a “leaky bucket”: Moving money around always ends up wasting some of it. Moreover, a dollar spent in the private sector generally has a more beneficial effect on the economy than a dollar spent by the government. Add it all up, and big governments that tax heavily and spend freely on social transfers ought to hurt economic growth.

That matters from a moral perspective — a lot. Other things equal, people are better off on just about every measure of well-being when they’re wealthier. Relative economic equality is nice, but it’s not so nice when relatively equal shares mean smaller shares for everyone. Just as small differences in the rate at which you put money into a savings account can lead to vast differences in your account balance 40 years down the road, thanks to the compounding nature of interest, a small reduction in the rate of economic growth can leave a society’s least well-off people much poorer in absolute terms than they might have been.

Here’s the puzzle. As a general rule, when nations grow wealthier, the public demands more and better government services, increasing government spending as a percentage of GDP. (This is known as “Wagner’s law.”) According to standard growth theory, ongoing increase in the size of government ought to exert downward pressure on rates of growth. But we don’t see the expected effect in the data. Long-term national growth trends are amazingly stable.

And when we look at the family of advanced, liberal democratic countries, countries that spend a smaller portion of national income on social transfer programs gain very little in terms of growth relative to countries that spend much more lavishly on social programs. Peter Lindert, an economist at the University of California Davis, calls this the “free lunch paradox.”

Lindert’s label for the puzzle is somewhat misleading, because big expensive welfare states are, obviously, expensive. And they do come at the expense of some growth. Standard economic theory isn’t completely wrong. It’s just that democracies that have embraced generous social spending have found ways to afford it by minimizing and offsetting its anti-growth effects.

If you’re careful with the numbers, you do in fact find a small negative effect of social welfare spending on growth. Still, according to economic theory, lunch ought to be really expensive. And it’s not.

There are three main reasons big welfare states don’t hurt growth as much as you might think. First, as Lindert has emphasized, they tend to have efficient consumption-based tax systems that minimize market distortions.
When you tax something, people tend to avoid it. If you tax income, as the United States does, people work a little less, which means that certain economic gains never materialize, leaving everyone a little poorer. Taxing consumption, as many of our European peers do, is less likely to discourage productive moneymaking, though it does discourage spending. But that’s not so bad. Less consumption means more savings, and savings puts the capital in capitalism, financing the economic activity that creates growth.

There are other advantages, too. Consumption taxes are usually structured as national sales taxes (or VATs, value-added taxes), which are paid in small amounts on a continuous basis, are extremely cheap to collect (and hard to avoid), while being less in-your-face than income taxes, which further mitigates the counterproductively demoralizing aspect of taxation.

Big welfare states are also more likely to tax addictive stuff, which people tend to buy whatever the price, as well as unhealthy and polluting stuff. That harnesses otherwise fiscally self-defeating tax-avoiding behavior to minimize the costs of health care and environmental damage.
Second, some transfer programs have relatively direct pro-growth effects. Workers are most productive in jobs well-matched to their training and experience, for example, and unemployment benefits offer displaced workers time to find a good, productivity-promoting fit. There’s also some evidence that health care benefits that aren’t linked to employment can promote economic risk-taking and entrepreneurship.

Fans of open-handed redistributive programs tend to oversell this kind of upside for growth, but there really is some. Moreover, it makes sense that the countries most devoted to these programs would fine-tune them over time to amplify their positive-sum aspects.

This is why you can’t assume all government spending affects growth in the same way. The composition of spending — as well as cuts to spending — matters. Cuts to efficiency-enhancing spending can hurt growth as much as they help. And they can really hurt if they increase economic anxiety and generate demand for Trump-like economic policy.

Third, there are lots of regulatory state policies that hurt growth by, say, impeding healthy competition or closing off foreign trade, and if you like high levels of redistribution better than you like those policies, you’ll eventually consider getting rid of some of them. If you do get rid of them, your economic freedom score from the Heritage Foundation and the Fraser Institute goes up.
This sort of compensatory economic liberalization is how big welfare states can indirectly promote growth, and more or less explains why countries like Canada, Denmark, and Sweden have become more robustly capitalist over the past several decades. They needed to be better capitalists to afford their socialism. And it works pretty well.

If you bundle together fiscal efficiency, some offsetting pro-growth effects, and compensatory liberalization, you can wind up with a very big government, with very high levels of social welfare spending and very little negative consequences for growth. Call it “big-government laissez-faire.”

The missing political will for genuine pro-growth reform

Enthusiasts for small government have a ready reply. Fine, they’ll say. Big government can work through policies that offset its drag on growth. But why not a less intrusive regulatory state and a smaller redistributive state: small-government laissez-faire. After all, this is the formula in Hong Kong and Singapore, which rank No. 1 and No. 2 in economic freedom. Clearly that’s our best bet for prosperity-promoting economic freedom.

But this argument ignores two things. First, Hong Kong and Singapore are authoritarian technocracies, not liberal democracies, which suggests (though doesn’t prove) that their special recipe requires nondemocratic government to work. When you bring democracy into the picture, the most important political lesson of the Canadian and Danish rise in economic freedom becomes clear: When democratically popular welfare programs become politically nonnegotiable fixed points, they can come to exert intense pressure on fiscal and economic policy to make them sustainable.

Political demand for economic liberalization has to come from somewhere. But there’s generally very little organic, popular democratic appetite for capitalist creative destruction. Constant “disruption” is scary, the way markets generate wealth and well-being is hard to comprehend, and many of us find competitive profit-seeking intuitively objectionable.

It’s not that Danes and Swedes and Canadians ever loved their “neoliberal” market reforms. They fought bitterly about them and have rolled some of them back. But when their big-government welfare states were creaking under their own weight, enough of the public was willing, thanks to the sense of economic security provided by the welfare state, to listen to experts who warned that the redistributive state would become unsustainable without the downsizing of the regulatory state.

A sound and generous system of social insurance offers a certain peace of mind that makes the very real risks of increased economic dynamism seem tolerable to the democratic public, opening up the political possibility of stabilizing a big-government welfare state with growth-promoting economic liberalization.

This sense of baseline economic security is precisely what many millions of Americans lack.

Learning the lesson of Donald Trump
America’s declining economic freedom is a profoundly serious problem. It’s already putting the brakes on dynamism and growth, leaving millions of Americans with a bitter sense of panic about their prospects. They demand answers. But ordinary voters aren’t policy wonks. When gripped by economic anxiety, they turn to demagogues who promise measures that make intuitive economic sense, but which actually make economic problems worse.

We may dodge a Trump presidency this time, but if we fail to fix the feedback loop between declining economic freedom and an increasingly acute sense of economic anxiety, we risk plunging the world’s biggest economy and the linchpin of global stability into a political and economic death spiral. It’s a ridiculous understatement to say that it’s important that this doesn’t happen.

Market-loving Republicans and libertarians need to stare hard at a framed picture of Donald Trump and reflect on the idea that a stale economic agenda focused on cutting taxes and slashing government spending is unlikely to deliver further gains. It is instead likely to continue to backfire by exacerbating economic anxiety and the public’s sense that the system is rigged.

If you gaze at the Donald long enough, his fascist lips will whisper “thank you,” and explain that the close but confusing identification of supply-side fiscal orthodoxy with “free market” economic policy helps authoritarian populists like him — but it hurts the political prospects of regulatory state reforms that would actually make American markets freer.

Will Wilkinson is the vice president for policy at the Niskanen Center.

Property Rights and Modern Conservatism



In this excellent essay by one of my favorite conservative writers, Will Wilkinson takes Congress to task for their ridiculous botched-joob-with-a-botchhed-process of passing Tax Cut legislation in 2017.

But I am blogging because of his other points.

In the article, he spells out some tenants of modern conservatism that bear repeating, namely:

– property rights (and the Murray Rothbard extreme positions of absolute property rights)
– economic freedom (“…if we tax you at 100 percent, then you’ve got 0 percent liberty…If we tax you at 50 percent, you are half-slave, half-free”)
– libertarianism (“The key is the libertarian idea, woven into the right’s ideological DNA, that redistribution is the exploitation of the “makers” by the “takers.”)
– legally enforceable rights
– moral traditionalism

Modern conservatism is a “fusion” of these ideas. They have an intellectual footing that is impressive.

But Will points out where they are flawed. The flaws are most apparent in the idea that the hoards want to use democratic institutions to plunder the wealth of the elites. This is a notion from the days when communism was public enemy #1. He points out that the opposite is actually the truth.

“Far from endangering property rights by facilitating redistribution, inclusive democratic institutions limit the “organized banditry” of the elite-dominated state by bringing everyone inside the charmed circle of legally enforced rights.”

Ironically, the new Tax Cut legislation is an example of reverse plunder: where the wealthy get the big, permanent gains and the rest get appeased with small cuts that expire.

So, we are very far from the fears of communism. We instead are amidst a taking by the haves, from the have nots.

====================
Credit: New York Times 12/120/17 Op Ed by Will Wilkinson

Opinion | OP-ED CONTRIBUTOR
The Tax Bill Shows the G.O.P.’s Contempt for Democracy
By WILL WILKINSON
DEC. 20, 2017
The Republican Tax Cuts and Jobs Act is notably generous to corporations, high earners, inheritors of large estates and the owners of private jets. Taken as a whole, the bill will add about $1.4 trillion to the deficit in the next decade and trigger automatic cuts to Medicare and other safety net programs unless Congress steps in to stop them.

To most observers on the left, the Republican tax bill looks like sheer mercenary cupidity. “This is a brazen expression of money power,” Jesse Jackson wrote in The Chicago Tribune, “an example of American plutocracy — a government of the wealthy, by the wealthy, for the wealthy.”

Mr. Jackson is right to worry about the wealthy lording it over the rest of us, but the open contempt for democracy displayed in the Senate’s slapdash rush to pass the tax bill ought to trouble us as much as, if not more than, what’s in it.

In its great haste, the “world’s greatest deliberative body” held no hearings or debate on tax reform. The Senate’s Republicans made sloppy math mistakes, crossed out and rewrote whole sections of the bill by hand at the 11th hour and forced a vote on it before anyone could conceivably read it.

The link between the heedlessly negligent style and anti-redistributive substance of recent Republican lawmaking is easy to overlook. The key is the libertarian idea, woven into the right’s ideological DNA, that redistribution is the exploitation of the “makers” by the “takers.” It immediately follows that democracy, which enables and legitimizes this exploitation, is itself an engine of injustice. As the novelist Ayn Rand put it, under democracy “one’s work, one’s property, one’s mind, and one’s life are at the mercy of any gang that may muster the vote of a majority.”

On the campaign trail in 2015, Senator Rand Paul, Republican of Kentucky, conceded that government is a “necessary evil” requiring some tax revenue. “But if we tax you at 100 percent, then you’ve got 0 percent liberty,” Mr. Paul continued. “If we tax you at 50 percent, you are half-slave, half-free.” The speaker of the House, Paul Ryan, shares Mr. Paul’s sense of the injustice of redistribution. He’s also a big fan of Ayn Rand. “I give out ‘Atlas Shrugged’ as Christmas presents, and I make all my interns read it,” Mr. Ryan has said. If the big-spending, democratic welfare state is really a system of part-time slavery, as Ayn Rand and Senator Paul contend, then beating it back is a moral imperative of the first order.

But the clock is ticking. Looking ahead to a potentially paralyzing presidential scandal, midterm blood bath or both, congressional Republicans are in a mad dash to emancipate us from the welfare state. As they see it, the redistributive upshot of democracy is responsible for the big-government mess they’re trying to bail us out of, so they’re not about to be tender with the niceties of democratic deliberation and regular parliamentary order.

The idea that there is an inherent conflict between democracy and the integrity of property rights is as old as democracy itself. Because the poor vastly outnumber the propertied rich — so the argument goes — if allowed to vote, the poor might gang up at the ballot box to wipe out the wealthy.

In the 20th century, and in particular after World War II, with voting rights and Soviet Communism on the march, the risk that wealthy democracies might redistribute their way to serfdom had never seemed more real. Radical libertarian thinkers like Rand and Murray Rothbard (who would be a muse to both Charles Koch and Ron Paul) responded with a theory of absolute property rights that morally criminalized taxation and narrowed the scope of legitimate government action and democratic discretion nearly to nothing. “What is the State anyway but organized banditry?” Rothbard asked. “What is taxation but theft on a gigantic, unchecked scale?”

Mainstream conservatives, like William F. Buckley, banished radical libertarians to the fringes of the conservative movement to mingle with the other unclubbables. Still, the so-called fusionist synthesis of libertarianism and moral traditionalism became the ideological core of modern conservatism. For hawkish Cold Warriors, libertarianism’s glorification of capitalism and vilification of redistribution was useful for immunizing American political culture against viral socialism. Moral traditionalists, struggling to hold ground against rising mass movements for racial and gender equality, found much to like in libertarianism’s principled skepticism of democracy. “If you analyze it,” Ronald Reagan said, “I believe the very heart and soul of conservatism is libertarianism.”

The hostility to redistributive democracy at the ideological center of the American right has made standard policies of successful modern welfare states, happily embraced by Europe’s conservative parties, seem beyond the moral pale for many Republicans. The outsize stakes seem to justify dubious tactics — bunking down with racists, aggressive gerrymandering, inventing paper-thin pretexts for voting rules that disproportionately hurt Democrats — to prevent majorities from voting themselves a bigger slice of the pie.

But the idea that there is an inherent tension between democracy and the integrity of property rights is wildly misguided. The liberal-democratic state is a relatively recent historical innovation, and our best accounts of the transition from autocracy to democracy points to the role of democratic political inclusion in protecting property rights.

As Daron Acemoglu of M.I.T. and James Robinson of Harvard show in “Why Nations Fail,” ruling elites in pre-democratic states arranged political and economic institutions to extract labor and property from the lower orders. That is to say, the system was set up to make it easy for elites to seize what ought to have been other people’s stuff.

In “Inequality and Democratization,” the political scientists Ben W. Ansell and David J. Samuels show that this demand for political inclusion generally isn’t driven by a desire to use the existing institutions to plunder the elites. It’s driven by a desire to keep the elites from continuing to plunder them.

It’s easy to say that everyone ought to have certain rights. Democracy is how we come to get and protect them. Far from endangering property rights by facilitating redistribution, inclusive democratic institutions limit the “organized banditry” of the elite-dominated state by bringing everyone inside the charmed circle of legally enforced rights.

Democracy is fundamentally about protecting the middle and lower classes from redistribution by establishing the equality of basic rights that makes it possible for everyone to be a capitalist. Democracy doesn’t strangle the golden goose of free enterprise through redistributive taxation; it fattens the goose by releasing the talent, ingenuity and effort of otherwise abused and exploited people.

At a time when America’s faith in democracy is flagging, the Republicans elected to treat the United States Senate, and the citizens it represents, with all the respect college guys accord public restrooms. It’s easier to reverse a bad piece of legislation than the bad reputation of our representative institutions, which is why the way the tax bill was passed is probably worse than what’s in it. Ultimately, it’s the integrity of democratic institutions and the rule of law that gives ordinary people the power to protect themselves against elite exploitation. But the Republican majority is bulldozing through basic democratic norms as though freedom has everything to do with the tax code and democracy just gets in the way.

Will Wilkinson is the vice president for policy at the Niskanen Center.

Neo.Life

This beta site NeoLife link beyond the splash pagee is tracking the “neobiological revolution”. I wholeheartedly agree that some of our best and brightest are on the case. Here they are:

ABOUT
NEO.LIFE
Making Sense of the Neobiological Revolution
NOTE FROM THE EDITOR
Mapping the brain, sequencing the genome, decoding the microbiome, extending life, curing diseases, editing mutations. We live in a time of awe and possibility — and also enormous responsibility. Are you prepared?

EDITORS

FOUNDER

Jane Metcalfe
Founder of Neo.life. Entrepreneur in media (Wired) and food (TCHO). Lover of mountains, horses, roses, and kimchee, though not necessarily in that order.
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EDITOR
Brian Bergstein
Story seeker and story teller. Editor at NEO.LIFE. Former executive editor of MIT Technology Review; former technology & media editor at The Associated Press
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ART DIRECTOR
Nicholas Vokey
Los Angeles-based graphic designer and animator.
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CONSULTANT
Saul Carlin
founder @subcasthq. used to work here.

EDITOR
Rachel Lehmann-Haupt
Editor, www.theartandscienceoffamily.com & NEO.LIFE, author of In Her Own Sweet Time: Egg Freezing and the New Frontiers of Family

Laura Cochrane
“To oppose something is to maintain it.” — Ursula K. Le Guin

WRITERS

Amanda Schaffer
writes for the New Yorker and Neo.life, and is a former medical columnist for Slate. @abschaffer

Mallory Pickett
freelance journalist in Los Angeles

Karen Weintraub
Health/Science journalist passionate about human health, cool researcher and telling stories.

Anna Nowogrodzki
Science and tech journalist. Writing in Nature, National Geographic, Smithsonian, mental_floss, & others.
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Juan Enriquez
Best-selling author, Managing Director of Excel Venture Management.

Christina Farr
Tech and features writer. @Stanford grad.

NEO.LIFE
Making sense of the Neobiological Revolution. Get the email at www.neo.life.

Maria Finn
I’m an author and tell stories across multiple mediums including prose, food, gardens, technology & narrative mapping. www.mariafinn.com Instagram maria_finn1.

Stephanie Pappas
I write about science, technology and the things people do with them.

David Eagleman
Neuroscientist at Stanford, internationally bestselling author of fiction and non-fiction, creator and presenter of PBS’ The Brain.

Kristen V. Brown
Reporter @Gizmodo covering biotech.

Thomas Goetz

David Ewing Duncan
Life science journalist; bestselling author, 9 books; NY Times, Atlantic, Wired, Daily Beast, NPR, ABC News, more; Curator, Arc Fusion www.davidewingduncan.com

Dorothy Santos
writer, editor, curator, and educator based in the San Francisco Bay Area about.me/dorothysantos.com

Dr. Sophie Zaaijer
CEO of PlayDNA, Postdoctoral fellow at the New York Genome Center, Runway postdoc at Cornell Tech.

Andrew Rosenblum
I’m a freelance tech writer based in Oakland, CA. You can find my work at Neo.Life, the MIT Technology Review, Popular Science, and many other places.

Zoe Cormier

Diana Crow
Fledgling science journalist here, hoping to foster discussion about the ways science acts as a catalyst for social change #biology

Ashton Applewhite
Calling for a radical aging movement. Anti-ageism blog+talk+book

Grace Rubenstein
Journalist, editor, media producer. Social/bio science geek. Tweets on health science, journalism, immigration. Spanish speaker & dancing fool.

Science and other sundries.

Esther Dyson
Internet court jEsther — I occupy Esther Dyson. Founder @HICCup_co https://t.co/5dWfUSratQ http://t.co/a1Gmo3FTQv

Jessica Leber
Freelance science and technology journalist and editor, formerly on staff at Fast Company, Vocativ, MIT Technology Review, and ClimateWire.

Jessica Carew Kraft
An anthropologist, artist, and naturalist writing about health, education, and rewilding. Mother to two girls in San Francisco.

Corby Kummer
Senior editor, The Atlantic, five-time James Beard Journalism Award winner, restaurant reviewer for New York, Boston, and Atlanta magazines

K McGowan
Journalist. Reporting on health, medicine, science, other excellent things. T: @mcgowankat

Rob Waters
I’m a journalist living in Berkeley. I write about health, science, social justice and policy. Father of 1. From Detroit.
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Yiting Sun
writes for MIT Technology Review and Neo.life from Beijing, and was based in Accra, Ghana, in 2014 and 2015.
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Michael Hawley
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Richard Sprague
Curious amateur. Years of near-daily microbiome experiments. US CEO of AI healthcare startup http://airdoc.com
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Bob Parks ✂
Connoisseur of the slap dash . . . maker . . . runner . . . writer of Outside magazine’s Gear Guy blog . . . freelance writer and reporter.

CREDIT: https://medium.com/neodotlife/review-of-daytwo-microbiome-test-deacd5464cd5