Healthcare

Being in a multi-bed room overnight, or being in the OR, or even sometimes when the chemotherapy room is crowded over-full and they are putting people in cheap plastic chairs before hooking them up to clear bags of poison–this is the worst. And the worst thing about being in the hospital overnight is that you can’t sleep. I understand intellectually that your doctors need to know what your blood pressure is. I mean, sort of. What if you don’t have any heart problems? Why always with the blood pressure? But between your IV bag running out and beeping and the irrational fear that air bubbles will get inside you and kill you, and the checking of the temperature and blood pressure every four hours, and the breakfast you actively don’t want being slammed down at 6:30, and the cleaning staff, well, you don’t sleep. No knitting up the raveled sleeve of care for you! And this is true even in a private room! This article in the NYT explores a very obvious point, namely that multi-bed wards are a terrible idea all the time. I felt vindicated to read that the decrease in hospital-borne infections outweighs the cost of constructing a hospital with individual rooms.

As a doctor, I’m struck daily by how much better hospitals could be designed. Hospitals are among the most expensive facilities to build, with complex infrastructures, technologies, regulations and safety codes. But evidence suggests we’ve been building them all wrong — and that the deficiencies aren’t simply unaesthetic or inconvenient. All those design flaws may be killing us.

It’s no secret that hospital-acquired infections are an enormous contributor to illness and death, affecting up to 30 percent of intensive care unit patients. But housing patients together very likely exacerbates the problem. Research suggests that private rooms can reduce the risk of both airborne infections and those transmitted by touching contaminated surfaces. One study reported that transitioning from shared to private rooms decreased bacterial infections by half and reduced how long patients were hospitalized by 10 percent. Other work suggests that the increased cost of single-occupancy rooms is more than offset by the money saved because of fewer infections. Installing easier-to-clean surfaces, well-positioned sinks and high-quality air filters can further reduce infection rates.

The whole thing is worth a read. Perhaps unsurprisingly, having a window out of which you can look at trees or nature has a huge impact on recovery time. I personally have always wanted to get the Magic Mountain treatment in which I am bundled in specially folded blankets and put out on a lounger to enjoy a view of the Alps.

The author doesn’t discuss bad fluorescents, though the commenters do. New compact bulbs can mimic the warmer light of incandesents reasonably well now, and that is another terrible hospital thing that could be fixed. I feel I should note two things here. One, the staff at hospitals is almost uniformly composed of kind helpful people who are working very hard. Nurses are great. The sub-nurses who are supposed to be just emptying bedpans or whatever are delightful. But let’s be honest: the actual doctors are the least friendly. Sorry actual doctors. I know you are busy. (But so are the ladies emptying the bedpans, probably?) Two, I am not in the hospital or accompanying anyone to same at the moment and this is just a general complaint so don’t worry about me; more importantly my migraine treatment worked. Since I made it to the first week (at which the Botox takes full effect) I have used my migraine meds only once. John was disappointed that I can have a headache at all but he doesn’t know that not having a real migraine every day after having had that happen for months oh God is a fairy wonderland (I don’t know why I’m not being more sparkly and cheerful all the time; I’m sorry, beloved family. I have terrible jet lag still). I asked my neurologist if there were any side effects and he said, “you’ll be running back here every twelve weeks begging me to do it again, but other than that, no.” OMG Dr. Fineman you are right. Thanks for the Tinkerbell-clapping, everyone! Now tell me of your experiences with flimsy curtains separating you from people with dementia shouting all night. The airing of grievances can be therapeutic; anyway it’s better than reading articles about politics amirite?

The Guardian today [publishes a vast number of leaked reports from Nauru](https://www.theguardian.com/australia-news/2016/aug/10/the-nauru-files-2000-leaked-reports-reveal-scale-of-abuse-of-children-in-australian-offshore-detention), one of Australia’s offshore processing sites for asylum-seekers (in reality, a camp for the indefinite detention of asylum-seekers). The reports, or “unconfirmed allegations” as the Australian government would have it, are a harrowing catalogue of physical and sexual abuse, and of consequences for mental and bodily well-being, often suffered by children. These places exist to appease an Australian citizenry hostile to the arrival of “boat people” who believe that such people — even those determined to be refugees by Convention criteria — are not their problem. Though Nauru is a particularly vile example, it would be wrong to think that Australians are alone in their attitudes to refugees and asylum seekers. Other Western governments are happy to do deals with other states beyond their borders to ensure that the wretched of the earth are out of sight, where they can exist as an abstraction, not disturbing the conscience of their own citizens. Human rights, together with other liberal principles like the rule of law, have become, for many liberal democratic states, the exclusive right of the native-born citizen or, at best, someone else’s problem, somewhere else.

I’d be interested to learn from people in Australia now, how much traction this latest leak is getting in the Australian media. A surf to the websites of the Australian and the Sydney Morning Herald suggests not much.

This week’s picture is quite an old one, of the sculpture outside the then-new Bristol Children’s Hospital which is directly adjacent to the Bristol Royal Infirmary, where I spent a good past of the last week following an acute gallstone attack (with associated pancreatitis) last weekend. On the Thursday I had my gall bladder removed (which turned out to be slightly more complicated than anticipated) and by Friday I was home. I’m now resting and recuperating, but basically feeling fine. Some reflections on the experience below the fold.
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I realize our blog was curiously silent when we were all thinking, “gay marriage–in your FACE bitches!” And, “isn’t it a good thing that not quite enough Supreme Court justices were swayed by a ludicrously weak argument first tendered in the spirit of ‘0bummercare’ on IIRC the Volokh Conspiracy; at the same time, wasn’t that scary? Still, in your FACES hypocritical Jesuitical bastards!” And, “oh Lord why in the church why? How did he steel himself to it after they welcomed him and he did bible study for an hour. An hour! What kind of mordant acid of racism could etch a stain so black on the filth-splattered escutcheon of Dixie?” And, “I love the president of the United States of America. I am crying watching YouTube. There is snot on my face.” And, “holy shit, people are giving a crap about the confederate flag?! Are you serious? No, really, what?” I’ll be honest as a girl born in Savannah “home of the official platinum-level flag of bigotry” GA; a girl whose step-father was Edmund Kirby-Smith (the fourth and only)—this last one has me reeling. Also, has me realizing that I wasn’t cool in the 90s when I used a metal Dukes of Hazzard lunchbox as a purse for like 3 years. I was a dick. Well, truth be told I was going to post about the evil of Tom Bombadil, but then I felt like I needed to explain myself, so I’ll just wait a short while (and don’t you steal my thunder!).

The thing was, we flew to my in-laws in Eugene, OR (via HK and SF) and then I found out I had to do something in Indonesia so I flew back another 24 hours maybe six days later, to Singapore and then Bali, and now I’ma sort this out, fly back to Singapore, fly HK to SF to Eugene, and then the next day fly from Eugene to SF to Newark New Jersey to Savannah, and then 6 days later to Dulles, then National, then Martha’s Vineyard? No, I must have to fly to Boston. Whyyywwyyyy? OK, some people have real problems that don’t involve them flying around the world to beautiful places, so I’ll stop moping and let’s join in a carefully composed round of huzzahs and somber reflection and sore winner uncharitable triumph, shall we? In short, America: F@#k Yeah.

MIGRAINES ARE THE WORST. Well, no, I mean, obviously having your children be sick and not having money for the doctor is the worst.* Our domestic helper here in Singapore is prone to really bad migraines and yesterday she was totally felled, lying down in the dark and vomiting so much I had a hard time bringing her water–since you can’t drink water just after you’ve thrown up. We have O.R.S. but she hates them, and she was so miserable I didn’t want to force them down her. It is so hard to make her rest when she’s ill that if she ever listens or lies down of her own accord we know she is feeling truly awful. John half-hoped some common unknown environmental factor was the culprit and that she and I would both get better when we moved out of our old, colonial-era house. Sadly, no. I have also been having terrible migraines for the last 18 consecutive days, and unfortunately they are remodeling in the flat upstairs. This has been a source of unhappiness. THEY HAVE BEEN DRILLING.

I have also cut my pain pills down slowly over the last six months, which was clever and virtuous of me, but now I don’t have enough pain medicine and I’m like “I forgot quite entirely how horrible this was! Pain! It’s your body’s way of saying, ‘hey something is probably sort of broken or something.'” Also topamax, medicine which I take for migraines, and which I am taking more of, makes you stupid. It’s called “dope-a-max” for a reason. The combination of all these factors has made it difficult for me to learn my Japanese characters (kanji), I’ll tell you what. This is some Harrison Bergeron shit on the 24th floor. I got all 15 right on the practice quiz Zoë made for me and then I blanked on a full five when I took the real quiz half-an-hour later on Sunday evening. Years of caring about academics make it very painful for me to do badly on quizzes. Really, it is like a knife in the guts. If she would just give us a list of the English meanings it would be OK. But our tutor gives us an actual sentence with any other, as-yet-unknown-to-us kanji spelled out (in Japanese they can write the pronunciation in hiragana or katakana on top of them, small and light; they would do this for very rare words, I think, in an adults’ book, and they do for commoner ones in a book for children or learners), and then the hiragana or katakana for the kanji we are meant to have learned underlined, and we have to write the kanji below that. So we need to read the sentence correctly as well as remember that, for example, ‘ka’ can mean ‘borrow’ as well as like five other things (I say this, and we have learned only about 50 kanji so far.) Violet continues to enjoy mocking me (in the most friendly, cheerful way imaginable!) about my troubles, criticizing my disinclination to use the large full squares in my notebook (I have small, very neat handwriting, and the big boxes don’t appeal), and writing Chinese characters in the margins that are similar but a million times harder, just to put things in perspective for me.

Now, a person can listen to music in this situation, but sometimes that’s just like turning the whole thing into a rock concert. It’s better than drilling, though, usually. I don’t like to listen to podcasts, but John does and he listened to one about a year ago that was an interview with Brian Eno. In it, the interviewer was saying how much he loved Here Come The Warm Jets and Eno said that he hadn’t actually listened to it in over twenty years?!? This was flabbergasting and wrong and bad, since we should all be listening to it, be we Brian Eno or no which, on balance, we are unlikely to be. I feel awkward about your experience of this song, because on the LP, the harsh intro of the next song, “Blank Frank” starts really soon after the last note of this–sooner than the start of a hypothetical next measure. I thought of linking to within a youtube clip of the whole album but am not certain it would come off. It’s distinctive and crucial, though, so I recommend you listen to the whole of Here Come The Warm Jets on principle.

This song somewhat resembles the Cure’s “Just Like Heaven” in that the sad, sweet vocals only enter after what seems an unexpectedly-long music-only intro, and that it is shorter than you want it to be, such that you want have to re-play it.
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Update, Feb. 5th: Figure and Table updated to identify Catholic Private schools. And again later the same day, finding more Catholic schools.

I took another look at the vaccination exemption data I discussed the other day. This time I was interested in getting a closer look at the range of variation between different sorts of schools. My goal was to extract a bit more information about the different sorts of elementary schools in the state, just using the data from the Health Department spreadsheet. As we saw before, the smaller the unit of observation the more variability we are likely to uncover. So, looking at the rate of Personal Belief Exemptions (PBEs) in public vs private schools shows less variation than looking at the rates across counties, which in turn show less variation than what we observe at the district and school level. At the same time, the larger the number of observations within any particular category, the more variability there is likely to be as well. There are far more public schools than any other sort of school in California, so even if most public schools have very low rates of PBEs, the fact that there are thousands of them makes some outliers more likely.

To get a more fine-grained sense of the different sorts of schools there are, I used their names as a guide. How many private schools have the word “Christ” or “Christian” in their names, for example? How many have “Waldorf” or “Montessori”? This is an imperfect measure because it’s not guaranteed that, say, a private Christian academy will have the words “Christ” or “Christian” in its name. But it’s imperfect in a generally conservative direction—though not uniformly, as if you don’t search carefully you might mistake Christa McAuliffe Elementary, a public school, for a private Christian school. So you take care not to write regular expressions that aren’t too greedy, and double check against their public/private status, which is also given in the CDPH data. With this in mind we can produce a table of different types of schools ordered by mean PBE rate.

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I’m very grateful to Ingrid for setting up this discussion of capabilities. I enjoy the general discussions of social and political issues we have here at CT, but this is one of many venues for such discussion (among the best, I think, but I would say that). What’s truly unique for me is the opportunity to discuss the issues raised by my own academic work in an environment that is totally different from those offered by the economics profession.

As has already been mentioned, most of the discussion of capabilities has concerned poor/developing countries. Moreover, most of it has been qualitative rather than quantitative. One consequence is that, although the idea of capabilities has been around for a while now, its impact on the policy process in developed countries has been modest at best.

My own work on capabilities, represented by an article[1] published last year in the Journal of Health Economics has also had a modest impact, but for very different reasons. While not strictly quantitative, it’s mathematical, more so than the average reader of JHE tends to be comfortable with, and its direct relevance to policy is limited by the fact that we are, at least to start with, not addressing distributional issues.

The main objective is to explore the idea that capabilities can provide a basis for allocating health care resources based on the QALY (Quality-Adjusted Life Year) measure. in previous work, we looked at the “welfarist” idea that policy should be based on maximizing lifetime expected utility. It turns out that, considered purely as a technical problem, this can’t be done, except in very special cases. The appeal of capabilities is that they provide a non-welfarist (or at least ‘extra-welfarist’ in that it is more than a simple expected utility maximization) rationale for policies involving scarce resources like health care.

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A little while ago, Ross Douthat tweeted a link to this Aeon article of mine, reflecting on Keynes ‘Economic Possibilities for our Grandchildren’, which gave rise to some interesting discussion (Memo to self: Find out about Storify). Now he’s addressed the topic in the New York Times, linking directly to Keynes essay. There’s some interesting food for thought here. Unfortunately, it’s mixed up with some silly stuff reflecting his job as the NY Times token Republican, in which capacity he has to do some damage control over the exposure of the latest Repub lie saying that Obamacare will cost 2.5 million jobs. As Douthat delicately puts it “this is not exactly right”. But, although his heart clearly isn’t it, he tries to construct a narrative in which the Repubs might be right for the wrong reasons, or, in an even less-felicitous defence, mean-spirited and inaccurate but justified by the success of Reaganism thirty years ago.

More interesting though, is Douthat’s discussion comparing idealised hopes for a post-work society with the reality in which well-educated professionals are working longer hours than ever, while many at the bottom end of the income distribution, particularly poorer men have withdrawn from the formal labour force altogether (presumably, relying on disability benefits or scraping a living in the informal economy). One possible solution to this problem, is simply to give the poor more money, for example, in the form of a basic income, and not worry about whether they choose to work. Douthat isn’t too happy about this idea, saying

Both “rugged individualist” right-wingers and more communitarian conservatives tend to see work as essential to dignity, mobility and social equality, and see its decline as something to be fiercely resisted. The question is whether tomorrow’s liberals will be our allies in that fight.

But this position elides a bunch of crucial issues.

First, while work may be necessary to “dignity, mobility and social equality” in a market society, it certainly isn’t sufficient. For unionised US workers in the mid-20th century, earning middle-class incomes in relatively secure jobs and expecting better for their children, work was, arguably both necessary and sufficient to achieve a fair measure of these things. But an at-will employee, juggling two or three tenuous jobs that pay $7.25 an hour, and looking at a steady decline in real income, is scarcely getting much in the way of dignity, let alone mobility or social equality.

Equally importantly, market work isn’t the only kind of work people can do, and certainly not the most valuable. Most obviously, there’s the raising of children. The US the developed countries that does not provide any kind of paid parental leave, and even the legislative provision for unpaid leave (12 weeks a year for mothers in firms with more than 50 employees, nothing for fathers) is incredibly stingy. The idea that the ‘rugged individualists’ who block any improvements to these conditions actually care about the dignity of the working class is simply laughable.

I don’t need to tell Douthat any of this. It’s all in his book Grand New Party with Reihan Salam, notably including a proposal for a full year of paid parental leave. The book received cautiously respectful reviews from many in the centre and centre-left, but fell entirely flat with its intended audience in the Republican Party.

I’ll have a bit more to say about the kind of technological determinism that seeks to explain labour market polarisation as arising from computers and the Internet a bit later. For the moment, I’ll repeat the conclusion of my Aeon essay that a response to technological change that will preserve the link between work, dignity and equality will require both a reduction in total hours of work and an expansion in the range of social contributions regarded as work, beyond those that generate a market return

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ETA: It has occurred to me only just now that this post would have better had it been titled “America: rRuck Yeah!”

You have probably already read about the horrible chemical spill in West Virginia last Thursday, which the New York Times has a stunner headline: Critics Say Chemical Spill Highlights Lax West Virginia Regulations. Oh, really? (You can read lots of good posts on this and previous environmental and labor disputes at Lawyers, Guns and Money–you can start looking at Erik Loomis’ posts as he also has great series along the lines of ‘this day in labor history’.)

300,000 were left with poisoned drinking water (coming out of the tap!) after specialty chemical-producer Freedom Industries spilled some 5,000 gallons of 4-Methylcyclohexane Methanol into the Kanawha Valley’s water treatment intake near Charleston. The water remains clear although poisonous, but smells helpfully like licorice. Also, boiling it doesn’t help.

Obviously this logo is but a minor blot on the company’s record vs. its actual malfeasance but uh…it’s a crime against good design, since my daughters looked at it and asked, “what’s rReedom Industries?” Also really looks as if it should have the smoking twin towers photoshopped into the background, and perhaps a big glistening tear into the eagle’s eye, and it would be a good blog header for Pamela Geller. Hey, remember her? (She doesn’t follow good trigger safety at all, I totally just learned this. But she’s a teetotaler also, so.)

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What I am curious about in the Singer/infanticide/ending the life of the disabled vein is, what do those who are totally opposed to every form of infanticide think about anencephalic babies (and babies who have similarly non-survivable, severe birth defects)? I don’t think that, as a formerly pregnant person who has given birth to healthy children, my opinions on these questions have any extra merit, but I do think others not so situated may share my opinions without feeling so strongly about them, or in the same way. Perhaps the situation calls for some epistemic humility? The terrifying prospect to me, and to many mothers, of “late-term” abortion bans, is that pregnancies which are terminated after 20 weeks are almost all wanted pregnancies in which something horrible has occurred or been discovered. (And, in those cases where the baby is unwanted, there are almost certainly serious problems in the woman’s life that have led to the delay in getting an abortion sooner.) So, in a situation of supreme horror, the fetus might die, but the mother might be forced to carry the dead fetus inside her and have labor induced, to struggle in pain and blood to bring her dead baby into the world. She would feel the liquid inside her, and the lax ligaments, and all the other things she felt in pregnancy, but she would know the baby was dead. I have heard of mothers knowing right away. So close to you then, infinitely close, but infinitely far, and a rotting thing now, a poison for the rest of your body. So awful.

My first pregnancy was easy and wonderful. I felt and looked glowing, and although I was in labor for more than 40 hours (remind me not to do that again) I gave birth vaginally to a healthy girl who latched onto the breast just a few minutes after she was born, and fed well and naturally. In my second pregnancy I had unexplained bleeding starting at 19 weeks. Bright pink fresh blood in the toilet bowl. I thought my heart would stop. I thought her heart had stopped. They couldn’t figure out what was wrong. I was in terrible pain (I often am; but it seemed like she was tap-dancing on the worst bit of me.) I kept bleeding on and off. I knew how many movements she was supposed to make in an hour and I counted, and counted, and counted, hour after hour, so scared, and then another hour. The doctors were determined to deliver her surgically as soon as they felt she was cooked up right, so, 37 weeks. It turned out to be nothing serious, placenta previa (the organ grew over the cervical os, the opening to the birth canal, blocking the baby’s egress.) She was fine.

But sometimes when the doctors check, they find that the fetus, which has appeared to be developing fine, has no brain at all, that the blackness inside her skull on the scans is only water. This is not even a fetus, really–certainly not a future infant. It will never feel pleasure at a mother’s touch, or pain from being pinched by a crib mattress, or see anything, or hear anything. It is empty. Laws that would force a woman to stay pregnant and nourish and grow that wrongly-made creature inside her, and to suffer the agonies of childbirth, and to bring forth this…not-baby–laws like that are torture. I would go mad. I would try to abort the fetus myself. I would try to kill myself. I would want to be put to sleep then, there, in the doctor’s office, and wake up, not pregnant, and with a little coffin to bury my hope and love inside. With ashes inside, only, because I would want not to look, but I would look, and I would always wish I had not.

But let us say an unjust, oppressive, Christian regime forces me to endure, and to deliver this severely deformed baby. Does anyone think we should use artificial life support to keep the baby alive? Almost all fetuses of this type are stillborn, and those that are not usually die on the first day of ‘life.’ Even the Catholic Church has some hand-waving about letting God’s will take its course. That is, they are not insistent on providing hydration and nutrition–no one even considers artificial respiration. Reading on it, three children have lived a year or so. There are pictures of course, and now I wish I hadn’t looked at them, and I am so sorry, the poor little things, and so sorry for the parents. For the mothers! When I think of those oscillations inside you, feeling movements you didn’t make, the mysterious gliding of blood-wet surfaces over each other in the absolute black, the not-you inside you…what if you knew in the end there was nothing? Some kind of seasickness of death? At the last you would be holding a newly hatched chick, naked and grey and dead, grey and jerking with dying? But back to the matter at hand, we all think a form of infanticide is appropriate here, right? No one’s on team ‘drastic measures for resuscitation?’ Artificial respiration for 80 years, for something that can never feel you hold his hand? A rough golem on whose forehead no glyph has been inscribed? So isn’t there a small number of real-world, continuously-occurring cases in which we are all pro-infanticide?

UPDATE: so misinterpreted! Obviously my fault also. I didn’t jump in to give Singer crucial moral support. I’m not totally sure how I did…I guess I’m implying all his critics are disingenuous and have parked themselves at the top of a slippery slope with some dubious wedge. I apologize to sincere Singer-critics for insulting their position in this way. That wasn’t actually what I was trying to do at all. I was genuinely curious. There was a case maybe eight years ago now, but I can no longer find it in the welter of anti-abortion and pro-abortion articles, in which a woman’s 24 or even 26-week-old fetus died, and the laws of her state required a waiting period before you could get a late term abortion (Texas IIRC?). The removal of a dead fetus is done via dilation and curettage, i.e., via abortion. So she had to go talk to some doctor, and then go stay by herself in a motel with her dead baby inside her for two days. She wrote about her experience and I remember thinking, I don’t know if I could live through two days of that. A responsible, thoughtful doctor would have deemed the dead fetus a threat to her health and her ability to have future children and had it removed on those grounds, but in this particular case, it was a Catholic hospital and none of these things happened. So I did mean to say, I think there are a number of infants born each year whose lives everyone agrees cannot go on in any way. That doesn’t mean that–HAHA! now everyone is obliged to accept all Singer’s positions; I was honestly curious, not mock-curious, and I honestly don’t know what all Singer’s positions are. But I also meant to describe to people who haven’t been pregnant the terror of something going wrong, and how you hope you would be a good enough person to accept your baby any way she came, but you fear you’re not brave enough, not really, not truly brave enough. And that as long as she was inside maybe you could pretend it would be alright somehow? But even then there is only one feeling that is ever like this, of having something inside you that is alive, that isn’t you, that you are waiting for, and how would it be if you were waiting for nothing? That’s all. I really don’t know enough about Singer’s positions to arbitrate on any of these questions; I was just thinking, we need to hear from severely handicapped people who were written off as a total loss before we know whether he can be right. We might also be interested to hear from mothers. And I’m only the mother of perfectly healthy babies! That’s it. I’m not laying down my life for in-group sacrifice.

There’s a lot of good stuff in Colin Crouch’s new book, _Making Capitalism Fit for Society_ (Powells, Amazon), but one point seems particularly relevant today. As umpteen people have pointed out, the rollout of the federal enrollment system for Obamacare has been a disaster. The polymathic David Auerbach has been particularly excellent on this.

The number of players is considerably larger than just front-end architects Development Seed and back-end developers CGI Federal, although the government is saying very little about who’s responsible. The Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS), which issued the contracts, is keeping mum, referring reporters to the labyrinthine USASpending.gov for information about contractors. … By digging through GAO reports, however, I’ve picked out a handful of key players. One is Booz Allen … Despite getting $6 million for “Exchange IT integration support,” they now claim that they “did no IT work themselves.” Then there’s CGI Federal, of course, who got the largest set of contracts, worth $88 million, for “FFE information technology and healthcare.gov,” as well as doing nine state exchanges. Their spokesperson’s statement is a model of buck-passing … Quality Software Solutions Inc …[have] been doing health care IT since 1997, and got $55 million for healthcare.gov’s data hub in contracts finalized in January 2012. But then UnitedHealth Group purchased QSSI in September 2012, raising eyebrows about conflicts of interest.

… Development Seed President Eric Gundersen oversaw the part of healthcare.gov that did survive last week: the static front-end Web pages that had nothing to do with the hub. Development Seed was only able to do the work after being hired by contractor Aquilent, who navigated the bureaucracy of government procurement. “If I were to bid on the whole project,” Gundersen told me, “I would need more lawyers and more proposal writers than actual engineers to build the project. Why would I make a company like that?” These convolutions are exactly what prevented the brilliant techies of Obama’s re-election campaign from being involved with the development of healthcare.gov. To get the opportunity to work on arguably the most pivotal website launch in American history, a smart young programmer would have to work for a company mired in bureaucracy and procurement regulations, with a website that looks like it’s from 10 years ago. So much for the efficiency of privatization.

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Last Thursday I went to the launch party for Katie Green’s Lighter Than My Shadow (just published by Jonathan Cape) a graphic memoir in which she tells the story of her descent into and recovery from anorexia (and quite a bit besides). It is a big book, 524 pages in all, which somewhat belies its title, yet I read the whole thing in one sitting. I know I’m not alone in having done this: once you start, it is very hard to stop. It is compelling but a hard book to read: I felt the tears welling up several times. It is also a great book. The graphic format works perfectly for the story and Katie – a terrific illustrator – has managed to convey very vividly some little part of what it felt like from the inside. The black cloud of despair, the screaming monsters in the head, the desperate urge to control, control, control and the sense of alienation from those closest to her, the pain she knows she’s inflicting on them but can’t help doing so.

When she spoke at the book launch Katie said that she hadn’t written the book to help anyone. Nevertheless, I’m sure it will help one very large group of people, the people who can’t imagine what it is like for someone in her position, who can’t understand the sense of compulsion, and why the sick person can’t just “pull themselves together”. In giving voice to this inside, Katie has pulled off something comparable to what William Styron did for depression in Darkness Visible. That’s a pretty high standard of comparison, I know, and I’m feeling swayed by the immediate experience of just having read Lighter Than My Shadow, but I don’t think it an unfitting one.

I should disclose a slight interest. I know Katie slightly (she’s a friend of one of my children) and a photo I took is on the cover flap. So I’m not entirely impartial. Still, I think this is, objectively, a very great achievement. And I don’t mean to relativise in a way that suggests that it is great for someone who has gone through her experience to have produced something this good. I mean that it would be great for anyone to have created this, even though her experience is a condition of having done so. Anyway, people out there, this is a book that most of you ought to read. You can get it at Amazon of course, but better to buy from somewhere else. (The Guardian had a feature on the book last week.)

I was working on a piece about how to respond to anti-vaccination beliefs, when it struck me that, in the absence of the germ theory of disease, vaccination looks a lot like homeopathy – you use a tiny amount of something that causes a mild version of the disease you want to prevent. I wondered whether the success of vaccination in the 18th century had any impact on the development of homeopathy. A very casual search suggests not, though there is something called homeopathic vaccination. Does anyone know more about this?

Dave Weigel calls this, from Yuval Levin, the ‘best riposte’ to the new HHS regulations. I must say: if this is the best they can do …

Levin’s objection is that HHS is just looking for a way in which they can say that, technically, we’re not doing this thing people say infringes their religious liberty. HHS is hereby neglecting to address the larger spiritual issue of religious freedom. But the original complaint about the contraception mandate was that technically you can be made out to be making us do this thing. Technical hitch calls for technical fix. It ain’t pretty, but what were you expecting from a lawyerly work-around? [click to continue…]