Health Care Comparison

This week I did a "physical assessment" at Kaiser Permanente--it's their jargon for an old fashioned physical. Interesting contrast with private physician service, in that their laboratory is in the same building as the doctor's office. So when I told the doc that my hip hurt sometimes, he sent me off to get x-rays, it took 15 minutes, and he told me I've moderate arthritis in the hip, take anti-inflammatories and so long.

One of the points I'd make is that, when we think of "patients" as being reasonably healthy and mobile, the travel and coordination required by the specialization of services in different organizations (as I blogged in August) is tolerable. It's like New Orleans thinking of its citizens as mobile and able to evacuate. But when the patient is ailing and hurting and not so mobile, it becomes a real big deal.

Factors Affecting Government Response to Katrina

I commented at Marginal Revolution on a Tyler Cowen post.
(I thought I did, but it's not visible, so here is a modified version):

Being a retired bureaucrat, not an economist,and operating from ignorance, I'd put another slant on the subject. Though I voted against Bush, I have to console myself that the criticism, some unwarranted)he's getting now is balanced by unwarranted praise after 9/11. I'm particularly interested in the comparison between Katrina and last year's hurricanes. Factors I haven't seen fully discussed include:

1. Wealth tells. The hurricanes last year hit Florida, much richer than Mississippi and Louisiana. The physical infrastructure is greater (more roads, more of everything) and the redundancies in networks are greater. Skinny people and skinny governments can have problems handling sudden illness. One truism of free markets is "you get what you pay for". That's also true for government. (It's no coincidence that Fairfax county, VA ranks high both on wealth and on government.) My impression is that all three states affected by Katrina are less than models of democracy. (See "All the Kings Men".)
   
2. Timing counts. Yes, those who live from check to check, whether pay or welfare, were hurt by the timing of Katrina. But Bush wasn't the only bureaucrat on vacation on August 28. French society notoriously shuts down in August. The U.S. government isn't that bad, but late August is a great vacation time.
   
3. "The American government system is a mess", a paraphrase of a BBC reporter, is right (as the Founders intended). Because we don't have the sort of hierarchical system Cuba has (a post referenced from Marginal Revolution said that Cuba had successfully evacuated last year in advance of a big hurricane using its system of and China and the USSR used to have, schools are the best way to get information into the community. I doubt that New Orleans schools were open yet, and if they were, the weekend timing would have cut off that avenue of coordinating evacuations.
4. The power of math. FEMA coordinates. In last year's Florida hurricanes they were coordinating mostly with one state and I don't think the Corps of Engineers, Coast Guard, or regular military had any significant role. This year they had multiple states simultaneously, plus a bunch of new players. (Just ask your secretary about the amount of work to place one phone call versus setting up a conference call--as the number of parties expands the work involved increases exponentially, not arithmetically.) Assuming they trusted the state people, last year the only allocation issue was: do we have what you need? This year, the issue is: which state needs limited resources most.
5. Two disasters, not one. We've not had levee breaks and hurricane damage in one event for a long time. It pulls in more "stakeholders" to coordinate and poses new problems to learn.
   
6. Never underestimate learning. I say over and over, we never do things right the first time.
7. Finally, politics matters. Last year every bureaucrat in the Florida and federal governments knew that their boss's rear was on the line if the hurricanes weren't handled well. Neither George nor Jeb had to say a thing; it was in the air. That knowledge makes a difference on the margins, not the center. The question is: do you make one more phone call, check one more city block, bite your tongue a little harder to work cooperatively with someone in another agency. Knowing the big boss will get very excited over failure helps then. This year, George is a lame duck, the Louisiana governor is a Democrat, so....

Regardless of the above, neither Albaugh nor Brown nor Brown's no. 2 should have been appointed to that job. That's Bush's culpability--personnel selection.

Social Networks and Katrina

One of the interesting things (rather cold statement) in the aftermath of Katrina is the unexpected (to me) profusion of extended families among the evacuees. Mostly black, but some white, although that's the proportion of media coverage, it seems lots of people have lots of siblings, cousins, uncles, aunts, who may evacuated together, got separated in the evacuation, or stayed behind to help relatives. It makes for a good story, a lot better than the individuals who were by themselves. Is this area of the South home to more extended families who seem to have been relatively immobile than other areas?

I've a hypothesis in mind--familial bonds are literally that--ties that can and do hold one back from individual achievement but supports that rescue one in times of peril.

Ganging Up on Barbara

The Post ran an article this morning on Barbara Ehrenreich and her new book. I'd had mixed feelings about her last one, Nickeled and Dimed, along the lines of "yes, but". Haven't read the new one, but was ready to fire off a blog article saying: " a 64-year old looks for a $50K job in PR while lying on her resume? Give me a break, there should be no reasonable expectation that she get a job."

Then I found that Tyler Cowen and Alan Wolfe in Slate were taking the same line, after having read the book (they try to uphold intellectual standards, I don't).

But consider this excerpt from the Post article (which is standard puff-the-writer stuff)--No Help Wanted, hitting a point Cowen and Wolfe haven't discussed yet:

"But in the end, what outraged her the most was the pervasive blame-the-victim ethos she encountered. Personal responsibility is a fine thing, she says, but it's not the same as omnipotence. Yet over and over, the newly unemployed were told: You totally control your own fate. At an 'executive boot camp,' the leader hammered the core message home:

'It's never about the external world,' he said. 'It's always between you and you.'"

I can understand how that might provoke outrage, but the reality in the situations is that it is all about "you". In today's environment, neither unions nor political action are a realistic route for the middle class job seeker. Controlling oneself is the only thing a person can control. So their alternatives are bleak: change oneself to be a more acceptable employee or endure. (Or perhaps, seek ease in religion.) (Can you see my inherited Calvinism emerging?)

Social Structure--Tsunami and New Orleans

Heard someone on TV observe that there was more reconstruction activity at tsunami sites he'd seen than there was in Katrina's aftermath. First, I'd take that with a grain of salt--comparisons are tricky, particularly when comparing something that's fresh on our mind and something from a year ago. Second, it's probably true, for a number of reasons:

• the disaster is different--the tsunami, like 9/11, destroyed one time. Katrina's flood waters are still in New Orleans (Biloxi and Gulfport would be similar to the tsunami
• the social structures are different--Indonesia and Sri Lanka have flatter structures than New Orleans
• the technology is different. If the water comes from a dug well, it's easier to reestablish than if it comes from a water treatment plant dependent on power.
• the expectations are different. The rescuees in New Orleans, many of them, accept the idea that the government should be responding. I doubt the rescuees in the tsunami had the same expectation--they'd little experience of a reasonably effective government before the disaster so why should they wait to see what it would do after? (This is the "moral hazard" that insurance companies and right wing economists love to cite--by doing something to decrease risk you change the behavior--sort of like the heisenberg uncertainty principle. However, I don't buy it as an argument against effective government.)

Disaster as Revealing Social Structure

Several years ago a heat wave caused several hundred deaths in Chicago. A social scientist, Eric Klinenberg studied the event and wrote a book . The review on Amazon is fair and interesting--here's an excerpt:

"When the record-breaking heat and humidity arrived and stayed, these men and women started dying, one at a time and quietly, behind closed, locked doors. The immediate reasons were apparent. Many seniors did not have air conditioning in their houses or apartments. Of those who did have air conditioning, many chose not to use it, fearing utility bills that they could not afford to pay. Fear of crime kept others from leaving their homes to use free neighborhood "cooling centers." Still other elderly Chicagoans knew, from a physiological standpoint, that they were hot but were simply unaware that they were in danger. Klinenberg shows in detail how the tragedy was compounded by many factors and interests, including a public health and medical establishment that did not anticipate the magnitude of the looming danger and local news media that treated the severe heat and humidity as little more than a novel topic for lighthearted feature stories. The author also examines key sociological factors relating to the elderly, including the perils of "aging in place" while the surrounding environment changes; the idealization and valuing of personal independence among seniors; and differences between men and women in the establishment of friendships and other interpersonal connections.."

[The review criticizes Klinenberg for politicizing his analysis, which may be fair.]

I'm wondering how much of this is going to turn out to be true in New Orleans, replacing lack of AC with lack of operational cars?

A side note, while some have seen racism in the response to the hurricane, I suspect a fair part of the problems in the pre-hurricane planning is our human tendency to stereotype--that is we can't comprehend the vastness and variety of the human landscape so we simplify, thinking of the two-parent family with car, etc. etc.

What Does "Modem" Mean?

I'm still amazed that there's problems in communicating across radio systems. 25 years ago engineers had solved the problem of converting analog sound signals into digital signals and back in something call a "modem". (Anyone remember when a modem had a cradle for the phone receiver?) Surely you could kludge up a partial solution to the problem without much effort. But I guess FEMA and DHS never made a market for such solutions. Did they hope to convert everyone to the same system? That would be optimal, but the best is often the enemy of the good.

Silos and Katrina

Katrina exposes not only the class divide that David Brooks cites, but the silos resulting from our system of weak and divided government. (Professor Bainbridge cites the opposite position--the problem is big public bureaucracies.) Items:

• each entity has their own communication system and, incredible as it seems, almost 4 years after 9/11 there are still areas where they can't communicate (I note that private enterprise hasn't been able to agree on standards for the next version of DVD so there's no magic there.)
  
• the National Guard works state by state
• each bureaucracy does its own thing by its own rules
  
• the Corps of Engineers and FEMA may not coordinate well (it will be interesting to see in the postmortems the extent to which the design limits of the levee system was factored into disaster planning and whether, in the decisionmaking leading up to the design decision, the problems of evacuating 100,000 people with no means of private transport were realized)

It all gets back to the question of how you achieve aims by organization and minimize the problems across organization. I don't think there's a perfect solution, but we can certainly improve on Katrina

Respect for All Beliefs, or Just Religious Ones?

The Washington Times reports that the Naval Academy will retain its noonday prayer described thus:

" The brigade of about 4,000 students gathers at noon at King Hall. They stand by their chairs for announcements and the welcoming of any guests. Then, one of the school's six chaplains delivers a nondenominational prayer. Sometimes a moment of silence is observed instead.
'Those who want to participate may do so,' Cmdr. Gibbons said. 'Those who do not wish to participate do not have to pray. But they are expected to remain respectful for those who do.' "

While the ACLU might have a problem with this, I don't, except. (There's always an "except".) A paper, maybe the Times, did a piece recently on the chaplain problem in the military, including a table listing the number of military personnel by religious affiliation and the number of chaplains. The focus was on evangelical chaplains, but I was fascinated to see that around 100,000 military had no affiliation. Of course, there were no chaplains with "no affiliation".

My point is that there seems to be no military context/ceremony that would call for religious people to "remain respectful" for those who have different beliefs.

God Is Better Than "I"?

The New Scientist reports on a study of meditation which showed that:

"People practising spiritual meditation were more relaxed and better able to withstand pain than those performing secular meditation.

College students who volunteered for the study were randomly assigned to one of three groups regardless of their spiritual beliefs. The 25 students in the spiritual meditation group were told to concentrate on a phrase such as 'God is love' or 'God is peace' during their meditation periods. Those in the secular meditation group used a phrase such as 'I am happy' or 'I am joyful' while the third group were simply told to relax."

Seems to me a biased study. Surely the variables should be "God" (perhaps using various names and concepts) and "the universe". My image of Christianity is that one's sins are washed away in a union with God; my image of atheism is that one's defects and sins lose significance when viewed with the universe. Am I saying I'm more of a pantheist than an atheist? Perhaps but that's a fairer comparison than asking someone to focus on himself as opposed to God.