Jeffrey Simpson: Chronic Condition

This entry is a bit late coming. Why? I hated this book!  You tend to not pick up a book when you aren’t enjoying it. I didn’t quit, I gutted out all 376 torturous pages.

Chronic Condition is a look at Canada’s health care system, written by Jeffrey Simpson. Full disclosure, I’ve never liked Simpson. I’ve always thought he is a Liberal party stooge that toes the media line and never says anything interesting. The main problem with this book is that Simpson is a political writer, not a policy wonk.  I never got the impression he understood the Canadian healthcare system or even how the bureaucracy works. A political affairs writer is essentially TMZ for something more important than Snooki. It covers people involved in public policy, but it doesn’t get into the ins and outs of government programs and policies.  As a result the book was scattershot, highly repetitive and dedicated 100 pages to a political history of Canadian health care, when it could have been 10.

I never gave too much thought to the ins and outs of our health system in my twenties, but over the past two years I’ve been chronically ill. My partner is also an MD and we talk a lot about her work. The system works well in some ways (making sure people at immediate risk of dying don’t die mainly), but the more I learn the more I realize that it is an inefficient and incoherent mess. And nobody seems to mind this. Like all  massive bureaucracies “that’s just the way it is” and good luck changing it. I don’t think that’s good enough when it accounts for 40% of our provincial taxes!

I was hoping this book would give me some real insights, but I knew there’d be little insight when, speaking on the matter of finding efficiencies in the system, Simpson just says “that never works.” True it is inordinately hard to change the way a large, complex and entrenched system functions, but the book should be about giving it a crack. The other glaring omission is that Simpson barely speaks at all about what technology can do to make health care cheaper, or to better serve patients.

The book confirms that if you have cancer or are in a horrible car accident, you’ll be treated first and receive excellent care. It is everything else where we fail: wait times for specialists; treating chronic conditions; access to primary care; mental health services; and overall navigability.

In 2017 our medical system still runs on paper, phones and fax machines. Doctors communicate and refer among each other based, in large part, on who they happen to know. This is beyond inefficient, it is wasteful.

The system also serves mainly the practitioner and not the patient. Horribly ill and have to move 500 kms away? No, the Doctor will not talk to you over the phone for even 5 seconds. You must travel 1000 kms.

For the patient there are no options, no evident triaging based on need, no knowledge of what records are sent where. My family Doctor is part of a family health team that operated an after hours walk-in for its patients. Great, it’ll keep people out of the emergency room. At some point the after hours clinic stopped operating, but nobody ever told me. They don’t email patients. They don’t have a website. They have no incentive to inform me of how the system works, so why would they bother?

In my own case I waited so long to see specialists, that I ended up in the hospital for a couple of weeks.  This is probably, without exaggeration, 1000 times more expensive to the state than the ten 15 minute appointments that never happened.

At my wife’s clinic, probably 10% of appointments are not kept. Perhaps an automated auto-dialer or e-mail reminder might help lower this number? Nope. No time to call people.  That’s 10% of the time for someone being paid, on average, $250,000. Might as well burn $25,000 for each Doctor at the clinic (there are about 6 so that’s $150,000, almost enough to hire a new Doctor or a couple of nurses).

There should be some obvious priorities to fix:

  • Mandatory electronic health records that are connected to all physicians and pharmacies and which the patient can access. We do this for our taxes, why not health care?
  • Referrals to specialists that are structured, not based on who a Doctor happens to know. If a patient is willing to travel 1000 kms if it saves three months wait, let them have the option. It frees up space and gets people healthy.
  • Electronic referral, based on your geographic location and your health problem, to the correct practitioner (hospital, family Dr, nurse practitioner, walk in clinic etc.).
    • Let’s say I have a cut that needs stitches. Where should I go? I know that the hospital will deal with this, albeit after about an 8 hour wait. This is by far the most expensive place to go for the system. Is there another option? How do I even go about figuring this out? I don’t know. I doubt others do either, so they go to the hospital.
      • It is assumed patients understand how the system works. They don’t. How would they?
    • Do we need a yearly check up? My wife gets people coming in for these appointments, but they are apparently unnecessary.  How would the patient know this?

I agree with Simpson on this: some private medicine is a good idea; pharmaceutical prices should be negotiated by the federal government (we pay the 2nd highest prices for drugs in the world); there should be nominal fees for access ($15); and funding should follow patients and performance.

All and all a dull read that only touches the surface of what’s wrong and likely what’s possible. It could have been fascinating and there is still an amazing book out there for the right author!

Antoine de Saint – Exupery: Wind, Sand and Stars

Explorers and adventurers have always fascinated me and there are endless books in this genre. Robert Scott’s tragic diary, the tale of the USS Jeanette and Captain James Cook’s travels are all personal favourites. What drives us to seek adventure or take enormous risks, when we have but one life to live?

Saint-Exupéry’s Wind, Sand and Stars, a memoir of his time as an aviator in the early days of flight, tries to answer this and many other questions. What do we derive meaning from? What is a life well-lived? The writing itself provides his answer, as he approaches the world with a child-like sense of awe, the pages dripping with majestic imagery and metaphor, often reflecting a sense of pure joy.  If he must choose specificity (dates or other particulars) or beauty in recounting his experiences, he opts for beauty and wonder.  Where Orewell’s Homage to Catalonia, a memoir from the same era (both men were in Spain during the civil war), reads like a log of his time, mixed with withering analysis, Wind, Sand and Stars is a piece of art where light on a plane’s wing radiates “in the form of a bouquet of pink flowers.” The titles reflect this difference best.

Though not an explorer, aviation itself was in its exploratory stages.  Saint-Exupéry flies by sight and map, with only rudimentary controls, in small planes that feel the full brunt of nature’s effects.  Navigating by the stars, his course dictated by the wind, he crosses the Pyrenees and the Andes, sails through typhoons, crashes in the Sahara and nearly runs out of fuel over the ocean.  When thought lost for dead in the Sahara he notes that he has “gambled and lost” but has no regrets. He states clearly that “it is not danger I love. I know what I love. It is life.”

Life isn’t shuffling papers in a government office or earning a certain arbitrary amount of money. Man is not “cattle to be fattened for market.” Man’s fulfillment is not to be found in logic, it is to be found in what culture, activity or scale of values brings self-fulfillment or awakens an inner spirit. For Saint-Exupéry the plane was a means towards experience. One does not die for air mail, the same as most men in a war do not die for whatever banner they happen to fight for. Far from escapism, shirking off daily drudgery for something more is the embrace of reality.  Finding beauty, in music or art, is reality.  Love is experiencing this with another person. This is the only way to realize one’s full potential, to test one’s self, to experience freedom.

Consumerism and technology are a constant backdrop to this book.  Saint-Exupéry initially is supportive of new technology, noting that over time it is eventually accepted. The plane, he notes, doesn’t divorce man from nature or feeling, it puts man in touch with nature. At the time this was quite true as he flew in a tiny plane, feeling the cold, rain, his vision obscured by clouds, his destination governed by wind that flew in his face. But what would he think of a modern airplane, on auto-pilot for 90% of the flight, the pilot not feeling the wind or viewing the stars, but instead a series of knobs and monitors? Of a world where any place on Earth could be viewed with the click of a button? Where, like his prisoner digging a hole for punishment, work is neither purposeful nor enriching? Where a car drives itself? This is what I wondered as I finished the book.

It seems I may have received my answer as I then read that Saint-Exupéry went missing in his plane in 1944, just as airplane navigation became heavily dependent on reading instruments, which he was not enamoured with. When a French fisherman pulled his nets in 2004 he found a bracelet with Saint-Exupéry’s name inscribed and his plane was found shortly after. It had no bullet holes and appears to have flown directly in to the sea, with suicide strongly suspected.

I suspect Saint-Exupéry would hate much of the modern world, as it eliminates wonder and joy. For being a world divorced from reality.  One wonders if he hasn’t got to the reasons for why our modern world, despite its benefits, is so full of depression, anxiety and isolation? Where men in droves seek nothing as they see nothing offered in return. Perhaps the technology is no longer a means, as his plane was, but an end itself.

A truly brilliant book and I’d highly recommend reading this back to back with Orewell’s Homage to Catalonia. Was Orewell truly fighting mainly to rid Spain of fascism? In favour of socialism? As he states he joined mainly as it was the thing to do in Spain and his best justification at the end of the war for choosing his side and being shot in the neck is a weak plea that no war is without a difference depending on the victor. I suspect Saint-Exupéry understood better than he what brought Orewell to arms.

George Orewell: Homage to Catalonia

I’ve known that Orewell fought in the Spanish Civil War on the side of the Republicans, but my knowledge basically ended there. It was mostly a historical tidbit to me.  Homage to Catalonia, a recounting of his time in Spain, fills in the blanks, both for this period and as explanation for 1984 and Animal Farm.

A memoir of his time spent in Spain fighting on behalf of the Republicans in the Civil War, Orewell’s time is split between the front and behind the lines in civilian Republican Spain, mainly Barcelona.

Orewell rates his own time at the front as nothing but boredom and drudgery; at best he shoots fruitlessly at a fascist over no man’s land, more to ease his own boredom than with a hope of actually shooting a fascist. You’d think someone as insightful as Orewell would spend his time in deep thought, but he notes that “when I get mixed up in war or politics – I am conscious of nothing save physical discomfort and a deep desire for this damned nonsense to be over.”

The most interesting part of the war to Orewell and the reader is the internal strife on the Republican side, which was a hodge podge of different left-wing factions.

At the beginning when Orewell arrives Spain is viva la revolution! Women fight with men, all dress identically, military ranks are abolished. Comrade is the only available title. There was a “feeling of having suddenly emerged into an era of equality and freedom. Human beings were trying to behave as human beings and not as cogs in the capitalist machine.”

This unity of purpose begins to splinter. After the Republican side loses a position Orewell notes that “it was the first talk I had heard of treachery or divided aims…hitherto, the rights and wrongs had seemed so beautifully simple…it set up in my mind my first vague doubts about this war.”  This reminded me of the Great Gatsby and the exact moment when infidelity is suspected, in horror, by an aggrieved spouse.

As the war progressed the Stalinist and conservative elements within the Republican side ultimately banned their own “comrades”, the anarchists and the far-left Trotskyists, which Orewell was a member of.  Upon returning to Barcelona from the front Orewell is visibly struck by the change as it becomes clear the bourgeoisie were mostly feigning revolution out of fear of the proletariat, not solidarity. As time ticked forward and they felt safer, the wealthy reasserted their status. The worker’s revolution was not a new beginning, just a fleeting jubilant moment in time, like a drunken escapade.

At the end of the book Orewell reflects on the propaganda used against the Republicans and to justify crushing the far-left. The reporting on the war, fed by the fascists, labels the Republicans as traitors, murderers, cowards and spies.  The Republicans then spread the same lies about the anarchists, calling them traitors, fascists, saboteurs and enemies of the people, arresting them en masse. These are men, some as young as 15, that Orewell has seen killed or horribly wounded fighting for the people.

Lie after lie is told retold, to the point where it becomes truth. A man fighting for the poor is called a fascist, a man wounded in battle a coward. It “gives me the feeling that the very concept of objective truth is fading out of the world.”  A history of the war, given the volume of lies, would be “unreliable on every minor point.”  A basic sense of fairness is destroyed as as “practically the law was what the police chose to make it…it was no use hanging on to the English notion that you are safe so long as you keep the law.”

A world without truth, without reality, where up is down and left is right, supposing it fits ones agenda, is madness. The aim of mankind, since the earliest philosophers, has been to uncover truth. To say that it no longer exists or to divorce oneself from it is to deny the main benefit of being human. We see this in the United States, where inconvenient information is labelled “fake news” or a conspiracy.

The most disturbing part of Trump is that there is no pretense of truth. Watching the Republican convention the volume of lies being spouted was obvious. More sickening was to see these lies given credence as CNN attempted to provide “balance.” Trump stating that Obama bugged his home, with no evidence, is given equal weight to Obama stating he hasn’t. Those who know the truth, which ought to be the entirety of the Republican Congress, cast the truth aside in favour of propaganda and personal gain.

The US left is better, but not without fault. As Orewell notes “one feature of the Nazi conquest of France was the astonishing defections among the intelligentsia, including some of the left-wing political intelligentsia. The intelligentsia are the people who squeal loudest against Fascism.” Just yesterday in the wake of a shooting by a madman who was once part of Bernie Sanders campaign, the NY Times, as Glenn Greenwald noted, were quick to defame Sanders’ ideas and campaign (https://twitter.com/ggreenwald/status/875176196237127680).

As Orewell states, the lowest class of society is the only one that can’t be permanently bribed. To win the working class the standard of living has to be improved, something fascists and sometimes capitalists can’t do. Eventually the lower classes will (or should) see through the trick that has been played on them, no matter how ignorant.

In the context of the USA the Trump lies were meant to appeal to the lower classes, though without any realistic way of delivering. These people were too ignorant to understand this. The Clinton candidacy didn’t try to appeal to them in any meaningful way, so it isn’t shocking that she lost. The only candidate honestly trying to solve their problems, Sanders, was castigated by the establishment.

As Orewell notes, what the working class wants is a “fight to win a decent life they knew to be their birthright.” Whomever offers this most convincingly stands to reap a reward, but if it is an authentic attempt it will be opposed by elites that rule the parties, media and money. So it seems the only path to equality is through some sort of perverted double-cross intended to trick the disenfranchised and the rich simultaneously.

Thinking of my own province, the Liberal party, uncaring towards the poor for years, have tried to save their political hide by offering, only after more than ten years in office and the impending prospect of being voted out of power, a 30% increase in the minimum wage and subsidized electricity. It remains to be seen if this bribe will be accepted.

I didn’t mean to write so much on this, but Orwell packs a mountain of ideas into a small space. The other things that struck me were:

  • The homogeneous nature of journalists. Compare your average “personality” on TV or in print, nearly all of whom have similar views (or parrot party lines to a tee in faux disagreement), to an Orewell, later a journalist, who served in the police, taught at a school and fought in a war. Whether you agree with them or not some of the best journalists today are Glenn Greenwald (civil rights lawyer), George Monbiot (zoology) and Malcom Gladwell (barely graduated university). I also consider Mark Styen (disc jockey), though often deliberately disingenuous, a brilliant writer. Monbiot himself makes such an observation about broadcasters here: https://www.theguardian.com/commentisfree/2017/jun/13/election-tories-media-broadcasters-press-jeremy-corbyn.
  • The level of inequality in Spain was striking (the poor were almost completely illiterate), as was the absence of any concept of due process or rule of law. Recently on a Freakonomics podcast (Earth 2.0) on income inequality it was argued that this is in large part an explanation for the differences between North America, based on the British system, and South America, colonized by the Spaniards. The English tended to integrate workers into their systems of production and trade, whereas the Spanish sought solely to extract as much wealth as possible. I find this argument compelling as in the absence of basic fairness and opportunity, society devolves into warfare for control, as we saw in 1938 Spain and in much of modern Latin America. Aside from warfare the only other option is a depressed form of nihilistic fatalism.  Say what you want about the British, but if you have been aggrieved you at least have a chance for a mostly impartial hearing, governed by laws.  See: http://freakonomics.com/podcast/earth-2-0-income-inequality.

Orewell demonstrates powerfully the need to pursue truth, freedom, fairness and equality. None will ever be realized, far from it, but it is far more advisable than not trying at all.

George Monbiot: Heat

George Monbiot is a writer I’ve sadly only discovered recently; but that’s fantastic as it means I’ve got an extensive back catalogue of excellent writing to work through. I liken it to my belated discovery of Game of Thrones and the Sopranos this past year.

I’ve chosen Monbiot’s Heat (2006) as a starting point for this site as climate change seems timely given that my own province is in the thrust of skyrocketing electricity costs related to renewable energy and as President Trump has just withdrawn from the Paris Accord, proclaiming climate change a GIANT BIG FAT HOAX.

Monbiot’s Heat takes for granted that climate change is real and tries to figure out how we can go about fixing the problem, using the UK alone as his petri dish. It’s an interesting and near impossible exercise, but Monbiot deserves credit for taking a crack and coming up with, theoretically, a workable solution.

I won’t go into the fixes he suggests as I’m no expert on these subjects and as a lot has probably changed since 2006, but he finds the required reduction of emissions through a mixture of energy efficient homes, better public transit, renewable energy and buried carbon dioxide.

All of this is wonderful, but it doesn’t get to the Faustian pact that Monbiot uses as a theme throughout the book. If Faust could agree to damn himself in exchange for temporary worldly delights, what chance is there that humans wouldn’t choose these same delights in exchange for damning someone else? The damned aren’t “us” they are our grandchildren, people in very hot or low lying places, and of course, the poor.

I see no chance of this, not because Monbiot’s proposals would take us back to the stone age, but because the level of privation proscribed would still be deemed unacceptable to those who won’t personally feel the impact of climate change.

To get a glimpse at human nature, look no further than the world’s most powerful man. He’s an unmitigated narcissist, unable to even momentarily consider someone other than himself. A powerful nation, with more information available to it than at any other time in history, freely chose him as their representative.

Monbiot’s riddle is theoretically solvable, but I’m afraid humanity’s is not.

As an aside I thank Monbiot for identifying other environmentalists as part of the problem. Many do wish to see a return to the stone age, which I consider inadvisable – others are hypocrites who enjoy luxuries they wish to deny others. Some, like Paul Ehrlich, ply fictions as fact in exchange for prestige and notoriety. In my own province the Government has transferred billions in exorbitant contracts to specific companies building windmills as, for all intents and purposes, these politicians and companies are one and the same.  Meanwhile the elderly go without heat and people lose their homes as their money is transferred to the wealthy.

Human nature will damn us all to hell it seems and this is a far more intractable riddle than the one Monbiot solves in this book.

As with all of Monbiot’s work this book is extraordinarily well written and researched. He does an impressive job of taking a massive complicated mess of a problem and breaking it down into manageable parts. Most of all I appreciate that he comes off as sincere and well meaning.