Gingrich is a loon

Either Gingrich believes he can con the religious right into thinking he's one of them, or he really believes this ...

Shared sacrifices - Paul Krugman - NYTimes.com

... "I think this is one of the most critical moments in American history,” Gingrich said. “We are living in a period where we are surrounded by paganism."...

Either way, he's a loon.

The implications of cyber war in an interconnected world

This is the first cyber war discussion I've read that's had anything interesting to say ...

I, Cringely - Collateral Damage

... Forget for the moment about data incursions within the DC beltway, what happens when Pakistan takes down the Internet in India? ... The next time these two nations fight YOU KNOW there will be a cyber component to that war.

And with what effect on the U.S.? It will go far beyond nuking customer support for nearly every bank and PC company, though that’s sure to happen. A strategic component of any such attack would be to hobble tech services in both economies by destroying source code repositories. And an interesting aspect of destroying such repositories — in Third World countries OR in the U.S. — is that the logical bet is to destroy them all without regard to what they contain...

Sounds plausible. I'd say we have a problem ...

Requiem for a gerserker - Gordon's Laws of Geekery

So we'll go no more a-hackin
So late into the night
Though the heart be still as geeking,
And the moon be still as bright...

Apologies to Byron

Able I was ere I saw Elba. Anon.

It is hard to remember a time before the Man-machine war. Things were bad in the TSR years, and yet again when QEMM laid waste to the minds of men. Strong warriors weep to remember when Mac OS 7 crumbled before TCP/IP, or the Hell that was Hayes. We hoped for peace with OS/2, but got Me instead.

Yet we won those battles. The machines seemed chastened. Windows 2000 was peaceful. Modems died. OS X 10.3 was good. We thought a world of true productivity lay ahead.

We were wrong. The machines were only playing for time. The synchronization front claimed thousands of mortal minds. OS X turned vicious, and XP maniacally senile. The powers of Google gave us new hope, but was Google truly on the side of flesh?

It's not only that the machines are becoming ever more powerfully complex. We of the first generation are growing weary. Many comrades have retired from the front. We can't weave and dodge as in the days before bifocals. Exercise, sleep, work and ... yes ... family -- they take their toll.

Yet I fought on. I was a Gerserker; I threw myself into battle. When others held back I charged Sharepoint heights and fought Outlook hand to hand. Yes, I synced contacts with the iPhone.

I went too far. In my bones I knew the end was near. OS X Tiger lived up to its man-eating namesake. My ancient XP box was dying slowly of chip rot. Office 2007 bit my ankles.

I was weakened when I met IT. Active Directory is a rabid shark on steroids. We fought for weeks. Some days I was netlocked seven times, but I struggled to my keyboard every time. One day I thought I had it beat, but it raged back when I turned my head. Finally we fought tooth, nail and hackery until I pulled the poisoned dagger from the treacherous heart of Outlook 2007.

The battle was won, but the my war was done. Even replacing my mother's cable modem and upgrading her plain Mini to 10.5 had too many bizarre bugs.

My time as a Gerserker is done. I still contend, but no longer do I leap to the battle.

Just as I have sworn by Gordon's Laws of Acquisition, so I do By Darwin Swear upon Gordon's Laws of Aged Geekery ...

1. Avoid Microsoft. They are one with the Darkseid.
2. Fear authentication, above all fear authentication with synchronized credentials.
3. Fear that which is beyond the hand of the Geek, such as networked data that cannot be copied locally. Above all, fear the services of those foreign domains that lack an effective and responsive Help Desk.
4. Embrace redundancy.
5. Simplify, even at the cost of power.
6. Pace technology. Take on new battles only when the supply lines are strong and the forces are rested.

It's a new world for me. It means I don't want a 10.6 iMac -- instead I'll buy a 10.5 iMac once the 10.6 "up to date" program is announced. I doubt I'll do 10.6 before 2012.

I won't be doing any more Windows installs outside of a VM. I embrace the Virtual Machine and the Sandbox as my allies.

I'm putting off my new SLR purchase, partly because Canon has gone mad, but mostly because those images are too large for old G5. I will need to get a new iMac completely pacified before I take on new camera. The SLR will move into 2010.

I'm going to get the new iPhone -- but not at the same time as the new iMac. They'll have to be spaced.

At work I'll drastically reduce my participation in anything new beyond the absolutely essential.

In the fearsome Cloud I'll be stay closer to Google -- the Demon I ride -- and avoid the complications of distributed authentication and extended identity.

I have returned upon my shield, and the night is now for sleeping ...

Update 6/8/09: Added Virtualization tag (label) to my tech blog.

Update 7/13/09: I missed this Gizmodo cry for gadget reliability when it came out in late 2008. Peace brother.

AvantGo RIP - memories of the roaring 90s

The demise of AvantGo has not received much attention. I am one of the few who remember the deceased Palm application, so I'll deliver the obituary.

I knew it well. In 1998 I did a little presentation on AvantGo for the primary track of the American Medical Informatics Association (my little JavaScript driven slideshow applet still works btw - 10 years later on Safari 4beta). It got a mention on my 1998 PalmPilot web page and my old AvantGo targeted medical notes page is still around.

In its youth AvantGo was bright, clever and reliable. There were two parts - a server and a client. The net server based web spider processed a URL to specified limits and stored the results in AvantGo format. Then, whenever I serial cable synched my Palm III or Vx the results updated the Palm AvantGo client.

AvantGo was a way for me to carry static snapshots of web pages. Even then my extended memory was moving to the web, but there were no portable browsers, no G3 networks, no wireless to speak of - so a static snapshot of my web memories was pretty handy.

At work we built a handheld prescribing application around AvantGo and a server we controlled locally. In the late 90s AvantGo wanted to become a platform provider to the palmtop. That prescribing app was one of my ideas, for what it was worth (not that much unfortunately!).

Alas, the strategy didn't work for them. Their main business, unfortunately, was streaming newspaper output to the Palm. Yes, like Byline or Google Reader, but before feeds. Newspapers have been looking for electronic delivery options for a long time, AvantGo was just one more failure. You didn't really think anything was new, did you?

It was a nice idea, but there was no money in it. In retrospect AvantGo's failure heralded the death of the traditional newspaper business.

Even before the dotCom crash AvantGo was getting bloated and buggy. They wanted to become a handheld browser, but that was a tough road. We didn't get a decent small scale web browser until the iPhone -- AvantGo never got close. Even as AvantGo struggled the PalmOS platform was slowly dying.

I lost track of AvantGo, though even now I wouldn't mind the ability to offline cache spidered web pages on my iPhone. Heck, I'd even pay for that, though I'm probably the only one who would.

Now the AvantGo I knew is gone. Wikipedia says they the company was founded in 1997 and that it once had a market cap of $1 billion. It was sold to Sybase in 2002 for $38 million.

$1 billion. Back when a billion dollars was real money.

Man, the 90s were good times. 

Who will acquire Palm ... and the Pre?

As a long-suffering and occasionally joyful iPhone user, and as scarred and bloodied Palm-era road-kill, I'm very happy that the Palm Pre is receiving first class review coverage. Yes, Pogue and other reviewers are keen to praise the underdog, but this is a genuine achievement.

It's also a desperate Hail Mary pass -- and the goal is not corporate survival. The iTunes hack (the Pre forges iPod credentials) and the expected severe product shortage are just two early signs of how badly Palm is limping now.

I'm with Blodgett ...

The Palm Pre Will Bomb (PALM, AAPL) - Henry Blodgett

.. The smartphone game has become a waltz of elephants, and Palm is just a Jack Russell terrier.  In the US, the smartphone war is between Apple, RIM, and, to a lesser extent, Google.  Palm can yip a bit and run around nipping at the others' feet, but it's too late to become one of the big dogs.

One thing Pre does do for Palm is turn it into a more attractive acquisition candidate.  We doubt Apple, RIM, or Google would buy it, but there's always Nokia, which is nowhere in the US smartphone market...

Nokia is everyone's number one guess for the soon-to-be home of the Palm Pre. I'd wonder about SONY and Samsung -- neither company can afford to surrender the computer infrastructure of the next 15 years.

I also wouldn't write off RIM. It's difficult to describe how badly the BlackBerry OS sucks. Yes, I know it sells well in the consumer market, but that's because most consumers are clueless. I don't think that's going to continue. If RIM's only strength is Exchange server they're in trouble.

So my choices for the future home of the Pre are Nokia first, RIM second then SONY and lastly Samsung. Dell is a wildcard. Any other lists out there?

The long slow development of human culture - and technology

Modern humans are a new species -- but not born yesterday. Why did it take so very long for humans to develop art and varied technologies? This Economist article doesn't convincingly answer the question, but it presents the current consensus on the problem...

Warfare, culture and human evolution: Blood and treasure | The Economist:

... The species is now believed to have emerged 150,000-200,000 years ago in Africa and to have begun spreading to the rest of the world about 60,000 years ago. But signs of modern culture, such as shell beads for necklaces, the use of pigments and delicate, sophisticated tools like bone harpoons, do not appear until 90,000 years ago. They then disappear, before popping up again (and also sometimes disappearing), until they really get going around 35,000 years ago in Europe...

The astounding part is that we got going about 90,000 years ago, but then didn't really reboot until 35,000 years ago. We get writing about 6,000 years ago and the web about 20 years ago.

So the next big leap should be about 10 minutes from now. Oh wait, that's the Singularity.

My personal bias, probably arising from reading John Hawks, is that our brains were changing a lot over those 90,000 years. The odd bit is the false start.

BBC's annotated version of Obama's speech to the Islamic world

BBC NEWS had the full Obama speech with clickable inline annotations.

We're luckier than we deserve to have this President.

Kristof was at Tiananmen square - his memories

I don't remember him writing this story before. It's very powerful. One day China will remember, and one day China may honor those who fell.

Op-Ed Columnist - Bullets Over Beijing - Nicholas Kristof

It was exactly 20 years ago that I stood on the northwest corner of Tiananmen Square and watched “People’s China” open fire on the people.

It was night; the gunfire roared in our ears; and the Avenue of Eternal Peace was streaked with blood. Uniformed army troops massed on the far end of the square, periodically raising their assault rifles and firing volleys directly at the crowd I was in, and we would all rush backward in terror until the firing stopped.

Then the volley would end, and in the deafening silence we would stop and look back. In the hundred yards between us and the soldiers would be kids who had been shot, lying dead or wounded on the ground.

Some protesters shouted insults at the troops or threw bricks or Molotov cocktails that landed ineffectually in the open area. But none of us dared to go forward to help the injured as they writhed. I was the Beijing bureau chief for this newspaper, and I was cowering behind a layer of other people whom I hoped would absorb bullets; the notebook in my hand was stained with perspiration from fear.

Troops had already opened fire on an ambulance that had tried to collect the injured, so other ambulances kept their distance. Finally, some unlikely saviors emerged — the rickshaw drivers.

These were peasants and workers who made a living pedaling bicycle rickshaws, carrying passengers or freight around Beijing. It was those rickshaw drivers who slowly pedaled out toward the troops to collect the bodies of the dead and injured. Then they raced back to us, legs straining furiously, rushing toward the nearest hospital.

One stocky rickshaw driver had tears streaming down his cheeks as he drove past me to display a badly wounded student so that I could photograph or recount the incident. That driver perhaps couldn’t have defined democracy, but he had risked his life to try to advance it.

That was happening all over Beijing. On the old airport road that same night, truckloads of troops were entering the city from the east. A middle-aged bus driver saw them and quickly blocked the road with his bus.

Move aside, the troops shouted.

I won’t let you attack the students, the bus driver retorted defiantly.

The troops pointed their guns at the bus driver and ordered him to move the bus aside. Instead, he plucked the keys from the ignition and hurled them into the bushes beside the road to ensure that no one could drive that bus away. The man was arrested; I don’t know what happened to him...

... When you educate citizens and create a middle class, you nurture aspirations for political participation. In that sense, China is following the same path as Taiwan and South Korea in the 1980s.

In Taiwan in 1986, an ambitious young official named Ma Ying-jeou used to tell me that robust Western-style democracy might not be fully suited for the people of Taiwan. He revised his view and now is the island’s democratically elected president.

Some of my friends are Communist Party officials, and they are biding their time. We outsiders also may as well be similarly pragmatic and patient, for there’s not much we can do to accelerate this process. And as we wait, we can be inspired by those rickshaw drivers of 20 years ago.

Fifteen years more. I hope to live to see the day.

China's perspective on North Korea

Via James Fallows, I came across a Washington Post columnist's summary of how China sees North Korea.

Superb. Seems some of today's best newspaper journalism never sees newsprint.

Fallows contrasts this piece to a dangerously stupid article that did appear in print.

I'll have to start reading Pomfret now. I stopped reading WaPo a while ago, they're a 3rd rate paper. Seems they do have some good journalists though.

Wisdom from the flames - a different OS X future

Gizmodo had fun recently comparing Windows 7 buzz to the disinterest in OS X 10.6 (Snow Leopard). The photo of a demonic Ballmer about to devour a sleeping Snow Leopard kitten should hang in his office.

It makes for lots of links and traffic, but I think there's a deeper lesson.

Windows 7, aka Vista 3.0 is very important. XP is decayed and too vulnerable to attack. Vista has gotten a bad rap and is not much used by businesses. Windows 7 will either be immensely successful or one of history's great corporations will go under. That deserves attention.

Snow Leopard? Ummm, tell me again why I need it?!

Sure, I love scalable UIs -- but I'm not sure that's in Snow Leopard and it should be an update to 10.5, not yet another big migration. Yes, 64 bit would be nice, but I can wait a few more years. We could do a lot with 4GB of memory if we were a wee bit less sloppy. I wouldn't mind putting those GPUs to use, but I suspect that need not require a big OS revision.

To be honest, I'm a bit tired. The 10.5 transition has not been a pleasant experience. There've been too many problems with OS bugs and hardware incompatibility. Too many parts of OS X 10.5, from iChat to accessibility to managed users to security usability (why can't one escalate privileges to modify a locked Dock?) need rework and finish.

I don't need 10.6. I don't want 10.6. I want Apple to pour a few millions in to making 10.5 better.

Ahh, but there's the rub. Apple needs to make money.

So here's my proposal to Apple.

Sure, keep working on 10.6. Maybe ship it this year if you need to, preferably ease off and wait until the summer of 2010. Meanwhile, find a way to make money off 10.5 updates. I don't know how Apple can fudge this and live within accounting rules, but there must be a way. Maybe Apple could bundle 10.5 enhanced with MobileMe, so that MobileMe subscribers get a steady stream of 10.5 fixes and improvements.

Please Apple, do something to make my life better. The current arrangement really ain't working that well for me.

Unheard stories of the 19th century - Irish evacuation to Montreal

Sometime in the 20th century, I was a medical student at St Anthony Hospital in the north of Newfoundland. The Hospital was a legacy of the Grenfell Medical Mission, so I read Grenfell's (sometimes fanciful) stories of the late 19th and early 20th century european hunter gatherers of those remote lands.

Those were, and are, tough lands. The native population was small even before the european plagues.

Foreign to those all but uninhabitable lands the europeans hunted fish and seal, lived as debt slaves in squalor and misery, and died in droves on the ice. I was not long from a stay in 1980s Bangladesh, then a synonym for misery, and I though that hot misery had its advantages over cold misery.

No-one in those days, incidentally, would have predicted Bangladesh would do as relatively well as it has. That's worth remembering.

The stories of Newfoundland's back country are fascinating, but they are all but forgotten to our time. Just like this glimpse of the Malthusian agony of Ireland's 19th century, seen from Montreal, Canada in the years before America's immigration-amplified civil war ...

Seeking hope, they found death Rene Bruemmer, The Gazette

The Irish came by the tens of thousands in 1847, packed like cordwood below deck in fetid ship holds meant for timber....

... There were so many corpses, trenches were dug to dispose of the dead in what is now Point St. Charles. Twelve years later, labourers building the Victoria Bridge would uncover the bones of their brethren and insist the remains be protected. To make sure of it, they planted a massive 30-tonne, 10-foot high boulder dredged from the St. Lawrence River over the burial site, and inscribed it, in part: "To preserve from desecration the remains of 6,000 immigrants who died of ship fever."  [Epidemic Typhus, a Rickettsial disease transmitted by human lice]...

... In 1845, potatoes were struck by a fungal infection that caused half the crop to rot in the earth. In 1846, the blight returned, wiping out almost the entire crop, followed by one of the harshest winters in living memory, and the people starved....

... Most would have preferred the well-established promised lands of New York and Boston, but America had set strict standards and fares for passage to the U.S. were too high for the impoverished. But British traders who shipped lumber from Quebec City and St. John's were happy to have emigrants paying a low fare to serve as ballast for their return trips to Canada. Many passage brokers told passengers food would be provided for the 45-day journey, which was untrue...

... Canadian immigration officials, who had no say in emigration policies determined by the British colonial authorities, were sorely unprepared and underfunded for the deluge of emaciated Irish. At the immigration depot on Grosse Île, an island in the middle of the St. Lawrence 50 kilometres east of Quebec City, the medical officer in charge of the quarantine station prepared beds for 200 invalids, thinking 10,000 emigrants had departed from Britain. That summer, more than 100,000 would flee to Quebec.

By the end of May, there were already 40 ships lined up for three kilometres, awaiting to discharge passengers. The ships kept coming till the river iced over in October....

... The ill overflowed the quarantine stations, lying outside on the grass and sand beaches. Healthy passengers were stuck waiting on the ships for 20 days, a death sentence for many. Bodies were pulled from the holds with hooks and stacked on shore. Between 3,000 and 5,000 died on Grosse Île...

... Overwhelmed health officials started waving many ships with "healthy" passengers on to Montreal.

They disembarked, malnourished and diseased, dying in the streets and on the wharves, begging for water on the steps of churches. Worried about an epidemic, authorities constructed three wooden "fever sheds" 150 feet long and 50 feet wide at Windmill Point, near where Victoria Bridge now stands in Point St. Charles. The sick and dying lay two or three to a bed, side by side with the dead, leaving hundreds of orphans behind. The number of sheds grew to 22. Military cordoned off the area so the sick couldn't escape.

Seeing the ill dying alone, the Grey Nuns went to help, attending to the sick and carrying women and children in their arms from the ships to the ambulances. Thirty of 40 nuns who went to help fell ill, and seven died, writes historian Edgar Andrew Collard. Other nuns took over, but once the surviving Grey Nuns had convalesced, they returned...

When a mob of frightened Montrealers threatened to toss the fever sheds into the river, Montreal mayor John Easton Mills quelled the riot, and later went himself to help in the evenings, giving them water and changing their straw bedding. The father of a large family, he died in November.

The Roman Catholic Bishop of Montreal urged French Quebecers, linked to the Irish by their Catholic faith, to help the orphans. Many came from the country to adopt one or two children, accepting them in to their families, in some cases passing their land on to them...

... Grosse Île, site of the largest Irish famine graveyard outside of Ireland, is now known as the Grosse Île and the Irish Memorial National Historic Site of Canada...

I grew up in Montreal, but this is the first I read this story. John Mills was born in deeply Protestant and English Massachusetts twenty years after the American revolution, but ended up in Canada. Were his family loyalists fleeing the rebels?  At 50 this presumably Protestant mayor of English descent died helping starving, diseased and exiled Catholic Irish. I wonder if any of his family survive to tell more of what must a remarkable life.

The movie almost writes itself, doesn't it? There would be worse ways to remember those people and those times.

There's a long way down from where most of the world is today. It would do us all well to look over the edge once in a while, the better to inspire our kindred ascents.

Videotron torments and choice in broadband markets (revised)

I wrote the original version of this post as a cautionary tale of miserable experiences with my mother's Quebec-based Videotron customer service. I related my personal story to broader concerns about lack of choice and competition in most broadband markets.

After I wrote it Videotron service did somewhat better. My original post was too one-sided. Things work differently in the old country.

Instead I wrote a technical summary of what I learned about managing a (Quebec) Videotron cable modem that's dropping connections.

There's one part of the original note I'll retain, and I expect to return this theme over the next few years. Most broadband markets in North America are increasingly served by only one or two providers. These at best oligopolies, and in many regions there's an effective monopoly.

This is a very bad thing for customers, and not such a good thing for employees who want to deliver good service. Oligopolies are corrosive. Always.

There's a role for government here. If we can't avoid oligopolies then we'll need regulation -- but that's a desperate solution. We need to encourage competition, even if that means breaking up companies that currently hold monopoly power.

Broadband is too important to become a part of a monopoly market.

The WHY of medical cost variation

The inescapable Dr Atul Gawande has drilled down on the why of medical cost variation: Annals of Medicine: The Cost Conundrum: Atul Gawande: The New Yorker. He drills down into the town with the world’s (universe’s?) highest health care costs -- McAllen, Texas – a mid-sized city with explosive population growth – and a significant amount of poverty …

… The median income for a household in the city was $33,641, and the median income for a family was $36,050. Males had a median income of $30,089 versus $22,480 for females. The per capita income for the city was $14,939. About 20.9% of families and 23.8% of the population were below the poverty line, including 30.5% of those under age 18 and 20.3% of those age 65 or over…

This isn’t another boring (boring) article on health care cost variation. Gawande, who is no amateur, knows the interesting question is “why?”. I loved his description of the body language of an anesthesiologist and hospital entrepreneur during one of his visits. I bet that CEO would prefer a root canal to a Gawande interview…

… I visited the top managers of Doctors Hospital at Renaissance. We sat in their boardroom around one end of a yacht-length table. The chairman of the board offered me a soda. The chief of staff smiled at me. The chief financial officer shook my hand as if I were an old friend. The C.E.O., however, was having a hard time pretending that he was happy to see me. Lawrence Gelman was a fifty-seven-year-old anesthesiologist with a Bill Clinton shock of white hair and a weekly local radio show tag-lined “Opinions from an Unrelenting Conservative Spirit.” He had helped found the hospital. He barely greeted me, and while the others were trying for a how-can-I-help-you-today attitude, his body language was more let’s-get-this-over-with.

So I asked him why McAllen’s health-care costs were so high. What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. “The people in charge of the purse strings don’t know what they’re doing.” (2) If anything, government insurance programs like Medicare don’t pay enough. “I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays.” (3) Government programs are full of waste. “Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste.” (4) But not in McAllen. The clinicians here, at least at Doctors Hospital at Renaissance, “are providing necessary, essential health care,” Gelman said. “We don’t invent patients.”…

Gawande, like me, is interested in the (too few) qualitative studies of health care spending decisions

… Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from…

But is it really where doctors trained, or is it something far more concrete?

.. I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.

“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.

He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to…

… many physicians are remarkably oblivious to the financial implications of their decisions...

.. Others think of the money as a means of improving what they do…

…Then there are the physicians who see their practice primarily as a revenue stream...

In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme….

When we talk about practice variation we don’t usually think anthropology. That’s probably a mistake …

Woody Powell is a Stanford sociologist who studies the economic culture of cities..

.. Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream…

…The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up…

Culture really, really, matters. Damnit.

And now from my neighborhood (more or less) …

I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country…

…The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.

“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially possible…

…Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys…

Gawande tries to come up with ways to replicate the lessons from Mayo et al. It’s not easy. One of lessons, which he quietly skates around, is that superb physicians will deliver superb medical care for much less than they’re paid in Texas. We don’t overpay our specialists as insanely as we overpay our CEOs – but we do pay far more than is needed to fill the jobs. CEOs are paid perhaps 5-20 times what they’d work for, but surgeons and many specialists are probably only paid 3-5 times too much.

Rationalizing reimbursement and incentives would more than pay for high quality universal health care – but it would be a devastating transition.

hat tip: Richard Neill, via Facebook

Mobile phone and automotive GPS collision avoidance for pedestrians, bicyclists, tricyclists, skaters and pets

Years ago I wondered about collision avoidance systems for bicycles and pedestrians.

Something like a vest that would reflect radar signals broadcast by cars.  The primary automobile use of the radar broadcasts would be to avoid auto collisions, but bicyclists would also benefit.

There would be lots of ways then to avoid bicycle fatalities. Maybe the bike is illuminated on an active windshield. Maybe there’s an audio alarm if vectors appear to intersect.

Now that we’ve got systems like Google Latitude (not available for iPhone – it needs background multitasking!) though, it’s obvious we can do the whole thing with next generation mobile phones.

We don’t even need to worry about this patent …

GPS collision avoidance system - Patent 5872526

… A collision avoidance system for a plurality of vehicles equipped with GPS receivers, each broadcasting current location information to other vehicles and receiving and displaying location information from other vehicles, enables a vehicle operator to be aware of the location of the other vehicles. For vehicles not equipped with GPS, and transceivers, information about location is taken from common ground control equipment such as an FAA control station and broadcast to all vehicles. In an aircraft environment, flight plans can be filed and closed out automatically…

The GPS source would be the mobile phones of the automobile passengers, and the mobile phone of the bicyclist. Not to mention the mobile-phone like device attached to dogs.

The phones can even manage the collision avoidance, though there are obvious advantages to having the car computer manage that.

It’s interesting to think how it could work with just phones, however.

If a phone knows it has a history of travel over 35 mph, it can assume it’s in a car. If Google Latitude 3.0 detects a car/mobile vector intersecting with a bicycle/skating/pet/pedestrian mobile vector it can send an audio message to the car stereo (“Pedestrian collision in 5 seconds … 4 seconds … 3 seconds … …. …. ambulance and police now enroute …”).

You can imagine lots of variants. Unfortunately, lots of opportunities for nasty abuse as well.

In a post-Peak Oil America of aging boomers, domesticating the wild and savage automobile will become increasingly important. These kinds of collision avoidance systems will mandated within 10 years.

How Apple could surprise

We know what to expect for our July iPhone. Sounds excellent. I'll buy one.

Sad not to have any surprises though.

Unless ... how about a combo display, keyboard, battery and iphone cradle for, say, $250?

Add iPhone, get netbook.