Tom Munnecke’s Eclectica

In all of the discussion about health care reform today, it seems to me that we are still stuck in our thinking of trying to make a perverse system more “efficient.”  This is like trying to get out of a hole by digging faster, cheeper, deeper.  We have to face the fact that we are despite the overwhelmingly positive goals of individuals drawn to the healing professions, we are now dealing with a Disease Industrial Complex whose growth threatens to swamp our GDP and damage society far beyond that of the Military Industrial Complex that Eisenhower warned us about.

I was involved with an effort in health care reform called Vvaleo with Dee Hock, David Cooperrider, Rob Kolodner, Tom Garthwaite, Ken Kizer, and others.  It was a wonderful learning experience, with lots of counter examples to cherish.  My chief Aha! (or duhhh! ) was that gathering all the stakeholders in a perversely incentivized industry sector and asking them to self organize into a more efficient organization is simply not going to work.  Who is going to offer to get off a gravy train to allow the others to continue without them in the name of “efficiency?”

I wrote a 1995 paper with Heather Wood Ion based on Jonas Salk’s vision for health care reform called for Creating an Epidemic of Health – the last paper he reviewed before his death.  I had some 1999 workshops on the topic, and it became the catch-phrase of the Vvaleo effort.  Since then the web has appeared, and we know a lot more about viral processes.  Here’s a conversation I had with UCSD’s James Fowler and his analysis of the Framingham Heart Study data for network effects of health and happiness.

Martin Seligman, a leader in the discipline of positive psychology, has successfully flipped people’s thinking to a new balance between “positive” and “deficit” discourse in psychology, introducing an ontology of the positive in Character Strengths and Virtues to balance the disease-based model in Diagnostic and Statistical Manual of Mental Disorders.

Flipping our thinking from a disease-first to a health-first model is not asking for a trip to California lala land thinking – it is a fundamental recognition that fixing problems and amplifying resilience, adaptation, and coping are two very different things.  If a toaster cord breaks, we can fix it by replacing the cord.  If a cat loses its tail, trying to reattach it is not likely to be successful.  The cat can still be a cat without its tail.

Toasters are systems in which the whole is equal to the sum of its parts.  Understanding what’s wrong with a toaster is and how it works are equivalent forms of knowledge.  However, cats are systems in which the whole is greater than the sum of its parts.  Understanding a dissected cat and understanding a live cat are two very different ways of understanding this.  Fixing what’s wrong with the dissected cat is not going to fix the whole cat.

So it is today with our health care system.  We are applying toaster-like thinking to a cat-like problems.  The whole of our health care system is far greater than any of the parts, and operates at a level far beyond anything we can appreciate with the endless catalogs of disease-fixes.

It is encouraging to see the Department of Health and Human Services’ Healthy People 2020 initiative.  I hope that it takes more radical outlook than simply “preventative.”

Here’s some more of my writing on the subject in: Health People: Person-Centered, Outcomes-Driven, Virtual Health Systems I’m ashamed that this is in such an expensive, copyrighted book, so here is the opening chapter I wrote with Rob Kolodner, former head of national health IT for HHS, called Inverted Perspectives: Triggering Change.

Our current perspective is that health is what the enterprise does to the patient.  If we just add up all the things doctors do to patients, then we can get a grip on expenses, add things up to maximize quality of life years, and all is good.  We just need to figure out what parts of the toaster to fix, get some MBAs to do some linear programming analysis, and we have the perfect health factory with sick people coming in and healthy people coming out the other end.

But there is something wrong with this perspective.  People aren’t toasters, and hospitals aren’t factories.  Things that don’t happen, never triggering transactions from which outcome analyses can be performed, are the most significant part of the health process.  There is no way to count the things that count the most to a happy, healthful life.

Imagine a group of thugs blocking entrance to a public park, forcing you to pay an admission fee to use it.  You’d be outraged: “How can this group block me, a taxpayer, from accessing a park also funded by taxpayers?”

Now, substitute “scientific knowledge” for “public park” and “scientific publishers” for “thugs” in the above example.  Want to read the latest research on positive psychology done at a public university under public funds? Chances are, that unless you belong to a university or have some other academic affiliation, you’ll have to pay a hefty fee.

What right do these publishers have to force me, a taxpayer, from freely accessing scientific knowledge that was performed at taxpayer expense at a public university? Is their behavior that much different than those gentlemen at the park collecting their admission fees?

This has happened to me.  One of the most influential papers I’ve ever read was Jonathan Haidt’s 2000 paper on The Positive Emotion of Elevation, and his suggestion that positive emotions could create an “uplift spiral” – of good things creating more good things in an ever-widening cascade of uplift.  I blogged about this in 2003 in About Schmidt, Elevation, and Poverty Porn and in 2002 in Positive Emotions.

At the time I posted these papers, the link was freely available to all.  Here is the version that was captured on the Internet Archives at the time.  However, after it was published freely, the American Psychology Association decided to move it behind their academic firewall.  If you want to read it, you will have to register with them, provide a credit card to pay $11.95, and agree to the conditions “I UNDERSTAND that further reproduction or distribution of downloaded content other than for personal use is not permitted without written permission from the American Psychological Association….  I UNDERSTAND that I am purchasing viewing rights to a single article for $11.95 and that those viewing rights will be in effect for 12 months from the date I download the article for the first time.”

This is a little like a book publisher printing in disappearing ink to maximize future sales.

Rather than acting as a promoter of scientific knowledge, APA is engaging in what economists call Rent Seeking, wallowing in the same economic gutters as illegal drug dealers, taxi medallion, bribery, and government corruption:

“In economics, rent seeking occurs when an individual, organization or firm seeks to earn income by capturing economic rent through manipulation or exploitation of the economic environment, rather than by earning profits through economic transactions and the production of added wealth.

Rent …  is obtained when a third party deprives one party to a transaction of access to otherwise accessible transaction opportunities, making nominally “consensual” transactions a rent-collection opportunity for the third party. The abnormal profits of the illegal drug trade are considered rents by this definition, as they are neither legal profits nor the proceeds of common-law crimes. Taxi medallions are another commonly referenced example of rent seeking….

Rent seeking is held to occur often in the form of lobbying for economic regulations such as tariffs. Regulatory capture is a related concept which refers to collusion between firms and the government agencies assigned to regulate them, which is seen as enabling extensive rent-seeking behavior, especially when the government agency must rely on the firms for knowledge about the market.

The concept of rent seeking has been applied to corruption by bureaucrats who solicit and extract ‘bribe’ or ‘rent’ for applying their legal but discretionary authority for awarding legitimate or illegitimate benefits to clients.^[6] For example, many tax officials take bribes for lessening the tax burden of the tax payers. Faizul Latif Chowdhury suggested that ‘bribery’ is a kind of rent-seeking by the government officials.

Yes, the paper is available through a separate “request this paper” transaction at Haidt’s web site.  But this does not allow me to link directly to the information, nor does it provide access in the future if he’s no longer around to personally send copies.  It does not allow a permanent name or identifier (the DOI, for example).  If we are to support a “web of knowledge” we can’t have each node in the web setting up toll booths to rent access to information.  Paper-based authors, bloggers, email writers, twitterers or whatever should be able to freely link to scientific information or portions thereof (e.g. the Methods section)

Locking up scientific papers into obscure, restricted access web sites not only restricts access to those specific papers, but it also damages the connectors between those dots.  People all over the world are used to seeing a web page with a hyperlink to another page, which is instantly available. Why should scientific knowledge be locked up in this maze of proprietary, outrageously expensive links?

I once wrote a chapter for a Springer Verlag book, Person-Centered Health Records : Toward HealthePeople, edited by Demetriades, Kolodner, and Christopherson. I didn’t receive any royalty, nor did the other authors.  We had an editor who chased the authors into submitting their material, and did light copy editing, whom I presume was paid.  The book hit the shelves for $88.  Where did the money go?  How can Springer-Verlag impose these fees on people?

I’m sure that this is a hot topic in many places, but I think its time for the public to confront the bullies who are keeping the public from publicly supported research.  Enough is enough!  The results of scientific publishing should be open, freely, and permanently available to all.  Period.

Here are some things that I’ve seen relating to open publishing:

UC Riverside (my alma mater)  physicist John Baez’ response to this situation:

1. Don’t do free work for overpriced journals (like refereeing and editing).
2. Put your articles on the arXiv before publishing them.
3. Only publish in journals that let you keep your articles on the arXiv.
4. Support free journals by publishing in them, refereeing for them, editing them… even starting your own!
5. Help make sure free journals and the arXiv stay free.

The Open Access Scholarly Publishing Association

And here is an interesting slide show to Free the Facts by Dave Gray: