Meat Life

Nail them to the wall

In September 2017 Philip Morris International (PMI) – one of the world’s largest cigarette companies – introduced a new foundation to the world: The Foundation for a Smoke Free World. This foundation will receive $80 million per year from PMI for the next 12 years and devote this money to researching “smoking cessation, smoking harm reduction and alternative livelihoods for tobacco farmers”, with the aim to draw in more money from non-tobacco donors over that time. It is seeking advice on how to spend its research money, and it claims to be completely independent of the tobacco industry – it receives money from PMI to the tune of almost a billion dollars, but it claims to have a completely independent research agenda.

The website for the Foundation includes a bunch of compelling statistics on its front page: There is one death every six seconds from smoking, 7.2 million deaths annually, second-hand smoke kills 890,000 people annually, and smoking kills half of all its long-term users. It’s fascinating that a company that as late as the late 1990s was claiming there is no evidence its product kills has now set up a foundation with such powerful admission of the toxic nature of its product. It’s also wrong: the most recent research suggests that 2/3 of users will die from smoking. It’s revealing that even when PMI is being honest it understates the true level of destruction it has wrought on the human race.

That should serve as an object lesson in what this Foundation is really about. It’s not an exercise in genuine tobacco control, but a strategy to launder PMI’s reputation, and to escape the tobacco control deadlock. If PMI took these statistics seriously it could solve the problem it appears to have identified very simply, by ceasing the production of cigarettes and winding up its business. I’m sure everyone on earth would applaud a bunch of very rich tobacco company directors who awarded themselves a fat bonus and simply shut down their business, leaving their shareholders screwed. But that’s not what PMI wants to do. They want to launder their reputation and squirm out from under the pressure civil society is placing on them. They want to start a new business looking all shiny and responsible, and the Foundation is their tool.

PMI have another business model in mind. PMI are the mastermind behind iQos, the heat-not-burn product that they are trialling with huge success in Japan. This cigarette alternative still provides its user with a nicotine hit but it does it through heating a tobacco substance, rather than burning it, avoiding much of the carcinogenic products of cigarettes. PMI have been touting this as the future alternative to cigarettes, and are claiming huge market share gains in Japan based on the product. Heat not burn technologies offer clear harm reduction opportunities for tobacco use: although we don’t know what their toxicity is, it’s almost certainly much lower than tobacco, and every smoker who switches to iQos is likely significantly reducing their long term cancer risk. What PMI needs is for the world to adopt a harm reduction strategy for smoking, so that they can switch from cigarettes to iQos. But the tobacco control community is still divided on whether harm reduction is a better approach than prohibition and demand reduction, which between them have been very successful in reducing smoking.

So isn’t it convenient that there is a new Foundation with a billion dollars to spend on a research platform of “smoking cessation, harm reduction and alternative livelihoods.” It’s as if this Foundation’s work perfectly aligns with PMI’s business strategy. And is it even big money? Recently PMI lost a court case against plain packaging in Australia – because although their foundation admits that smoking kills, they weren’t willing to let the Australian government sell packages that say as much – and have to pay at least $50 million in costs. PMI’s sponsorship deal with Ferrari will cost them $160 million. They spent $24 million fighting plain packaging laws in Urugay (population: 4 million). $80 million is not a lot of money for them, and they will likely spend as much every year lobbying governments to postpone harsh measures, fighting the Framework Convention on Tobacco Control, and advertising their lethal product. This Foundation is not a genuine vehicle for research, it’s an advertising strategy.

It’s a particularly sleazy advertising strategy when you consider the company’s history and what the Foundation claims to do. This company fought any recognition that its products kill, but this Foundation admits that the products kill, while PMI itself continues to fight any responsibility for the damage it has done. This company worked as hard as it could for 50 years to get as many people as possible addicted to this fatal product, but this Foundation headlines its website with “a billion people are addicted and want to stop”. This Foundation will research smoking cessation while the company that funds it fights every attempt to prevent smoking initiation in every way it can. The company no doubt knows that cessation is extremely difficult, and that ten dollars spent on cessation are worth one dollar spent on initiation. It’s precious PR in a time when tobacco companies are really struggling to find anything good to say about themselves.

And as proof of the PR gains, witness the Lancet‘s craven editorial on the Foundation, which argues that public health researchers and tobacco control activists should engage with it rather than ostracizing it, in the hope of finding some common ground on this murderous product. The WHO is not so pathetic. In a press release soon after the PMI was established they point out that it directly contravenes Article 5.3 of the Framework Convention on Tobacco Control, which forbids signatories from allowing tobacco companies to have any involvement in setting public health policy. They state openly that they won’t engage with the organization, and request that others also do not. The WHO has been in the forefront of the battle against tobacco and the tobacco industry for many years, and they aren’t fooled by these kinds of shenanigans. This is an oily trick by Big Tobacco to launder their reputation and try to ingratiate themselves with a world that is sick of their tricks and lies. We shouldn’t stand for it.

I think it’s unlikely that researchers will take this Foundation’s money. Most reputable public health journals have a strict rule that they will not publish research funded by tobacco companies or organizations associated with them, and it is painfully obvious that this greasy foundation is a tobacco company front. This means that most researchers won’t be able to publish any research they do with money from this foundation, and I suspect this means they won’t waste their time applying for the money. It seems likely to me that they will struggle to disburse their research funds in a way that, for example, the Bill and Melinda Gates Foundation do not. I certainly won’t be trying to get any of this group’s money.

The news of this Foundation’s establishment is not entirely bad, though. It’s existence is a big sign that the tobacco control movement is winning. PMI know that their market is collapsing and their days are numbered. Sure they can try and target emerging markets in countries like China but they know the tobacco control movement will take hold in those markets too, and they’re finding it increasingly difficult to make headway. Smoking rates are plummeting in the highest profit markets, and they’re forced to slimmer pickings in developing countries where tobacco control is growing in power rapidly. At the same time their market share is being stolen in developed countries by e-cigarettes, a market they have no control over, and as developing nations become wealthier and tobacco control strengthens e-cigarettes grow in popularity there too. They can see their days are numbered. Furthermore, the foundation is a sign that the tobacco companies’ previous united front on strategy is falling apart. After the UK high court rejected a tobacco company challenge to plain packaging laws, PMI alone decided not to join an appeal, and now PMI has established this foundation. This is a sign that the tobacco companies are starting to lose their previous powerful allegiance on strategy against the tobacco control movement. PMI admits they’ve lost, has developed iQos, and is looking to find an alternative path to the future while the other tobacco companies fight to defend their product.

But should PMI be allowed to take their path? From a public health perspective it’s a short term gain if PMI switch to being a provider of harm reducing products. But there are a bunch of Chinese technology companies offering e-cigarettes as an alternative to smoking. If we allow PMI to join that harm reduction market they will be able to escape the long term consequences of their business decisions. And should they be allowed to? I think they shouldn’t. I think the tobacco companies should be nailed to the wall for what they did. For nearly 70 years these scumbags have denied their products caused any health problems, have spent huge amounts of money on fighting any efforts to control their behavior, and have targeted children and the most vulnerable. They have spent huge amounts of money establishing a network of organizations, intellectuals and front groups that defend their work but – worse still – pollute the entire discourse of scientific and evidence based policy. The growth of global warming denialism, DDT denialism, and anti-environmentalism is connected to Big Tobacco’s efforts to undermine scientific evidence for decent public health policy in the 1980s and 1990s. These companies have done everything they can to pollute public discourse over decades, in defense of a product that we have known is poison since the 1950s. They have had a completely pernicious effect on public debate and all the while their customers have been dying. These companies should not be allowed to escape the responsibility for what they did. Sure, PMI could develop and market a heat-not-burn product or some kind of e-cigarette: but should we let them, when some perfectly innocent Chinese company could steal their market share? No, we should not. Their murderous antics over 70 years should be an albatross around their neck, dragging these companies down into ruin. They should be shackled to their product, never able to escape from it, and their senior staff should never be allowed to escape responsibility for their role in promoting and marketing this death. The Foundation for a Smoke Free World is PMI’s attempt to escape the shackles of a murderous poison that it flogged off to young and poor people remorselessly for 70 years. They should not be allowed to get away with it – they should be nailed to the wall for what they did. Noone should cooperate with this corrupt and sleazy new initiative. PMI should die as if they had been afflicted with the cancer that is their stock in trade, and they should not be allowed to worm out from under the pressure they now face. Let them suffer for the damage they did to human bodies and civil society, and do not cooperate with this sick and cynical Foundation.


Another year has passed, and a chance to review the games I played and the great things I did in them, as well as to preview what I hope to play (and GM) in the year to come. This year was a relatively quiet one in gaming, actually, possibly because business travel for me interrupted a lot of gaming opportunities and possibly also because, by the standards of the two previous years, gaming has been a little bit low key in 2017. Besides a few minor side sessions, 2017 has been about playing in one major Shadowrun campaign, and running the new Mutant system. But playing, particularly, didn’t reach the heights of the previous two years. Here’s a brief review.

Undriel: The Gaelic high fantasy that floundered

I started the year playing a series of adventures in a world called Undriel, a classic fantasy setting with a Gaelic twist, which was run using a home-brew system our GM developed based on World of Darkness. I was officially very resistant to playing in World of Darkness rules, which I have had bad experiences with and really don’t like, and flat-out barred using the standard magic rules of e.g. Vampire: The Masquerade, which I think is a terrible system. The magic system we came up with was quite flexible, however, and I liked my character quite a lot: Xenobia the unwilling necromancer, a young noblewoman who was accidentally infected with necromantic powers by a dark ritual gone wrong. I enjoyed playing her as a creepy girl aiming to do good, but the system didn’t work as I expected (WoD, natch!) and for some reason this campaign floundered after about session 5 or 6, only 2 of which I joined for reasons of travel. I think in truth that all the players carefully avoided further participation in this because we all just did not like the system, and the Gaelic twist on the fantasy world meant we had to know too much detailed mythological background to figure out what was going on. So this campaign died in the arse somewhere around April, quite stillborn but sadly not especially mourned.

Shadowrun: Continuing the New Horizon campaign with magic

After Undriel failed a different GM stepped up, to run a short and low-demand Shadowrun campaign. This was a continuation of our excellent and wonderful New Horizon campaign, a classic cyberpunk setting run in Cyberpunk (which is an awful system). The New Horizon campaign was amazing, and featured probably my all time favourite PC, The Druid (aka Drew), a rifle-toting teenage girl with psychopathic tendencies, and we were all eager to run a continuation. The New Horizon campaign ended with our characters waking a dragon and bringing on the Awakening that heralds the opening of the sixth world, and the shift from Cyberpunk to Shadowrun. So our new, 2017 campaign was set 50 years or so later, in the ruins of New Horizon, in a world of magic and assault rifles and metahumans. This Shadowrun campaign has been a lot of fun, with nine sessions completed in the second half of 2017 and a lot of tense and fun adventures featuring a fairly tight-knit and well-functioning group. My character, Jayden, is a bit boring compared to Drew but he is a highly effective melee combatant and I have really enjoyed playing a character who is competent and completely comfortable in his world, without any of the psychological baggage that made Drew and Xenobia a little bit thorny for the other PCs to be around. Shadowrun New Horizon hasn’t had as many memorable moments as the original New Horizon Campaign, even though it’s run by the same GM, but this is partly by design: After a couple of high-tension high-stakes campaigns, he consulted with us and we all agreed we wanted something more low key and traditional, just a bunch of guys and girls running in the shadows and getting by as best they can. It’s been a good chance for us to explore Shadowrun pretty much as it’s written, in a Hong Kong-type setting with our GM’s flair for exceptional settings and tense scenarios but without the demands of an over-arching story. We’ve all been enjoying it and we expect it to continue into 2018.

Mutant Year Zero: A startling new system and a fun world

For the second half of the year I have been GMing a short campaign using the Mutant: Year Zero system by The Free League. As I stated in my review of the game, I have been really stunned to find this system which is light, highly playable and extremely flexible, and has made GMing fresh again for me. It’s a simple system that really finely balances risk and reward, and seems to have been really popular with my players. On balance over the past couple of years I think the game I ran that my players enjoyed the most was Flood, a post-apocalyptic waterworld setting run in Cyberpunk where the low-tech setting made the terrible system almost bearable, and I really really wish I had known about Mutant when I ran that campaign, because I think this system would have made it even better. Instead I’m running a campaign set in post-apocalyptic London, with the PCs doing nothing more really than exploring the area around their Ark and slowly uncovering things about the ancient world and the history of the Ark. I expect this to only run for one or two more sessions, but the players all seem to have been really enjoying it and they all really love the simplicity and elegance of the system. I can’t say that the Mutant campaign has been a masterpiece of GMing on my part but it has flowed smoothly and the system has inspired me enough that I (and I think my players too) really feel like I’m there, crouched around the trashcan fire after the fall of the world, when I break out those dice.

GMing in 2018: Coriolis and a real high fantasy campaign

Our other regular GM is moving away from Japan in mid-2018 and I am hoping to be able to take over the core GM role for our group for the foreseeable future, which I am hoping will give me the opportunity to run a long, detailed campaign of the type I haven’t run for years. After Mutant finishes I intend to stick with a similar system by the same company, Coriolis, and run a short campaign in that setting until I take receipt of the Forbidden Lands RPG, which is currently in production stage. That is Free League’s attempt to merge the system used in Mutant: Year Zero with a high fantasy setting, and everything I have seen in the reports on the kickstarter suggests it is going to be an awesome high fantasy system that – for the first time in years – makes me want to GM high fantasy.  I am hoping to take that and make it our group’s primary campaign setting for at least the next year and hopefully longer, running the kind of sprawling, 1st level-to-lordship fantasy campaign that historically has only really been possible in crappy systems like D&D. My whole group have been wanting to run a high fantasy campaign but we just can’t get into any of the current systems, and Forbidden Lands offers the real possibility of a setting and a system that finally work. So having played Coriolis to adapt to a richer version of the Mutant: Year Zero system, we will switch over to a full fantasy setting and get to grips with the kind of fantasy role-playing we’ve all been yearning for for years.

That’s my 2018 Big Plan!

Playing in 2018: Muskets and Magic

I have joined a second group which is running a GURPS-based muskets and magic setting. I haven’t started playing with them yet but I’m hoping it will prove to be an excellent addition to my gaming in the new year. I haven’t played GURPS before, it looks complex and fiddly but viable, but the setting will be very similar to the Compromise and Conceit setting I was GMing when I first started this blog. I’m hoping that will provide not just a refreshing setting and a chance to play in a world I only ever GMd in the past, but also a chance to meet new players, new GMing styles, and new ideas. Hopefully this will mean that 2018 brings with it a whole bunch of fresh new game worlds and experiences.

Real life in 2018: Less business, more exercise

I have been making adjustments to my work life in 2017, including scoring some big successes, and I am hoping that in 2018 I will do less business travel, spend more time in my home, and have more time for both gaming and blogging. This blog has taken some hits in 2017, with posting dropping down to fortnightly or even monthly at times, and I have been less enthusiastic about it at times than I would like. Next year will be 10 years since I started the blog, which has held together over that whole time, and I’m hoping that in 2018 I will be able to pick up the posting a bit and get back to where it was at a few years ago. I have also discovered a much better kickboxing gym in 2017, where I am slowly recovering my love of kickboxing, and I’m hoping that in 2018 I will be exercising more and regaining the fitness that drained away slowly over the past few years. So overall in 2018 I’m hoping for less exotic destinations in the real world, and more exotic destinations in my imaginary life – which is way more interesting, anyway, than traveling for work.

I hope you, my reader(s), who have patiently stuck by this blog over these past few years, will get to see more gaming reports and more interesting worlds in 2018, posted more regularly, and hopefully follow my players as they grow from first level adventurers to mighty heroes, in a fantasy world worth adventuring in. And I hope you too get to enjoy a rich and varied imaginary world in 2018, with large dice pools and mighty deeds. Bring it on!

UPDATE: Dr. Monnat has left a comment pointing out that I made a major error in reading her methods (I assumed she used non-standardized rates but in the methods she specifies that she did). So I have removed one criticism of her paper and modified another about regression. This doesn’t change the thrust of my argument (though if Dr. Monnat is patient enough to engage with more of my criticisms, maybe it will!)

Since late 2016 a theory has been circulating that Donald Trump’s election victory can be related to the opioid epidemic in rust belt America. Under this theory, parts of mid-West America with high levels of unemployment and economic dislocation that are experiencing high levels of opioid addiction switched votes from Democrat to Republican and elected Trump. This is part of a broader idea that America is suffering an epidemic of “deaths of despair” – deaths due to opioids, suicide and alcohol abuse – that are part of a newfound social problem primarily afflicting working class white people, and the recent rapid growth in the rate of these “deaths of despair” drove a rebellion against the Democrats, and towards Trump.

This theory is bullshit, for a lot of reasons, and in this post I want to talk about why. To be clear, it’s not just a bit wrong: it’s wrong in all of its particulars. The data doesn’t support the idea of a growing death rate amongst white working class people; the data does not support a link between “deaths of despair” and Trump voting; there is no such thing as a “death of despair”; and there is no viable explanation for why an epidemic of “deaths of despair” should drive votes for Trump. The theory is attractive to a certain kind of theorist because it enables them to pretend that the Trump phenomenon doesn’t represent a deep problem of racism in American society, but it doesn’t work. Let’s look at why.

The myth of rising white mortality

First let’s consider the central framework of this story, which is the idea that mortality rates have been rising rapidly among middle-aged whites in America over the past 20 years, popularized by two economists (Case and Deaton) in a paper in PNAS. This paper is deeply flawed because it does not adjust for age, which has been increasing rapidly among white Americans but not non-white Americans (due to differential birth and migration patterns in earlier eras). Case and Deaton studied mortality in 45-54 year old Americans, differentiating by race, but failed to adjust for age. This is important for surprising reasons, which perhaps only epidemiologists understand, and we’re only figuring this out recently and slowly: ageing is happening so fast in high-income countries that even when we look at relatively narrow age categories we need to take into account the possibility that the older parts of the age category have a lot more people than the younger parts, and this means that even the small differences in mortality between say 53 year olds and 45 year olds can make a difference to mortality rates in the age category as a whole. If this seems shocking, consider the case of Japan, where ageing is so advanced that even five year age categories (the finest band of age that most statistical organizations will present publicly) are vulnerable to differences in the population. In Japan, the difference in the size of the 84 year old population to the 80 year old population is so great that we may need to adjust for age even when looking at narrow age categories like 80-84 years. This problem is a new challenge for epidemiologists – we used to assume that if you reduce an analysis to a 10 or 15 year age category you don’t need to standardize, because the population within such a band is relatively stable, but this is no longer true.

In the case of the Case and Deaton study the effect of ageing in non-hispanic white populations is so great that failure to adjust for it completely biases their results. Andrew Gelman describes the problem  on his blog and presents age-adjusted data and data for individual years of age, showing fairly convincingly that the entire driver of the “problem” identified by Case and Deaton is age, not ill health. After adjustment it does appear that some categories of white women are seeing an increasing mortality rate, but this is a) likely due to the recent growth of smoking in this population and b) not a likely explanation for Trump’s success, since he was more popular with men than women.

White people are dying more in America because they’re getting older, not because they have a problem. I happen to think that getting older is a problem, but it’s not a problem that Trump or anyone else can fix.

The myth of “deaths of despair” and Trump voting

Case and Deaton followed up their paper on white mortality with further research on “deaths of despair” – deaths due to opioid abuse, suicide and alcohol use that are supposedly due to “despair”. This paper is a better, more exhaustive analysis of the problem but it is vulnerable to a lot of basic epidemiological errors, and the overall theory is ignorant of basic principles in drug and alcohol theory and suicide research. This new research does not properly adjust for age in narrow age groups, and it does not take into account socioeconomic influences on mortality due to these conditions. But on this topic Case and Deaton are not the main offenders – they did not posit a link between “deaths of despair” and Trump voting, which was added by a researcher called Shannon Monnat at Pennsylvania State University in late 2016. In her paper, Monnat argues for a direct link between rates of “deaths of despair” and voting for Trump at the county level, suggesting that voting for Trump was somehow a response to the specific pressures affecting white Americans. There are huge flaws in this paper, which I list here, approximately in their order of importance.

  • It includes suicide: Obviously a county with high suicide mortality is in a horrible situation, which should be dealt with, but there is a big problem with using suicide as a predictor of Trump voting. This problem is guns. Uniquely among rich countries, the US has a very high prevalence of gun ownership and guns account for a much larger proportion of suicides in America than elsewhere – more than half, according to reputable studies. And unfortunately for rural Americans, the single biggest determinant of whether you commit suicide by gun is owning a gun – and gun ownership rates are much higher in counties that vote Republican. In America suicide is a proxy for gun ownership, not “despair”, and because gun-related suicide depends heavily on rates of gun ownership, inclusion of this mortality rate in the study heavily biases the total mortality rate being used towards a measure of gun ownership rather than despair.
  • It uses voting changes rather than voting odds: Like most studies of voting rates, Monnat compared the percentage voting for Trump with the percentage voting for Romney in 2012. This is a big flaw, because percentages do not vary evenly across their range. In Monnat’s study a county that increased its Republican voting proportion from 1% to 2% is treated exactly the same as a county that went from 50% to 51%. In one of these counties the vote doubled and Trump didn’t get elected; in the other it increased by 2% but Trump got elected. It’s important to account for this non linearity in analysis, but Monnat did not. Which leads to another problem …
  • It did not measure Trump’s success directly: In a first past the post electoral system, who wins is more important than by how much. Monnat used an ordinary least squares model of proportions voting Trump rather than a binomial model of Trump winning or losing, which means that meaningless small gains in “blue” states[1] had the same importance as small gains in “red” states that flipped them “blue”. This might not be important except that we know Trump lost the popular vote (which differences in proportions measure) but won the electoral college (which more closely resembles binary measures of win/lose). Not analyzing binary outcomes in a binomial model suggests you don’t understand the relationship between statistics and the political system you live in, i.e. your analysis is wrong.
  • It did not incorporate turnout: A 52% win for Trump can reflect two things – a change in attitude by 2% of the voters, or a non-proportionate increase in the number of people who chose to turn out and vote. If you analyze proportions (or differences in proportions) you don’t account for this problem. In addition, you don’t adjust for the overall size of the electorate. If you analyze proportions, an electorate where 52 people voted Trump and 48 people voted Clinton is given the same weight as an electorate where 5200 people voted Clinton and 4800 people voted Trump. If you use a proper binomial model, however, the latter electorate gets more weight and is implicitly treated as more meaningful in the assessment of results. A reminder of what is fast becoming a faustusnotes rule: the cool kids do not use ordinary least squares regression to analyze probabilities, we always use logistic regression.
  • It did not present the regression results: Although Monnat reports regression results in a footnote, the main results in the text are all unadjusted, even though in at least some states the impact of economic factors appears to eliminate the relationship with mortality rates. Given that people who own guns are much much more likely to vote Republican, and the main predictor variable here incorporated suicide, adjustment for gun ownership might have eliminated the effect of “deaths of despair” entirely. But it wasn’t done as far as I can tell, and wasn’t shown.
  • It did not adjust for trends: Monnat openly states in the beginning of the paper that “deaths of despair” have been rising over time but when she conducts the analysis she uses the average rate for the period 2006-2014. This means that she does not consider the possibility that mortality has been dropping in some counties and rising in others. A mortality rate of 100 per 100,000 could reflect a decline over the period 2006-2014 from 150 to 50 (a huge decrease) or an increase from 25 to 175. We don’t know, but it seems likely that if “deaths of despair” is an issue, it will have had more influence on electoral decisions in 2016 in counties where the rate has risen over that time than where it has declined. There are lots of policy reasons why the death rate might have increased or decreased, but whether these reflect issues relevant to Republican or Democrat policy is impossible to know without seeing the distribution of trends – which Monnat did not analyze[2].

So in summary the study that found this “relationship” between “deaths of despair” and voting Trump was deeply flawed. There is no such relationship in the data[3].

There is no such thing as a “death of despair”

This study has got a fair bit of attention on the internet, as have the prior Case and Deaton studies. For example here we see a Medium report on the “Oxy electorate” that repeats all these sour talking points, and in this blog post some dude who fancies himself a spokesperson for ordinary America talks up the same issue. The latter blog post has some comments by people taking oxycontin for pain relief, who make some important points that the “deaths of despair” crew have overlooked. To quote one commenter[4]:

I too am a long time chronic pain sufferer and until I was put on opiate medications my quality of life was ZERO. I’ve heard horror stories of people actually being suicidal because they can no longer deal with the constant pain. It took me two years before I realized I could no longer work as an account manager with a major telecom company. I was making decent money but leaving work everyday in pain. I finally started going to a pain management doctor who diagnosed me with degenerative disc disease. I had to go on medical leave and now am on SSDI. My doctor prescribed me opiates in the fall of 2006 and I’ve been on them ever since. I have to say, I totally AGREE with you. I don’t know how I would be able to manage without these medications. At least I’m able to clean my house now and now without being in horrible pain. I don’t know what I would do if suddenly I was told I could no longer be prescribed opiates.
Who is someone that will champion those of us who legitametly need these medications? Do we write to our senators?? I sure hope Trump takes into consideration our cases before kicking us all to the curb!

This person (and others) make the valid point that they are taking pain medication for a reason, and that they were in despair before they got hooked on opioids, not after. Unfortunately for these commenters, we now have fairly good evidence that opioids are not the best treatment for chronic pain and that they are very, very dangerous, but regardless of whether this treatment is exactly the best one for these patients they make the valid point that it is the treatment they got and it works for them. To use an Americanism, you can take the opioids from their cold dead hands. In stark contrast to other countries, a very large proportion of America’s opioid deaths are due to prescription drugs, not heroin, reflecting an epidemic of overdose due to legally accessible painkillers. It’s my suspicion that these painkillers were prescribed to people like the above commenter because they could not afford the treatment for the underlying cause of their pain, because America’s healthcare system sucks, and these people then became addicted to a very dangerous substance – but in the absence of proper health insurance these people cannot get the specialist opioid management they deserve. America’s opioid epidemic is a consequence of poor health system access, not “despair”, and if Americans had the same health system as, say, Frenchies or Britons they would not be taking these drugs for more than 6 months, because the underlying cause of their condition would have been treated – and for that small minority of pain patients with chronic pain, in any other rich country they would have regular affordable access to a specialist who could calibrate their dose and manage their risks.

The opioid death problem in America is a problem of access to healthcare, which should have been fixed by Obamacare. Which brings us to the last issue …

There is no theory linking opioid addiction to voting Trump

What exactly is the theory by which people hooked on oxycontin are more likely to vote Trump? On its face there are only two realistic explanations for this theory: 1) the areas where oxycontin is a huge problem are facing social devastation with no solution in sight, so vote for change (even Trump!) in hopes of a solution; or 2) people who use drugs are arseholes and losers. Putting aside the obvious ecological fallacy in Monnat’s study (it could be that everyone in the area who votes for Trump is a non-opiate user, and they voted Trump in hopes of getting the druggies killed Duterte-style, but the data doesn’t tell us who voted Trump, just what proportion of each area did), there are big problems with these two explanations even at the individual level. Let’s deal with each in turn.

If areas facing social devastation due to oxycontin are more likely to vote Trump, why didn’t they also vote Romney? Some of these areas were stronger Obama voters in 2012, according to Monnat’s data, but opioid use has been skyrocketing in these areas since 2006 (remember Monnat used averages from 2006-2014). The mortality data covers two election cycles where they voted Obama even though opioid deaths were rising, and suddenly they voted Trump? Why now? Why Trump and not Romney, or McCain? It’s as if there is something else about Trump …

Of course it’s possible that oxycontin users are racist arseholes – I have certainly seen this in my time working in clinics providing healthcare to injecting drug users – but even if we accept such a bleak view of drug users (and it’s not true!) the problem with this theory is that even as opioid use increases, it remains a tiny proportion of the total population of these areas. The opioid users directly cannot swing the election – it has to be their neighbours, friends and family. Now it’s possible that a high prevalence of opioid use and suicide drives people seeing this phenomenon to vote Trump but this is a strange outcome – in general people vote for Democrats/Labour in times of social catastrophe, which is why they voted Obama to start with – because he promised to fix the financial crisis and health care. There has to be some other explanation for why non-opioid using people switched vote in droves to Trump but not Romney. I wonder what it could be?

American liberals’ desperate desire to believe their country is not deeply racist

The problem is, of course, that Trump had a single distinguishing feature that no one before him in the GOP had – he was uniquely, floridly racist. Since the election this has become abundantly clear, but for Donnat writing in late 2016 I guess it still seemed vaguely plausibly deniable. But the reality is that his single distinction from all other GOP candidates was his florid racism. Lots of people in America want to believe that the country they live in – the country that just 150 years ago went to war over slavery, and just 50 years ago had explicit laws to drive black people out of the economic life of the nation – is not racist. I have even recently seen news reports that America is “losing its leadership in the movement for racial equality.” No, dudes, you never showed any leadership on that front. America is a deeply racist nation. It’s racist in a way that other countries can’t even begin to understand. The reason Trump won is that he energized a racist base, and the reason his approval remains greater than 30% despite the shitshow he is presiding over is that a large number of Americans are out-and-out fascists, for whom trolling “liberals” and crushing non-whites is a good thing. That’s why rural, gun-owning Americans voted for Trump, and if the data were analyzed properly that fact would be very clear. Lots of people in America want to believe second- or third-order causes like the rustbelt or opioids, but the reality is staring them in the face: it’s racism. Don’t blame people with chronic pain, blame people with chronic racism. And fix it, before the entire world has to pay for the vainglorious passions of a narrow swathe of white America.

fn1: I refuse to take the American use of “blue” and “red” seriously – they get scare quotes until they decide that Republicans are blue and Democrats are red. Sorry, but you guys need to sort your shit out. Get proper political colours and get rid of American Football, then you’ll be taken seriously on the world stage. Also learn to spell color with a “u”.

fn2: I’m joshing you here. Everyone knows that Republicans don’t give a flying fuck if an electorate is dying of opioid overdoses at a skyrocketing rate, and everyone knows that the idea that Republicans would offer people dying of “deaths of despair” any policy solutions to their problem except “be born rich” is a hilarious joke. The only possible policy intervention that could have helped counties seeing an increasing opioid death rate was Obamacare’s Medicaid expansion, and we know republicans rejected that in states they controlled because they’re evil.

fn3: Well, there might be, but no one has shown it with a robust method.

fn4: I’m such a cynic about everything American that I really hope this commenter isn’t a drug company plant…

I curate my Facebook feed very carefully so that it contains only nice things. It’s possible that my Facebook feed is the only one remaining on planet earth that still regularly gets cute cat videos in it. I prune my content regularly, and in particular I make sure that I hide or defriend people who regularly clog my wall with nastiness, internecine spats, or heavy quantities of political material (of any persuasion). One of my key considerations for whether to hide/defriend is whether the content a friend puts up regularly shocks me or creates a sudden feeling of discomfort when I see it. I guess, if it triggers me. Usually this is things like people putting up political material that features torture or animal cruelty, people who spam my feed with inspirational pictures, and people who regularly say or upload things that heap scorn on others. By ferociously following this principle, I manage to make sure that my Facebook is a world of happiness and light. But sometimes things still slip through that shock me or make me uncomfortable, and one regular occasional event on my Facebook feed is one of my female friends approvingly posting a Celeste Barber picture.

If you aren’t familiar with Celeste Barber’s work you can read about it in this Guardian profile, and you can see some more pictures here. Basically, she’s a frumpy 30-something (?) woman who takes “real-life” versions of models’ PR pictures and posts them alongside the original pictures on Instagram. For example, a model might take a carefully posed shot of herself “falling” out of bed, and Celeste will take an equivalent shot intended to show her “ordinary” equivalent of this posed shot. Some of these are cute, like the one where she mimics a model sitting in her underwear holding grapes, but Celeste is holding a wine bottle – this makes a nice juxtaposition between the perfect and the everyday. Others rightly take the piss out of some of the extremely silly poses that these Instagram models take (the model falling out of bed, for example). But a lot of them just seem to be making fun of these models simply for making a living by being models, or in some way mocking them for being prettier and more posed than real women.

It’s not clear to me what Barber is actually trying to achieve with these pictures. For example, when she takes a picture of herself in a wet t-shirt and juxtaposes it with a picture of a model in a wet t-shirt, what is she trying to say? Sure, her picture looks slightly silly and stupid and reminds us that standing around in wet t-shirts looking sultry is not what women normally do during their day. But the point of a model’s Instagram feed is that it is not normal – that they are presenting an image of perfection and of things outside the everyday, that we admire and look up to. The point of models is that they don’t look like us, and the idea of a model’s Instagram feed is to showcase her beauty and the best photographs depicting it. Most model’s Instagram feeds are feeds of professional shots, that they may have taken a long time setting up and preparing for – this is why they’re models. If the point of Barber’s photos is to show that models take posed photos that aren’t natural, it’s kind of vapid. We all know that.

But I don’t think this is the point of Barber’s project. I think she aims to mock the standards of beauty that these models represent and embody, more than the silly poses they are adopting. This is why actually many of her photos are piss-takes of relatively unposed pictures of models – that is, the model’s picture is obviously from a photoshoot, but she’s not doing anything super weird or super silly, she’s just being pretty in a picture. Some (like the Zayn Malik lover shot or the doorway yoga thing) could be construed as making fun of the extreme lengths that people go to get a good shot on Instagram[1], but many can only be interpreted as mocking the models themselves. They attempt to show that the models are doing something wrong by contrasting them with what an ordinary person looks like in the same position. She herself says

I get a little miffed with fashionista people thinking that they are much better than other people because they are very slim and have architect husbands and get to wear free stuff

But is this all she’s doing, popping the bubbles of these “fashionista people”? I think this statement artificially conflates being beautiful with being better, which models and fashion people don’t necessarily agree with (I’m friends with one or two models who don’t think like this at all, though I’m friends with one who probably does). She also says she’s campaigning against how the media presents images of women. But is this what she’s doing? Because what she appears to actually be campaigning against is how models present images of models. Is she saying that she herself should be considered as beautiful as these women? If so, how come she uses her photos of herself to mock these women?

I think what Celeste Barber is actually trying to say here is that feminine beauty – or the aspiration to feminine beauty – is wrong, and that it is not possible for ordinary people to be feminine and beautiful. I think she is mocking the ideal of femininity itself. This is why her photos only target female models – she doesn’t, for example, take aim at the ludicrous poses male underwear models carefully adopt, or at the over the top presentation of masculinity and machismo in many male sports and film stars. She isn’t alone in this – our society has a strong undercurrent of scorn for femininity and feminine beauty, presenting it as something that can’t be trusted, a mask or veil over who a woman really is. I think Barber is expressing this undercurrent of hatred. She’s saying that real women, in the privacy of their own homes, in their underwear, are not feminine at all, that femininity is just a mask they pull on to impress others, and that it’s not real or valid, and these models’ instagram feeds full of perfect images of femininity need to be torn down in this way because femininity itself is a problem. If she were trying to present a model of accessible feminine beauty she wouldn’t be mocking these feeds, but trying to reinterpret them in some more viable way. But she’s not – she’s laughing at them.

I think this is an example of how some feminists have internalized a deeply misogynistic undercurrent in our society. There is a valid critique to be made of unrealistic representations of and expectations of women and women’s beauty, but this critique doesn’t have to throw femininity and feminine beauty out entirely. But this is what people like Barber do. This is why she doesn’t mock firemen’s nude calendars, or bodybuilder’s poses, which are just as ludicrously set up and unrealistic. These are okay, because masculinity and masculine beauty is considered to be healthy and real in our society. This is why we have a special qualifier for masculinity that has gone off the rails (“toxic masculinity”) but “feminine” is itself the special qualifier for ordinary social practices gone wrong (“feminine wiles”). Femininity is seen as an entirely negative thing, which if it is a deep-seated part of a woman’s character is purely a flaw – weak, diffident, vain and shallow – while if it is surface deep, is deceptive and untrustworthy. There is no model of femininity in mainstream society that is considered to be healthy, acceptable and good for a woman to adopt. We don’t talk about “toxic” femininity, because our society sees all femininity as poisonous. This is why feminists will share Barber’s mocking pictures on Facebook – because they think they’re saying something real about the way the media depicts women, when actually what they’re doing is channeling an age-old hatred of how women present themselves and who women really are.

Obviously someone like Barber isn’t going to have much effect on the adult feminists who share her pictures on my feed. But I wonder what impact this kind of material has on young women and girls growing up in our increasingly macho and competitive society. They’re told from all sides that being feminine is wrong, and presented with a world where the only valid form of beauty is masculine beauty, preferably achieved as a by-product of some serious activity (like sports, or soldiering, or firefighting), that beauty as an end in itself is wrong and that feminine beauty is bad for them and femininity is bad. But many women and girls want to be feminine and want to express their femininity through the kind of models of beauty that we see in these Instagram feeds (this is why these feeds are so popular – they aren’t getting all those followers from men). Then their feminist role models – the women who tell them it’s okay to want to work, that you can be anything you want to be, that no one can stop a girl chasing her dreams – put up pictures telling them that any aspiration to feminine beauty or any kind of construction of beauty at all (posing, make up, dream images) is wrong, and sexist. I think this must be hard on young women and I think that feminists watching Barber and reading this kind of thing need to consider the impact they’re having on young women and what space of beauty they leave open for young women to explore. I think that feminists should also consider whether their reaction to models of feminine beauty is first and foremost about whether they’re bad for women, or whether it’s a kneejerk, visceral response in a misogynist christian culture to the very concept of femininity itself. And is this a good thing?

I’ve been in Asia for 11 years now and one thing I have noticed since I left the Christian world and moved to a pagan country is that Asians have different expectations and views of both masculinity and femininity. In particular, they have no cultural attachment to the story of the fall, of the deceptive serpent and the woman who lures the man into sexual knowledge. As a result both masculine and feminine appearance and manners are seen as a much more natural and uncomplicated part of who humans are, and in my experience people in Asia have a much more comfortable relationship with women’s beauty and feminine behavior. I think this is something western people could learn from, and I think in particular western feminism could learn that instead of rejecting femininity and feminine beauty and reacting against it as a terrible expression of female repression, it should be seen as a natural part of who women are, and just as valid a form of expression of gender difference as anything else. It’s clear that many women in the west want to be like the models they idealize, but they grow up in a world where they’re told in no uncertain terms that they’re wrong, shallow, or even self-hating to feel this way. But these women’s desires and ideals are not a construction – they’re a real and deep part of who these women are. The kind of mocking that Barber is performing, and the general social acceptance it has in the west, does not help young women to grow up into a stronger model of beauty and better gender relations. It just puts them down. Western feminism needs a better relationship with female beauty if it wants to reform this aspect of gender relations in a way that ordinary women are actually comfortable with, and western feminism needs a more critical understanding of its own assumptions and the role of Christian misogyny in constructing modern feminist attitudes, if it really wants to make a better world for western women. Which could start with not mocking girls who want to be pretty!

fn1: Which, btw, what’s wrong with this and what is up with the constant negative carping about how “fake” Instagram is. Instagram is a site exclusively for sharing photographs. Why would you not go to great lengths to take a good photograph for Instagram?

Who doesn’t want to be this guy?!

Trigger warning: Long rant; gender and racial theory; I may use the qualifier “cis-” in a non-ironic way[1]; Since saying “male genitalia” or “female genitalia” is apparently bad, I may use the words “cunt” and “cock” to refer to the things they refer to; Aussie pride; excessive footnotes[2]; dead naming of dead dudes[3]; anti-Americanism; as always, sex positivity, along with a healthy dose of trans positivity (I hope, though maybe 800 people will judge me a bastard) and my usual disdain for radical feminism; insufficient or excessive trigger warnings

TLDR: WTF is going on with feminist philosophy?! Also, if you think that transgender people are serious and real and should be given full rights and respect, you probably also need to accept that transracialism is cool; but unless you’re American you probably already did, without even thinking that it was A Thing.

I just discovered a horrific conflagration overtaking the world of feminist philosophy, which has got me thinking about a concept that I didn’t even really know existed, but which is apparently A Thing: Transracialism. Transracialism is the practice of people of one race adopting the identity of another and living that identity even if they hadn’t been born into or raised with that identity, so superficially it has this transition process in common with being transgender. I’ve obviously been out of touch with left wing radical social ideals for a while, because I didn’t know that transracialism was A Thing, and that it is Bad while being transgender[4] is Good. In this post I want to talk about transracialism and the stultifying consequence of Americans hogging the debate about sex and race, and also about the disastrous state of modern leftist discourse[5] about so many things.

The controversy concerns an interesting paper in the philosophy journal Hypatia, discussing some of the logical consequences of accepting transgender as a real and serious issue[6]. The article, In Defense of Transracialism, examined the similarities between transitioning to a new gender and transitioning to a new race, and argued that logically if you accept one you really run onto rocky ground if you don’t accept the other. For case studies (and not, apparently, as the fundamental logical basis of the argument) the paper presented the case of Caitlyn Jenner as a transgender, and Rachel Dolezal as a transracial person (“transracer”?) As we know, Jenner got widespread public acceptance for her decision, while Dolezal received widespread public scorn. The article argues in what, to me at least, appears to be a quite tightly reasoned and accessible style, that it’s hard logically to accept one and reject the other, and maybe that means transracialism is actually okay.

The paper was published in March but recently a bunch of Associate Editors connected to the journal published an open letter demanding that the paper be retracted because its publication caused many “harms” to transgender people, and because it was academically poor. The outline of the case, and a solid takedown of the public letter, can be read at this New York Magazine post. It should be noted that the author of the paper is a non-tenured Assistant Professor, a woman, who is therefore quite vulnerable in a highly competitive field dominated by men, and that some of the signatories to the open letter were on the author’s dissertation assessment committee, which makes their signing the letter an extremely vicious act of treachery, from an academic standpoint. For more background on the viciousness of the letter and its implications for the author’s career and for the concept of academic freedom, see Leiter Reports, a well known philosophy blog (e.g. here) or the Daily Nous (e.g. here). It appears that the author has a strong case for defamation, and that many of the leading lights of feminist philosophy have really made themselves look very bad in this affair. (In case you haven’t gathered, I am fully supportive of the author’s right to publish this article and I think the open letter, demand for retraction, and pile-on by senior academics to an Assistant Professor near the beginning of her career is a vicious over-reaction of which they should all be deeply ashamed).

Beyond the obvious bullying and the ridiculous grandstanding and academic dishonesty involved in this attack on the author[7], I am disappointed in this whole issue because it is such a clear example of how Americans can dominate feminist (and broader social justice) debate in a really toxic way. I’ve discussed this before in regards to the issue of sex work and radical feminism, and I think it needs to be said again and again: American influence on left wing social debates is toxic, and needs to be contained. Just look at the list of signatories to this attack on this junior academic – they’re almost all American, and this is yet another example of how America’s conservatism, it’s religious puritanism, its lust for power, and its distorted republican politics, combined with its huge cultural output, is a negative influence on left wing politics globally.

I’m also really interested in this paper because I think it shows not just that transracialism may actually be an okay idea, but when I thought about the implications, I realized that I think most people on the planet already accept transracialism, and if Rachel Dolezal had occurred in any other country we would probably just have shrugged and got on with our lives. So in this post I’d like to discuss what Americans can learn from other countries’ approach to race.

Transracialism in Australia

Just to clarify, I was born in New Zealand to British parents and moved to Australia aged 13, taking Australian citizenship when I was 21. My grandfather was a Spanish war hero, a proud soldier in the losing side of the civil war and a man who spent nine years fighting fascism, and I was raised by him and my (deeply racist, white) British grandmother for two years as a child. So actually I’m a quarter Spanish, and so in theory I could have been raised Spanish but wasn’t, and don’t know anything about my birth race, which at various times in history has been defined as a separate race or just a culture. This makes me probably really normal in Australia, because Australia is a nation of immigrants making a new life in a land swept clean by genocide. It’s my guess that if you grew up in Australia you know a lot of mixed-race people, and if you paid any attention to the discussion of the Stolen Generations in the 2000s you’re aware that race is a very contested and contestable concept, and that Australian government policy has always assumed that race is a mutable concept subsidiary to culture. I think it’s likely that if you grew up in Australia you will know at least one of the following stereotypes:

  • An Aboriginal person who doesn’t “look” Aboriginal, and who maybe has no connection to their Aboriginal culture; you may even not be sure if they are Aboriginal, suspect they are but don’t know how to ask
  • A young Asian Australian who looks completely Asian, acts in ways that are stereotypically associated with Asian Australians (e.g. the guy holds his girlfriends bag for her, the girl is a complete flake in a very Asian Australian way) but is in every other way completely and utterly unconnected from their Asian heritage and is thoroughly through-and-through “whitebread” Australian
  • A completely Australian guy who speaks fluent Greek and goes back to Greece to “be with his family” every year
  • A person who has discovered that they have an ethnic heritage of some kind and is trying to recover that heritage in some way that might inform them about their own past, even though they are effectively completely disconnected from it, but they are clearly serious about rediscovering their heritage and all their friends and family support this apparent madness
  • A black or dark-skinned Australian who literally knows nothing about the culture of whatever race gave them their skin colour

If you’re a little older, like me, or know a wide range of older Australians, you may also have encountered an Aboriginal Australian who was stolen from their family at an early age and raised white but is on a bittersweet quest to recover the heritage they never had – and may have found that that heritage was extinguished before they could be led back to it. When I was 20 I was paid to provide maths tutoring to a bunch of 50-something women who were training to be Aboriginal Teaching Assistants – a kind of auxiliary teacher who will assist fully qualified teachers in remote Aboriginal communities – and some of them couldn’t even do fractions. When I asked how they missed such an early stage of education they told me they were taken to “the mission” when they were young, and didn’t get a proper education. I was young and this kind of issue wasn’t discussed then but now I understand that they were from the Stolen Generation, and were at various stages of understanding of their own racial heritage. They were going back to help their community, and recovering their own heritage, not just to settle the question of their own background but also to right wrongs done and change society[8]. These kinds of people are a normal thing in Australian cultural life. But can you look at that list of archetypes and say they aren’t all in their own way transracial? Indeed the underlying philosophy of the Stolen Generations was that you can eliminate racial traits of Aboriginality in half-Aboriginal people simply by raising them white; and the underlying principle of Multiculturalism is that culture transcends race, and we can all get along. Also in Australia there is a lot of tacit recognition of the problems second and third generation migrant children go through as they “transition” from the cultural heritage of their parents to that of their born country, where although racially they’re distinct from the majority they are clearly culturally more similar to the majority than to their parents. In the 1990s this was happening with Greek and Italian kids, in the 2000s with Vietnamese kids, and in the 2010s with Lebanese kids. Everyone in Australia knows that this happens, which surely means that everyone in Australia sees transracialism as a common pattern of multiculturalism.

Since I’ve moved to Japan I’ve seen this confirmed in many ways, but the best I can think of is a child I knew in a rural country town. His parents were both white New Zealanders but he had been brought to Japan at the age of 3 and raised in rural Japan, and when I met him at 17 he was thoroughly and completely Japanese. He didn’t speak English, communicating with his parents in a mixture of Japanese, really really bad English, and typical adolescent boy grunts. He hadn’t experienced much racism in Japan and had been sheltered in a very nice and welcoming rural environment, had a good group of close Japanese friends, communicated in the (ridiculously incomprehensible) local dialect, and was a typical cloistered Japanese boy. But he was also a big, white lump in his Japanese world, standing out like dogs balls. His race was irrelevant to his cultural background, except that he knew he was “white” and that therefore every Japanese person who ever meets him will engage in a boring conversation about why he is so. Fucking. Japanese. How is this not transracialism? Sure, a lot of transracial experience is not a choice per se, but whether it is a choice is surely irrelevant to the fact that it is completely possible and that for some of us – probably only a small proportion – changing “race” is a choice we feel compelled to make. I.e. not a choice. Rachel Dolezal might be a bad example, but whatever her motives might be, is her ability to do it under question? I would suggest that from an average Australian perspective, it is a completely ordinary concept. The only thing at issue is “why?” But since most well-meaning people don’t impugn the motives of strangers, who gives a fuck?

Race is a social construct

The possibility of transracialism becomes even clearer when you recognize that race is a social construct. This doesn’t mean race doesn’t exist – it clearly does – but that it is an invention of humanity structured around clear physical lines, not a real thing. While there is a clear difference between black and white people, there is no boundary at which this difference can be defined, and no genetic markers that clearly distinguish between one and the other. This isn’t some weird fringe idea popular only amongst Black Panthers, but a fundamental plank of modern science, reasonably well accepted at least in the biological sciences and anthropology. When we talk about races what we really are referring to is distinct cultural identities that can be mostly distinguished by noticeable visual cues (e.g. Nigerians are black, and stress the first syllable of every word in a cool way). This also means that race has very little influence on the culture you can actually adopt, which is why although I’m a quarter Spanish I’m completely white, while there are Aboriginal or Maori people who are one quarter Aboriginal but completely wedded to the culture of that quarter.

In comparison, sex is an absolute category that is definable and distinct. It has a chromosomal origin, and multiple definable, distinct characteristics. It is also clear across cultures that men and women tend to be different in many physical and personality characteristics, though these aren’t always the same in every culture and there can be lots of differences between people of a single sex between and within cultures. But sex is a clear, binary concept that, for all its massive cultural baggage, is not independent of its biological underpinnings. This, by the way, is not an idea anathematic to feminism – lots of feminists accept that the sexes are fundamentally different, and although there may be argument about to what extent these differences are biological vs. cultural, there is a large body of feminist work that assumes these differences are real and important.

And yet still people can want to change sex. Really want to change sex! And this phenomenon is common across almost every culture, though it receives higher levels of acceptance in some cultures (e.g. some Asian and Indigenous cultures) than others (e.g. modern USA). It’s also clear that you can’t force someone to change sex the way you can race. You might be able to “breed out the colour” of “half-caste” Aboriginal people by stealing them from their parents and raising them in a white family, but you can’t breed out the pink by forcing a girl to grow up as a boy – she’ll still know that she’s a girl. The same is true of sexuality of course – most people can define their sexuality clearly by the gender of the people they fuck, but we have no evidence that you can change that, no matter how hard you try. We know in fact that down that road lies tragedy. And so most of us take people’s sexuality – and the right to express it freely – very seriously. Yet most of us also accept that the right to change sex, to express a desire to be the opposite sex to our birth sex or even to be a third sex, very seriously as well.

So why not race? It’s way more fluid than gender, it has no biological basis, and we have huge amounts of evidence that people do it by accident all the time. Yet when Rachel Dolezal was outed as white she attracted general derision across the political spectrum; and Trump trades on the Pocahontas slur for Elizabeth Warren, whose sole crime apparently is to have been raised thinking she might have Native American heritage. There’s clearly something wrong with this picture, especially if like me you grew up in a race-fluid environment. Why is it so wrong to be transracial?

The toxic American influence on sex and race debates

Of course in America race is not a simple issue, because of slavery. America has a complex, toxic and quite unique racial environment which makes it very hard for Americans to react reasonably to these debates. Just consider the “politically correct” term for black Americans – African American. How is this not a transracial identity? Africa is neither a country, nor a culture, nor a race. Being “African American” is a completely concocted identity, a race that didn’t exist until the 1970s and the advent of pan-Africanism. Nothing wrong with that per se, obviously, but it leads to strange contortions in which, for example, the previous president[9] was dismissed as not “African American” enough by some of his critics even though his dad was Kenyan. We also see unedifying moments like this, where we discover that one of Dolezal’s trenchant critics was raised in a white household from the age of 2, and has clearly made a conscious choice to be black – but rejects Dolezal’s choice on clearly spurious racial grounds.

I think the problem here is simply that Americans need to come to terms with their own racist history, and simultaneously with their role as centre of empire and cultural hegemon. It’s not just that white Americans are beneficiaries of a long history of slavery, or that a sizable portion of white Americans can’t even yet accept that slavery was really wrong, or that treason in defense of slavery was really bad. It’s also the case that black Americans are simultaneously deprived in their own country but hyper-privileged globally, benefiting from many of the profits of empire just as their white compatriots do. This is why, for example, in response to the water poisoning crisis in Flint, Michigan we heard so much about how this was happening “even in a developed country” – black Americans are used to certain basic things that many of the people in America’s tributary nations don’t get. Similarly, black Americans can talk about pan-Africanism while black Americans are bombing Libyans. This is a complex, messed up problem that Americans have to come to terms with before they preach to the rest of us about transracialism. Combine this with America’s well-established puritanism and religious extremism, and you have a perfect storm of stupid. It makes you wonder why they even bother doing philosophy.

It also makes me think that they don’t really have a proper grip on some of these issues. Instead of talking about their own race issues, I think a lot of American feminists could stand to look around the world and learn from others. Australia has a unique culture of multiculturalism and acceptance that, while far from perfect, offers important lessons on how to negotiate racial conflict. We also have a history of genocide and responding to genocide that is deeply entangled with old fashioned racial theories that still seem to have some influence on both the left and right of American politics. But as an Australian I think we have learnt a lot and grown a lot, both about sex and race, in ways that Americans need to learn from. Instead, however, these American philosophers seem to think that their experience of race is unique and universal. I even recently stumbled across a tweet by a “key” philosopher of transgender issues (American) who claimed that transracialism had never been practiced anywhere except by one person (Rachel Dolezal). What a joke! This shows deep ignorance of broader issues of race and culture and a kind of infantile understanding of what the rest of the world is doing. I bet right now there are huge debates going on in China in Chinese about people faking ethnic minority identity (or vice versa) that no American philosopher of race even knows about, let alone can turn into a lesson for American philosophical dialogue.

I think it’s time Americans learnt some humility. America is a nation of religious extremists with a history of slavery that just elected an orange shitgibbon for president. Some humility would be in order.

And a little less bullying too! So if, like me, you think that this article might have pointed you to a phenomenon that is more common than you think, that you didn’t even know existed, maybe you should read it. And then reconsider whatever passing judgement you might have made of Rachel Dolezal, and ask yourself how easily the media are fooled by ugly narratives, and what that says about their quality.

And then, I guess, be whatever race you want to be!

fn1: Google it!

fn2: Including but not limited to references to Aussie pride

fn3: Until today I didn’t know that this term existed, though I think that I probably tried to avoid doing what it refers to. Google it!

fn4: You’ll note that I am writing “transracialism” but not writing “transgenderism”. This is because apparently the latter term is offensive while the former is not; and this has nothing to say! Nothing at all! About how one of these processes is accepted by those who police our language in the name of social justice, while another is not.

fn5: Add “will non-ironically say ‘discourse'” to the trigger warnings! Too late!? Too bad!

fn6: Because for arbitrary and stupid reasons I can’t say “transgenderism”, every sentence where I want to refer to the process or state of being a person who is transgender is going to involve these slight awkwardnesses of English language. I’m going to stick to the politically correct phrasing here, but I hope that everyone sees how awkward this is, and how telling the acceptability of one -ism but not another -ism is.

fn7: I’m making a decision not to name the author because I suspect that if things go badly for her and the paper is retracted she is going to want her name not to be associated with the paper that she struggled over; I know that my actions won’t make a difference to the google search results, but I choose not to add to them. Nonetheless I think this is work she should be proud of and I hope she doesn’t have to retract or disavow it. Also what kind of budding philosopher wants their name turning up on a disreputable blog like this, associated with fantasy gaming and sex positivity?!

fn8: And they were being taught fractions by an ignorant white dude half their age. Can you imagine the indignity!? But they were very nice to me, and I think I did a good job of the teaching. But teaching fractions is HARD.

fn9: Please come back!

In the wake of the Republicans’ catastrophic inability to repeal Obamacare, many people have begun to accept that the Patient Protection and Affordable Care Act is the new basis on which the US health system will be built. This means that for the foreseeable future, assuming the Republicans are not able to suddenly develop a competent and coherent health financing agenda, progress towards universal health coverage (UHC) in the USA will depend upon improvements of and reform to the free market system as it is regulated by Obamacare. Obamacare is unusual among developing nation health financing systems for its heavy reliance on private insurers as the fundamental providers of risk pooling, as opposed to most other health financing systems where some form of government insurer provides the overwhelming majority of national health financing. For a lot of critics of Obama and Clinton from the left this is seen as a failure, and a sign that they are neoliberal sellouts: under this view of health financing reform, no market-based system will work and Obama sold out his own supporters when he put forward a plan that did not include single payer or a public option. For conservative policy makers in non-crazy countries – for example the UK[1] or Canada – and also in developing countries moving towards UHC, this offers an opportunity to see whether a free market approach to health financing can deliver the key goals of universal coverage and financial risk protection. The problem for conservative thinkers on health care is that there seems to be very little evidence that free market systems work, and the problem for left wing critics of Obamacare is that there is no evidence single payer could have been delivered in the modern US political environment. So for both far left critics and moderate right wing admirers of Obamacare the obvious question is: can UHC be achieved without a single payer system?

This week’s issue of the Journal of the American Medical Association has published an opinion piece addressing this issue. Entitled Achieving universal health coverage without a single payer: Lessons from 3 countries, it gives a brief overview of how Singapore, Germany and Switzerland have achieved UHC with at least nominally non single-payer systems. It attempts to address some of the key differences between these systems and the USA, and some ways in which the health market in those countries is different. Since JAMA is behind a pay wall, I thought I would give a brief summary of a few of these points.

First the article opens with a clanger, asserting that “Universal coverage is a top priority not only for Democrats but also for President Trump,” which does lead one to wonder how critical the authors are. It then goes on to dismiss summarily one of the key ideas raised by Republicans for making private health coverage more affordable in the US: high risk pools. The intention of a high risk pool is that patients with high cost or pre-existing conditions be offered insurance from a special fund financed by the government, thus removing them from the main private insurance risk pool and enabling insurance companies to reduce the cost of mainstream health insurance products. The problem with this model is that it is enormously expensive and there is no evidence that it works. The article points out that no US government will be able to justify the amount of money required to properly finance high risk pools, and that it probably costs upwards of 8 billion US$ a year to do this. It also notes that – contra Paul Ryan’s assertion that pre-ACA high risk pools worked great – most of the state-based high risk pools in the pre-ACA era were hideously expensive and did not work. The article also points out that a preferred strategy of some left-wing critics of Obamacare – shifting high risk patients onto Medicare – may also not work, since Medicare is already a high risk pool and expanding it by dumping in the highest cost patients will be impossible without increased funding (the article uses the language of sustainability, about which I’m suspicious because of its origins, but it cites well-respected sources on the challenges of continuing to finance Medicare if it is treated as a high risk pool).

So given this, the only way that a private system will be able to achieve universal coverage is if everyone is enrolled in insurance, and insurance is properly financed. The article describes the systems in Singapore, Germany and Switzerland, and how each of them force all their citizens into insurance coverage. For example, about Singapore it says:

Singapore institutes compulsory contributions from employers on behalf of their employees to create medical savings accounts. Employees maintain these accounts for health care expenses such as health and disability insurance premiums, hospitalization, surgery, rehabilitation, end-of-life care, and outpatient services. Those failing to pay their premiums are subject to garnished wages and other legal actions that can force payment of back premiums, penalties, and interest. Unemployed or low-income individuals are eligible for government subsidies that enable them to pay for the premiums.

and it points out that Germans are enrolled automatically in “private” funds that take a guaranteed 7.3% of their income. It’s hard to imagine any such plan being popular in the modern US, where the individual mandate has been subjected to years of withering don’t-tread-on-me type criticism and the idea of paying an income-based premium is terrifying to the GOP’s donors. In Switzerland and Singapore, where the systems do not use tax-based payments, they have government subsidies for (according to the article) up to a quarter of their population. So these systems – which by all accounts are functioning, affordable and tolerated by their citizens – share Obamacare’s key tactics of means-tested subsidies and individual mandates.

The article also makes the point that these systems have a very healthy free market structure, with much more vibrant private markets than the USA:

Germany in 2015, for example, had 124 sickness funds and 42 private health insurance companies, and the average resident of Switzerland in 2011 could choose from 59 health insurers offering coverage, with the 5 largest insurers covering 43% of the population. By comparison, in California, a state with approximately half Germany’s population, only 7 firms covered more than 95% of privately insured individuals in 2011, with the 3 largest firms covering 75%. In Massachusetts, with a population slightly smaller than Switzerland’s, 3 insurance companies enrolled 79% of individuals with private insurance.

I think this might be pushing the comparison a little bit, because many of the “sickness funds” in Germany are likely union-run or industry-based mutual associations with very strict management criteria, non-profit structures and guaranteed membership, and they may be regionally based so not actually directly competing with each other[2]. Also, I’m very confident that all three countries studied have rigorous price regulation and strict government oversight of providers (hospitals and clinics), so that they cannot for example price gouge the insurance provider for an infamous $500 band aid as they can in the USA. It’s much easier for private insurers to compete with each other for market share when they know what the cost of the insurance payout is likely to be, and can be confident that the provider won’t charge them arbitrary amounts, and I suspect that this certainty also removes a whole layer of administrative staff at both provider and insurer, for which the US system is infamous.

Having given an overview of these systems the article draws a simple conclusion and gives a firm recommendation: Obamacare needs tougher enforcement of a more punishing individual mandate. I think this conclusion is only partially correct, missing the role of price regulation and cross-subsidization from general taxation that protects these private markets.  So I think that the article is a little strong in concluding that the USA can definitely achieve universal health coverage without at least, for example, introducing a public option to every market place (or at least the rural areas). But it does make the point that a better regulated insurance market with better subsidies and a much tougher mandate would likely encourage competition, and achieve universal health coverage (or close to it) without driving up costs. It certainly seems that the architects of Obamacare knew this and had a long term plan for its expansion and improvement, and assuming the world survives Kim Jong Il’s birthday this weekend, hopefully the Democrats will be back in power in the USA soon enough to begin taking the next steps along that road. I’m not convinced yet, but it is still possible that Obamacare could show the way to a genuinely private, free market alternative to achieving UHC without single payer. In my view, however, if Obamacare (and human civilization!) does survive the Trump presidency, it is likely to become an increasingly state-regulated and state run system, rather than a robust private market place, because introducing a public option, slowly squeezing out private provides, and then making health insurance premiums fully means-tested and tax-based, is a much more reliable way to make everyone happy.

Still, for genuinely interested conservative policy-makers outside of America (whose “conservatives” have no interest in anything resembling policy), the next few years of Obamacare offers an exciting opportunity to develop new pathways to UHC. Given the complexity of movement towards UHC in some low income countries, and the very limited government finances in many of them, it would be interesting to see whether Obamacare’s roll out, expansion and improvement offers a new and more viable pathway to UHC than those currently on offer. I’m not holding my breath, but it will be interesting to see what lessons we can learn from this new and quite unique approach to one of America’s (and the developing world’s) big remaining problems.

First we have to survive the Trump presidency, though.

fn1: Caveats on the use of “non-crazy” should be inserted here, especially after Brexit

fn2: Interestingly, these sickness funds sound a lot like the non-profit mutuals that Obamacare was supposed to encourage, and which US “conservative” critics of Obamacare constantly sneer at and declare completely unviable.

By now everyone has learned the news that after 17 days of massive effort to try and force it through the legislature in the dead of night the Republicans have given up on their godawful attempt to repeal and replace Obamacare, and have accepted that Obamacare is now the “law of the land.” Having made no effort at all to reach out to Democrats, and after trying to push it through the Senate using a reconciliation process that was explicitly designed (and admitted) to negate Democrat votes, Trump’s first act of contrition for his and Paul Ryan’s failure was to blame the Democrats for not working with him. He went on to repeat the lie that Obamacare is “exploding” (it’s probably not) and openly admitted that he is going to try and hasten its collapse through executive action, following the logic that a program initiated by Democrats that is screwed into the ground by a Republican government will somehow be seen to be the Democrats’ fault.

Trump initiated this process of screwing Obamacare on his first day in office, when he passed a notoriously vague executive order that instructed all responsible departments to not comply with the details of the law to the extent they could legally get away with. A lot of people were duly concerned about this, because there are a lot of aspects of Obamacare that rely on administrative guidance that can be modified by the government in power. So this week’s New England Journal of Medicine has a short editorial by Jost and Lazarus about whether Trump can actually successfully undermine the workings of the act through administrative action alone. The two authors appear to be lawyers, one with a connection to the Constitutional Accountability Center, which supports the cause of “progressive constitutionalism” (which appears to be the idea that the Constitution is a living document whose interpretation can change over time), so presumably their understanding of constitutional law is fairly good.

The authors point out that reaction to Trump’s executive order ranged from fear to snorts of derision, and proceed to show at least one way in which it has failed bigly. One of the big fears expressed in initial response to the order was that the Inland Revenue Service (IRS) would stop collecting taxes it is required to under the “mandate”, the unpopular part of the law which punishes through the tax system anyone who does not purchase insurance. This was probably Trump’s intention in passing the executive order, but it turns out the IRS ignored him: it admitted on February 15th (a month after the order was signed) that it was still collecting mandate taxes, and that it’s sole response to the order has been to shelve a planned crackdown on tax evasion related to the mandate.

The authors point out why this should be unsurprising: government agencies are required to enforce the laws of the land, and there is a long-standing history of jurisprudence forcing them to. They point out that in fact

it is one thing to delay temporarily a legal requirement or to phase in a new law to facilitate adjustments by affected people or entities; it is quite another to refuse outright to enforce a law already in force, with the aim and effect of undermining that law. The Supreme Court has said that courts may step in to correct any such “abdication” of the executive branch’s duty to faithfully execute the law.

Apparently the highest court in the land has built up a body of precedent which requires government agencies to enforce government law, and the authors seem quite confident that if agencies don’t do this, court action would likely force them to. They go further than this, though, considering the hypothetical case in which the IRS bends the definition of “financial hardship” sufficiently to enable anyone affected by the mandate to be exempted from it on the basis of “financial hardship” (apparently some devious Republicans had considered this oily move). They write:

In a critical 2015 Supreme Court case upholding nationwide availability of ACA “premium assistance” tax credits for eligible low-income insurance purchasers, Chief Justice John Roberts held that courts and agencies must interpret and apply individual provisions of a law — indeed, of the ACA in particular — so as to further its overall “legislative plan.” Roberts concluded: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. . . . [W]e must interpret the Act in a way that is consistent with the former, and avoids the latter.”

This might seem quite reasonable to outsiders, but apparently in America the idea that government agencies must act according to the legislative intention of the law of the land is novel and requires clarification from the Supreme Court.

(Also note that this statement was made by justice John Roberts, a conservative judge appointment by Bush Senior, not one of those quisling liberals who think all toilets should be unisex because they’re radical feminists!)

In conclusion the authors are unconvinced that Obamacare can be undone by administrative action alone, though they concede it could become less generous and function less smoothly as a result of meddling. But the Republicans need to be careful here, since administrative overreach in this regard is likely to be punished by the courts, stacking further humiliations on Trump’s already woeful record of mistakes and inactions. Worse still, there is a big and growing split in the Republican movement over Obamacare, and signs that some of the 19 states that resisted the Medicaid expansion are going to cave, further entrenching Obamacare’s role. In particular Kansas, whose economy has been completely wrecked by Republican Crazy Caucus economic ideals, is desperate for money and is very close to taking the Medicaid expansion because balancing the budget will require the extra money. Virginia’s governor is also trying to get that state covered, and activists are using failure to take the expansion and its associated funds as a stick to beat Republicans locally. With Trump’s popularity nosediving, the collapse of the American Health Care Act showing the impossibility of reform through Congress, and many of the areas that voted for Trump most vulnerable to executive action, it is unlikely that vulnerable Republicans are going to want to push this issue at a local level. So the conclusion of this opinion piece in the NEJM is that while Obamacare won’t work as well under Trump, it is unlikely to be seriously damaged. And the longer it continues to function, the harder it will be for Republicans to repeal it or to continue to even talk about it. My guess is that over the next two years – and especially as the mid-term elections approach and it begins to look like a wave election is going to swamp a lot of Republican congress people – we will see more states take the Medicaid expansion, and moderate Republicans begin to talk strong talk about repairing the existing law rather than destroying it. Whether any of them survive the mid-terms will be another question entirely – but if they don’t, they will be replaced by angry Democrats, raising the possibility that after a wave election in 2019 the Dems might be able to force a veto-proof bill across Trump’s desk, requiring him to sign a public option into law.

Regardless of what happens at the next election, though, it appears that there is no easy way for the Republicans to undermine Obamacare enough to destroy it, and it would be increasingly reckless of them to try. Obama’s legacy looks to on increasingly solid ground, and I think it’s now safe to say that he was one of the greatest of the modern presidents. Who would have thought a Kenyan Muslim could go so far!?

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