Compromise and Conceit

Infernal adventuring…

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An Australian statistician and role-player living in Japan, interested in the theory and practice of role-playing…

  • Watching the Privatization of Britain’s National Health Service

    Yesterday the UK government passed the Health and Social Care Bill, which institutes sweeping changes across the National Health Service (NHS) that some observers claim will see it completely transformed from its present form into a privatized health provider. Depending on who you ask, we are about to witness the dawning of a golden age in health gains for ordinary Britons, or the unravelling of Britain’s healthcare system with terrible consequences. Those of us who don’t currently depend on the NHS for our healthcare get to watch the fascinating spectacle of the world’s largest centralized healthcare system (and I think according to some reports the world’s largest single employer) being dismantled piecewise from the comfortable vantage point of our functioning universal healthcare systems (unless we’re American, of course – you guys just get to be jealous that the UK has a universal health system to dismantle).

    The Health and Social Care Bill contains, in  my view, one of the most appalling pieces of healthcare reform that a human being can conceive of inflicting on an otherwise functioning system, but it also contains at least the seeds of some important reforms that are long overdue for the British system. The former is, of course, the ludicrous idea of “clinical commissioning,” in which about 60 billion pounds of NHS funding is to be taken away from area health services (called “Primary Care Trusts”) and given to family doctors, who are expected to form up into consortiums that will then determine what care gets funded with the money they’ve been given. The latter is the decision to split the health system into providers of care (hospitals and health care services), who offer services that then purchased by the NHS (or the afore-mentioned godforsaken GP commissioners). If it were possible to achive this latter reform successfully, the NHS would have been transformed so that it worked along lines similar to almost every other universal health care system in the world, and would also open the way for significant private investment in healthcare infrastructure in the UK. I’ll give some examples of how simple and profound that could be in this post.

    What’s Wrong with the NHS

    The biggest problem with healthcare in the UK – and the problem that governments on both sides don’t want to talk about – is that it is underfunded. The UK spends just under 10% of its GDP on healthcare, compared to between 11% and 17% for France and the USA[1]; before Labour’s reforms in the early 2000s, it spent closer to 8.5% on healthcare. You can’t expect modern health outcomes with this level of funding, though the NHS has shown that you can still do pretty well. The reason that this funding is so low is that the UK system is a centrally managed, entirely publicly-funded service, from which private providers have been excluded since its inception. With no ability to participate in the NHS, tax rates high, and the NHS goal to provide all services free at the point of care, private providers cannot make money and are left providing boutique services to the very rich. Hence, private investment in health is low. But it’s extremely difficult for the government to make up this shortfall – it’s likely doing so would require the government to increase spending on the NHS by potentially as much as 20% (to take it from the 9.5% of GDP it is now to the 11 or 12% other countries enjoy). Obviously such a funding boost is politically impossible, and so the NHS has languished.

    Funding isn’t the only problem though. A centrally-managed organization of this size is inflexible, conservative and inefficient, and forcing efficiency gains from such a behemoth is extremely difficult. Centralized decision making forces diverse organizations in diverse regions that have individual priorities to commit to goals and priorities set nationally, and leads to the classic inefficiencies and inflexibility of a centrally-managed utopian institution. Other health systems leave much regional flexibility and priority-setting to be determined both at a local level and privately, and force at least some health organizations to respond to patient needs by going out of business if they can’t. Classic examples of this kind of inflexibility abound in the NHS: until recently patients didn’t have a choice of hospital, but had to go to one that was linked to the area in which they lived. You can’t shop around GPs (in theory) but need to “register” with a GP and visit only one – you can’t, e.g. have a different GP for sexual health needs vs. chronic disease management, which is pretty common in other countries. Furthermore, GPs can refuse to accept new patients if their list is full, and many GPs require you to register before you can attend for health care, which is inflexible. There is no incentive for GPs to invest in their own services, since they can refer patients to a hospital for almost every condition, and have a largely captive audience, so the UK has an abundance of one-doctor surgeries with archaic opening times. At least a portion of their renumeration is based on their list size, so there’s no incentive for new GPs to enter the market or to try and increase the amount of services they provide: their ideal business model (financially) is to have a large list of patients and very short working hours, and there’s no incentive for them to merge to form larger GP clinics that might, e.g., provide out of hours services. This all changed slowly under labour since the mid-90s, but GPs – the gatekeepers into the health system in the UK – are very highly paid for a very poor service model.

    The hospital sector in the UK is also under-funded and subject to the kind of rigid service models one expects of a centrally-managed system. The outpatient system is over-burdened from the broken gatekeeper model, and many of the hospital systems are lacking investment and modern infrastructure. This is a throwback to years of underfunding but it’s also a consequence of current funding constraints: both recurrent costs and capital investment need to be funded from the government’s budget, but they can’t contract out e.g. pathology services that would be routinely privatized in other systems, so where much of this investment is done by private companies in Australia, in the UK it’s all part of that 9.5% of GDP. The system is plagued with waiting times and archaic technology and systems, and everyone is overworked.

    Hospitals can’t consolidate or specialize, which is a key method of improving efficiency, quality and safety of care. We know that larger facilities tend to have lower death rates and better success rates, but to achieve such benefits hospitals need to shut down under-performing clinics or specialties and focus on a more limited range of services – and some hospitals need to shut altogether. But in the UK there is a direct relationship between the government and the hospital sector, so every time a hospital plans to close even a single ward you see protests aimed at the local member, followed by political blowback, taken up with gusto by the press (who love an NHS scandal). The government inevitably buckles, and under-performing or inefficient (and sometimes dangerous) smaller facilities can’t relocate or close. In fact, the whole system is vulnerable to political campaigns – on nurses’ or doctors’ pay, on hospital closures, or even on particular treatment methods – in a way that a more mixed model is not.  So it creaks along, unable to consolidate for modern efficiency gains, unable to reform its failing gatekeeper model, and unable to inject the capital required to modernize. Plus, even if it did inject the capital, much of it would be subjet to political debate and delays that would mean it was inefficiently used.

    A Model Example: Privatization of General Practice

    For these reasons, the system needs to be diversified and decoupled from the political pressures that currently constrain its operations, and doing so is inevitably going to mean privatization. There is no reason, for example, that the entire primary health system (that is, GPs) couldn’t be thrown entirely to the whims of the market, with GPs offered payment only on a fee-for-service basis and the market opened up to corporate investors. If the government did this, international health care companies would be in faster than greased lightning, setting up large, efficient and modern clinics with heavy capital investment, bringing in overseas doctors or buying in the local younger doctors, incorporating allied health care services and providing a huge injection of capital to the GP market overnight. Older, settled GPs would hate it because they would be drummed out of the market, but this is exactly what is needed – get rid of these little shoddy one man clinics operating 9-5 and no weekends, and replace them with large, bustling services that provide evening and weekend medical care, physiotherapy, dental care, public health nursing and rehabilitation under one roof. It would immediately take pressure off of hospitals and make healthcare far more easily available for the majority of the working population. These services are the norm in other developed nations but still held back in the UK by the lack of private investment or public vision.

    The Political Mistakes in this Bill

    With these ideas in mind, the government has started outsourcing NHS services, and the Guardian reports on a controversial example from Devon, possibly the first in the UK: privatization of children’s health services. These services will be purchased by the NHS, but provided by either Serco (a private prisons company) or Virgin Healthcare (a branch of Richard Branson’s Virgin empire). This is a classic insurer/provider split: the NHS collects insurance from everyone in the UK and then purchases health services from a private provider. Unfortunately, from what one can tell of the process in the article, it’s going to go down the classic British privatization pathway: give the contract to a single provider without a fee-for-service element and then hope they don’t cock it up. The NHS, with no expertise in contracting from private services, is going to be writing a 100 million pound contract with a famously predatory company like Serco or Virgin. And not just for any services, but for the most controversial possible service they can find: child protection. This isn’t just a political risk but a healthcare risk, because these services are far more complex than say, radiology or pathology services, and there are very few private contractors with any experience in them.

    The linked article on children’s health services makes the people bidding for this contract seem like very reasonable people driven by a genuine desire to provide decent health care and an awareness of what is holding the NHS back. For example, the Serco spokesperson says:

    It has to cut £20bn a year. It can’t invest, but we can invest to improve quality and generate efficiency. We have to bid to deliver at prices that are a lot lower than the NHS to win contracts and that gives the NHS more money to put into the NHS itself.

    This is a good example of why efficiency gains are important. They don’t just benefit the profits of the insurance company doing the purchasing, but also the health of all members of the plan, since they enable the insurance company to fund a greater number of services, and/or to extend its funds to new services. Unfortunately the Conservatives aren’t selling these points, but are instead talking up the need to save money.

    Ideally, the privatization program the Tories are running would start with something simple – pathology or radiology services, or a small rural hospital – and be trialled over several years before being introduced nationally, and the most complex and controversial services (large teaching hospitals, prison healthcare, children’s services) would be privatized last or not at all. Lessons learnt in the initial small trials would be incorporated into the bigger privatization program, and where things failed they would be kept in public hands until better privatization methods could be trialled. Also, the system wouldn’t be privatized in a one-contract-per-service method as is shown here, especially not in rural areas where locals can’t easily choose another service not being provided by the sole contractor. Rather, services would be offered competitively to the lowest bidder, thus allowing the NHS itself to compete. The risk with solo contracts such as planned here are that they don’t actually exert a competitive pressure on the provider – they’re only as competitive as the tendering process. Patients as well as commissioners should have the ability to shop around.

    Unfortunately, the Tories seem to have decided to push forward recklessly, implementing clinical commissioning and hospital privatization at the same time. There’s a risk of chaos, poor contract management, and cost overruns or service failures without any significant benefits to patients, at least in the short term.

    The Most Likely Outcomes

    The privatization of children’s services in Devon is a good example of the radicalism underlying the Conservative Party’s agenda on this topic: they don’t want to see a gradual unravelling of the NHS, starting with the easiest services and building up, and instead want to sell off the most complex bits while simultaneously managing the mish-mash of clinical commissioning, and cutting funding to the NHS by something like 20billion pounds over 5 years. The obvious result is going to be a 5 year torrent of bad news stories, and the public perception that health system privatization is both a kooky agenda (tainted by the confusion and chaos that clinical commissioning will bring) and driven only by the need to cut costs, rather than the very real need to improve the NHS. Thus, when the Conservatives finally lose power, the privatization agenda will be inevitably linked with their other policy radicalism and the agenda of “the cuts” (oh how I hate that term), and the chance to reform the NHS so that it actually works will be lost.

    Furthermore, the Tories aren’t actually testing a health system reform that has any pedigree. A single payer insurer offering fixed payments on a fee for service basis to primarily private providers has been tried and tested in the USA (Medicare) and Japan (kokumin hoken). A weird system of ordinary family doctors holding millions of dollars in health system funding and using it to contract services from private providers on a block funding basis – that is unheard of in modern health systems. Why test it?

    Mistaken Ideas About Health Inequality

    Much of the debate about healthcare in the UK still revolves around this issue of central planning versus US-style free market models. In February the shadow (Labour) spokesperson on health, Andy Burnham, penned a piece for the Guardian in which he criticized privatization. There he claimed:

    In the US system, for instance, it is possible to find some of the world’s most advanced and innovative examples of care. But, alongside it, we find very poor or non-existent care. The question we must ask is not which system produces the best individual examples of treatment, but rather which is best for everyone. On this test, the centrally planned NHS wins hands down.

    This is a completely unreasonable comparison. The US has “poor or non-existent care” because it doesn’t have universal health care. The US could do away with this problem tomorrow by nationalizing all the insurance companies, forming one national insurance company funded by taxation, and then funding all medical care on a strictly fee for service basis. The system would be completely unplanned, with no government hospitals involved, but it would be pretty likely to eliminate “non-existent care” overnight, since all Americans would be eligible for care. Burnham also claims the NHS

    provides the precious ability to set standards and entitlements to services at a national level. Market-based health systems do not afford a similar ability to control costs at national level, and allocate resources in a fair and consistent way.

    But this is also not true. The government, providing all funds for purchasing health care services, can decide exactly how much it will pay, and provide it is not stupid or unrealistic, it is likely that the private sector will fall into line (we’re talking about 100 billion pounds a year of essential services here – people will be shoving into line to get a piece of that). Similarly, the USA has the ability to “set standards and entitlements” even now – for example, it’s very hard for a US health insurance company to refuse someone a policy because they’re black. The problem in the US is that the government won’t set those standards well enough, and by refusing to provide a universal health coverage model, has lost the ability to compete financially in this market place or to control it through its own considerable financial muscle. There have been many models proposed that would reform much of the US healthcare market without making it centrally planned, and would improve both its equality and its ability to contain costs – and in fact some private US organizations (especially HMOs) are famous for good cost containment. The tragedy of the US political system is that many of the education proposals coming from moderate republicans – voucher systems and the like – would significantly reduce health inequality if adapted to the health market, yet even relatively rational and minimal reform plans that would otherwise be favourable to their right wing are rejected out of hand because they involve “government intervention in medical care.”

    The problem in the UK is that this debate about access to care has been framed as a debate between the NHS and the US system for so long that even experts and well-intentioned politicians with a strong understanding of the system (like Burnham) have fallen into it. But the reality is that centrally planned systems don’t necessarily reduce inequality. This is because inequality is not purely a function of inability to afford healthcare: it arises from the interaction between individuals and systems, the design of systems, and the inevitability of resource constraints. Wherever resources are restricted one finds that the wealthy, the educated and the powerful are better able to seize more of these resources, or seize them sooner (an important consideration in health systems). For example, in 2010 I showed that poor and older people tend to receive less referrals or take longer to be referred for a wide range of conditions within the NHS – this despite the fact that the NHS is free to all. This is because the referral system is a type of resource management system, and for reasons we don’t entirely understand, the wealthy and the educated are better able to negotiate any such system. So central planning doesn’t solve these problems, though the way the NHS is constructed makes these problems less life threatening than they would be in, say, the USA (where many of the people whose health outcomes I studied would simply not have access to health care at all).

    Another reason that centrally planned systems don’t necessarily reduce inequality better than other systems is that health inequality is caused by factors outside the health system. It is, simply, a function of inequality, and there’s only so much that even the best health systems can do to reduce the effect of problems created in broader society. The UK is a very unequal society, and the NHS has to deal with the human consequences of that. The goal of health planners concerned about inequality is to find the best system to provide good healthcare to everyone that will also reduce inequality. Balancing these two goals in a resource-constrained setting is difficult, and I see no a priori justification for the idea that central planning is always the best way to do this.

    Some Theories About Modern Healthcare Systems

    Once the NHS and the US’s overly private system are done away with the world will essentially be left with a range of mixed-market models, largely based on the idea of a central universal insurance provider and a partially- or completely- privatized marketplace of service providers. Some, like Canada and Australia, will tend to be more heavily publicly run than others, like Japan or Germany. There will be a few unique hold outs, like China, Cuba and Switzerland, but largely the ideal form of health provider will have been settled. This decade the WHO is focusing on universal healthcare as a central policy theme, and the goal will then be to expand models like Japan’s to encompass the developing world – a pressing problem given the resource constraints there. There is no place in health policy for a purely market-based model and, as far as I can see, there is equally no place for a fully centrally managed model. The debate now is about how to extend the most functional mixed-market models to the rest of the world (including China and India) as a development goal, and how to resolve pressing issues of cost containment in the developed world.

    Given this settled state of policy, it seems now to me that there are some central lessons that have been learnt since the expansion of universal care systems across the developed world over the past 100 years:

    • Governments and markets can’t go it alone: models based entirely on one sector running the whole show don’t work, because health systems are enormously complex, requiring market-based flexibility and government intervention to prevent market failure and enforce standards and access
    • Cost containment, universal access, and timely access are hard to balance: Most health systems can’t manage all three of these at once. The USA has managed timely access but not cost containment or universality; the UK has managed two of the three; Japan, Germany and France have probably got all three down but Germany is heading into financial trouble and Japan has inherited a unique set of social factors (a very healthy population and a very equitable society). This trio of goals for modern health systems are going to become harder and harder to balance as populations age and more expensive health care is developed
    • You can’t fix inequality just by throwing money at it: obviously achieving universal care is an important part of reducing inequality, but that’s not the end of it. How your system functions and how people interact with it is important in determining where inequality arises and how well it is reduced. A complex system with non-financial resource constraints (like the NHS) can create or perpetuate inequality even though on paper everyone has access to care
    • Centrally planned systems don’t solve inequality: Central planning can be an attractive way to reduce inequality, but it doesn’t necessarily work that way. In health systems, inefficiencies or inequities in one area inevitably produce problems and workarounds elsewhere, and centrally planned systems may be able to stamp out some inefficiencies or inequities, but they don’t necessarily have the capability to react to (or even notice) the problems their solutions create
    • Muddled political visions produce muddled outcomes: They may claim to be friends of the NHS but the Tory political program in health is not just about improving the NHS. They also want to cut costs (to the government), and they want to reduce government interference. I think they also have an ideological goal of increasing the role of the private sector in healthcare, and I don’t think this view arises purely from a belief that this will make the system better – they have an ideological commitment to reducing the size and role of government. This muddled goal will produce a partially privatized system that doesn’t work because it wasn’t privatized with the goal of improving the system. Similarly, the Labour party may be friends of the NHS but they also had a goal of privatization with the intention of improving services, but they couldn’t separate that practical plan from their commitment to a centrally planned and government run NHS. The result was a series of aborted privatization plans that satisfied no one.

    Health systems planning is where ideologies go to die, and the NHS is the classic example of this. It has long since proven that the centrally planned, socialized system envisaged in 1948 is insufficient to the long term management of a health system, but subsequent interventions to improve it have been hampered by ideology and have inevitably failed when they meet reality. The latest attempt by the Tories, though it has some good qualities and has the potential to take the NHS in a good direction, is highly likely to meet the same fate. If they do fail the rapidity of the changes, their timing and their entanglement with the Tory cost-cutting agenda could permanently damage the idea of introducing a mixed market system to the NHS, setting back much-needed reforms for a whole generation. This will leave the British people very poorly served by their health system, and continuing to fall behind the rest of the OECD in health outcomes. It will be sad indeed if the country that introduced the modern, free health service is overtaken by even the post-Obamacare USA as a model for health service provision.

    —

    fn1: These figures taken roughly from the Commonwealth Fund’s annual report on health care comparisons between the UK, Germany, Netherlands, NZ, Australia and USA.

  • How Many Punks Does It Take to Change a Light Bulb?

    Answer: None, because punk never changed anything. And today, courtesy of the Guardian, we have an amusing interview with an Indonesian punk that confirms the truth of this cute joke:

    The first wave of Indonesian punk stretched from 1990 to 1995, and saw the arrival of groups called Submission, Antiseptic and the elegantly named Dickhead. It was sparked by records by such British punk groups as the Sex Pistols and the Exploited, a Scottish band whose take on punk could charitably be construed as somewhat reductive (older readers may remember their debut album, Punks [sic] Not Dead, and their only performance on Top of the Pops in 1981, much discussed in British schoolyards the following day).

    A second Indonesian phase began in 1996, inspired by a US punk fanzine and record label called Profane Existence, and the British band Crass, who shared an essentially anarchist ideology. This development played into a sea change in Indonesian public opinion, as opposition to the Suharto regime – which fell in 1998 – hardened. With the regime on its last legs, says Karib, punks tended to be left alone. “We continued to play, without much attention from the authorities,” he says. “They were focused on the student movement, not music.”

    Here the interviewee, a punk musician called Fathun Karib, confirms the long-held suspicion that the punk movement is not a serious threat to genuinely repressive regimes: the closer Suharto came to the crunch point in his leadership, the less police attention the punks attracted, because Suharto’s apparatus of state repression was concentrating its efforts on the genuinely dangerous movements in Indonesian society: the students, according to Fathun Karib, though I suspect that unions and general democratic movements (as well as the armed separatists in the territories) were getting a fair amount of attention too. Punk, apparently, wasn’t. Also note that punk didn’t bring any change in political consciousness to the people of Indonesia – it “played into a sea change in Indonesian public opinion.”

    Now don’t get me wrong, I like me the odd bit of punk and as a cultural critique I think it has its merits: Crass‘s Reality Asylum remains a classic of anti-Christian polemic (“He hangs in glib delight upon his cross above my body, lowly me”), and the punk strains of metal bands like Sepultura and Suicidal Tendencies – especially the message of spiritual and personal independence beautifully displayed in songs like You Can’t Bring Me Down – is uplifting and energizing. But punk can also be nihilistic and destructive, and some of its messages can be enormously reactionary: the subtle link between women who shave their bodies, skinhead women, and wartime collaborators in Crass’s Shaved Women is an example of the toxic conservatism of the classic punk strain of feminist theory, basically a piece of slut-shaming via a very very nasty metaphor. Punk also had a strong trait of anti-everything that made it ultimately hard to find a coherent political program amongst its greatest representatives: fuck off and leave me alone may be a good approach to dealing with constraints on one’s personal freedom, but as a political manifesto it’s on about the same level of sophistication as “lower taxes” (and even less practically realizable). At their best, these bands (like Suicidal Tendencies) turn this individualism from nihilism into a code of personal behavior (“Are you feeling suicidal? Are you feeling suicidal!!?”), but this was never a strong achievement of punk itself. So it’s no wonder that it never turned into a solid political threat, given that its movement representatives couldn’t come up with a plan or a goal, and the only coherent political paradigm it connected with – anarchism and anarcho-syndicalism – was hopelessly backward and politically directionless. As cultural critique punk has some interesting things to say, but as political activism it was empty and meaningless.

    Fathun Karib confirms what the British punk movement was too embarrassed to ever admit: that their nihilism and individualism made them incapable of providing a coherent opposition to even relatively middle-of-the-road Thatcherite authoritarianism, let alone the kind of out-and-out state repression that Suharto was willing to bring to bear on his political opponents. You don’t overthrow a man who climbed to power over half a million bodies by spiking your hair up and yelling insults.

    So, thanks to Indonesian punk for telling it how it is!

    As an aside, the article’s casual inclusion of modern Indonesia alongside Burma, Iraq and Russia as a “repressive state” really shits me. Indonesia is a functioning modern democracy and although it has its problems it is not in the same league as those countries, and one rather egregious instance of (by repressive standards, pretty low-key) violence in a semi-autonomous state does not qualify a nation of the size and diversity and dynamism of Indonesia as a “repressive state.” The fact that this happened in a state that the central government has granted semi-autonomy should be a clue as to just how wrong that inclusion is, and I think it’s another example of a British journalist writing on Asia out of complete ignorance of what really goes on in this part of the world. Problems of political repression in modern Indonesia should be treated the same way as they are in Australia, Britain or continental Europe: by talking about problems of police corruption, governance, policy failings and better forms of oversight, rather than equating them with the practices of a regime that the Indonesian people went to great lengths to overthrow. And it’s particularly rich coming from a newspaper writer in Britain, a country that has seen significant problems of repression since 2001: police murder innocent bystanders at demonstrations, murder foreign workers in cold blood in front of multiple witnesses and get away with it, infiltrate political movements and entrap their members while having relationships with the membership, and assist powerful media organizations in spying on at least one serving PM and a future head of state. Given this history of murder and spying, and the obviously corrupt and too-cozy relationships between the current British government, police and powerful media, I’d say an Indonesian journalist would have every right to lump Britain in with Russia – but no one does[1], because we discuss these issues in Britain in terms of the mundane problems of managing a powerful and politically important institution of state violence in a modern democracy. We should extend the same consideration to Indonesia, and not assume that because it has a large Muslim minority and is Asian that it must be a repressive state.

    This particularly shits me about the western attitude towards Indonesia (and especially western leftists’ attitudes) because back when Indonesia was actually a repressive state, its political opposition was largely abandoned by the organized apparatus of western leftism (the unions, social democratic governments and democratic organizers of the western political establishment). When Indonesians decided they’d had enough of their backward state and wanted to move to a modern democracy, they did it themselves, without much help from the west at all, and they did a much, much better job of overthrowing tyranny than most western states have ever achieved (see, e.g., Russia or the USA for examples of how overthrow tyranny with maximum violence, and how to fuck up the ensuing peace while you’re at it). Now that they’re making a genuine and well-thought-out effort to build a modern democracy in a developing nation in Asia, infused with Asian (and yes, Muslim) values but genuinely politically representative, they have one little moment of police corruption against an opposition movement that is admitted to be ineffectual, and they get lumped in with Iraq? This is the thanks that Asia gets for trying to join the elite Western club of successfully functioning democracies – derided as a repressive state and chucked in with Iraq and Russia by a lefty journalist from a country whose police have been behaving like the paramilitary wing of a tin-pot dictatorship for the last, well, since at least the 70s. It’s particularly rich given that there is a clear skidmark of corruption a mile wide in British politics, it’s perfectly obvious from outside, but the Guardian has yet to manage to join the dots because they’re so sure of the political superiority of their own archaic form of democracy.

    Or, to put it more simply, if your society’s best contribution to political struggle in 100 years is Johnny Rotten, you shouldn’t be criticizing a country of 100 million people that successfully overthrew a murderous dictatorship and became a democracy with, well, pretty much zero bloodshed. They probably already have you outsmarted in the political struggle stakes, even though they’re Asian and sometimes Muslim and much poorer than you.

    —

    fn1: Actually, punk activists would. Which tells you all you need to know about the political sophistication of such a tactic.

  • Could You Eat Uterus?

    I went to a Korean restaurant tonight, which was a bit of a disaster because I don’t know much about Korean food. The menu seemed to consist entirely of large bowls of spicy stuff (I got topkip, I think, rice cakes fried with onion and chilli in a chilli sauce, topped with chilli) or grilled meats. The grilled meat menu was extensive, but I didn’t want to go there. It was also a bit like looking at a butcher’s slab – there were Japanese descriptions of all the meats, and Japanese really doesn’t mess around with euphemisms when it comes to eating bits of a cow. They had “number three stomach” and “liver” and “number one stomach” and “small intestine,” so you knew exactly which bit of the inside of the cow you were getting. And there on the board, slap bang in front of me, was shikyu, 子宮, no mistaking it – uterus. Apparently it has a “light” flavour, and goes well with anything. And, unsurprisingly, it’s cheap – half the price of the cheapest bit of actual cow meat.

    Could you eat uterus? Not in the “I was trapped in the amazon so I had to eat raw spiders” sense of “could.” I mean, casually, knowing what it is, on a Thursday evening in the city, when the menu also presents you with perfectly reasonable alternative meat-based options for a couple of dollars more. I vote “no” on the uterus question. How about you?

  • White Day in Japan

    Today is the day that Japanese men have to repay the largesse they were shown by the fairer sex on Valentine’s Day; and so it’s the day that I have to repay my own massive chocolate haul. The White Day “tradition” in Japan (if you can call a wicked scheme hatched by Big Chocolate a “tradition”) is for men to give chocolates to women in repayment for the chocolates they are given on Valentine’s Day. Typically the man’s responsibilities are lesser: he doesn’t have to give chocolate to women who didn’t give to him, whereas women are expected to shower all the men in their lives (friends, lovers, family and colleagues) with chocolate. I find this imbalance in gift-giving very pleasing. Nonetheless, I’m nothing if not a stickler for tradition, so today I delivered some Godiva chocolates (specially packaged for White Day!) to the Delightful Miss E, and last night I gave a small box of truffles to a friend. I also gave chocolates to the office staff at my work today: they didn’t give me anything but nothing makes life easier than small kindnesses to one’s office staff. Who me, mercenary? I’m not giving chocolates to the one student who observed the Valentine’s Day tradition, because she baked a chocolate cake (a very delicious one!) for the entire Department, which presumably means that she’s now received a year’s supply of chocolate in return, and I refuse to repay that kind of callous profiteering.

    At every significant railway station in Tokyo there is at least one stall selling White Day goods, and today when I emerged from the barriers in Kichijoji I saw a long line of harried Salarymen waiting to buy White Day chocolates at the local stalls (there were two). Hell hath no fury like a woman spurned on White Day, and so they lined up … harmony in the home, harmony in the nation and all that… but I did notice a sizable number of women in the queue too. This would probably be because lots of women have taken to buying chocolate for their female friends on Valentine’s Day, which then naturally leaves them obliged to buy repayment chocolate (okaeshi) on White Day as well. Truly, women have it tough …

    Though I noticed at Ochanomizu station that the florist had a sign up on Valentine’s Day, which depicted a man giving a woman a rose, and the slogan “Let’s try a new kind of Valentine’s Day.” I hope the flower of Japan’s manhood are wise enough not to let this kind of pernicious nonsense catch on hereabouts …

  • Miss Fisher’s Murder Mysteries: Australian Crime Fiction Exotica?

    I’ve started watching Miss Fisher’s Murder Mysteries, an Australian TV show based loosely on the series of Phryne Fisher murder mystery novels by Kerry Greenwood. The basic idea behind these novels and the TV show is simple, effective and fun: Phryne Fisher is a young (28 year old) Australian woman who has returned to Melbourne after serving as a nurse in the Great War (1914-1918), having received an inheritance and a title from a distant aunt in the UK. Suddenly wealthy and flung into the licentious era of the twenties, she starts an investigative agency, and begins meddling in police affairs, as well as having many affairs. She’s “not the marrying kind,” and of course in the twenties this kind of attitude is scandalous but also increasingly accepted. The implication in the TV show (I’m not sure about the books) is that she comes from a poor background and has a sad past (in the books this is her wartime experience as a nurse; in the TV show it’s her younger sister, who was murdered). Since 1918, she tells us, she “hasn’t taken anything seriously,” and this is the atmosphere in which she conducts her investigations. She also collects poor people around her: she has adopted two orphans, and is close friends with a pair of communist activists, one a wharfie and one a cabby.

    The TV show definitely has its flaws – sometimes the acting is a bit wooden and it feels like the directors weren’t sure if they were writing a comedy or a drama – but this is the normal experience of watching Australian TV. Typically, the only TV shows that Australian directors can make with any confidence are shit-boring dramas about enormously boring middle-class suburban lives, quirky comedies about rural idylls, or gritty stories of political corruption. Anything else is approached with a kind of self-conscious dread of being caught being pretentious, and this trepidation inevitably spoils the product as the director tries to inject a bit of self-deprecating humour, or gets caught looking over their own shoulder checking that they aren’t taking themselves too seriously. It’s an Australian thing. This self-consciousness is why Australia can make excellent quirky rural comedies (e.g. Seachange) but will never, ever produce a decent science fiction show. Something like Firefly is physically inconceivable to the average Australian movie critic – merely glancing sideways at the script for an Aussie Firefly would cause 99% of Australian movie critics’ heads to explode[1].

    So, having attempted to break out of the standard mold of Aussie drama, Miss Fisher’s Murder Mysteries is already painfully self-conscious. But if you can deal with that (and I’m sure it will relax as future episodes are unveiled) you get an actually pretty excellent TV show. Phryne is a fun character: she’s got guts, she’s going against convention, she’s clever, she’s compassionate and she’s lusty. Her two working class friends, the wharfie and the cabby, are intensely Australian men, laconic and kindly and macho all in one, simultaneously shy and big-hearted. Her maid, Dot, is an amusing combination of sassy girl-next-door and Catholic repression. The setting is unashamedly Australian – the Ballarat express[2], the Melbourne University boat club, flying a Tiger Moth out to the countryside to meet “Vic” – who leans in the doorway and talks out the side of his mouth in just the way you expect of an Aussie shearer – the dodgy Turkish baths and the backyard abortionist behind the pie shop, they’re all classic Australian settings. The characters also convey that strange Australian combination of conservatism and vital, progressive energy that makes our politics and culture simultaneously so small-minded and so visionary. For non-Australian viewers this show manages to present Australia in a suitably exotic light even though it’s set in Australia’s second largest city. It’s a nice introduction to some of Australia’s wilder history, as well as to the very special physical environment of South East Australia, which in its own way is easily as exotic as the Top End. At any moment you expect Phryne to just waltz out of the city and go solve the mystery of hanging rock.

    Another thing that this show does very nicely is its depiction of gender issues. The twenties were an era of newfound sexual liberation against a backdrop of essentially very conservative sexual values, and this show does a good job of depicting the sexism of the time without making it menacing or overbearing: it depicts this sexism as contested and malleable, as also is the homophobia and racism, so that we don’t have to endure a stultifying atmosphere of overpowering misogyny such as mars shows like A Game of Thrones. Phryne is clearly liberated not just because she is a woman in the twenties, but because she is rich; the women around her are not so lucky, and we see this, but we also see how they make their own place in the world despite adversity, and how the men of the time adapt and respond to these challenges to traditional gender roles. Even though as a crime show it has license to be grounded in “gritty realism,” we get a much better example of how to depict institutional sexism without creating an atmosphere of woman-hating, which I think directors with much bigger budgets might benefit from watching.

    I guess for people living outside Australia this TV show is going to be hard to see – it’s been produced by our public broadcaster but it’s not available over the internet if you live outside of the country. I’m sure there are ways, though … and if you’re interested in seeing a nice depiction of how Australians view our own history, through the vehicle of a fairly well-designed (but occasionally overly self-conscious) murder-mystery show, then I recommend this. Obviously, as well, the twenties are a fun era full of progressive girls wearing splendid clothes and men who spout over-the-top English. However, if you can’t abide shows with slightly stilted acting that don’t quite know what they want to be, or you can’t handle anything that isn’t standard American crime fare, then you should probably steer clear. I like it though, and will be watching more where I get the chance.

    —

    fn1: oh, I wish someone would write one!

    fn2: which seems to take all night, even though Ballarat is – what – 3 hours from Melbourne?

  • The Great East Japan Earthquake One Year On: Reconstruction and Reappraisal

    The coastline of Minamisoma city, one year on

    It’s a year today since the earthquake and tsunami that devastated Japan’s Tohoku area, and this weekend the people of Japan are pausing to reflect on what happened then, how it affected them, and what could have been done differently. The Japan Times is holding a one year memorial special, some of which is available in English. I thought I’d do a brief review and give some of my own thoughts on the last year before I head out to the memorial.

    My own experience of the events of that day was perhaps more distant than most, because I was in Tokyo and I spent the entire afternoon cut off from any form of news or current events, since I was walking across Tokyo and had no knowledge of what was happening a few hundred kms to my North: but for a single message from my partner that somehow slipped through the congestion to my phone, I had no idea that anything bad had happened – it was just a confusing afternoon of earthquakes and failed trains as far as I was concerned. Then, of course, the next few days were full of power cuts and confusion and some very scary aftershocks, so after a few days I bailed by Shinkansen to Beppu, and it was then that I realized that the rest of Tokyo was in a state of panic, which I described here. I came back a week later and by then everything had died down, recovery had begun and although things were still chaotic in the north east, nothing seemed very different in Tokyo.

    Now of course everything is much more measured and calm, and media coverage has turned towards learning lessons from the events of that day. The most obvious lessons concern disaster preparedness, especially for the heavy industry and energy sector, which needs to be built on the coastline. It seems possible that these catastrophic tsunami hit the area every thousand years, and although no one knew that a year ago, it does seem that there was some awareness of the tsunami risk in the area. My partner volunteered with the Peace Boat recovery team in Ishinomaki for a week, and while she was cleaning beaches there they stumbled upon a series of tumbled cairns that had been erected a hundred years ago. Written on them was a warning not to build homes around them, since a tsunami had reached their location a hundred years earlier; this warning had been ignored. It’s not just the big power plant makers who ignored the possible seismic risks in the area.

    I think this event contains messages about disaster response in an ageing society that extend far beyond Japan. The affected region has a very old population, and we’re discovering that disaster response for such a population is necessarily different. Just as the aftermath of Hurricane Katrina showed that populations with a high prevalence of chronic illness can suffer quite terribly from the loss of modern amenities, even if they’re quite young, so this disaster showed that elderly populations need special responses that take into account their frailty, the dangers of moving them, their ties to homes that they may have lived in for their whole life, and their particular chronic illnesses. On the one hand there was a need to evacuate populations from the fallout of the nuclear accident; but on the other hand, many of them had nowhere to go and no desire to leave the place of their birth – and little long term threat from radiation. Should the response to a nuclear accident be tailored to the population surrounding the plant? Chernobyl was surrounded by a young population with many children, but Fukushima is characterized by a very much older, more settled group of people who are at low risk of radiation-related illness. Should they have been treated differently? In such a period of chaos, perhaps a more tailored and nuanced evacuation response would have been in order.

    I have become involved in some research about this and other issues in the town of Minamisoma city, and I’m hoping to explore them in more detail this year. I have visited the town once, when I took these stunning pictures, and although disaster response and radiation epidemiology are not my specialty I’m hoping to contribute in some small way to understanding how the response to a disaster of this kind should be handled in an ageing society. China is going to be ageing rapidly under the influence of its one child policy, and it is not only prone to earthquakes in some regions but also has a large nuclear power program. The UK and France have nuclear power and an aging population, so I think the lessons from Fukushima will extend to those countries as well. What we learn from Japan may be instructive for those countries in the future. Tonight on NHK I watched a documentary about the 4000-odd American marines who responded to the initial tsunami and helped to save lives all along the coast, and this show made clear to me that even the most developed and richest countries are not necessarily able to handle events like this in isolation. I hope that lessons learnt from this event will help us to prepare for future events on the same scale, to respond rapidly and effectively to minimize disruption and loss of life.

    Asia has seen huge loss of life from natural disasters in the last 10 years – the Asian tsunami of 2004, the floods in Pakistan, a couple of nasty earthquakes in Iran and then last year’s floods in Thailand. Let’s hope that the 2011 tsunami will be the last such horror to visit the region for a long while, and that any lessons to be learnt from Japan’s experience don’t have to be acted on anywhere for a very long time.

  • Economic Collapse and Health Inequality in Japan

    Yesterday a paper I co-authored was published in the British Medical Journal. The paper, available free of charge at the BMJ website, analyzes mortality among Japanese working age males between 1980 and 2005 and estimates the changes that occurred after the collapse of the bubble economy. Our main findings were that a previously existing inequality in health between professional/managerial workers and the remainder of the population was reversed in the 10 years after the economic collapse. This reversal happened not because the health of non-professionals improved, but because professional and managerial workers saw a rapid increase in mortality.

    Before 1990 there was a fairly clear pattern amongst the main causes of mortality in Japanese men: the managerial and professional occupations had lower mortality rates. Mortality rates for all groups were largely declining over time, and at roughly the same rate, but managerial and professional occupations on the whole had lower mortality rates. However, after the collapse mortality rates in these two groups suddenly began to increase, while those amongst the non-professional categories largely maintained their previous trajectory. These trajectories and the changes can be seen easily in Figure 1 of the paper, and the changes that occurred at the time of the collapse are summarized in Table 4. For example, before 1995 the relative risk of all cause mortality in managers/professionals was 0.70 (i.e. 70% of that in the other occupations). After 1995 it was 1.18, about 20% higher (and this difference was statistically significant). Table 4 shows that while before 1995 managers/professionals had lower mortality across almost all the major causes of mortality, after 1995 this relationship disappeared or was reversed.

    As an aside, the paper also shows that massive increases in suicide rates in all professions coincided with the economic collapse of the late 80s/early 90s.

    There is a possibility that so-called “numerator-denominator bias” might have affected the results: if people registered their employment status differently on their death certificate (the numerator) to the population census (the denominator), we might over-estimate the effect of the stagnation in those occupation groups (like managers) that shrank fastest at that time. This effect might be possible if, for example, after the economic collapse managers and professionals moved into other professions or became unempoyed, but after they died their family recorded their profession on their birth certificate as that which occupied the majority of their career. However we checked carefully for this and confirmed that even the most extreme possible effect of numerator-denominator bias doesn’t change the essence of the results, only the magnitude.

    It’s dangerous to ascribe reasons and causal relationships to these kinds of phenomena, but the strong implication is that there is a relationship between the economic aftermath of the collapse and this reversal in health inequality in Japan. We postulate that this might be due to the rapid shrinking of the size of the managerial/professional workforce and changes in its working conditions that did not affect the labour/service industries as much. Other possibilities include changes in insurance status and access to healthcare, or perhaps some kind of health-system effect on cancer survival. It’s probably not due to unemployment: unemployment is categorized separately in the labour market statistics and death certificates, so theoretically a person who is sacked in 1985 and dies in 1990 should be counted as an unemployed person, and since we checked for numerator-denominator bias we think we ruled this out.

    Japan has very different patterns of mortality to other developed nations, but this paper gives us an indication of the possible large effects that an economic downturn and subsequent stagnation can have on population health. It also shows that an economic downturn doesn’t necessarily affect everyone equally, and doesn’t necessarily affect the poor, or non-professional occupations, more than it does the rich. I guess the results of this paper and its lessons about the role downturn and stagnation can play in health may be applicable to countries like the UK and USA, which are just beginning to experience what Japan did in the 1990s. This paper suggests that we should expect significant effects of the downturn on health, but that we shouldn’t assume it will hit the poorest hardest, and should be aware that every nation’s post-depression experience may follow a unique trajectory. It also tells us that significant health gains made over a long period of time, such as are seen in this data, can be reversed rapidly after a major economic downturn, and economic collapse can undo 20 or 30 years of health gains. In health terms, major economic events are certainly not to be sniffed at!

     

  • Choice of Cars After the Zombie Apocalypse

    Not exactly the last of the Interceptors, but…

    It’s the little things that can do you in, and watching The Walking Dead recently I noticed that the group have made some serious mistakes in choice of vehicle for their road trip. Who is responsible for their vehicular management? That sanctimonious old meddler, Dale, of course. They really need to start viewing him as “just another mouth to feed.” Here is why they have made bad vehicle choices, and what I consider to be good choices for the zombie apocalypse road trip.

    The Winnebago, the hi-tech liability and the chopper

    The Walking Dead‘s group drive across America in a Winnebago camper van, a couple of urban runabouts and a Harley Davidson. Three of their four vehicles are bad choices: the Winnebago, the modern urban runabout, and the Harley. Their overall group transport strategy is flawed because the Winnebago is carrying too heavy a load and they haven’t built in any redundancy to account for it. Specific reasons for the flaws in each vehicle are easily identified.

    The Winnebago

    This is the big mistake in the road trip plan. The Winnebago has many flaws:

    • It carries too much material, which means that if it breaks down in a high-risk area (near a town or an obviously infected area) the group won’t have time to empty it before they need to move on. They’ll have to leave a lot of important gear behind if they’re in a hurry, because they have too much stashed in one vehicle
    • It’s not manoeuvrable, so when they reach traffic jams or narrow roads they have to go around. Worse still, if they see trouble ahead and need to turn around in a hurry, they need to do a three point turn rather than a u-turn. To avoid this they need to stay on large, wide roads which are likely to be heavily infested.
    • It’s inefficient, so that despite its large size it only really carries a couple of passengers and beds. As a hospital vehicle it’s little better than a normal van, but it also carries less people than a mini bus. Furthermore, all the heavy fittings and camping style are simply a waste of space. They won’t use the toilet, and they could get by perfectly well with camp chairs rather than heavy fixed tables. All this stuff is taking up space and using fuel but providing little comfort. As a source of shelter it’s not large enough for the whole group, yet the whole group is constrained in road choice by its size
    • It’s noisy and has high wind resistance, meaning it draws attention to the group and uses a lot of fuel. Fuel efficiency may not be a long-term issue in a world depleted of competition, but in moving between gas stations and fuel sources it is crucial. If you’re going to use a heavy, fuel inefficient vehicle you need good reason
    • It’s heavy: hard to push out of the road, hard to replace wheels

    The worst case scenarios involving the Winnebago arise from the combination of its lack of manoeuvrability and its excessive storage usage. On a narrow road, if the group see zombie trouble up ahead they will need to turn the Winnebago around, running the risk that it will get bogged off-road. This could potentially trap other cars between the Winnebago and the zombie horde, meaning loss of those cars too. But even if this doesn’t happen, bogging the vehicle down will mean having to empty it into the other cars. This will take a long time, and as the zombies approach the group will have to choose to abandon large amounts of stuff. This wouldn’t happen if that stuff had been distributed between more, smaller vehicles.

    The urban runabout

    The group also has a green hatchback, quite modern, that is probably highly fuel efficient, comfortable, reliable and quiet. This is overall a good choice of vehicle, but it has a significant downside: it’s too modern. Modern cars can’t be easily repaired by unskilled users, and often require computer diagnostics and specialist service centres, sometimes affiliated with the company that sells the car. Also, parts are often specific to the car and can’t be scavenged. This means that any breakdown more serious than a simple puncture will put the car out of action. That’s fine if your group has significant redundancy, but the group in the Walking Dead don’t have this luxury.

    The Harley Davidson

    The Harley is probably a good idea for long road trips – I get the impression that these bikes are designed for comfort in long journeys. It also has the potential to carry a rider fairly comfortably on pillion, and carry a small amount of luggage, so is a good survival tool. But it suffers from the drawback that all motorbikes do: it’s uncovered, so dangerous. However, it lacks the advantages of other smaller bikes: it doesn’t have the speed, manoeuvrability and acceleration of a road bike, nor does it have the off road capabilities of an off-road bike. It’s also likely to be noisy and less fuel efficient than other bikes. What’s its use? If it is to be used for long range reconnaissance, a road bike – extremely fast, highly manoeuvrable and quieter – would be a better option, since it will be able to travel far ahead of the group in a short time, and escape any trouble. If short-range off-road scouting is necessary, then a standard farm bike would be better. This can be used to get through partially-obstructed regions (e.g. old road blocks and traffic jams) easily, is highly manoeuvrable so can be turned around quickly to escape sudden gangs of zombies, and can go off-road to investigate old houses and farms. In the hands of an experienced motor-crosser it can even potentially go over some obstacles, though at high risk. A Harley is only good for open-road cruising. But you can do that much, much more safely in a car, which at least has the advantage of seat belts.

    The problem of redundancy and overloading

    Another significant problem arises for this group from the combination of lack of redundancy and overloading of the Winnebago. If the Winnebago breaks down irreparably, the group will need to move all the stuff out of it into just two urban runabouts, which also need to transport all the people in the group. Short of the obvious solution – shooting Dale for the sanctimonious moralizing loser that he is and using his seat for storage – the group is going to face a hard choice between supplies and people, because their two small cars won’t have enough room for both. This choice is going to probably have to be made in a hurry, and will lead to the loss of a significant amount of important material. If one of the other runabouts dies, the problem is not so severe but they will be immediately forced to hunt for a new car, even if the only locally available cars are in very dangerous settings. They have no choice in this – if one of their runabouts fails and then the Winnebago breaks down in a dangerous place, they won’t have sufficient capacity to take the whole group to safety and will have to repair the Winnebago under pressure. Bad move.

    Furthermore, lack of small vehicles means they don’t have the ability to circle the vehicles at night – not a perfect defense tactic but an important part of safe camping techniques. And of course, they don’t have a spare vehicle to use to block a street or set alight as a barrier.

    The ideal road trip strategy

    Cars offer the benefits of mobility, shelter and security. However, on a road trip one runs the risk of becoming stranded between locations with no source of supplies, so the key to any safe zombie apocalypse road trip is redundancy. Ideally you need lots of small cars with the following properties:

    • Fuel efficiency
    • Good storage space
    • Manoeuvrable
    • Easily pushed, for jump-starting or getting out of the way
    • Disposable
    • Easily accessible (four doors!)
    • Readily accessible spare parts

    The thought of hooning along post-apocalyptic open roads in a Nissan Fairlady may appeal, but it has very few advantages. The group should choose cars that meet most of the above conditions, and ideally some of these vehicles should be able to be used as excess storage spaces, shelters, or hospital vehicles. Thus a good combination would be VW kombi vans (for space, shelter and repairability) or similar vans, four-door utilities (for storage and convertability), and older four-door hatchbacks. For the utes, ideally they would be the sort of ute that gets used as a “technical” by somali warlords – so an older Toyota or Subaru, something reliable and trustworthy that can use parts from any old car and can itself be cannibalized.

    The group should have more vehicles than it needs to carry all its materials and all its people, and some of them (the kombi vans) should be sufficient to provide shelter and security in a pinch (bad weather, sudden unexpected zombie onset). All of them should be able to turn easily to get out of trouble, and be pushable by two adults. All the vehicles should carry enough supplies to be self-sufficient for a short time: basic materials for the engine (pipe, radiator, spark plug, battery, jump cables); a couple of days’ food; water; fuel; basic medical supplies. This means that if any one vehicle needs to be abandoned its contents can be stripped out quickly and moved to another vehicle, but can also be abandoned un-stripped without catastrophic loss of vital materials. All back seats should be left empty and the doors unlocked, for rapid transfer of people from broken cars in an emergency. The utes can be used to carry excess material that isn’t so important and can be dumped where necessary; the utes can also be used as emergency evacuation vehicles or even ambulances where things go wrong. All vehicles should be given a priority (High, Medium or Low) and this should be painted on bonnet and doors so that everyone knows which vehicle to head for if not all vehicles can be saved. The group should travel at the optimal speed for fuel efficiency, well spaced out, and stop regularly to rest and check maps – you never know when you might need to turn around, so it’s good for everyone in the group to be aware of potential hazards in the road behind. All vehicles should be driven with at most 2 people in them (to ensure redundancy) and single occupancy vehicles should be avoided – it’s not fuel efficient and it opens the risk of loss of communication. Ideally some kind of radio contact should be maintained between vehicles – hourly checking in, regular reports, etc.

    All vehicles should also be fitted with a usable sharp piercing implement such as a sharpened iron spike by every door, so that zombies that break through window glass can be dealt with easily. When driving, everyone should wear seat belts – what’s the point of surviving the apocalypse only to die in a low-velocity car crash? Or worse, survive but be put down like a dog by your comrades because of a lack of suitable medical equipment to handle serious injuries… Finally, motorbikes should only be used if the group really sees a need for single-person reconnaissance. Otherwise they’re a dangerous luxury vehicle that should be avoided.

    I think if a group follows these principles it will be able to survive longer on the open road and escape from even quite dangerous and pressing situations without significant lives or material. As it stands the group in The Walking Dead are one breakdown away from either losing a significant load of supplies and/or having to abandon people; or becoming lunch. Don’t make their mistakes, and instead adopt an industrial design approach to your post-apocalyptic convoy: share the load-bearing and ensure redundancy.

    A note on the zombie road-trip of the future

    As the world shifts to a low-carbon future, cars are going to become electric. In the further future they may even become robot driven. This means that sometime in the far future, the apocalypse will see a collapse from a much higher-tech society than we have now, to a much lower-tech society, with no pause in the Mad Max zone. Isn’t that interesting?

    Addendum

    If you appreciate my thoughts on zombie survival strategies, please consider reading my novella Quarantine Breach, set in the world of 28 Years Later, which is freely available at Royal Road.

     

     

  • Comparing Two Health Systems by Example

    Being still sick today, I decided to kill two birds with one stone and go see a doctor about a hand injury that’s been getting worse over the last few months. It’s a common kick-boxing related problem, no big deal, just a strain in the area at the base of my thumb, but it has been slowly getting worse (usually this goes away with some stretching) and so it’s worth checking if there isn’t some kind of minor fracture or strain that requires medicinal assistance or complete rest from punching. So off to the doctor I went.

    The doctor I chose was the Abe Orthopedic Clinic near Kichijoji station, and when I turned up at 3pm (the start of afternoon opening hours) it was already full to over-flowing with old people, all of whom were waiting their turn patiently for a “rehabiliation massage.” Each would go into a room and sit on a chair where, for about 15 minutes, they would receive a massage from a physiotherapist. Then they emerged, got charged ridiculously small amounts (“100 yen!” “150 yen!”) and go home. After an hour I was called in, told it was just a minor strain and given a prescription for some kind of anti-inflammatory stick-on treatment, and out I went again. Total charge: 1050 yen for the consultation, about $10 US. Before my health insurance is taken into account that would be about $30 US, about the same as an equivalent consultation in Australia. My drugs cost a further $7 US.

    Now let us compare with the same process in the UK. First I have to visit my general practitioner (GP), which I can only do with an appointment in most cases. The appointment will require a wait of 1-4 days, so I couldn’t have done it on a random day when I was already home sick. The GP won’t offer me any medical opinion, but will prepare a referral to a local hospital outpatient clinic, which I then book. This referral will take between 2 weeks and 3 months, usually somewhere more toward 6 weeks – unless one of the new-fangled “Referral Management Centres” decides my referral was inappropriate, in which case I’ll be redirected either to a specialist or back to the GP (with further waiting in both cases). So after 2-12 weeks (roll 2d6!) I will get to the outpatients’ clinic in the hospital, and assuming I am seen on time (unlikely) and don’t need an X-ray, will be given my prescription and sent home. Total cost: nothing.

    Which system would you rather be getting treated in? Bearing in mind that when I say “health insurance” about Japan I don’t mean it in the American sense of “capricious company with a god complex that will decide whether you get reimbursed,” but “government-run single payer that covers everything.”

    Which system would you be more likely to not bother attending for non-urgent healthcare in, especially if you’re a healthy young male who thinks he’s invincible? So, your health problem niggles away but you wait until it becomes acute because, well, this whole thing is too much trouble. Sure it’s still your fault when your diabetes gets out of control, you lazy shit; but wouldn’t it have been better if the unnecessary barriers to care weren’t there in the first place? And ultimately, from a health system perspective it doesn’t matter whose fault it is: you’ll still be turning up at the emergency department with acute unmanaged diabetes.

    This isn’t necessarily just a problem with financing (everything in the NHS is free so queues can be used as a form of rationing). It’s a fundamental problem of the gatekeeper system that the NHS uses: if the gatekeeper doesn’t provide a good range of medical services onsite and/or the time from gatekeeper to gate is very long, it acts as a huge disincentive to voluntary healthcare-seeking behavior. And in modern health systems, voluntary healthcare-seeking behavior is very important: in testing as a component of controlling infectious diseases like HIV and TB; in managing chronic illness like diabetes; and in identifying preventable health conditions like osteoporosis.

    Anyway, nothing’s wrong with my hand, and no nasty comments about the real cause of inflammation in my right wrist, if you please!

  • Should the Government Subsidize D&D?

    In most social democratic countries (that is, the UK, Australia, New Zealand, Canada, Japan, troll-infested Scandinavia and much of Europe), the government provides some state support to the arts and sport, either directly through grants and training or indirectly through subsidies for community participation and activity. Let’s consider a few examples of these from around the world that I know.

    The UK

    Before the 2008 Beijing Olympics the UK invested heavily in amateur sports that would be represented in the Olympics, and in that year for the first time in a long time its sportspeople performed at a level that one would expect for a country of its size: this was preparation for the UK Olympics of 2012, where it’s expected they’ll do even better and, in a remarkable turnaround, will repeat the 2008 performance of beating Australia in sports we’re usually good at (I think they beat us at swimming in 2008). The UK also famously maintains free access to its public museums, which is a great thing (though my god they are crowded).

    Australia

    Australia has a long-standing practice of funding sports at many levels, including a cricket academy and soccer academy. State and local governments also maintain a very large number of public sports grounds that see heavy use: this community participation is the main reason Australia has four healthy football codes, one more than the UK and three more than the US. Women’s soccer in Australia is also booming and in fact the main break on its growth was the limited availability of grounds, which put women’s soccer into competition for resources with men’s soccer. Given the nature of a soccer ground, this kind of problem is often only resolved through public funding (to make more park space available). Australia also maintains a very well-organized system of political support for sport, which is manifested through e.g. the martial arts accreditation scheme and state-sponsored inquiries into the management of elite soccer. This sort of stuff is necessary to maintain momentum in the growth of new sports. Australia also maintains a system of grants for artists (the Australia Council) which fund any kind of new art through a supposedly competitive process. In addition to separate funding for the major elite arts (like opera and orchestras), Australia’s most famous landmark building, the Sydney Opera House, was built from public funds. So the arts at many levels are funded well by the state, through our taxes.

    Japan

    Japan maintains a network of public halls, kominkan, which are available for use for any cultural pursuit: flower-arranging, book groups, role-playing groups, you name it. The Japanese prefectures and city offices also maintain special martial arts buildings (budokan) for the practice of all forms of combat sport – you can book rooms in these halls to practice your own. Sumo is supported through public funding to some extent, I think (a source of much dissatisfaction to many Japanese when they see match-fixing and gambling scandals, and notice that the best-behaved sumo wrestlers are the foreigners!) Japan’s public schools and universities also maintain a heavy level of sports participation through clubs. I’m sure there’s other types of arts and cultural funding over here too, if I care to look.

    Of course before the modern state this type of subsidy also existed, in the form of noble or religious patronage, but this subsidy came with the rather sad downside of requiring its recipients to either directly sing the praises of their patrons, or to at least look the other way from their worst flaws. So subsidy is not new, even if it is more systematized and conducted under more complex institutional arrangements in the modern world.

    Since the mid-70s, however, the developed world has seen a flowering of cultural activities that were almost exclusively developed in the private sphere and/or through private sector initiative, without a skerrick of direct state subsidy. As a few examples: plane- and train-watching; martial arts; various forms of collecting; computer gaming[1]; lego and meccano; wargaming; and, of course, role-playing[2]. These cultural activities have developed over a long period of entirely private investment and support, in the sense that there was no government support for them as cultural activities either on the corporate side (in setting up companies to sell the activity); the individual side (in turns of subsidization or support for involvement); or the community side (in, e.g. special halls or facilities for them). Indeed, famously, after 9/11 the state intervened actively (though not deliberately) to make plane-spotting a good deal harder than it was.

    Would the government have saved us from 4e?

    One obvious question that this raises is whether these activities would have been more or less successful, or even different at all, if they had received state support as burgeoning cultural activities. Looking at the history of TSR, for example, it appears to have folded or near-folded several times, and gone through all sorts of weird product-redesign and marketing strategies to save itself (plus there was all that internal nastiness). Would the company’s history, and thus the game’s development trajectory, have been different if in the period from, say, 1972 to 1985 it had been able to receive some small quantity of government support as a cultural activity? One argument would be that with “handouts” supporting it the game would have disappeared up its own arsehole, becoming some post-modern weirdness disconnected from its market of gamers; the other is that with a bit of basic financial support the designers would have been freed up to focus on quality product rather than chasing the next bonanza, or at least able to spend a few years producing a coherent game system without worrying about matching their production activities to whatever marketing scheme they thought would save the company. I guess this argument comes down to one about industrial policy (should your government pick winners like Japan and the USA do, or should it foster competitiveness like Australia and New Zealand do). But I think we can boil this issue down to one simple question: would TSR have needed to make 4th Edition if they were receiving a government subsidy[3]?

    What sort of subsidies would be appropriate?

    Taking as read that social democratic societies will continue this practice of funding cultural and sporting activities, what sorts of things would be suited to RPGs if they were included under the rubric of “cultural activity”? Here are a few things I’ve thought of that I think actually would help to make gaming more widespread, more enjoyable, and perhaps more diverse:

    • Sponsorship of conventions: this would enable the conventions to be held in better locations, to have budgeted conference dinners, prizes, and possibly pay for attendance by renowned designers or GMs. It would also enable the game to spread outside of its heartland areas a little.
    • Recognition of some games as cultural icons, and their preservation either in print or digitally for common use: for example, the UK government might declare Warhammer Fantasy Roleplay 2 an iconic game and provide funds to maintain it in print or in an online archive, thus ensuring that it didn’t disappear. Some games that I think this would be a really good idea for include ICE’s Middle Earth Role-Playing, some form of OD&D, WFRP2, and the original Shadowrun. This wouldn’t preclude the companies from making new versions of these games, but it would mean that games of cultural significance were retained. Look at the effort the OSR puts into producing variants of OD&D as an example of the benefits of retaining these games in print or online.
    • Funding and research support for those elements of, eg, the OSR that are trying to piece together the history of the game, for example through funds to travel and do interviews, support in archiving and organization, and specialist research tasks (including translation)
    • Greater support for academic study of gaming, for example through research grants
    • Support for copyright issues: no gaming company can afford the rights to Harry Potter, I suspect, but a Harry Potter game would really help to spread RPGs around. If the government fronted up the money for the rights, then maybe this could happen – even a flawed Potter game would be a huge benefit to the gaming community, I think. More generally, access to the rights for game settings and art connected to them could help the industry a lot
    • Support for culture-specific games: e.g. the Australian government could hold a contest for development of a game setting that was uniquely Australian in feel, or the US govt could give out grants for the development of culturally-sensitive Native American game supplements
    • Technical support: development of online platforms, more research into the complex probability models used in some games, better editing and book-binding or just provision of support to overcome barriers to entry into new media would be really useful for diversifying the style and types of game and gaming methods
    • Establishment of an independent, high-quality magazine: most gaming magazines are owned by the publishing houses and have been for a long time. A genuinely independent magazine with high production values and an industry- and community-wide remit will never flourish in such a small culture industry, at least not in print, but I think with government subsidies it could and it would be interesting
    • Support for the online community: Prizes for bloggers, financial support for annual physical meet-ups, perhaps technical support in the form of grants to expand the use of the internet for gaming collaboration. Also, money for me.

    None of these ideas seem to fundamentally change the basic modern business model of gaming, but I think many of them would help start-up gaming companies with both the cultural background of their activities, and access to some of the technical matters that can help a game work out. Other funding ideas here are largely about supporting the community that the gaming industry is built from, because as a cooperative activity role-playing needs more than just our private money. The RPG hobby only flourishes when individuals have the space, time, money and inclination to come together to make games happen, and it’s (rightly) difficult for private companies like TSR to build this by themselves. It’s easy for us as individuals to put in the basics – our money, our time and our living rooms – but when it comes to the deeper, more complex aspects of maintaining the hobby, perhaps we could do with the same support that recognized cultural activities obtain. Communities may not require support to maintain but it certainly helps, and governments are ideally placed to provide that support.

    What do you think?

    —

    fn1: I include computer gaming in this list because although in some times and places the computer game companies have received state support as start-ups (e.g. in Australia), this state support is through industry development funds, as a pure business enterprise, not as a cultural activity per se. i.e. you can approach the government of a social democratic nation (in some times and places) and say “I want to start a business selling X” and they’ll fund it even though it’s a kooky hobby; but the same funds don’t seem to have been available for “X” as a cultural activity.

    fn2: My reading of the early history of role-playing in the UK suggests a lot of the early games did actually happen in public facilities, like community halls. But a lot of these were church- or school-run, and when I was gaming in London these halls didn’t seem to exist, so I think this aspect of state subsidization of community art in the UK has died off in the past 20 years. I guess this is because public halls have been defunded, and since certain religious issues arose in connection with D&D it’s hard to ask to rent a church hall for an RPG convention.

    fn3: And the related question: if you were a benevolent dictator subsidizing TSR, would you have let them?