Category Archives: Rants&Rambles

Political, Rants&Rambles

Hard Choices

Some jobs nobody wants.

Telling a parent that their child is dying has to be up there with the worst jobs in the world, the flip side perhaps to telling them that you can save their child’s life. Telling parents that their very sick child cannot be helped, and worse still, you believe that keeping them alive is pointless and possibly damaging, telling them you’d like to switch off the machines keeping their child alive, must be amongst the most soul-destroying jobs in the world.

Recent newspapers have been full of the difficult case of the British boy Charlie Gard, the latest in a series of court cases in the UK when parents and doctors have disagreed about medical treatment for a child. Charlie Gard is a 9-month-old boy with the rare neurodegenerative disorder severe encephalomyopathic mitochondrial DNA depletion syndrome.

He is dependent on life support and has been in intensive care at Great Ormond Street Hospital for Children in London, UK, since October, 2016. In such disputes, typically, doctors regard life support treatment as “futile” or “potentially inappropriate”.

Parents, by contrast, want treatment to continue. In the current case, High Court Judge Mr Justice Francis has recently rejected the request of Charlie Gard’s parents for him to travel to the USA for an experimental medical treatment, nucleoside therapy. On April 11, 2017, Justice Francis ruled that it would be lawful and in Charlie Gard’s best interests to withdraw artificial ventilation and provide palliative care. Charlie Gard’s parents have appealed this ruling.

When doctors and the courts consider cases like this one, they often focus exclusively on the best interests of the patient. In some cases, however, it is uncertain whether or not treatment would be in the interests of the patient. Indeed, there could be stronger and clearer arguments to limit treatment on the basis of finite and scarce medical resources. Although it feels brutal, keeping this little boy alive inevitably means less money to spend on keeping other children alive.

The different ethical reasons that justify a decision not to provide treatment might come together, or they might come apart. If treatment would be both affordable and in the child’s interests, it should unquestionably be provided. If it is neither affordable, nor in the child’s interests, treatment should not be started or should be stopped.

Where there is uncertainty about the benefits and costs of treatment, parents’ views are crucial. But sometimes the picture is more mixed. Perhaps treatment is in the interests of the patient, but unaffordable within a public health system. In the case of Charlie Gard, the parents have raised money over the internet through crowdsourcing to enable him to be taken to the USA for medical treatment. That would mean that the resource issue is not relevant. Perhaps for him treatment would be affordable, but contrary to Charlie Gard’s best interests?

One way of thinking about what would be in someone’s best interests is to imagine a set of scales. On the right side of the scales are the reasons in favour of a course of action, on the left are the reasons against. If it were a question of weighing a small chance of a positive outcome against an empty scale, the balance would be tipped in favour of treatment, even if the chance (or magnitude) of benefit were tiny.

But there are often substantial negatives in the balance.

Although health professionals do their best to provide pain relief, sedation, care, and comfort to severely ill children and babies, that ability is finite and imperfect. Children on long-term ventilation often seem uncomfortable at least part of the time, they endure needles and invasive procedures, and might be distressed and unable to communicate the source of their distress.

It is possible to argue that the small chance (perhaps one in 10 000) of benefit would outweigh the negatives of treatment in intensive care. However, a shift in perspective casts that argument into doubt. Charlie Gard’s condition is extremely rare, but imagine that there were a sudden epidemic of mitochondrial DNA depletion syndrome affecting thousands of newborn babies. Would it be ethical to artificially ventilate for months thousands of infants to achieve some measure of improvement in one infant? Setting aside any consideration of resources, it seems wrong to subject thousands of infants to invasive and unpleasant life-support treatment to benefit one child. That implies that this chance of recovery is too slim to make treatment plausibly in the current child’s interests.

The reason why these decisions come to the court at all is because parents do not have an absolute right to make medical decisions for their children. Parents are given broad discretion about how to raise their children, for example, how to feed them, how to educate them, and whether or not to immunise them. Parents will not always make the best choices, but for the most part the state will not interfere or intervene. However, where parents’ decisions run a substantial risk of causing serious harm to their child, their decisions must be challenged, if necessary in a court.

When it comes to experimental treatment, there can be different reasonable views among health professionals about how to weigh up the chance of benefit against the burdens of the treatment. In the face of such disagreement, the decision properly belongs to the parents. Assuming the treatment is affordable, and the parents want it, it should be provided. However, when no health professionals think that the experimental treatment is worth pursuing, parents’ request for treatment should not be granted.

In the case of Charlie Gard, just one expert in the USA was prepared to provide experimental treatment. However, the expert admitted that the treatment had never been tried in a child with established encephalopathy and that benefit was “unlikely”; in his ruling, the judge clearly thought that this possibility did not represent a reasonable treatment option.

Decisions about life-sustaining treatment for critically ill children are fraught and difficult for all involved. Parents are, rightly, at the heart of the decisions that are made in intensive care. Their views about treatment are important, and their wishes are usually followed. However, there are limits. Sadly, reluctantly, doctors and judges do sometimes conclude—and are justified in concluding—that slim chances of life are not always better than dying. Providing comfort, avoiding painful and unhelpful medical treatments, supporting the child and family for their remaining time: sometimes that is the best that medicine can do, and the only ethical course.

Pending appeal Charlie Gard continues to be kept alive.

Rants&Rambles, Science

STOP

Throughout history, humanity has been blighted by epidemics of communicable diseases that medical science and public policy have, to varying degrees, been able to control. Sanitation, immunisation, mosquito nets, and antimicrobial agents are examples of developments that have helped to generate substantial reductions in cholera, dysentery, smallpox, measles, HIV, tuberculosis, and many other infectious diseases.

More people die in the developing world from non-communicable disease than communicable, though it can be tricky to raise funds for heart attacks over diphtheria. Non-communicable diseases are now emerging as major burdens in low-income and middle-income countries. This is especially true of the epidemics of lung cancer, chronic obstructive pulmonary disease (COPD), cardiovascular disease, and other disorders that are caused by tobacco smoking.

We know it’s bad for us to smoke, but maybe not quite ho bad.

A new report in The Lancet using data from the Global Burden of Disease Study provide comprehensive estimates of death and disability caused by smoking at the country level. The findings are sobering. In 2015, smoking caused more than one in ten deaths worldwide, killing more than 6 million people with a global loss of nearly 150 million disability-adjusted life-years.

Smoking prevalence and consequent morbidity and mortality are now falling in most (but not all) rich countries, but future mortality in low-income and middle-income countries is likely to be huge.

Worldwide, one in four men, and a total of 933 million people, are estimated to be current daily smokers, and 80% of these smokers live in low-income and middle-income countries. Half of these, or half a billion people alive today, can be expected to be killed prematurely by their smoking unless they quit.

At present, smoking prevalence is still low in countries with a low socio-demographic index, but, on past experience in richer countries, it is only a matter of time before men and then women in all countries take up smoking, and in due course die from lung cancer, COPD, and other diseases caused by smoking, as has happened in the richer world. Even though the prevalence of smoking is decreasing in many low-income and middle-income countries, including many of those with the most smokers (eg, China and India), population growth means that the number of smokers, and hence the burden of harm from smoking, continues to rise.

Responsibility for this global health disaster lies mainly with the transnational tobacco companies, which clearly hold the value of human life in very different regard to most of the rest of humanity.

For example, the latest annual report from British American Tobacco (BAT), historically the most global of today’s five transnational companies, details with apparent pride their geographical diversity, strong earnings and market share growth, market leadership in more than 55 countries, and manufacturing facilities in 42 of them.

In 2016, BAT sold 665 billion cigarettes, making £5·2 billion in profit; and recorded rising profits across most of the world. Countering the heft and influence of commercial behemoths such as this demands human resources, governance, expertise, and financial backing that few rich countries have yet to fully establish, let alone those countries at the lower end of the development spectrum.

The WHO Framework Convention Alliance provides detailed guidance to support implementation of a growing range of effective tobacco control policies, including taxation, advertising bans, smoke-free policies, and protection against the vested interests of the tobacco industry, but, in most parts of the world, translating this guidance into effective legislation has a long way to go.

Like in many rich countries, tobacco control legislation too often becomes mired in procedure and delayed or otherwise undermined by tobacco industry misrepresentation of science, fearmongering over tax revenue and illicit supply, corporate social responsibility activities, offers of help drafting tobacco laws, threatened or real legal action, and, in some countries, economic dependence on tobacco growing, and conflicts of interest.

The persistence of smoking in the countries first affected by the tobacco epidemic reflects decades of failure first to recognise smoking as a health problem, and second to take decisive action to implement the policies currently promoted by the WHO Framework Convention on Tobacco Control, but articulated long ago in the Royal College of Physicians’ report of 1962

Today, the smoking epidemic is being exported from the rich world to low-income and middle-income countries, slipping under the radar while apparently more immediate priorities occupy and absorb scarce available human and financial resources. The epidemic of tobacco deaths will progress inexorably throughout the world until and unless tobacco control is recognised as an immediate priority for development, investment, and research.

Rich-world experience also teaches that where the tobacco industry leads and succeeds today, so the alcohol and food industries follow tomorrow

Rants&Rambles

Truth

I was once told by “he who knows everything and knows it best” that my knowledge was severely limited because the UK media just plain lies. It tells lies. Where it doesn’t lie, it omits to tell the truth.

I was told this on the basis of an article this guy (it’s always a guy, isn’t it?) about football hooliganism read on a plane highlighting a problem with a UK club that this fellow followed. The violence had not been reported in the UK, or at least, nowhere where this chap had read it.

Aside from the madness of being lectured by someone who knows nothing about the media I consume, who clearly has a very limited consumption himself and on the basis of “foozball” it’s a strange idea in the modern world. Yes, there clearly is a bias within national media to report stuff that is topical and interesting and since most of the people writing in that media are from the country involved, there’s probably more of a bias than any of us recognise at the time.

We just don’t find the same things as exciting or interesting as our neighbours. So I subscribed to a number of different media from around the world and waited to be enlightened.

There really isn’t that much of a difference, truth be told. The UK is desperately interested in who gets to become next PM. No one else really cares too much. The US is desperately interested in the actions and inaction of President Trump and the machinations around the Affordable Healthcare Act. The UK less so. Der Spiegel is interested in Brexit and in the manoeuvrings of Putin, plus the rise of populism as opposed to popularity. And Australia is concerned with China more than seems right or rational to a Brit.

But then there’s some international crisis such as the malware cyber attack yesterday which has obviously had a huge impact almost everywhere, and at home has hit the NHS hard.

A new strain of ransomware — malicious software that encrypts a computer’s files and then demands payment to unlock them — spread rapidly around the world on Friday. This map shows tens of thousands of Windows computers that were taken hostage by the software, a variant of the WannaCry ransomware

Since the UK is pretty transparent about our disasters and talks about them in English, the US media has lots of information and seems to have run with the story. Most damage is said to have occurred in Russia, but translating those stories, once you’ve found them, is pretty expensive for the mainstream media outlets. So the US talks of the crappy NHS tech systems not being updated, the underlying tech code being probably sourced from code stolen by from the American secret services, the NSA, so providing both an excuse to bash the British health system (“Just look what happens with socialised medical care!) and a perverse but very real sense of pride in the amount of damage created by a dangerous American product.

In the UK, we’ve also run with the crappy NHS side of the story, because there’s nothing a Brit likes more than knocking their own society, but mitigated also by the story of a guy who sees to have become the accidental hero of the piece. The malware code included an off switch of sorts whereby the code looked up a site (non-existent domain name) for no apparent reason. A British coder, seeing this though to buy up the domain ($15) and make it live, at which point thousands of references came through to the site and virus spread was halted.
The plucky Brit saves America narrative never appears in America.

 

Political, Rants&Rambles

ONS

I love the ONS. All of those numbers, those unambiguous facts.
There has been a bit of a storm centred on the Labour Party’s rather mild suggestion that anyone earning more than £70,000 in the UK is wealthy. Yet on the face of it, this seems pretty unambiguously true. Anyone earning that amount of money would be well within the top 5% of earners within the UK but immediately on-line media was full of rejections and deflections. Apparently we should look at asset wealth instead. Either that or tax the beggars to oblivion.

Looking through the ONS figures on tax, there are lots of useful numbers to consider.

In the financial year ending 2015 (2014/15), the average income of the richest fifth of UK households before taxes and benefits was £83,800, 14 times greater than that of the poorest fifth who had an average income of £6,100 per year.But after taking into account taxes and benefits the ratio between the average incomes of the top and the bottom fifth of households (£62,500 and £16,500 respectively) is reduced to 4 to 1.

The richest fifth of households paid £29,800 in taxes (direct and indirect) compared with £5,200 for the poorest fifth.

In 2014/15, 50.8% of all households received more in benefits (including benefits in kind) than they paid in taxes, equivalent to 13.6 million households. This continues the downward trend seen since 2010/11 (53.5%), but remains above the proportion seen before the economic downturn.

On average, households whose head was between 25 and 64 paid more in taxes than they received in benefits (including in-kind benefits) in 2014/15, whilst the reverse was true for those aged 65 and over, as the state pension starts to kick in, the largest single component of the welfare bill in the UK.

Analysis on changes in median household disposable income and other related measures, which used to form part of this report, were published earlier this year in “Household Disposable Income and Inequality, financial year ending 2015”. It looks at the various stages of redistribution of income:

Figure 1: Stages in the redistribution of income

Flowchart of the effects of taxes and benefits on the redistribution of income.

Source: Office for National Statistics

The overall impact of taxes and benefits (especially the latter) are that they lead to income being shared more equally between households.

Cash benefits are paid to mainly to the poorest in society and therefore act to reduce income inequality. In 2014/15, the highest amount of cash benefits was received by households in the second quintile group, £8,900 per year compared with £7,700 for households in the bottom group (Figure 3). This is largely because more retired households are located in the second quintile group compared with the bottom group and in this analysis the State Pension is classified as a cash benefit.

Figure 2: Summary of the effects of taxes and benefits by quintile groups, ALL households, financial year ending 2015, UK

Taxes have increased across all quintiles. The net position is highest in the bottom quintile.

 

Looking at individual cash benefits, in 2014/15, the average combined amount of contribution-based and income-based Jobseeker’s Allowance (JSA) received by the bottom 2 quintile groups decreased, consistent with a fall in unemployment, as well as the ongoing implementation of the Universal Credit (UC) system.

Claimants of UC and JSA are subject to the Claimant Commitment which outlines specific actions that the recipient must carry out in order to receive benefits. This may also have affected the number of households in receipt of these benefits. JSA rates, along with other working age benefits, were increased by 1% in 2014/15, below the CPI rate of inflation. The phasing out of Incapacity Benefit, Severe Disablement Allowance and Income Support paid because of illness or disability and transfer of recipients to Employment and Support Allowance (ESA) has seen average amounts received from the former benefits fall in 2014/15, whilst average amounts received from ESA have risen, reflecting the increased number of claimants.

The roll-out of Personal Independence Payment (PIP), which is replacing Disability Living Allowance (DLA) for adults aged under 65, also continued in 2014/15.

We are told that these rollouts and replacements are not cost-cutting exercises, that the government is not deliberately targeting benefits to the ill and disabled, yet that does seem to be their impact.

There was a 20.3% decrease in the amount of Child Benefit received by the richest fifth of households, due to fewer households in this part of the income distribution receiving this benefit. This is likely to be related to the High Income Benefit Charge, which may have resulted in some households electing to stop getting Child Benefit (“opt out”) rather than pay the charge. Since Child Benefit claims process is linked to my on-going entitlement to the State pension (Carers’ Allowance) , we decided to continue to claim and re-pay the tax.

Direct taxes (Income Tax, employees’ National Insurance contributions and Council Tax or Northern Ireland rates) also act to reduce inequality of income. Richer households pay both higher amounts of direct tax and a higher proportion of their income in direct taxes.

The majority of this (16.3% of gross income) was paid in Income Tax. The average tax bill for the poorest fifth of households, by contrast was equivalent to 11.0% of their gross household income. Council Tax or Northern Ireland rates made up the largest proportion of direct taxes for this group, accounting for half of all direct taxes paid by them, 5.5% of their gross income on average.

The amount of indirect tax (such as Value Added Tax (VAT) and duties on alcohol and fuel) each household pays is determined by their expenditure rather than their income. The richest fifth of households paid just over 2 and a half times as much in indirect taxes as the poorest fifth (£10,000 and £3,700 per year, respectively). This reflects greater expenditure on goods and services subject to these taxes by higher income households.

However, although richer households pay more in indirect taxes than poorer ones, they pay less as a proportion of their income (Figure 5).

This means that indirect taxes increase inequality of income. 

Today, Theresa May has committed to not increasing VAT in the forthcoming parliament though obviously the highest rate set is already far in excess of the EU minimum. She obviously hasn’t committed to not extending the reach of VAT, to move more consumer goods into the VAT charge rate.

In 2014/15, the richest fifth of households paid 15.0% of their disposable income in indirect taxes, while the bottom fifth of households paid the equivalent of 29.7% of their disposable income. Across the board, VAT is the largest component of indirect taxes. Again, the proportion of disposable income that is spent on VAT is highest for the poorest fifth and lowest for the richest fifth.ce for National Statistics

Grouping households by their income is recognised as the standard approach to distributional analysis, as income provides a good indication of households’ material living standards, but it is also useful to group households according to their expenditure, particularly for examining indirect taxes, which are paid on expenditure rather than income. Some households, particularly those at the lower end of the income distribution, may have annual expenditure which exceeds their annual income. For these households, their expenditure is not being funded entirely from income. During periods of low income, these households may maintain their standard of living by funding their expenditure from savings or borrowing, thereby adjusting their lifetime consumption.

When expressed as a percentage of expenditure, the proportion paid in indirect tax declines less sharply as income rises (Figure 6) compared with the level of indirect taxes paid as a proportion of household disposable income. The bottom fifth of households paid 20.1% of their expenditure in indirect taxes compared with 17.6% for the top fifth. These figures are broadly unchanged from the previous year.

After indirect taxes, the richest fifth had post-tax household incomes that were 6 and a half times those of the poorest fifth (£56,900 compared with £8,700 per year, respectively). This ratio is unchanged on 2013/14.

The ONS also considered the effect on household income of certain benefits received in kind. Benefits in kind are goods and services provided by the government to households that are either free at the time of use or at subsidised prices, such as education and health services. These goods and services can be assigned a monetary value based on the cost to the government which is then allocated as a benefit to individual households. The poorest fifth of households received the equivalent of £7,800 per year from all benefits in kind, compared with £5,500 received by the top fifth (Effects of taxes and benefits dataset Table 2). This is partly due to households towards the bottom of the income distribution having, on average, a larger number of children in state education.

Overall, in 2014/15, 50.8% of all households received more in benefits (including in-kind benefits such as education) than they paid in taxes (direct and indirect) (Figure 7). This equates to 13.6 million households. This continues the downward trend seen since 2010/11 (53.5%) but remains above the proportions seen before the economic downturn.

The trend seen for non-retired households mirrors that for all households, except that lower percentages of non-retired households receive more in benefits than pay in taxes, 36.9% in 2014/15, down from a peak of 39.7% in 2010/11.

In contrast, in 2014/15, 88.7% of retired households received more in benefits than paid in taxes, reflecting the classification of the State Pension as a cash benefit in this analysis. A retired household is defined as a household where the income of retired household members accounts for the majority of the total household gross income2. This figure is lower than its 2009/2010 peak of 92.4% but is broadly similar to the proportions seen before the downturn.

There are a number of different ways in which inequality of household income can be presented and summarised. Perhaps the most widely used measure internationally is the Gini coefficient. Gini coefficients can vary between 0 and 100 and the lower the value, the more equally household income is distributed.

The extent to which cash benefits, direct taxes and indirect taxes together work to affect income inequality can be seen by comparing the Gini coefficients of original, gross, disposable and post-tax incomes (Effects of taxes and benefits dataset Table 10). Cash benefits have the largest impact on reducing income inequality, in 2014/15 reducing the Gini coefficient from 50.0% for original income to 35.8% for gross income (Figure 8). Direct taxes act to further reduce it, to 32.6% in 2014/15. However, indirect taxes have the opposite effect and in 2014/15 the Gini for post-tax income was 36.4%, meaning that overall, taxes have a negligible effect on income inequality.

Figure 3: Gini Coefficient impact of taxes and benefits

Impact of cash benefits and taxes on income inequality. Cash benefits has the most effect on the gini coefficient for post-tax income

Source: Office for National Statistics

 

Political, Rants&Rambles

Peter Pan is forced to Grow Up

I was hoping that Theresa May knew or understood something about the brexit process that I was missing, and I’m sure that she must have more information. She’s the PM after all, the woman in charge.
Part of me was convinced that the only reason she had for being PM was the absolute convictions that although brexit was a disaster, with anyone else but her it would be an even more fucked up disaster ie. she would work in “damage limitation” mode making th most of her competency.
But at least from the outside it’s beginning to look as if she’s been caught up in the happy, clappy enthusiasm mode of some of her fellow prisoners in government, all of them trapped in the galley of the ship desperately rowing and subject to the flogging of “leave” campaigning zealots. As the months have gone by, it seems clear that rather than risk the difficulties of selling limited contributions to the EU in return for access to the single market or customs union, she’s settled for the clearest route out, and damn the financial consequences.
Some of the assumptions being made are beginning to look rather dubious. The idea that negotiations can be kept secret seem doomed to fail if the twitter riff sourced from the FAZ below are to be believed, and some of it does ring very true. I can imagine David Davis rattling on about his civil liberty battles with Ms May frowning in the background.
It’s also entirely believable that the UK government may well have underestimated the level of detail to be negotiated as part of agreeing citizens rights post brexit.
Basically we’re been governed by a bunch of broad brush cowboys who, thanks to the EU diplomatic corp. haven’t had to worry themselves about the detail for decades and now cannot conceive of the idea that the detail is where the devil might be found. Maybe if the EU were similarly slapdash all would be well but it must be clear to everybody by now that the EU is in love with the detail, with dotting the i and crossing the t.
I’m sure Merry Somerset Webb from the FT is right to suggest that in ten years we’ll all look back and wonder what the fuss was about, renegotiating (slightly) our trade deal with the EU. Well, maybe twenty years…

Today’s FAZ report on May’s disastrous dinner with Juncker – briefed by senior Commission sources – is absolutely damning.

1) May had said she wanted to talk not just Brexit but also world problems; but in practice it fell to Juncker to propose one to discuss.

2) May has made clear to the Commission that she fully expects to be reelected as PM.

3) It is thought [in the Commission] that May wants to frustrate the daily business of the EU27, to improve her own negotiating position. 

4) May seemed pissed off at Davis for regaling her dinner guests of his ECJ case against her data retention measures – three times.

5) EU side were astonished at May’s suggestion that EU/UK expats issue could be sorted at EU Council meeting at the end of June.

6) Juncker objected to this timetable as way too optimistic given complexities, eg on rights to health care.

7) Juncker pulled two piles of paper from his bag: Croatia’s EU entry deal, Canada’s free trade deal. His point: Brexit will be v v complex.

8) May wanted to work through the Brexit talks in monthly, 4-day blocks; all confidential until the end of the process.
 
9) Commission said impossible to reconcile this with need to square off member states & European Parliament, so documents must be published.
 

10) EU side felt May was seeing whole thing through rose-tinted-glasses. “Let us make Brexit a success” she told them.

11) Juncker countered that Britain will now be a third state, not even (like Turkey) in the customs union: “Brexit cannot be a success”. 

12) May seemed surprised by this and seemed to the EU side not to have been fully briefed.

13) She cited her own JHA opt-out negotiations as home sec as a model: a mutually useful agreement meaning lots on paper, little in reality.

14) May’s reference to the JHA (justice and home affairs) opt-outs set off alarm signals for the EU side. This was what they had feared.

15) ie as home sec May opted out of EU measures (playing to UK audience) then opted back in, and wrongly thinks she can do same with Brexit

16) “The more I hear, the more sceptical I become” said Juncker (this was only half way through the dinner)

17) May then insisted to Juncker et al that UK owes EU no money because there is nothing to that effect in the treaties.
 
 18) Her guests then informed her that the EU is not a golf club
 

19) Davis then objected that EU could not force a post-Brexit, post-ECJ UK to pay the bill. OK, said Juncker, then no trade deal. 

20) …leaving EU27 with UK’s unpaid bills will involve national parliaments in process (a point that Berlin had made *repeatedly* before).

21) “I leave Downing St ten times as sceptical as I was before” Juncker told May as he left

22) Next morning at c7am Juncker called Merkel on her mobile, said May living in another galaxy & totally deluding herself

23) Merkel quickly reworked her speech to Bundestag to include her now-famous “some in Britain still have illusions” comment

24) FAZ concludes: May in election mode & playing to crowd, but what use is a big majority won by nurturing delusions of Brexit hardliners?

25) Juncker’s team now think it more likely than not that Brexit talks will collapse & hope Brits wake up to harsh realities in time.

26) What to make of it all? Obviously this leak is a highly tactical move by Commission. But contents deeply worrying for UK nonetheless.

27) The report points to major communications/briefing problems. Important messages from Berlin & Brussels seem not to be getting through.

28) Presumably as a result, May seems to be labouring under some really rather fundamental misconceptions about Brexit & the EU27.

29) Also clear that (as some of us have been warning for a while…) No 10 should expect every detail of the Brexit talks to leak.

30/30) Sorry for the long thread. And a reminder: full credit for all the above reporting on the May/Juncker dinner goes to the FAZ

Rants&Rambles

Free for what?

Free speech is held up as an inherent good, an invaluable bastion of the democracy, the freedoms of the Western developed world.

We are told that modern day “snowflakes” contest this self-evident truth and look to curb our everyday freedoms but in fact what is often contested is not the right to free speech, but rather the definition of free speech. What does it mean?

At one of the premieres of his landmark Holocaust documentary, “Shoah” (1985), the filmmaker Claude Lanzmann was challenged by a member of the audience, a woman who identified herself as a Holocaust survivor. Lanzmann listened politely as the woman recounted her harrowing personal account of the Holocaust to make the point that the film failed to fully represent the recollections of survivors. When she finished, Lanzmann waited a bit, and then said, “Madame, you are an experience, but not an argument.”

Lanzmann’s blunt reply favored reasoned analysis over personal memory. In light of his painstaking research into the Holocaust, his comment must have seemed insensitive but necessary at the time. Yet ironically, “Shoah” eventually helped usher in an era of testimony that elevated stories of trauma to a new level of importance, especially in cultural production and universities.

 Widespread caricatures of students today as overly sensitive, vulnerable and entitled “snowflakes” fail to acknowledge the philosophical work that was carried out, especially in the 1980s and ’90s, to legitimate experience — especially traumatic experience — which had been dismissed for decades as unreliable, untrustworthy and inaccessible to understanding.

The philosopher Jean-François Lyotard, examined the tension between experience and argument in a different way.

Instead of defining freedom of expression as guaranteeing the robust debate from which the truth emerges, Lyotard focused on the asymmetry of different positions when personal experience is challenged by abstract arguments.

His extreme example was Holocaust denial, where invidious but often well-publicized cranks confronted survivors with the absurd challenge to produce incontrovertible eyewitness evidence of their experience of the killing machines set up by the Nazis to exterminate the Jews of Europe. Not only was such evidence unavailable, but it also challenged the Jewish survivors to produce evidence of their own legitimacy in a discourse that had systematically denied their humanity.

Lyotard shifted attention away from the content of free speech to the way certain topics restrict speech as a public good.

Some things are unmentionable and undebatable, but not because they offend the sensibilities of the sheltered young. Some topics, such as claims that some human beings are by definition inferior to others, or illegal or unworthy of legal standing, are not open to debate because such people cannot debate them on the same terms.

All people must be free to speak, if we are to have free speech, and that is self-evidently not possible if one group is excluded from being “people”. Freedom applies to the rights of all people to be included, as well as what is said.

The recent student demonstrations at various campuses can be understood as an attempt to ensure the conditions of free speech for a greater group of people, rather than censorship.

Liberal free-speech advocates rush to point out that the views of these individuals must be heard first to be rejected. But this is not the case. Universities invite speakers not chiefly to present otherwise unavailable discoveries, but to present to the public views they have presented elsewhere. Yet when those views invalidate the humanity of some people, they restrict speech as a public good.

The great value and importance of freedom of expression, for higher education and for democracy, is hard to underestimate. But it has been too easy for commentators to create a simple dichotomy between a younger generation’s oversensitivity and free speech as an absolute good that leads to the truth.

We would do better to focus on a more sophisticated understanding, such as the one provided by Lyotard, of the necessary conditions for speech to be a common, public good. This requires the realization that in politics, the parameters of public speech must be continually redrawn to accommodate those who previously had no standing.

Because the idea of freedom of speech does not mean a blanket permission to say anything anybody thinks. It means balancing the inherent value of a given view with the obligation to ensure that other members of a given community can participate as fully recognized members of that community.

Free-speech protections — not only but especially in universities, which aim to educate students in how to belong to various communities — can never mean that someone’s humanity, or their right to participate in political speech as political agents, can be freely attacked, demeaned or questioned.

The recent controversies over the conflict between freedom of expression and granting everyone access to speech hark back to  1963, when Yale University had rescinded an invitation to Alabama’s segregationist governor, George C. Wallace. In 1974, after unruly protests prevented William Shockley from debating his recommendation for voluntary sterilization of people with low I.Q.s, and other related incidents, Yale issued a report on how best to uphold the value of free speech on campus that remains the gold standard for many other institutions.

Unlike today’s somewhat reflexive defenders of free speech, the Yale report placed the issue of free speech on campus within the context of an increasingly inclusive university and the changing demographics of society at large. While Yale bemoaned the occasional “paranoid intolerance” of student protesters, the university also criticized the “arrogant insensitivity” of free speech advocates who failed to acknowledge that requiring of someone in public debate to defend their human worth conflicts with the community’s obligation to assure all of its members equal access to public speech.

What is under severe attack, in the name of an absolute notion of free speech, are the rights, both legal and cultural, of minorities to participate in public discourse.

The issues to which students are so sensitive might be benign when they occur within the ivory tower. Coming from the brexit campaign trail and now the US White House, the threats are not meant to merely offend. Like President Trump’s attacks on the liberal media (or indeed right wing press attacks on the British judiciary) as the “enemies of the people,” these insults are meant to discredit and delegitimize whole groups as less worthy of participation in the public exchange of ideas.

Rants&Rambles, Science

Who wants to live forever?

People are very afraid of cancer, with good reason. Unlike other things that kill us, it often seems to come out of nowhere.

But evidence suggests that cancer may be preventable, too. Unfortunately, this has inflamed as much as it has assuaged people’s fears.

As a physician, I have encountered many people who believe that heart disease, which is the single biggest cause of death among Americans, is largely controllable. After all, if people ate better, were physically active and stopped smoking, then lots of them would get better. This ignores the fact that people can’t change many risk factors of heart disease like age, race and family genetics.

People don’t often seem to feel the same way about cancer. They think it’s out of their control. A study published in Science in January 2015 seemed to support that view. It tried to explain why some tissues lead to cancer more often than others. It found a strong correlation between the number of times a cell divides in the course of a lifetime and the risk of developing cancer.

In other words, this study argued that the more times DNA replicates, the more often something can go wrong. Some took this to mean  that cancer is much more because of “bad luck” than because of other factors that people could control.

But this is not really what the study showed. Lung cells, for instance, divide quite rarely, and still account for a significant amount of cancer. Cells in the gastrointestinal tract divide all the time and account for many fewer cancers. Some cancers, like melanoma, were found to be in the group of cancers influenced more by intrinsic factors (or those we can’t control), when we clearly know that extrinsic factors, like sun exposure, are a major cause.

Further, this study was focused more on the relative risks of cancer in one type of tissue versus another. What we really care about is how much we can reduce our own risk of cancer by changing our behavior.

A more recent study published in Nature argues that there is quite a lot we can do to prevent cancer. Many studies have shown that environmental risk factors and exposures contribute greatly to many cancers. Diet is related to colorectal cancer. Alcohol and tobacco are related to oesophageal cancer. HPV is related to  cervical cancer, and hep C is related to liver cancer.

And you’d have to be living under a rock not to know that smoking causes lung cancer and that too much sun can lead to skin cancer.

Using sophisticated modeling techniques, the researchers argued that less than 30% of the lifetime risk of getting many common cancers was because of intrinsic risk factors, or the “bad luck.” The rest were things you can change.

Most recently, in JAMA Oncology, researchers sought to quantify how a healthful lifestyle might actually alter the risk of cancer. They identified four domains that are often noted to be related to disease prevention: smoking, drinking, obesity and exercise.

They defined people who engaged in healthy levels of all of these activities as a “low risk” group. Then they compared their risk of getting cancer with people who weren’t in this group. They included two groups of people who have been followed and studied a long time, the Nurses’ Health Study and the Health Professionals Follow-up Study, as well as national cancer statistics.

Of the nearly 90,000 women and more than 46,000 men, 16,531 women and 11,731 men fell into the low-risk group. For each type of cancer, researchers calculated a population-attributable risk, which is the percentage of people who develop cancer who might have avoided it had they adopted low-risk behaviors.

About 82% of women and 78% of men who got lung cancer might have prevented it through healthy behaviors. About 29% of women and 20%t of men might have prevented colon and rectal cancer. About 30%t of both might have prevented pancreatic cancer. Breast cancer was much less preventable: 4 percent.

Over all, though, about 25% of cancer in women and 33% in men was potentially preventable. Close to half of all cancer deaths might be prevented as well.

No study is perfect, and this is no exception. These cohorts are overwhelmingly white and consist of health professionals, who are not necessarily like the population at large. But the checks against the national data showed that if anything, these results might be underestimating how much cancer is preventable by healthy behaviors.

This also isn’t a randomized controlled trial, and we can certainly argue that it doesn’t prove causation.

A bigger concern to me is that people might interpret these findings as assigning fault to people who get cancer. You don’t want to get into situations where you feel as if people don’t deserve help because they didn’t try hard enough to stay healthy. Much of cancer is still out of people’s control.

In this study, “low risk” status required all four healthy lifestyles. Failing in any one domain put you in the high-risk category, and that seemed like a lot to ask of people.

On further reading, though, it’s clear that the requirements weren’t overly burdensome. Not smoking was defined as never having smoked or having quit at least five years ago. That’s clearly good for health. Moderate alcohol consumption was defined as no more than one drink a day on average for women, and no more than two for men. It in no way requires abstinence.

Adequate weight was defined as a B.M.I. of at least 18.5 and no more than 27.5. The cutoff for “overweight” is 25, meaning that you don’t have to be thin; you just have to be less than obese (B.M.I. 30). Finally, exercise was defined as 150 minutes a week of moderate-intensity activity or 75 minutes of vigorous-intensity activity. That’s a reasonable and quite achievable goal.

I was surprised to realize that I’m already “low risk.” I bet many people reading this are “low risk,” too.

As we talk about cancer “moonshots” that will most likely cost billions of dollars and might not achieve results, it’s worth considering that — as in many cases — prevention is not only the cheapest course, but also the most effective.

Simple changes to people’s behaviors have the potential to make sure many cancers never occur. They have a side benefit of preventing health problems in many other areas, too. Investment in these efforts may not be as exciting, but it may yield greater results.

Rants&Rambles

Identity

Amidst the recriminations and collective shock in the face of Trump’s victory (and the myriad other reverses suffered by progressives in 2016), a consensus is emerging: the weakness of the left is attributable to its embrace of “identity politics”.

Rather than focussing on the interests and priorities of the majority, the story goes, the left has for too long embraced a simplistic and sectional politics in which the interests of racial and sexual minorities have taken centre stage, at the expense popularity and electability.

A recent outburst from the perhaps unlikely figure of Stephen Kinnock typifies this narrative. “What we need to see in the progressive Left is an end to this identity politics”.  & in its place “we need to be talking far more about commonality rather than what differentiates from each other – let’s talk about what unites us.”

Similar pronouncements have recently been made by Bernie Sanders, as well as a number of left-liberal commentators on both sides of the Atlantic.

However, this unease about so-called “identity politics” has been a longstanding feature of left commentary and scholarship.This disdain for identity politics is not isolated to a few individuals: it is a widespread sensibility expressed by Marxists and left-liberals alike

But what, precisely, is this “identity politics” that inspires such animosity?

At a basic level, “identity politics” refers to any politics that seeks to represent and/or advance the claims of a particular social group. But in the narratives outlined above, it has a more specific meaning: in left circles, “identity politics” is, as Nancy Fraser pointed out back in 1998, used largely as a derogatory term for feminism, anti-racism and anti-heterosexism.

The implication was – and very often still is – that gender, race and sexuality are identity-based in the sense that they are seen as flimsy, superficial and, to use Judith Butler’s memorable phrase, ‘merely cultural’.

This is contrasted with its constitutive outside, class. Class relations, in the eyes of the identity politics critic, exhibit a depth, profundity and materiality that ‘mere identity’ lacks. Furthermore, the alleged universalism of class is contrasted with the narrow, sectional concerns characteristic of so-called identity politics.

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But what, precisely, is wrong with this framing of the problem?

To start with, the implied distinction between “identity” (read: narrow, shallow, self-interested) and “class” politics (read: broad, deep, universal, authentic) misconstrues the character of these different strands of progressive politics, in at least three ways.

All forms of politics arguably involve some kind of appeal to an identity, insofar as they clearly involve claims to speak for a politically salient constituency (and thus an “identity” of sorts). This applies as much to “class” as any other dimension of power and identity. Indeed, these appeals to “class” are quintessential identity politics: they appeal to an identity category – the (presumed white) working class – whose interests have been shamefully neglected by elitist, out of touch leftists and liberals.

The question is not, therefore, universalism or identitarianism, but whether or not we acknowledge the “identitarian” character of our political claims. Something akin to this is eloquently described by James Clifford in a 1999 essay entitled ‘Taking Identity Politics Seriously’, where he argues that ‘opposition to the special claims of racial or ethnic minorities often masks another, unmarked ‘identity politics’, an actively sustained historical positioning and possessive investment in Whiteness’.

Few contemporary feminists or anti-racists would adopt the  view that one’s identity necessarily gives rise to specific forms of politics. Indeed, the recent history of feminism, queer politics and anti-racism is precisely one of challenging identity by analysing and questioning the various ways in which heteronormativity, capitalism, white supremacy and patriarchy shape identity-formation.

Basically there is a frankly bewildering inference made by Pinnock et al that the left in its various guises has spent its time of late doggedly pursuing the interests of women, sexual minorities and racial minorities. The reality, however, is that left-wing movements and political parties in the UK and US have an at best patchy track records on race, gender and sexuality, as recent scholarship by the likes of Janet Conway, Julia Downes, Lara Coleman and Abigail Bakan make clear.

All the way from the moderate liberal left to the radical Marxist left, race, gender and sexuality continue to be cast as minority concerns at best, and “bourgeois distractions” at worst, while sexism and misogyny (including, but not limited to, the sexual abuse of women comrades) remain depressingly prevalent across a variety of left spaces.

Consequently, left-wing denunciations of identity politics yield a number of alarming consequences: they naturalise gendered and racialised hierarchies by casting white, male class politics as universal. Such a narrative is therefore not only powerless to challenge, but actively complicit in, the re-energised white supremacism which, as Akwugo Emejulu has recently outlined, has been fundamental to the context of Trump’s victory.

What is more, to pit class politics against identity politics casts women, racial minorities and sexual minorities as outside the boundaries of true, authentic “working classness”. As such, the political claims of working class ethnic minorities, queers and women increasingly go unheard. This is exacerbated by the continued use of “left behind” as euphemism for “white working class”, with its inference that white poverty is unnatural, exceptional, worthy of our attention, while black poverty is either invisible or simply part of the natural order of things. Who is seen to “count” as authentically working class has thus become a key terrain of struggle in the era of Trump and Brexit.

Let us, therefore, not be under any illusions about how these dismissals of “identity politics” function: they are, in effect, a kind of dog whistle to those on the left who might, for instance, agree that black lives matter, but ultimately believe that when push comes to shove it is the (white male) working class that matters more.

As others have pointed out, this is tantamount to being called upon to sacrifice a range of constituencies – women, racial minorities, queers, immigrants (and at times perhaps also trans people, non-binary and gender non-conforming folk, sex workers) – on the altar of political expediency. Putting aside any doubts as to whether this would actually work in terms of galvanising electoral support, this is clearly a morally bankrupt form of politics.

Any solution that insists we forget, minimise or ignore the disadvantage of those who are not white and male is not one I want to sign up to.

Political, Rants&Rambles

Leading Light or Lead Balloon?

Labour’s predicament is that Jeremy Corbyn is hugely unpopular. His poll ratings are worse than for any comparable leader in British polling history. The gap between his standing and that of the PrimeMinister Mrs. May is now alarmingly wide. In a recent poll, 17% approved of Corbyn’s leadership and 58% disapproved. The comparable figures for Mrs. May were 46% and 33%. (In both cases, the rest had no opinion).

A recent article in the left-leaning Guardian newspaper suggested that the policies of the Labour Party were actually quite popular with the electorate right up to the point where Corbyn’s name was associated with them.

There are those amongst his many supporters within the party who argue that Corbyn is being judged both prematurely and by the wrong standards. Those attracted to him were looking for a different model of leadership, whose role is to empower, to galvanise and to operate as a standard bearer of a new mass movement.

In this context it could be useful to explore James MacGregor Burns’s distinction between ‘transactional’ and ‘transforming’ leadership. The former envisages leadership in terms of a transaction between the leader and other players in the party. For example, a leader may seek the co-operation and compliance of others through offering a range of incentives, such as policy concessions and personal advancement. Each party to a bargain would be aware of the power resources, proclivities, and preferences of others, and would engage in a process of mutual adjustment.

Transforming leadership, in contrast, envisages as the crucial leadership functions teaching, inspiring and energising, with fervor and dedication in the service of promoting a party’s collective purposes. Endowed with clear visions, transformational leaders are primarily concerned with the advocacy and pursuit of wide-ranging values – such as social justice and equality – and are loath to engage in too many compromises that might jeopardise them.

This approach meshes well as the radical (or ‘hard’) left’s model of the party. Labour’s prime purpose should be to give effect to the ideals and objectives with which it was historically associated. These should be embodied in policies determined by the wider party, and not by any parliamentary conclave. The role of the leader should be to ‘rally their own side effectively’, to appeal to the party’s base and to facilitate both its democratisation and ‘an empowerment of a new grassroots movement.’ Corbyn’s role as a transforming leader is, in short, to invigorate, mobilise and enthuse as the new voice and standard-bearer of a remoralised party.

Corbyn’s ability to perform this role has undoubtedly been severely handicapped by an unrelentingly and often venomously hostile media. It also needs to be said that his limitations as a communicator and his inability to convey the impression of a man possessing the skills and stature of a prime minister in waiting has not helped.

This is widely recognized (at least by his critics). But, even more fundamentally, his very concept of leadership– the leader as transformer – is flawed.

Here it may be useful to take the argument further by citing Weber’s distinction between ‘the ‘ethic of responsibility’ and the ‘ethic of ultimate ends.’ A political leader who accepts the former is animated by a prudential and calculating spirit, is acutely aware of the consequences of any action, and sees political choice in terms of balancing priorities and awkward trade-offs.

But the ‘ethic of responsibility’ can too easily slide into opportunism, careerism, self-serving actions and mere expediency. It is this that the ‘ethic of ultimate ends’ vehemently rejects. It stands for a more steadfast, determined, and uncompromising form of politics driven by principle and honesty. Corbyn’s appeal for many in Labour’s ranks is that he embodied this ‘ethic of ultimate ends’ and rejected Labour’s customary mode of leadership, with all its equivocations, evasions, and half-measures.

The danger is that the personal appropriation of a higher morality and a disregard for pragmatism and compromise can transmute into unyielding and obdurate political stance. As Weber commented, ‘the believer in an ethic of ultimate ends feels “responsible” only for seeing to it that the flame of pure intentions is not quenched.’ 

This might be compatible with effective leadership when a leader directs a tightly centralised party with full mastery of its key institutions. But Corbyn presides over a party in which power is dispersed among a whole range of institutions, several of which are centres of resistance to his rule. Labour is riven by multiple divisions, over policy, strategy, ideology and, most of all, internal organisation.

Most damagingly, it is suffering from a veritable crisis of legitimacy.

At present, Corbynistas and their critics lack a shared understanding of the ground-rules and values (democracy, accountability, and representation) which should underpin and validate the way in which power is distributed, decisions taken, and sovereignty located. In short, Corbyn both lacks consent and is hemmed in by institutional constraints, without control of decisive levers of power and the confidence of key players.

In such circumstances transforming leadership imbued by an ethic of ultimate ends is peculiarly inappropriate. Labour is a pluralist organisation composed of people attached to a range of often divergent interests, objectives, and values. When this is compounded by profound internal divisions, the skills of a transactional leader are essential.

This mode of leadership ‘requires a shrewd eye for opportunity, a good hand at bargaining, persuading, reciprocating.’ It demands an orientation to leadership governed by the ethic of responsibility, incorporating an open and conciliatory style of engagement, a ‘capacity to modulate personal and political ambitions by patient calculation and realistic appraisal of situations’ and an overriding emphasis upon the importance of reaching consensus and coalition-building. It involves accommodating public opinion with membership preferences, regulating disagreements, astute political maneuvering and a capacity, above all, to hold the party together.

Corbyn has merits – decency, honesty, integrity – but it is not at all evident that concept of leadership is what the party requires.

Home, Rants&Rambles

Healthy

In our house we are counting down months towards retirement, which is both a positive expectation and a financial worry.

It isn’t about how long we expect to live for necessarily since the cost of living will change as our old age changes. The first ten years will be relatively expensive as we plan to travel and enjoy our lives. We’ll also  probably end up spending some money helping to make our kids independent lives a little easier.

Then we’ll probably start to settle down and travel less extensively, live closer to home, more baby sitting and less rock climbing.

And finally we’ll settle into proper old age when our biggest weekly trip will be to the supermarket and relatives, maybe the bridge club once a week, with a (hopefully) brief last two years when physically it all goes “tits up”. The last seems to be true whenever you die, whether at 60 or 90: the last two years can be grim.

Life expectancy at age 65 for men in the UK reached 18.4 years in 2012–2014 and for women it reached 20.9 years. This means that a man aged 65 could expect to live to age 83 and a woman to nearly age 86.

In 2009-11, Disability-Free Life Expectancy (DFLE) for males at birth was 63.9 years, for females it was longer at 64.4 years. Despite having shorter DFLE, males expect to spend a greater proportion of their lives (81.0%) free from disability, compared to females (77.8%). basically women live longer but not in perfect health. Disability can hide a multitude of sins at this age, but given our socio-economic class the cards are stacked in our favour a little.

 

Before we all rush to book one-way tickets to Dignitas when we are 80, it is important to remember that many older people have no social care needs. If you ask people what they would do, knowing now what they do about old age, to prepare for it.

The advice went something like this: make a will, make a living will, put in place power of attorney, have a pension, avoid being overweight, don’t smoke, drink moderately, stay active, think about your needs in old age before you get there and, if necessary, downsize and move to somewhere more suitable, don’t stick your head in the sand about old age, have a social network, stay mentally active, keep out of hospital if you can (a geriatrician told me that 10 days in hospital is equivalent to 10 years of muscle wasting in elderly people), work for as long as you can, and find what you enjoy and do it.

That is as much as we have control over. Except, knowing all this, we may also want to start voting for a political party that invests in elder care. You know, just in case.