Perspectives in Public Health

Monday, April 23, 2007

This diagram from Franklin's text book shows the basic parts and connections for a "cruise-control" system, to keep a car moving at a pre-set speed.

It's relevant because the parts and the flow are universal patterns that you can find in almost any system, whether it's man-made or biological or chemical.

The discussion below will start to get way more complicated than is typical for a public health model, but still far less complicated than a typical "control system" problem that engineers solve routinely when, say, designing a new fighter jet.

It doesn't matter that it has many parts and connections, which televisions and cell-phones also do -- it only matters that they number is small enough that the data fit into the computer tool and generate an answer that can then be tested independently. Even three loops, as in the Beer Distribution problem Senge describes in "The Fifth Discipline", is beyond normal human intuition, so beyond that it is pretty much all the same whether the model has 4 loops or 14.

Obviously, for parameter fitting, we want to have a lot more data than unknowns, a constraint that may often be easily met in practice with time-series data. For example, in a year there may be 365 blood glucose readings, which may be rich enough to nail down an 12-parameter model with data to spare.

So, bear with the complications. They turn out not to matter very much.

The picture above shows is a goal, which in the case of a car is the desired speed, shown way at the left of the diagram. This goal goes into the blue box, labelled "controller", which we'll discuss much more shortly. For now, that functions is done by either the computer or the person driving. The controller has something it can control, in the case of a car this is the gas-pedal (throttle). Pushing the pedal down asks the engine to produce more power, which may have some lag time before that takes effect. The power flows into the body of the car, tending to make it go faster, if it weren't for the outside influences that also affect the car, such as whether it is climbing a hill or going down one. The two forces combine to produce one outcome - the actual speed of the car.

The actual speed is perceived by some sensor, such as a speedometer, which also has some distortion and noise affecting it, and possibly some additional lag time. Then the perceived or "Measured" speed is conveyed back to the blue box, the "controller".

At this point, the cycle starts again, but this time with a difference. The controller "knows" what speed it wanted, and can "see" what speed it has achieved, and so it can measure whether it has succeeded in getting the car to go fast enough. The "feedback", by itself, is not positive or negative - it is just information about the car. What the controller does with that information is positive or negative, and is based on an analysis of (a) what the difference is from what was wanted, (b) and how fast the difference is changing or closing the gap.

Part B is really important. If the decision was simply to hold down the gas pedal to the floor until the desired speed was reached, and then release it, the car would overshoot the right speed and be going too fast. Then, if the decision was to slam on the brake until the car slowed down to the right speed, the car would overshoot again, and end up going too slowly. The result would be a rapid cycle of going from too fast to too slow that would never stop.

Not only does the controller have to have some wisdom, it has to have some foresight. If a baseball outfielder's rule was "run towards the ball", as soon as the ball was hit by a batter the outfielder would run towards home plate, where the batter is or just was. Instead, the right thing to do is to run towards "where the ball will come back down, not where it is now."

So, the controller has to decide several things. How far off from the goal is the current outcome? How fast is it catching up? Should something be changed and, if so, which direction?
(For example as it comes up near the correct speed, the gas pedal will have to be let up on slightly, even though the car is still going too slowly!)

It's even worse if the controller had no idea to start with what each of the pedals did, as with a student driver, and had to learn that "pushing the one on the right often makes the car go faster, except going up a steep hill when the car still slows down" and "pushing the one on the left makes the car go slower, except when going down a steep hill when the car may go faster anyway."

Now, add to this the addtional problem that maybe the controller cannot actually see what the ground is doing and has to guess at that as well, based on the response of the car. Finally we have a situation typical for a person learning how to control their blood sugar -- SOMETIMES, eating more carbohydrates helps, but SOMETIMES it doesn't seem to matter, except that SOMETIMES it really makes things worse.

Control System Engineering (CSE) is the study of how such control systems behave, although this is about as simple as one gets, with only one loop in it. Real systems, as are studied in "Systems Thinking" or "Systems Dynamics" have multiple loops that intersect each other, possibly in multiple places. To predict the behavior of those, or to CHANGE their behavior in a desired way without "unintended side-effects", intuition is almost impossible, and some more powerful tool is required.

Fortunately, CSE is well over 100 years old, and has already developed full tool-boxes that do the computational heavy lifting for you, just as products like STATA and SAS and SPSS do the heavy math of statistics for you, so you can just use the results.

The issues in designing a control system come down to figuring out what should go into the blue box, the "controller", which is unhelpfully left off entirely from most "feedback diagrams" in the public health or health literature.

Some of the issues that can be solved involve trade-offs in these factors:

Stability: will the overshoots and oscillations calm down over time and go away, or will they actually get worse and worse until something breaks?
Steady state value: if left alone, where will it settle?
Rise time: how fast does the system close the gap between the actual and desired outcomes?
Cost: how much does it cost to make such a system?
Overshoot: how much does the system overshoot the desired value? (Sometimes overshoot is very bad and has to be avoided, as in an example of too high a dose of medicine, in which case the system should come up to the right value slowly from below.)
Disturbance rejection: this is a fancy name for how well the system can maintain a steady value despite changes in the outside world. For a car going 60 miles per hour, for example, it measures how much the speed will change if the car goes down or up a hill.
Response time: How long does it take the controller to figure out that something external has changed and it needs to apply some sort of corrective action?
Lead time and lag time: How long does it take, from the time the gas pedal is pushed, before the engine starts to produce more power? In a small airplane for example, it takes about 4 seconds from the time the throttle is changed until the engine starts delivering more power.
Sensitivity: what happens if the engine gets older, or some days the "oomph" just isn't there, even when the "gas pedal" is pushed? Can the controller adjust for that?
Dynamic tracking: if the goal is changing, how well can the system "keep up" with the ever-changing goal? Can the system deal "if the cheese is moved" or did it only learn one pattern and if the rules change the system will just keep on trying to use the old way to try to cope with a new problem?

With human beings involved, there are some additional variables that are not quite so prevalent in hardware.

For one thing, there is a second "motivation" loop that can sag if too little "success" occurs, so it may be necessary to "lower the goal" temporarily to get motivation interested in action again, before raising the goal back up again slowly enough to not lose that sweet relation between the goal and success.

Also, humans have a third loop that can reduce the frustration of conflict between a goal and the actual outcome by changing the sensor - that is, altering their perception of how well they are doing, so that it better matches the goal.

Too strong a demand and pain related to conflict can result in altering perception, not altering action or actual outcomes.

Finally, humans have a fourth loop that can reduce the gap - simply shoot the messenger, or stop going to the doctor. Eliminate the thing that is making that annoying goal show up at all.

Of course, exactly the same relief from pressure can be accomplished by letting the feedback loop simply fall apart. Hospitals tend to do that with JCAHO requirements, once JCAHO team leaves. And, patients tend to do that with medical advice.

So, a fifth and sixth loops are needed to capture the external world's pressure and impact, not just on the "body" in question, but directly on the goals, in response to the actions taken (the equivalent of pushing the gas pedal), and onto the ability of the person to perceive what is going on, that is, on their "sensors."

Brief digression for two stories:

A crowd or audience can dramatically shift what can be perceived, something I have first hand knowledge of from doing stage magic in a crowd. Interestingly a crowd of young children is way more perceptive than one child, but a crowd of adults is way less perceptive than any one adult alone, at least when it comes to seeing how a magic trick is "done". In my own experience with such deceptions, a person can see what you have done, then try to tell a neighbor, and if the neighbors all put him down and say "No", he will actually forget entirely that he ever saw the issue in the first place. It's remarkable.

Research on the impact of crowds on individuals has one dramatic video in it that may have been done at Cornell in the late '60s, and was certainly presented by Allan Funt on the TV show "People are Funny." An unwitting subject gets on an elevator on floor 1 of a building going up, and the elevator only has a front door. At each successive floor upwards, an investigator gets on, walks to the back of the elevator, and faces the blank back wall - that clearly cannot possibly open. When the first one does this, our victim glances and ignores it. When the second one does it, he looks somewhat anxiously to see if there is a back door, but decides against it. When the third one does it, the victim simply pivots in place and faces the back wall along with everyone else. The magic number at which people spin around seemed to always be 3.

Returning to the main discussion:

So, we have a tangle of loops that leave the one person and go up to the person's family and friends. Is the problem now hopeless? No, because there is another "break point", after the "single person" break, there is a person and his or her "posse" or "gang" or small group of reference people. This is a cluster of people that are far more interactive with each other than with the outside world, and in some ways a "unit".

In a hospital or health care system, as the IOM report "Crossing the Chasm" points out, there are natural breaks and natural edges to "small care teams" or "microsystems." These are a group of people who collectively deliver care, and who interact far more with each other than they do with the outside world. They are, in a very real sense, a "unit", or "a system", but not just a heap or list of people who communicate - it is far deeper than that. They are directly tied into each other's goal setting, reward system, norm setting, etc. They are directly dependent on each other in a very real way many times a day. They can't get their job done if the other people don't do theirs.

So, the IOM conclusion, demonstrated in many examples, is that this next higher level unit of tangled control loops, the 'small team' or "microsystem" is an even better place to intervene in changing behavior and perception than at the individual level.

It's easier to change a dozen tangled people at once than one person. In fact, there is no way to change "just one person" in such a distributed control system, because the others will restabilize them right back to where they were as soon as you let go.

This is a deep and profound insight. It totally changes how to proceed.

Taken a little further, this suggests that the concept of "a patient" as "an individual" is a broken model. This is certainly true of primates, where there is a saying that "There is no such thing as one chimpanzee." The reason this is true is that a solitary chimp doesn't behave at all the way it will behave in its normal group of chimps. In fact, given the choice of food or a look out a window to see what its herd (?) is doing, even a hungry chimp will select opening the window. Without belonging, there is no point in eating or being alive. It's a chimp level equivalent of cellular apoptosis - where a perfectly healthy "cell", if removed from a human, and subjected to no other stresses, will basically lose the will to live and commit suicide.

Connectivity seems to be some kind of critical factor for humans. Infants that are not touched can simply die. Adults who lose social connectivity have far worse outcomes than those who have not.

The point for us, however, is that the simplest feedback loop is, in reality, a tangle of maybe a dozen or so loops.

This is ok, because no one has to have intuition about the tangle directly, it just has to be small enough that the data can be put into the computer so the computer tools can figure out the simplest feedback loop model that fits the data.

This process of "model discovery" is also well known and there are tools for it as well.
However, to my knowledge, no one has ever tried to fit a multi-person dataset using such tools from control system engineering, let alone used the model to design an intervention and deduce, as it were, "where to push" so that the desired outcome will emerge after all the echoes die down.

One more sidebar. Because the purpose of all this system may be to produce a "clamp", that is, to lock an outcome to a particular value (say speed of a car) despite many external changes (hilly terrain), the use of classical statistical reasoning and "causality" breaks down, and process control measures have to be used instead. If the inputs are varying all over the place and the output is constant, classical statistics will say "NOT ASSOCIATED", yet is precisely the role of the 'control system' to BREAK the association between external events and some outcome. The challenge is to spot that two things are unexpectedly NOT associated.

That's more than enough text for one slide.

References will go here, when I have time.

"Systems Thinking" is now part of the 2006 ASPH MPH Curriculum, and was featured in the March, 2006 AJPH issue. Stedman's book "System Dynamics" is certainly enough to intimidate anyone, at 998 pages. See the links in "the law of unintended consequences"
to the MPH curriculum, Stedman, Jay Forrester's classic paper, etc.

capstone slide 17

It is really important to distinguish between analytically solving a problem, and navigating through to a solution.

Academics may attempt to discern what is involved, in the general case, in getting to Safeway to buy groceries, but most of us don't wait for the answer and just go.

This is a problem which can be navigated, even though the solution cannot be well articulated. That such things exist, and are in fact common, is a rather important insight.

In fact, there is no solution to the question "which way do I need to point my car so it will go directly, without changing direction, from the School of Public Health to the Safeway down by the harbor southeast of the Wolfe-street building?"

If you seek "an intervention" that will get the car from here to there in "one direction" it will be fruitless. What is needed is a strategy for navigating, and the flexibility to recognize that "driving", like "living" involves many changes in direction. Seeking "one change" that will accomplish a task, on the geographic-direction world, won't work. The change has to be sought on the "how do I navigate?" world.

In the "navigate" world, the answer is easy: "Head south till you can't go south anymore because you'd run into the water, then turn left, keep the water on your immediate right, and go till you get to Safeway. "

What I'm thinking here is that too much expert advice is attempting to give a patient a "single direction solution" when there are no single-direction solutions in the real world, and patients need to be encouraged to open their eyes and steer their own car and not drive into the water.

Empowerment is not an "option" -- it is the only way to navigate rough terrain with unknown and unknowable obstacles ahead.

capstone slide 18

Pathmaker software vendor: http://www.skymark.com/

Index to the whole capstone presentation is here.

Link to my entire 1o minute presentation with audio, in powerpoint is here.

capstone slide 19

capstone slide 20

The University of Michigan Diabetes Center has a diabetes patent empowerment survey instrument, which they say is validated, which can be taken over the web. See Anderson RM, Funnell MM, Fitzgerald JT and Marrero DG, The Diabetes Empowerment Scale: a measure of psychosocial self-efficacy,
Diabetes Care, Vol 23, Issue 6:739-743, 2000 (journal of the American Diabetes Association)

and a letter: Anderson RM et al, The Diabetes Empowerment Scale Short-Form(DES-SF), Diabetes Care 26:1641-1642, 2003.

The Michigan Diabetes Research and Training Center has additional information on this and other survey instruments.

capstone slide 21

capstone slide 22

capstone slide 23

37 signals has marvelous products that have received extraordinarily good reviews for being amazingly easy to use. (disclosure: I have no financial association with 37signals - I just love their philosophy and product design!)

You can see the site here
http://www.37signals.com.

Or, if you are at the live presentation, I'll give you a link to my own BaseCamp site and you can check it out directly and play around with it.

From that site, comments I agree with entirely:

94% recommended
In a recent random customer satisfaction survey, 94% of Basecamp
customers and 96% of Backpack customers surveyed said they would recommend
the products to their friends, family, and colleagues. Thanks!
The buzz
We’re fortunate to have the press saying nice things about us. Basecamp received a BusinessWeek Best of the Web award in 2005 and 2006. A PC World review called Backpack “Tremendous.” [see the blue box] Time Magazine named us one of the Net's rising stars.
Business Week is quoted in the BaseCamp specific page as follows:
“Basecamp is so simple you can't do anything wrong. It's addictively easy-to-use.”
-Robert Hof, BusinessWeek
And - a simpler user version of all the products is zero cost, free. And, even if you want to upgrade because you're hooked, there is no set-up cost, it's billed month-to-month, and there's no termination cost. That's about as good as it gets.
I wrote an entire paper on how 37signals tools would be useful for Disaster Preparedness, that I may put on-line soon.

capstone slide 24

capstone slide 25

Saturday, April 21, 2007

REACH Detroit , a CDC project

So, I was discussing my 1-day-old Johns Hopkins MPH Capstone project with Bree, and she said, oh yes, she'd worked with the "REACH Detroit" group, sponsored by the CDC, as part of her MPH work at UM/SPH. So I came home and found REACH Detroit Partnership.

(to the left is a picture of my wife Cheryll holding Bree's new daughter.)

REACH, by the way, turns out to mean: Racial and Ethnic Approaches to Community Life.

See this on the REACH 2005 Community Report (in English) for Detroit

which me refers to Dr. Michele Heisler's work, as in:

Heisler, M., Piette, J., Spencer, M. S., Kieffer, E., & Vijan, S. (2005). The relationship between knowledge of recent hemoglobin A1c values and diabetes care understanding and self-management. Diabetes Care, 28, 816-822.

Michael S. Spenser, UMich School of Social Work.
Spencer, M. S., & Chen, J. (2004). Discrimination and mental health service use

Dr. Jackie Two Feathers (see cite further below)

Dr. Edie Kieffer "Reducing Disparities in Diabetes Among African-American and Latino Residents in Detroit: The Essential Role of Community Planning Focus Groups", in Ethnicity and Disease

It may be that Edie Kieffer was or is the PI of the project.
The CDC National site on REACH has links to others of the 24 cities involved and a map.
and links to funding announcements (looks like a Cooperative Research).

THE Detroit site lists other articles (go there for actual working links)

Sunday, April 01, 2007

Key findings from public health

Healthy "people" aren't localized rocks, but are normally well-interconnected bidirectionally into the social fabric around them.

Social connectivity is the most robust predictor of internal, "physiological", "biomedical" outcomes, such as morbidity, mortality, survival rate of surgery, resistance to infection, level of depression, outcome of diabetes, obesity, "mental" health, you name it.

Prevention is a thousand times more cost effective than repair. ( A lesson from software engineering and many other fields as well.)

The caring human loving touch of another individual is very important to human health and healing. Infants who aren't touched do poorly or simply die.

All interesting social phenomena (such as relationships, jobs, teams, family, stress, love, sex, the economy, depression) involve intimately bidirectional feedback loops.

But, classical statistical measures and attitudes, based on prediction of yields of crops, assume critically that causality is defined in one direction only, and that all phenomena of interest can be "isolated" from context and one part of it varied by the experimenter while other parts of it are "held constant." None of that applies to "complex adaptive systems", including social systems, which are inextricably interconnected, context-dependent, interdependent, and riddled with bidirectional feedback loops. Since the tools and expertise breakdown when applied to these areas, rather than admit that the tools and expertise are inadequate, the problem space is instead defined as "non-scientific" or "soft-science" and demeaned as unimportant or "non-scientific."

Possibly due to such schizophenia, the US "healthcare" system behaves as if none of the above solid empirical facts were known. There is no focus on social connectivity, less than 2% of the budget is spent on prevention, and machines and processes have replaced people at the bedside. People are treated like machines, and diseases are treated as if they were independent of each other and the rest of peoples lives. "People" are reduced to "patients". "Caregivers" are too busy to stay and chat for a while with "patients" and are increasing renamed "providers" which is ironic, since mostly they consume resources, particularly money, while being forced by "the system" to be too busy to stick around and observe the actual outcomes of their "treatments" on the people they serve. It's a lose-lose scenario, disliked by the patients, disliked by the caregivers, and apparently continues to exist because it's loved by the insurance companies. The whole thing needs to be rethought based on the above new facts of life.

Perhaps, not surprisingly then, the outcomes of the US Healthcare system are terrible, compared to peer countries. Infant mortality is something like 19th in the world. Costs are huge but a recent study showed that the BEST quartile of US citizens (the rich) have health outcomes worse than the WORST quartile of British citizens in the UK. (ref ?). Depression, obesity, diabetes are widespread and rampant epidemics in the US.

But, efforts to build healthcare interventions that are designed around social connectivity and whole persons are demeaned and ridiculed as being "non-scientific", or avoided because the feedback loops make computing "p-values" problematic for academic researchers, for whom such mathematical bases for certainty are held with a sort of blind obsession despite the fact that the assumptions of the theory (General Linear Model) don't fit the problem they're trying to address.

The result is that the most effective interventions are known, and involve teams of people assisting individual humans to modify or control their behavior and life style, but the advocates of these interventions are academically shunned and have to present their work in embarrassment in back rooms. The Office of Behavioral and Social Science Research (OBSSR) within NIH is treated like an awkward in-law.

Probably the single best book that summarizes interventions in health care that actually work is Health Program Planning : An Educational and Ecological Approach by Lawrence W. Green and Marshall W. Kreuter, now in it's fourth edition. (c) 2005 McGraw Hill, initial version written in 1961. It was around that year that non-communicable diseases began to replace communicable diseases as the leading causes of death, disability, and impaired quality of life, but the older, biomedical model had a very tightly held death-grip on the "health care industry."

On page 3 of that book the authors note:

Ecological approaches have proven difficult to evaluate because the units of analysis do not lend themselves to rand assignment, experimental control, and manipulating characteristic of preferred scientific approaches to establishing causation. Although the linear isolatable cause-effect model of scientific problem solving remains the point of departure for the training of health professionals, practitioners find ... they cannot ignore the contextual reality that health status is unquestionably influenced by an immensely complex ecological system. ...

To address those systems in our planning, we must first be able to see them ...
By definition, ecological sub-systems do not operate in isolation from one another ... [but] interact with one another to influence health. [We need] a kind of ecological map or "web" or "systems model" enabling us to visualize the network of relationships that need to be taken into account as we plan our intervention strategy tailored to the unique circumstances of the target population and the place where they live and work.

The primary tools up to this task are described by John Sterman in his tome Business Dynamics, 999 pages in length. The simpler techniques of mapping on a white-board is known as Causal-Loop Diagramming or CLD. These qualitative webs can be assigned some semi-quantitative values, such as directionality and general magnitude (large, small, strong, weak) and then simulated using tools such as Vensim (tm).

That, however, is a lot of work. "Systems thinking" didn't show up in the MPH curriculum until 2006, and is absent, by that name, in most courses, even at leading universities. Only MIT and Worcester Polytechnic Institute seem to have embraced these tools, although the Ross School of Business at the University of Michigan is starting to build a systems thinking program after the auto industry started demanding it.

Note that the pressure for innovation here is from business, and the academics are lagging behind, sometimes kicking and screaming, in stage 2 of Schopenhauer's three stages:

All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.
Arthur Schopenhauer

So, this pretty much summarizes the state of affairs today. Johns Hopkins Bloomberg School of Public Health has started a new department of Health Behavior along the lines of the new theory, but most health and public health people are famously non-quantitative, and so they are attempting to think through such problems mentally, unassisted by available tools used in other industries for over 50 years now in systems dynamics.

And, the biomedical establishment has a strong lock on most thinking and peer-review journals, and alternates denial and violent opposition to the "new paradigm" which it perceives as a throwback to mystical soft thinking instead of a more general version of the scientific method that can embrace feedback loops and complex adaptive systems without distortion of the tools or violation of the assumptions behind the models and statistics.

Even at Hopkins in the department of Epidemiology, the ratio of new thinkers to old-paradigm thinkers is essentially 3 to 70, and this new paradigm is ridiculed, rejected, opposed, despised, by most old-school thinkers who wish the answer to health had stayed down the microscope, under control, where they had strong muscles and good intuition - instead of showing up increasingly outside the window of the lab, in the social fabric of society, in all the places the scientists grew up despising and where their tools and muscles and intuition all fail.

So, where does that leave us humans?

Apparently, we can't expect either academics or health care workers to take the lead in fixing this terrible mess, and business is going to have to get down to business and do something about it.

(This is not without precedent - the center of innovation in the USA has increasingly moved out of universities and into businesses, despite the very strong marketing campaign with the opposite message. Witness the pulling-teeth it's taken to get systems thinking into the Ross Business School curriculum.)

Business today is much more cybernetic on a real-time basis than academia, and utilizes "good enough" models which, with cybernetic feedback control, get the job done and produce the desired outcomes - - while driving academics crazy because the underlying models are "so bad."
The National Institutes of Health is still heavily dominated as well by biomedically oriented researchers of the old school, who resist the new paradigm.

So, with a few exceptions, industry money may be the only way to advance health care in serious ways, and address the findings at the top of this post sometime this century when we're still alive to care about it.

We have, as in so many of M.C. Escher's paintings, (see this link:
http://en.wikipedia.org/wiki/Image:Escher_Waterfall.jpg
created a world that is locally-sensible and globally nonsense, but few people working locally are motivated to address the global wrongness, and no Masters or PhD student or young researcher would be encouraged to tackle a "large" problem, and so it sits there, unaddressed by academia and a thorn in the side of everyone: patients, doctors, nurses, payers, industry.
Like Escher's paintings, one is hard pressed to see or point to exactly "where" the wrongness is, and yet, standing back, it's clearly wrong.

That's where things are today.

[ M.C. Escher website: http://www.mcescher.com/ ]

Thursday, March 15, 2007

Sam Harris on "God's Dupes"

Sam Harris is one of the 3 major writersfor the "New Atheists", along with Richard Dawkins (of Oxford, author of "The God Delusion" and "The Blind Watchmaker") and Daniel Dennett. A summary of the movement is given in Wired News "The Crusade Against Religion." Below is an article by Sam Harris from today's LA Times. ( As always, I'm not advocating this position, only describing it.)

God's dupes
Moderate believers give cover to religious fanatics -- and are every bit as delusional.
By Sam Harris
SAM HARRIS is the author of "The End of Faith: Religion, Terror and the Future of Reason" and "Letter to a Christian Nation."

March 15, 2007

PETE STARK, a California Democrat, appears to be the first congressman in U.S. history to acknowledge that he doesn't believe in God. In a country in which 83% of the population thinks that the Bible is the literal or "inspired" word of the creator of the universe, this took political courage....

Of course, no religion is monolithic. Within every faith one can see people arranged along a spectrum of belief. Picture concentric circles of diminishing reasonableness: At the center, one finds the truest of true believers — the Muslim jihadis, for instance, who not only support suicidal terrorism but who are the first to turn themselves into bombs; or the Dominionist Christians, who openly call for homosexuals and blasphemers to be put to death.

Outside this sphere of maniacs, one finds millions more who share their views but lack their zeal. Beyond them, one encounters pious multitudes who respect the beliefs of their more deranged brethren but who disagree with them on small points of doctrine — of course the world is going to end in glory and Jesus will appear in the sky like a superhero, but we can't be sure it will happen in our lifetime.

Out further still, one meets religious moderates and liberals of diverse hues — people who remain supportive of the basic scheme that has balkanized our world into Christians, Muslims and Jews, but who are less willing to profess certainty about any article of faith. Is Jesus really the son of God? Will we all meet our grannies again in heaven? Moderates and liberals are none too sure.

Those on this spectrum view the people further toward the center as too rigid, dogmatic and hostile to doubt, and they generally view those outside as corrupted by sin, weak-willed or unchurched.

The problem is that wherever one stands on this continuum, one inadvertently shelters those who are more fanatical than oneself from criticism...

There is no question that many people do good things in the name of their faith — but there are better reasons to help the poor, feed the hungry and defend the weak than the belief that an Imaginary Friend wants you to do it. Compassion is deeper than religion. As is ecstasy. It is time that we acknowledge that human beings can be profoundly ethical — and even spiritual — without pretending to know things they do not know.

Let us hope that Stark's candor inspires others in our government to admit their doubts about God. Indeed, it is time we broke this spell en masse. Every one of the world's "great" religions utterly trivializes the immensity and beauty of the cosmos. Books like the Bible and the Koran get almost every significant fact about us and our world wrong. Every scientific domain — from cosmology to psychology to economics — has superseded and surpassed the wisdom of Scripture.

Everything of value that people get from religion can be had more honestly, without presuming anything on insufficient evidence. The rest is self-deception, set to music.

Navy and Army Hospitals compared

Md. Naval Hospital Staff Reports 'Fatigue'
Workload, Poor Maintenance Driving Workers Away, Some Testify at Hearing

By Steve Vogel
Washington Post Staff Writer
Thursday, March 15, 2007; B01

A doctor at the National Naval Medical Center yesterday warned a Pentagon review panel that medical staff at the Bethesda hospital are overworked and suffering from "compassion fatigue."
Even as relatives of injured Marines universally praised the medical care and treatment of families in Bethesda, the doctor and several other current and former employees spoke of problems with the workload, maintenance and facilities at the sprawling complex...
Lt. Cmdr. Brandt E. Rice, a family medicine practitioner at the naval hospital, testified that doctors are saddled with too many administrative duties, lack enough time to devote to patients and face bureaucratic hassles. "My vocalness about this need has been met by some degree of resistance and also retaliation," Rice said.
Piles said ... "We have struggled for two years with a contractor who can't keep up..."
Sandra Bonifant, ...complained of an effort to get a handrail installed to help disabled veterans go up steps into a building on the hospital campus. "We were strong-armed into letting it drop," she testified.
After the hearing, panel members said they were struck by contrasts with the testimony heard the previous day at Walter Reed.
A number of speakers at the Army hospital praised the medical care, but many witnesses told of problems with outpatient care and lack of support given to family members. No such complaints were heard at Bethesda...
No Walter Reed staff members volunteered to testify during Tuesday's hearing. "We really need to understand that difference," Charles Roadman, a retired Air Force lieutenant general and panel member, said of the contrast to the Bethesda hospital hearing.

Thursday, March 01, 2007

Spiritual solutions for technical problems

If we reframe an intractible "technical" problem as a "spiritual" problem, it can reveal a hidden solution.

Here's an example. I worked in a lab once where we had special glass vials we needed to do our tests. The supplier was back-ordered over 3 months and we ran out and were stopped cold. So, this was clearly a "technical problem." Then I found out that there were crates of these vials 40 feet away in the next lab down the hallway. But, we weren't allowed to use those, because that researcher had a long-standing gripe with out lab's boss over some incident 10 years prior, and they weren't on talking terms.

The point is, solving the underlying spiritual problem of lack of reconciliation of these two researchers was an alternative way to get our lab functioning again.

This is not an isolated case. In fact, when you think about it, there are many "techical" and "economic" problems in our own lives that would go away if we addressed some interpersonal spiritual issues that are in the way. I hate to think of what fraction of corporate and national resources are spent trying to make it possible for us to avoid facing our broken personal relationships and dysfunctional organizations.

What brought this to mind this morning was an article in the New York Times on new $400 antennas that increase your cell phone's reception.

Coaxing More Bars Out of That Cellphone
New York Times
March 1, 2007

Garbled conversations and dropped calls are the bane of cellphone users — not to mention the dead zones where calls cannot go through to begin with. But some recent products are designed to overcome these annoyances, improve cellular reception, and, in some cases, even extend coverage....

So, probably, if everyone spent an additional $400, we could get better reception. That would be the "technical solution."

Take a minute before rushing on and consider what a "spiritual solution" would be. Hint - it would involve cooperation instead of fragmentation between people, with each person trying to reinvent the wheel on their own.

Here's another clue. Glance at my prior post
One laptop per child - grid computing for the poor.

The New York Times covered this yesterday (november 30,2006) in an article "For $150, Third world laptop stirs a Big Debate" by John Markoff. Compare to "Microsoft would put Poor Online by Cellphone", also by John Markoff, Jan 30, 2006.
According to Markoff's article yesterday "Five countries — Argentina, Brazil, Libya, Nigeria and Thailand — have made tentative commitments to put the computers into the hands of millions of students, with production in Taiwan expected to begin by mid-2007." Much of the rest of the article deals with pricing, technology, and competing views about the impact of this computer on education.

That misses the most important aspect of this, in my mind, which Markoff mentions near the end of the piece:

One factor setting the project apart from earlier efforts to create inexpensive computers for education is the inclusion of a wireless network capability in each machine.

The project leaders say they will employ a variety of methods for connecting to the Internet, depending on local conditions. In some countries, like Libya, satellite downlinks will be used. In others, like Nigeria, the existing cellular data network will provide connections, and in some places specially designed long-range Wi-Fi antennas will extend the wireless Internet to rural areas.

When students take their computers home after school, each machine will stay connected wirelessly to its neighbors in a self-assembling “mesh” at ranges up to a third of a mile. In the process each computer can potentially become an Internet repeater, allowing the Internet to flow out into communities that have not previously had access to it.

The distinction between "computers" and "cell phones" has become almost irrelevant these days, so what does this suggest.

It suggests that a different way of connecting cell-phones to the national grid would be to have them able to self-assemble a communications grid, in real-time, borrowing a little spare capacity from any other phone or computer in the neighborhood.

In other words, I don't really need my phone to be in line-of-sight to a cell-phone tower if the phones cooperate and silently set up their own relay chain behind the scenes. My phone can talk to my upstairs neighbor, which talks to the phone 2 floors above that, all the way to the top of the building, where someone's phone can talk to another distant building's phones which in turn are in line of sight of the cell-phone tower on the other side of the mountain. Voila, I have a path for my call.

We don't need new $400 antennas for each cell phone - we only need the existing cell phones to talk to each other.

Aside from finding a clear path, the phones could also automatically deliver much more power. This is the sort of thing that radio astronomers use, to connect 20 different radio antenna "dishes" across the world into a single virtual antenna that can be "virtually" pointed directly at the target, delivering thousands of times the effective power because it all goes the right direction instead of off into space.

The downside is that different phones and phone systems and even people would have to be willing to let "their" phone participate as part of a larger social grid. The upside is that this would work even in some Katrina type disaster, and auto-assemble a pathway from the existing phones to a cell-tower or satellite that could relay calls out of the disaster area.

The changes are essentially all in software and procedures. Probably this could be done with existing phones today, if we, collectively, decided that's what we wanted to do.

Without a single new cell-phone tower, or a single dollar being spent for new hardware or phones, everyone in the country could get 100 times better service.

There are no "technical" reasons we couldn't do that.
There are only "spiritual" reasons we put up with that make us dysfunctional.

This kind of problem is very widespread, especially in the USA today, where cooperation and collaboration seem to have gone the way of the phonograph in many places. We're all working overtime, way more hours than any other country, trying to make the payments on purely technical solutions that we mistakenly think we need to solve our issues.

Quoting my earlier post, looking at the chaos caused by lack of communications following Katrina in New Orleans,

By W. David Stephenson International Conference on Complex Systems June 26, 2006

So we know that emergent behavior is possible even under the trying circumstances of a terrorist attack or a natural disaster.
... Equally important but less understood by decision makers, unlike landline phones or the broadcast media, these devices are themselves increasing networked, self-organizing, and self-healing. In many cases, such as mesh networks that were originally developed for the military in battlefield conditions and now are being used by civilians, the networks don't require any kind of external networking: simply turn them on and the network self organizes.
I am convinced that such a networked homeland security strategy is feasible today, using existing technology and requiring much less time to create and deploy than some of the costly, dedicated emergency communications systems government is creating. Equally important, by facilitating those three qualities needed in a crisis: flexibility, robustness, and self-organizing, it could transform the general public from hopeless victims, waiting for aid that may never come, into self-reliant components of the overall response. To paraphrase Dr. King, which will it be, chaos, or community? [emphasis added]

On a larger scale, communications is just one problem we saw in New Orleans. Tens of thousands of cars left the city with one passenger, while a hundred thousand people were stranded without transportation. Food and water were hoarded not shared.

One explicit principle of the Baha'i faith is where this line of thinking ends up, and it's a lesson
that Michigan and the USA need to pay attention to. The economic downturns can be viewed
as "technical" problems, yes, but that hides the much closer, much cheaper solutions, that don't
require new technology.

PRINCIPLES OF THE BAHÁ'Í FAITH

#10 -
A spiritual solution to the economic problem.

I'm reminded of the monkey traps used in some countries. A cocoanut has a hole cut into the side, just large enough for a monkey's paw to fit into it. Then the cocoanut is chained to the ground, and some delicious nuts put inside it. Then we wait. The monkey comes along, smells the nuts, reaches in, grabs a handful, and then can't get it's overstuffed hand back out the hole. At that point people can just walk over and drop a net on the monkey, who will refuse to let go of the nuts that are "so close."

Americans have this fixation on having to fix everything with individual solutions - everyone has to have their own car, their own house, their own everything -- and even the phones or computer lines, if not being used, can't be shared with others for a whole variety of invented "legal" reasons.

There's a lesson here. In our case, it's not some guy with a net coming after us, it's the entire economy going south on us, loss of jobs, etc. Within each company, there's a collapse of innovation, all to protect this competitive concept and a myth of rugged individualism, that probably was never true. Like our SUV's that dress like they're going off-road, but never do, we have these attitudes that dress like we don't need anyone else to survive, but we do.

If we admitted that, and went from there, most of the rest of these problems could be solved. It's like everyone is trying to be the most fanatastic word or note in the universe, and forgetting that great books and great music need lots of different words and notes to work.

We need each other. We don't need more technology to make up for our lack of friends. We need to help each other learn how to make friends again. It seems to be a lost art for at least one in five people in the USA today. We should fix that, then see how much "depression" is left.

Perspectives in Public Health

Monday, April 23, 2007

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