Science


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…

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I have just finished reading Locked In: The True Causes of Mass Incarceration and How to Achieve Real Reform, by John Pfaff. This book describes the growth of mass incarceration in the United States and describes a set of reform policies to reduce the prison population. In itself this is not unusual – the book takes as its launching point the political consensus in the USA that there is a need to “decarcerate” a large number of people – but this book presents a completely different set of causes of mass incarceration to the accepted story, and lays out a very different strategy for achieving real change. It also argues that the existing reform effort, while valuable, may actually sow the seeds of a long term failure to decarcerate, and risks normalizing a political framework that will be disastrous if crime rises again in America.

Pfaff defines the accepted causes of mass incarceration as the “Standard Story,” which argues that mass incarceration is driven primarily by three factors: the war on drugs[1], excessively long sentences, and private prisons. In the first few chapters he demolishes this story succinctly and using detailed statistics. Only 16% of all prisoners are in prison for drug crimes, and of these a large proportion probably were charged on drug crimes as an easier alternative to conviction for violent crimes; and releasing all of these prisoners would do almost nothing to shift the racial disparities in incarceration, because these disparities are universal. Indeed, since 1990 only 14% of new prison admissions were due to drug use, while 60% were for violent crimes. He then presents a wide range of evidence that prison sentences have not actually increased in length over the past 30 years in the USA: Increased prisoner numbers are due to increased admissions, not larger number of prisoners hanging around longer. Finally, Pfaff drags out the statistics on private prisons, to show that only 8% of US prisoners are in private prisons; and he argues that the lobbying efforts of private prisons are tiny compared to the lobbying efforts of prison guard associations, and from other interests that have greater influence in the zero-sum funding environment of state financing decisions in the USA (most private prison lobbying happens at the state level, where a dollar given to one interest is necessarily a dollar not given to another). In fact, throughout this book Pfaff regularly revisits the power of prison guard associations and lobby groups for prosecutors, and regularly makes the point that the USA’s mass incarceration problem is a catastrophe entirely wrought by public agencies on the public purse. Private prisons in the US might suck, and you might think it’s a bad or a weird idea, or that profiting from human misery is nasty, but they aren’t the cause of the problem.

Having demolished the “Standard Story”, Pfaff then goes on to explain what he thinks are the real causes of incarceration in the USA, which is a complex mish-mash of bad design, lack of political accountability, and public choices, against a backdrop of rapidly increasing crime rates. At the core of his story is the prosecutor. Prosecutors in the USA are the equivalent of the Crown Prosecution Service in the Westminster system, but they are radically different from the CPS. They are generally elected in county (local) elections, and funded at this level, so they are answerable to only local political forces. They have complete discretion as to who to charge, how and with what crime, and they typically are supported by a police force that is funded at the county level. Prosecutors typically are always re-elected, and no incumbent ever suffers from being too harsh on crime. But the real problem is in two aspects of the deployment of their considerable discretion: Whether to charge for misdemeanour or felony, and what plea bargain to make. If a prosecutor charges someone with a felony, that person goes to prison (not jail! The US has some kind of weird distinction!) – but prisons are funded by the state, not the county. This means that there is no financial pressure on them not to send people to prison. But it is the state that makes the laws, and at the state level there is often political pressure to create new laws and increase maximum penalties for those laws. So in recent times the prosecutor has been gifted with a wide range of potential felonies that they can threaten suspects with, that carry very large maximum penalties that are unlikely to be enacted by the judge but sound terrifying to the suspect. This means that it is very easy for prosecutors to get suspects to make plea deals for low level felonies, and there is no local pressure for them not to, but at the next election they are most likely to be judged for successfully putting felons away. This increasing freedom and power has occurred at a time when numbers of prosecutors have increased rapidly, and public defenders – the service that the government supplies to suspects – are massively underfunded and often barely have the time to meet their clients, let alone to help them defend their case. Prosecutors are also notoriously defensive about their work, there is almost no data on what they do, and their representative organizations have enormous clout. These are almost always the people whose perspective you see on shows like Law and Order, Major Crimes, etc.: they are the completely unconstrained and unmonitored heroes of the judicial system, and in the past 30 years the proportion of all cases that they decide to recommend for felony charges has doubled, at the same time as the number of prosecutors has doubled, and crime rates have risen. This, Pfaff argues, is the root cause of the growth of mass incarceration.

But beyond this, Pfaff identifies a much more challenging and much more politically challenging aspect of the growth of mass incarceration, which is going to be very difficult to reverse. Most people in US prisons are in prison for real, serious crimes: 60% of the growth in prisoner numbers since 1990 was due to people imprisoned for violent crimes, and people convicted of the most serious violent crimes (murder, manslaughter, forcible sexual assault, aggravated assault and robbery) take up a disproportionately large amount of prison space and prison time. Seriously reducing the US prison population is going to require that the US voter be comfortable with releasing these prisoners, and being less harsh on violent criminals in future. This is a very politically challenging project, and lies at the core of the reform process: If the US criminal justice system doesn’t find a way to deal differently with violent criminals, the prison population will never significantly decline. To his credit Pfaff makes a powerful and clear argument that from a human rights and a law enforcement perspective, more lenient sentences and better policing are the key to reducing crime and mass incarceration. I find his argument persuasive, but then I would, wouldn’t I? And if you don’t, then you have to accept that the US is going to have a very large number of prisoners, much larger than most other countries, and there is no solution to this problem.

Pfaff goes further, to point out that much of the rhetoric of the prison reform movement is antithetical to this ultimate goal. Many prison reform efforts are pushed as efforts to release low-level prisoners to make space for those who “truly deserve prison”, and even if this balance is not stated explicitly it is implicit in the argument that prison should be for violent crime. America is experiencing a period of declining violent crime at present, but if that should reverse then this logic of reform will be hard to reverse, and it will be hard to argue for more lenient sentences for violent criminals after years of arguing that prison is what these people deserve. Pfaff also points out that the last 10 years of prison reform efforts – which he argues have been supported by all sides of politics in the US – have shown very limited effect, and that this is primarily because they are focusing on a very small proportion of the US prison population (first time drug offenders) and that they need to move from these “low hanging fruit” to the real drivers of prison growth – and those who really suffer in this system – violent offenders.

Within this story there is a lot of other material to consider – this book is a short and well written work with a rich vein of material to consider. It certainly changed my view of the drivers of mass incarceration in the USA and the real reforms it needs. It also shocked me with how callous the US criminal justice system is, and how shambolic. In contrast to the UK, Japan or Australia, where the prison, police and legal systems are all relatively well organized around a single structure that coordinates well, the US system is fragmented and full of perverse incentives, all corrupted by the horrors of having public servants like prosecutors elected at the county level (shudder!) Pfaff also consistently returns to a discussion of how damaging prison is for inmates, their families and the communities they are drawn from, reminding the reader regularly that prison is a destructive experience for everyone involved, and he also reminds the reader regularly of the US electorates’ appetite for punishment. But the real challenge of this book is his focus on the need to treat violent offenders differently. He even challenges the concept of “violent offenders”, arguing that we should refer to them as “people who committed violent crimes”, and argues compellingly that our attitude to violent crime is completely wrong. This struck me because although I’m generally in favour of not sending people to prison for all the reasons Pfaff describes, I am just as prone as anyone else to demanding people be locked up (e.g. that was my first response to the Grenfell Tower fire) or to thinking a sentence isn’t harsh enough (as if I, someone who has never been to prison or spent any time as a free adult anywhere I didn’t want to be, could possibly comprehend whether a three year sentence is any less harsh than a five year sentence!). And Pfaff’s argument is pretty clearly that probably I, and most of the rest of us, have got it completely wrong on prison sentences – that a suspended sentence or a year or two is probably just as good a deterrent as five or ten years, but has significantly less social and economic cost.

If I had any complaints about this book it would be that although he talks about race a little he doesn’t go into a discussion of race in depth, a problem in the American context. Also, although he repeatedly describes the lack of financial disincentives to county prosecutors sending prisoners to state prisons, Pfaff doesn’t seem to draw the obvious extra lesson here – that county prosecutors might have strong disincentives to send people to county jails, which have much less serious ramifications for their inmates than state prisons. In avoiding a full confrontation with the issue of race, and not fully drawing out all the implied pressures on prosecutors, Pfaff manages to miss the obvious possible extension argument underlying the points he makes: that a lot of prosecutors may well be cruel, racist arseholes, and that a root-and-branch reform of the entire prosecutorial system may be in order. But this is a common problem when confronting Americans’ assessments of their own problems, whether its Bernie Sanders or the gun control movement or Black Lives Matter: The American political system is rotten to its core, and it is going to take a lot more than a few piecemeal changes to parts of it to fix the huge problems lurking at its base. We’ve just passed the 4th July, so it’s probably worth reminding my American reader(s): you could ask the UK to take you back, you know. For all its flaws, the UK’s democracy is vastly superior to yours. You’ll have to give up your guns and you may have to learn to shut up occasionally, but in exchange you’ll get a functioning democracy. Think about it!

Anyway, jokes aside, this is a great book, a truly enlightening exposition of one of America’s great problems. If you are interested in drug decriminalization and have always assumed that this issue is at the heart of America’s prison problems, or if you are generally concerned about the way America needs to reform its criminal justice system to become a better country, then this book is a must read. It’s well written, well argued, dry but not exhausting, and compassionate towards the people at the core of the story: the prisoners, who by now are a large proportion of America’s population. If you care about the human rights of all people, regardless of what you might think of their worth as individuals, then this book is a compelling read. I recommend it to anyone interested in this important topic.


fn1: this is often characterized on the left and by libertarians as “the war on (some classes of people) who use (some classes of) drugs” but this book makes it very clear that the prejudice in the criminal justice system extends across the board, and that singling out one class of crimes (drug crimes) as a cause of racial disparities in incarceration won’t work, because the same racial disparities exist across all laws.

Last week the Lancet Public Health published a comment piece by me about the challenges it faces in the near future. This comment was linked to a research article that found a huge increase in elderly people with care needs in the UK population over the next 10 years. This article predicted that 10 years from now there will be a 25% increase in the number of people aged over 65 who have care needs, which corresponds to a numerical increase of 560,000 people. The largest growth will be in dementia-related disability, which may perhaps have been a slightly stinging finding for the government given that Prime Minister May had released a deeply unpopular policy for paying for dementia care in the same week. The article and my comment received some media coverage (see e.g. here), focusing on the impending massive increase in care needs and the risks to the NHS. My article made the point that this growth in elderly people needing care comes at a time when a unique combination of policy challenges confronts the incoming government: an underfunded social care service, an NHS in crisis, a looming workforce shortage, and the risk that Brexit will lead to an immediate loss of staff and a long term reduction in the number of staff entering the NHS. I made the simple point that the British health and social care system needs more money and a commitment to expand the local workforce to make up for the looming drop off in European staff. This is particularly pressing for the social care sector, which unlike the NHS employs large numbers of very low paid staff who have a very high turnover rate and are very often European. Once Brexit hits that turnover is going to bite, because new staff simply won’t be there to replace the high churn rate. There is no solution to this problem except to increase pay and improve working conditions to ensure this sector of the economy can attract British workers and retain them.

The problem is not limited to social care, however: something between 5-10% of staff in the NHS are recruited from Europe, which means that even if the final Brexit deal allows existing staff to stay, over the medium term natural attrition will mean that the NHS needs to increase local recruitment to cover that 5-10% of new staff who are not being recruited from Europe. Worse still, Brexit will hit just as the health workforce hits a wave of retirements of staff recruited from the baby boomer generation, and as junior doctors show increasing signs of burnout and the nurses association is talking about striking to preserve pay and conditions (the strikes themselves will not necessarily be a crisis – though I’m sure Jeremy Hunt can turn them into one! – but the underlying problems they signify will be). It takes 10 years to make a new doctor and about 7 years to make a new nurse, so the entire workforce planning system in the UK needs to be restructured and enhanced rapidly in the next 1-2 years if the UK health and social care system is to be ready to handle this. To be clear the issues are huge: A rapid increase in disability and health risks in elderly British people occurring after a decade of leakage of staff back to the EU, as a generation of older staff retire, and just as the cut to the nurse’s bursary and NHS funding leads to a shortfall in new staff, with no way to make it up through EU recruitment. This will affect every aspect of coverage, quality of care, equality of access, and timeliness of access in a system that is already struggling to handle basic pressures.

Today the Nuffield Trust released a report that adds to the pressures revealed by the article I was commenting on, by discussing additional health system pressures that will arise from leaving the EU. This report finds that:

  • If the Brexit agreement does not properly support UK citizens abroad and the welfare sharing arrangements they benefit from, 190,000 elderly Britons will return home and cost the government an extra 500 million pounds a year
  • If these elderly Britons return home they will require hospital beds equivalent to two new hospitals to care for them
  • If the NHS cannot continue to recruit nurses from the EU there will be a shortfall of 20,000 by 2025
  • The 350 million pounds a week that can be saved by leaving the EU was a myth, but in the first two years after leaving there may be more money to pay for health and social care – if the government is willing to spend it

The publication I commented on predicted an extra 560,000 people with care needs by 2027; this Nuffield Trust finds 190,000 more elderly people the study didn’t cover, and suggests they will have significant care needs currently being (basically) paid for by Europe, and it quantifies the shortfall in staff I identified. It’s worth noting that the NHS employs 320,000 nurses, so the 20,000 shortfall is about 6% of the workforce, but this 6% shortfall comes also when a large number of nurses will be retiring, and about the same time as the current reduced nursing student cohort hits the workforce. A lot of these numerical details are very hard to predict, but it appears likely that there is going to be a major reduction in a nursing workforce that is already not well stocked by OECD standards. Nurses are the bedrock of a functioning health system, and although there is no international evidence on the best nursing levels, a rapid decrease in numbers is only a bad thing, especially if combined with a rapid increase in health care demand.

This problem will face whoever wins the election in two weeks, since a lot of these pressures are the result of a Brexit decision we are supposed to believe is set in stone, and population ageing. But any party that does not have a plan to increase the health workforce, to restore funding to social care, and to improve payment, retention, credentialling and work conditions for the workers at the bottom of the social care heirarchy, is not serious about the depth and seriousness of the crisis the NHS faces. Although the Tories like to talk about working better rather than increasing funding, the reality is that the NHS desperately needs more money; and so long as Labour continue to dance around the issue of exactly how they will handle free movement, they present no serious plans to handle the looming workforce crisis. The British people voted for Brexit without having any clear information about what it would mean for the social care sector, while Boris Johnson flounced around the country in a bus that was advertising a clear lie. Now the election looms, and both parties have to come up with policies to handle this unavoidable crisis on a 10 year deadline. I think from a brutally practical standpoint, the real winner of this election will be the party that loses it, because whoever wins is going to be held responsible not just for Brexit’s short term economic damage, but for the long-term health and social care crisis that neither party is properly prepared to deal with.

The NHS needs more money and more staff. Without it, unless the winning party can deliver a truly miraculous Brexit deal, the UK health and social care system is heading for two decades of increasing and unavoidable crisis. I’m not confident that anyone in British politics is ready to deal with this problem, or even listening to the warnings. Let’s hope, for the sake of Britain’s elderly population, that I’m wrong.

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!

Reports have been filtering out recently of a study that found a relationship between US unemployment rates and deaths due to opioid use. The Washington Post reported on these results, suggesting that there is a connection between unemployment and death due to “diseases of despair” (their words), and citing the unfortunate Case and Deaton study that found increasing mortality rates among non-hispanic whites in the USA. The implication is that some kind of post-2008 economic depression-related despair has driven the white working class to drugs, with an attendant high death toll. This is particularly poignant in light of the recent election, since some of the states (like West Virginia) that voted heavily for Trump are also heavily affected by opioid abuse. The implication here is that the economic despair supposedly driving Trump voting is also driving high mortality in these communities, which have also supposedly been hollowed out by globalization, immigration and Democratic neglect (only Democrats can neglect poor white people; Republicans ride in to save them with trickle down economics while Democrats abandon them for groovy inner-city Black Lives Matter activists and funky Chicago law professors). But is any of this true?

The news reports are based on the findings of a study by Hollingsworth, Ruhm and Simon, Macroeconomic conditions and opioid abuse, published in my bete-noir, the National Bureau of Economic Research (NBER) working papers series. This is where economists publish their brain farts before they are shot down in peer review, and this paper is a typical economist brain fart. This study suffers from the usual problems of NBER papers: it has a ludicrous model, uses the wrong modeling approach, does some dubious data manipulation, and probably isn’t representative. Worse still, the study is based on a failed and useless model of drug addiction that eschews a balanced understanding of drug addiction in favour of a lazy just-so story about the causes of drug addiction that has no basis in reality. I will briefly discuss the modeling problems that make this study useless, and then discuss in more detail the problem of its underlying theoretical structure.

Modeling problems with the study

The study is a classic example of how economists just cannot handle data well. First, the authors have presented a ludicrous model which has an enormous number of explanatory variables – one for every county in their data set, one for every year, and an additional term for the combination of states and years – which means that the model has a huge number of terms to be estimated. Worse still, they do not include age or sex in the model, so they don’t adjust at all for differences in age structure between different counties and states or ethnic groups. Non-heroin opioid addiction in the USA seems to be clustered in rural whites, and probably reflects addiction pursuant to pain relief for real health problems. If so the problem is likely more prevalent in older groups (which have higher levels of chronic pain) who may well be more vulnerable to early death – so adjustment for age is important in these studies. The authors find mortality rates in whites increasing much faster than blacks or hispanics but this could well be because these groups are younger and thus earlier into their drug addiction, or simply less likely to die. This complexity is further compounded by the authors decision to impute drug types to drug-related deaths where the drug is not specified – they simply statistically estimate what drug caused the death, which makes all their results highly vulnerable to the quality of the model by which they impute 30% of all drug-related deaths. So the authors have estimated a model with a huge number of terms and have not properly adjusted for the age structure of the population. This is extremely important, since the CDC has shown that opioid-related mortality is much higher in older people, and if areas with many old people also have high unemployment there will be a spurious relationship between unemployment and mortality if age is not adjusted for.

Incidentally, this paper gives completely different crude opioid mortality rates to the CDC, probably because it uses a subset of states with unusually high mortality rates. So there is a huge generalizability problem right there.

The other big problem with the model is that, of course, being economists, the authors do not use the correct modeling approach. Opioid mortality is a rare even with very small numbers of deaths when disaggregated by race at the county level – even the authors admit that many of their data points have zero deaths – but the authors have chosen to divide the counts of mortality by the population of the area, to get crude rates, and then to model these using ordinary least squares linear regression. As I have repeatedly said here, OLS regression is completely the wrong method to use on data that is constrained. In this case the data is constrained to be greater than or equal to zero, and is likely very close to zero in most cases. OLS regression assumes a completely different probability structure to the correct method, Poisson regression, and applying OLS regression to rates means that you are assuming all zero rates have the same probability. In contrast, a Poisson regression adjusted for population size models a zero count with a different probability depending on the population size, so a zero event in a large population has a different meaning to a zero event in a small population. It also models a non-linear relationship between the underlying death rate and the unemployment rate, which is crucial to understanding how the underlying death rate is related to unemployment. By not using a Poisson regression for rare events the authors have mushed together a bunch of very different mortality patterns as if they were all the same, and completely changed the nature of the relationship between unemployment and mortality.

Big no no!

So the modeling is completely flawed, but this isn’t the worst part of this study. The worst part of this study is that the underlying theory is completely flawed.

Opioid use is not a disease of despair

The fundamental problem with this model is the assumption that macroeconomic conditions drive opioid use. Figure 1 shows the observed and modeled number of monthly deaths due to heroin overdose in New South Wales, Australia between 1995 and 2003, taken from Degenhardt and Day, Impact of the Heroin Shortage: Additional Research (I prepared this figure for this technical report).

Figure 1: Monthly observed and modeled heroin overdose deaths in New South Wales, 1995-2003

This figure shows a clear rapid peak occurring in 1999, followed by a gradual decline and then a sudden downward step in January 2001. This downward step is even more evident in heroin possession offences (Figure 2, also prepared by me, from Gilmour et al, Using intervention time series analysis to assess the effects of imperfectly identifiable natural events: A general method and example, BMC Medical Research Methodology 2006; 6:16).

Figure 2: Observed and modeled trend in heroin possession offences in New South Wales, 1995-2003

Is it really conceivable that trends in unemployment were so intense over the 8 years of this data series that they caused heroin possession offences to more than double, and heroin mortality to double, within 2 years, and to then decline by 50% before halving in one month? What are the macroeconomic effects driving this phenomenon? In fact youth unemployment in NSW declined consistently over the 1990s, and was at a historic low when heroin mortality peaked. What changed over the 1990s was the availability of heroin, which was flooding the market in the mid-1990s; and what changed in 2001 was that new models of drug interdiction and cooperation between police agencies led to unprecedented success in fighting drug traffickers, so that in the early ’00s they pulled out of Australia in favour of easier targets. The result was a sudden precipitous decline in heroin availability, a massive increase in cost, a temporary increase in street-based sex work and cocaine use, and a rapid flight of young people from the market. This occurred against a backdrop of readily available harm reduction services and widespread, free methadone treatment, to which many drug users fled when the price skyrocketed.

The reality is that drug addiction patterns are driven primarily by availability of the drug and availability of treatments for drug addiction. Far from being a “disease of despair” as the Washington Post described it, with patterns of use determined by social dislocation and poverty, heroin addiction is a disease of opportunity, driven primarily by the presence of the drug, its ease of use, and the economic potential to purchase it. There is no relationship between drug use and unemployment or poverty, and we have known this since Robin Lee did her groundbreaking work on returning heroin addicts after the Vietnam war. I suspect the truth of the American opioid epidemic is much more boring, and much more difficult to explain, than unemployment: It is a problem of availability. I don’t know what causes that problem but my guess is that sometime in the 2000s legislative changes made opioids much more easily available. In 2003 the Medicare Prescription Act was passed, and my guess is that it made it much easier for middle-aged poor people to get access to pain relief – pain relief they desperately needed for a wide array of real problems. With access to affordable opiates but with no corresponding access to specialist pain management professionals a cohort of middle-aged workers became addicted to opioids, and in the subsequent 10 years they started dying. It’s a boring health policy explanation for a terrible problem, and it can only be fixed by improvements in quality of care, access to specialists, and careful attention to modern strategies for pain relief.

Unfortunately this story doesn’t fit with a narrative – popular on left and right – of drug addiction as a disease of despair. In this narrative the left sees drug addiction as a product of an alienating and destructive society, best solved by improvements in welfare and labour rights, while the right sees drug addiction as a consequence of unemployment and poverty, which are best solved by getting everyone into work (since good welfare programs are anathema to the right). For economists both of these stories show the primacy of economics as a driver of social problems, and make a good just so story. But the reality of opioid addiction is that it is a complex health policy problem best solved by careful attention to the way that opioids are dispensed and pain is managed. True, this policy prescription requires potentially quite radical changes in the way that doctors approach chronic illness, poverty and occupational health – but it’s completely boring outside of health policy. Stories of a “generation left behind”, forced to vote for Trump because of the carnage sweeping through their blighted communities, are much more interesting than “oh yeah, we made dangerous drugs cheaper and didn’t train doctors how to manage them.”

This article and the interest it drove are another example of two pernicious problems in modern debate: economists can’t be trusted with health data, and journalists are too quick to believe economists. When this is tied with a problem that is easily amenable to sensationalism and patronizing assumptions, of course you get a narrative that is completely divorced from the truth. In this case we don’t know what the truth of the numbers is, since the economists in question made a model so bad it has no bearing on the truth; and we were led into believing that this model could ever explain the very real problems facing these communities by credulous economists and journalists all too willing to believe lazy stereotypes about drug users and drug use.

Let’s score that as another failure for two of the worst professions, and hope we can make some real changes to prescription laws and pain management so that the people affected by this problem can find better, safer ways of managing their chronic pain. And please, please please, can economists please stop touching health data until they learn a method other than OLS regression?

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The New England Journal of Medicine appears to have plunged deep into the debate on health insurance reform since Trump was elected, and in its 9th March issue has a series of articles and opinion pieces on Obamacare’s effects. This includes a piece pointing out that Obamacare expanded access to treatment for substance addiction, including opioid addiction (a big and growing problem in the US at the moment) and also a research article examining the impact of the medicaid expansion on specific health and health financing outcomes (the findings: it was broadly very positive). It also has a short research article examining the claim that the individual insurance markets have been thrown into a death spiral by the poor design of the law.

This claim has been going around for about a year now, and is generally based around the fact that some insurers have left some markets, and in some cases blamed Obamacare for their decision. For example, Zero Hedge made this claim in 2015, and the National Review took it up in July 2016. Articles discussing the alleged failings of the exchanges typically point to the withdrawal of big companies such as Aetna from some exchanges, suggesting that these companies are withdrawing because the fundamental dynamic of the exchanges prevents them from making a profit. This is important in the US context because for people earning above 138% of the federal poverty line who do not have employer-based insurance, the best and most efficient way for them to get insurance coverage is through a marketplace called an exchange, which is a special clearinghouse for selecting Obamacare-compliant insurance plans that is set up either by your state or by the federal government if your state refused to cooperate with the law. (An example of a generally well-liked exchange in a Republican-run state is Kentucky’s Kynect exchange). Obamacare’s defenders have pointed out that some consolidation is natural in markets when they change, and that new entrants or changing business practices will naturally force some businesses to fail or leave – that’s capitalism! Under this defense, the exchanges are working as intended and there’s nothing to worry about, except that in some smaller states this process may lead to a collapse of competition as only one or two insurers remain – a problem Clinton intended to fix by introducing a public provider in all markets if she won the presidential election.

The new article in the NEJM explores this issue in detail, by collecting data on all the plans that operated in exchanges from 2016 – 2017 and comparing those that left with those that remained. The authors make the particular point that once the exchanges opened the marketplace itself changed, and this had implications for insurers. They say:

In particular, the ACA’s insurance-market reforms required firms to develop and market new products that were attractive to low-income Americans who faced few access and pricing restrictions based on their underlying health status.

This means that organizations that are unfamiliar with these market conditions might struggle. They explain this as follows:

Anecdotal evidence supports the argument that the skills of particular insurers may not have been well suited to these marketplaces. Many of the exiting firms, such as UnitedHealth, have primarily covered enrollees in the self-insured–employer market, in which insurers provide administrative services and are not primarily responsible for bearing actuarial risk or for developing products targeting low-income consumers. In addition, many of the assets that have proven quite valuable in the self-insured market — such as a large national footprint that is attractive to multistate employers — may not be particularly useful in state-based individual insurance marketplaces.

They then present the results of their detailed assessment of the properties of those businesses that entered or left the market place, which they summarize in a table, reproduced as Table 1 below.

Table 1: The characteristics of leavers

This table makes clear that the insurers who left the marketplace in 2016 were offering more expensive plans with narrower networks and lower levels of behavioral health coverage; they were also much more likely to be bigger actors in the market for fully-insured people and much less likely to have experience in Medicaid markets. Overall this suggests that these companies left the exchanges not because the exchanges were flawed, but because these companies were not experienced in targeting low-income Americans who make up a large share of the individual insurance market, and having made a play at the individual market decided to get out when they were out-competed by organizations with more experience in the marketplace. The authors further note that actually a lot of the insurers active in the exchange markets are making a profit and are aggressively targeting new marketplaces – but these insurers tend to be smaller organizations with experience in Medicaid services, and don’t attract the same attention as the big employer-market insurers who failed.

This study isn’t definitive and has some limitations – for example it did not compare leavers in 2016 with historical leavers before Obamacare was implemented, and it only compared silver plans (which are the most popular but not necessarily the most profitable, I guess). Nonetheless, it gives the lie to the claim that Obamacare’s exchanges are not working, or at least suggests that they are working well enough to warrant tweaks and improvements rather than complete abolition. Once again the NEJM has shown that Obamacare’s opponents are long on rhetoric and short on facts, and that although this health care law is not perfect, it is doing okay and is certainly a significant improvement on the status quo. Let’s hope that whatever reforms proceed over the next two years will lead to improvements in the areas that are not working, and not wholesale destruction of America’s best chance at universal health coverage in half a century.

(This review is a little pointless because the exhibition closes tomorrow).

Yesterday I visited the Mori Art Museum in Roppongi Hills to see the Universe and Art exhibition. This exhibition attempts to show the relationship between artists’ and scientists’ attempts to explain the cosmos and the human relationship with the stars. It incorporates artistic visions of the cosmic order, scientific explanations of space over time, and artistic interpretations of science, from many different cultural perspectives. To do this it displays a wide array of art, items, scientific objects, film and video art. These objects have been drawn from many different cultures – Indian, Asian, Europe and the Americas – over several thousand years, with a particular emphasis on Japanese material from the past and the present. They include mandalas from India and Japan, star charts from China and Japan, and early stories about space from Japan and Europe. It also includes film, photos and objects from the space programs of several nations, science fiction art and stories inspired by these programs, and visual art that either glorifies or critiques or reinterprets them. Some highlights that I particularly enjoyed are listed below.

The meteoric iron katana

Blade of coolness +5

Blade of coolness +5

What can I say? Apparently Okayoshi Kunimune made two swords from meteoric iron, which took three weeks to craft and required several trips to the local shrine for prayer. One of these is on display, and it is quite impressive. It has all the fine lines of a classically-forged katana, but the metal is kind of darker and less shiny, more sinister-looking. Also the scabbard has “Meteor sword” written on it, which just says it all really. This blade was forged the old-fashioned way in 1898, which was after the samurai era, but was forged in the traditional way, which means that it has that slight rippling pattern in the metal around the blade. Viewed end on it looks wicked sharp. The photo I took is just a snap and overstates how dark the blade is, but I do think it is darker than a normal blade (I haven’t seen many of these artifact blades so I don’t know how dark an original samurai blade is). One of these blades ended up in the possession of the Taisho Emperor, which means that he was decked out in a sword made from a meteorite. I think that makes this a kind of unique artifact and it genuinely is very cool, just sits their heavy with its own sense of foreboding awesomeness. Everyone was impressed by this sword.

Bjorn Dahlem’s Black Hole (M-Spheres)

Space!

Space!

This installation is large and imposing and when viewed in detail kind of naff – it’s just a bunch of fluorescent lights stuck onto some wood – but viewed from afar with that kind of disfocused gaze that you have to take with certain kinds of art it suddenly becomes much more imposing and abstract. In the centre is supposed to be a black hole, with what I guess are galaxies or some kind of star tracks circling around it. A single sphere of black metal somewhere in the middle is, I guess, the black hole that it all is meant to be built around. It’s surprisingly cool (though the windows at the far end of the room give a view of Tokyo from the 52nd floor of this building and are kind of more awesome in their own way). It doesn’t move or anything, unlike …

The God Machine

It watches and waits ...

It watches and waits …

This monstrosity is set up in its own room, and is basically just a series of robust metal arms circling slowly in rings of different size and speed, with brilliant lights on the arms. The lights themselves move in simple planar orbits but the whole structure is set at an angle to the floor surrounded by walls of white, and the motions of the shadows of the arms on the wall are complex, occasionally threatening, and frustratingly close to predictable. The size, clarity, depth and position of the shadows changes as the arms complete their loops, and depending on the direction you look you see a very different system of shadows interacting. A single spike sticking up from the floor casts a complex pattern of shifting triple shadows on the floor. The whole thing is a simple set of ordered moving parts, but it carries this sense of immensity and brooding threat that makes it really cool. I think it’s by Wolfgang Tillmans, who contributed a few beautiful images as well. His website gives a sense of some of his other art, which is quite striking.

The great books

Original history

Original history

The exhibition also featured first editions of Newton’s Principia, Darwin’s The Origin of the Species, and the first works of Copernicus and Kepler. Kepler and Copernicus’s books are open at centre pages so you can see the quality of their work, while the Principia is open to the frontispiece.

On the shoulders of giants ...

On the shoulders of giants …

I studied physics in my undergraduate years, and then statistics, and so for me even just the frontispiece of Newton’s original work (shown above) carries an enormous weight and power – this is truly a book of vast importance in the history of science, and to stand in front of a work that is so close to the original hand of one of science’s greatest and most influential minds is really a great privilege. This book is over 300 years old, heavy and worn with the weight of history, and everything in my career and everything I love about the science I do is built on what is in its thick and fragile pages. So it was really great to stand looking at that frontispiece and revel in the significance of of those three words: Naturalis Principia Mathematica. I imagine if one were an evolutionary biologist one would get the same feeling from Darwin’s Origin of the Species, which was also on display, but for me as someone trained in physics this book is a great treasure and it was the first (and I guess, the last) time I will be in the presence of this original piece of history.

The exhibition had other contributions from the scientists of that era, including an excerpt from da Vinci’s Codex Atlanticus that described the movement of the planets (his handwriting is incredibly beautiful, every letter a work of art), armillary spheres and beautiful navigational tools made in intricate and beautiful detail out of brass, and a replica of Gallileo’s original telescope (also, his Sedereus Nuncius and his sketches of the moon, that he made with that incredibly primitive telescope). It’s really humbling to stand in the presence of so many of the original moments of modern science, and to think that almost everything we do now depends on the work these men put into these humble books, or that once people had to find their way to Tokyo using nothing more than one of those brass navigational instruments. It’s quite incredible to see them and realize just how primitive it all was – these scientists really were fumbling around the universe, making guesses on the basis of almost nothing, when you think about what we can do today. And almost everything we can do today depends on their fumbling efforts … So it was quite amazing to see all this stuff in one exhibition, and also to see some of the wild, amusing and speculative ways in which artists of that time and since have speculated on the implications of those scientific endeavours. It’s also obvious when you see that early work that there is no barrier between science and art – those scientists were technicians but they approached their work with a religious zeal and an obvious sense of aesthetics, a joy in the beauty of maths and physics as well as in the discovery of the unknown. For all the challenges of that era, for these men it must have been a very exciting time to be alive.

The Crows and the Insects in Amber

Some of the video installations weren’t so great but there were two amazing works. The first was a high resolution high magnification video exploration of a piece of amber with insects trapped inside it. Set to eery backing music, it moved through the amber filming different parts of it in such a way that it produces spacescapes and scenes like starscapes, nebulae or distant galaxies. In between these strange galactic visuals it zoomed in or out on the insects themselves, so that they loomed in the camera like Cthulhoid monsters, alien horrors, or strange planetary landscapes. This installation was probably 4-5 minutes long (or at least the part I saw was) but it was a fascinating way to turn a piece of something ancient, terrestrial and tiny into something vast, timeless and cosmic. A brilliant idea.

The second was a video work by teamlab, Crows are Chased and the Chasing Crows are Destined to be Chased as well, Blossoming on Collision–Light in Space. For this you enter a large dark room and stand in a specific spot in the centre of the room, then the entire room begins to shift and move as the video covers all the walls, floor and ceiling. From your central spot you watch crows take flight and then you chase them along the lines of their flight, and then they burst over you and disappear and suddenly you’re chasing new ones. I don’ t know why crows, I don’t know why we’re chasing them, but it’s really good. It’s a kind of mixture of video game and interactive exhibit, I guess, but all through a movie. It probably wasn’t entirely suited to this exhibition – it could easily be the open sky rather than space that these crows are flying through – but it was still a splendid experience.

This exhibition finishes tomorrow so there is not really any point in recommending that you, dear reader(s), rush on down to see it, but at least now you know what you missed. This was a really interesting attempt to combine two fields of human endeavour that are often seen as at odds with each other or unconnected, and it did a really good job both of merging the two and also of introducing me to some genuinely cool modern artists working in this field. It also serves as a good reminder of how space exploration, from its earliest beginnings, has been not just an engineering and physics endeavour, but an artistic effort that expresses something about what it means to be human and what our position is in the cosmos. As we watch new and modern efforts to explore our solar system – and, possibly, to colonize it – it’s worth remembering that they are always about more than just science, which makes them simultaneously both a luxurious waste of money, and an essential attempt to understand the core of what it is to be human. I hope in the future other museums and art galleries will attempt a similar exhibition to this, so people outside of Japan can share this unique insight into how art and science have worked together over thousands of years to bring humans closer to the stars, both physically and spiritually.

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