Marcus' World

UCSF Mini-Med School 1: Health Reform via Economic Policy

Tonight I began the UCSF mini-med school series on healthcare reform, attending an engaging lecture by Dr. Laura Schmidt about how economic inequality is the root of healthcare disparities.  She argued that achieving universal health care coverage, although it's a laudable goal, would not do much on its own to close gaps between different populations. 

The more serious solution for improved health outcomes--as she argued with a bevy of studies, although some of them were quite dated--is to redistribute the wealth within a society. (This is not the same thing as socialism, as Dr. Schmidt strenuously argued toward the end of her talk.)  The idea isn't to make the pie bigger, but to change the allocations of wealth that already exists.  So progressive taxation is in, and flat taxes are out.  Dr. Schmidt feels that the tax policies supported by President Obama are a major step in the right direction.

So it was a standard left-wing health policy talk, in good measure.   What did stand out among the usual fare was the discussion of anomie, Emile Durkheim, and social hierarchies.

1. Anomie and Durkheim:  Emile Durkheim is the father of modern sociology, and developed the concept of anomie--a state of normlessness that could ultimately tear societies apart.  People who experience anomie, Dr. Schmidt argued, are less integrated into their larger society and ultimately more susceptible to health ailments and early deaths.  For those who argue that correlation is not causation, Dr. Schmidt responds that this connection between social status and health outcomes is a "robust finding" that has been validated repeatedly. 

A great deal of epidemiological research seeks to isolate various factors that lead to health disparities among different populations--poor nutrition, little exercise, etc.   Obviously these factors have some effect, but the root cause remains the difference in social status between various groups in a society.

2. This leads to the reality of hierarchies.  All societies have them, and it is hard to imagine a world with no pecking order.  However, it is possible to minimize or magnify the reality of hierarchy.  More redistributionist societies soften the edges, more individualistic societies magnify them.  And thus Dr. Schmidt made the inevitably unflattering comparison between the US and more egalitarian countries like Sweden. 

I always grow weary at this juncture in the health care debate, because there is never any allowance for the fact that the individualistic US model also has benefits--to some extent the rest of the world's health care systems depend on the R & D funded here.  It's a yin yang relationship between the individualistic and collective impulses, not a zero-sum game. 

But I digress.  One aspect of hierarchies was completely new to me, and I'm glad Dr. Schmidt shared it. I learned that a person's level of autonomy over their work has a significant impact on their health--two people can have an identical income, but the person with greater control over their activities and schedule on the job will tend to be healthier.  This was a key finding of Sir Michael Marmott, who led the landmark World Health Organization Social Determinants of Health study.

Just today I pondered how fortunate I am to have a great deal of autonomy at work.  Obviously I have to coordinate my activities with others.  But I can take a long lunch one day and grab a quick bite the next day, all at times of my choosing.  And in most cases I can shuffle my schedule around if new opportunities or needs arise.

Normally I don't think twice about this.  Perhaps this came to mind because I'm going back to Ohio for a few days on Saturday, and am hoping to meet a childhood friend for lunch Monday.  For planning purposes, I needed to know if his lunch hour was fixed or flexible.  (Flexible, it turns out.)   As I typed the email, I realized how long it had been since I'd asked such a question--anyone I lunch with at work has equal or greater autonomy than me.

So on the whole I'm very fortunate, despite this difficult year.  I've now made a vow not to take my level of control at work for granted--not only do I have a good job, but I'm healthier than I might otherwise be.

Let the Sunshine In

This morning I watched the inaugural ceremony at UCSF, in the student union. The large room was filled to capacity, and there was thunderous applause as Chief Justice Roberts called Barack Obama "Mr. President."   I clapped steadily until the clapping stopped, which took a while.

It felt great.

 

Public Radio Explains the Financial Crisis

Now that the House has rejected the Wall Street bailout, who knows what our economic future holds?  My strategy is to refuse to look at how our investments are doing, especially since the Dow fell 778 points today.

For a week or so I've been looking for a primer on how we got here.  Excellent reporting abounds, in the mainstream media and in the blogosphere.  But what's been lacking is a "cheat sheet" that offers the big picture.

Now, thanks to David Carr, I know that the public radio show "This American Life" offered an excellent overview of the roots of the crisis a few months ago.  In its inimitable documentary style, the show explained what happened through the perspective of everyday people who got swept up in a mortgage market that made no rational sense.  It was too easy for people to obtain huge mortgages they could not afford, because for several years everyone all along the mortgage chain continued to make money.  Now the party's over.

I haven't listened to the complete show, but the short excerpt offers the essential what went wrong.  While not exactly a pick-me-up, this is compelling radio that is worth a listen. 

Sarah Palin--Go Easy on Her About the Passport

Tomorrow I'll send in a renewal application for my passport, which expires next year.  They last for a decade, and I've had mine since 1999.  Since then I've had the great fortune to visit parts of Asia, Africa, South America, and Europe.  And I've been to Mexico and Canada, so North America is covered.  I'm pretty sure I'll get to Australia at some point in my life, and--why not?--perhaps even Antarctica.  I can't imagine life without a passport.

But I'm in the minority.  Most Americans don't possess passports, as the statistics clearly show.  Republican VP candidate Sarah Palin's decision to get a passport only two years ago has aroused some criticism, but I think this is excessive and misplaced.  In last week's interview with Katie Couric (which I''m just catching up with this weekend), Palin skillfully deflected the charge that she is incurious about the world as only being the concern of elitists who have lots of money to send their kids abroad after college.  Shrewd Democrats would do well not to hammer the passport agenda too much; it plays right into Republican hands about how the Democratic Party is out of touch.

But there are more principled reasons not to dwell on Palin's passport.  Perhaps her statement to Couric that she's gained perspective about the world from "books" and "education" rings hollow; maybe it was rehearsed.  But there is no doubt that there are many Americans who are curious about the world but do not have the means to see most of it firsthand.  These people go to public libraries; they look up web sites; they read books.  They don't have a passport because they can't use it, not because they are rubes. 

And supposedly, these are the everyday people that Democrats care about.

Don't get me wrong: I do not think that Palin would be a good Vice President.  At that level, we need people who have renewed their passports several times; Joe Biden is one of the Senate's foremost authorities on foreign affairs.   But the merciless ridicule of Palin symbolizes merciless ridicule of millions of other Americans. This is what we--especially those of us who dwell in coastal bubbles where the passports are more plentiful--should always guard against.

Of Wyoming Libraries and Financial Bailouts

I've been doing my best to understand the financial turmoil gripping the US and with it the rest of the developed world.  I'll never have a complete grasp of what's going on, I but know it has to do with making mortgages too easy for people to obtain.  These risky mortgages underwrote other types of investments; when people began to default on the mortgages that much broader pool of investments began to teeter.  And then credit lines froze and the Bush administration decided that a $700 billion bailout was in order.  If no money is forthcoming, much of our economy could be stopped in its tracks.

So whatever the final plan is, I accept the argument that something must be done.   On this point, President Bush and I agree. 

I was particularly struck by this statement in the President's address to the nation Wednesday night: "The government is the one institution with the patience and resources to buy these assets at their current low prices and hold them until markets return to normal."  Coming from a man who touts that government is always the problem, never the solution, this is a startling admission. 

But it wasn't news to me.  Growing up I became a Democrat when I realized that Republicans want to regulate what should be private (whom people marry, what they do in their own bedrooms) while Democrats stress regulation of what affects everyone (such as our economy.)  Excessive and onerous regulation is not good; when the markets work smoothly that's great.  But markets aren't always rational, as we are learning anew this week.  There is a constructive and enduring role for government in economic affairs, whatever conservative demagogues might say.

Amidst this financial turmoil I stumbled upon a short article in the Economist about how people in conservative southern Wyoming love their public libraries. They check out more books than people in other states, and the selection of books is mostly predictable but with some pleasant surprises (like the extensive offering of novels by Margaret Atwood.)

The centerpiece of the Laramie County libraries is in Cheyenne, and it works so well because of a $27 million sales tax increase.  Just like the economy needs the government, the benefits of life in a civilized society require paying taxes.

But don't take it from me.  Even cowboys in Dick Cheney's Wyoming say so.

Moving Washington Out

The proposal by former IRS Commissioner Mark W. Everson, to disperse many components of federal Washington throughout the country, seems very likely to gain no traction whatsoever.   Inertia and tradition are powerful forces.  But as a thought experiment, if nothing else, it is a fascinating idea. 

Everson argues that lower costs of living elsewhere, and the wide dispersal of educated workforces throughout the country, make decentralizing the federal bureaucracy viable.  He proposes that the Departments of Homeland Security and Veterans Affairs--which are operational rather than policy-setting bodies--are particularly ripe for relocation.  (I'm not sure how non-political Homeland Security really is, but that's another discussion.)  As evidence of the viability of this idea, he cites the viable Atlanta location of the Centers for Disease Control and Prevention.

I support Everson's proposal, although for different reasons than he cites.  During every campaign cycle, an easy applause line is to rail against "out of touch politicians in Washington DC."  Another bit of red meat is to take on those conniving people who squirm away "inside the Beltway."  If parts of Washington are spread throughout the land, these meaningless attacks would be harder to sustain.  Everson is not proposing moving Congress itself (which I would not support).  But moving much of the rest of Washington would definitely reduce the  potency of these barbs. 

The root problem is that the county was much smaller than it is now when it began, and nobody lived that far from Washington. But tonight I'm writing this blog post from 3,000 miles away, in a place that has little real connection to the capital.  Dispersal of the people who make up the government (although Everson isn't recommending the Bay Area, as it's even more pricy than Washington) would remedy this problem.

Why do I care about all this?  Because in the two years we lived in Washington DC, I realized how much it gets an unfair rap.  At the National Library of Medicine, I worked with very dedicated civil servants; they weren't faceless, lazy bureaucrats.  And all throughout town, people cared about issues of the day and debated them passionately.

Washington isn't Shangri-la; many residents of the District are poor and disadvantaged.  (I used to volunteer for the Washington Literacy Council.)   And it's still true that residents of the District have no real voice in Congress--just a non-voting delegate in the House and nobody in the Senate. 

These are longstanding and thorny concerns.  But for now, the point is simple:  Washington has a lot to offer, and the federal apparatus is easy to knock because it feels very distant from most people.  Everson's proposal--quixotic though it may be--would narrow this gap. 

Sarah Palin is no Hillary Clinton

You have to hand it to John McCain for chutzpah, and for condescension too.  One woman is just like another in John's world, which is why he's using his Vice President nominee Sarah Palin as a sop to reach out to disappointed supporters of Hillary Clinton.

I have nothing against Palin, but it's worth pointing out that the Alaska governor has very little in common with Clinton besides that second X chromosome.  Palin is anti-choice, pro-gun, and strongly evangelical.  These are outstanding credentials for someone on the right, but any supporter of Clinton should have a really hard time supporting Palin without committing an extreme act of cognitive dissonance.   Rather than doing that, all Clinton suppoters should vote for Obama-Biden. 

The Dark Side: The Inside Story on How the War on Terror Turned into a War on American Ideals

On this evening of the Olympic opening ceremonies, with tenuous dreams of One World in the air, I found myself listening to Jane Mayer discuss her new book The Dark Side: The Inside Story of How the War on Terror Turned Into a War on American Ideals.  Mayer is a reporter for the New Yorker, and her book has won wide acclaim for its thoroughness in documenting the dark corners into which the US has ventured in response to the attacks of September 11, 2001. 

In brief: We've justified torture even in the face of overwhelming evidence that it won't yield any useful evidence that would prevent additional attacks, and sought to give legal cover to the President to do absolutely anything he pleases in the name of keeping us safe.  John Yoo, who is currently on the law faculty at UC Berkeley but used to work for the Department of Justice, was a major legal enabler of this shameful approach. Hopefully the next President (either Obama or McCain) will be able to repair some of the deep damage done to our moral standing in the world.

It's always dicey to attend such events in Berkeley, where activists come to roost.  Mayer handled the crowd very well--on multiple occasions she mentioned that she wanted to write a book that would stand the test of history rather than a mere political screed.  Many people would have preferred a screed, but she offered and defended investigative journalism instead. That was refreshing.

Bring on $5.00 a Gallon

Today's report that many people are now taking public transportation to work, in response to high gas prices, is very welcome news indeed. There will be fewer pollutants in the air and more opportunity to show that public transit is (or should be) a very viable option for getting around. 

In Tokyo this year--and in Hong Kong, Paris, and London before that--I was once again struck by how far behind US public transit is from much of the rest of the world.  Buenos Aires and Sao Paolo also have decent train systems, and Argentina and Brazil are much poorer than us.

Gas at $3.25/gallon was merely a nuisance, while gas at $3.50-$4.00/gallon seems to be the tipping point in changing behavior.

Come on $5.00! Let's have a revolution.

Clinton Should Keep Running if She Wants To

The last few weeks have shown Hillary Clinton at her worst: peddling sham gas tax relief and beating the drums of war against Iran. A month or so ago I was wondering if perhaps I'd misjudged her.  Today I'm very happy to support Barack Obama.

That said, why should she bow out now?  Although the chattering class has declared her candidacy over, it's not.

Next week she's likely to prevail in West Virginia (a state with similar demographics to Pennsylvania, where she did very well).  Success is also waiting in Kentucky; if she's able to get the votes in Michigan and Florida counted (whatever you might think of that maneuver), Clinton is right back in the race.

This interminable campaign has had many inflection points when either Clinton or Obama were supposedly finished.  But it's not over yet.