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…

  • The War Criminal as Muse

    Brian Murphy at The Silver Key has been running something of a series of posts on realism in fantasy, and his mild objections to it. I have been commenting occasionally in mild support of this trend, because I think that the fantasy genre is very conservative and needs to have its perspective broadened and conventions loosened. This inevitably involves experimentation, not all of which is going to work; and the folks at The Silver Key are generally quite conservative, so overly prone to see any experimentation as some form of radicalism or nihilism. However, recently Brian posted about Richard Morgan’s new novel The Cold Commands as a continuation of this theme, and Richard Morgan himself turned up in comments.

    I’m a fan of Richard Morgan’s science fiction, but I hope that it’s been noted around here that I’m not shy of criticizing work I like, and Richard Morgan’s defense of his style of realism really doesn’t do him or the concept of realism in fantasy any favours. Basically, in defense of presenting gore in fantasy he refers to a poem by a Vietnam veteran that describes the “fierce joy” of murdering innocents, apparently based on real life experience. Richard Morgan has cited a war criminal as his muse. It shouldn’t take much effort by most people to recognize that defending your slasher-fiction on the basis that its honest to the experience of war criminals isn’t going to win you any favours with the majority of your critics (or, one hopes, your fans).

    But Richard Morgan goes one better than this, and presents this “realistic” depiction of war – as seen through the eyes of a murderer – as somehow preferable and more realistic than eliding the details or glorifying the emotional and spiritual dimensions of war.

    If Morgan wants to represent realism in war he has most certainly chosen the wrong path to go down here. A “realistic” depiction of the horrors of war would be much more likely to come from the eyes of the mundane majority of modern soldiery, that is the ordinary enlisted men who resisted the pressure to commit war crimes at every turn. These men didn’t write poems about how they loitered at the back of the squad, avoiding being too close to the commander who might order them to murder; they don’t make fine lines out of the “fierce joy” of firing high so they can avoid killing a non-combatant, only to have one of their more eager squadmates finish the job anyway. The only poetry that is written about these men will be the cruel beauty of Wilfred Owen, if they are so unlucky. They don’t get promoted by their war-criminal commanders, and if they take the ultimate risk of turning their arms on their colleagues to save innocent lives they don’t get medals until many years later. In modern war these men are the vast majority of the uniformed ranks, doing their best in very difficult circumstances to follow strict rules that have been laid down for them by a society that has spent 60 years learning what a nightmare modern warfare is. But there’s no joy in the “realistic” stories of ordinary squaddies doing their best to stay moral in immoral circumstances, so it’s much easier for Morgan to fall back on the psychopathic visions of a war criminal in his defense of “realism.” Give me Tolkien’s glorification of the nobility and sacrifice of war over this grubby version of realism any day of the week.

    I suppose as his yardstick Morgan should try reversing his role, and asking himself what muse he would take to his side if he were one of the Vietnamese villagers who survived? If Miyazaki Goro chose to defend his misinterpretation of le Guin’s Wizard of Earthsea on the basis of a poem by a decorated Japanese war criminal, would Morgan consider that to be of high merit? If Nabokov had defended writing Lolita through reference to the self-expulcatory ravings of some child-fucking Victorian-era pervert, would he be lauded for his difficult choice of representing “realism”? If Dostoevsky had defended Crime and Punishment through references to Chopper Read’s biography, would he have in no way diminshed his tale?

    Of course this isn’t entirely Morgan’s fault, because our societies seem to be going through a slow period of forgetting just how horrible and senseless war is. If Guantanamo Bay and the invasion of Iraq represent the nadir of that process of forgetting, it should always be remembered that these things can’t happen in isolation – they need a culture of forgetting to support them, and as we moderns get further and further removed from the cruelty and cost of the wars we start, and as the horrors we committed those years ago fade into distance, of course it’s easy for authors like Morgan to come along, raised and taught during the end stages of this process, and so manufacture justifications for literary savagery from the poetry of war criminals. But I like to hope that if the fantasy genre is reformed and its conventions loosened, it will not be just to shift its attitude to war from the pre-world war 2 justifications and elisions of Tolkien’s era to the self-serving ignorance of our modern times. We can surely do better than that.

  • Rats in the Ranks Session 9: Corruption and Lies

    The final session continued where the previous session left off, with our heroes standing on a pile of corpses… again.Having looted their victims, but none the wiser as to the purpose of the rat-catchers’ guild they were so efficiently destroying, they decided to go back to the start of the sewer complex and explore every room. Amongst the pile of recently-dead they found a map of the sewers in full detail, though it didn’t tell them that a nest of giant spiders was waiting for them near the entrance, or that the warehouse for normal sewer workers was situated perilously close to a Giant Toad’s lair, but inevitably they would deal with these obstacles in the time-honoured fashion. They returned to the entrance from the safe-house above, and set about exploring the remaining spaces in the sewers.

    The Giant Spiders

    Some distance from the rat-catchers they had previously killed the PCs stumbled into a room containing 4 giant spiders. The spiders’ attempt at a stealthy ambush was only partially successful, and in the ensuing battle three of them died very quickly. Several of the PCs were bitten, but no venomous effects ensued, and the remaining spider panicked and fled. The PCs discovered that its lair hid an entrance to an ancient jeweller’s workshop, and looted it accordingly[1]. This old gem cutters room seemed to have been long forgotten by the sewer’s other denizens, and the last person to stumble into this room was now enshrouded in webs, his last healing potion unused and free for the PCs to take. They marked the location of the remaining spider, and retreated to the main causeway.

    Toad-in-the-Hole

    They crossed from the main causeway back past the entry to the sewers, to another causeway that placed them roughly diametrically opposite the location of the spiders. Here the causeway flowed deeper into the sewers, but first it passed a storage room for sewer workers, the stairs from which led up to a perfectly normal city building, such as sewer workers might occasionally use to prepare for their work. This room contained nothing of interest, but at one end there was a closed door, which the characters wanted to enter. Next to it a rough note had been scrawled on the wall:

    Be careful of Frogs

    Assuming this to be a warning against some kind of giant beast, the PCs girded themselves and opened the door. They passed through into a large cave-like room, the floor of which was flooded with stagnant water. One of them threw a rock into the middle of the pool but nothing happened. They decided to what PCs throughout time and space always do in this situation, and press forward. Sure enough, as soon as they were into the pool, a massive toad lunged from the water and struck out with its tongue, which wrapped up Heinze the soldier and started dragging him into the pool. This toad was big enough to eat a grumpy Reikland soldier whole[2], so everyone charged recklessly into the fray. The wizard, unfortunately, had to pause to draw power, and Suzette the Disciple was also somewhat under powered. While Aruson the thief fired arrows into the toad’s repulsive, warty hide, Suzette grabbed its tongue and tried to help Heinze free his sword arm. She offered him just enough assistance to be able to get in one good strike, and he managed to stick his spear right through the toad’s mouth and out one eye. It gargled horribly and died. The PCs continued through the room to a rough-hewn tunnel on the other side, and stumbled on the secret they had been searching for.

    The Rat-catchers’ Secret

    Beyond the abode of the hungry toad was a dark corridor, at the end of which was perhaps a vague light. Aruson crept forward and found himself facing an opening into a larger cave, guarded by two rat-catcher sewer guards. He couldn’t pass them easily into the room and couldn’t see inside, but voices inside the room carried easily to his hiding place. He listened to a conversation between a frightened-sounding man and a strange, sibilant voice that was surely not human:

    • [Sibilant Monster]: Have you opened the entrance?
    • [Frightened Man]:Yes, it has been opened. Since we kidnapped the nobleman’s daughter he has been very helpful in teaching us how to open it. He still believes his daughter will be returned after we execute the plan.
    • [Sibilant Monster]: Good… but, recently your activities have been discovered, have they not?
    • [Frightened Man]: I’m sorry to say that we have been discovered by some new adventurers
    • [Sibilant Monster]: Do you think they’re servants of the nobleman?
    • [Frightened Man]: I don’t think that’s the case. The nobleman is too scared of losing his daughter to employ any adventurers. We don’t know why these adventurers have become involved. We’re moving against them, but the task has consumed many of my rat-catchers
    • [Sibilant Monster]: I don’t care to hear the excuses for your failure. If your organization is no longer convenient to me I don’t need you, and if evidence of your relationship to me is discovered before the attack, I will have to remove all evidence of it. Do you understand me?
    • [Frightened Man]: I understand. We will resolve this problem with the adventurers soon. Then my remaining rat-catchers will help you in the attack.
    • [Sibilant Monster]: That would be best. Your assistance in this plan has made it easier to carry out, but if you fail your organization will no longer be useful to me.
    • [Frightened Man]: (gulps)
    • [Sibilant Monster]: Okay, I’m returning. I leave this in your hands. Don’t fail me.
    • [Frightened Man]: We will put all our efforts in!

    This was followed by the sound of light footsteps, and a door being opened and closed. The Frightened man began calling in guards from other parts of the cave system, and the PCs realized it was time to act. Aruson picked off the two guards nearest to the PCs with a single volley of shots, and the group charged into the main cave. Here they found the boss of the rat-catchers’ guild, a bodyguard and 6 sewer guards. The battle that followed was brief and brutal, but soon finished with minimal injury to the PCs. They took the sewer lord captive, and offered him a simple choice – tell them everything or spend the last few hours of his life in the spider’s lair.

    With this option before him, and looking at the bodies of the last 8 members of his organization, the rat-catcher leader realized that his only safety lay in betraying his monstrous master, and he told the PCs everything. His rat-catcher’s guild was working as spies for a group of monsters that lived below the city, and had been doing their bidding for a little while. Most members of the guild didn’t know about these monsters and believed they were doing the bidding of a local nobleman. In fact the nobleman in question was doing what the rat-catchers told him, because they had abducted his daughter and were holding her prisoner as security against his good behaviour. In fact, his good behaviour was essential to the monster’s plan. They had uncovered an ancient entrance from the sewers to the Temple of Sigmar, but the door could only be opened by a specific key – a key that was a long forgotten heirloom for an Ubersreik noble family. This nobleman was from that family, and had found the key for the rat-catchers. Now they were biding their time, clearing out the area around the door and preparing for a large force of the monsters to attack Sigmar’s Temple from the sewers. Apparently there was something in the temple that they wanted, and they intended to slay all of Sigmar’s servants while they sought it. They knew that the High Priest of Sigmar would be away in Altdorf within a month, and so they were going to attack then, when she and her strongest bodyguards were away.

    The rat-catcher the PCs had found all those weeks ago when travelling to Ubersreik had been on a mission for the monsters. Apparently these monsters had been having difficulty with an orc tribe whose territory abutted their own somewhere underground, and had asked the rat-catchers to send a spy aboveground to find out if the orc tribe were connected to any other tribes or groups that would make it dangerous to attack. He had somehow failed, and the Orcs had been trying to dump his body in a way that hid their presence in the area when the PCs found him. It was purely through happenstance that the PCs had become entangled in the rat-catchers’ plans at all.

    When asked to describe the monsters, the sewer lord told them that they were a kind of twisted, monstrous hybrid of rats and humans.

    Skaven.

    The Rat Ogre

    The PCs demanded he take them to the nobleman’s daughter to free her, and he duly did, leading them down a long, dark tunnel. He didn’t mention, however, that the room at the end was guarded by a rat ogre. The PCs almost blundered straight into this beast’s grasp but were sensible enough to scout ahead. When they saw it they roughed up their captive a bit, then set out to ambush the Rat Ogre. Though fearsome in aspect, this thing fell quickly and easily to their combined forces, and they were able to rescue the girl from her captivity at the edge of the room. From there, having eliminated the rat-catchers’ guild, caught its leader, looted its possessions and uncovered its plans, there was nothing for it but to go to the Temple of Sigmar and explain the situation.

    Resolution and Rewards

    The High Priest of Sigmar was very interested in this news, and together they set a trap. The sewer lord was put under a geas and forced to return to the skaven and tell them that he had destroyed the adventurers, and that rumours abroad in town suggested the High Priest was moving a dangerous and evil item to Altdorf within days. The skaven would have to attack sooner than expected. This he did, and the Priests and soldiers of the town set a trap for them in the basement of the temple. A force of maybe 50 Skaven emerged from the sewers a few days later, and were set upon in a vicious battle that claimed many lives. The skaven quickly withdrew, but were unable to take all their dead with them, and so the town of Ubersreik were able to find physical evidence of those beasts that were previously only an evil rumour. The High Priest quickly took these bodies and their possessions away, “to do research in Altdorf,” and all that remained of the battle in Ubersreik was rumour and hearsay. The PCs were able to find out that the Skaven had entered the temple to steal a piece of warpstone that was being held there under guard while the Priests of Sigmar sought ways to destroy it.

    As a reward for their efforts, the PCs were given some money, and a deed of land title over Black Rock Keep, in nearby Heideldorf, where recently they had vanquished some mutants and uncovered a cannibalism ring. None of the players viewed this as a particularly good reward…

    Conclusion

    Because of my sudden move to Tokyo this campaign had to be wrapped up quicker than expected, so the truth of the guild and the skaven had to be revealed in a sudden ending rather than dripping out piece by piece. In my next post I will give some final thoughts about Warhammer 3, GMing in Japanese, and Skaven.

    —

    fn1: In case you know it, I’m using an entry from the One-Page Dungeon for this adventure’s map…

    fn2: If you’re wondering how a toad that big can hide in a pond, try visiting an Australian crocodile farm sometime. In those places, beasts big enough to be dinosaurs can hide from view in a foot of water. They are truly loathsome beasts…

  • Zombie Ants Eat Cairns

    Apparently there has been a hundred year quest to find them, ever since Darwin’s contemporary discovered the first Zombie ants, but lost all records in a mysterious fire that destroyed his ship. Some new researchers have discovered them in Brazil. But will they, too, be ruined by a strange curse?

  • Kebabs are not Made of Cthulhu Meat

    … according to the Daily Mash.

  • A Brief Comparison of Subways in Two Cities

    While I’m trying to find the time this week to write a game report… a brief comparison of London and Tokyo subways, that I thought of while I was riding on the Marunouchi Line (Tokyo) this morning, reading a sign that said the train had air-conditioning and an air-cleaning system installed. Reading it reminded me of being crammed into the London subway (“the Tube”) and the inevitable comparisons.

    The London tube is a filthy, grim affair, with narrow, claustrophobic trains travelling through tunnels barely wider than the carriages themselves, like bullets in a chamber. The interior of the tube is so low that tall men have to bow their heads unless they can push to the middle; the seats are so filthy that they are literally ringed with grime at their edges – the centre of the seat is blue cloth but the edge is brown or black with grime. The trains have no airconditioning, and the city famously refuses to find a solution to the problem of the intense heat in the carriages and passageways – in summer in the UK the outside temperature may not go above 23, but down below in the multiple tubular layers of hell, it is well above 35. And of course, in that special London way, there is the constant stink of unwashed bodies packed together. The stations themselves are tiny, cramped affairs with dark, often unfinished tunnels that are already fraying at the edges. Everyone is in the same 3 brands (Zara, TopShop, H&M) and stands sluggishly on the long escalators, staring at the sluggish people passing the other way. Like British houses, the Tube is dark and grey and stuffy.

    All this is in contrast to Tokyo, whose metro stations are wide, large and brightly lit with many exits, shopping centres connected to them, and throngs of bustling, active people who walk briskly up the escalators, and are dressed in the myriad contrasting fashions that only Tokyo can support. The trains are bright and clean, wider and taller than the Tube, even though the people here are smaller and shorter. The trains are air-conditioned and they travel through wider tunnels. In contrast to the intense noise of the Tube as the carriages rattle through the claustrophobic tunnels, passengers and announcers yelling over the din, all is quiet and ordered. Screens over every door broadcast the day’s Korean lesson, or some notes on successful communication. People are packed together, but the train is not stuffy or filled with the reek of unwashed bodies.

    And so this contrast struck me. In London, the workers are hurled to their destination like so much unwanted snot. In Tokyo they are swished to their place of work as treasures, like the money through the automated tube systems of a Love Hotel.

    Of course there’s no point in comparing to Sydney trains… in that “international city” you’re lucky if they turn up at all!

  • Lies, Damned Lies and Statisticians 2: The Fugu Rule

    Could you lie to this little guy?

    On Thursday night I had my farewell party, primarily filled with my partner’s co-workers, who have been good companions for the past year. Most of them know that I’m an inveterate liar, so I nevertheless considered announcing to them at the party that actually “the job in Tokyo was a lie and I’m not going, and this dinner party was held to reveal the secret to you.” This would have been doubly brilliant, since I would have used my reputation for deception-jokes to pull the mother of all deception jokes. Unfortunately I didn’t think my skills were up to it and anyway, if I succeeded they probably would have lynched me.

    However, during dinner one of my partner’s colleagues, a Japanese-American “half” who speaks perfect English and Japanese – let’s call her Miss Accomplished for the purposes of this story – told me I look like a horse. Unable to let this pass, I responded by pointing out her resemblance to a puffer fish (in Japanese, fugu). This led, naturally, to a discussion of how I quite like puffer fish because I used to keep them. Miss Accomplished asked me where I kept them, and I told her that I kept them when I lived in Shimane Prefecture, three years ago. This is true – I had two very cute little freshwater puffer fish when I lived in Shimane prefecture, and they were cute.

    So, then Miss Accomplished made the mistake of indicating surprise at this – presumably because I was in Shimane for only a year and a half, though I don’t know for sure – and asking me why?

    To which I responded that Shimane Prefecture has a rule that all male residents under a certain age are required to keep puffer fish, in order to preserve a rare species of local puffer fish that is endangered. Miss Accomplished was stunned at this revelation, and asked me for more details about the law, whether all men have to keep them, etc. My partner watched all of this with mild amusement, since it was patently obvious what I was doing. Eventually, once I’d led Miss Accomplished far enough up the garden path to have her up to her neck in fertilizer, I revealed that the whole thing was a lie and Miss Accomplished, up until then thoroughly and completely taken in, slapped me.

    It was worth it. So how do I rate this lie?

    Degree of Difficulty: Given we had just been talking about how I’m a liar, and were surrounded by people who should know better, Miss Accomplishment herself knows I’m a liar, and was sober, and I was doing this in Japanese, I would give this a degree of difficulty of 4.5. However, I think Miss Accomplished might be religious, which indicates a natural susceptibility to bullshit, so I’m downgrading it to a 4.

    Degree of Preposterousness: I think this is actually a pretty preposterous lie. It’s inconceivable that a government would try and pass such a law, could if they did, or would get anyone to follow it. But it’s particularly preposterous that it would only apply to men. So I rate this a 4.5.

    Degree of Success: Completely believed, but she didn’t leave the scene unaware of the lie, so 4 out of 5.

    Overall Rating: 17 out of 25. A good effort.

  • Slight Change of Blogging Plans…

    Would you risk your fate with this man?

    On Tuesday I start working at the Tokyo University Department of Global Health Policy as an Assistant Professor, which means that on Sunday I am moving from Steamy Beppu to the City of Light. I will also be returning to full time work after a year working part time and being a househusband.

    This means that my Japanese Warhammer 3rd Edition group has broken up, and my Japanese role-playing plans in general have to go on hold until I can find a suitable group in Tokyo. I don’t know how easy that will be. It also means that I’ll have a lot less time for, and material to put into, long posts, so my posting frequency will go down, which is a shame because I’ve been on a bit of a roll recently.

    To keep my posting frequency up I may add a new posting series, about bars and restaurants in Tokyo, because I will be exploring them. I may also put in some taste-testing of various Japanese sake, which I’m becoming interested in… we’ll see. It’s a bit off topic but when I go searching for information about Tokyo night life I appreciate other peoples’ views, so maybe someone will appreciate it being here… also there may be some general aspects of Tokyo life to comment on, so the blog may open a little beyond nerd culture to include general big city culture.

    I will of course be trying to expand my role-playing horizons in Tokyo – who knows, I may even play in English! – and exploring nerd life a little. There may also be some Harajuku-related material on here too… we’ll see how busy I am. But the move to Tokyo may well indicate a move to a broader focus on Japanese otaku life, hopefully from the perspective of someone at least slightly involved in it. We’ll see. But for the meantime, expect me to post slightly less frequently, and don’t be disheartened.

    The miniature at the top of this post was painted by one of my players, Tencho-san. It’s a likeness of me. You can’t see it in the photo but the book has “Master” written on it’s cover, and on the back of the wizard’s jacket is written (混沌東大), which is Japanese shorthand for “Tokyo University Chaos!” This was part of my going-away present, along with the game Make You Fortress and a collection of cards for the game Make You Kingdom, which contain colour cardboard cutouts of all the cute monsters from the game. I really need to play this game at some point…

    A report of the last session of the Rats in the Ranks campaign will be going up soon. In the meantime, any particular requests for investigation you would like to see conducted in Tokyo, please let me know in comments (and yes, if I find a used underwear vending machine I will post a photo!)

  • UK to get Australian-style Health System?

    Well, not quite, but in Sunday’s Daily Telegraph the UK Prime Minister, David Cameron, outlined his vision for the NHS (and all other public services) and it looks like a strong departure from the existing system, and a significant move toward the kind of system I’ve been suggesting would work well in the UK as it does elsewhere. Of course, we can’t judge a government policy on a newspaper editorial, and the White Paper hasn’t been released yet so we don’t know the details, but it appears that the plan is to open up health services for competition between private and public providers. I haven’t found much analysis of this yet (presumably because the details haven’t been published) but Polly Toynbee gives her typically strident take in the Guardian. Under her version of the policy, we read that companies will be able to force the NHS to open any service to tender competition, and if they can prove that they will provide the service at a lower cost than the government, and that quality won’t be reduced, then the NHS will be obliged to fund them to provide that service. This seems (ideological rants aside) broadly consistent with the implication of the Cameron article, where he says

    We will create a new presumption – backed up by new rights for public service users and a new system of independent adjudication – that public services should be open to a range of providers competing to offer a better service

    This will mean that significant services within the NHS that can be separated out from general services could be forcibly privatized, for example the provision of radiology services could be targeted by a major healthcare provider, and then prized loose from existing hospital services and tendered out. It also opens the field for (largely American, but also some European) private healthcare companies to conduct hostile takeovers of British hospitals, provided they can prove that they can offer the same services. It’s kind of the opposite of nationalization, being promulgated by a government.

    Cameron then goes further, to argue that services should be localized as well as privatized, with communities being able to argue that a service should not be managed centrally:

    For example, we will give more people the right to take control of the budget for the service they receive. In this new world of decentralised, open public services it will be up to government to show why a public service cannot be delivered at a lower level than it is currently; to show why things should be centralised, not the other way round.

    I think this part will be a flop, and I have some concerns about its effects on inequality if it were successful, but regardless of its degree of success, I think we’re actually seeing something genuinely, amazing and new here: somewhere in the Western world, a Conservative party has come up with a new idea that works within the Social Democratic framework. We’re not just seeing a repeat of the tired mantra of “cut taxes! me!” And it isn’t a piece of naked self-interest either – as in all of his work to date on the NHS, Cameron retains an awareness of the issue of inequality:

    Of course, the state will still have a crucial role to play: ensuring fair funding, ensuring fair competition, and ensuring that everyone – regardless of wealth – gets fair access.

    So, how will this new service model resemble an Australian-style system, how could it be better than the current NHS, in what possible ways can it fail, and what will its effects on inequality be?

    Resemblance to the Australian system

    Australia of course has no model of enforced privatization or anything resembling it, but we do have a system in which a universal health insurer – the Federal Government – pays for medical services from a health care sector that is primarily composed of private providers. This is the primary care system in Australia, but what happens in practice is that primary care doctors (General Practitioners; GPs) provide a significant range of quite advanced medical services, including radiology and minor surgery. They then refer more complex patients to private specialists, or to publicly-funded hospitals that provide specialist services. These publicly-funded hospitals are funded by the State government, and serve to prevent market failure in the provision of healthcare, to prevent costs spiralling out of control, and to maintain a strong medical infrastructure. The single universal government run insurer helps to hold down the cost of health care, and the State-run health systems also fund some community health services that provide GP services to those who might not fit into the general health system (e.g. injecting drug users, transgender people, Aborigines, etc.) Australia also runs a fairly large private health sector, in which privately-run hospitals cherry pick the easy, high-profit cases from public hospitals and are paid from private health insurance funds that are affordable and accessible, and partially publicly subsidized. The reason these funds are affordable and accessible is that the government runs all emergency services and provides baseload public medical care, so that the private services don’t have to get into the business of providing extremely high-cost, high-risk services. Also, as far as I know there is no obligation for a publicly-funded hospital to provide all the services using public employees. I think they can contract out, e.g. cleaners, or form contracts with private specialists if they think it will benefit them (though of this I’m not 100% sure).

    It’s a kind of mixed economy where public and private services cooperate to keep people healthy, and Australians are very healthy by world standards. We also don’t pay that much for our healthcare by international standards, because of the extensive cost containment built into the system. No one can say that the system is perfect but it works very well, it’s responsive to new threats (e.g. HIV/AIDS), it’s fairly equitable (except for the shameful issue of Aboriginal health) and it’s cheap.

    David Cameron’s plans could well move Britain organically towards this same system. If the privatization process works effectively, we will see private providers cherry-picking the easy services and the best hospitals in the healthiest areas, providing services from these hospitals at less than it costs the government, and freeing up the government to focus resources in unattractive or challenging areas[1]. We will also see some services within hospitals being privatized at reduced cost, so that the hospitals have more resources to spend on other things. But at the same time the government will still be free to establish new hospitals in underserved areas, to invest in existing hospitals to upgrade or expand them, and to invest in programs to reduce health inequality.

    How it Could Improve the Current System

    The influx of service providers and private investment, the opening of the market to private providers, and the increased efficiency of small private providers competing against monolithic NHS systems will undoubtedly lead to increased capacity and lowered costs. It might also improve workforce size and skill, as these providers in setting up quickly would (hopefully) employ more people. There are a lot of caveats on this, though. If private providers aren’t able to compete in the GP marketplace they will be barred access to the most lucrative part of the market; many of the bigger hospitals and/or the services that they could provide are probably already being run at low cost and high efficiency, and private providers may find it unattractive to take them on after they do the maths.

    With private providers given a foothold in public services, they will then have a presence in the British market that they can leverage to expand the private health industry, which may take pressure off public services[2] and enable private providers to achieve efficiency gains. In the long-term this system will potentially bring private investment in publicly-funded facilities.

    If this model extends to primary care, we will also see large international companies (including, probably, some Australian ones) establishing new, vastly superior models of primary care service provision and competing with existing GPs to provide lower cost, higher quality primary care. And I bet some of those companies will set up in poor areas, where existing provision of GP services is poor. But I am also willing to bet (see below) that GPs will be explicitly excluded from the privatization model, because they have too much power and for GPs this model if implemented would mean a price war, that would drive their wages down rapidly[3].

    I don’t subscribe to the view that all public services must be performing worse or less efficiently than private services, but it is undoubtedly the case that an organization as large and unruly as the NHS will have significant efficiency gains built into it, and it may well take an external provider to realize these. Also, the NHS is capacity-constrained by government funding limits, but private providers may see some benefit in initial infrastructure investment in order to compete for NHS services. The NHS needs investment, and there are some areas – especially elective surgery – where there is no reason to think that the private sector cannot provide a service that is at least as good as the NHS at at least the same cost. If in setting up these services the private sector need to invest, then this is a good thing for the British health system – especially if some companies invest with the long term intention of expanding the scope of services they provide into a growing private health care market. It’s also possible that private providers might combine plans for health tourism with plans for competition in the domestic publicly-funded market, which could make the Tory’s plans for health care tourism of greater benefit to the domestic population.

    How Could it Fail?

    There are a few ways in which this system could be a complete disaster, or at least fail to achieve any of the stated aims.

    Failure to Include GPs: GPs in Britain provide a woefully inadequate, hideously overpriced service that is massively capacity constrained. The GP system costs a lot of money and compared to other primary healthcare systems it doesn’t do a very good job. Because the UK NHS operates a gatekeeper system, but has long waiting times. poor GP referral practices can lead to significant delays in access; there is some evidence that there is inequality in referral practices and access. If the GP system is not shaken up under this privatization process, one of the major barriers to better quality care will continue to function at a very poor level. Currently there is little to no incentive for GPs to improve their service in the UK, because there is no private competition and a demand management system that encourages them to work limited hours in small practices, providing little in the way of significant medical care. Introducing competition to GP services would be an excellent way to improve healthcare, but if this is not done the system will continue to be inefficient at the commonest first port of entry.

    Failure to properly integrate private providers in planning: future growth in the British health system depends on expansion of the workforce, a slow process that depends on negotiation with universities (who train new staff) and representative organizations (who set and maintain healthcare training standards). If private providers are excluded from proper involvement in this planning process, then they will end up competing with public providers for limited workforce resources, rather than adding to them. This has been a perennial problem in the British system, which doesn’t have enough GPs or nurses. Proper workforce planning requires central involvement at least at a regulatory level (to prevent, for example, doctors choosing to restrict numbers of trained GPs in order to increase their wages) and it also requires government or private investment in universities. This needs to be coordinated in some way, and it’s not clear that this is easily done.

    Paper Tiger Regulation: The British privatization environment seems to involve this model of private providers being regulated by public agencies, but these public agencies can often be toothless, weak agents. In order to ensure Cameron’s central goal of proving that the private sector will provide a service of the same quality at lower price, the agencies that assess quality need to be tough as nails. If they’re not, the British will get lower quality services. I suspect that the Tories are not the best party to oversee strong regulation of the private sector, but then Labour were terrible at this (there was a small financial problem in the UK partly related to their unwillingness to regulate their mates, after all). If regulation is not strong and well funded, there will be little oversight of the privatization process and quality will decline. On the flipside, the NHS is no doubt not great at managing itself (in fact Labour had to set up various arms-length industry bodies to do this) so maybe offloading some functions to private sector agencies will improve the ability of the NHS to monitor quality. Certainly, a wholesale recasting of the NHS as primarily a purchaser and regulator of healthcare services has the potential to vastly improve the quality of the services. But we’ve heard this before amongst the arguments for privatization in the UK, and the UK still has crap power systems, crap water systems, crap railways and crap phone providers…

    Inequality: privatization has the potential to increase inequality, because private providers tend to find that providing services to the wealthy is more profitable than providing them to the poor; and private providers themselves have no particular obligation to look out for the poor or disadvantaged. We’ll look at this separately …

    Contract Failure: Based on what little is available about the new plan, it doesn’t appear that the NHS will be moving towards a limited role as healthcare purchaser and regulator; it will be involved in service provision as well. Also, it doesn’t appear that a fee-for-service model or a straight out insurance model will be adopted. Rather, it appears that the government will put out bids for contracts to provide services. This is kind of similar to how it manages GPs (through contracts) and hospitals (through block grants, I think) now. But while such service agreements may work for publicy-owned and run services they may not be the best model for privately run services. If the funding model doesn’t suit the system, it may lead to under-funding, or to excessive funding of some private bodies. Also, I don’t think I’d be too confident with the ability of the NHS to assess tenders and make good contracts. My own experience of the NHS is that you can drive a truck through their contracts, and come out the other side loaded with booty; there is some recent evidence of huge variations in payment levels by area in the NHS that aren’t related to area-specific needs (i.e. some NHS areas are being fleeced). Contract failure runs the risk of turning the whole thing into a big rort for smart private organizations.

    Effects on Inequality

    Privatization and competition have the risk of increasing inequality, by concentrating private investment and better quality services in areas that have more money, and depriving poor areas of some services or forcing them to rely on second-rate under-funded government services. The government says it’s going to address this specifically, and for two or three years now the Tories have talked a lot about inequality, so I don’t doubt that at least some of them (Cameron and Lansley included) are serious. But how they aim to go about ensuring inequality doesn’t increase is not yet clear. There’s no fundamental reason it should, since the government will remain involved in providing care and so can address market failure in poor areas directly; and I presume that the increased privatization will come along with continual improvements in patient choice that free poor people up to go to wealthy areas for their care.

    Another, in my opinion potentially more serious, cause of inequality is the Tory focus on localism. To my mind “localism” and “inequality” go hand in hand, and while it’s good to have local flexibility in the provision of services it’s also important to keep central control over just how much inequality in distribution of and access to services this causes. If “localism” means that local councils or community groups get to choose to defund GPs in one area so they can fund fancy services in a wealthier area, then someone at some point is going to have to step in and stop them. It’s not clear that the new Tory system has a way of doing this; but then, it’s not clear that this has ever been done effectively in the NHS. Plus, of course, much of health inequality in the UK is an upstream issue, caused by social inequality that is reflected in health, and better addressed through welfare and employment policy, urban planning, educational improvements, etc. than patched up by the NHS.

    Nonetheless, when you overhaul a system to give it a greater dependency on service providers who are going to follow money rather than central diktats, you open the risk that they’ll provide less or lower quality services to poor people. This needs to be avoided. And when you introduce increased localism you also need to account for the increased risk of inequality (or, for that matter, just plain bad decisions) that comes with it. How the new plan will do that is not yet clear.

    Conclusion

    Though I still don’t think the proposed plans offer the flexibility the NHS needs, and while I still think injecting funds is more important at the moment than reform, these plans do suggest some cause for optimism, and may lead to a more efficient, more flexible system that is a little closer to the kind of systems that the rest of the developed world has found seem to work best. The changes carry the risk of failure, of some private providers being able to loot the system, and of an increase in inequality or loss of quality – particularly seeing as they’re being introduced at a time of cost cutting and funding cuts. But if they’re managed well, and properly regulated, they will at least open the NHS up to future improvements. I’m tentatively in favour of them, at least until I see the details in the White Paper.

    —

    fn1: In theory. The UK government will probably choose to spend this money on something worthless, because this is Britain we’re talking about here, but let’s try and be optimistic

    fn2: I’m really dubious that this is a big effect of private insurance in mixed systems, but with the private system in the UK quite small I can see how it would make a large difference in the short term

    fn3: One of my visions for the UK system is an Aussie or South African private provider setting up a 24 hour GP clinic in a poor, inner city area in the UK, employing Aussie and Polish doctors at much lower wages than a British GP gets, providing all sorts of on-site services that a British GP will not offer, and vastly improving the quality of local health care, while taking pressure off local hospital emergency and elective care services, and driving all the surrounding GPs out of business or forcing them to negotiate new, lower-price contracts. Somewhere at the back of this will be a flamboyant, oily Antipodean doctor – in my vision he has been barred from practicing himself[4], probably for shagging patients – who drives fast cars, has 3 mistresses, and blows huge amounts of money up his nose. It’ll never happen, but it would be great if it did.

    fn4: And this oily guy is always male

  • Current Reading: Flood

    Flood is a disaster story of epic proportions, written by Stephen Baxter. The story follows a group of 4 friends over a 30 year period from the moment in 2012 when they make a pledge under strange circumstances to always look out for one another, as a disaster of incredible size overtakes the earth. This disaster is a biblical-style flood, caused by huge, previously undiscovered reservoirs of water under the earth’s crust that escape into the world’s oceans after a seismic event. The seepage is initially small, leading just to increased amounts of rain, and then to unexpected floods, but the rate of increase is exponential and the quantity of water beneath the globe sufficient to completely submerge all land on earth. This isn’t a global warming event – though the increase in quantities of warm water accelerates the effects of global warming – but a massive,worldwide seismic catastrophe causing a rapid and catastrophic loss of human habitat.

    The early part of the story, when the flooding is still manageable, is more of a human interest story about how the four friends recover from the circumstances of their initial meeting and settle into a new and waterlogged world. But as the floods intensify and it becomes clear that something is up the story turns into one of discovery as the friends find out what is really happening, then a slow devolution from adaptation to survival to extinction. The later stages of the story become more of an overview of how human society tries to cope with its own imminent extinction by forces beyond any technology’s ability to control, and attempts to describe both the geopolitical, social, and personal effects of the essential collapse of human civilization and the potential disappearance of the human race.

    This is a very interesting idea. How do societies behave as their collapse becomes inevitable, and what will people do to survive? And can people even come to terms with the possibility of their civilization’s inevitable destruction? What measures would they put in place? And can humanity survive without land? Obviously irrelevant questions, because the science of the catastrophe is completely unrealistic, but this is the kind of speculation science fiction was built for. After I finished this book I spent a lot of time wondering how society could adapt to living on a water world where all mining is impossible, and energy can only come from sun, wind and waves. What raw materials could you use? How would you prepare the remnants of your society for this? An interesting intellectual exercise. The book covers this primarily through the perspective of an egotistical company direct who runs a corporation specializing in disaster preparedness and recovery. As the world retreats from the sea he conceives of increasingly desperate schemes to protect his family and friends, and to remain powerful and on top in the new world. His schemes are ultimately fruitless in a sense, though he and his allies survive a lot longer than almost everyone else, and can be said to have escaped the catastrophe in a sense. His failure is no fault of his personal failings, either – the water just got the better of him, and the constant failings of the increasingly fragile societies within which he works continually set his schemes backwards. There is also the implication that other approaches – cooperation with other organizations and states – may have worked better, though I suspect we’ll find that their schemes were even crazier and less successful if we read the sequel, Ark. Certainly he seemed like an ingenious survivor to me, and lasting 30 years as the sea wipes out everything seems like quite an achievement to me.

    The science of this book being obviously, ludicrously impossible, the main flaws in this book concerned characterization and dialogue. It’s definitely hard sci-fi and sometimes the prose was a little dry and uninteresting, the interactions of the characters a little stilted and hollow, and in this sense the book is definitely driven forward by the continual unfolding of events, and the fascination with watching everyone drown. For this reason it’s definitely not a book to everyone’s tastes, but if you’re interested in questions of social adaptation, survival and how the world changes under extreme environmental pressure, it’s worth looking into. I don’t think it has much direct relevance to global warming and its effects – the most extreme predictions of which don’t hold a candle to the events in this tale – but it does serve as an interesting tale about the importance of “ecological services” to human social cohesion and economic success. To this end it also fits in well with the movie I watched on the weekend, The Road, and some of my thoughts about zombies and survivalism. But ultimately the disasters in all these books and movies are so beyond anything we can expect to actually befall the earth that really they’re just interesting speculative tales. I wonder what it says about modern sensibilities that they all involve, one way or another, cannibalism?

    Anyway, in summary this book is a good read if you’re interested in ecological catastrophes and/or disaster tales, it’s easy to read if you can be carried forward by plot and are willing to overlook occasional clumsiness in writing style and characterization. Overall I recommend it.

  • Current Viewing: The Road

    This is not a milk delivery

    The Road is a nasty post-apocalypse movie by John Hillcoat, based on the novel of the same name by Cormac McCarthy. The basic story is very simple – a man and his son are walking south towards the coast through a post-apocalyptic landscape, trying to survive while they head for the sea. The cause of the apocalypse is not described, but the land has been locked in a perpetual winter, all the animals and plants are dead and gone, and there are no surviving communities. What few humans there are mostly live by cannibalism, scavenging the ruined towns and cities for any edible remnants of the time before but mostly living by killing and eating other travellers – or keeping them alive and eating them bit by bit, depending on how clever they are. The sky, the land and the buildings are all grey, there is regular rain and snow, and the father in the story is slowly dying of what appears to be some kind of apocalypse-related disease. They are heading south in hopes of finding land capable of sustaining life and communities, and also some warmth, because they realize they can’t survive another winter in the freezing inland.

    The majority of this movie is a story completely without goodness or hope. The scenes of cannibalism are quite horrific, and the two lead characters do not have any positive encounters with people during their travels. They hide from any people they see, and don’t trust anyone. On several occasions they stumble on functioning small communities of about the size of a small gang, only to discover that they are cannibals living in horrifyingly primitive and evil circumstances, and have to flee. Even the non-cannibals they meet have hints of terrible pasts – an old man who may have eaten his own son, for example – and the two main characters are themselves constantly starving, so that the question of “would you or wouldn’t you?” weighs heavily upon them.

    This movie was probably a little too grim for my tastes, and strikes me as one of those moments where a book shouldn’t have been made into a film. It’s just too nasty to put actors to, even if the actors in question manage to do the job brilliantly. The world of the apocalypse is powerfully done, so that you really do feel like you’re there, and there’s not really anything you question about the veracity of the setting – it’s internally very consistent. Viggo Mortensen puts in a powerful performance as the father, and all the other actors live up to their parts most admirably. But you find yourself thinking, by the end of it, that surely even the most powerful artistic powers are thoroughly wasted if they are bending their prodigious talents to the production of something so horrific and grim as this.

    My only two complaints with this movie are minor, but they may bug other viewers too. The boy – Viggo Mortensen’s son – played by Kodi Smit-McPhee, is annoyingly weak and innocent, and does things that after 7 or 10 years of post-apocalyptic life you’d think would be well beaten out of any sensible survivor. He seems to have no cynicism or mistrust, he is physically weak (reasonable, I suppose) and he is incapable of being silent when he needs to be. He also doesn’t seem to analyze situations very well, either. His innocence and purity are so inconsistent with the world around him that it makes one think he was written into the story as a kind of allegory of human conscience, in which case it was all done rather clumsily. At times his mistakes and weak points are quite frustrating, and it’s hard to believe that after 10 years of dodging cannibals – and in some cases watching them kill and eat the people who don’t dodge them – he hasn’t quite managed to work out that he is living in a world where no-one can be trusted. But I can also see that this is the intent of the story – the father has managed to shelter his boy from the worst of the apocalypse for years, and has difficulty preparing the boy to look after himself once papa dies.

    My other complaint is that the ending seems a bit deus ex machina, in that after setting up a world of such unrelenting cruelty, that presents its survivors with such hard and nasty choices, the final resolution to the plot seems so unbelievable as to be almost an act of god. However, the presence of a moment of hopefulness in an otherwise completely forlorn and ruined world made it acceptable. Had the movie ended more realistically, with the final scene being the kid being butchered and eaten by scumbags, I probably would have set fire to my tv. Or myself.

    In short, this is a great movie that it’s best not to watch.