Risk Mitigation, Political Ineptitude, and the Failure of Public Health Policy

Various reactions to the coronavirus pandemic in mid-to-late May raise a disquieting thought: What if the logic model of public-health policymaking is structurally flawed? I don’t claim to have an answer or a solution, but I think the question requires meaningful discussion.

Let’s start the conversation by reviewing CDC guidance about preventing the spread of SARS-CoV-2. Then we’ll explore individual and social risk mitigation, followed by the long-term political risks of over-reliance on public health guidance.

Public Health Guidance: The Dirty Secret

Everyone’s heard the CDC guidelines for staying safe during the Coronapocalypse — 

  • Wash your hands often with soap and water or use a hand sanitizer of at least 60 percent alcohol before you touch your eyes, nose and mouth
  • Avoid close contact and practice “social distancing” of at least 6 feet
  • Wear a cloth mask at all times when you’re around others
  • Do not wear an N95 mask; that model should be reserved for healthcare workers only
  • Clean and disinfect frequently-touched surfaces daily
  • Take your temperature

Simple, right? But the devil’s in the details.

Public-health officials reduce the management of complex diseases and medical conditions into a small set of easily comprehended behavioral norms. These rules, because they’re intended to be fully intelligible even to people with below-average cognitive repertoires, often elide the details and the counterfactuals. Doctors and public-health bureaucrats issue directives intended to serve as maxims — as a catechism of sorts — that everyone memorizes and observes. Deviation from the catechism is bad, either for your own health (as with chronic-disease avoidance) or for others. When others come into the equation (as with Covid-19), deviation may even be accompanied by legal sanctions or social shunning. In most cases, though, the maxims are useful and benign.

All these rules offer broad generalizations that won’t be applicable in all circumstances, however. That’s the problem with broad-based, simplistic rulesets: They work at a 60,000-foot level, but sometimes prove incoherent at a 6-foot level of social distancing. But because they’re The Rules™ they’re inviolable, even when a proportion of the population recognizes that a specific application of those rules proves absurd. The reaction in Michigan to Gov. Gretchen Whitmer forbidding big-box stores from selling gardening supplies or from people engaging in recreational boating offers an excellent case in point. She invoked restrictions about essential and non-essential business activities that might, at first glance, enjoy some grounding in Science™ but in context stood in almost perfect contradiction to the best available clinical evidence.

(Turns out, you actually should be outside, and both gardening and boating are great environments to get some sun and to get some fresh air while not being in close proximity to others.)

Let’s go back to those CDC guidelines, developed by public-health officials to serve as an easily understood catechism. What are their vulnerabilities?

  1. Wash frequently: Frequent hand-hygiene is default best practice. The CDC guidelines for frequent hand-washing with soap and water (normal soap, not the antibacterial kind, I might add) is always called for, as is alcohol-based sanitation in the absence of soap and water. This is a good guideline, but it’s universal — not just applicable to SARS-CoV-2. You should always practice good hand hygiene, pandemic or not!
  2. Social distancing: Useful in principle, useless in (some) practice. Social distancing has been invoked as some sort of magical talisman to ward off infection, but it isn’t. The six-foot exclusion zone is just an average. Given what we know about the way SARS-CoV-2 spreads, in some cases six feet isn’t enough, but in other cases, it’s superfluous. To be infected, you must be exposed to a certain number of active virus particles. At a clean, well-lit and well-ventilated supermarket, passing within two feet someone who isn’t coughing isn’t likely to materially increase your risk of infection. However, it’s several orders of magnitude worse to stand cheek-by-jowl for 10 minutes to buy Michigan Lottery tickets in a dank liquor store with no active ventilation. And the risk of infection outdoors is almost zero; the infinitesimal number of confirmed outdoor-infection cases in China relate to people who stood in close proximity and talked face-to-face, unmasked, for an extended period of time. Keeping eight to 10 feet of distance from unmasked people in a dark and poorly ventilated space makes a ton of sense; keeping six feet away from masked people in a bright, breezy public park offers comparatively less value. But because the rule must be simple and universal, it doesn’t admit to context-sensitive refinement or prudent situational enforcement.
  3. Cloth masks: The CDC tweaked its message; nowadays, the rule is to wear a cloth mask to prevent the infection of others, not to avoid infection yourself. To be clear: Wearing a cloth mask doesn’t stop you from being infected. Rather, those masks minimize the transmission of virus particles by infected but asymptomatic or pre-symptomatic carriers. That being the case, after you’ve been confirmed to have antibodies and aren’t symptomatic, you aren’t a transmission risk. Yet the “thou shalt wear masks” rule is considered an absolute, with some stores refusing service if you don’t wear one, even when any individual person presents literally zero risk to others or the environmental context is not favorable to virus transmission. In fact, the CDC recommends masks only when “other social distancing measures are difficult to maintain.” When you read the fine print, you discover that the recommendation is not for all people to wear masks in public at all times.
  4. Avoid N95 masks: From the beginning, CDC said N95 masks weren’t necessary. This lie (and it was a deliberate lie) was intended to minimize runs on these masks, preserving supply for frontline healthcare workers. And as someone who’s worked in health care for two decades, I totally get it. But an N95 mask, if properly fitted and used according to spec, not only reduces your outbound infection risk, but also your inbound infection risk. Everyone should be using N95 masks, not homemade cloth masks. But because the supply chain proved fragile, the CDC offers guidance that is deliberately inaccurate to distort the market for these masks. No matter how noble, a lie is a lie, and when people know it’s a lie, then why should they trust any of the other guidance? Especially when it breaks down within a specific context? It’s difficult to understate the credibility hit that public-health officials took over this about-face on masks.
  5. Clean and disinfect: CDC recommends daily cleansing of surfaces. However, different pathogens react differently to different surfaces in different contexts. For example, on copper, SARS-CoV-2 has an estimated life of just four hours. On cardboard, it’s 24 hours. On glass, it’s up to five days—but not glass exposed to direct sunlight. But you don’t get infected from a surface; SARS-CoV-2 doesn’t enter the body through hands or skin. If you practice religious hand hygiene, you will not become infected from surface contamination. That said, obviously you should not allow your stuff to become a petri dish of pathogens. But the practice of ostentatiously disinfecting, say, shopping-cart handles doesn’t really matter as long as you wash or sanitize your hands after shopping but before you touch your eyes, nose or mouth. This surface-disinfection practice certainly helps to a degree (what if you involuntarily touch your eye to remove an eyelash? or absently re-adjust your cloth mask and touch your lips?), so it’s not a useless exercise, but it’s an adjunct practice to limit transmission of the virus through the respiratory tract. Fetishizing the cleansing of surfaces brings diminishing marginal utility, but it creates a false sense of security that makes other precautions seem less urgent. (“I won’t bother with hand sanitizer because the nice lady sprayed my cart handle with something, so I’m safe.”) So, yes, clean your surfaces — but understand that surface contamination in itself isn’t an infection risk.
  6. Take your temperature: Something like 40 percent to 80 percent of all transmission events are estimated to occur from people who are asymptomatic or pre-symptomatic. That’s the big reason for the “wear a mask” rule — you’re highly contagious early in the infection, before symptoms manifest (if they manifest at all). But you only show a fever when you’re symptomatic, and fevers aren’t restricted to SARS-CoV-2 infections. The practice of some healthcare organizations, TSA and some retail establishments of taking surface skin temperatures is therefore odd. If you’re sick enough to be symptomatic, you’re likely not traveling anyway, and even if you are traveling, an elevated temperature (unmanaged by a fever reducer like acetaminophen, which will fool the thermometer in low-grade cases) could source from any of hundreds of infections, not all of which are transmissible. You’ll get a fever if your appendix is about to burst, but you’re not going to mass-infect people with appendicitis if you’re out in public. Public temperature reads are very obviously kabuki theater — no different from TSA “randomly screening” an 85-year-old grandmother.

Put differently: CDC guidance is directionally useful at a population level, but the value of the guidance — because it must be simple enough for low-IQ people to understand — diminishes as you move from the general to the particular.

This phenomenon always applies to the management of any disease condition. Public-health officials focus on the herd, not the individual. Public-health guidance is replete with “rules” that don’t make sense in specific situations but reduce herd risk in the aggregate. Perhaps the classic pre-coronavirus example relates to HIV transmission. The official guidance is to not engage in unprotected sex (without a condom or pre-exposure prophylaxis or both) with someone who is HIV positive or who is uncertain about his HIV status. Yet a person can be HIV positive but maintain clinically undetectable levels of the virus thanks to modern antiretroviral therapies. There’s almost no risk of contracting HIV through unprotected sex with someone with an undetectable viral load. But that kind of asterisk doesn’t fit on a bus poster and it’s not easily digested by a low-IQ audience, so the high-level rule remains unchanged.

(Obviously, unprotected sex can generate other infections beyond HIV, but that’s beside the point.)

Plenty of problems arise when individuals and politicians maximize the 60,000-foot advice at the expense of useful context, though. People cannot properly account for risk through universal rules, and when they experience the disconnect between the universal and the particular, they may dismiss the universal guidance wholesale as “fake news” or “political posturing.” 

This 60,000-foot-to-6-foot scale problem may be a fatal structural flaw with the entire discipline of public health management.

Risk Mitigation for Individuals and Groups

In the WEIRD world, transparent and open access to information is crucial. With information, individual actors price risk effectively. That’s why we’ve got laws against insider trading. The pricing of risk — actuary science — can be arcane, but it’s a critical skill for thriving in a complex environment. Every action entails some degree of risk, from which we protect ourselves with insurance or with behavior modification. High-risk activities tend to require higher premium payments, because the insurer is likely to experience higher or more frequent payouts, or more elaborate safety mechanisms. It’s well known that humans tend to suffer loss aversion and retroactively rationalize predicable but low-frequency loss as a black-swan phenomenon. In other words, by default, we tend to suck at accurately estimating risk on the fly. Actuaries are simultaneously boring and critical.

Risk mitigation works on an individual level, too. We all take various steps to reduce potential harm, often when the mitigation step is minor and the potential cost is very high but the risk is very rare — as with wearing a seatbelt to prevent ejection through the windshield after a high-speed impact. Other forms of risk mitigation incur minor costs when the risk is high but the cost is low, as with frequent handwashing during cold-and-flu season. And sometimes, as with Covid-19, we don’t know enough to estimate cost or risk.

Each person must judge risk for himself, though. The relative risk-to-reward ratio is a subjective assessment. One reason the “don’t tread on me” types rejected both the Affordable Care Act and the wear-masks-in-public rule stems from a sense that they price risk differently from the authorities; mandates that overrule a person’s innate risk threshold are seen as an infringement of liberty. They don’t like that their choice to act or not-act has been taken away from them, that someone else imposed a risk-reduction cost that they wouldn’t have voluntarily accepted. And in a tort-happy legal system, the dial seems to turn ever more tightly into a health-and-safety framework that nowadays results in CPS referrals if a kid plays alone in the front yard. A big part of the modern populist movement is, in a sense, a reaction against costly or invasive mandates arising from irrationally low risk tolerances in public policy.

Think of it this way. Assume that two years from now, a new respiratory virus spreads across America. We know that if you venture into a mass public gathering, you have a one-in-five chance (20 percent) of acquiring the illness, and if you’re infected, you have a 1 percent chance of dying. A public-health expert says that in a nation of 300 million, half the people venture out in public once per year. Thus, they estimate that 300,000 people will die in a year from this new virus without interventions. They deem this risk unacceptable, so they ban public gatherings, driving both the infection rate and the case-fatality rate to very low numbers. 

A win for the experts, right? All it cost was 1 percent of GDP from lost economic activity arising from the banning of those gatherings, including the loss of 1 million jobs. (And no one calculates the secondary effects of the solution, including increased rates of alcoholism, drug addiction and diseases of despair that arise from the economic dislocation of the public-health intervention.)

But what if instead of ordering a banning of those events, officials laid out the risks? If you as an individual realized that each mass public gathering you attended translates to a 0.2 percent morality risk, would you still go? Would your opinion change if you realized that the only people who died were those with a defined set of risk characteristics that you either did or did not share? It’s likely that these events would shrink, but they wouldn’t be banned. Some people would likely die that wouldn’t in an outright ban, but the secondary economic and health risks wouldn’t materialize, either. It’s not an easy choice, but it’s a necessary one.

The structural bias of public-health policy is that the average citizen is too disengaged, or simply not capable, to make an informed decision in light of these facts. Thus, they set rules — intelligible at a fourth-grade reading level, and often accompanied by pictures — that easily distill to a few slogans that anyone can understand. Even, significantly, people with an IQ that’s more than one standard deviation below the mean, which therefore necessitates the removal of a lot of context in order to preserve the universality and intelligibility of the rule. Plus, they favor population-level interventions (mandatory masks and social distancing, quarantines) in lieu of targeted strategies for clinically relevant sub-populations. 

Perhaps, though, public-health officials ought to focus on risk identification and quantification and risk-cohort stratification, and let the mitigation strategy fall to individuals and elected leaders. Because when the experts in a very narrow field gain control of the levers of power, too much goes awry.

The Long-Term Political Risk of Public Health Kabuki Theater

Remember in March when the primary justification for state-level quarantine orders rooted in a fear of over-stressing the health systems and running out of ventilators? Turns out, people across the ideological divide got behind that argument. Then, when the feared stresses and ventilator shortages failed to materialize, some governors changed their tunes. Now, emergency orders were justified to “bend the curve” or to prevent people from becoming ill.

It doesn’t take a constitutional genius to realize that neither state nor federal governments labor under an affirmative duty to prevent individual citizens from acquiring a respiratory infection, even a particularly nasty one. Offer high-level advice? Sure. Pen emergency orders requiring people to remain in their homes and, in many cases, to lose their livelihoods? Maybe not.

Public health officials throughout this pandemic did what they always do: They offer a maximalist case for applied epidemiology: “To minimize harm, engage in these activities and refrain from these other activities.” Too many political leaders simply parroted this advice without translating it into a broader risk profile that included considerations far removed from the public-health officials’ domain of competence. Like, for example, economics. Political leaders who outsourced policy to the most risk-averse public-health expert didn’t effect a good kind of balance. This dynamic played out — in part, from partisan-media laziness — in a red-vs-blue divide among the governors. The reality is a bit more complex; after all, Gov. Brian Kemp of Georgia (a Republican) was targeted by the media for opening Georgia while Gov. Jared Polis of Colorado (a Democrat) did pretty much the exact same thing at the exact same time and the media didn’t pounce.

A better example might source from a pair of Democrats. In Michigan, Gretchen Whitmer cloaked herself in the righteousness of public-health virtue even as some of her directives offered no meaningful effect on public health but scored Democratic Party talking points. Meanwhile, the attorney general, Dana Nessel, publicly argued with President Trump over wearing face masks at the same time that Whitmer herself appeared at a news conference without one. In Colorado, however, Jared Polis reopened the state using a model that balanced emerging cases relative to economic risks. (So did Brian Kemp. And a few other governors, Republican and Democrat alike, didn’t shut down their states at all.)

It’s not red-vs-blue; it’s holistic vs. outsourced. Governors most averse to pandemic risks tended to maximize vague public-health rules and talk about “safety” while governors most averse to long-term economic and secondary public-health costs tended to blend expert advice from many disciplines into a more comprehensive plan of action. 

The effect of the safer-than-thou governors may prove catastrophic in the long run — not from Covid-19 morality figures, but from public rejection of the “we’re in this together” argument that makes early, strong action uncontroversial. If, two years from now, a new coronavirus appears with significantly “worse” clinical profiles to SARS-CoV-2, and Gretchen Whitmer invokes emergency powers to shut down the state, will she get an early bipartisan consensus and public support like she did in 2020, or will a non-trivial chunk of the population trot out the “fool me twice” canard and actively resist from Day One?

Worse, ostentatious compliance or non-compliance becomes a form of virtue signaling. Security guards have been killed because they refused admittance to non-masked store patrons; some store patrons have chased un-masked shoppers out of stores. It’s dangerous that a face mask, which is only contextually useful, absolutizes into totemic status. Yet here we are.

You get one chance to deploy public-health emergency powers. Screw it up politically, and you don’t get a second chance, even if the second occurrence justifies the emergency more strongly than the first chance did. I’m terrified of the long-term repercussions of Gretchen Whitmer’s deferral to public-health authorities and her refusal to work effectively with the Republican-led state legislature. Because the next crisis will be worse. And now, we’ve potentially lost a vital tool because we misused it the first time.

But Whitmer’s fecklessness isn’t the whole problem. Perhaps our public-health officials, who are so sure of themselves and of the principles of their discipline, ought to take a long look at whether they made things worse by offering systemic policies that source from one domain of knowledge only, and which didn’t allow for reasonable tailoring at the 6-foot level where ordinary citizens reside.

A Covid-ing We Will Go

Several close friends have asked me a handful of questions about the SARS-CoV-2 virus and the Covid-19 disease. So I’m sweeping around with another post, focused mostly on the pandemic and wrapping up with miscellaneous personal updates, current as of April 19, 2020.

Sections in this post include:

  • The Problem of Relevant Knowledge
  • The Political Response to the Coronavirus Crisis
  • Re-Opening the Country
  • The Ad-Tech Power Play for Covid-19
  • Supply Chain Chaos
  • Personal Updates [mostly cat-focused]

This post offers some extra oomph—it clocks in at around 6,300 words and should take the average visitor 20 minutes to read. (Of course, visitors to A Mild Voice of Reason are well above average, but mean readability stats are what they are.)

Although I’ve enjoyed more than 20 years in the health care industry and have worked both as a manager responsible for population-health analytics and as a clinical ethicist, I am not a licensed provider or an epidemiologist. My pop-health work stands adjacent to infection prevention, but it’s not the same thing—significantly, I interpret population-level data rather than fine-tune or implement the interventions that affect that data. Please take my professional history into account as you review this post, and understand that I do not present myself as an epidemiologist or a virologist.

The Problem of Relevant Knowledge

We’ve seen over the last few weeks an interesting trend—the worst-case models continue to dial backward, with top-of-crisis projections decreasing by significant proportions. The “we could face more than 1 million deaths” concerns early in the the widely used IHME projection now seem to settle on “we could face up to 70,000 deaths” while the feared ventilator shortage—well, we haven’t yet run out of vents.

Let’s be clear: None of the experts have been lying or scare-mongering for the lulz. Rather, the message changes as our understanding of SARS-CoV-2 and Covid-19 continues to refine. Some of the usual bloviators have harvested much succulent hay about these revisions, but these estimates were originally offered in good faith. Yet the solutions—social distancing and lockdowns—that made sense with potential million-person death tolls look disproportionate to current-state fatality estimates. And that discrepancy isn’t helpful as the crisis migrates from a public-health concern to a socioeconomic concern, particularly when models (like the IHME model) have been advanced as being “good science” despite that the modelers appear, from the outside, to perform the methodological equivalent of pulling numbers from betwixt their glutes.

Here’s the fundamental problem: No one knows what the hell is going on. So let’s unpack what hell means.

Think of a population-wide viral infection as occupying four distinct stages:

  • Stage I: Awareness. In the first stage, we don’t know much about the virus but we do know that something significant is afoot. How significant remains a matter of scientific investigation. To borrow a Star Trek reference: We’re at Red Alert, but we haven’t yet identified the enemy vessel so we cannot specify a particular defensive or offensive strategy.
  • Stage II: Management. In the second stage, we understand the way the virus spreads and how to contain it, as well as how to assess its impact on specific populations. We don’t have a good way of neutralizing it pharmacologically, but we know it well enough to understand how it operates and how to limit its spread across a broad population.
  • Stage III: Mitigation. Not only do we understand the virus, but we’ve developed specific therapies to limit its spread within the “herd” through targeted pharmaceuticals like vaccines and effective post-infection therapies. Approaches to identifying and avoiding it are well-established in clinical literature and reasonably well-known by the average person.
  • Stage IV: Normalization. The virus is part of everyday life, something to be managed through primary care but not—regardless of the waxing and waning of its prevalence—a matter of significant concern for the average lay person.

Consider common viruses: The common cold is Stage II, HIV is at Stage III and seasonal influenza is at Stage IV. SARS-CoV-2, the virus that causes Covid-19, remains at Stage I. Here’s what we do not know about SARS-CoV-2 and Covid-19:

  • The current population prevalence of the virus (the denominator of any public-health metric). Numbers from China are almost surely a bald-faced lie intended to protect the corrupt Xi Jinping regime, and the World Health Organization—defunded by the Trump administration last week—has remained a willing participant in China’s disinformation campaign. Agree or disagree with Trump, but in the long run, the WHO has a lot to answer for. Prevalence numbers in the U.S. vary by location, with the Eastern Seaboard spiking and California proving vexingly quiescent. The numbers out of Italy look bad, but Italian authorities use a non-standard method of classifying cause-of-death. Some recent pre-press studies suggest that up to 20 percent of the U.S. population has been infected without symptoms, while other studies suggest the number is an order of magnitude smaller. Bottom line: We don’t know the denominator for any ratio about this illness, nor do we yet enjoy even a right-order-of-magnitude estimate of the denominator.
  • The case-fatality rate (the number of people who die per thousand from infection). Aboard the aircraft carrier USS Theodore Roosevelt, one crewman of 600 infected died from Covid-19 and four more were hospitalized, although none of them required a ventilator. These stats translate to a case-fatality rate of 1.7 per thousand, compared to 1.3 per thousand for the 2016/2017 seasonal flu. These numbers differ from a global rate of 69 per thousand as per Bing stats as of 4/19 versus a typical 1 per thousand for seasonal flu averaged across years. Why the difference? To a degree, it’s a question of cohort segmentation. Evidence suggests that Covid-19 is much more deadly for the elderly and people with several chronic comorbid conditions. Thus, the population of Lombardy, which skews older, saw a much higher death rate than the younger, healthier sailors aboard the Roosevelt. In addition, criteria for death reporting vary wildly, leading to inconsistent results among geographic hotspots and population cohorts. Revised all-population death figures from Wuhan, per the linked data from New York Times, currently stands at 14 per thousand and may likely decline as numbers refine.
  • The virulence of the virus (how contagious it is, expressed as the metric R-naught, with a ratio of “one person infected then infects two others” expressed as R0 = 2.0). Without a good estimate of population prevalence as captured through random serology testing among the general public, it’s hard to estimate the R-naught value. And without that core number, estimates about disease transmission ring hollow.
  • The mechanism of impairment (the specific way the virus causes symptoms among individual humans). Why do older people die disproportionally to the young? Why do people with chronic conditions die more readily from Covid-19 than others? The truth is, no one really knows how SARS-CoV-2 actually affects the human body. We know that a leading cause of Covid-19 death lies with acute respiratory insufficiency. Some physicians now theorize that ventilators, themselves, are part of the problem. The bias in Western medicine is that once your blood oxygenation saturation falls below 95 percent, you’re at risk. Below 90 percent or so, and you’re going on a vent. But plenty of cases have surfaced were people with sats in their 70s are still talking and functional despite not being on oxygen support or a ventilator. Why? Theories abound. One leading hypothesis suggests that Covid-19 performs less like pneumonia and more like high-altitude pulmonary edema, for which mechanical ventilation (as opposed to mere oxygen supplementation) actually proves more harmful in the long run. Another theory is that the virus disrupts hemoglobin, although subsequent pre-press studies question this finding. Another theory is that our whole logic model for ventilation—which depends on O2 sat levels—has been wrong for decades and that perhaps we’ve been putting people on vents who’ve never needed it in the first place because the old guidelines weren’t sufficiently refined. The point is, we don’t yet have a well-recognized theory about how SARS-CoV-2 disrupts respiratory function, and the little we know suggests that decades-old received medical wisdom could be egregiously wrong. So we don’t even really know what the problem is, let alone the optimal way to treat it.
  • The origin of the virus. A common conspiracy hypothesis suggests that evil Chinese warlords released the virus from a lab in Wuhan. That theory is idiotic. The two more-plausible contenders—that it originated from a bat-to-human event somewhere in or near Wuhan, or that it was accidentally released from a lower-security zone of a lab near Wuhan—don’t free the Chinese Communist Party from its willful culpability in spreading disinformation, but it does suggest that whatever happened, wasn’t intentional. But the story of what really did happen, which is essential to understanding the virus itself, still hasn’t been revealed by the corrupt Xi Jinping regime.

These things we do not know about SARS-CoV-2 and Covid-19 pretty much include every single metric an epidemiologist requires to get a good handle on what the virus is, how it works, and how dangerous it is in the long run. The TL;DR version—we don’t know enough about the virus or its disease to make informed public policy decisions about how to confront it. Such epistemic reticence hasn’t stopped public-health officials and elected leaders from nevertheless making significant social and economic decisions. So why are we practicing social distancing and why are political leaders shutting down travel and broad swathes of the economy? Because of the Precautionary Principle, as refined by epidemiologists.

The Precautionary Principle first arose from concerns about environmental degradation arising from potentially harmful chemical pollutants. It’s considered a cornerstone philosophy for regulation within the European Union, and its logic model extends beyond the EU into politically progressive approaches to risk mitigation. It’s well-established as a governing principle of elite health-policy guidance. In a nutshell, the principle holds that the absence of clear evidence shall not be considered a good reason for postponing well-intended cost-effective interventions. Thus, as long as there’s at least plausible justification to suspect that harm might result from inaction, then the proper response is to act to stop harm even if the science lags in justifying a particular intervention. 

When epidemiologists are empowered to set public policy, they’ll typically work within the Precautionary Principle. Thus, despite a lack of clear evidence about how bad Covid-19 really is, the first instinct among regulators in the absence of a recognized therapeutic regimen is to aggressively manage R0 by means of strict social-distancing regimes. This approach is basically Public Health 101—a generic intervention intended to reduce the spread of a pathogen. In the long run, this strategy may prove prescient. However, we’re not far enough into this pandemic to grasp whether aggressive population-wide quarantining is optimal from a health and economic perspective. In hindsight, we may well conclude that everyone over-reacted … or that we weren’t aggressive enough in enforcing social isolation procedures. Until we progress into Stage II or Stage III, we cannot be confident that anyone’s opinion, whether permissive or restrictive, acquits as prudent. Likewise, we must be on alert for people who engage in post hoc rationalization of strict social quarantine regimes as “proving their value” by lower-than-expected R0 or in proving that social quarantines were unnecessary to begin with. Not only do we not know enough to justify these broad lockdowns, but we don’t know enough to determine whether the lower-than-expected severity of Covid-19 relative to early models arises from the effectiveness of these unprecedented interventions or from some other source altogether. (Nor, for that matter, do we know enough to suggest that these interventions were inappropriate. The moral of the story is that we do not know enough. Period.)

I want to be clear about something: I’m not dismissing the advice of public-health officials or suggesting that the Precautionary Principle in the context of Covid-19 is inappropriate. I lack the data and the technical expertise to render an authoritative opinion either way. And I’m voluntarily adhering to the the strictest form of the combined CDC and State of Michigan guidance about appropriate behavior, mostly because I’ve been doing pop-health analytics work for far too long to pretend like the risk isn’t well-enough defined to justify a reasonable behavioral modification.

But conformance doesn’t occur in a vacuum, and I fear that the ham-fisted way that some political leaders—including Michigan Gov. Gretchen Whitmer—have approached the problem will only exacerbate the the long-run socioeconomic crisis.

The Political Response to the Coronavirus Crisis

Politics, fundamentally, is the art of allocating scarce resources. I’m skeptical of outsourcing public policy to doctors and epidemiologists in part because these experts, despite their necessity, operate with a single-minded focus on the subject to which they claim expertise in light of the Precautionary Principle. So the idea that there’s virtue in letting “science” or “public-health officials” determine governmental response to a public-health crisis rings hollow. Politicians should be setting the policy—informed, of course, by experts, but sensitive to the needs of the electorate and to the economy.

One reason that Michigan has devolved into bitter acrimony over Covid-19 restrictions relates to the fairly transparent accommodation of rent-seeking behavior from Democratic constituencies by our Democrat governor, Gretchen Whitmer. Here’s a partial summary of what’s legal and illegal “to protect public health” within The Mitten—

  • The Michigan Lottery remains open and available. Why? (Because of tax revenue, despite that lottery players must, in many cases, interact closely with retailers to purchase their tickets.)
  • Marijuana dispensaries are considered “essential” and thus can both operate and deliver the goods, despite that federal law prohibits such activity. Why? (Because the pro-pot lobby is a core part of the Democratic constituency in Michigan.)
  • Big-box stores must shut down nurseries and home-improvement areas. Why? (Because people taking advantage of at-home quarantine seem to be “not taking it seriously“, thus necessitating the shutdown of gardening, home improvement, and flooring sections of big-box retailers as a form of class-conscious legalized shaming.)
  • State parks are either closed or closed to “nonessential travel.” Why? (Because any exception to the stay-at-home order undermines the legitimacy of the stay-at-home order, no matter how little evidence suggests outdoor transmission of the virus.)
  • Recreational boating is off limits. Why? (Because hunters and sportsmen are not a core Democratic constituency, despite that there’s no known risk to letting people tool around a lake on a motorboat. The official argument is that “the provision of boating services or supplies does not itself constitute critical infrastructure work” although it’s not clear why a person cannot use a motorboat that doesn’t require “boating services.”)
  • Gun shops are not considered “essential.” Why? (Because a Democratic governor thinks gun sales are a non-essential business. It’s not a surprise that elective abortion is, however, considered a “life-sustaining service” despite that the procedure’s purpose, ironically, is to explicitly end lives even as other elective procedures are verboten.)

Here’s the thing: There’s been a significant difference in approach among Republican and Democratic governors across the country. A big chunk of this difference relates to the data, but as we’ve seen, there’s no fucking data. Thus, any public-health interventions are based not on vetted, peer-reviewed evidence but on supposition heavily informed by pre-existing ideology. People inclined to see government as a solution to a crisis, or people who defer to the opinion of experts, are more inclined to support quarantines and related activities ordered by people with “MD” and “MPH” after their names. People who resist deep-but-narrow expert opinion or who oppose aggressive government regulation tend to question the value of the quarantines and protest the shutdown of the economy as a whole. In the absence of solid evidence to guide behavior, political leaders descend to picking winners and losers among favored rent-seeking constituencies under the pretext of acting in a scientific and non-partisan way to protect the public good. That’s a typical, albeit cynical, ploy, and consistent with behavior from Republican and Democratic officials alike. But it’s an approach that’s transparently partisan, thus undermining the legitimacy of the claim to a non-partisan public-health emergency.

We lack hard evidence to prove, as of April 19, whether the pro- or anti-interventionists enjoy the stronger case. Voters may forgive aggressive, targeted interventions if they mean well, but interventions that appear to be partisan point-scoring—as Whitmer’s recent behavior suggests—may earn far less long-run grace from voters.

Part of the problem lies, I think, with political leaders refusing to own up to the fact that they’re reacting (favorably or unfavorably) to expert public-health opinion as a way of inoculating themselves from claims of over- or under-reacting to the Coronavirus crisis. And, having invoked emergency powers, it’s hard to continue to shape public behavior if the emergency rolls back. I think the evidence, on balance, suggests that broad public lockdowns are counterproductive. The best strategy is likely to engage in normal universal precautions (hand washing, masks in public spaces) with special precautions for at-risk populations like the elderly and people with chronic conditions or immunosuppressive disorders. But the data don’t prove that isolating just high-risk populations is the ideal strategy, and accepting the premise means that emergency orders are likely not justified. So we get the kabuki theater in the public-health space that post-9/11 flyers know all too well from TSA checkpoints—the make-believe game that everyone’s a risk.

When the people question the legitimacy of the emergency because interventions seem to favor a particular political agenda, a crisis of political authority becomes almost inevitable.

Re-Opening the Country

A wave of protests about Coronavirus-related travel and economic restrictions now surges across the country. In Michigan, last week, thousands of people flocked to Lansing to protest Governor Whitmer’s revision to her quarantine executive order. Her unexpectedly inartful response to the protest—a variation on the theme of “if these right-wing science-denying whackjobs keep whining, I’ll just keep prolonging the emergency to prove who’s boss”—didn’t help. People want to know what the end game is. Any seasoned patient-experience professional will tell you that one of the biggest contributing factors to hospital satisfaction ratings lies in the “authorities” (e.g., doctors and nurses) offering clear, consistent and comprehensible information about the next transition to the care plan. Likewise, people want a plan about what happens next for the economy. Lots of folks have formulated a personal opinion about the relative risk of Covid-19 and how political or apolitical the official response seems to be. To the degree that authorities lack a transition plan, people will graft their opinions onto the governmental uncertainty—leading, inevitably, to mass civil unrest and a defiance of public-health orders that just yesterday seemed legit.

People itch for a release from generalized lockdown. A good indicator of the phenomenon attends to a visit to my local supermarket, Meijer. I love Meijer. Over the last few weeks, as I’ve visited the Knapp’s Corner store to pick up sundry items, I’ve noticed that perhaps as many as half the staff and shoppers wore masks of various types and seemed to steer clear of each other. Yesterday’s shopping run felt different. Fewer than one in 10 wore a mask, and I saw several clusters of unmasked people standing shoulder-to-shoulder talking in places like the produce section and the cat-food aisle. More cars dotted the roads. The local McDonalds featured more than a dozen cars in line to order. The sidewalks in the Heritage Hill district overflowed with people walking and running, usually without masks. Almost overnight, public-health precautions appear to have tossed out the window.

I’ve been a “good boy” and have generally worn either a bandana or a shemagh in public. The latter item—a 42-inch-square piece of patterned cotton, protective against sand and sun in desert climates and snow in cold climates—has proven the most versatile and the item most likely to elicit positive comments from other shoppers. I’ve been willing to wear these cloths (I don’t own any N95 masks and never saw the utility of surgical masks) mostly to legitimize the practice. Masking really is an effective method of reducing the transmission of respiratory viruses, and the typical American reticence to mask probably leads to excess avoidable illness—I’d love to see more people on airplanes wearing them. Plus, masking helps foil facial-ID systems. The first person who figures out how to manufacture at scale a comfortable bivalve mask with a good filter that stops the bad stuff, doesn’t leave someone feeling air-starved under moderate-exertion conditions, and doesn’t look as if it shipped from the latest BDSM fashion catalog, is going to become a billionaire.

As public-health officials continue to revise downward the relative population threat of Covid-19 while governors have tightened quarantine rules, a sense of cognitive dissonance is setting in. Especially when some of the executive orders have bordered on the absurd and people’s jobs and businesses vanish, the average citizen begins to wonder whether the consistent naysayers have been right all along. The too-quick response of “well, social distancing is working, which is why the doom-and-gloom scenarios haven’t arisen” is too obvious a ploy. Most people see through it. They understand that claiming success in the absence of data is disingenuous at best.

The most effective way to preserve the value of social distancing and masking—strategies that really do minimize transmission of SARS-CoV-2—is to give people a clear expectation of the next transition in their public-health care plan so they feel that today’s sacrifice is tomorrow’s reward. So far, we’ve seen governors mostly kicking the can down the road, President Trump making vague and irritable gestures about wanting to “reopen the economy,” and some epidemiologists suggesting that we might be locked down until 2022. People won’t tolerate long periods of indecision, and the public support for a “we’re all in this together” quarantine ends when summer comes, unemployment runs out, and the authorities still can’t get their stories straight.

Of course, in the absence of data, projecting reasonable dates for the next milestone is a fool’s errand, and no politician wants to look the part of the fool. The risk of open public defiance rises in this gap between epidemiological certainty and political cowardice. I’ve never been a fan of the idea of some sort of mass public insurrection in the face of incompetent and heavy-handed governance—that kind of thinking always struck me as a masturbatory fantasy of both the Prepper Right and the Resistance Left—but the growing anger over prolonged, indeterminate shutdowns is very real. 

The people don’t need a “will open by” date, but they do want a clear roadmap of what decisions will be made in what timeframes. Absent that roadmap—well, that’s the only scenario in this whole sordid mess that keeps me up at night.

The Ad-Tech Power Play for Covid-19

Remember how Facebook and Twitter were so averse to policing content? They had some good and not-so-good reasons for avoiding strict content moderation, but all of that’s gone out the window now that Covid-19 is a thing. The Atlantic offers a compelling write-up of the pivot. In an nutshell, companies like Facebook protested that they can’t adjudicate the factual accuracy of material that appears on their platform. Except, now, they are—removing, for example, content that they judge to be factually inaccurate about Covid-19, including “conspiracy theories.” Even the president of Brazil has been caught up in this mess, with several of his tweets deleted by Twitter for this reason. 

Think about that. Instead of allowing the democratic process to judge political leaders’ prudence, private corporations have decided that presidents simply can’t say things that they deem to be “inaccurate.” That’s a breathtaking assault on free-speech rights, made worse by that these “decisions” to remove content aren’t even being made by people. Algorithms are doing the heavy lifting.

What happens when we accept as normal the premise that an algorithm can determine what any individual person may say in the public square? Especially when we cannot retroactively determine why the algorithm performed as it did?

A lot of smart minds have grown more cautious of the spread of algorithms and the incompetence of the major social platforms to effectively manage public discussion in an even-handed manner. In the context of Covid-19, the challenge is that in many cases there are no objective facts yet about the virus or the disease. So what’s feeding the algorithm? What separates truth from disinformation from conspiracy theories from “bad opinions” about social distancing from ever-shifting factual assertions by epidemiologists? 

Hard questions, even in the best of times. And these are not the best of times.

Supply Chain Chaos

Let’s go back to the ventilator problem that (so far) wasn’t. In March and even into April, America marshaled the troops to get more ventilators everywhere. President Trump strong-armed GM into manufacturing more of them through the Defense Production Act. Governor Andrew Cuomo held press conference after press conference complaining that a ventilator shortage loomed in New York. States entered into agreements to share ventilators across state lines with the expectation that supplies would flex to hotspots.

The “we’re out of vents” problem (so far) hasn’t arisen. Praise Jesus! But the arguments around the supply of ventilators proves vexing. In the debate about whether we should have stockpiled more of them or whether we should source critical medical infrastructure from domestic companies only, two very important points tend to be elided:

  • The average health care organization suffers an active disincentive to stockpile items, even routine stock like personal protective equipment. The initial investment and long-term storage overhead for self-sufficiency in a 100-year pandemic is ridiculous, likely shaving several percentage points off an organization’s annual net margin. Organizations — across the board, not just in health care — usually practice just-in-time inventory management to reduce warehouse and inventory costs. They expect that supply chains will flex to accommodate local crises. But international crises? Supply chains rarely fail on a global scale. It’s not obvious that any health system ought to plan for long-term self-sufficiency. Besides which, dotting the country with a thousand different proprietary storehouses proves wildly inefficient at a national level unless your goal is Thunderdome.
  • People have blamed governments for lacking stockpiles of ventilators and personal protective equipment. But why? Why do state or federal governments, which generally do not directly administer medical care to civilians, suddenly bear the expectation of warehousing this stuff? Are governments somehow supposed to be supply-chain sugar daddies, bearing the cost of bailing everyone out of every conceivable 100-year disaster? Think of the early claims about Covid-19 and ventilators. In a perfect world, some suggest, Uncle Sam or Governor George would throw open a vast warehouse and distribute stuff quickly and at little or no cost. But just think about those ventilators. They do have a maximum shelf life. If you stock up for a 100-year crisis, but the supplies have a 20-year shelf life, you rotate the entire inventory four times, unused and useless, before you finally draw from it. From a tax perspective, this situation generates a tremendous amount of avoidable waste. And for critical life-saving equipment, a device that’s 20 years old may well, in light of advancing technology and aggressive staff training, prove more harmful than no device at all.

It’s clear that America’s supply chain for essential items is fragile. But then, we’ve known as much for a long time. Increasingly, Chinese companies own a monopoly on essential stuff (or the essential components of essential stuff) because it’s inefficient for U.S.-based companies to produce those goods or the components thereof. In a peaceful free-trade world, that’s a great bargain — it’s efficient for all parties, including consumers. But in times of stressed supply chains (war, disease, natural disasters, economic rivalries), the country on the dependent end of that goods flow will suffer disproportionately.

Do we need an anti-fragility analysis to harden certain essential supply chains? Absolutely. But the solution can’t be to just chuck a bunch of shit in a warehouse, slap a “break glass in case of emergency” sticker on the front door, and hope for the best.

Part of the problem relates to domestic sourcing—which, alas, tends to be much more expensive per-unit than offshore sourcing for a surprisingly large swathe of the product catalog. Right now, each stakeholder orders from a vast network of suppliers spread over the globe, and those suppliers themselves source internationally. Free-market folks trust that pricing transparency and open access to markets through services like Amazon will ultimately equalize the supply and demand curves. If the world runs out of hand sanitizer, for example, then entrepreneurs will produce hand sanitizer and sell it on the open market.

People preternaturally inclined toward socialism hate the profit-seeking that results from rapid market mobilization, and governments have proven quite adept at emergency orders against “price gouging” that disrupts short-term price optimization. Yet the high cost to convert production lines and produce new items must be offset, usually, by high unit cost to make that initial investment worthwhile; in a true scarcity situation, the market will bear that cost for essential supplies, but the cost declines as more producers enter the market. Politicians and activists decry the short-term emergency prices and don’t hesitate to use public shaming or the force of law to artificially depress prices, which then dis-incentivizes producers. As long as the state aggressively compels minimum or maximum pricing to conform to non-emergency levels, the supply and demand curves (probably) cannot harmonize in an emergency’s short run, which upends market incentives and its attendant re-optimized supply chain.

Perhaps an alternative solution for some essential goods is to treat it like some states treat alcohol sales—state governments might establish central stores for essentials like personal protective equipment, certain standard devices like ventilators, certain drugs, maybe even items like plasma or banked blood. The state warehouse negotiates volume pricing and keeps an excess supply, out of which routine orders from hospitals and clinics are then fulfilled (i.e., so inventory doesn’t “get old”). If every hospital in Michigan ordered its PPE from a central state repository, at a fixed price, and if the state set a 90-day inventory requirement within the warehouse at taxpayer expense, then broader supply-chain crises for these products would prove far less disruptive in the critical short term. 

Of course, large hospitals with special buying power would be free to source from anywhere, but with the proviso that they obtain second-tier claim to warehouse stock during a crisis. This approach might actually reduce long-term supply costs for critical access hospitals in the long run, too, which might treat such state-run central stores as a primary source of essential products. In other words, warehousing might work if it uses volume purchasing agreements to lower stakeholder prices and the tax power of the state to support excess inventory that makes no sense on corporate balance sheets. But a warehouse that just sits there, waiting for an emergency that may never arise? Less defensible.

Regardless, much hard work lies ahead to decrease the fragility of our supply chains. Finger-pointing about warehousing and post-hoc whining about the long-since-foreseen challenge of Chinese sourcing isn’t going to advance the cause of domestic stabilization.

Personal Updates

For me, as a self-employed consultant who works from a home office, the lockdown has been just another day that ends in a Y. The biggest accommodation relates to social engagement. A bunch of group activities have long since been canceled, for example, and my occasional lunches with Patrick or cigars with Scott or cocktails with Tony are on hold for now. But some things have improved—like family time. Usually, I see my family (most of whom live within 10 miles of me) a few times each year for holidays or birthdays, despite that we actually all like each other. But after the lockdown, my mother and brother and sister-in-law and I started daily group chats that featured old photos. And a few weeks ago, we spent something like three or four hours together in a Discord video-group chat, playing online games and chatting and enjoying cocktails.

Funny enough, my friend Emilie—who is an Episcopalian—started a group chat that live-texted the live-streamed Easter Mass at St. Patrick’s in New York. Cardinal Dolan presided, and Emilie kept asking why-this questions about Catholic liturgy that were quite a delight. It’s interesting to see how non-Catholics view the Mass in that context.

In addition, I’ve been developing a relationship with Kali the Calico. She’s a semi-feral feline who discovered that I put cat food on the back porch. She is likely part of a small local colony; another member, a grey male I’ve cleverly named Grey, often shows up, too. But Kali is a daily presence now. She’s there each morning waiting for food, and often in the evening too. The last few days, she’s taken up a semi-permanent residency, including spending the full days sleeping on chairs back there.

At first, in December, Kali would skedaddle when she saw me. Then, she’d just run toward the far porch door. A few weeks after that, she’d be okay at about a five-foot quarantine zone from the human, a turn of events which persisted for a while. Starting two weeks ago, she approached to within one or two feet—usually to bury her face in the food plate as I was filling it up. Then, this week, she’s gotten even closer, meowing and purring when she sees me and once or twice brushing her body against my leg while I fill the food dish. She will (sometimes) cautiously sniff my hand, bopping her nose against my fingers, and once I pet her for perhaps three strokes before she was like, “Wait, what’s this?”

Slowly but surely, Kali is coming around. Grey probably won’t—he’s a bit more skittish, and he consistently appears afflicted by a respiratory infection that I assume is not Covid-19. And as those two took over the back porch, my long-time friend Ziggy d’Cat has migrated to the South Porch, adjacent to my office and living room, where he jumps upon the air conditioner and paws at the window to advise me when he requires a resupply of shredded rotisserie chicken breast, dry kibble and a fresh cup of water. He’s figured out how to put the meaty part of his paw against the glass to make a loud noise as he scrapes the glass; he’s smart enough to realize that claws upon glass don’t make enough of a noise for me to hear. He’s one of the smartest, canniest felines I’ve ever encountered. Ziggy has been visiting two or three times a day now for several weeks, and he’s very obviously gaining weight. Which is good. Last October, I thought he was about to die. Now, he’s still lean, but not skeletal. Then again, I thought he was skinny when he first started visiting nearly four years ago.

In other news:

  • I upgraded my old iPhone 6s Plus—which I hadn’t used since I purchased my iPhone X—to a Samsung Galaxy S10. I actually have two lines on my T-Mobile plan, and one of those lines I haven’t used in ages. I added the second line when I migrated to iPhone from Windows Phone several years ago, because it was easier to add the line and get the iPhone than to try upgrading from Windows Phone. But then that original line went literally unused since then. I thought I’d just purge it, but it’s the primary line for my account and given my plan, the incremental cost is trivial. So I got a good deal on a device upgrade, and then I got the bright idea that I can use that line with the new S10 as my business phone, rather than paying different vendors for dedicated business phone numbers. So that’s what I’m doing. It’s odd to see modern Android (it runs 9.0/Pie) compared to the last Android I used, a 2.x/Froyo device many, many years ago. I am still not willing to go all-in on the Google ecosystem given my deep distrust of Google’s corporate integrity, but simultaneously using an iOS 13 device and an Android 9 device makes for an interesting set of contrasts. The most significant of which is that the S10 works with Microsoft’s Your Phone app, so calls/messaging and even screen mirror “just works” between the S10 and Win10. I can’t get that with iPhone unless I bought a Mac.
  • I haven’t done a ton of writing over the last few months on account of the persistent low-grade illness that struck over the last half of winter. But I did dust off my writing projects on Thursday night and am getting back in the groove.
  • Speaking of dusting, on Friday I opened my to-do list for the first time since the end of January. It’s … bizarre. I basically lost 10 weeks of productivity to the one-two punch of the Bonaire trip and lingering malaise. I added 90 days to all deadlines and got back into the get-things-done fray. I’ve accomplished a ton over the last two weeks, although I’ve been triaging stuff in order of most time-pressed significant. I still have roughly 1,800 emails now to work through. While sick, I’d go a week at a stretch without opening Outlook. Such a vacation from email was nice, although unhelpful, while it lasted.
  • Because Brittany made me do it, I started playing World of Warcraft Classic. It’s different playing when you’ve got friends online and everyone’s also on Discord. I’m not on a ton, just an hour or so, a couple nights per week, but it’s a great callback to, say, 15 years ago. Elianna the Undead Affliction Warlock lives on Sulfuras, if you’d like to say hi.
  • My reading has also slowed down, although I’m now plowing through three books simultaneously—The Lies That Bind: Rethinking Identity by Kwame Anthony Appiah, On Human Nature by Sir Roger Scruton, and Return of the Strong Gods: Nationalism, Populism, and the Future of the West by R.R. Reno. However, I’ve been doing more podcast watching on YouTube to partially offset the reading. I’ve watched dozens of hours of Joe Rogan, Dave Rubin, Bret Weinstein and Heather Heying, Douglas Murray, and Eric Weinstein. Good stuff. YouTube plays on the third monitor while I’m working, usually.

All for now. Stay well, my friends!

Writing a Book in AsciiDoc with Version Control

I’ve long enjoyed a love-hate relationship with Scrivener, the all-in-one writing platform for novels, short stories, textbooks and other written endeavors. I love it because it offers excellent outlining and note-taking features, plus it integrates with programs like Scapple for mind-mapping and Aeon Timeline 2 for timeline management. Scrivener supports many different compile settings, so exporting content is never a challenge.

hate it, though, because Scrivener’s full-screen editor is abysmal—the worst “distraction-free” implementation I’ve ever seen in any app that supports this feature—and because Scrivener projects are essentially a giant cluster of Rich Text Format files named by number and stored in a byzantine file-tree structure, separating me from my work by requiring the application to mediate my content.
My preferred approach to writing is to enter a full-screen, distraction-free mode. (Usually after dark, in an unlit room, working with an amber-on-chocolate color scheme, with soft music playing and either the windows open to the breeze or a fire roaring in the fireplace.) Over the years, I’ve played with different approaches to writing in Markdown and AsciiDoc with a dedicated text editor, but these efforts haven’t proven satisfactory because the apps tend to take a single window and full-screen it, cutting me off from my notes.

Until recently, that is—for now Microsoft’s Visual Studio Code allows for multi-pane windows, even in distraction-free mode. I know you can open multiple simultaneous buffers in Emacs or whatnot, but my willingness to learn Emacs or Vim syntax remains too weak to justify the technical debt of mastering these systems just to write. So VS Code, which is much simpler, fills me with joy.

I played with it and got hooked. And because VS Code does a great job of working with the git system, I explored even more deeply with version-control on my text documents. I’m now far enough into the process to have decided that I’m migrating all of my writing out of Scrivener and into my new infrastructure.

I’ll share how I set up this environment in the context of a book I’m writing about healthcare data analytics, and then why I think plain-text writing with version control makes more sense for complex writing projects.

The Setup Process

After initial testing seemed favorable, I created a DigitalOcean droplet with a one-click install of GitLab Community Edition. GitLab CE is a free, open-sourced platform for storing and sharing computer code, with enhancements designed to make the code-writing job easier. I’m paying $10/month for the DO droplet (a droplet is a virtual server, in this case, an implementation of Ubuntu Linux that already has GitLab CE configured on it, so I didn’t have to do any tedious manual installations). I use DO to host this website, and the jegillikin.com domain name, so I mapped the new droplet to a subdomain—code.jegillikin.com. This approach is significant because I can add new users to my GitLab environment with permissions to participate in one or more projects as collaborators, without having to email Word documents back-and-forth. Less tech-savvy collaborators may simply use the built-in Web editor to work, without having to download or install or configure anything.

It took roughly 10 minutes to fine-tune the GitLab installation after the droplet was set up. Perform the usual Ubuntu security-hardening steps, and voila. Good to go.

I downloaded the most current release of Visual Studio Code (the app receives updates monthly) and then installed a few specific extensions to make my drafting process easier:

  • Active File in Statusbar—to show the file path in the status bar
  • Amber Theme—the colors I want, amber-on-chocolate
  • AsciiDoc—adds rich language support, syntax highlighting, live previews and snippets for AsciiDoc files
  • Better Comments—manages specific comment types with configurable formatting
  • BibManager—Manages BibTex bibliography files
  • bibtexLanguage—adds syntax highlighting for BibTex files
  • Bookmarks—ability to mark specific lines and then jump between them
  • Clock in Status Bar—adds a small clock, useful in the distraction-free mode
  • Code Settings Sync — syncs your complete configuration to GitHub (not GitLab) so you can clone your setup on a different computer or a re-installed computer
  • Epub Tools—inserts epub-specific syntax and output support into VSC
  • Git History—views the git log and file history to compare versions over time, within VSC
  • RTF—adds native RTF support to VSC (helpful if you’re migrating RTFs from Scrivener)
  • Spell Right—a lightweight spell checker
  • Todo Tree—shows your comments (todo, fix, cite, etc.) in a project-level tree
  • VScode-Spotify—integration so I can manipulate a Spotify playlist from the VS Code taskbar (so no more getting out full-screen mode just to adjust my tunes)
  • VScode-Timer—a simple configurable countdown timer that sits in the statusbar
  • Word Statistics for Text—runs a frequency analysis by word on a particular file or folder
  • WordCounter—a counter, in the status bar, showing the number of words, characters and lines, as well as the estimated reading time for the file
  • YAML—support for YAML blocks (helpful for ePub files)

I also tweaked a few VS Code stock settings to my liking, including font choice (I’m a fan of monospaced fonts for writing, so I use Liberation Mono) and color swaps for the statusbar.

You’ll also need to down the Github for Desktop client. The Github client works just fine with a GitLab server. The client installs git on your computer. VS Code uses git to push and pull content between your local machine and the GitLab CE server.

With the server and the software configured, the next step was to create a project. More than one way to do it. I opted to create it in the GitLab CE control panel, then I used the Github for Desktop client to clone repository, selecting the URL of my GitLab project and a folder on my PC. (Bonus: I sync the local folder witihn my OneDrive structure, so there’s yet another cloud backup lurking out there.)

Using AsciiDoc

AsciiDoc is one flavor of a text-based markup language. In AsciiDoc, writers focus on the text, not the formatting of the text. It uses a straightforward syntax for noting formatting through coded characters. For example, to italicize text, wrap it in a pair of underscores. To indicate a header level, prefix it with an equals sign.

AsciiDoc requires installation. The most common toolkit, AsciiDoctor, requires installation of Ruby on your local machine, but the stock tooklit requires Python 2.6 or higher.

Writing in plain text with markups offers several advantages over writing with a visual word processor:

  1. You’re not distracted by how the words appear on the page.
  2. Using markup elements like underscores and asterisks permits fine-tuning of formatting moreso than double-clicking text.
  3. Elements like admonition blocks (text call-outs like “warning” or “note” boxes) require no additional work.
  4. The appearance of the final document is governed by a stylesheet, so you need not fuss with formatting while writing.
  5. Plain-text files support version control to facilitate collaborative writing and to avoid 85 differently named copies of the same file.

Some people prefer Markdown or MultiMarkdown for plain-text writing. Although I first started plain-text writing in MMD, I learned the hard way that the Markdown syntax consists of too many competing flavors with too weakly typed of a syntax. AsciiDoc is much more strongly syntax-coherent, and as a bonus, it naturally outputs to formats including HTML and DocBook.

(DocBook is significant. It’s essentially a giant XML file—but one that cleanly imports into Adobe InDesign for layout with the hard structuring work already complete.)

The Writing Process

With a cloned repository, whatever you write on your local computer—as long as the file is stored in the folder you selected when you cloned it—will sync with the server. Unlike tools like OneDrive or Dropbox or Google Drive, syncing with git isn’t automatic, however. You only sync when you want to. When you do sync (in a process called a commit), you’ll be prompted to add optional change notes. I find it helpful to offer a sentence or two summarizing what I just did. Every sync creates a new revision, or current-state snapshot of the project, and all of those revisions are maintained. So if you work on the same chapter over three months and commit changes 36 times, you’ll be able to check all 36 versions and even compare them—like “what’s different between version 23 and version 32?”.

That said, writing is straightforward. Just write. Don’t worry about formatting or margins or fonts: All of those concepts are superfluous during the drafting process when you’re working with Markdown. Instead, just write. And commit changes frequently. Any specific formatting requirements, like headings or bold/italic typefaces or lists, are effected in a straightforward manner using AsciiDoc syntax within the file.

Why AsciiDoc Plus Version Control Rocks for Complex Writing

One thing’s for sure: You must be reasonably comfortable using a text editor (instead of a word processor) to write in order to thrive in this production model. And you must possess some expertise in working with a version-control system, although you’re free to either use GitLab’s free online service or subscribe to GitLab or GitHub so you don’t need to run your own server.
But the benefits to this drafting process are substantial:

  • Although Microsoft Word is a very capable application for writing complex long-form projects, not many users know how to use Word optimally. As such, file corruption and the need for complex reformatting can suck away at precious writing/editing time.
  • Version control means you don’t need to save a billion different copies of a file, each with a slightly different name. And, you can compare those files easily. And because your files are committed to the repository, you don’t run the risk of losing “all your work” if your thumb drive gets lost or your hard drive crashes.
  • A VCS with an online portal—like GitLab CE—opens the door to tightly controlled access to specific files, protecting your intellectual property and facilitating broad collaboration with other contributors, without the need to email drafts back-and-forth and then harmonize them by hand. In fact, GitLab CE contains an issue-management system, so edits and questions remain with the project and accessible to all contributors.
  • Tools like VS Code (and, admittedly, Emacs, Vim, Notepad++, Atom and countless other text editors) support high degrees of customization, so you can write how you want without being locked into the fixed interface options of Word, Scrivener, etc. Don’t be misled into thinking that text editors are only for hard-core computer programmers. Plain-text writing in Markdown is absolutely a valid and supported use case for these software platforms.

An October Update

After a brief stretch of unseasonably warm weather in late September, West Michigan has unambiguously slipped into autumn. I look out my home-office window—the air is nice, with that charming mix of cool and moist that suggests “tailgate season”—and I see more and more orange and red amidst the green. Squirrels scamper with earnestness. Bugs are vanishing. Things slow down.

“Winter is coming,” I’m told. And I hope it does. I’m excited for this year’s holiday season. In my head, it kicks off with my mid-September birthday, which marks for me the end of summer (Labor Day doesn’t do it for me) and the beginning of “winter Lent.” Then October sees the tree transitions and sweater weather and writing prep that culminates in Halloween—holiday season kickoff!—and the beginning of National Novel Writing Month. Thanksgiving re-grounds me with family and marks a pivot point for NaNo. And as soon as the mad-dash of writing is over, I pivot to Christmas and then take two or three weeks off from the day job to recharge, etc. It’s a great time of the year, even in years when I’m not “feelin’ it.”

So today seems like as good of a time as any to offer some updates, offered as usual in no particular order, but as always under the watchful gaze of my feline overlords.

VLO’s Summer Vacation. Tony and I took a half-vacation (i.e., work slowdown) in late July and throughout August; as of September, we were back to a normal weekly podcasting schedule. The upside to VLO now rolling in its sixth year is that we’re stable and mature. And, of course, that we have thousands of downloaders and hundreds of engaged listeners on Twitter, Facebook, the blog, etc. Given that we don’t monetize this program—it’s a hobby and labor of love—the response by people all across the world has been fantastic. And for almost all of the shows for September and October, our alcohol segments came to us free of charge courtesy of gifts from our listeners. It’s a ton of work, but it’s a joyful thing.

NAHQ @ Cincinnati. On my birthday, I flew to Cincinnati for the back-to-back board meeting and educational conference for the National Association for Healthcare Quality. It was a professionally rewarding experience. Being a board member means that the conference is tightly scheduled for us. Six days, five nights. But what made it personally rewarding was the deep camaraderie among the current members of the board and the great cadre of seasoned, senior volunteers who work with us. NAHQ is about to go into a very tight period where the organization pivots from an association-management model (i.e., a separate company “manages” the association, hires the staff, provides the office, etc.) to a fully stand-alone model where the association itself handles all its own operations, leases its own offices, hires its own team, stands up its own I.T., etc. This is a huge deal. We’re bigger than most groups that make the independent pivot and we have only about a quarter of the time the average group enjoys to make the move … but our staff are awesome (almost all are leaving the management company to be hired by NAHQ outright) and our finances are rock-solid. It’ll be a heavy lift, but it’ll be done with finesse and—we expect—utterly transparently to our thousands of dues-paying members.

Jot That Down. I’m pleased to share that Jot That Down: Encouraging Essays for New Writers has been successfully released. I worked with A. L. Rogers, the book’s editor, to get it produced in print. It’s a great resource for new/aspiring writers, covering a variety of topics and genres in an easy-to-digest manner. Currently available for purchase for $14.95 from Caffeinated Press or by special order from your local independent bookseller.

Other CafPress books. And speaking of Jot That Down, I’ve wrapped up Isle Royale from the AIR, an anthology edited by Phillip Sterling that collects stories, poems and art from former artists-in-residence at Isle Royale National Park. I’m also in the production phase of Brewed Awakenings 3, our annual anthology, and Off the Wall: How Art Speaks, a collection of poetry and art co-developed by Elizabeth Kerlikowske and Mary Hatch. And final edits are due from the advance review copy for Ladri, a novel by Andrea Albright. Barring disaster, each of these books should be in-scope for a boost event we’ll host at the end of the month. Two more novels await this year—Kim Bento’s Surviving the Lynch Mob and Barbara David’s A Tale of Therese—plus Jennifer Morrison’s local-history book The Open Mausoleum Door, then I’m caught up with production across all of our lines of business.

NaNoWriMo. NaNo’s coming, so that means that I’ve had to (a) re-curate my author page and (b) think about what I’m going to work on. I think my technical focus will be on sharpening conflict and using that conflict to be the primary driver of the plot (instead of my usual, which is to let the plot drive the conflict). The story itself will be another bite at a Jordan Sanders murder mystery because I’m well-acquainted with the characters in this universe. But I still have three weeks to nail down my idea.

Grand River Writing Tribe. The Tribe has been together for 10 months now, and it’s been going gangbusters. People are participating. Getting published. Supporting each other. Without a regular, focused critique group, a writer stands at a significant disadvantage. GRWT meets twice monthly for three hours, combining critiques, focused education and dedicated writing time. And we still welcome potential new applicants!

Juicing. So this happened. On October 1, a scant week ago, I began a significant diet program. I had purchased a juicer and accessories. For several days, I had nothing but fruit and vegetable juice. Then, on the advice of clinicians at work, I’ve migrated to a part-juice, part-good-food regimen. So it’s been juices with a little bit of, e.g., shredded chicken or sushi or carrot/celery sticks. The thing is, I’m avoiding all processed sugars, alcohol, refined carbs, etc. Not even doing my traditional Lean Cuisines. It’s either juice I prepared myself, or plain shredded chicken or sashimi without the rice. (Tonight, I’m making a salmon fillet with asparagus.) Already down five pounds in a week. And although the diet part isn’t hard—I really like what I’m consuming—what’s been more interesting is the level of planning I’ve had to do. Actually preparing a shopping list (“I need this many swiss chard leaves, this many pears, this many ounces of blueberries …”) and planning my evening schedule around my dinner schedule has been both illustrative and challenging. And now that I bought an elliptical, which just got set up in my living room—whoa! Credit to my friend Tony who did a 30-day juice diet in May (and lost a ton of weight!) and who remains incredibly supportive even when I mock him unfairly for becoming a vegan.

The Great Outdoors. Tomorrow, a half-day kayaking trip beckons, with Jen, Brittany and Steve. Next Saturday, I’m doing a day hike on a section of the North Country Trail in the Manistee National Forest.

Home Shopping Spree. With the annual management bonus we received at the day job, I was able to pay off some bills, pay other bills early and invest a bit in both Caffeinated Press and my own home front. Of note, with the mid-summer swap of my bedroom and my office, I had to buy all new bedroom furniture. That’s done: Dresser, headboard, vanity with bench. Then some odds-and-ends, including the aforementioned elliptical, some knickknacks like candles and new lamps, a full-length mirror and a stool for the bathroom, and a replacement computer. My “normal” all-in-one home computer is very old and has been intermittently hostile, so it’s been retired to be a dedicated writing machine at my dedicated writing desk. The new machine—the first upgradeable tower PC I’ve owned since, I think, 2005—is an iBuyPower box with a quad-core i7-7700 processor, 16 GB of RAM and a 3GB GPU (GeForce GTX 1060). In all, a decent if not bleeding-edge machine. The only real hesitation I had with it is that it appears to have been designed by a 13-year-old boy, with proliferating LED lights (that I covered with electrical tape!) and a keyboard that looked like a l337 toddler toy. Picked up a 27-inch monitor for it; almost got two but I’m glad I didn’t because with it and the 17-inch aux monitor I already had, I’m literally out of room on my desk. I literally cannot fit two 27-inch monitors. Anyway, Duane, if you see this: “SIXTEEN GIGS OF RAM.”

Great Lakes Commonwealth of Letters. It’s an exciting time at GLCL. The board has been discussing a very, very robust programming schedule for 2018 as well as rebranding and an expansion of the board. A ton of work, to be sure, but I think it’ll help focus the organization and promote local literary citizenship. More to come.

All for now. May your autumn Winter Lent warm your soul even if it chills your toes!

Updates: Annapolis, Bats & More!

Where to begin?
Maryland Association for Healthcare Quality
I flew to Annapolis on Wednesday to speak at one of the semi-annual educational conferences of the Maryland Association for Healthcare Quality. I’ve known the MAHQ president, Monica, for several years; in fact, she keynoted the Michigan Association for Healthcare Quality conference I hosted in Traverse City two years ago. Lovely lady.
The MAHQ event lasted one full day. My colleague Gayle ran the morning session — about advanced Excel tips and an introduction to some intermediate-level statistical concepts — and I led the three-hour afternoon block. My session focused on the “why” of health data analytics; I presented a list of characteristics of a high-performing team, then I presented real-life use cases illuminating the value of each characteristic.
I also presented what’s increasingly my personal call-to-action about health data analytics:

Health care is in a value crisis precipitated by suboptimal structures and misaligned incentives. We’ve mostly eaten the low-hanging fruit from IOM/IHI. The sole remaining path for driving improvements in cost/outcomes/access/satisfaction rests in data-driven PI initiatives. Yet, our industry’s capability is still in its infancy. Until we get smart about data, costs will go up — and we’ll continue to inflict avoidable harm or even death on the patients we serve.

On a personal note, it was lovely to have dinner with Gayle and Stephanie at the Severn Inn on Wednesday. Our table overlooked the Severn River, immediately across the water from the United States Naval Academy. The cover photo for this post, in fact, was taken from the Inn’s parking lot. And on Thursday, Monica took me to the Fleet Reserve Club, where she’s a member, to enjoy drinks and to see the sights along the Ego Alley (Spa River) waterfront. A lovely experience.
This trip also marked my first time flying United Airlines. Good experience. The planes were in clean condition. The flight attendant on the ORD-to-BWI leg was wonderful. However, the biggest lesson is that despite how often I shuffle through O’Hare — a dank, crowded place that reminds me of Dallas-Fort Worth — United operates Concourse C at Terminal 1, which is beautiful, tall, light and airy. American Airlines hangs around Terminal 3, which is a much more depressing place.
Bat in the Bedroom
The morning after Memorial Day, I was awoken by the sound of my feline overlords chasing a bat in my bedroom. I caught the bat safely. I then deduced that neither I nor the kitties had been bitten or scratched by the little winged devil. So I carefully released the bat back into the wild.
Good idea, right?
Well, later that week, a co-worker came across a story on NPR about bats in the bedroom. And thus began a Seinfeldian journey of ridiculousness. For starters, the U.S. Centers for Disease Control and Prevention recommends that people seek post-exposure treatment for rabies if they awake to a bat in their bedroom, even if they’re confident they weren’t bitten. Accordingly, I use the MyHealth app to leave a “non-emergency medical question” with my physician. His medical assistant calls me and basically says: “We don’t know nuthin’ ‘but no bats; you better call the health department.” So I did. And the public-health nurse on the other end of the line — besides having a delightfully morbid sense of humor — suggested that there wasn’t any real risk and that Canada has abandoned the CDC’s strict rules because the CDC’s recommendations followed from a decade-long observation period with a total N count of five infected humans. Then she said the only two bats in Kent County that tested positive for rabies so far this year are both from my street, so maybe I should consider it anyway. Which … well, my street is very long. So then there’s the “do I go to the E.R. for shots, or not?” question, which boils down to this: Do you spend a ton of money to go to the ER for injections, knowing that you have an infinitesimally small risk of acquiring a virus that’s effectively 100 percent fatal, or not?
It’s the Precautionary Principle run amok, and an excellent case study in why we have so much waste in the health care industry.
And then, of course, the “what about the kitties?” question.
I figure I’ll take the cats to the vet this coming week, but I’m not going to get poked, myself. So if you see me frothing at the mouth later this summer — you’ll know I chose poorly. And that you should stay out of biting range.
Miscellaneous Morsels of Misanthropy

  • Although I’ll keep the victims (and their loved ones) of the Orlando shooting in my thoughts and prayers, I’m disappointed — but not surprised — that the immediate reaction circled around gun control. In Kalamazoo earlier this week, a crazy man plowed into a group of cyclists with his truck, killing five, but no one’s calling for a ban on automobiles. As long as we’re polarized about firearms, we’re going to continue to miss the point about the triggers of social decay that make mass-violence episodes occur in the first place. And more will die as a result. This is, foremost, a cultural problem, which requires solutions that transcend legislation.
  • Our writer’s meeting went well on Friday. We’re going to Ann Arbor next weekend to sell books at the Ann Arbor Book Festival. I’m excited.
  • I nearly forgot to mention — a few weeks ago, my friend Jared stopped into town for a visit. He used to live/work here, but he and his wife took up employment in Abu Dhabi. It was nice to connect. I’m going to interview him, and a few others, for the next issue of The 3288 Review. And I’m probably going to take him up on his offer to visit him in the Middle East.
  • Speaking of The 3288 Review — it’s on sale. Buy now, before we sell out! Copies arrived this past Wednesday. It’s a lovely volume. As usual, my column appears in the back; this time, I wrote about the literary representation of rape.

Updates: Annapolis, Bats & More!

Where to begin?

Maryland Association for Healthcare Quality

I flew to Annapolis on Wednesday to speak at one of the semi-annual educational conferences of the Maryland Association for Healthcare Quality. I’ve known the MAHQ president, Monica, for several years; in fact, she keynoted the Michigan Association for Healthcare Quality conference I hosted in Traverse City two years ago. Lovely lady.

The MAHQ event lasted one full day. My colleague Gayle ran the morning session — about advanced Excel tips and an introduction to some intermediate-level statistical concepts — and I led the three-hour afternoon block. My session focused on the “why” of health data analytics; I presented a list of characteristics of a high-performing team, then I presented real-life use cases illuminating the value of each characteristic.

I also presented what’s increasingly my personal call-to-action about health data analytics:

Health care is in a value crisis precipitated by suboptimal structures and misaligned incentives. We’ve mostly eaten the low-hanging fruit from IOM/IHI. The sole remaining path for driving improvements in cost/outcomes/access/satisfaction rests in data-driven PI initiatives. Yet, our industry’s capability is still in its infancy. Until we get smart about data, costs will go up — and we’ll continue to inflict avoidable harm or even death on the patients we serve.

On a personal note, it was lovely to have dinner with Gayle and Stephanie at the Severn Inn on Wednesday. Our table overlooked the Severn River, immediately across the water from the United States Naval Academy. The cover photo for this post, in fact, was taken from the Inn’s parking lot. And on Thursday, Monica took me to the Fleet Reserve Club, where she’s a member, to enjoy drinks and to see the sights along the Ego Alley (Spa River) waterfront. A lovely experience.

This trip also marked my first time flying United Airlines. Good experience. The planes were in clean condition. The flight attendant on the ORD-to-BWI leg was wonderful. However, the biggest lesson is that despite how often I shuffle through O’Hare — a dank, crowded place that reminds me of Dallas-Fort Worth — United operates Concourse C at Terminal 1, which is beautiful, tall, light and airy. American Airlines hangs around Terminal 3, which is a much more depressing place.

Bat in the Bedroom

The morning after Memorial Day, I was awoken by the sound of my feline overlords chasing a bat in my bedroom. I caught the bat safely. I then deduced that neither I nor the kitties had been bitten or scratched by the little winged devil. So I carefully released the bat back into the wild.

Good idea, right?

Well, later that week, a co-worker came across a story on NPR about bats in the bedroom. And thus began a Seinfeldian journey of ridiculousness. For starters, the U.S. Centers for Disease Control and Prevention recommends that people seek post-exposure treatment for rabies if they awake to a bat in their bedroom, even if they’re confident they weren’t bitten. Accordingly, I use the MyHealth app to leave a “non-emergency medical question” with my physician. His medical assistant calls me and basically says: “We don’t know nuthin’ ‘but no bats; you better call the health department.” So I did. And the public-health nurse on the other end of the line — besides having a delightfully morbid sense of humor — suggested that there wasn’t any real risk and that Canada has abandoned the CDC’s strict rules because the CDC’s recommendations followed from a decade-long observation period with a total N count of five infected humans. Then she said the only two bats in Kent County that tested positive for rabies so far this year are both from my street, so maybe I should consider it anyway. Which … well, my street is very long. So then there’s the “do I go to the E.R. for shots, or not?” question, which boils down to this: Do you spend a ton of money to go to the ER for injections, knowing that you have an infinitesimally small risk of acquiring a virus that’s effectively 100 percent fatal, or not?

It’s the Precautionary Principle run amok, and an excellent case study in why we have so much waste in the health care industry.

And then, of course, the “what about the kitties?” question.

I figure I’ll take the cats to the vet this coming week, but I’m not going to get poked, myself. So if you see me frothing at the mouth later this summer — you’ll know I chose poorly. And that you should stay out of biting range.

Miscellaneous Morsels of Misanthropy

  • Although I’ll keep the victims (and their loved ones) of the Orlando shooting in my thoughts and prayers, I’m disappointed — but not surprised — that the immediate reaction circled around gun control. In Kalamazoo earlier this week, a crazy man plowed into a group of cyclists with his truck, killing five, but no one’s calling for a ban on automobiles. As long as we’re polarized about firearms, we’re going to continue to miss the point about the triggers of social decay that make mass-violence episodes occur in the first place. And more will die as a result. This is, foremost, a cultural problem, which requires solutions that transcend legislation.
  • Our writer’s meeting went well on Friday. We’re going to Ann Arbor next weekend to sell books at the Ann Arbor Book Festival. I’m excited.
  • I nearly forgot to mention — a few weeks ago, my friend Jared stopped into town for a visit. He used to live/work here, but he and his wife took up employment in Abu Dhabi. It was nice to connect. I’m going to interview him, and a few others, for the next issue of The 3288 Review. And I’m probably going to take him up on his offer to visit him in the Middle East.
  • Speaking of The 3288 Review — it’s on sale. Buy now, before we sell out! Copies arrived this past Wednesday. It’s a lovely volume. As usual, my column appears in the back; this time, I wrote about the literary representation of rape.

Learnings from the @myNAHQ #NAHQsummit for Population Health

This week I attended the National Quality Summit in Dallas, Texas. The event, sponsored by the National Association for Healthcare Quality, was chaired by Dr. Drew Harris, a nationally known expert on population health, and co-chaired by NAHQ’s own Len Parisi and Nancy Terwood.

Disclosure: I’m a member of the NAHQ board of directors, and part of our attendance in Dallas included our quarterly board meetings. However, my summary of the summit does not constitute a NAHQ-endorsed communication. My observations, below, are solely my own.

The summit included roughly 250 in-person and more than 400 virtual attendees. The event highlighted current trends in population-health management presented, partially, as case studies in how health quality professionals can help move the needle on the health of patients at a population level.

The “population” distinction is significant. Much of healthcare today focuses on the treatment of individual patients. Although some initiatives, like Pay for Value, roll up results at an aggregate level, the truth is, we don’t manage the health of cohorts very well. Even the vaunted Patient Centered Medical Home model is, at heart, a treatment paradigm for individual human beings. But treatment at a population level requires different incentives, different skills and (potentially) a different political climate.

Some core learnings from the summit:

  • “No margin, no mission” migrates to “no outcomes, no money.”
  • Hospitals might decline as incentives against inpatient care mount, but health systems will endure. Those systems must be adaptive, not reactive, if they are to thrive.
  • Population health features a dual focus: from the “patient out” (looking at individual humans within a system) to the “population in” (looking at the community as a whole to remediate socioeconomic problems contributing to poor health outcomes.
  • The community aspect requires a reliably delivered, broad set of preventative interventions for prevalent but inadequately addressed health risks. Advanced preventative care mixes care coordination across the continuum with effective chronic disease management and personalized prevention services. However, “personalized prevention” is wildly under-employed.
  • Programs must be relevant to the targeted population. It’s foolish to develop a program and then find a population to channel toward it.
  • Good pop-health programs use a portfolio of 30-35 robust, evidence-based interventions. No one-size, one-program approaches work. Analytics should rely on statistical process capability techniques to assess ongoing effectiveness (before a formal evaluation study) and make better use of geomapping capabilities.
  • Population targeting presents an interest set of challenges —
    • What’s the aim of the targeting initiative?
    • Why obsess over 1-5% of costs if other populations with lower costs can yield better clinical results? [A CMS study suggested better cost savings with low-to-medium risk targeting (aversion) instead of high-risk (management) activities.]
    • Can we target rising-risk patients?
    • Can we move beyond claims data to identify a population?
  • An optimal mix for program targeting might include moderate-to-high risk patients based on diagnosis, physician opinion and health-risk assessments. A typical candidate pool might be roughly one-fifth of the 65+ population and with good outreach, perhaps 40-50% can be enrolled.
  • The system perversely incentivizes wasteful care precisely because some stakeholders profit from it. But when average costs for a median family of four consume 40 percent of disposable income — there’s a problem. The fee-for-service model creates a structural barrier to the care of populations. And despite their unpopularity, narrow networks consolidate care teams and health information much more effectively than wide networks.
  • Over-reliance on primary care physicians, instead of comprehensive care teams spanning stakeholders, isn’t helping advance the cause. PCPs can be an entry point, but they can’t do it alone. Clinical integration (including coordinated care, evidence-based practices, waste reduction and network management) is essential, as are the infrastructure pieces like health IT, info exchanges, predictive modeling, population segmentation and a stronger emphasis on behavioral-health and wellness services.
  • Could an Uber-like model disrupt healthcare at a consumer level?
  • We have a lot of data, but not much capability to transform data into actionable information. If you can’t measure it, you can’t improve it.
  • We tend to focus on high-cost/high-risk patients, but perhaps we should invert the pyramid. It’s easier and better in the long run to focus on wellness and routine gaps in care than to let people progress through rising risk until they hit a “you’re at the edge of the cliff” threshold after which — when it’s too late — the care team rallies.
  • Partnership with health plans is essential (integrated wellness, behavioral health services, patient engagement) but the messaging has to be deliberate. In one case study, telephonic care management engagement jumped from 15 to 80 percent when the caller-ID string changed from the insurer to the provider.
  • The move from “volume” to “value” will be hugely disruptive.
  • Clinical interventions take time — from 3 months to 5 years — to generate value. Need to level-set expectations accordingly and avoid premature evaluation and trending.
  • Pharmacists are one of the least appreciated professionals in the industry. PharmD’s make a real difference when integrated into the care team. Coordinating pharmacists, dietitians and SNFs as part of overall home-health outreach may be worth exploring.
  • Decision science — using aggregate data to inform strategy — is under-valued in health analytics. Metric-based decision making can be a barrier to effective population health. Solo dashboards — data viz w/o substantive analysis — are rarely helpful and sometimes harmful. You can’t do “analytics” without storytelling.
  • Problems in most health-analytics projects: Not asking the right questions from the outset, disregarding qualitative information, not reviewing published research, not acting on the results of the analysis.
  • Let some analysis follow from “microtrends” (the small forces behind big changes). Census-block analysis is more helpful than it appears.
  • Near-real-time surveillance is key, and can be built by individual institutions with adequate resources. BRFSS is broad, NHANES is detailed — but both lag. By the time you know your population, you’ve lost your actionability window, unless you do your own surveillance using claims and lab data with incremental census data. Knowing something useful about your community helps shape the tree of questions during individual patient encounters — i.e., you’re treating your patient as being a member of the population they represent instead of an automaton disconnected from their community.

Because of the board meeting, we were not able to attend the second-day sessions. But the first day certainly left me with many valuable take-aways.