Saturday, November 26, 2016

Blame IT

Peak Human. Accelerated globalization.  Weak mass media. Weaponized Facebook. Crisis T.

Peak Human and Mass Disability are the same thing

For reference - DeLong’s Peak Human and my Mass Disability are synonyms. Both refer to a surplus of productive capacity relative to labor supply, particularly the supply of non-elite cognitive labor.

I like the term ‘mass disability’ because we have a long history of supported labor for people we have traditionally called ‘cognitively disabled’.

Ok, that’s not the whole story.

I also like the term because I have a personal agenda to support persons with traditional cognitive disabilities. Using the term ‘disability’ forces us to think about how individual features become abilities or disabilities depending on the environment — something Darwin understood. Addressing the needs of the majority of human beings can also help the most disadvantaged.

Thursday, November 24, 2016

Crisis-T: stop talking about white *men*

I don’t believe exit polls that claim half of white college women voted for Trump — though clearly that must have been true in many parts of the United States. It is certain, however, that a majority of white women voted for him, his policies, his speech, his history.

So when I read essays that blame white *men* for Trump I stop and move on.

White women own this too.

Patriarchy? Sure. Name and blame patriarchy.

But don’t let white women hide. They have more education than white men. They have experience at the receiving end of patriarchy. They own this too.

Monday, November 21, 2016

I can't recommend the Mac any more

I don’t think Mac users should switch, but I can’t recommend any newbies join MacShip.

Aperture users abandoned. Sierra’s scary data shifting behaviors. No updates to Mac Mini or Pro. Airport routers dropped — leaving no AirPlay or network backup options. Mac App store rotting away.

And, above all, the price of the “mainstream” MacBook Pro laptop: $2000.00. Dell has a good enough laptop for $1350 with twice the SSD capacity.

Apple makes a nice pocket computer, but otherwise they’re kinda nuts.

Saturday, November 19, 2016

Excerpts from Remnick's recent Obama interview

Read it …

Obama Reckons with a Trump Presidency - David Remnick - The New Yorker Nov 28, 2016 issue

… I’m half Scotch-Irish, man!” he said. “When folks like Jim Webb write about Scotch-Irish stock in West Virginia and Kansas and so on, those are my people! They don’t know it, always, but they are.”..

… The official line at the White House was that the hour-and-a-half meeting with Trump went well and that Trump was solicitous. Later, when I asked Obama how things had really gone, he smiled thinly and said, “I think I can’t characterize it without . . . ” Then he stopped himself and said that he would tell me, “at some point over a beer—off the record.”

… So it is a mistake that I think people have sometimes made to think that I’m just constantly biting my tongue and there’s this sort of roiling anger underneath the calm Hawaiian exterior. I’m not that good of an actor. I was born to a white mother, raised by a white mom and grandparents who loved me deeply. I’ve had extraordinarily close relationships with friends that have lasted decades. I was elected twice by the majority of the American people. Every day, I interact with people of good will everywhere.”…

…I think now I have some responsibility to at least offer my counsel to those who will continue to be elected officials about how the D.N.C. can help rebuild, how state parties and progressive organizations can work together…

… But at some point, when the problem is not just Uber but driverless Uber, when radiologists are losing their jobs to A.I., then we’re going to have to figure out how do we maintain a cohesive society and a cohesive democracy in which productivity and wealth generation are not automatically linked to how many hours you put in, where the links between production and distribution are broken, in some sense…

and "You don’t start worrying about apocalypse. You say, O.K., where are the places where I can push to keep it moving forward.”

Evidently his retirement has been canceled. These are hard times, but this time Lincoln is still in the game.

Thursday, November 17, 2016

The electronic health record problem list - how I'd do it for the third time

I did corporate research and development in clinical software for about 20 years. During that time I couldn’t write about informatics ideas.

In my current job I have more scope. I can’t write about anything specific to my work, but I can share some general thoughts on medicine and health informatics. Like my idle thoughts about how I’d implement an electronic health record problem list if I were doing one for the third time. (Of my two previous efforts I liked the first one best; this proposal is an improvement on it.)

One problem with the patient “problem list” is it’s a “roach motel”. Easy to enter, hard to leave. It gets cluttered up with obsolete junk nobody dares clean out. Another problem is one man’s poison is another man’s wine — orthopods aren’t interested in minor eye disease findings. A third problem is that problem lists are typically assembled from “billing codes” (ICD-9/ICD-10) that are often misleading and a treacherous basis for decision support. Unfortunately, because of the way we use it, ICD-10-CM is worse than ICD-9-CM. A fifth problem is that every minor variant of Diabetes gets its own entry, cluttering the list. Lastly to get real value out of the problem list it should be useful in automated decision support and population health monitoring, but again ICD-10-CM does poorly.

So here’s what I’d do:

  1. I’d base my problem list on a SNOMED subset (wait, I can explain).
  2. The SNOMED subset would be quite small, probably less than 1,500 concepts.
  3. I’d choose the concepts based on the ICD-10-CM codes that are “containers” (non-leaf) for leaf codes. This is far less than the total number of ICD-10-CM codes. I’d also restrict my coverage to those ICD-10-CM “container” codes that map to SNOMED CT Findings.
  4. The only time I’d go finer grained than this high level set would be if I had a decision support rule that needed more definition (most won’t).

Given these constraints the ICD-10-CM back maps are easy to build and maintain. Any ICD-10-CM code associated with an encounter would have a corresponding SNOMED concept. In the UI I’d support displaying all ICD-10-CM codes historically associated with the problem concept — so the detail would be available on request. Clinical rules would be written off the small space of problem list concepts.

I’d give problems an algorithmic lifetime — unless the provider explicitly makes them “sticky”. If a related ICD-10-CM code doesn’t reappear for two years the problem becomes “historic”. All decision support rules that are declined would have an option to say the “problem” no longer applies — that would remove the item.

If a problem were marked “sticky” it could still be removed manually or by the decision support action — but the provider who made it “sticky” would be get a message about the change. They could choose to investigate or ignore it.

I doubt I’ll get a third go round at this problem, but that’s what I’d like to try.

Wednesday, November 16, 2016

Crisis-T: What's special about rural?

I think 40% of Americans are disabled in the context of the modern work environment because of automation and globalization. That’s why we have “Crisis-T”.

Crisis-T is particularly associated with white non-college voters in the “rural” rust belt of America. I think I can talk to that. I did my residency in Williamsport PA (Appalachia North - and quite beautiful), my medical practice in Michigan’s Upper Peninsula, and we often traveled across the Northeast to visit family in Montreal.

Eight years ago I wrote about traveling across the northern tier …

Gordon's Notes: History and demographics - notes from a long commute

I've driven from the Great Lakes region to Montreal about twenty times over the past thirty years.

The route has changed.

Two years ago we stopped traveling along the old Erie Canal route. The northern US border, from the Lakes to Vermont, had become too depressing. There were too many signs of dying communities. History moved on eighty years ago, but the post-9/11 collapse of Canadian tourism and the the lousy US economy of the past decade have accelerated the long decline.

This year we're seeing the same changes along the Canadian route. Businesses are vanishing, gas stations are closing, communities are disappearing. In the towns we visited we saw almost no children. I suspect the causes are similar to the American changes, but the demographic decline seems even more marked. Some of these northern communities depended on the lumber trade; they would have had good years before the housing crash, very bad times now.

Fifteen years ago we thought that the net might allow these communities to prosper. I was a small town physician for five years in the 90s, and I liked where I lived.

Maybe that will still happen, but there's a lot of competition from places with better airports and milder climates.

It's a story as old as the ghost towns of the old west. These communities are small enough that a few energetic people will keep a few of them alive, but most will fade away.

Update 8/26/10: Three of the cities on the list of the top 10 dying American Cities were related to the old Erie canal and NE manufacturing route: Cleveland, Buffalo and Albany.

Four years ago I wrote about the sadness of losing mill towns. We just don’t need the paper any more …

Gordon's Notes: When paper dies, what will happen to all the mill towns?

Between Minnesota and Montreal, across Wisconsin and the UP and along the 17, there are hundreds of communities. Most are a few thousand people.

When we drive that route, we always wonder -- how did these people come to live there? Why do they stay?

No, it's not smart-ass urban elite kind of question. We know some of the answers. Emily grew up on a mill town north of nowhere…

We both practiced medicine in an even smaller but less remote mill town.

So we know how people can end up in those towns -- and we know why many stay. It's a bit surprising to many, but mill towns can be very pleasant places to live -- assuming the mill is modern and downwind (though you get used to the smell). There's work for a wide range of people there -- not just for the elite. There are usually forests, and they're not all tree farms. We liked our towns a lot.

Of course not all of the towns we pass through are mill towns. Some are agricultural centers, some are government towns, and a few are former industrial centers turning into college towns.

Many of those towns have their own problems, especially because the live-anywhere-work-on-the-net vision of 1995 didn't work out. Mill towns though, they have bigger problems.

Twenty-five years after it was proclaimed dead, paper is finally going away ...

… Newspapers and magazines are shrinking. … Lexmark has stopped making inkjet printers. China makes its own paper.

The end of paper, or at least it's semi-retirement, has a bright side. We burned a lot of carbon and energy moving that paper around (though the replacement is hardly energy-free). It's not all bright though. A lot of very fine towns are going to be facing some hard transitions ...

The globalization and automation that disabled 40% of working age Americans isn’t unique to rural areas, but those areas have been ailing for a long time. They’ve been impacted by automation ever since the railroad killed the Erie canal, and the harvester eliminated most farm workers. Once we thought the Internet would provide a lifeline to rural communities, but instead it made Dakka as close as Escanaba.

The root causes of crisis-T apply everywhere, rural areas are just a bit ahead of the curve.


Mass Disability - how did I come up with 40%?

How, a friend asked, did I come up with the 40% number for “mass disability” that I quoted in After Trump: reflections on mass disability in a sleepless night?

I came up with that number thinking about the relationship of college education, IQ curves, and middle class status. The thesis goes like this…

  1. Disability is contextual. In a space ship legs are a bit of a nuisance, but on earth they are quite helpful. The context for disability in the modern world is not climbing trees or lifting weights, it’s being able to earn an income that buys food, shelter, education, health care, recreation and a relatively secure old age. That is the definition of the modern “middle class” and above; a household income from $42,000 ($20/hr) to $126,000. It’s about half of Americans. By definition then half of Americans are not “abled”.
  2. I get a similar percentage if I look at the percentage of Americans who can complete a college degree or comparable advanced skills training. That’s a good proxy for reasonable emotional control and an IQ to at least 105 to 110. That’s about 40% of Americans — but Canada does better. I think the upper limit is probably 50% of people. If you accept that a college-capable brain is necessary for relative economic success in the modern world then 50% of Americans will be disabled.

So I could say that the real number is 50%, but college students mess up the income numbers. The 40% estimate for functionally disabled Americans adjusts for that.

As our non-sentient AI tech and automation gets smarter the “ability” threshold is going to rise. Somewhere the system has to break down. I think it broke on Nov 8, 2016. In a sense democracy worked — our cities aren’t literally on fire. Yet.

Friday, November 11, 2016

After Trump: reflections on mass disability in a sleepless night

I’m having trouble sleeping. There are a few boring reasons for that, but the election is not helping. So it’s time to write while sleep-impaired. I’ll try to keep this short, but I’m also going to break it into sections.


My son has a substantial cognitive disability and little prospect of self-sustaining employment. His temperament is different from mine. I am novelty-seeking and instinctively skeptical of authority, he loves routine and structure. I am Vulcan, he is Klingon.

I am elite. He is not. Obama is my ideal President, he declared for Trump (though, interestingly, he chose to abstain in the end). I used to be uneasy around police, he loves K9 cops.

My son’s growth and development has shaped my life and thought for 20 years. He has informed my thinking about mass disability, something I’ve been writing about for 8 years. Because of him I have sympathy even for the Deplorables, angry and lost in a world that doesn’t want them any more.

The Big Picture

I don’t think any period in human history has seen as much cultural change as America 1950-2016. Civil Rights. Feminism. Gay Rights. Atheist Rights. Gender Rights. I have a flexible mind, and I feel a bit awed by all I have had to unlearn and learn. It’s not just America that’s changed of course. I believe that, in addition to ecological collapse and economics, the 9/11 world is a reaction to the education and empowerment of women.

And then there’s the demographic transformation of America. There’s a fertility transition that continues to drop family size; without immigration America’s population would be shrinking.  There’s the rapid aging of the post-war boomers. There’s the transition of the euro-american to minority status.

Now add China. No period of human history has seen anything comparable to the rise of China — if only because it is nation of a billion people. The economic transformation is severe; there is a limit to how quickly economies can adapt.

And, of course, no period of human history has seen an intelligent machine. We live in the AI era. Not the sentient AI era, or at least not so far as I know. But we now have distributed, almost ubiquitous, machine intelligence. Pre-AI technologies have already eliminated much of the work that supported the non-college middle class. The service work that remains pays far less and demands strong emotional control. A control that many men, and some women, don’t have.

The AI era is the era of mass disability. An era when the work that is valued and compensated requires cognitive and emotional skills that perhaps 40% of the US population does not have. No, more college will not help.

Extreme cultural transformation. Demographics. China. The AI era and mass disability. I haven’t even mentioned that pre-AI technologies wiped out traditional media and enabled the growth of Facebook-fueled mass deception alt-media.

We should not be surprised that the wheels have come off the train.

The GOP in 2016

We will lose the consumer protections and financial regulation slowly built over the past 8 years. We will lose Obamacare. The Gender Rights movement will stall.

I’ve seen some talk of the Senate minority slowing this, but we are also going to lose the filibuster.  We are unlikely to win the House or Senate in 2018 — so this will happen.

This will be sad and it will hurt a lot of people, not least Trump supporters.

It may not be as bad as some fear though. ObamaCare was failing. It was a tough political compromise that ran into GOP hellfire; the GOP blocked the post-launch fixes any big legislation needs. It was from the start intensely corporate and bureaucratic, with a misguided focus on analytics and top-down controls. GOP Representatives and Senators are not going to risk the wrath of their constituents, especially the non-college whites who are at risk of losing coverage. There will be a replacement. It will cover fewer people but perhaps it can be built up.

CO2 control seems to be hopeless now, but I’m not so sure about that. Sure, Trump is an idiot, but not everyone in the GOP truly believes that global warming is a good idea. There’s a chance the GOP will make changes that Obama could never get past the GOP.

This was all going to happen with any large GOP victory. Indeed, with his political core of white non-college voters Trump is going to be more cautious that Cruz or Ryan.

Trump: the mass disability conversation

I once wrote a blog post titled "Donald Trump is a sign of a healthy democracy. Really.”. It was really prescient:

… I enjoy seeing the GOP suffer for its (many) sins, and it would be very good for the world if the GOP loses the 2016 presidential election, but Trump won’t cause any lasting political damage. Unless he runs as a third party candidate he’ll have no real impact on the elections.

Hah-hah. Laughs on me.

This part holds up better:

Trump appears to be channeling the most important cohort in the modern world — people who are not going to complete the advanced academic track we call college. Canada has the world’s highest “college” graduation rate at 55.8%, but that number is heavily biased by programs that can resemble the senior year of American High School …

… about 40-50% population of Canadians have an IQ under 100. Most of this group will struggle to complete an academic program even given the strongest work ethic, personal discipline, and external support…

… this cohort, about 40% of the human race, has experienced at least 40 years of declining income and shrinking employment opportunities. We no longer employ millions of clerks to file papers, or harvest crops, or dig ditches, or fill gas tanks or even assemble cars. That work has gone, some to other countries but most to automation. Those jobs aren’t coming back.

The future for about half of all Americans, and all humans, looks grim. When Trump talks to his white audience about immigrants taking jobs and betrayal by the elite he is starting a conversation we need to have.

It doesn’t matter that Trump is a buffoon, or that restricting immigration won’t make any difference. It matters that the conversation is starting. After all, how far do you think anyone would get telling 40% of America that there is no place for them in current order because they’re not “smart” enough?

Yeah, not very far at all.

This is how democracy deals with hard conversations. It begins with yelling and ranting and blowhards. Eventually the conversation mutates. Painful thoughts become less painful. Facts are slowly accepted. Solutions begin to emerge…

I guess we’re having the conversation now. Too bad we didn’t have it four years ago. Obama, my ideal president, missed that one. He wasn’t alone, as recently as 2015 I complained “Both DeLong and Krugman missed the college vs. no-college white middle-age cohort, and I think that’s the important story” (K had a false start in 2012.)

Late in the campaign Obama picked up the theme with work on labor market monopsony and “predistribution”. Some of the Bernie Sanders themes that Clinton adopted, like free community college, were a first step. Overall though my team missed this one. It was a huge miss. They should have been reading Gordon’s Notes …

Trump: white nationalism and patriarchy

Half of college educated white women voters voted for Trump. I can’t quite get my head around that one. That cohort would have given Clinton the election.


What do we understand that? We need to resurrect anthropology and fuse it with journalism. How? I’ve no idea, but we need a way to explain ourselves to ourselves. A NYT piece made a good start with an interview of some of these women. Rage about the Black Lives Matter movement and critiques of police (prime job for the blue collar) were a factor; as well as susceptibility to Facebook-fueled right wing agitprop. I suspect these women are also relatively comfortable with traditional male-female roles. They want a “strong leader”; maybe they favor “enlightened patriarchy”. (The article had one significant error, it claimed white college-educated women voted for HRC. They did not. If they had we wouldn’t be talking about this.)

The whites are acting like a tribe. It’s different from acting like we own the country. This is shades of old racism mixed with aggrievement, loss, and bitterness. Unfortunately, unlike other tribes, the white tribe votes.

Reagan pioneered the use of white racism to win power. Trump has kicked it up several notches. He has summoned  our demons at just the right wrong time. Now we live with the consequences. Trump isn’t going to beat these demons back, he is much more racist than Reagan was (more than most of us imagined).

On the other hand the GOP is going to get nervous about this. The party is not going to be comfortable with overt white racism. There will be some GOP help with stuffing the Nazis and Klansmen back in the bottle. We will need that help.

The Resistance

In my home town of St Paul Minnesota a mob has been blocking a freeway. That’s dumb team. Stop doing that. We need more leadership. There’s a guy I know who’s going to be out of a job in seven weeks…

Ok, so Obama is probably going to want to take a break. We are going to need someone though. This isn’t just one crazy election. Remember the “Big Picture”. There are huge forces at work, especially the lack of demand for non-elite labor (what I call “mass disability”). If you think we’re in trouble now, imagine what’s going to happen to China in the next few years. (Russia is toast.)

We need to oppose Trump. He’s a twisted wreck. I suspect, however, that he’s going to find a lot of long knives in DC. The GOP leadership are not nice people, and they prefer Pence to Trump (not that Pence is good news).

We need to oppose Trump, but we also need to remember why we have Trump. We need to focus on the big picture - there are solutions. We live in whitewater times; we need to hold onto each other while we try to steer the raft. Because there’s a waterfall ahead …

See also: 

I’ve been writing about this for a bit over 8 years …

KRISTOF: Watching the Jobs Go By - his weakest column in years 2/2004. Very early thoughts in this direction.

Why your daughters should be roofers — not architects 3/2004. Precursor ideas.

On redistribution 6/2004. From an article in The Atlantic: “It is doubtful that in any society with universal suffrage the majority is going to sit on the sidelines and watch, generation after generation, while a handful of investors and corporate managers reap almost all the benefits of technological and economic progress."

The limits of disaster predictions: complex adaptive systems 2/2007. We have survived doom before.

Mass disability and Great Depression 2.0 3/2008. 

"I believe that about 20% of adult Americans aged 25 to 65 are effectively disabled in our current globalized post-industrial economy. I believe this number will rise as our population ages. I believe this is the fundamental problem, along with network effects, driving modern wealth concentration.

Over time the economy will change to develop niches for unused capacity (servant economy?), but the transition need not be comfortable. In the meantime technological shocks, such as ubiquitous robotics, may induce new disruptions to a non-equilibrium economic structure — risking extensive economic breakdown."

Causes of the Great Recession: China, GPSII and RCIIIT. Now for Act III 4/2010

Civilization is stronger than we think: Structural deficits and complex adaptive systems 5/2010. Hope.

Post-industrial employment: adjusting to a new world 5/2010. College is not the answer.

Unemployment and the new American economy - with some fixes. 1/2011 “In a virtualized economy workers with average analytic and social IQ less than 125 are increasingly disabled. Since this average falls with age the rate of disability is rising as the we boomers accumulate entropy …Start applying the lessons learned from providing employment to cognitively impaired adults to the entire US population.” Looking back this is when my thinking about mass disability began to crystallize.

Mass disability goes mainstream: disequilibria and RCIIT 11/2011. I thought we’d have the conversation then, but it didn’t go forward. Unfortunately.

Life in the post-AI world. What’s next? 9/2011

The Post-AI era is also the era of mass disability One of my favorites. 12/2012

Addressing structural underemployment (aka mass disability) 5/2013 Some ideas on solutions. Good ideas by the way.

Donald Trump is a sign of a healthy democracy. Really. 8/2015

Trump explained: Non-college white Americans now have higher middle-aged death rates than black Americans 11/2015 “Both DeLong and Krugman missed the college vs. no-college white middle-age cohort, and I think that’s the important story” 

Trumpism: a transition function to the world of mass disability 8/2016

How does the world look to Trump’s core supporters? 9/2016.

After Trump: information wants to be free, but knowledge is expensive 11/2016. This feels fixable, but it’s a fundamental problem.

Sunday, November 06, 2016

After Trump: information wants to be free, but knowledge is expensive

Fourteen  months ago I wrote that Trump was a sign of a healthy democracy.

That one might rank up with my Peak Oil prediction. I’m really not very good at the precision business. It’s hard to know what the future will be like, it’s harder to know when the future will be.

Trump now looks more like a cardiac arrest. Not a bit of chest pain that inspires healthier living; a full out arrest with defibrillators, chest compression and, at best, a long slow recovery. Whatever Systems we had to prevent something like Trump, they didn’t work. We have a political never event; the worst of America contending for the presidency.

When the plane crashes, when the healthy patient dies, we do a root cause analysis. Usually half a dozen things went wrong all at once; multiple safeguards failed. Some of these we know about. We had the Great Recession. We had home and wealth loss concentrated in the non-college population. We had globalization. We had, have, will have the AI world eliminating jobs — especially for the non-college. We have a demographic transition form white protestant to a mix of peoples. We have rapid evolution of social mores and constant technology churn. We have the secularization of America, the end of a historic religious consensus. We have the collapse of the GOP’s historic coalition of the wealthy and the white working class.

Those are big things. But I think we needed something else to create Trump. We needed to eliminate reality.

In our era it started with right wing AM talk radio and Rupert Murdoch’s media empire — not least Fox News. Today it manifests as a torrent of consensual hallucination racing across Facebook. Most of America, especially the non-college, live in world of dreams with only a loose connection to reality. I didn’t see that coming.

How can we correct this? The economics are not good. It takes money to do run the New York Times, almost nothing to create a false news story. The New York Times costs $200 a year — only the elite can read it now. Breitbart is free — supported by AARP ads.

Making knowledge available only to the elite is not a great survival strategy.

See also: