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Hmm, is the China juggernaut that obvious?

I’ve done several posts — as recently as yesterday — mentioning the spectacular rise of China as a change driver with widespread effects. My assessment is that this will have big impact on people everywhere and be a disquieting influence that will disturb a lot of people. But my question now is: Am I just reitterating what’s become obvious to Americans?

In today’s Washington Post there’s a report of a Washington Post-ABC poll headlined: “Poll shows concern about American influence waning as China’s grows.”

Facing high unemployment and a difficult economy, most Americans think the United States will have a smaller role in the world economy in the coming years, and many believe that while the 20th century may have been the “American Century,” the 21st century will belong to China. […]

Asked whether this century would be more of an “American Century” or more of a “Chinese Century,” Americans divide evenly in terms of the economy (41 percent say Chinese, 40 percent American) and tilt toward the Chinese in terms of world affairs (43 percent say Chinese, 38 percent American). A slim majority say the United States will play a diminished role in the world’s economy this century, and nearly half see the country’s position shrinking in world affairs more generally.

This has a lot of Americans worried. Losing economic hegemony is not only perceived as a loss of power, but it also suggests that perhaps the country has lost its mojo, it’s in decline. I’d look at it another way. I’m a big fan of Fareed Zakaria’s 2008 book, The Post-American World. His first chapter is titled: “The Rise of the Rest.” His view is that America will remain a powerful and influential country, but other countries like China, India, and Brazil will gain much economically and gain world influence. In other words, wealth and power will have to be shared. His perspective suggests not that this is the end of American glory but that an adjustment to historical evolution is necessary.

The US is about 5% of the world’s population. Since WWII we’ve enjoyed enormous economic prosperity, military power, and prestigue. But history moves on, and the other 95% of the world’s people are developing too. How 5% would expect world dominance to last I don’t understand. Back in 1997 William Greider published a book I also admire: One World, Ready or Not: The Manic Logic of Global Capitalism. In essence, Greider said the capitalism widely advocated in America had won; communism was discredited. The consequence of that is that labor income would move to the masses of people around the world willing to work for less than Americans because they have a much lower standard of living. Capitalism is the force leveling incomes worldwide, and, hence, influence.

A participant in the WashPo survey put it pretty well:

Annetta Jordan, another poll participant, said in a follow-up interview that she has witnessed the shifting economic strength firsthand. Jordan, a mother of two from Sandoval, N.M., was working at a cellular telephone plant in the early 1990s as production and hiring were ramped up. By 1992, the plant had 3,200 workers. “Then this whole China thing started and we were very quickly training Chinese to take our jobs,” she said. Now the plant has 100 people left. “We’re transferring our wealth to China,” she said. “I see that as a very negative thing. When I was younger, a lot of corporations had a lot of pride and patriotism toward America. But corporations have changed. If we in the U.S. go down, that’s okay; they’ll just move their offices to Beijing.”

Ahh, the fruits of success!

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Global economics as a force of change

I played out my career in the nonprofit part of the economy: public health cancer control. I knew people involved in many causes who were constantly striving to achieve specific kinds of “change.”  Toward the end of my years in the field it struck me that what is actually happening is the converse: there are an unprecedented number of broad forces instigating change and they interact in weird and wonderful ways. Indeed, in today’s world there’s really no way to stop change; but many outcomes are not controllable or consistent with what folks want to see. In the USA today there are those who “want our country back,” and they blame the Obama administration for upsetting a past order they recall as more satisfying and proper. From what I can  tell a lot of people have a hard time putting their finger on just what it is that’s wrong, but somebody is to blame for their unease.

A couple of weeks ago I posted about the huge growth in the economy of China forecast by economists: $123 trillion GDP by 2040. I was reminded of that again in a recent article in Wired News by Zach Rosenberg about how the American auto industry is swinging to fulfill the thirst of the Chinese middle-class for automobiles. They’ve read the projections too. It’s not exactly a nuclear secret that the next 900 lb. creature in the room will be a giant panda. Rosenberg quotes a GM executive:

“This is clearly the market of the future,” says Freidhelm Engler, General Motors director of design in China. “It’s not going to slow down.”

To sell cars in China a lot of cultural tweeks are need. For example, a design concept of the Buick Regal specifically for China has new features.

Inside, the back seat envelops the passenger “like a clam” … in the same manner as an emperor’s throne. Interior coloring is nearly monotone from the rear passenger’s perspective in accordance with Chinese expectations of a car. Notice the deep purple color. GM says was “chosen to elicit the right level of attention and respect” and named it euphemistically after a rare and slow-growing Chinese tree, It was designed, Engler says, to look like a smooth fabric blowing in the wind.

And beyond that, the Chinese will begin to exert influence back on the US.

With the demands of the enormous Chinese market, the expansion of Chinese companies into the West and the introduction of Chinese vehicles to U.S., American consumers should expect to see some Chinese characteristics make their way across the ocean. “Decoration to enhance proportion,” says Engler, “may show up in North America in coming months.”

Do you suppose these changes are going to result in more jobs in the US on the assembly line? Are Americans going to be happy with “Made in China” stickers in the most sacred of American symbols: the automobile? This is certainly not going to be a resurrection of the era of the ’57 Chevy.

For people who are unsettled by change the future is going to be a very distressing place. Even for the people who keep calling for change, what we get may not be what you had in mind.

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Health 2.0: four decades of experience

As I’ve posted before, I’m interested in Health 2.0. I say that from the perspective of someone with nearly 40 years of experience in social science and cancer public health. I hope my long-term perspective can add something to the discussion of this interesting trend, especially the recent discussion kicked off by the Susannah Fox and the infamous “Darthmed” concerning the value of Health 2.0.

If you’ll indulge me a little I’d like to step back to when I studied sociology in the late 1960s. The conventional methodology of sociology was survey research. Surveys as a social science tool go back to the 1940s, and many of the field thought we knew enough to reduce prejudice, poverty, crime and other social ills. I was in a PhD program in sociology and fell in with some rennegrade sociologists who were skeptical. They maintained surveys were not a sound basis for verifiable “scientific” sociology. They argued that the data had too many poorly understood variables in linguistics, scales that were not consistent with statistical mathematics, and data gathering interaction effects to claim it was a verifiable body of knowledge. Also efforts to apply sociology wasn’t getting much in the way of results. I ended up dropping out of the degree program because I realized we didn’t know enough about the platform — about consciousness, brain function, semantics, and behavior drivers — to have a solid scientific theory of human behavior.

I went to work in local public health for a couple years and then entered a school of public health to get an MPH in health education. I remember having debates about the ethics of using what some students though was such powerful behavior change technology that we needed to have rules for using it. You’d think we were talking about nuclear energy! I had to laugh and say, “Look, a year after you get out of here you’ll be willing to hit people over the head with a two-by-four to get them to change their health behavior!” I’d already gotten some experience with how difficult “good” change could be to produce.

When I graduated I eventually went to work for a nationwide cancer organization just as the first smoking cessation programs were being developed. Techniques of education and group support were being used to encourage people to give up cigarettes. It seemed simple: give rational people solid infomartion about how bad cigarettes were for them and they’d be motivated to give them up. It turned out not to be so simple. After years of effort and tweaks to programs it became clear that, as an old friend from Mississippi told me, “the juice ain’t worth the squeezin'”. It became clear we weren’t going to solve the smoking problem one person at a time. Because “activism” in the 1960s and ’70s was associated with confrontational marches in the streets protesting the war in Vietnam, most nonprofit organizations wouldn’t touch anything political like “advocacy” as we know it. Finally, however, some militants began to articulate “non-smoker‘s rights”. Before, the social norm was that smokers had a “right” to smoke in public and it was rude to ask them not to. Eventually the first excise tax on cigarettes was passed in California to increase their cost. Jacking up the price began to get behavior change. The social context began to change as well. People began to recognize that smoke hurt not only the smoker but anybody around, and non-smokers had a right to protest. Eventually higher taxes and laws to restrict smoking in public were passed across the country. It took a couple of decades but the social perception of smoking changed from accepting to negative and mass behavior change began to come about. When I look back over about 35 years of smoking wars I’m kind of amazed that there has been as much change. Because it took so long it seemed for years like nothing was happening. The key, at least for smoking, was monetary disencentives and– after perceptions changed — restrictive laws. So what lessons am I suggesting?

  • Individual change is difficult to get, especially if the society doesn’t have attitudes that reinforce the change.
  • You need to work on societal attitudes and even laws that may positively or negativel sanction the problem you’re trying to solve. Billions will be spent by commercial interests to maintain the behavior.
  • It takes a long time to achieve much change because there’s resistance on the individual, group, and economic levels.
  • Giving citizens more power and authority over their health today is part of a long trend. Another quick example: in the1970s the Women’s Health Collective wrote a book called Our Bodies, Ourselves because women were dissatisfied about how male gynecologists were treating them. It was a signature piece of the feminist movement that produced real change. I think “our bodies, ourselves” is a good slogan for all of us. To my mind Health 2.0 is another step in this tradition.
  • Health 2.0 is oriented to a lot of technology. By itself technology will not produce much change, but over time it can become a great platform to facilitate communication and information but only once social perceptions and attitudes change.

The technology of Health 2.0 is still primitive. It’s mainly, as far as I can see, preliminary, disconnected equipment and software. It needs to mature into an integrated system that works seamlessly for people, has supporting institutions at all levels, has just-in-time information at the user’s fingertips, and is premised on a model where the person is in charge, not the doctor-institutions we’ve adopted for the last couple of centuries. Health behavior change has never been easy. There’s nothing new in that situation. Health 2.0 fans need to keep moving ahead as early adopters and enthusiasts. But really visible results are not likelhy to emerge for years. It may take a new generation to see widespread adoption of someting that would be a real paradigm change. You’ve got to have patience and understand that all this will be in constant evolution. Whatever behavior you’re looking for needs to be well interlocked with complementary systems.

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Have we learned anything from the recession?

In my last post I talked about the trade-off between committing personal and national financial resources to education of the up-and-coming generation versus the end-of-life expenses of the Baby Boom generation. When we Boomers entered the world after WWII it cost US society a lot to expand educational and other systems across the country to accommodate the Baby Boom. But it may cost even more to pay for the exit of this generation at the prices that the last years of life cost through Medicare and family supplements.

I quoted from $123,000,000,000,000*, a recent article by economist Robert Fogel in Foreign Policy. Fogel was drawing attention to the huge commitment to education that China is making. He estimates that as a result of education and other things, the country’s economy will soar to $123 trillion by 2040. The inference is that this will reduce the US and Europe to much lesser financial powers in the world; an outcome that is undesirable if not something to be feared. The implied message is that the US needs to make a similar commitment to education and other economic steps to enable it to compete and grow in the next three decades.

Fogel seems to be in awe of China’s coming achievement, and the article’s subtitle is: “China’s estimated economy by the year 2040. Be warned.” By contrast, Fogel seems rather contemptuous of Europe’s social situation: falling population and low economic libido. He states:

One-hundred fifty years ago, it was considered a sin to enjoy sex, the only legitimate purpose for which was procreation. But today, young [European] women believe that sex is mainly a recreational activity. Behind the fertility trend is a vast cultural shift from the generation that fought in World War II, which married early and produced the great baby boom of 1945 to 1965. The easy availability of birth control and the rise of sex as recreation mean that populations are likely to shrink in many European countries. […]

In another way, Europe’s culture confounds economists. Citizens of Europe’s wealthy countries are not working longer hours to make higher salaries and accumulate more goods. Rather, European culture continues to prize long vacations, early retirements, and shorter work weeks over acquiring more stuff, at least in comparison to many other developed countries, such as the United States. In my observation, those living in most Western European countries appear to be more content than Americans with the kind of commodities they already have, for example, not aspiring to own more TVs per household. Set aside whether that’s virtuous. A promenade in the Jardin du Luxembourg, as opposed to a trip to Walmart for a flat-screen TV, won’t help the European Union’s GDP growth.

Perhaps Fogel is being tongue-in-cheek in this implied criticism, but the inference is that poor Europe is a slacker culture that doesn’t want the benefits of ingesting more goods and boosting its GDP. Shame on them for not wanting a flat-screen in every room!

Let’s see: smaller population, lots of recreational sex, and a population that values taking time for life experiences rather than expending it to have more “stuff,” as Fogel puts it. Future Europe sounds to me like a great place to live. When I imagine 2040 China with  ~1.5 billion people on hamster wheel’s generating $123 trillion worth of “stuff” and activity annually, I can hardly imagine a less appealing place to live. Is an economy of that scale  supposed to be some form of Nirvana, a “worker’s paradise” perhaps?

As I recall, over the last 18 months the media have been telling stories about people in the US  who have learned that it isn’t the end of the world if they can’t afford a 50″ TV, or the latest pair of Nike collectible basketball shoes. When you remodel the kitchen is it really vital to your happiness to have granite counter tops and a professional gas range?Reportedly, some folks have even learned that a simple, less consumption-driven life could be happier than one haunted by debts to get stuff that provides thrills that expire much sooner than the bills.

I suspect that Fogel is tweaking our noses to make his point about China’s imminent ascendency. I’m with him that a nation’s wellbeing is deeply connected to it’s intellectual capital (i.e., ideas and well-educated citizens), but gross GDP is not, to my way of thinking, the best measure.

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Taking the measure of healthcare “elephant in the room”

I called this blog The Vortex because it seems to me we’re in the midst of some really big forces that’ll send us spinning. One of those — here in the US and elsewhere — is demographics. Specifically, the denoument of the Baby Boom generation — of which I am a member — is going to cause perhaps even more turbulence than our advent.

I seldom read George Will’s column in the WashPo because I almost never agree with his perspective on things, but the one he published yesterday brings up the issue of the cost of care of the elderly and its impact in the next couple of decades. I think the situation is of great concern even if I don’t agree with Will’s conclusions about what to do.

The column quotes data about the increase cost of care with age from “Forecasting the cost of US Healthcare” in  the American Enterprise Institute’s newsletter.  The author, Robert Fogel, cites what I think is pretty compelling data about the cost of the end-of-life and, by implication, the possible total cost of the expiration of my generation.

Figure 1

…In this figure, the burden of per capita healthcare costs, which is based on U.S. data, is standardized at 100 for ages 50–54. Figure 1 shows that the financial burden of healthcare per capita rises slowly in the 50s, accelerates in the 60s, accelerates again in the 70s, and accelerates even more rapidly after the mid-80s. The financial per capita burden at age 85 and older is nearly six times as high as the burden at ages 50–54. Notice that the financial burden of healthcare for ages 85 and older is over 75 percent higher per capita than at ages 75–79. However, the physiological prevalence rates (number of conditions per person) is roughly constant at ages 80 and over.

Costs rise, even though the number of conditions (comorbidities) per person remains constant, because the severity of the conditions increases or because the cost of preventing further deterioration (or even partially reversing deterioration) increases with age. It should be kept in mind that standard prevalence rates merely count the number of conditions, neglecting both the increasing physiological deterioration with age and the rising cost of treatment per condition.

Mr. Fogel goes on to discuss various ways the curve could play out over the next couple of decades and ends with what I think is an amazingly optimistic forecast that rising US incomes is going to inspire greater use of biotechnology that results in longer life, fewer chronic conditions and — by some calculus unclear to me — less than devastating total health care cost. In other words, not to worry about the hockey-stick graphs of huge long-term costs, and healthcare is a great business to be in. Read it for yourself and see what conclusion you reach.

This information is cited by George Will as part of a point I think is worth considering. The health care data sets up a contrast between the health care expenditures ahead for the US versus the very large expenditures being made for education in China as a stride toward having by the world’s largest economy by 2040. Will cites another article by Fogel in Foreign Policy titled: “$123,000,000,000,000*” — Fogel’s estimate of the total GDP of China in 2040. That’s a number intended to rock your world that will put China at 40% of world GDP while the US produces only 14%. So China replaces the US as the world’s economic hegemon less than 30 years from now.

The idea doesn’t make me shudder as badly as it would some other poeple, but I think the conundrum identified is valid: how is the US to allocate it’s resources? How much is going to be allocated to health care for us Baby Boomers versus how much is to be allocated to development of the next generations in a highly competitive world? That dilemma faces indivicual families as well. If grandma doesn’t have the money for things not covered by Medicare like long-term-care (which can run thousands of dollars per month), are you doing to wipe out the kids’ college funds?

During the recent health care reform debate calls for evidence-based treatment or comparative effectiveness were greeted by the demagogic  charge of “death panels.” Nevertheless, decisions about resources will be made, even if they’re only the path of least confrontation. This elephant-in-the-room isn’t going away, and it’s big.

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Tipping-point to government as #1 health payer is at hand

Today a burst of news about the cost of health care in the US, now and in the future, has hit the front pages. An AP report in says that yesterday Medicare’s Office of the Actuary released estimates indicating that by 2012 half of the health care in the nation will be paid for by federal and state government though Medicare and Medicaid. Earlier projections put the crossover in 2016.

There are two main reasons for this: 1) Baby Boomers will start hitting the Medicare system in 2011, and 2) the recession. The recession has thrown people out of work and out of health care plans onto Medicaid.

The report estimated that in 2009, the United States spent $2.5 trillion for health care, with government programs – mainly Medicare and Medicaid – paying $1.2 trillion. Employer health insurance and various private sources covered the other $1.3 trillion. Even as the economy shrank because of the downturn, health care spending grew by 5.7 percent from 2008. Spending by government grew nearly three times faster than private spending, closing in to overtake it.

In other data reported in Health Affairs looks at a little differently.

In 2009 the health share of gross domestic product (GDP) is expected to have increased 1.1 percentage points to 17.3 percent—the largest single-year increase since 1960. Average public spending growth rates for hospital, physician and clinical services, and prescription drugs are expected to exceed private spending growth in the first four years of the projections. As a result, public spending is projected to account for more than half of all U.S. health care spending by 2012.

So…government in one form or another is set to become the biggest payer of all in health care, ready or not.

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My self-tracking: the prequel

I mentioned a few weeks ago that I’m doing my thing with adopting a permanent exercise and diet regimen. (Who isn’t?) This program has evolved. Starting back in July 2009 I wanted to get on a self-improvement track. At the same time I was getting interested in what I think is a very significant trend: health 2.0, participatory medicine, e-medicine or whatever else people are calling it.

I started by setting up accounts in both Google Health and HealthVault. Neither is very suitable for what I wanted to do: keep track of my exercise and diet. Both are designed to enable people to set up computer accessible versions of the records their doctor or health provider has. Fortunately I’ve been in good health most of my life, and I don’t have any complicated records of disease episodes or conditions to put in there — even if I wanted to. I say “if I wanted to” because it became apparent that getting records into these PHR (personal health record) systems either requires hooking-up with a limited number of providers, using go-betweens, or just getting your paper records and manually transferring everything in. It didn’t seem worth it in my case.

However, I discovered that HealthVault offers the option of linking your medical records account up to the MSN Health & Fitness site. Health & Fitness is specifically for recording exercise and food consumption. The data and graphs are then accessible in HealthVault.

Good idea, I thought, so I started recording what I was doing in the fitness form. The Health & Fitness recording system calls for you to make a daily exercise and diet plan. Then you keep track of what you actually eat and do for exercise that day and enter it at day’s end. The program then compares your goals with what you really did. That was a problem for me because I never know what I’m going to eat, and I wasn’t embarking on such a controlled diet routine that I was going to control it by, say, preparing and packing my lunch to the office. So, for me, the food consumption planning was useless.

Also, the interface for diet planning and recording is poor. You can search for a food or drink and select from alphabetical drop-down menus. But no matter how many times you have the same thing there’s no way to get a shortcut to your commonly consumed items. Finally, the exercise planning and recording is set up around running or gym workouts. All I wanted to focus on was walking. Believe me, I’m way beyond the six-pack-abs stage.

After about three or four days I realized this wasn’t going to be something I wanted to do for weeks much less years. There was way too much “paperwork” involved through an interface that wasn’t very helpful. Indeed, I ran smack into what I think is a very common obstacle for getting people engaged with health routines: doing the manual labor of keeping track of your progress. There are notorious hurdles in the way of people keeping up sustained health routines, and this is a big one.

I realized pretty quickly that I needed a better way of gathering my data. Coincidentally my cell phone contract was up for renewal, and I latched on to what I hoped (or rationalized) would be a big step forward in convenience of recordkeeping: the iPhone. That was the next phase on my self-tracking saga, and I’ll go into using a smartphone in more detail in the next installment.

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Epigenomics in breast cancer

In my last post I talked about how empigenomics is a hot topic in understanding how genes get expressed in organismic development and how errant development can lead to disease. Well, here’s a specific case where epigenomics plays a role in a common form of cancer: breast cancer.

An article about research on — my favorite science news site — reports how epigenomics plays a role in breast cancer. The interesting thing is that, to understand it, you have to realize that there’s a kind of cellular double-back-flip involved. Let’s see if I can spell this out.

  1. There is a “signaling pathway” called tumor growth factor beta (TGF-beta) that gets over-expressed in some advanced cancers: in this case breast cancer.
  2. TGF-beta sustains the activity of an epigenetic molecule called DNA methyl transferase 1 when a cancerous cell divides and produces offspring cells. The combination of the two factors is key to sustaining the progression of the cancer because they block the expression of genes that have been turned off in the process of turning normal cells into cancer cells. In this case the “epigenetic environment” is essential to enabling the cancer promoting process to be passed on to new cancer cells.
  3. But if the TGFR-beta can be blocked it causes the methyl transferase — the epigenetic factor — to fade away. With the epigenetic factor reduced the offspring cells re-expresses normal genetics and retard the cancer characteristics.

In my last post on epigenetics I mentioned that epigenetics is ordinarily thought of as passing temporarily acquired factors from one generation of an organism to the next. But epigenetics happens also at the level of cell generations, and acquired, abnormal cancer characteristics need to be passed from one generation to the next for cancer cells to stay cancer cells through several generations as tumors grow.

So there you have it: epigenetics at work in cancer. But all this blocking and unblocking in order for cancer to be sustained opens up the possibility it can be disrupted by a drug and stop the disease.

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