Corinne Ellen Kretzmann

September 13 1925 to January 17 2008

We pray.. for rest to the soul of the departed in a place of light, in a place of repose, in a place of refreshment, where there is no pain, sorrow, and suffering.
- Orthodox Memorial service.

We the living can do nothing for the dead but remember them. In time all the memories of my mother will be perfected, in the single remembrance of God or oblivion.

Until then all I can do is remember to celebrate her life, a life that did good in the world; a faithful life; a merry, kind-hearted life. I never knew all the stories of my mother's life. By now, some of them have traveled past the boundaries of forgetting. This looks like the end of the tale, but of course it is not. Ma lives on in the families of her children, and in the greater family of all those who loved her. It is only the closing of a chapter. All of the new stories run back into this story, and beyond.
I will remember this merry, kind-hearted life.

nunc est bibendum

"Running out into the summer rain with mouth wide open to catch the heavy raindrops; drinking milk from the ladle in the cowshed down on the farm during the long vacation; later in life, searching for truth in a wineglass - those are just a few of the stages in the evolution of a being.

To blame, of course, is that thirst which befalls poor mortals as soon as they see the light of day and which never lets up again afterwards. Feeling its intensity rise, our smallest contemporaries emit an appropriate acoustic signal (the primeval yell).

To blame too is the thirst for knowledge which fires our ingenuity in devising ever more thirst-quenchers (monks showing the way with holy glee)."

This appears to be a translation from the original German, on the Hotel Schloss Zell website. Marvellous, whatever language it originated in.. holy glee indeed.

Image from the inimitable Alex Waterhouse-Hayward.

Edit 2010: for some inscrutable reason this post shows up on the second page of results for Googling "nunc est bibendum translation": but I do not in fact provide a translation. Sorry folks. Here's a good one, from a Pharyngula comment: 

"Nunc est bibendum, nunc pede libero pulsanda tellus

Now is the time to drink, now the time to dance on the earth. Horace goes on to explain that there will be no drinking or dancing in the afterlife."

Children's Song

We live in our own world,
A world that is too small
For you to stoop and enter
Even on hands and knees,
The adult subterfuge.
And though you probe and pry
With analytic eye,
And eavesdrop all our talk
With an amused look,
You cannot find the centre
Where we dance, where we play,
Where life is still asleep
Under the closed flower,
Under the smooth shell
Of eggs in the cupped nest
That mock the faded blue
Of your remoter heaven.

R.S. Thomas

rehabilitation

When I was young, I used to work out a lot, and rehabilitate injuries occasionally. Now I'm old, I rehabilitate a lot, and work out occasionally. Bah.

I have my first overuse injury from swimming, some kind of rotator cuff problem. Suspect infraspinatus tendonitis but it hardly matters, since the rehab is going to be much the same whichever of the rotator cuff components is busted. Usually with overuse injuries, the cause can be tracked back to some change - more volume or intensity in workouts, new running shoes, old running shoes, etcetera. This time nothing changed, swimming the same distances and intensities as in the past seven years. Then I realized, oh something did change - I got older :-( again :-(

Frankly I'm devastated. Swimming used to be a reliable fallback position, whenever some run or bike or paddling injury sidelined me from the usual pursuits, I could work out as hard as I liked in a swim, with no let or hindrance. Now it's gone, and probably forever: tendinitis in my experience is never cured, only managed. So, I can add regular shoulder icing, stretching and strengthening, to the routine of achilles icing, stretching and strengthening. No time left for actual workouts..

me and Moominpappa

"I cannot stress enough the perils of your friends marrying.. One day you are all a society of outlaws, adventurous comrades and companions who will be pushing off somewhere or other when things become tiresome; you have all the world to choose from, just by looking at the map...
... and then, suddenly, they're not interested any more. They want to keep warm. They're afraid of rain. They start collecting big things that can't fit in a rucksack. They talk only of small things. They don't like to make sudden decisions and do something contrariwise. Formerly they hoisted sail: now they carpenter little shelves for porcelain mugs. Oh, who can speak of such matters without shedding tears !"
Moominpappa's Memoirs, Tove Jansson.

And how much worse it is when you marry in fact your own self, carpentering quietly in a warm little house and wondering where it all went, what was all that ?

pretty colours

playing with the new digital camera, Canon A630 Powershot. It seems to be proof against at least my foolishness, though I am overwhelmed by its software. All I want is a manual focus with automatic exposure bracketing, but setting that up is beyond my capability. I have a postgraduate degree in computer science and decades of tinkering - what do the simple folk do when confronted with one of these 'simple' cameras ?
Oh well. At least I was able to turn the flash off. I like its viewfinder too, saves a bit of power and it's a lot easier to see than most LCDs.


Virginia creeper in rain. It's invasive in warmer climes.


V. creeper in sun


sugar maple alone

cosmos on its own


Gloria cosmos, sugar maple leaves

healthcare nonsense

I see via the reliably interesting Jon Udell that yet another 'health-care database' is being trumpeted abroad in the land. Apparently neither Google nor Microsoft has noticed (or perhaps they prefer not to acknowledge) that the technical problem has been comprehensively solved already, by the Veterans Affairs medical system. The remaining problems are not technical but political. As Jim Gray benevolently wished for us, "may all your problems be technical". The world is full of smart people who can solve technical problems: all the smart in the world can't solve politics.

We can talk about 'shoulds' and 'translucency' all we like, in the end the insurance business will find a way to use such a database punitively.

The real question is how to arrive at a health-care system that doesn't punish the sick. The answer is technically simple but politically difficult. It starts with acknowledging that health care isn't a market. More accurately, it is a market, but the good being traded is healthy individuals, not health care itself. Senator Edward's health-care proposal (or Sen. Clinton's, as it's much the same thing) is a good first step. Once we have a system where we need not fear the database, we can proceed to establish evidence-based medicine.

Until that time, I fervently oppose all attempts to establish a database of medical records. The incentives in our current system are so perverse, that the database will be very dangerous to our health.

A secondary issue is one of simple data gathering. According to the optimistic hurrahs of Microsoft,
"People want to be able to collect, and securely store, and share their private health care information which is today scattered all over the place, with doctor A and doctor B and hospital C, and wherever they were born."
Lovely. How do they propose to extract that information from doctors and hospitals ? For them, that data is part of their competitive advantage. Whenever I get tests or procedures done (and I've had a lot recently) the results are kept secret from me: sent only to my doctor and doubtless a variety of financially interested parties, insurance companies, and so on. On a few occasions kindly nurses or technicians have actually shared the information with me, but that's the exception. For the most part an inquiry as to obtaining the technical details is treated with a kind of amazed wondering contempt by the administrative staff.

Update 2011:
Via the New York Review of Books I see:
"this past April, the Supreme Court heard arguments in Sorrell v. IMS Health, in which IMS Health, in challenging Vermont’s statutory restriction on the sale of patients’ prescription information to data-mining companies, argued that harvesting and selling medical records data is a First Amendment right. "
I don't have much confidence this Court will decide for the patient: then our data will belong to everyone but us ourselves.
Update 2017: the Supreme Court decided that the companies' right to sell your data is more important than the individuals' right to privacy. As expected.

Another notable database effort is the Personal Genome Project. In the different world where this information wouldn't be used by insurance companies to deny care, I'd enthusiastically volunteer. Well, maybe not, given the involvement of the egregious Ms. Dyson.

Update October 2007: turns out these databases aren't subject to the HIPAA privacy regulations. Microsoft's response ? "Trust us". Well, no, I believe I won't.


Update March 2008: ars technica has a decent overview of the situation. The takeaway: "many of the reasons for poor US health outcomes have much deeper structural roots related to a lack of preventative care versus emergency care, issues that are tied in to the lack of a universal healthcare system and the nature of insurance companies, that are outside the scope of medical records databases".

Update March 2010: The announcement of $20 billion in the stimulus bill for electronic health records (EHR) has started a gold rush. There's excellent coverage of the IT issues by Andy Oram on the O'Reilly Radar weblog. It elides the political question unfortunately - with single-payer many of the complexities of the IT implementations simply disappear. The problem of interoperability of competing systems vanishes, for one.

An IEEE Spectrum article covers some of the security implications. In particular my paranoia above is confirmed by Dr. Deborah Peel, who writes
"Today our [the patient's] lab test results are disclosed to insurance companies before we even know the results. Prescriptions are data-mined by pharmacies, pharmaceutical technology vendors, hospitals and are sold to insurers, drug companies, employers and others willing to pay for the information."
EHR will only expedite this process. I'd like to see a blunt rule in the HIT regulations that gives ownership of the medical record to the patient and his heirs and assigns. Currently the ownership is vested somewhere in the aether.

Update July 2010:
the HIT has released its "meaningful use" criteria for the adoption of EHR by doctors, etc. This offers a few thousand dollars (from the stimulus package) for implementation of an EHR. As Andy Oram observes,
"The catch is that they can't just install the electronic system, but have to demonstrate that they're using it in ways that will improve patient care, reduce costs, allow different providers to securely share data, and provide data to government researchers in order to find better ways to care for patients. That's what "meaningful use" means."

A few thousand isn't going to do it. The costs of EHR fall upon the doctor, the benefits accrue to society and the patient. The costs are much higher than a couple of thousand, especially considering the current wholly dysfunctional state of EHR. Many EHRs have no API at all, others have incompatible ones, and so depressingly on. Single-payer with a single EHR solves all these problems at once, but because it's politically impossible, we're left with hideous technical problems.

I am however happy to see that HIT has included the requirement that the EHR be available to the patient.

EHR update 2021, in conversation with an implementer: 

Connecting Epic instances across hospital systems is relatively involved

I said,
This is the same software, running in different places, and it can't manage the most basic of EHR requirements, interoperability. The whole point of EHRs was to be able to interchange health records between different software systems and healthcare systems.
The state of healthcare in the USA is always worse than can be believed..
He responded,

I had a conversation this morning about the best way to exchange a certain class of data, which there was a "standard" established over a decade around said exchange. Our conclusion was that flat files (basically giant CSV files) were likely to continue to be the best option here as every example we found/knew of was either flat files or places that had attempted to implement the standard and then went back to flat files. Maybe next decade the standard will be sufficiently ironed out...

Back to the original 2007 post..

Side rant on a related note, the faery realm of consumer-directed health care: how is it that society spends six to ten years training doctors to provide health care, then rewards them handsomely for their expertise: yet, once the market fairy appears, consumers (who may not have completed high school) are supposed to be able to 'direct' their own health care ?
For what value of 'direct' can this policy actually work ?
Airily assuming that the policy works, the next question arises - What is the market failure that makes doctors so expensive, when untrained consumers are able to effectively make the same decisions and determinations as said doctors, about their health care ?

Shadowfax makes this point much better than I, patients are not and cannot be consumers. From there, "HALF of all health care costs in the US is concentrated in only 5% of the population". It really doesn't matter how scrupulously the other 95% shop for cheaper bypasses, chemo medications, etc.

Update 2015: Apple now plunges enthusiastically into the swamps, with the HealthKit app(endage) to the Apple Watch, which itself requires an Apple Phone. I do not expect it to end any differently from the Microsoft, Google or Samsung projects. The IEEE provides a thoughtful analysis again.

Update 2016: John Quiggin in the Guardian, on market failures:
"Many of the same issues arise in healthcare. Obviously, if we knew what was wrong with our health and how to fix it, we wouldn’t need doctors to tell us. As it is, we need to rely on the judgment of our doctors to give us the right treatment and, equally importantly, to tell us when we will get better without treatment. The greater the role of profit in the system, the greater the incentive to provide unnecessary or overpriced services. The example of the United States, which spends more on healthcare than any other country, with worse results, is an illustration."

Update 2017: the market in healthcare turns out to be your data.  
“Data scientists can now circumvent Hipaa’s privacy protections by making very sophisticated guesses, marrying anonymized patient dossiers with named consumer profiles available elsewhere – with a surprising degree of accuracy”. 

Also in 2017, the state of EHR - still wholly dysfunctional, as predicted.
"43 percent reported that outside patient information was available electronically when necessary, but more than one-third reported that they rarely or never used it. The most common barrier these hospitals reported to using outside information was that their clinicians could not see it embedded into their own system's electronic health record."

Update 2019: Facebook isn't making enough money, so they are also making a health-care play. As @emilymullin notes, of course none of this data is protected by HIPAA either. Facebook says, "trust us" but I think I do not.

Update January 2020: Google now has all your health care data, to do with as it will. So it goes.
" In just a few years, the company has achieved the ability to view or analyze tens of millions of patient health records in at least three-quarters of U.S. states, according to a Wall Street Journal analysis of contractual agreements.
In certain instances, the deals allow Google to access personally identifiable health information without the knowledge of patients or doctors. The company can review complete health records, including names, dates of birth, medications and other ailments, according to people familiar with the deals."

From that same WSJ article, this part is hilarious: 
"Cerner ultimately accepted a less generous offer from Amazon, in part because the company decided Amazon was more trustworthy on security." 
Jeff Bezos, who started Amazon as relentless.com, which he still owns and redirects to Amazon; the company that does this, and this, as we live in serfdom. Trustworthy ?  

Also this month, via @WolfieChristl,  
Experian announced that 'every person in the U.S. population, of an estimated 328 million Americans, have been assigned a unique Universal Patient Identifier'.
The ID is 'not intended' to be 'patient-facing' and is 'not known to the patient'.
'Each individual in the U.S. that has received medical care or utilized a pharmacy has been processed through the solution and assigned a UPI.'
A universal ID that is opaque to the individual, what could go wrong.
This solution comes to you from Experian, with its unparalleled expertise in losing sensitive data and walking away scatheless.
The patient behind the UPI of course might take some harm, but it's unlikely to harm Experian's profit margin, so that's all right then. 

Update 2021: A huge well-funded initiative to 'disrupt health care' run by the smartest guys in the room, just collapsed as we all expected. Helaine Olen has the rundown in the Washington Post. 

The reason our health-care system fails to work for so many is the same reason people were convinced three CEOs could solve the problem: our nation’s worship of the free market and business success. Instead of taking such common-sense steps as permitting the government to regulate the cost of pharmaceuticals or hospital charges for services, we leave it to a pastiche of insurance companies, hospitals, pharmacy benefit managers, corporations, private equity — you name it. The result is that no one is responsible, costs run rampant and the patient all too often gets stuck holding the bag.
...
Bezos, Buffett and Dimon could not successfully take on the U.S. medical system, because when it comes to health care, there is no substitute for systemic government action and overall reform. 

Those magical disruption market beans just aren't giving ROI anymore.

Update 2024: now with AI ! 

Today Sam Altman and I published a piece in TIME sharing our vision for how AI-driven personalized behavior change can transform healthcare and announcing the launch of Thrive AI Health, a new company funded by the OpenAI Startup Fund and Thrive Global, which will be devoted to building an AI health coach. The company’s mission is to use AI to democratize access to expert-level health coaching to improve health outcomes and address growing health inequities. 

This is the Sam Altman that said,

“I probably trust the answers that come out of ChatGPT the least of anybody on Earth,” Altman told the crowd at Bagler’s university, to laughter.

He doesn't trust his product, but I guess it's good enough for the rest of us in the Altman calculus. 

"Compel the poor to live upon a crust of bread, by soft mild arts

when a man looks pale

With labour and abstinence, say he looks healthy and happy"

The fine print shows this coach will give you helpful advice like, sleep more, eat better, exercise more. These are choices that are available only to the wealthy like Sam Altman and Arianna Huffington, and to the upper middle class which has stable employment, predictable work hours, and health care. For the other 80% of the world this coach does nothing. Not to mention that it does absolutely nothing to address inequities. Who is buying this nonsense ? 

"Wisdom is sold in the desolate market where none come to buy"