• This week a student and I published an article in PLOS ONE examining the relationship between healthcare-related expenditure and financial catastrophe in Bangladesh. Because PLOS ONE is an open access journal it is possible to read the entire article free online, here. Our study was a statistical analysis of data from a probability-sampled survey of households in Rajshahi, an urban area in Northwest Bangladesh. We collected data on their self-reported illness, household consumption and healthcare-related payments, and used it to estimate the prevalence and risks of financial catastrophe.

    Bangladesh doesn’t really have any effective risk-pooling mechanisms, and a large portion of all health financing is derived from direct payments by individuals, usually referred to as out-of-pocket (OOP) payments. The lack of risk-pooling mechanisms mean that households with limited savings are at risk of financial catastrophe from unexpected healthcare costs, and may have to use a wide range of quite unpleasant coping mechanisms to deal with the costs. Our research project aimed to identify the drivers of costs, factors associated with financial catastrophe, and the coping mechanisms used to deal with high costs.

    These kinds of research projects have a lot of challenges, and are necessarily flawed as a result. In low-income nations like Bangladesh it is difficult to assess wealth directly, since households often obtain income in kind or through bartering or intensive production (family gardens, etc); and often official income is not declared in order to avoid taxes or other costs. This is usually dealt with through assessing household consumption, rather than income, adjusting for fixed and productive assets. It’s also difficult to assess illness, which is usually done through self-report, and obviously also medical expenses can be hard to keep track of. There is an extensive body of literature on how to deal with those problems though, and we used mostly quite standard methods to handle them. Despite the obvious limitations in such a survey, I think this one presents fairly robust results.

    We found a high prevalence of financial catastrophe, with an average of 11% of household consumption spent on healthcare and 9% of households facing financial catastrophe under our definition. Financial catastrophe was much more likely in the poorest households, even though these households spent considerably less on healthcare, and financial catastrophe was also associated with inpatient service use. Chronic illness was associated with higher OOP payments. Bangladesh is currently passing through the “epidemiological transition,” in which chronic non-communicable disease (NCD) prevalence is rising, but infectious diseases remain a significant problem, so the finding that chronic illness is associated with increased OOP payments is concerning: with a baseline proportion of their income already consumed by such illnesses, households will be less able to adapt to unexpected sudden illness or injury, both of which are relatively common in low-income countries compared to high-income countries.

    Our findings suggest that Bangladesh needs to move rapidly to implement and scale-up risk-pooling mechanisms; deal with problems in public facilities that mean they don’t seem to be protective against financial catastrophe even though they are ostensibly free or heavily-subsidized; and prioritize NCDs in its health policy agenda. We’re currently conducting more research on disease-specific costs, coping mechanisms, and other aspects of the health-financing challenges facing Bangladesh. Other countries in Asia are moving towards universal health coverage (UHC) and Bangladesh lags some of them; but with care, a little reform, and some coordinated action to target NCDs, there’s no reason that despite its poverty Bangladesh can’t follow in the footsteps of other countries like Vietnam in reducing risk of financial catastrophe and improving healthcare access for the poorest members of its population.

    As an aside, 9% is a very high prevalence of financial catastrophe, but I’d be interested to see how it compared with the USA (which also doesn’t have widespread and effective risk-pooling mechanisms). I don’t think the research is done the same way for US systems as in low-income countries, but there appears to be some evidence that financial catastrophe can be high, at least amongst the poor. For example, this New England Journal of Medicine article suggests that Medicare provides limited protection against financial catastrophe, and shows figures indicating that 4% of recipients pay >$5,000 on medical expenses in any one year, which would probably qualify them for financial catastrophe (since most Medicare users have low incomes). I would be interested to see the rates of financial catastrophe amongst the uninsured in the USA, and to compare them before and after Obamacare is introduced, but I don’t think research on the topic is done in the same way in the high-income countries, so I doubt it will be possible. Although health insurance (private or public) is supposed to protect against unexpected medical expenses, it can still be ineffective, and furthermore access to health insurance enables people to purchase healthcare they might otherwise have neglected, which could put them at risk of financial catastrophe where the insurance system fails to provide adequate coverage. Obamacare is going to extend no-frills coverage to the currently uninsured, but this doesn’t mean they’ll get benefits sufficient to prevent financial catastrophe, so it will be interesting to see whether it meets both of the goals of a health-financing system (improving access and reducing financial risk), just one of them, or neither. And if it fails on either or both of those goals, does this mean that Bangladesh will achieve effective UHC before the USA? That would be interesting … but first Bangladesh needs to start the move toward UHC, and hopefully this research will provide useful information and a little impetus in support of that process …

  • Next week sees the release of the Ken Loach movie The Spirit of ’45, which describes the UK’s attempts to implement socialism through the ballot box between 1945 and 1951. Ultimately a failed project, this revolution has left one enduring and much-loved symbol, the UK National Health Service (NHS). In the same month as the release of Loach’s movie, the NHS is going to undergo what are generally touted as the largest reforms in a generation, the Health and Social Care Bill, which see significant market reforms introduced to the NHS, and a major reorganization of its hierarchy. This is all happening against a backdrop of unprecedented government austerity, recent reports finding significant failings in the way the NHS cares for patients, and a Conservative-run government with a very strong ideological bent towards radical experimentation with the UK’s institutions. It is also happening against the backdrop of a worldwide movement towards universal health coverage (UHC) which is even taking hold in the USA – given this global movement, and the UK’s central role as a model for that movement, it’s unlikely that even the most ideological of governments is going to attack the basic principle of the NHS: to provide healthcare on the basis of need, not ability to pay.

    It’s easy to make predictions about how these reforms will turn out, without even analyzing the policy, because a cynical outside observer of the UK can always fall back on three simple principles: nothing in the UK works very well, the British government is terribly incompetent regardless of its ideological stripe, and you can’t improve healthcare by reducing the amount you spend on it[1]. However, I’ve written before about what I think will happen as a result of the new Bill, and the specific good and bad points I see in it; I won’t repeat these in detail here. For those interested in the Bill itself, the Guardian gives an outline of its main points, and since I wrote my post the Bill has been beefed up a little. The revised Bill includes a sneaky little clause that supposedly forces clinical commissioning groups (CCGs) to make all health services they purchase subject to tender, rather than allowing existing NHS services to be preferred providers. CCGs are organizations supposedly formed by doctors which are charged with disbursing government money to providers of healthcare – they are the main purchasers of health services after the reforms have been passed. By forcing them to open all non-emergency services to tender, the Bill will (it is claimed) force existing NHS hospitals and GPs to compete with private services for government money, ideally driving down costs. It’s not clear to me how the contracts between these services and the CCGs will be negotiated, and this aspect of the reforms gets my spider-senses tingling, because it just stinks of “a potentially good idea done badly.” Some of the background on the way the Health and Social Care Bill forces CCGs to use competitive tendering is presented in this opinion piece (but beware, huge amounts of this piece are just factually wrong or very misleading, so take everything it says with a grain of salt). Below are a few reasons why I think this particular competition reform is going to fail.

    • It puts family doctors in charge of paying family doctors: a Clinical Commissioning Group is meant to be a group of general practitioners (GPs, or family physicians in the American parlance) who will be given money by the government with the task of purchasing all health services for patients in their area. This is supposed to put the health service back into the hands of GPs. The problems here are two-fold and, I should think, blindingly obvious. Much of the money that these CCGs need to distribute will be spent on purchasing GP services, so it puts GPs in charge of purchasing services from GPs. This is a notoriously tightly-knit community with strong common interests, and I find it hard to believe the money will be dispensed wisely. The second problem with this plan is that GPs may be good doctors, but that doesn’t make them good at resource-allocation decisions, and often doctors are the worst people to decide how to spend money wisely. A good health financing system should find ways to efficiently and equitably enable doctors to make good clinical decisions. It’s not obvious to me how putting doctors in charge of the financing decisions is congruent with this. A lot of commentators in the Guardian are decrying the role of major accounting services, who are being contracted by some of these CCGs to handle the decision-making process[2], but to me this seems like a good thing: the further you can move the pot of money from a GP the better, in my opinion.
    • It seems to rely on bulk contracts: The NHS to date seems to have structured a lot of its purchasing decisions on contracts that offer bulk funding – that is, a hospital or GP contracts to provide a service for a specified fee, but the service is very generalized and not broken down into its particulars. In the case of GPs, this usually means they are paid a fixed amount per year to provide services to patients on their list, but no detail is specified as to how they should provide services or what they should provide – not even a minimum basket of services. This is why many GPs in the UK operate single-handed surgeries with inconvenient opening times, have very little time for patients, and don’t provide services (like chest x-rays or chlamydia testing) that are taken for granted as routine in other countries. These contracts don’t encourage efficiency, and when these types of contracts are negotiated with large providers (like private healthcare organizations or big hospitals) it’s likely they will be highly beneficial to the provider unless the CCG negotiating the contract has a very adept team of lawyers. Unless the new Bill includes very strong support for this contract writing framework (and see my further point below) then I expect we will see profligate misuse of funds as the providers take these naive and poorly-supported CCGs to town.
    • The financing system is not obvious: It’s not clear to me how the CCGs are expected to decide what is the most economically effective (or, for that matter, clinically effective) service, what benchmarks will be established for comparing services that they are accepting tenders from, and how they are expected to make contracting decisions. This isn’t all the fault of the people writing the Bill: within the field of health services management, there is still much dispute about how best to assess the quality of care provided by a large service. For example, in-hospital mortality might be considered an important measure of quality, but how does one account for the mix of patients and the severity of their illness in comparing two hospitals? Should one trust the figures the hospital presents, and if not who is the central provider of assessment services to which a CCG should turn when attempting to compare hospitals on this measure? And if two hospitals have slightly differing mortality rates, how much extra should a provider be expected to value the difference at? Can a provider make a judgment to buy services from a cheaper hospital with higher age/sex-adjusted mortality rates, or is that decision unethical on its face? Have CCGs got any expertise on these issues, or received any guidance? It could be that the Health and Social Care Bill provides extensive information on this, and supposedly the reforms will include the establishment of a new organization to help CCGs with this task. But the reality is that no one really knows the answers to many of these questions, and it’s not clear that the structure for health financing proposed by the Health and Social Care Bill is going to be invulnerable to problems because of them.
    • It lacks centralized guidance and pricing structures: At the moment there is a single contract that all GPs sign with the NHS when they provide services. Will this contract be used by the CCGs? This contract basically gives a fixed pricing system for obtaining GP services – if it is used, how can the CCGs claim to be operating a competitive tendering system? If it is not used, and GPs are to negotiate their services on the basis of the price negotiations, how are the CCGs going to decide the correct price? We’re not talking about a fully free market here, since most CCGs operate to purchase services within a given area and, in general, patients won’t be going outside that area for services, so there won’t be multiple CCGs competing in the area, and patients won’t be voting with their feet if prices are too high (in fact the patients won’t even see the prices). If the system is going to operate without market signals, then it’s going to need some very carefully arranged pricing mechanisms to ensure it doesn’t waste money. These are not likely to be most optimally set at the level of individual CCGs, but would be better off set by the government. It’s not clear to me that this is going to happen, or that the CCGs are going to get much guidance at all on how to fix prices. By way of comparison, Japan operates a system in which private hospitals and clinics charge patients for services on a fee-for-service basis, then charge the government’s insurance system for 70% of the total cost. However, the government maintains a strict schedule of service fees, so it’s extremely difficult for doctors to over- or under-charge. Essentially in this market the government provides a very strong centralized pricing guideline to keep the market at a stable price. The Australian government uses a similar mechanism through setting a minimum fee for GP services provided and allowing patients to vote with their hip pocket when choosing GPs. It’s not clear that the NHS will be using any such system, but in the absence of a strictly market-based mechanism for setting prices[4], how are the CCGs going to be able to choose what to charge, or even to know that they are getting value for money?

    Given these concerns, I can see all sorts of disasters befalling the revised network of CCGs, including (for example) the possibility that they set up contracts that take up all their budget, only to find their area massively underserved with health services but no funds left to purchase more. What are they going to do then? How is the government determining how much money each CCG needs, and how can they be sure they have gotten it right? Does the government have any fallback position or plan B if over the first few years of the system the CCGs massively cock-up their purchasing decisions?

    On the face of it the reforms appear to consist of a poorly-structured semi-marketization, to be managed by inexperienced and new organizations that have been given arbitrary budgets in an environment with very limited centralized guidance, to purchase services in a marketplace where even the experts are uncertain about how to define value for money or quality of service provision, but with an extremely limited set of real market mechanisms as an alternative way of providing pricing signals. It’s like a healthcare Frankenmarket. How can this story possibly end well? I predict we’ll know before the next election, and I suspect that the results of this grand experiment are going to form the obituary for this government.

    fn1: well, theoretically you can – lots of governments have built health policy on “efficiency savings.” Practically, however, health systems improve by spending more to gain more, rather than spending less to gain the same.

    fn2: I provide no citation for this because I can’t be bothered looking, but really this shouldn’t require a citation, it’s the factual equivalent of saying “the sun rises in the morning.”[3]

    fn3: I know I know.

    fn4: I don’t maintain here that these systems are necessarily the best, simply that they are a strict guideline and they do roughly seem to work.

  • Advanced studies at the Miskatonic University...
    Advanced studies at the Miskatonic University…

    This being a report on a Call of Cthulhu session I played in on 2nd March, in the style of the times.

    In the decade since our return from the war, Mr. Ambrose and I have had our difficulties, but life had settled into a pleasant flow here in New Orleans, until we were thrown into the strange affair of the cannibal baby factory, and our eyes began to open to the dark secrets lurking beneath the veneer of American life.

    Our story began one lazy Sunday afternoon, as we sat on the balcony of the pleasant New Orleans home we had been sharing this past year. Bourbons and cigarillos in hand, we had just swung into reminiscence about the hard times that beset us after our return from the trenches – hard times that were a far cry from our recent good fortune. Just a year earlier I had finally been able to open my own medical practice just off of Canal Street, and though business was still slow, for the first time in years it appeared that I had a future. Of course matters were still more complex for Mr. Ambrose, who had shared my good fortune during the war and had witnessed the full horrors of trench warfare as a participant, rather than a sawbones, and who was having trouble settling into a steady civilian life even now. Nonetheless, things were looking up on that peaceful Sunday afternoon as we sat on our verandah, lazily discussing troubles that once held our lives in such a pinch, but now seemed just vaguely amusing from the perspective of a little distance, and a little whisky. Oh, to think now that we could have been so pained by the troubles of the mortal flesh – as if such concerns as addiction, poverty and strife could hold any real terror, when compared to what we were about to discover in our neighbour’s basement …

    For it was at that moment, as we embarked upon our second glasses of bourbon, that our neighbour came home. Our neighbour Mr. Corbett – good, upstanding citizen, semi-retired from his shipping business, who still attended his warehouse three days a week, whiled away most middays at a well-respected gentleman’s club in the centre of town, and commuted regularly to New York – New York! – in pursuit of his extensive business interests. A man of such wealth and respectability that he owned his own Model T Ford, and a house across the way from our somewhat ramshackle bachelor’s pad, where he enjoyed extensive grounds and even a separate garage for his car.  There he was now, as the Bourbon warmed my palate, struggling up the pathway to his front door with two packages in his arms – one round like a bowling ball, the other roughly the length of a folded billiard cue, both wrapped in butcher’s paper. He seemed to struggle with them, and as he attempted to open his front door he dropped one on the porch. Then, the strangest thing: he looked all about him most furtively, as if caught in the act of smuggling something illegal through his own front door, snatched up the parcel as if it were contraband of some kind, and slipped inside his house most surrepititously.

    Perhaps his act would have been dismissed as merely a whiskey-induced vision, and forgotten as a lazy Sunday afternoon’s fancy, were it not for the strange events that followed. When we were perhaps some distance into our third or fourth slugs of that fine Bourbon, lights came on in Mr. Corbett’s basement.  We would not even have noted this, but that the light we could see through his basement window grew brighter and brighter, till it was fit to dazzle us; and then, with a distinct popping sound as of electrical shorting, suddenly went dark. Upon first seeing that light, I had remarked to Mr. Ambrose that perhaps Mr. Corbett were in possession of a subterranean billiards room; however, that bright light spoke more of a workshop or laboratory.

    This, too, would have passed unremarked, but for the later events of the evening. I had just laid myself down to sleep, having finished another chapter of Fishbein’s New Medical Follies (that pertaining to Eclecticism, I believe) when I was struck by the fancy that I could hear a low moaning, crying sound coming from across the road. I initially discounted it as some old tinnitus, but in truth that tinnitus was only ever psychosomatic and is long cured; and certainly though he bears many ills from the war, Mr. Ambrose has no hearing difficulties, and he had not only heard it but was up and about, trying to fathom it. I joined him and we returned to the verandah, there to listen more closely. It was a strange sound, in some regards like a baby’s crying, but in others like that of an animal or some swamp beast; a kind of gurgling, unpleasant choking sound, interspersed with sloppy gusts of breath and low wails. It was obviously muffled from within Mr. Corbett’s basement and insufficient to wake the neighbours, but it set me to shivering and nervousness such as I have not experienced for years, and perhaps Mr. Ambrose too. For it resembled a sound we had not heard in 10 years, and which the last time we heard it we discounted as merely the horrific vapours of wartime: sometimes, lying in the trenches at night after one of those reckless charges that left so many dead on the battlefield, after the last cries of the dying had subsided, we would hear that same sound, as of some wild beast that prowled the no-man’s land and perhaps feasted on the dead and dying. And once, approaching the bins behind the field hospital where we would dump amputated limbs, I also thought I caught such a sound, though I never found its source. Both Mr. Ambrose and myself dismissed those mysterious and ugly tones at the time as mere trench-madness; yet here it was, clearly emanating from our ageing neighbours basement.

    We must, perforce, investigate. Dressing hastily, we marched across the road to Mr. Corbett’s front door. After a brief listen to confirm it was indeed his basement from which the wails and slurps arose, we knocked upon his door. After a considerable delay he answered, wearing that same furtive expression as crossed his face during the incident of the dropped package. I proceeded to make a noise complaint, and to ask him to still “whatever wild animal he was keeping in his basement.” He looked most alarmed at our having caught his game, and immediately tried to mollify us, also promising to still the beast at once. By now my curiosity was piqued, and placing a foot surreptitiously in the door to stop its closing, I offered to accompany him down to his beast, observing that he was old and perhaps not well, and might prefer to be accompanied by two men in the prime of life, lest there be some accident? He declined firmly, and begged of us to wait outside his door – all the while pushing the door against my foot as if to close me out, the scoundrel! I assured him we would wait, and that it were better he left the door open lest there be trouble. Being unable to close the door against me, he finally agreed, and off he went to still his beast. Listening at the door and window, we could faintly hear him talking to the mewling animal, saying to it “hush now!” and “be still, it’s okay!” and other phrases as if he were speaking to a baby, rather than a beast! Whatever he kept down there went silent, and he soon returned, looking even more furtive, and bid us please be gone. After we left him, assuring him we would assist him with his beast were he to need us, we heard the sound of several locks being turned in his front door. Why such security, in peaceful New Orleans?

    The next morning we determined to break into his house and see what manner of beast he kept. We convinced ourselves that we did so only out of civic duty, but I think we both felt something was wrong, and needs must assure ourselves that some primeval fear waking in us were unjustified. Oh, had we only had the lack of imagination necessary to assure ourselves it were but a wild beast, and to return to our normal daily routine, we would never be troubled by those horrors such as subsequently have haunted us daily.

    While I did my morning at the surgery Mr. Ambrose sought out and purchased the services of a Mr. Boleyn, a feckless and worthless man who spent some time in the trenches with us, and proved himself good for little but causing trouble. One line of trouble he was very good at was breaking into our Colonel’s whiskey safe, and it was the employ of these skills that we engaged for $15 and the promise of a bottle of good tequila. We met him on Mr. Corbett’s verandah at midday, and once he had us through that multi-locked door we bid him wait in the hallway, both to watch the door and to assist us were we to run into further barriers. We then proceeded into Mr. Corbett’s basement, me carrying that bottle of tequila as insurance against Mr. Boleyn’s services and Mr. Ambrose carrying his service revolver.

    The basement was surprisingly spacious, consisting of a hallway with two doors on each side, all closed. We followed the traditional process for room clearing that we learnt in darker times, moving anti-clockwise down the hall, and so opened the first door on our right, entering the strangest room we have ever been in, and the first room to ever test our sanity. Before us lay an ordinary nursery, in which were a normal cupboard, a cot, a rocking horse, and over the cot a mobile of little winged angels. From within the cot came the sound of a baby sleeping gently, and the entire room was rich with the smell of formaldehyde. One door led out of the room, though we did not immediately notice it. We approached the cot to view Mr. Corbett’s basement-dwelling baby, thinking perhaps here was the source of last night’s sounds, and before we had time to prepare ourselves we found ourselves facing the most terrible of sights.

    The cot did indeed hold a baby, but it was a monstrous construction, a baby with six arms, and all the parts of its body stitched together from what were obviously the discarded remains of other bodies. The arms were of mismatched sizes and colours, unmatched either with his legs; I say that it was a “he,” but that part most necessary to designate gender was not attached; and I swear his ears must have been procured from a girl, though I had no way to prove it. This monstrous frankenstein baby was also the source of that formaldehyde smell – for the body parts from which it had been made were obviously once pickled.

    Both Mr. Ambrose and I would have loved to have dismissed this beast as some kind of grotesque doll, constructed for god knows what reason by Mr. Corbett. We knew he had lost his own son and wife, so perchance he was in the midst of some mad delirium, constructing a family life for himself out of the dregs of others; but at this point something so alarming, so horrific, happened that we would never again be able to look upon the macabre and seek easy or dismissive answers for it in the pscyhology of others. For as we stood looking into the cot, the dead eyes opened – and the baby started to scream. The eyes were the most chilling of all for me, because they had obviously been procured from different people. One was blue and slightly rheumy with early cataracts, as if snatched from a middle-aged diabetic; the other was, I am sure, taken from an Oriental of some kind, dark brown and almond shaped and much younger. As if the horror of this were not enough, though clearly the baby could see us and was responding to our presence, those eyes retained the glassy stare of the dead, a look we had both seen many times – but never thought to see mobile and directed at us!!!

    We stepped back from the cot in disgust, and it was then that the baby sprang from the cot, hitting me in the face and proceeding to grab on to me with all six arms, bearing down on me with superhuman strength as it chewed at my face. The pain was abominable, as was the stench of mild rot and formaldehyde given off by this grotesque beast. I fear we both panicked, for I have a memory of punching myself in the face and screaming at Mr. Ambrose to get it off me! But after some moments we managed to drag it from my face, and Mr. Ambrose was able to place the upturned cot over it, then putting the rocking horse onto the cot to ensure its immobility. We then squatted before the cot and looked at this beastly thing, as it stuck its fat little mismatched arms through the bars of the cot and hissed and spat at us. We looked into its dead eyes for just a few more seconds before, turning my back on it, I said to my colleague, “Mr. Ambrose, if you please…?” Understanding my intent immediately, he shot that abomination in the head, right between the eyes, and it fell bloodlessly to the ground, dead at last. Shaking and disturbed, we retreated from that room and closed the door fast, leaning against the wall in horror and disbelief. What had we witnessed in there? How could such a golem be made real? Our world had begun to turn …

    Our interest, though, had begun to rise. We must find what horrid scheme Mr. Corbett was engaged in, we must end it, and we must confront him and, if necessary, end him too. We would explore the rest of the basement.

    The next room proved to be a kind of study. Its walls were lined with bookshelves, and there was a desk with a journal upon it, and next to it a strange, irredescent metal box. The box held a strange allure for me, and without much thought I put it in my jacket pocket. The journal I read, and it told us what we needed to know: Mr. Corbett was engaged in some strange ritual of reanimation, which he believed connected to some ancient Indian god called Ramasekval, and he was obtaining body parts from a deluded religious nutcase called Tomas Zewski, clearly some communist Jewish Pole, who worked at the local hospital. Mr. Corbett was plying Zewski with drugs, and in exchange convincing him that he served some dark lord, and that this lord’s purpose was served by cannibalizing bodies at the hospital for body parts to be sent to Corbett. Such a repulsive scheme as I had never heard of before! Though I spent two years sawing off legs and arms in the trenches of the bloodiest war the world has ever seen, believing myself to be as close to hell as it is possible for living men to go, I now realize that I had only just begun to splash in the shallows of human depravity – and that beyond what I already knew and believed so foul, was an ocean of depravity so deep no one could ever know what horrors lay at its depths. I fear now I am beginning to see just how dark and evil a man’s soul can be, and it unnerves me.

    The next room in the basement was confusingly normal: a laundry, full of drying baby clothes. We investigated, but found nothing of interest. At the far end of this room was a door, which we passed through into a machine room, stacked full of parts that had been stripped from various machines. In the corner was a massive generator, and many cans of petrol, that must clearly be used to power whatever light we had seen the night before. We left this room and returned to the hallway. There was one final room off the hallway that we had not looked into, and this we now entered, to find a small space cramped and full of jars and bottles. Many were empty, but some contained pickled body parts – heads, arms, legs. There was a strange picture on the wall at the end of the room, somewhat akin to Michelangelo’s man, but in an Indian style with many more arms and legs. We came close to this picture to investigate it, but it had a strange, unnatural aura that caused it to seem larger, as if it filled the room; strange sounds assailed our ears, and it were as if the painting had been painted on a canvas that was more complex and mathematical than real; only some part of it, wrongly folded, protruded into our own time and space, and looking upon it gave us a twisted and sick hint at those other places where its full form was stretched out. These bizarre contortions of reality sickened and terrified us, and for some minutes I passed out. I must confess that I soiled myself in my terror, and Mr. Ambrose had to drag me, twitching and frothing, from the room. When I came to he was cleaning me up in the laundry room. He had taken off my soiled jacket and trousers, and bid me wear replacements from amongst the stacked laundry of the room. I did, and did not notice at the time that in taking off my jacket he had also stolen from me that lustrous silver box.

    So, we had found all but the room in which Mr. Corbett made his baby, and we knew this must be in the room beyond the macabre nursery we had first entered. We needed to return to it, but before we did, I had an idea. I poured the tequila away, and returning to the machine room filled it with petrol. I then stuffed it with a rag from the laundry, also well-soaked in petrol, and thus made a makeshift firebomb. Now we were ready for trouble. We passed back through the nursery, trying not to look at that horrid infant, and through the other door in that room. This took us, we were not surprised to find, into a dissection room filled with the equipment required to build a horrific golem of flesh. We searched it thoroughly but found nothing more to enlighten us. We did, however, find a trapdoor leading deeper into the basement, and were just beginning to look down into it, contemplating further exploration, when behind us we heard the sound of pattering feet, a grinding sound, and a crash. Dashing back into the nursery, we saw the cot had been overturned and the baby’s body was missing! It had somehow survived Mr. Ambrose’s perfect shot, and was now out somewhere in the basement.

    We passed carefully out of the nursery and into the hallway, and yet still we could hear the sound of that baby’s feet, pattering around in the basement. Fearing it behind us, and wanting to calm our nerves, we ducked back into the room full of pickled body parts and slammed the door shut. I stood near the door, and Mr. Ambrose returned to look at the picture. As he did so, he suddenly disappeared! One moment he was there, and then he was gone! I was left alone in the room, with nothing but that maddening patter of baby feet, and the body parts. Somewhere behind me, an empty jar fell off of a shelf and smashed. I confess I panicked: I lit my petrol bomb, through it amongst the jars, and ran for the door. The bomb exploded, and up went the formaldehyde, creating in moments a conflagration I was sure would take that damned baby, and I dashed out of the room. Moments later though, leaning in the hallway, I heard Mr. Ambrose crying for help from inside! He had somehow reappeared in that inferno! I thew open the door, dragged him out, and slammed it shut again, then dragged him to the laundry to tend his wounds. He was badly burnt, though not in a life threatening way.

    We now, however, had no time. The basement was beginning to burn, and upstairs we heard Mr. Corbett returning. We dashed up the stairs to find him standing ready to confront us, and outside a crowd gathering as the fire began to consume the house. Having no time to spare, I punched Mr. Corbett in the face, and bid Mr. Ambrose drag him outside. I dashed upstairs to his room, grabbed the only useful thing I could find – a pile of letters on his desk – and dashed out after Mr. Ambrose. Putting the doubts of the gathered crowd to rest with my doctor’s manner, we dragged Mr. Corbett’s limp body to my house to “tend” to him.

    Once the crowd and the police were gone, and Mr. Corbett’s once-proud home nothing but smouldering ruin, we woke him and began to demand answers. He denied any knowledge of the doings in the basement, and professed to a singular terror at what we told him. We believed him innocent of the charges laid, though we could not think how such could be, and decided instead to investigate Mr. Zewski. It came as no surprise to me than elderly, respectable gentleman would not be the one most to blame for such evil deeds, when a Polish communist were also in the frame. It was time to visit with him, and to have words.

    What horrors do they seek beneath these peaceful avenues?
    What horrors do they seek beneath these peaceful avenues?

    Our pursuit of Mr. Zewski came to nothing. He tried to escape us in a car, and we were forced to commandeer an ambulance, eventually driving him off the road and nearly killing him. Under duress he revealed himself to be exactly the dupe Mr. Corbett’s journal described him as; less a communist mastermind and more a foolish drug addict who believed himself a satanist, though he was a member of no covern. I patched him up as best I could and we drove him back to the hospital in the same ambulance. At the hospital I procured a few harmless injectable placebos such as we occasionally use on the worst of psychosomatics, and we returned to our house. I was now convinced that Mr. Corbett knew more than he was admitting to, and enacted a fiendish plan to get the truth. I injected him with one placebo and told him that it was a poison, and the only antidote was in my possession. Showing him another vial of a harmless placebo, I placed a bell in his bound hand, and told him he had three hours to tell us everything. Before we had even left the room, he was ringing that bell madly, desperate to tell us all. Yet still, when we interrogated him, he denied all knowledge of the doings in his basement. Exasperated, we left him to his imagined death, and decided there was only one thing left to do: before the police dug deep and discovered the body parts from the ruins of his house, we needed to enter that trapdoor.

    We wasted no time, and kitting ourselves up with shotgun, pistol, rope and flashlight, we returned to Mr. Corbett’s ruined house. We re-entered the basement and, after digging away ash and rubble, opened the trapdoor. I went first while Mr. Ambrose covered me, and then he followed. We found ourselves in a narrow tunnel, that curved away and out of sight. Most perplexed, we followed it for some minutes. It descended a little and straightened, and we followed it for a few more minutes before encountering the most perplexing and disturbing of sights. Ahead of us the tunnel ended in a blank wall. In front of the wall were some dozens of the same homunculi we had seen in Mr. Corbett’s house, all constructed from discarded body parts, all of different sizes, though all vaguely human. They were digging frantically at the tunnel end, extending it through the earth, and as they dug they hurled the soil behind him. There, blocking a part of the tunnel, was a terrible ugly slug-like thing, larger than a man, that oozed along behind the monsters, eating the soil they threw away with a horrid slurping sound.

    The creatures had not seen us, so busy were they at their digging, and we were in no way well-enough armed to best them. We were also deeply, profoundly disturbed by what we saw. We backed slowly away and then fled in terror back down the tunnel, reemerging in the basement as fast as we could. We slammed that trapdoor shut and ran back up into the light, shaking in terror. What were we to do?

    Mr. Ambrose became then the most practical of men. He directed me to find a map and a hose. While I did so, he turned on the engine of Mr. Corbett’s car. The hose we snaked from the car’s exhaust pipe down to the trapdoor, where we fed it into that tunnel. We then sealed the trapdoor and returned to the surface to consult the map. Our guess was that those horrid cannibal babies were digging straight towards the centre of town, to an old statue that stood there. Perhaps there was something buried beneath that statue, something they sought, that we could dig up first?

    So I must end this diary entry, for we rest now before approaching the resolution of these mysteries. Why did Mr. Ambrose disappear before that warped and mysterious picture, and what was its purpose? Was his strange disappearance linked to the lustrous silver box? How can Mr. Corbett not know what goes on beneath his own feet? And why does his legion of homunculi dig towards that statue? By what fiendish power does he animate those corpses? What secrets have we uncovered in New Orleans? I fear we are on the cusp of a great and terrible discovery, and that our lives will never be the same again …

  • Looking for the one who got away
    Looking for the one who got away

    I cannot recommend Ripper Street highly enough. The actors are excellent, the dialogue fine, and the English a joy to listen to. The setting is grim and nasty, the lead characters compromised and gritty, but it has none of the bitterness and cynicism that so often accompanies those traits in a TV show. It’s also, I think, the first TV show I have ever seen that might be described as sex-worker positive. It’s what Deadwood could have been, if it weren’t so deeply and overwhelmingly misogynist.

    Ripper Street is a crime/mystery TV series set in the East End of London in the era of Jack the Ripper. The Ripper himself has been and gone, but the show focuses on the detective who failed to catch him, Detective Inspector Reid, his sergeant Bennett Drake (played by Bron from A Game of Thrones) and an American, Homer Jackson, who is their forensic doctor. Reid has lost a daughter, possibly to Jack the Ripper, and his personal life is on the rocks because of it; Jackson is an ex-Pinkerton on the run with his ex-girlfriend Susan, who runs a brothel (where Jackson lives); and Drake is tormented by his memories of soldiering in Egypt, where he may also have joined some satanic sect. The fifth person in the picture above (far right) is Miss Rose, one of Susan’s employees, who is in a relationship with Jackson but being wooed by Drake.

    Reid is played by Matthew McFadyen, most famous for his stirring portrayal of D’Arcy in the BBC adaptation of Pride and Prejudice, and as one might expect from such impeccable credentials, he does an excellent job of portraying a detective trying to use modern, scientific methods to solve crime in a world still steeped in cruelty, superstition and bigotry. Bennett Drake is like a soft version of Bron, capable of being just as vicious but also much more vulnerable. He is Reid’s hard man: in 19th century London no one has to adhere to the human rights act, and when confessions need to be extracted it is Drake who extracts them. Jackson is probably more dangerous than either of them, and has a very dubious past, but provides the medical skills (and to a large extent the real brains of the operation). He is also a selfish, lazy and arrogant man.

    So basically this TV series is like a grittier and slightly less fanciful version of From Hell if it somehow crashed into Pride and Prejudice, with Reid as a more down-to-earth version of Abberline, and a team of three putting together a modern approach to policing. In many ways the show seems to have really made a big effort to capture the reality of the times, portraying the East End of London as a far more diverse, contested, and hopeful place than perhaps we are used to seeing in Ripper-era television. I also think it deals particularly well with two classes of person: Americans and sex workers.

    The Americans in Ripper Street dress differently, they talk differently, they really do seem to come from a different world. They’re usually either on the run or looking for something, and they aren’t native in London – they don’t know the town, they often hate it, and they’re usually there with a purpose, not usually a good one. They’re gaudier, more dangerous or more sinister, and they’re also more modern – they have ideas and skills and ways of looking at things that the Londoners aren’t used to. This is how I imagine they would have seemed at the time the show is set, and it might be part of the explanation for why British society has such a strange love/hate relationship with American culture. I really like this depiction of the gulf between two apparently closely-related societies, a gulf that I think a lot of people feel in their day-to-day dealings in the real world, and it’s nice to see Americans in Britain being depicted as more than just a different accent.

    But where Ripper Street really excels for me is in its treatment of sex work. It’s the first TV show I think I’ve seen other than Deadwood where sex workers are major characters, but unlike Deadwood it doesn’t reduce them to weak and pathetic characters dependent upon men for approval and safety. Though they are constrained by the stupid mores of their time, the sex workers in Ripper Street aren’t weak, and they don’t wait for men to protect them or help them, nor do they seek men’s approval. They are proud, strong women trying to make their own way in a world where women have no formal power. They aren’t sluts or idiots, but ordinary women doing what needs to be done. The show also takes a narrative stance on sex work, not particularly openly, so that we can see the morality of the world in which the women work and trace its hypocrisies and cruelties; this isn’t done in a hamfisted way, generally, and it’s portrayed primarily through the efforts of Reid’s religious wife, Emily, who wishes to establish a shelter to protect homeless women without dictating morals or lifestyle. It’s really refreshing to see a TV show set in an oppressive era that doesn’t fetishize sexual violence and reduce its female characters to victims and objects. If only Deadwood had done the same …

    Ripper Street only has eight episodes so far, and a new season won’t be along any time soon, but I strongly recommend viewing what there is. It’s an excellent and enjoyable show, and a welcome addition to that small genre of TV shows about the genesis of modern policing. Don’t hesitate to try it out if you get the chance.

  • Is it just me, or has the Guardian embarked on a project of excessive tastelessness[1]? In the last two days they have shown video footage of 17 people dying in a hot air balloon (apparently you can see people jumping to their deaths) and of a man being dragged to his death by a South African police van. WTF? I don’t want to watch people die. I was always of the understanding that snuff videos were an urban myth. Call me crazy, but I don’t think media outlets should be showing footage of real people dying. I don’t want my death to be on film, and I don’t want to watch you die. Maybe occasionally there is some social value to watching you die, but in general I think your death should be something kept between you, your family and your god or gods.

    I remember years ago some stupid American politician shot himself in the face in front of the media, and pretty much every Australian TV station chose not to play it. I recall one station even had a statement about why they “censored” the sight of a man blowing his brains out. What has happened in the intervening years that grainy footage of some holiday-makers having an otherwise great day ruined by their horrible fiery deaths has become news? Why do I need to see some kid in South Africa being murdered?

    I think I can chalk this up as another example of how journalists and the media generally are losing track of reality. But let me say this: to the best extent that I can, I will try to avoid watching you die. Obviously, some stupid media may trick me into watching their horrid snuff films, but if I have any say over the matter, I will not watch you die.

    I’m sure that will make you feel better when you do.

    fn1: Obviously for a lot of people this has been a rhetorical question for a very, very long time now.

  • On Monday I was required to monitor at the Tokyo University undergraduate entrance exams. I shepherded 60 terrified 17 year olds through a 2.5 hour Japanese language test and then a 100 minute maths test. These tests were part of a two day examination process for those want to enter the humanities faculty of Tokyo University. About the Japanese test I can say nothing, but the maths test interested me, and can be found online (in Japanese) at the Mainichi Shinbun newspaper. In order, based on my feeble attempts at translating the exam, the four questions were:

    • A straightforward but nasty calculation of the properties of a line intersecting with a cubic function, including elucidation of all minima and maxima of the products of the lengths of two line segments
    • A geometry question with two proofs
    • A constrained linear programming problem
    • A simple Markov model with a slight twist

    The students had 100 minutes, and to their credit quite a few of the students managed all four, though a lot also stumbled and didn’t get past two. I would say that for a well-trained student with good maths skills, these four questions can all be done inside their allotted 25 minutes, but it’s a pretty risky process – even a small error at the start, or misconception of how to do the problem, and you have basically lost the whole question because you only have time to attack the problem once. And these problems are probably about the same level of difficulty as the questions on a standard year 12 maths exam in Australia – where usually we would have three hours.

    But these questions were for the Humanities Faculty of this university. If you want to study Japanese literature at Tokyo University, you first have to get through that 100 minutes of high level mathematics. It says something, I think, about the attitude of Japanese people towards mathematics, and towards education in general, that they would even set a mathematics test for access to a Humanities Faculty; and it says even more about the national aptitude for maths that the students could tackle this exam.

    At about the same time as these exams were being held, the Guardian and the Sydney Morning Herald released articles slamming the mathematical and science abilities of the average student in the UK and Australia, respectively. The Guardian reported on a new study that found English star students were two years behind their Asian counterparts in mathematics, with 16 year old English students at the same level as 14 year old Chinese. The study also found that

    The research also found England’s most able youngsters make less progress generally than those of similar abilities across the 12 other countries studied. The other countries studied were Singapore, Hong Kong, Taiwan, Japan, Australia, Slovenia, Norway, Scotland, the US, Italy, Lithuania and Russia.

    Meanwhile, the Sydney Morning Herald reported on a new study showing that the proportion of students doing mathematics is falling fast, with apparently only 19% of students studying maths, science or technology in their final year of school, and a rapid fall in mathematics enrollments amongst girls especially. The corresponding figure in Japan in 2002 was 64%.

    So is this a problem, why is it common to the English speaking world and viewed so differently in Asia, and what can be done about it? Obviously as a statistician I think this is woeful[1], and it certainly is my personal opinion that understanding mathematics is a good thing, but is it bad for a society as a whole to neglect mathematics education? I don’t know if that’s objectively verifiable. So let’s skip that question, assume for now that improving the number of people taking mathematics is good, and just jump onto the question of why it is unpopular in Australia, and why the British are so bad at it.

    First, I would like to dispute the possible explanation provided in the Guardian article by “the researchers”:

    In east Asian cultures education has historically been highly valued. This can be seen not only in teachers’ high salaries, but also in the heavy investment of families in private tutoring services

    While it may be true that “social and cultural factors” affect maths achievement, the idea that Asians are better at maths because they value education more highly is a very weak one. If this were the case, would it not also be the case that Japanese would universally be better at foreign languages than the British or Australians? Japanese get a long exposure to English teaching but are generally woeful at it, despite all the money they sink into private tutoring services. No, there’s something else going on here, something about the Asian approach to maths and the way it is taught that is important.

    It is certainly the case that private tutoring services need to be considered in the mix. When comparing a 16 year old English student to a 14 year old Japanese student, for example, you are comparing someone who does a 9 – 5 study day with very long winter and summer holidays against someone who does an 8 – 8 study day with two-week holidays, and who gets 2-on-1 or small group tutoring in key subjects for up to 3 hours a day, and on weekends. This process starts at age 10 and really ramps up at about age 15-16, just when the linked article finds the biggest gap between English and Asian students. It’s also the kind of process that benefits the “brightest” students most, and would explain the gap very nicely.

    It may be that if the UK wants to compete with the sleeping giants of Asia on basic educational outcomes, it’s just going to have to face up to a simple fact: British students need to study harder. A lot harder.

    There are some more nebulous cultural factors that come into play, however, and I am going to go out on a limb here and name a few factors in Japanese society (the part of Asia I am familiar with) that I believe make Japanese so much better at maths than their western counterparts.

    • It isn’t about native talent: A pet hate of mine about western approaches to mathematics is the idea that some people are talented at it, and most people aren’t. I don’t think this is true at all, and I think it’s not something that Japanese believe very strongly. The reality is that getting good at maths is a long, hard slog that involves a huge amount of repetition of basic skills (things like completing the square, substitution, differentiation, interpreting graphs, sign diagrams, etc.) – just like learning a language. Sure, solving maths problems requires creativity and intuition, but these are only of any value if you know the tools you can apply them to, and are familiar enough with those tools to recognize when and how to use them. Mathematics – and especially high school mathematics – is a process of drilling, drilling, drilling, and I think that Japanese recognize this. In Japan the default assumption is that if you pay attention at school and do your homework, you will be good at maths. Sure, they recognize that advanced maths requires extra commitment and talent, but there is a fundamental assumption here that the broad body of maths (up to and including differentiation, integration, limits, and basic probability theory) are things that anyone can learn.
    • The teacher is important: the flip side of the idea that education is important is an increased stress on the value of the teacher, and their role as a guide. The role of the guide is also viewed very differently if they are teaching something that they believe anyone can do, compared to if they are teaching a subject that everyone believes is impossible for most mortals to comprehend. Find me a westerner under the age of 30 who is “terrible at maths” and I will show you someone who was humiliated by an arrogant maths teacher at a crucial time in high school, usually around when they were 14. I was in the bottom class in mathematics when I was 14, expecting to drop out as soon as possible, until a good teacher put some time into teaching me, and I found that I really loved it. In Japan, teachers can be bullies and they can be cold and hard, but I would also argue that they have a much greater burden of personal care and responsibility placed on them compared to western teachers, and the failure of their students is treated more like a professional failure (rather than due to the student’s personal talents) than it is in the west. I think this is especially important with mathematics, because when you don’t get it it really hurts – like a kind of itching in the back of your brain – and the failures pile up rapidly. Just a single year between 12 and 14 in which you give up on maths is enough to make all the subsequent years ever more challenging, meaning the damage and the attendant confidence failures compound.
    • Being nerdy is cool: In Japan, it’s okay to be a nerd, and being good at mathematics is admired and respected. It’s virtually unheard of to find someone here who looks down on a man who can do maths, or thinks that it is beyond the female brain, or thinks that being interested in mathematics is weird. Furthermore, the nerd world in Japan is much more gender neutral than in the west, so there’s nothing unusual about girls doing maths. Good mathematics skill – up to and including being able to rearrange equations or solve systems of equations, for example – is not seen as a weird foible, but as an admirable sign that you are a rounded human being.
    • There is a social expectation of mathematical skill: In addition to nerdiness being much more acceptable, the range of mathematical abilities that qualify you as a nerd in Japan is much more esoteric and advanced than in the west. There is a general expectation that ordinary people can solve maths problems, that they understand the basic language of mathematics so that even if they can’t solve a problem they know roughly what it is and where it sits in the pantheon. Parents assume that their kids will learn mathematics, and don’t dismiss it as the too hard subject that only the special or the weird get ahead in. Whereas in Australia having a kid who is good at maths is unusual, in Japan it is unusual (and embarrassing!) to have a kid who is not good at maths.

    I think these properties add up to a society in which mathematical achievement is encouraged and widespread. I think that Australia and the UK need to change some cultural factors so that the intellectual and educational landscape is closer to that in Asia if they want to keep up on mathematics and technology achievement – especially since China’s education system is maturing, and other Asian nations like Vietnam, Singapore and India are getting wealthier, with all the educational gains that implies. So what should Australia do?

    • Ditch the nerd-baiting: there’s something really wrong with the way the English-speaking world treats people who do nerdy things. I’m sure it’s mellowed a lot since I was a kid but it’s still there, the kind of ugly-four-eyes assumption about anyone who is interested in anything that isn’t sport or fashion. Until this weird attitude dissipates – and until the nerd world becomes more gender-balanced, to boot – it’s going to be hard to encourage the kind of cultural changes needed to make maths achievement standard across the board
    • Less intuition and initiative, more drills: I think it’s very sweet that maths teachers want to encourage their charges to think about the broader world of maths, about creative problem-solving, about applying maths to the real world, etc. But I think those are natural talents all humans possess, that cannot be unlocked without a robust background in the basic skills that make mathematics work. So leave the creativity for people who need it, and stuff kids’ heads full of “useless” rote learning of techniques and drills. It’s boring, but it’s essential to the bigger stuff. If you aren’t able to immediately see when and how to complete a square, then any problem which requires this basic technique is going to be beyond you, no matter how intuitive you are. Maths, possibly more than any other discipline, is built from the ground up, tiny block by tiny block, and all those blocks are essential. So ram them down every kid’s throat, and make every kid think that knowing the quadratic formula is not a test of some kind of obscure talent, but a basic expectation of every 12 year old
    • Force mathematics at higher school levels: When I finished school our balance of subjects had to include at least one science/technology subject, but it didn’t have to include maths. This is wrong, and part of the reason that so many students in Japan do mathematics is that you can’t get into a good university if you take this approach: every one of the better universities includes mathematics in its entrance exam. My personal belief is that completion of higher school certificates should require one foreign language, mathematics, and English. That leaves two other subjects to choose from, and guarantees that you have to do some kind of mathematics to the end of school. Not only will this very quickly lead to a society where entire generations of people are generally familiar with mathematics, it will also put a real focus on the quality of teaching at the earlier years, since any student who is doing badly in years 8 – 10 is going to fail their higher school certificate. [Probably this suggestion for a national curriculum is completely unreasonable, but at the very least students could be forced to do mathematics up until year 11, for example].
    • Make school more robust: The Japanese school system is about to shift to a “tougher” system that will include Saturday morning classes, because the previous system was considered “relaxed” compared to earlier years. This is, frankly, ridiculous, but so is the attitude towards education of most of the English-speaking world. Summer holidays are way too long and relaxed, there is a real lack of extension classes and tutoring, and expectations are altogether too low. Education isn’t valued enough, and until this changes anyone who wants their child to do better is going to be swimming against a strong current. Educational achievement is partly supported through the shared goals of a whole society, not just through the targets of individual families, and the expectations we hold for education are primarily set through the school system. So toughen it up – not in the sense of making teachers scarier or bringing back outdated “three Rs” educational styles, but by increasing the amount of time students spend at school, setting tougher standards for graduation and university entrance, making schools compete with each other (as Japanese schools partly do) and forcing parents to take greater responsibility for and involvement in their children’s education. This change isn’t specific to mathematics, but it would certainly help.

    I don’t think there’s anything special about Asian students, or about Asian culture, that we can’t adopt. Asians’ mathematics achievements aren’t some kind of native or racial talent. It’s just a collection of attitudes towards education, mathematics and nerdiness that we can adopt if we want. Obviously there will be (potentially challenging) institutional changes required as well, and many people may judge it not worth the effort, but I personally think a world where everyone is good at mathematics is a better world, and we should be aiming for it. With these cultural changes maybe one day everyone will know the obvious thrill of being able to complete a challenging mathematics exam … and enjoying it!

    fn1: Though obviously, the less people doing maths, the longer I will remain competitive in the marketplace …

  • It's all Greek to you, isn't it?
    It’s all Greek to you, isn’t it?

    I received a very interesting hospital dataset recently, in excel format and containing some basic variable names and values in Japanese. These included the sex of the patient, the specialty under which they were admitted to hospital, and all variable names. Initially this would be reasonably easy to convert to English in excel before import, but it would require making a pivot table and fiddling a bit (my excel-fu) is a bit rusty, but also I have address data and though at this stage it’s not important it may be in the future. So, at some point, I’m going to have to import this data in its Japanese form, so I figured I should work out how to do it.

    The problem is that a straight import of the data leads to garbled characters, completely illegible, and very little information appears to be available online about how to import Japanese-labeled data into Stata. A 2010 entry on the statalist suggests it is impossible:

    Unfortunately Stata does not support Unicode and does not support other multi-byte character sets, such as those necessary for Far Eastern Languages. If you are working with a data set in which all of the strings are in a language that can be represented by single byte characters (all European languages) just choose the appropriate output encoding. However, if your dataset contains strings in Far Eastern langages or multiple languages that use different character sets, you will simply not be able to properly represent all of the strings and will need to live with underscores in your data.

    This is more than a little unfortunate but it’s also not entirely correct: I know that my students with Japanese operating systems can import Stata data quite easily. So I figured there must be something basic going wrong with my computer that was stopping it from doing a simple import. In the spirit of sharing solutions to problems that I find with computers and stats software, here are some solutions to the problem of importing far Eastern languages for two different operating systems (Windows and Mac OS X), with a few warnings and potential bugs or problems I haven’t yet found a solution for.

    Case 1: Japanese language, Windows OS

    In this case there should be no challenge importing the data. I tried it on my student’s computer: you just import the data any old how, whether it’s in .csv or excel format. Then in your preferences, set the font for the data viewer and the results window to be any of the Japanese-language OS defaults: MS Mincho or Osaka, for example.

    This doesn’t work if you’re in an English language Windows, as far as I know, and it doesn’t work in Mac OS X (this I definitely know). In the latter case you are simply not able to choose the Japanese native fonts – Stata doesn’t use them. No matter what font you choose, the data will show up as gobbledigook. There is a solution for Mac OS X, however (see below).

    Case 2: English language, Windows OS

    This case is fiddly, but it has been solved and the solution can be found online through the helpful auspices of the igo, programming and economics blogger Shinobi. His or her solution only popped up when I did a search in Japanese, so I’m guessing that it isn’t readily available to the English language Stata community. I’m also guessing that Shinobi solved the problem on an English-language OS, since it’s not relevant on a Japanese-language OS. Shinobi’s blog post has an English translation at the bottom (very helpful) and extends the solution to Chinese characters. The details are on Shinobi’s blog but basically what you do is check your .csv file to see how it is encoded, then use a very nifty piece of software called iconv to translate the .csv file from its current encoding to one that can be read by Stata: in the example Shinobi gives (for Chinese) it is GB1030 encoding, but I think for Japanese Stata can read Shift-JIS (I found this explained somewhere online a few days ago but have lost the link).

    Encoding is one of those weird things that most people who use computers (me included!) have never had to pay attention to, but it’s important in this case. Basically there are different ways to assign underlying values to far Eastern languages (this is the encoding) and although excel and most text editors recognize many, Stata only recognizes one. So if you have a .csv file that is a basic export from, say, excel, it’s likely in an encoding that Stata doesn’t recognize on an English-language OS. So just change the encoding of the file, and then Stata should recognize it.

    Working out what encoding your .csv file is currently in can be fiddly, but basically if you open it in a text editor you should be able to access the preferences of the editor and find out what the encoding is; then you can use iconv to convert to a new one (see the commands for iconv in Shinobi’s blog).

    Unfortunately this doesn’t work on Mac OS X: I know this, because I tried extensively. Mac OS X has iconv built in, so you can just open a terminal and run it. BUT, no matter how you change the encoding, Stata won’t read the resulting text file. You can easily interpret Shinobi’s solution for use on Mac but it won’t work. This may be because the native encoding of .csv files on Mac is unclear to the iconv software (there is a default “Mac” encoding that is hyper dodgy). However, given the simplicity of the solution I found for Mac (below), it seems more likely that the problem is something deep inside the way Stata and the OS interact.

    Case 3: English-language, Mac OS X

    This is, of course, something of a false case: there is no such thing as a single-language Mac OS X. Realizing this, and seeing that the task was trivial on a Japanese-language Windows but really fiddly on an English-language windows, it occurred to me to just change the language of my OS (one of the reasons I use Apple is that I can do this). So, I used the language preferences to change the OS language to Japanese, and then imported the .csv file. Result? Stata could instantly read the Japanese. Then I just switched my OS back to English when I was done with Stata. This is a tiny bit fiddly in the sense that whenever you want to work on this file you have to switch OS languages, but doing so on Apple is really trivial – maybe 3 or 4 clicks.

    When you do this though, if you aren’t actually able to read Japanese, you’ll be stuffed trying to get back. So, before you do this, make sure you change your system settings so that the language options are visible on the task bar (you will see a little flag corresponding to your default locale appear next to the date and time). Then, make sure you know the sequence of clicks to get back to the regional language settings (it’s the bottom option of the language options menu in your taskbar, then the left-most tab inside that setting). That way you can change back easily. Note also that you don’t, strictly speaking, have to change the actual characters on the screen into Japanese! This is because when you select to change your default OS language, a little window pops up saying that the change will apply to the OS next time you log in but will apply to individual programs next time you open them. So you can probably change the OS, open Stata, fiddle about, close Stata, then change the OS back to English, and so long as you don’t log out/restart, you should never see a single Japanese-language menu! Weird, and kind of trivial solution!

    A final weird excel problem

    Having used this trick in Mac OS X, I thought to try importing the data from its original excel format, rather than from the intermediate .csv file. To my surprise, this didn’t work! In programming terms, running insheet to import .csv files translates the Japanese perfectly, but running import to import the excel file fails to translate properly! So, either there is something inaccessible about excel’s encoding, or the import program is broken in Stata. I don’t know which, but this does mean that if you receive a Japanese-language excel file and you’re using Mac OS X, you will need to export to .csv before you import to Stata. This is no big deal: before Stata 12, there was no direct excel import method for Stata.

    A few final gripes

    As a final aside, I take this as a sign that Stata need to really improve their support for Asian languages, and they also need to improve the way they handle excel. Given excel’s importance in the modern workplace, I think it would be a very good idea if Microsoft did more to make it fully open to other developers. It’s the default data transfer mechanism for people who are unfamiliar with databases and statistical software and it is absolutely essential that statisticians be able to work with it, whatever their opinions of its particular foibles or of the ethics of Microsoft. It also has better advanced programming and data manipulation properties than, say, OpenOffice, and this makes it all the more important that it match closely to standards that can be used across platforms. Excel has become a ubiquitous workplace tool, the numerical equivalent of a staple, and just as any company’s staplers can work with any other company’s staples if the standards match, so excel needs to be recognized as a public good, and made more open to developers at other companies. If that were the case I don’t think Stata would be struggling with Asian-language excel files but dealing fine with Asian-language .csv files.

    And finally, I think this may also mean that both Apple and Microsoft need to drop their proprietary encoding systems and use an agreed, open standard. And also that Windows need to grow up and offer support for multiple languages on all their versions of Windows, not just the most expensive one.

    Lastly, I hope this post helps someone out there with a Japanese-language import (or offers a way to import any other language that has a more extensive encoding than English).

  • Today’s edition of PLOS Medicine contains an article describing a possible cap-and-trade scheme for global health investment, designed around a cap-and-trade carbon permit scheme. Built on the assumption that health is a global public good, it proposes that all countries sign up to a centralized system of permits based on disability-adjusted life years (DALYs). If a country wishes to invest in a low cost-effectiveness health project, it would need to offset the poor gains arising from its own scheme by purchasing DALYs for a low-income nation. The article contains some interesting examples, including the additional cost that a low-efficiency health project in a developed nation would incur through purchasing the DALY offsets.

    For example, introducing pneumococcal conjugate vaccination (PCV) in Australia is a highly cost-ineffective strategy (costing about $100,000 per DALY gained), well above the threshold defined for a cost-effective intervention in a low-income nation. In order to implement this project, Australia would have to purchase about 1300 DALY offsets, which it could do through (for example) increasing the coverage of a standardized vaccination schedule in South East Asia. Purchasing these DALY offsets through this project would add 0.2% to the cost of introducing PCV in Australia (see Box 2 in the text).

    The article also gives a cute chart showing which countries would need to increase investment and which could reduce investment in global health in order to meet the conditions of the scheme, and the authors suggest a significant change in the distribution of global health funding:

    19%–28% of the total increase, or US$6.8–US$10 billion, would come from the US, 5%–6% from Japan, 4%–6% from Germany, 3%–4% from France, while some of the bigger middle-income countries would also contribute substantially, with 6%–7% from China (i.e., US$2.1–US$2.7 billion), 3% from Brazil, and 2% from India. Our proposal, therefore, involves a marked change in perspective over who should contribute to meeting the health MDGs [millennium development goals], with contributions expected from large emerging economies such as China and Brazil.

    This is an interesting change in perspective and also a strong statement about the extent to which a few key countries (e.g. the USA, Japan and France, which it should be noted is an ex-colonial empire) are shirking their global health responsibilities.

    I don’t know whether cap-and-trade systems are the best way to solve problems of the commons – the authors claim they are and give a reference, but I don’t know if they’re on strong grounds – and I’m not sure how much of a case can be made for health as a global commons compared to, say, the climate. But even if you drop the argument about global commons and just propose this cap-and-trade system as a mechanism for enforcing global investment in health priorities, I think it’s an interesting case. Certainly, a lot of countries are failing to meet their millennium development goal (MDG) targets, and although the authors note a range of reasons that are independent of funding mechanisms, it’s fairly certain that some of the shortfall is simply due to a lack of investment, and (again, as the authors observe) extremely inefficient investment choices. From a global perspective, the amount of money Japan is going to commit from 2013 to funding PCV, with limited cost-effectiveness, to save just a small number of lives, is a terrible waste when it could be funding crucial vaccinations (like tetanus for pregnant women) in countries with very low incomes and fragile health systems. It would be interesting to see how fast these countries’ health metrics would improve if the entire world adopted a scheme that forced them to consider the most efficient health investments, from a global rather than a local perspective …

     

     

  • Rabbit-headed cuckoo clocks were all the rage!
    Rabbit-headed cuckoo clocks were all the rage!

    Yesterday was another Gothic Lolita-styled live event by the crew at A la Mode, the 42nd event of this venerable institution. This night had the same excellent value-for-money line up of 6 or so bands interspersed by DJs, for just 3000 yen, but this time there were less of the pretty little 5 minute floor shows, and instead there was an excellent steampunk fashion show, and a very weird 30 minute theatrical performance (pictured above).

    This time gas-mask free...
    This time gas-mask free…

    The fashion show appears to have been organized by one of the two members of the band Strange Artifact, who I refer to as Miss Artifact (pictured above, singing). I failed to get any functional pictures of the fashion show, but it was excellent – mostly women in voluminous 19th-century-styled dresses, wound about with belts festooned with mysterious gear, all intricately worked with geometric designs and brasswork. One girl was wearing a leather shoulder-guard that held glowing potions in test tubes, like an elegant and feminine version of the Witcher; two carried briefcases studded with brass designs; another carried a tiny pistol and what looked like a glowing, arcane power tube on her back. There was also a man in velvet pants and fine waistcoat, festooned with accessories and carrying an elaborate clockwork-styled gun, a feather jauntily perched in his top hat. Overall, it was an excellent showcase of craftwork and over-the-top steampunk sense, relatively free of gothic influences and heavily influenced by cowboys-and-indians railroad America, and industrial-revolution England.

    Death and the Angel...
    Death and the Angel…

    The show wasn’t lacking in gothic influences, though. The two bands that followed Strange Artifact, himemanik and Remnant, had a healthy dose of gothic style: himemanik with a nice electronic pulse, and (as can be seen from the photo above), Remnant with a large dose of over-the-top old school coffin-guitared goodness. I really liked himemanik, actually, but I failed to get any pictures of them. I also failed to get pictures of Elupia, who I have reviewed before. Elupia are working on a new album, and were really in fine form at this gig, playing with a lot of energy and strength. They really epitomize the level of technical quality that even minor Japanese bands achieve, and are a good advertisement for the Japanese live scene – which in my experience is worth spending money on even if you don’t know the bands, because they are usually at a very high standard.

    At this event, I had noticed a couple of women who had turned up wearing zombie nurse outfits, and who spent the afternoon drinking and checking their make-up (and sleeping). One of them was wearing a badge that said “Satan,” also incidentally one of the band names, so I was thinking we might be granted an audience with a zombie nurse rock band. However, as time passed my friend pointed out that the hall was becoming something of a “midgetorama” (his words) as it filled up with really, really short girls, some obviously very young (this was somehow an all-ages gig). These women seemed to have no fashion sense or style in common, but we soon discovered that they all shared a deep, powerful obssession with the headline act of the evening, Satan. For when Satan began playing, they all charged forward, unveiling Satan-themed sweat towels or t-shirts, and lined up at the front of the stage.

    You spin me right round baby, right round!
    You spin me right round baby, right round!

    What followed was a revelation. Satan (pictured above) are a standard thrash/punk band with nothing special to recommend them – good, savage, loud and raw, but so are all of their kind – except the slavish devotion and energy of their fans. They proved this early on by producing a troll doll and spinning it around before the audience. This was the trigger for all of their fans to form up in serried conga-line ranks and do a complete circuit of the dance floor, charging around in one revolution and returning to their places to resume head-banging crazily to the thrash. Satan invoked this ritual regularly through their songs, somehow managing to hold out an arm or do a spinning sign with one hand and get all their fans to charge around the room. The rest of us had to step back in stunned incomprehension to allow this horde of tiny 16 year olds to take the floor.

    It was then that Satan produced his pogo stick. At the sight of this wicked device of ancient power, his fans formed into three neat ranks, all facing in the direction he pointed, and began pretending to be pogo-ing, moving slowly up and down as the guitarist drew out a deep, ferocious roar. Then, of course, off they charged. Their dark lord could reproduce this pogo action just by crouching down on stage.

    Other things that Satan got his little girls to do included worshipping the guitarist – whenever a solo was played, the girls all fell to their knees and genuflected – and a kind of mini bus-stop dance, in which the entire crowd went through the same series of arm-crossing and uncrossing, head banging motions.

    He also produced a rubber hammer with which he whacked girls at the front of the stage, got them to slap his arse, spat water on them, and whipped them with his dreadlocks. Thus does Satan rule supreme over the gathered hordes of Tokyo’s schoolgirls …

    Unfortunately I couldn’t get a picture of all this because, even though Satan is just some second-rate Tokyo thrash/punk band with about 30 devoted followers, he fancies himself special, and has a staff member who came over to tell me further pictures were banned. Further proof, if proof were needed, that intellectual property law is the work of Satan.

    At this point as well my phone batteries died (all these photos were taken on my phone), and I failed to get any photos of the last band, Velvet Eden. No loss, since they were completely boring aside from the fact that their singer was cross-dressing, and stopped halfway through the performance to tell us that the band had been running for 10 years and this meant he had also been wearing a “T-back” (g-string) for 10 years. It was, he told us, 10 years since he became TBO – T-back Ore (g-string me!). Just as well he had the gimmick, since the band was ordinary.

    So, another a la mode gothic lolita night passed in style and (mostly) musical excellence. This one was quite different to the last, and it’s clear that they put a lot of effort into each night they run, with very different performances and themes for each one. The next will be in early March, and if you are in Tokyo then and have a chance I strongly recommend it …

  • Drawing on yesterday’s post about simplifying warhammer, here are the outlines for a high fantasy character class, akin to the Rogue class from Rolemaster.

    Introduction

    The rogue is a criminal and a thug, the kind of knave who hires themselves out to do nasty jobs in the bad parts of dirty towns. Rogues fight and kill for a living, but they don’t do so fairly: a rogue who finds themselves in a fair fight has made a tactical error, and given their natural tendencies towards cowardice and thuggery, the kind of rogue who regularly gets caught in open combat is likely to die. Rogues get ahead by a combination of bastardry and skullduggery. They don’t resort to “honourable” crimes like thieves, and they don’t resort to honourable combat as do Champions or warriors. They ambush, trick and run.

    Class skills

    Stealth, Weapon Skill OR Ballistic Skill, Coordination, Guile, Intuition

    Abilities

    Primary abilities: Agility, Fellowship

    Wound threshold: +0

    Strain: +0

    Starting talents

    • Agile defender: if the rogue is not attacking, he or she can make a 1D coordination check. Every success on this check adds 1 misfortune die to the enemy’s attack; every bane causes one point of strain
    • Surprise attack: The rogue gains two fortune dice to initiative when attacking from stealth, and two fortune dice on melee attacks against those who have not acted in the first round of such an attack
    • Fluster: make a Guile vs. Discipline challenged check, with +2 misfortune dice. All allies add 1 fortune dice per success for their next action against the targeted enemy

    Talent tree

    Rogues develop talents according to figure 1.

    Figure 1: Rogue Talents
    Figure 1: Rogue Talents