Our health-care system won’t be fixed by insurance reform. To contain costs and improve results, we need to move aggressively to adopt the tools of information-age medicine
We do more than 125 million ultrasound scans a year in the U.S., at an average charge of well over $800—that’s $100 billion. But we now have ultrasound probes that connect with a smartphone and provide exquisite resolution comparable to hospital lab machines. It is possible to examine any part of the body (except the brain) simply by connecting the probe to the base of a smartphone and putting a little gel on the probe’s tip. When I first got a smartphone ultrasound probe last year, I did a head-to-toe “medical selfie,” imaging everything from my sinuses and thyroid to my heart, lungs, liver, gallbladder, aorta and left foot.
That experience came in handy when I recently developed pain in my flank. Seeing my very dilated kidney on my smartphone screen helped to confirm the diagnosis that I had a kidney stone. The CT scan later ordered by my doctor showed a nearly identical image, but the charge for that was $2,200. If this single tool was used in a typical office visit, a large proportion of expensive and unnecessary formal scans could be avoided.
Smart medicine can also bring some sanity to how we handle medical screening, which today results in an epidemic of misdiagnoses and unnecessary procedures and treatments. The leading culprits are routine tests for breast and prostate cancer for individuals at low risk for these diseases. Because the tests have such extraordinarily high rates of false positives, they result all too often in biopsies, radiation and surgery for people in no medical danger.
.. Routine use of individual genetic information could also allow us to prescribe drugs more effectively, avoiding the waste, in clinical time and in money, caused by medications that misfire. More than 130 drugs in common use have an FDA label for DNA data—that is, they provide peer-reviewed research instructing doctors about dosage, side effects and potential responsiveness for patients with particular genetic profiles.
.. So why have we been so slow to adopt and encourage these potential solutions? Medicine is hard to change, especially when reforms threaten established modes of payment and the customary control of patients. And like everyone else, doctors are seldom eager for extensive new training. But our current course of medical spending and practice is unsustainable, and no change in how we handle health insurance is likely to alter that reality.
Recommendations Engines position themselves to amass power
The profit is not in the growing the food, or the transporting the food, or the preparing the food, or the serving the food, or the cleaning the dishing and restaraunt, but in shaping the decisions of customers. The profit is not to the driver but to Uber, who runs the platform.
Of Flying Cars and the Declining Rate of Profit
a particular generational promise—given to those who were children in the fifties, sixties, seventies, or eighties—one that was never quite articulated as a promise but rather as a set of assumptions about what our adult world would be like.
.. Where, in short, are the flying cars? Where are the force fields, tractor beams, teleportation pods, antigravity sleds, tricorders, immortality drugs, colonies on Mars, and all the other technological wonders any child growing up in the mid-to-late twentieth century assumed would exist by now?
.. In 1968, Stanley Kubrick felt that a moviegoing audience would find it perfectly natural to assume that only thirty-three years later, in 2001, we would have commercial moon flights, city-like space stations, and computers with human personalities
.. The usual move in science fiction is to remain vague about the dates, so as to render “the future” a zone of pure fantasy, no different than Middle Earth or Narnia, or like Star Wars, “a long time ago in a galaxy far, far away.”
.. The movie was terrible, but I couldn’t help but feel impressed by the quality of the special effects.
.. They thought we’d be doing this kind of thing by now. Not just figuring out more sophisticated ways to simulate it.”
.. The technologies that have advanced since the seventies are mainly either medical technologies or information technologies—largely, technologies of simulation.
.. The postmodern sensibility, the feeling that we had somehow broken into an unprecedented new historical period in which we understood that there is nothing new; that grand historical narratives of progress and liberation were meaningless
.. all this makes sense in a technological environment in which the only breakthroughs were those that made it easier to create, transfer, and rearrange virtual projections of things that either already existed, or, we came to realize, never would.
.. The postmodern moment was a desperate way to take what could otherwise only be felt as a bitter disappointment and to dress it up as something epochal, exciting, and new.
.. End of work arguments were popular in the late seventies and early eighties as social thinkers pondered what would happen to the traditional working-class-led popular struggle once the working class no longer existed. (The answer: it would turn into identity politics.)
.. What happened, instead, is that the spread of information technologies and new ways of organizing transport—the containerization of shipping, for example—allowed those same industrial jobs to be outsourced to East Asia, Latin America, and other countries where the availability of cheap labor allowed manufacturers to employ much less technologically sophisticated production-line techniques
.. an uneasy awareness that the postwork civilization was a giant fraud.
- .. Either our expectations about the pace of technological change were unrealistic
- .. or our expectations were not unrealistic (in which case, we need to know what happened to derail so many credible ideas and prospects).
.. the United States and the Soviet Union had been, in the century before, societies of pioneers, one expanding across the Western frontier, the other across Siberia?
.. If it wasn’t unrealistic in 1900 to dream of men traveling to the moon, then why was it unrealistic in the sixties to dream of jet-packs and robot laundry-maids?
.. Future Shock argued that almost all the social problems of the sixties could be traced back to the increasing pace of technological change.
.. by roughly 1850, the effect had become unmistakable. Not only was everything around us changing, but most of it—human knowledge, the size of the population, industrial growth, energy use—was changing exponentially. The only solution, Toffler argued, was to begin some kind of control over the process, to create institutions that would assess emerging technologies and their likely effects, to ban technologies likely to be too socially disruptive ..
.. One of Gingrich’s first acts on winning control of the House of Representatives in 1995 was defunding the OTA as an example of useless government extravagance
.. Auguste Comte, who believed that he was standing on the brink of a new age—in his case, the Industrial Age ..
.. The Industrial Age had developed its own system of ideas—science—but scientists had not succeeded in creating anything like the Catholic Church. Comte concluded that we needed to develop a new science, which he dubbed “sociology,” and said that sociologists should play the role of priests in a new Religion of Society that would inspire everyone with a love of order, community, work discipline, and family values.
.. The old, materialist Industrial Society, where value came from physical labor, was giving way to an Information Age where value emerges directly from the minds of entrepreneurs, just as the world had originally appeared ex nihilo from the mind of God, just as money, in a proper supply-side economy, emerged ex nihilo from the Federal Reserve and into the hands of value-creating capitalists.
.. existing patterns of technological development would lead to social upheaval, and that we needed to guide technological development in directions that did not challenge existing structures of authority—echoed in the corridors of power.
.. Marx argued that, for certain technical reasons, value—and therefore profits—can be extracted only from human labor. Competition forces factory owners to mechanize production, to reduce labor costs, but while this is to the short-term advantage of the firm, mechanization’s effect is to drive down the general rate of profit.
.. Back in the fifties, in fact, many United States planners suspected the Soviet system worked better. Certainly, they recalled the fact that in the thirties, while the United States had been mired in depression, the Soviet Union had maintained almost unprecedented economic growth rates of 10 percent to 12 percent a year—an achievement quickly followed by the production of tank armies that defeated Nazi Germany, then by the launching of Sputnik in 1957, then by the first manned spacecraft, the Vostok, in 1961.
.. We are used to thinking of the Politburo as a group of unimaginative gray bureaucrats, but they were bureaucrats who dared to dream astounding dreams.
The dream of world revolution was only the first.
.. most of them—changing the course of mighty rivers, this sort of thing—either turned out to be ecologically and socially disastrous
most were not military in nature: as, for instance, the attempt to solve the world hunger problem by harvesting lakes and oceans with an edible bacteria called spirulina,
- or to solve the world energy problem by launching hundreds of gigantic solar-power platforms into orbit and beaming the electricity back to earth.
- .. American victory in the space race meant that, after 1968, U.S. planners no longer took the competition seriously.
.. the direction of research and development shifted away from anything that might lead to the creation of Mars bases and robot factories.
.. the United States never did abandon gigantic, government-controlled schemes of technological development. Mainly, they just shifted to military research
.. by the seventies, even basic research came to be conducted following military priorities.
.. One reason we don’t have robot factories is because roughly 95 percent of robotics research funding has been channeled through the Pentagon, which is more interested in developing unmanned drones than in automating paper mills.
.. the technologies that did emerge proved most conducive to surveillance, work discipline, and social control.
.. provided the means by which employers have created “flexible” work regimes that have both destroyed traditional job security and increased working hours for almost everyone.
.. what will the epitaph for neoliberalism look like?
.. a form of capitalism that systematically prioritized political imperatives over economic ones. Given a choice between a course of action that would make capitalism seem the only possible economic system, and one that would transform capitalism into a viable, long-term economic system, neoliberalism chooses the former every time.
.. There is every reason to believe that destroying job security while increasing working hours does not create a more productive .. workforce.
.. It’s possible, in fact, that the very dead weight of the apparatus created to ensure the ideological victory of capitalism will sink it.
.. choking off any sense of an inevitable, redemptive future that could be different from our world is a crucial part of the neoliberal project.
.. the change shifted government-directed research away from programs like
- NASA or alternative energy sources and
- toward military, information, and medical technologies.
.. the preferred weapon almost everywhere remains the AK-47, a Soviet design named for the year it was introduced: 1947.
.. private enterprise is now funding twice as much research as the government
.. “Basic,” “curiosity-driven,” or “blue skies” research—the kind that is not driven by the prospect of any immediate practical application, and that is most likely to lead to unexpected breakthroughs—occupies an ever smaller proportion of the total
.. The Human Genome Project .. has mainly served to establish that there isn’t very much to be learned from sequencing genes that’s of much use to anyone else
.. Research and development is still driven by giant bureaucratic projects.
.. The increasing interpenetration of government, university, and private firms has led everyone to adopt the language, sensibilities, and organizational forms that originated in the corporate world.
.. the last thirty years have seen a veritable explosion of the proportion of working hours spent on administrative tasks at the expense of pretty much everything else.
.. In my own university, for instance, we have more administrators than faculty members, and the faculty members, too, are expected to spend at least as much time on administration as on teaching and research combined.
.. The growth of administrative work has directly resulted from introducing corporate management techniques.
.. everyone winds up spending most of their time trying to sell things: grant proposals; book proposals; assessments of students’ jobs and grant applications; assessments of our colleagues; prospectuses for new interdisciplinary majors; institutes; conference workshops; universities themselves
.. No major new works of social theory have emerged in the United States in the last thirty years. We have been reduced to the equivalent of medieval scholastics, writing endless annotations of French theory from the seventies, despite the guilty awareness that if new incarnations of Gilles Deleuze, Michel Foucault, or Pierre Bourdieu were to appear in the academy today, we would deny them tenure.
.. It is now the domain of professional self-marketers.
.. Jonathan Katz
.. You will spend your time writing proposals rather than doing research. Worse, because your proposals are judged by your competitors, you cannot follow your curiosity, but must spend your effort and talents on anticipating and deflecting criticism rather than on solving the important scientific problems. . . . It is proverbial that original ideas are the kiss of death for a proposal, because they have not yet been proved to work.
.. tell those same people they will receive no resources at all unless they spend the bulk of their time competing against each other to convince you they know in advance what they are going to discover.
.. the spread of the corporate ethos within the academy and research institutes themselves has caused even publicly funded scholars to treat their findings as personal property.
.. Those thinkers most likely to make a conceptual breakthrough are the least likely to receive funding, and, if breakthroughs occur, they are not likely to find anyone willing to follow up on their most daring implications.
.. the United States and Germany, the two rival powers that spent the first half of the twentieth century fighting two bloody wars over who would replace Britain as a dominant world power—wars that culminated, appropriately enough, in government-sponsored scientific programs to see who would be the first to discover the atom bomb. It is significant, then, that our current technological stagnation seems to have begun after 1945, when the United States replaced Britain as organizer of the world economy.
.. the moment we stop imagining bureaucracy as a phenomenon limited to government offices, it becomes obvious that this is precisely what we have become.
.. cemented the dominance of conservative managerial elites, corporate bureaucrats who use the pretext of short-term, competitive, bottom-line thinking to squelch anything likely to have revolutionary implications of any kind.
.. No population in the history of the world has spent nearly so much time engaged in paperwork.
.. we need to rethink some of our most basic assumptions about the nature of capitalism. One is that capitalism is identical with the market, and that both therefore are inimical to bureaucracy, which is supposed to be a creature of the state.
.. they were right to insist that the mechanization of industrial production would destroy capitalism; they were wrong to predict that market competition would compel factory owners to mechanize anyway.
.. the current form of capitalism, where much of the competition seems to take the form of internal marketing within the bureaucratic structures of large semi-monopolistic enterprises
Defenders of capitalism make three broad historical claims:
- first, that it has fostered rapid scientific and technological growth;
- second, that however much it may throw enormous wealth to a small minority, it does so in such a way as to increase overall prosperity;
- third, that in doing so, it creates a more secure and democratic world for everyone.
It is clear that capitalism is not doing any of these things any longer.
.. many of its defenders are retreating from claiming that it is a good system and instead falling back on the claim that it is the only possible system
.. they mean to convince us that technological progress is indeed continuing, that we do live in a world of wonders, but that those wonders take the form of modest improvements (the latest iPhone!)
there’s the problem of trying to convince the world you are leading the way in technological progress when you are holding it back. The United States,
- with its decaying infrastructure,
- paralysis in the face of global warming, and
- symbolically devastating abandonment of its manned space program just as China accelerates its own,
.. it will not happen within the framework of contemporary corporate capitalism—or any form of capitalism. To begin setting up domes on Mars, let alone to develop the means to figure out if there are alien civilizations to contact, we’re going to have to figure out a different economic system.
.. whatever replaces capitalism is based on a far more egalitarian distribution of wealth and power—one that no longer contains either the super-rich or the desperately poor willing to do their housework.