Siddhartha Mukherjee

“The promise of bringing medical recordkeeping into the digital age was to maintain a live record of a live patient, enabling clinicians to track patient care across hospital systems and over time. Instead, we’ve been saddled with systems that cut into patient care (clinicians typically spend an hour feeding documentation into a computer for every hour they spend with patients) and, often, are too fragmented to allow a patient’s file to follow her from one medical center to another. The E.M.R., as a colleague of mine put it, is “electronic in the same sense that your grandfather’s radio is electronic.” The energized, improvisatory role of medical Twitter inevitably draws attention to what our balky, billion-dollar systems should have been providing—to the cost, in dollars and lives, of the rapid clinical learning that we’ve forgone.

It’s hardly news that our E.M.R. systems have failed medicine, and yet an executive order from New York State, issued at the end of March by Governor Andrew Cuomo, amounted to a grim epitaph: “Health care providers are relieved of recordkeeping requirements to the extent necessary for health care providers to perform tasks as may be necessary to respond to the covid-19 outbreak. . . . Any person acting reasonably and in good faith under this provision shall be afforded absolute immunity from liability.” A system designed to expedite and improve the delivery of health care was officially recognized as an obstacle.

“When the tide goes out,” Warren Buffett once said, “you discover who has been swimming naked.” The pandemic has been merciless in what it has exposed. In many cases, the weaknesses in our medical system were ones that had already been the subject of widespread attention, such as the national scandal of health-care coverage that leaves millions of Americans uninsured. In others, they shouldhave been the subject of widespread attention, because we had plenty of warning. Again and again, in the past several weeks, we’ve heard of shortages—shortages of protective gear, of ventilators, of pharmaceuticals. Yet, even before the crisis, medicine was dealing with troubling scarcities of needed drugs and support systems. Last summer, long before the pandemic, pulmonologists were raising concerns about a lack of oxygen supplies—the result of cost-cutting measures by suppliers of durable medical equipment. Competitive-bidding programs drove margins down so low that more than forty per cent of such companies—responsible for the supply of portable oxygen tanks and concentrators—went out of business. Inventory diminished; delivery times increased. Patients suffered. Neeta Thakur, a pulmonologist and researcher at the University of California in San Francisco, told me about the byzantine process (involving “ten to fifteen disconnected steps”) that was required in order for a patient to receive oxygen at home—a patient who is then at the mercy of the intermittent delivery schedules of understocked venders. The problem builds into a failure cascade: if patients cannot be discharged from the hospital because they cannot have oxygen at home, the resultant logjam delays the treatment of other patients who need those beds for acute care.”

Yet, taxpayers have spent $38B+ (!) on back door electronic medical record subsidies since 2011…..

Bruce Schneier:

“My problem with contact tracing apps is that they have absolutely no value,” Bruce Schneier, a privacy expert and fellow at the Berkman Klein Center for Internet & Society at Harvard University, told BuzzFeed News. “I’m not even talking about the privacy concerns, I mean the efficacy. Does anybody think this will do something useful? … This is just something governments want to do for the hell of it. To me, it’s just techies doing techie things because they don’t know what else to do.”

I haven’t blogged about this because I thought it was obvious. But from the tweets and emails I have received, it seems not.

This is a classic identification problem, and efficacy depends on two things: false positives and false negatives.

• False positives: Any app will have a precise definition of a contact: let’s say it’s less than six feet for more than ten minutes. The false positive rate is the percentage of contacts that don’t result in transmissions. This will be because of several reasons. One, the app’s location and proximity systems — based on GPS and Bluetooth — just aren’t accurate enough to capture every contact. Two, the app won’t be aware of any extenuating circumstances, like walls or partitions. And three, not every contact results in transmission; the disease has some transmission rate that’s less than 100% (and I don’t know what that is).
• False negatives: This is the rate the app fails to register a contact when an infection occurs. This also will be because of several reasons. One, errors in the app’s location and proximity systems. Two, transmissions that occur from people who don’t have the app (even Singapore didn’t get above a 20% adoption rate for the app). And three, not every transmission is a result of that precisely defined contact — the virus sometimes travels further.

Assume you take the app out grocery shopping with you and it subsequently alerts you of a contact. What should you do? It’s not accurate enough for you to quarantine yourself for two weeks. And without ubiquitous, cheap, fast, and accurate testing, you can’t confirm the app’s diagnosis. So the alert is useless.

Similarly, assume you take the app out grocery shopping and it doesn’t alert you of any contact. Are you in the clear? No, you’re not. You actually have no idea if you’ve been infected.

Catherine Nixey:

In the spring of 1822 an employee in one of the world’s first offices – that of the East India Company in London – sat down to write a letter to a friend. If the man was excited to be working in a building that was revolutionary, or thrilled to be part of a novel institution which would transform the world in the centuries that followed, he showed little sign of it. “You don’t know how wearisome it is”, wrote Charles Lamb, “to breathe the air of four pent walls, without relief, day after day, all the golden hours of the day between ten and four.” His letter grew ever-less enthusiastic, as he wished for “a few years between the grave and the desk”. No matter, he concluded, “they are the same.”

The world that Lamb wrote from is now long gone. The infamous East India Company collapsed in ignominy in the 1850s. Its most famous legacy, British colonial rule in India, disintegrated a century later. But his letter resonates today, because, while other empires have fallen, the empire of the office has triumphed over modern professional life.

The dimensions of this empire are awesome. Its population runs into hundreds of millions, drawn from every nation on Earth. It dominates the skylines of our cities – their tallest buildings are no longer cathedrals or temples but multi-storey vats filled with workers. It delineates much of our lives. If you are a hardworking citizen of this empire you will spend more waking hours with the irritating colleague to your left whose spare shoes invade your footwell than with your husband or wife, lover or children.

Or rather you used to. This spring, almost overnight, the world’s offices emptied. In New York and Paris, in Madrid and Milan, they ready themselves for commuters who never come. Empty lifts slide up and down announcing floor numbers to empty vestibules; water coolers hum and gurgle, cooling water that no one will drink. For the moment, office life is over.

Even before coronavirus struck, the reign of the office had started to look a little shaky. A combination of rising rents, the digital revolution and increased demands for flexible working meant its population was slowly emigrating to different milieux. More than half of the Ameri­can workforce already worked remotely, at least some of the time. Across the world, home working had been rising steadily for a decade. Pundits predicted that it would increase further. No one imagined that a dramatic spike would come so soon.

Tony Perez:

You can argue that the openness of the web has been dying for the past decade. For the web, death comes in the form of a centralization of control and power, and arbitrary authoritarian changes made for the “greater good.” 

The current state of our fear for the safety of public health has created the perfect event to push the pendulum out of balance. 

Let there be no mistake in our minds, the actions that my fellow technologists, and associated companies, are taking, and pushing, are things that society as a whole will feel in the not so distant future. 

The scariest part for me is that as a technologists, I have seen first hand what an organization can do with unfettered access to data, when the checks and balances are lost, when we believe we are the ones capable of dictating what is good for society, on their behalf, without choice, and what a little power can do to any person. 

What further amplifies the concern is that it is not government that is driving this “big brother” state of affairs, its big tech. These are entities that are not elected officials, but corporations that transcend physical and logical boundaries. They have the ability to influence what you see, what you think, and they have the ability to choose sides. 

——-

This was not a case of individuals selling snake oil. They were sharing their observations, and opinions. Right or wrong, is not the point. It’s the process of normal debate and discourse. They were also seasoned medical professionals.

Shortly after its release, it was removed from the platform. Because it didn’t conform to the guidance from the World Health Organization (WHO). Say what?

It seems a far stretch to remove their content simply because it doesn’t conform to WHO, and goes contrary to spirt of the examples Susan provided. In essence, YouTube is saying you are not allowed to disagree with WHO, at all; do so, and your content will be removed. But what if they are wrong? Are we not allowed to question that?

Once it’s demonstrated that a company has this level of power, how, who, draws the distinction between what government policies they conform with, and which you don’t? What happens when society as a whole disagrees? How do you say yes to state government, but not Federal? How do you tell China, Cuba, North Korea they are wrong for their censorship when we do the same thing?

Craig Timberg,  Drew Harwell and Alauna Safarpour:

A major source of skepticism about the infection-tracing apps is distrust of Google, Apple and tech companies generally, with a majority expressing doubts about whether they would protect the privacy of health data. A 57 percent majority of smartphone users report having a “great deal” or a “good amount” of trust in public health agencies, and 56 percent trust universities. That compares with 47 percent who trust health insurance companies and 43 percent who trust tech companies like Google and Apple.

“I don’t feel like they have a good track record of taking care of people’s privacy and data. And I don’t want to give them more if I don’t trust them,” said Brent Weight, 43, a Republican-leaning independent voter who runs a small trucking company in Rigby, Idaho. “Seems like every other day you’re hearing of a data breach in a big company, and they’re losing credit card information and everything else. For them to just tell us it’s going to be safe and anonymized, I’m not going to take them at face value.”

Among Americans overall, 41 percent say they both have a smartphone and are willing to use an infection-tracking app, the poll finds. Oxford University researchers have suggested that 60 percent of a country’s population would need to use a coronavirus-tracking app like this to stop the viral spread. Reduced adoption could limit its effectiveness in slowing new infections and deaths.

J Cavanaugh Simpson:

Twenty biomedical companies. Seventy nations. An aggressive search for COVID-19 treatments and vaccines is underway worldwide. Yet even 21st-century technology can’t match one man who curbed a major influenza pandemic spreading across the United States in 1957. 

Pioneering virologist Maurice Hilleman, now oft-forgotten, detected that pandemic from across the globe, convinced reluctant U.S. health officials to take notice, and single-handedly fostered a vaccine that became publicly available. All in just four months.

An irascible, no-holds-barred Montana farm boy born in the midst of the 1918-19 influenza pandemic, Hilleman survived diphtheria and Great Depression-era poverty to earn a PhD in microbiology and chemistry at the University of Chicago. Practical and impatient, he turned down the prestige of academia and primarily worked in industry, at the pharmaceutical company E. R. Squibb & Sons and later Merck & Co, where he led vaccine research for 25 years.

An iconoclast who slung swear words like the proverbial sailor, Hilleman helped develop an astounding 40 vaccines: to prevent measles, mumps, rubella, pneumonia, meningitis, hepatitis A and B, and other infectious diseases. The measles vaccine alone has saved an estimated one million lives a year. “Maurice’s genius was in developing vaccines, reliably reproducing them, and [taking charge] of all pharmaceutical facets, from research to marketplace,” biographer Paul A. Offit, MD, told the British Medical Journal for Hilleman’s obituary in 2005. The New York Times later noted that researchers credit him with “saving more lives than any other scientist in the 20th century.”

Saul J Weiner, Shiyuan Wang, Brendan Kelly, Gunjan Sharma, Alan Schwartz:

$37,920,077,070 in Taxpayer Electronic Medical Record Subsidies: 2009 – January 2018

Victor Davis Hanson:

The Bloomberg viral ironies did not end there. During his campaign, his prior folk wisdom emerged in a series of embarrassing videos of past sermons. In one, he lectured an Oxford audience about the banality and rote of farming, ancient and modern, claiming that he “could teach anybody to be a farmer.” Information technology, Bloomberg insisted, required “a lot more gray matter.” During the lockdowns in Manhattan, the country did not need any more multibillionaires with brains full of “gray matter” capitalizing Chinese communist government companies, but instead needed innovative farmers—you could call them “anybodies”—to keep sending a sheltered-in-place America the most diverse, safe, plentiful, and cheap food in the world.

The apparently consensually led China touted by Bloomberg has lied about the birth, origins, spread, and infectiousness of covid-19; sent over one million of its citizens into U.S. airports after Beijing knew that the virus was communicable; had countless more circumvent U.S. restrictions; falsely declared that the U.S. military created the virus; threatened to cut off shipments of medical supplies produced in China by U.S.–Chinese joint ventures; and caused several thousand American deaths while causing trillions of dollars’ worth of economic damage.

Not having control of the supply of needed medical appurtenances and medicines may be the Boomers’ version of the Greatest Generation’s waking up on December 8, 1941, and realizing that there was nothing in the American arsenal comparable to the Japanese Mitsubishi A6M “Zero” fighter or Type 93 “Long Lance” torpedo—and would not be for the months of hard fighting and dying ahead. Likewise, Beijing now enjoys enormous advantages in the short term as it inventories all the ways the American military, government, and consumers are China-dependent. Whether China has woken a sleeping giant in the manner of the earlier Japanese, or just a purring kitten, remains to be seen. One test will be whether we begin to recalibrate key American industries or unleash Adam Schiff to conduct yet another congressional investigation against his nemesis Donald Trump.

Before the epidemic, critics of globalization could not convince our best and brightest that enriching autocracies by asymmetrical trade policies would not eventually turn China into Jackson Hole or Palm Beach. Doubters of America’s China policy complained that running up staggering American trade deficits with China would hardly lure China into the family of nations—at least in the manner of Barack Obama, who in 2014 once boasted that his new outreach initiatives with Beijing, inter alia, would “help affected countries to strengthen capacity-building on health and epidemic prevention so as to place the epidemic under control as soon as possible.” How has China’s envisioned “epidemic prevention” and “control” worked out?

So the virus confirmed what many Americans had long suspected at home as well. “Trump Derangement Syndrome” was no longer a Republican talking point, but was exposed as a psychosis with real consequences for the entire country. In the initial weeks of January, when Trump was told by the who, the Centers for Disease Control, Dr. Anthony Fauci, and most foreign and American leaders that the virus, like the earlier Chinese-born sars virus, was containable, the President, like they had at times, compared it to a bad flu. But by January 31 he had reversed course earlier than many of his future critics, rejected the earlier insistence of experts that xenophobia, racism, and chauvinism, and not the virus, were the real enemies, and issued travel restrictions—the one step that stopped some fifteen to twenty thousand Chinese nationals from arriving daily into the United States, including on direct flights from ground zero in Wuhan. Altogether over a million Chinese had arrived in October, November, December, and January. After the restrictions were enacted, many more found ways to enter the United States on connecting flights from non-embargoed nations in Europe and Asia.

No matter. House Speaker Nancy Pelosi claimed Trump’s response to the virus had been “deadly” and later added, “As the president fiddles, people are dying.” At about the same time, she tried to delay passage of a joint congressional bailout bill intended to keep endangered small business and the unemployed afloat as she scrambled to insert funding for the Kennedy Center and Planned Parenthood.

Rory Sutherland:

One obstacle might be the boredom threshold. If you are used to a high-octane life on the Grand Prix circuit, a three-hour meeting with healthcare regulators might leave you wanting to bite your arm off. Once, by accident, I ended up as part of a project-management workgroup seeking regulatory approval for a drug: after the 18th Gantt chart, I experienced one of those moments where boredom becomes physically painful.

But the other issue at stake is the difference between deterministic and probabilistic improvement. If you engage engineers, you don’t know what you are going to get. You may be unlucky and get nothing. Or their solution may be so outlandish that it is hard to compare with other competing solutions. On average, though, what you get will be more valuable than the gains produced by some tedious restructuring enshrined in a fat PowerPoint deck.

But in business, let alone in government, it is only in crises that people find a budget for probabilistic interventions of this kind (in peacetime, nobody would have given Barnes Wallis the time of day). The reason is that both bureaucrats and businesspeople are heavily attracted to the illusion of certainty. Standard cost-cutting ‘efficiencies’ can usually be ‘proven’ to work in advance; more interesting lines of enquiry come with career-threatening unknowability.

One problem with this pretence of certainty is that cost-savings are more easily quantified than potential gains — so business and government are increasingly geared towards providing people with more, poorer things at an ever-lower price. Yet much evidence suggests that people like fewer, better things at a slightly higher price.

Indeed one reason why the world is in a mess is because, for a long time, the ratio between ‘explore’ and ‘exploit’ has been badly out of whack. Entities like procurement have been allowed to claim full credit for money–grabbing cost-savings without commensurate responsibility for delayed or hidden costs. The shadow of this is everywhere, from Grenfell Tower to PPE shortages.

Daniel Larison:

The core of the book is a survey of three different sources for the unraveling of U.S. hegemony: major powers, weaker states, and transnational “counter-order” movements. Cooley and Nexon trace how Russia and China have become increasingly effective at wielding influence over many smaller states through patronage and the creation of parallel institutions and projects such as the Collective Security Treaty Organization (CSTO), the Shanghai Cooperation Organization (SCO), and the Belt and Road Initiative (BRI). They discuss a number of weaker states that have begun hedging their bets by seeking patronage from these major powers as well as the U.S. Where once America had a “near monopoly” on such patronage, this has ceased to be the case. They also track the role of “counter-order” movements, especially nationalist and populist groups, in bringing pressure to bear on their national governments and cooperating across borders to challenge international institutions. Finally, they spell out how the U.S. itself has contributed to the erosion of its own position through reckless policies dating back at least to the invasion of Iraq.

The conventional response to the unraveling of America’s hegemony here at home has been either a retreat into nostalgia with simplistic paeans to the wonders of the “liberal international order” that ignore the failures of that earlier era or an intensified commitment to hard-power dominance in the form of ever-increasing military budgets (or some combination of the two). Cooley and Nexon contend that the Trump administration has opted for the second of these responses. Citing the president’s emphasis on maintaining military dominance and his support for exorbitant military spending, they say “it suggests an approach to hegemony more dependent upon military instruments, and thus on the ability (and willingness) of the United States to continue extremely high defense spending. It depends on the wager that the United States both can and should substitute raw military power for its hegemonic infrastructure.” That not only points to what Barry Posen has called “illiberal hegemony,” but also leads to a foreign policy that is even more militarized and unchecked by international law.

Cooley and Nexon make a compelling observation about how Trump’s demand for more allied military spending differs from normal calls for burden-sharing. Normally, burden-sharing advocates call on allies to spend more so the U.S. can spend less. But that isn’t Trump’s position at all. His administration pressures allied governments to increase their spending, while showing no desire to curtail the Pentagon budget:

Retrenchment entails some combination of shedding international security commitments and shifting defense burdens onto allies and partners. This allows the retrenching power, in principle, to redirect military spending toward domestic priorities, particularly those critical to long-term productivity and economic growth. In the current American context, this means making long-overdue investments in transportation infrastructure, increasing educational spending to develop human capital, and ramping up support for research and development. This rationale makes substantially less sense if retrenchment policies do not produce reductions in defense spending–which is why Trump’s aggressive, public, and coercive push for burden sharing seems odd. Recall that Trump and his supporters want, and have already implemented, increases in the military budget. There is no indication that the Trump administration would change defense spending if, for example, Germany or South Korea increased their own military spending or more heavily subsidized American bases.

The coronavirus pandemic has exposed how misguided our priorities as a nation have been. There is now a chance to change course, but that will require our leaders to shift their thinking. U.S. hegemony is already on its way out; now Americans need to decide what our role in the world will look like afterwards. Warmed-over platitudes about “leadership” won’t suffice and throwing more money at the Pentagon is a dead end. The way forward is a strategy of retrenchment, restraint, and renewal.