"To see the world in a grain of sand" is the opening line of William Blake's "Auguries of Innocence", which is both irrelevant and impossible not to think of when you read a history of the world through a lens of salt. The author has written two other books, one about cod and the other about Basques, and the topics showcase his unique ability to turn narrow focus on one detail --a mineral, a fish, a small and mysterious people group living in isolation and speaking a language unrelated to any other in the vicinity-- into the long view of world history.
The topics intersect: salt is apparently a strategically important natural resource partly because it can be used to preserve cod. The Basques were great whalers who followed the Vikings to the Faroe Islands to fish cod so they could salt it and build their fortunes on the resulting preserved food. They may have even passed Iceland and reached Newfoundland in search of cod lands. And Mark Kurlansky is right there, letting salt (and Basques, and cod) lead you across the Atlantic Ocean, in his very accurately titled Salt: A World History.
He also takes us to ancient China, where impact drills were used to find both salt brine and (accidentally) the natural gas that could be lit to boil it down-- this around 250 B.C. He's where the Celts invented salt pork-- ham-- only to be defeated by the Romans, who claimed all the salt mines and invented salad and salaries. He's where the Anglo-Saxons peppered, as it were, their lands with saltworks, with names ending in -wich like Norwich and Nantwich. He's also where William the Conqueror destroyed these wiches to, as it were, crush rebellion and seal the conquest. The salt-destroying strategy was later used by the Northern forces to weaken the Confederacy during the Civil War-- without salt, the South could not preserve food long enough to get it to the troops. Salt was a weapon of war as late as the Indian independence from Britain, when Ghandi, instead of leading a tea party, led an illegal salt-harvesting expedition (for the same reason-- to protest unreasonable taxes and restrictions on production).
Which brings us to the geology of salt-making. It appears you can get salt two main ways: you can evaporate salty water until it precipitates out, or you can dig it out of rocky deposits that are usually found in veins, like coal. Occasionally, these salt deposits are the size of mountains, either exposed above ground or hidden by layers of other rock. Where they are exposed, of course they are highly subject to erosion; where they are hidden, the capacity to extract the mineral is limited by the weight above the deposit.
Salt mines have even become tourist attractions. They can be adventurous, beautiful, and healthful-- not only is salt a preservative, it's also a disinfectant, and people who spend time in the mines report relief from viruses and bacterial infections. For the same reason, my dentist recommends a salt rinse for irritated gums.
Salt has also motivated the construction of roads and canals, since money could only be made if large quantities of it could be gotten from where it is to where it isn't. Camels were attempted in Nevada, to the dismay of the salt miners, their other animals, and the camels themselves.
There are many kinds of salt. The color is caused by the presence of other minerals and impurities: the clay from the earth the salt evaporates on, iron oxide in Himalayan salt, minerals and even heavy metals not refined out of "natural" sea salt. There are also many different textures that people come to appreciate: the fine, even cubes of commercial table salt are great for baking, while chunkier, uneven "kosher salt" or flaky sea salt may provide a bigger "punch" of flavor. One thing's for sure-- reading this book really makes you want to eat some pretzels or popcorn. Iodine, of course, is an impurity added to salt on purpose as a public health measure, and has greatly reduced the incidence of goiter worldwide.
Salt is a recurring metaphor in the teachings of Jesus. What does salt do? It preserves and disinfects-- it prevents decay and disease. It provokes thirst and is, along with many other minerals, essential to health. It tastes good and enhances the flavor of everything it's added to. And one other thing: it cannot, in fact, lose its saltiness. It can become diluted, it can become adulterated, but sodium chloride will always retain the properties of salt. Those are the facts about salt-- make of them what you will.
Wednesday, January 8, 2020
Friday, November 22, 2019
550-559: Geology and Meteorology Book Haul
Lesson learned: don't underestimate your local branch library. I thought I did pretty well here.
And this doesn't even include what was too heavy to carry home! I could have chosen books about the exploration of Mars, so I guess all rocks are included, even ones on other planets. Also, water and air are big topics. Sam Kean, who wrote The Disappearing Spoon, which I kind of read last time, also wrote a book about air, which, seriously? NPR called it "breezy" (LOL), and I got enough of that before, so I passed on that one.
So, top to bottom: The Audubon Society, best known for its interest in birds, seems to make field guides for just about every natural phenomenon, 20 in all, at least two found in this section: Weather and Rocks & Minerals. Of course I wanted a full-color enumeration of the 30 pages worth of different kinds of snowstorms and ice storms found on our continent! I won't hold myself to reading the "Essays" at the beginning, but I may have to read some of the "Text Accounts' at the end, especially of "Mixed Skies,""Optical Phenomena," and "Obstructions to Vision." Those do beg further explanation!
Salt: A World History by Mark Kurlansky was a "Best Book of 2012" in our little library, so I guess I'm late to this party. It attracted my attention because of course in church we are always talking about salt, as in, being salt. The first few pages have already captured my attention, as the author describes the surprising behavior of a rock of salt he brought back from Spain that reacted to sun, humidity, metals... and licking. So that's why chemistry and geology are right next to each other!
Now take a deep breath before you read the full title of the last book in the pile. Moby-Duck: The True Story of 28.800 Bath Toys Lost at Sea and of the Beachcombers, Oceanographers, Environmentalists, and Fools, Including the Author, Who Went in Search of Them. Donovan Hohn's subtitle reeled me in when he mentioned that he was a character in the story.... because you know I love stunt memoirs! The book is written in a companionable first-person style and seems to touch on everything from the manufacture of plastic toys to the floating garbage island in the Pacific that they end up in, with 350 pages in between and an epilogue that (finally) actually discusses Herman Melville's well-known novel of obsession with another, slightly larger and more useful, denizen of the sea. If I commit to this book, I suspect it may completely talk me out of plastic toys... at least floating ones...
So, top to bottom: The Audubon Society, best known for its interest in birds, seems to make field guides for just about every natural phenomenon, 20 in all, at least two found in this section: Weather and Rocks & Minerals. Of course I wanted a full-color enumeration of the 30 pages worth of different kinds of snowstorms and ice storms found on our continent! I won't hold myself to reading the "Essays" at the beginning, but I may have to read some of the "Text Accounts' at the end, especially of "Mixed Skies,""Optical Phenomena," and "Obstructions to Vision." Those do beg further explanation!
Salt: A World History by Mark Kurlansky was a "Best Book of 2012" in our little library, so I guess I'm late to this party. It attracted my attention because of course in church we are always talking about salt, as in, being salt. The first few pages have already captured my attention, as the author describes the surprising behavior of a rock of salt he brought back from Spain that reacted to sun, humidity, metals... and licking. So that's why chemistry and geology are right next to each other!
Now take a deep breath before you read the full title of the last book in the pile. Moby-Duck: The True Story of 28.800 Bath Toys Lost at Sea and of the Beachcombers, Oceanographers, Environmentalists, and Fools, Including the Author, Who Went in Search of Them. Donovan Hohn's subtitle reeled me in when he mentioned that he was a character in the story.... because you know I love stunt memoirs! The book is written in a companionable first-person style and seems to touch on everything from the manufacture of plastic toys to the floating garbage island in the Pacific that they end up in, with 350 pages in between and an epilogue that (finally) actually discusses Herman Melville's well-known novel of obsession with another, slightly larger and more useful, denizen of the sea. If I commit to this book, I suspect it may completely talk me out of plastic toys... at least floating ones...
Saturday, November 9, 2019
540-549: Chemistry-- The Disappearing Spoon, by Sam Kean
The Disappearing Spoon is not a book about chemistry exactly. There's a basic explanation of atomic structure and why elements combine; there's a bit of unpacking of the structure of the periodic table; and then Kean just riffs for 346 pages. I enjoyed learning that "the noble gases" are those that are self-sufficient, that have a 'closed' outer shell already containing exactly the right number of electrons, so that they don't react with other elements. I was surprised to learn that almost all the elements are considered metals, even those that we call minerals, like calcium, or salts, like lithium. There were many interesting and entertaining stories about idiosyncratic scientists that I didn't learn; that is to say, I can't recall them anymore. But what really made an impression on me was Kean's reference to Mark Twain's interest in chemistry.
It turns out Twain wrote a short story with the dreadful title of Sold to Satan-- well, it's more of a sketch, really, and as it turns out, the point is not to tell a Devil-and-Daniel-Webster story, but to give Twain an excuse to write about that exciting new discovery of the late 19th century, radium. Twain says Satan appeared to the narrator as "a softly glowing, richly smoldering torch, column, statue of pallid light, faintly tinted with a spiritual green, and out from him a lunar splendor flowed such as one sees glinting from the crinkled waves of tropic seas when the moon rides high in cloudless skies." I won't be giving away much if I say this turns out to be because the Devil is made of radium, contained in polonium, and that the most interesting bit in the story is when-- right at very beginning of the 20th century-- he gives us a news report about Curie's activities in isolating this element and predicts the power-- and the problems-- of radioactivity.
Kurt Vonnegut also liked to throw a little chemistry into his fiction. In God Bless You, Mr. Rosewater, the title character at one point starts drinking with a group of volunteer firemen and ..."built gradually to a crying jag, during which he claimed to be deeply touched by the idea of an inhabited planet with an atmosphere that was eager to combine violently with almost everything the inhabitants held dear. He was speaking of Earth and the element oxygen." As it turns out, that's a bit of an oversimplification of the phenomenon of fire, but it does the job-- Vonnegut's job, after all, is often to make us pay attention to the basic weirdness of life.
And chemistry is pretty weird, after all-- or rather, the phenomena it studies are pretty weird. For example, it tells us that everything on this inhabited planet including ourselves is made up of millions of tiny solar systems of atoms, spinning around and swapping their electron planets back and forth so that they can all find some kind of stability, and that somehow this all works so that I am me and you are you and we don't spontaneously and violently combine with our atmosphere and go up in flames. So, although we are not "nothing but" chemical reactions, we certainly are that as well as "meat suits" (another Vonnegut phrase) as well as transcendent souls.
So, if you love chemistry, you should probably read some other, more serious book on the subject. If you don't love chemistry, read Twain's story, which is in the public domain. And maintain your sense of wonder about all the invisible processes that surround you!
It turns out Twain wrote a short story with the dreadful title of Sold to Satan-- well, it's more of a sketch, really, and as it turns out, the point is not to tell a Devil-and-Daniel-Webster story, but to give Twain an excuse to write about that exciting new discovery of the late 19th century, radium. Twain says Satan appeared to the narrator as "a softly glowing, richly smoldering torch, column, statue of pallid light, faintly tinted with a spiritual green, and out from him a lunar splendor flowed such as one sees glinting from the crinkled waves of tropic seas when the moon rides high in cloudless skies." I won't be giving away much if I say this turns out to be because the Devil is made of radium, contained in polonium, and that the most interesting bit in the story is when-- right at very beginning of the 20th century-- he gives us a news report about Curie's activities in isolating this element and predicts the power-- and the problems-- of radioactivity.
Kurt Vonnegut also liked to throw a little chemistry into his fiction. In God Bless You, Mr. Rosewater, the title character at one point starts drinking with a group of volunteer firemen and ..."built gradually to a crying jag, during which he claimed to be deeply touched by the idea of an inhabited planet with an atmosphere that was eager to combine violently with almost everything the inhabitants held dear. He was speaking of Earth and the element oxygen." As it turns out, that's a bit of an oversimplification of the phenomenon of fire, but it does the job-- Vonnegut's job, after all, is often to make us pay attention to the basic weirdness of life.
And chemistry is pretty weird, after all-- or rather, the phenomena it studies are pretty weird. For example, it tells us that everything on this inhabited planet including ourselves is made up of millions of tiny solar systems of atoms, spinning around and swapping their electron planets back and forth so that they can all find some kind of stability, and that somehow this all works so that I am me and you are you and we don't spontaneously and violently combine with our atmosphere and go up in flames. So, although we are not "nothing but" chemical reactions, we certainly are that as well as "meat suits" (another Vonnegut phrase) as well as transcendent souls.
So, if you love chemistry, you should probably read some other, more serious book on the subject. If you don't love chemistry, read Twain's story, which is in the public domain. And maintain your sense of wonder about all the invisible processes that surround you!
Sunday, September 22, 2019
530-539: Physics. The Shadow Club, by Roberto Casati
Okay, I definitely need to get back to the main library. I come home with the least uninteresting book I can find in the local library, and I still can't finish it! After all, in addition to this project, there are also so many novels, and, in these trying times, reading the news seems like another full-time job. An analysis of shadows in theory and practice, translated from the Italian, can't compete, even when it has pictures and is full of "whoa, have you ever really looked at your hand" moments.
The Shadow Club, by Roberto Casati, is not a bad book. I did appreciate the summary of Piaget's studies of children's beliefs about shadows. I do agree that shadows help us correctly interpret what we are looking at, whether in real life or in art. I can see that it's interesting that a shadow is an absence, and yet is treated like a substance: Peter Pan famously lost his and had to have it sewn on again; people of some cultures do not like their shadows to be stepped on or to touch other shadows. But I'm still not going to finish it, partly because I don't feel like I owe physics anything.
I took physics in high school and didn't mind the inclined planes and what not-- after all, as they say, "Gravity isn't just a good idea; it's the law!" As an adult, I read Brian Greene, and some Richard Feynman, and, most recently, I got a good halfway through a Neil Stephenson book called Seveneves-- the whole chunk that dealt with how to build a space colony in orbit around the earth. And if you've ever read any Neal Stephenson, you know that he throws full topical lectures into the middle of the action the way George MacDonald peppered his romances with chapter-long sermons or Anthony Trollope inserted blow-by-blow accounts of foxhunts into his analysis of Victorian politics. So, thanks to Stephenson, I'm all up on how gravity works in a multicentric orbital system; that should count for something.
The next Dewey topic is Chemistry, which is the one I actually actively dislike. But I bet if I go to the big library, they will have 30 running feet of books to choose from, and I can find one I can finish. Wish me luck!
The Shadow Club, by Roberto Casati, is not a bad book. I did appreciate the summary of Piaget's studies of children's beliefs about shadows. I do agree that shadows help us correctly interpret what we are looking at, whether in real life or in art. I can see that it's interesting that a shadow is an absence, and yet is treated like a substance: Peter Pan famously lost his and had to have it sewn on again; people of some cultures do not like their shadows to be stepped on or to touch other shadows. But I'm still not going to finish it, partly because I don't feel like I owe physics anything.
I took physics in high school and didn't mind the inclined planes and what not-- after all, as they say, "Gravity isn't just a good idea; it's the law!" As an adult, I read Brian Greene, and some Richard Feynman, and, most recently, I got a good halfway through a Neil Stephenson book called Seveneves-- the whole chunk that dealt with how to build a space colony in orbit around the earth. And if you've ever read any Neal Stephenson, you know that he throws full topical lectures into the middle of the action the way George MacDonald peppered his romances with chapter-long sermons or Anthony Trollope inserted blow-by-blow accounts of foxhunts into his analysis of Victorian politics. So, thanks to Stephenson, I'm all up on how gravity works in a multicentric orbital system; that should count for something.
The next Dewey topic is Chemistry, which is the one I actually actively dislike. But I bet if I go to the big library, they will have 30 running feet of books to choose from, and I can find one I can finish. Wish me luck!
Wednesday, August 14, 2019
520-529: When I Look at the Stars
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| The Flammarion |
So I should have known better than to choose Neil deGrasse Tyson's Astrophysics for People in a Hurry. Apparently it can be read aloud in 3 hours and 45 minutes, but that was about three more hours of detail about the origins of the physical universe than I could pay attention to. I'm sure if I had the right kind of mind I could find transcendence in the chemical formulas that turn hydrogen into carbon, but I don't, so I can't. Discussion of what happened in the first nanosecond of the Big Bang, or exactly how long ago that event was (yeah, I know, everyone is now saying 13.7 billion years ago, but I remember back when it was a mere shmear 6 billion, so don't act like the number isn't going to change again!) makes me feel more like Walt Whitman:
When I heard the learn’d astronomer,
When the proofs, the figures, were ranged in columns before me,
When I was shown the charts and diagrams, to add, divide, and measure them,
When I sitting heard the astronomer where he lectured with much applause in the lecture-room,
How soon unaccountable I became tired and sick,
Till rising and gliding out I wander’d off by myself,
In the mystical moist night-air, and from time to time,
Look’d up in perfect silence at the stars.
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Sunday, June 16, 2019
Extra Credit: Being Mortal by Atul Gawande (362.17)
Being Mortal, by Atul Gawande, is a revelation. It's full of doctors who are honest about the limits of medicine, patients who don't want to die but know how they want to live, and serious thought about what it means to be in either role in the face of terminal illness... or, in the case of Gawande's father, whose story runs through the book, both.
The Independent Self: Here's a surprising fact: as soon as any people group has the money, the health and the opportunity, their elderly will choose to age independently. A large number of elderly people, all over the world, given the choice, prefer living alone. We think American handles aging badly because we worship youth, when it's actually because we worship the independent self. We all want to paddle our own canoes.
So here's the problem we've set up: if most of us prefer to live independently, and most of us are living long enough that age is going to impact our ability to do so, what can we do? We say it's a medical problem, but it's really a personal problem, the conflict between our ambitions and the normal loss of functioning in the aging body. We don't want someone else to change our diapers and smash up our food and read to us because we can't see properly and help us get dressed because our fingers can't manage fasteners any more. But there's just a limit to how much medicine can restore our continence and preserve our teeth and vision and dexterity-- and I've watched that losing battle more than once.
Things Fall Apart: This situation is relatively new in the history of mankind. For most people throughout most of history, life and health were connected: if you were alive, you were probably pretty physically functional, because if you weren't, you would probably die pretty quickly of your infirmity. Concurrently, death and age were not at all connected. Of course there have always been extremely old people-- Solomon wrote about the ravages of old age in the book of Ecclesiastes-- but no more people died of old age than died of infections or viruses or accidents or violence or starvation.
But now, for the many people who do make it to old age, instead of rolling along feeling great and suddenly being bitten by a mosquito or having a stroke or getting hit by a vehicle and dropping dead, we experience a slow and uneven decline that may start in the middle of our working years. "Human beings fail the way all complex systems fail: randomly and gradually," says Gawande. But only recently have we been living long enough to realize that, so we act like it's an offense --against society, against ourselves, or against God-- to have infirmities and to need help.
Dependence: Gawande says"Old age is not a battle. Old age is a massacre." Both my parents experienced it that way. Your mobility dies, and your fine motor coordination is cut off at the knees, and your attention span gets hacked to pieces, and heaven help you if both your hearing and your vision go. Even the bravest survivors will pull me aside and tell me not to get old.
Nursing homes originated for one reason: to clear out hospital beds that were filling up with the walking-- or newly immobile, as the case may be-- wounded. This purpose survives in the specific kind of home called a Skilled Nursing Facility, where people who are too sick to back to their previous situation but not sick enough to qualify for hospital coverage any more go to regroup, get some rehab or wound care or IV treatments, and figure out what happens next. They are most likely there because they fell, or maybe because they got an infection or had a stroke or a 'heart event.' But they didn't sign up for this train ride, they just found themselves on it, and next thing they know, someone else is packing their things because they can't go home again.
Sociologist Erving Goffman groups nursing homes with prisons, military training camps, orphanages and mental hospitals as "total institutions"-- places cut off from wider society and run with a singleminded focus-- in the case of the nursing home, that focus would be "caring," defined primarily as "safety." The hospital's goal is to stabilize you and get you out. The SNF's goal is to fix whatever broke so you can, in due time, vacate that bed as well and move on. But the older you are, the better the chance that you will not be moving back to the location you left to go to the hospital. It has too many stairs, or you are too isolated, or you weren't eating right, or you got your meds mixed up, and now you need help just to be safe.
Assistance: In1983, Karen Brown Wilson invented an alternative to the traditional nursing home. She called it Park Place, "a living center with assistance, " and the residents were tenants, not patients. They lived as they pleased but had access to help with food, personal care and medications. They had call buttons and access to a nurse on site, but they also had the right to refuse restrictions that put the convenience of the staff, or even their own safety, above their autonomy. Care providers were trained to understand that they were guests in the tenants' homes. By 1988, it was clear that this model, the one followed more or less to this day in assisted living and personal care homes, resulted in higher levels of cognitive and physical functioning and greater satisfaction with life than patients in nursing homes enjoyed, while reducing costs by 20%.
The concept spread rapidly and of course became co-opted, diluted and regulated beyond recognition. Rolled into the "continuum of care" and dominated by the safety and survival priorities of medicine, residents soon once again found themselves limited in how they could live, what they could have, what they could do and when they could do it--treated like children for their own good. By 2003 the trademark combination of privacy, autonomy and support for the frail was only present in 11% of places labelled as assisted living. Wilson is still working on this problem, as are many care homes.
It is a lot of work for staff to understand how each resident defines life and what kind of assistance they might need to achieve their goals. Doing for residents-- turning them into patients-- is more efficient than allowing them to do what they can for themselves, even when it comes to something as simple as dressing in the morning. The matter is made more complicated by the fact that we ourselves are not always good at gauging our own abilities. Some people will fold at the first symptom of old age, begging others to take over responsibilities they could really still manage themselves. More commonly, people who were used to walking for miles or cooking for themselves or managing their own medical care insist on doing so long after it's clear to everyone else that they no longer have the ability to do so. Thus, staff is in a dance between what residents want to do and what they can do and what can be reasonably accommodated in compliance with the regulatory and financial environment of the institution.
After all, helping people really live is harder to measure than health and safety. Worst of all, the people staff are helping are not the real customers-- it's their kids! Wilson and other advocates for the "living with assistance" model know that "we want autonomy for ourselves and safety for those we love." Who can leave their parents in a situation that isn't really safe-- even if it's the parents' pursuit of their own best life that exposes them to risk?
A Better Life: But what is autonomy? Is it free action? For almost no one is that true. "Our lives are inherently dependent on others and subject to forces and circumstances well beyond our control." So regardless of the architecture or affiliation of the place we may find ourselves, we will still have to balance on the curb that lies between the story we have been writing all our lives and the bodies and minds we find ourselves in today. And for those whose stories have until now been built on productivity and action, that balance may be very difficult to find.
In 1991 Bill Thomas interested himself in how to lick "the Three Plagues of nursing home existence: boredom, loneliness and helplessness." He wanted to run a home, not an institution. He concluded that the answer was more life: plants, animals, a garden-- innovations he dubbed "the Eden project". He found that "the light turned back on in people's eyes." They walked the dog, they kept journals about their birds. The nursing staff resented the extra work, but the residents were excited to do it. Prescription meds dropped by half, deaths decreased 15%, and people who had been just sitting around started getting up and about. They had purpose. They were needed to tend the garden or walk the dog or watch the bird, so they exerted themselves.
It felt like my mother stayed at every facility in the county at some point, and the one amenity she would always choose to spend time with would be the aviary, or the fishtank, or, failing all else, the garden. Watching the behavior of the animals indeed turned her lights on. Another innovation Thomas spearheaded is the Green House Project, which is now in use across the country. It is based on home design that involves literally self-contained homes, with no more than 20 residents, all of whose rooms center on a dining room, living room, kitchen and family room. Residents are encouraged to conduct their daily life in the public areas, and caregivers are also encouraged to become part of the family, eating and relaxing with the residents as their schedules allow.
The principle that "simply existing--being merely housed and fed and safe and alive--seems empty and meaningless to us... we all seek a cause beyond ourselves," was well known before Josiah Royce articulated it in 1908. Victor Frankl, author of Man's Search for Meaning, famously founded a whole school of psychotherapy around this principle. Gawande observes that as we sense death approaching, "while we may feel less ambitious, we also become concerned for our legacy. And we have a deep need to identify purposes outside ourselves that make living feel meaningful and worthwhile." And yet, as Gawande observes, "For more than half a century now, we have treated the trials of sickness, aging, and mortality as medical concerns. It's been an experiment in social engineering, putting our fates in the hands of people valued more for their technical prowess than for their understanding of human needs."
Letting Go: Here are some fun facts for you: 25% of all medicare spending is for the 5% of subscribers in their last year of life, mostly for the couple of weeks or months where they are closest to death. 63% of doctors overestimate their patients' survival time, and those estimates average more than 5 times too long. We ask why people and their families have such a hard time accepting that they are at the end of the road, and maybe this is why: their doctors also can't accept that there is nothing left to do that is worth doing. As individuals, as families, we think we'll know when "there's nothing more they can do," but in a modern hospital, there's always something more that can be done.
"We pay doctors to give chemotherapy and to do surgery but not to take the time required to sort out when to do so is unwise.... in a war that you cannot win, you don't want a general who fights to the point of total annihilation." Gawande states that, based on outcomes, "If end-of-life discussions were an experimental drug, the FDA would approve it," because "you live longer only when you stop trying to live longer." He goes on to say that "A family meeting is a procedure, and it requires no less skill than performing an operation." It's a procedure doctors need to learn, because it shouldn't be the family's job to decide when the war is over. We are desperate, and we are ignorant and we have believed that medicine is Science when it's really half art and half voodoo. By the time a doctor is running down our odds and our options, we are sleep-deprived, we are in pain, we are running scared, and we are in no condition to understand our condition.
Hard Conversations: In theory, we should be making life and death medical decisions based on fact, but in fact, we have no hard facts. By the time my father was diagnosed with cancer, we knew it was bad, but 3 sets of images done in two different hospitals couldn't tell us how bad. His choices were to do nothing, go on hospice, and be almost certainly dead in six months, or have surgery which might or might not alleviate some symptoms that were bothering him and buy an unspecified amount more life. Nobody could tell him for sure what would happen, but it was as Gawande says: "The pressure remains all in one direction, toward doing more, because the only mistake clinicians seem to fear is doing too little. Most have no appreciation that equally terrible mistakes are possible in the other direction-- that doing too much could be no less devastating to a person's life." In the end, Dad went under the knife.
After a couple of hours, the surgeon came out to update me with bad news. The ugliest images were the accurate ones. Our options were a "heroic" surgery attempt that had a very high probability of killing my father on the table or leaving him completely crippled, or hospice. He didn't advise continuing the operation, but he offered it, and if I had insisted, he would have spent the rest of his day trying to pick cancer out of my dad's guts. Instead, I let him sew Dad up, wake him up and tell him the whole thing had been for nothing. He was now back to square one, but worse, because now he had a big surgery wound to heal from. Takeaway: Sometimes we can't even get a clear image of the problem until we open the patient up-- in the 21st century!
But here's the thing: my dad then proceeded to have three great months on hospice service. He went from being the terror of the retirement home to being "a marshmallow." He refused PT because he could-- he was on hospice! He lay in the bed, deconditioning, because he was dying anyway! He spent his waking hours watching movies, eating chocolate, drifting in and out of hallucinations that he obviously found intriguing, and receiving visits from pretty nurses and chaplains. He died more at peace than I had ever seen him before.
No doctor had known how to find out from him whether he really valued the life he found himself in at that time, where he struggled and strove to hang onto his identity, his activities, his accomplishments, losing ground almost weekly. He himself was ambivalent about whether he wanted to live or die. He had to go all the way, go under the knife, to realize that he was ready to crawl into bed and surrender to the death process.
Surgeons talk about "buying you more time"-- how much time are they talking about, exactly? or about a "60% chance of success"-- what is success, exactly? How did the doctor arrive at this percentage? What does failure look like? What does doing nothing look like? What is the shortest and the longest time a person with no treatment has lived? How about if they did get treatment? It would be nice if doctors could answer these questions even if we don't know to ask them.
Ezekiel and Linda Emanuel have identified three styles of medical communication. Some doctors act like priests and just tell you enough to get you to comply with what they have decided is best for you -- which is, of course, nearly always survival for one more day, one more month or one more year. Others dispense information-- too much information, indecipherable information, data delivered at 100 wpm-- and leave the decision to you, but the more you know, the worse all your options seem. How many doctors have the time and the inclination to be "interpretive," as Ezekiel and Linda Emanuel called it? They will ask questions until they understand your goals-- until you understand your goals-- and then inform you about the options and how they compare to the results you say you want. They are not generals on the battlefield or technicians under the hood of a car but counselors and contractors. And sometimes, they are life coaches, challenging your priorities and beliefs, pushing you to make better choices, and exposing what you really want, as opposed to what you want to want.
When we reach the stage where life becomes nothing but a series of medical crises and hospital visits, clarity on the actual probable length of one's remaining lifespan can be useful to narrow our focus and alter our activities in a way that is both freeing for ourselves and helpful for our material and spiritual heirs. We redefine our identity. We move our red lines. We stop butting our heads against the immovable object of chronic or terminal disease and decide what to do with our reduced circumstances. We find the realm where we still have autonomy.
By the time my mother found herself in this stage of life, experiencing what Gawande calls "One Damn Thing After Another" syndrome, I had not only my experience with my father, but a number oF other people's end-of-life journeys to draw from. I was starting to notice that most of the "damn things" that were following in rapid succession started with a hospital visit: deconditioning, MRSA, improper wound treatment, medical errors. And my mother knew that spending 20% of her year and $55,000 in medical facilities was no kind of life, and that she was tired of chasing cures. She fell again while I was out of town, and the assisted living called the ambulance, as procedure required, and I got on the phone with her and with them, and she refused treatment, and within the week she was on hospice status.
For nine months we went to the movies and to art shows and to the Olive Garden, and she read her Anthony Trollope collection. And when she fell off her scooter, probably as the result of a heart event, and realized she might die of complications, she literally said, "Whoopee." I knew if we agreed to get in the ambulance, and anything was broken, we would probably be talked into surgery, and that if she survived that, she would spend 6 weeks in a rehab hospital, and if she survived that, she would never be the same again. So instead, we sent the EMTs away again, and she spent her last two weeks sleeping, receiving visitors, listening to music and looking at her spectacular view. The last words she said to me were, "I love you too," and her last coherent conversation was a few days later, with a granddaughter she hadn't seen in a couple of years. Like my father, she was as much at peace as I had ever seen her, because she was allowed to exercise that one last slice of autonomy: choosing the way she died.
Courage: Gawande asks: "What mistake do we fear most? The mistake of prolonging suffering or the mistake of shortening life?" When we are terrified of losing one day we might have been able to save, we sometimes rob ourselves of the days we have in our hands. The dying role is important both to the terminal individual and to his or her community. As Gawande says: "People want to share memories, pass on wisdom and keepsakes, settle relationships, establish their legacies, make peace with God, and ensure that those who are left behind will be okay." They can't do those things very well with tubes in their mouths and heavy doses of morphine in their veins. The dying role becomes the role of the "fighter," who went down swinging... the general who led his troops to total annihilation in an unwinnable war.
Recently, I spent a weekend in the country with my extended family, celebrating my son's graduation. It rained most of the time, and my husband and I were both pretty sick, and the cabin I had rented sight unseen was moated with mud and beseiged by bees and really just too small. But it was a lovely weekend. Why? Because, as Daniel Kahneman tells us in Thinking, Fast and Slow, we seem to be literally of two minds. While we are experiencing something, every moment has equal weight-- the moment when we introduce Great-Grandma to the newest grandbaby, the moment when we realize that this commencement speaker is going to take the cake as the absolutely worst commencement speaker we have ever heard, the moment when we can't sleep because we can't stop coughing, the moment when 12 people crowd into a cabin living room and take turns reading Oh, the Places You'll Go to the graduate-- they all run together and all last forever. But when it's over, we evaluate the experience by two points: the best or the worst part, and the last part. And I was lucky enough to have several really great parts to look back on, and that the last thing we did on the trip was go to an Italian buffet for lunch. So, yeah, it was a lovely weekend. As Gawande says, "In stories, endings matter, and your remembering self is attempting to recognize not only the peaks of joy and valleys of misery but also how the story works out as a whole."
What kind of ending will bring sense to our life story? What makes life worth living? What will we pursue at any cost, and what is worthless to us? When is longevity the last priority? Is our goal just to make life longer, or to make it better? Endings matter-- are we holding the space for ourselves and each other to make good endings to the stories of our lives?
The Independent Self: Here's a surprising fact: as soon as any people group has the money, the health and the opportunity, their elderly will choose to age independently. A large number of elderly people, all over the world, given the choice, prefer living alone. We think American handles aging badly because we worship youth, when it's actually because we worship the independent self. We all want to paddle our own canoes.
So here's the problem we've set up: if most of us prefer to live independently, and most of us are living long enough that age is going to impact our ability to do so, what can we do? We say it's a medical problem, but it's really a personal problem, the conflict between our ambitions and the normal loss of functioning in the aging body. We don't want someone else to change our diapers and smash up our food and read to us because we can't see properly and help us get dressed because our fingers can't manage fasteners any more. But there's just a limit to how much medicine can restore our continence and preserve our teeth and vision and dexterity-- and I've watched that losing battle more than once.
Things Fall Apart: This situation is relatively new in the history of mankind. For most people throughout most of history, life and health were connected: if you were alive, you were probably pretty physically functional, because if you weren't, you would probably die pretty quickly of your infirmity. Concurrently, death and age were not at all connected. Of course there have always been extremely old people-- Solomon wrote about the ravages of old age in the book of Ecclesiastes-- but no more people died of old age than died of infections or viruses or accidents or violence or starvation.
But now, for the many people who do make it to old age, instead of rolling along feeling great and suddenly being bitten by a mosquito or having a stroke or getting hit by a vehicle and dropping dead, we experience a slow and uneven decline that may start in the middle of our working years. "Human beings fail the way all complex systems fail: randomly and gradually," says Gawande. But only recently have we been living long enough to realize that, so we act like it's an offense --against society, against ourselves, or against God-- to have infirmities and to need help.
Dependence: Gawande says"Old age is not a battle. Old age is a massacre." Both my parents experienced it that way. Your mobility dies, and your fine motor coordination is cut off at the knees, and your attention span gets hacked to pieces, and heaven help you if both your hearing and your vision go. Even the bravest survivors will pull me aside and tell me not to get old.
Nursing homes originated for one reason: to clear out hospital beds that were filling up with the walking-- or newly immobile, as the case may be-- wounded. This purpose survives in the specific kind of home called a Skilled Nursing Facility, where people who are too sick to back to their previous situation but not sick enough to qualify for hospital coverage any more go to regroup, get some rehab or wound care or IV treatments, and figure out what happens next. They are most likely there because they fell, or maybe because they got an infection or had a stroke or a 'heart event.' But they didn't sign up for this train ride, they just found themselves on it, and next thing they know, someone else is packing their things because they can't go home again.
Sociologist Erving Goffman groups nursing homes with prisons, military training camps, orphanages and mental hospitals as "total institutions"-- places cut off from wider society and run with a singleminded focus-- in the case of the nursing home, that focus would be "caring," defined primarily as "safety." The hospital's goal is to stabilize you and get you out. The SNF's goal is to fix whatever broke so you can, in due time, vacate that bed as well and move on. But the older you are, the better the chance that you will not be moving back to the location you left to go to the hospital. It has too many stairs, or you are too isolated, or you weren't eating right, or you got your meds mixed up, and now you need help just to be safe.
Assistance: In1983, Karen Brown Wilson invented an alternative to the traditional nursing home. She called it Park Place, "a living center with assistance, " and the residents were tenants, not patients. They lived as they pleased but had access to help with food, personal care and medications. They had call buttons and access to a nurse on site, but they also had the right to refuse restrictions that put the convenience of the staff, or even their own safety, above their autonomy. Care providers were trained to understand that they were guests in the tenants' homes. By 1988, it was clear that this model, the one followed more or less to this day in assisted living and personal care homes, resulted in higher levels of cognitive and physical functioning and greater satisfaction with life than patients in nursing homes enjoyed, while reducing costs by 20%.
The concept spread rapidly and of course became co-opted, diluted and regulated beyond recognition. Rolled into the "continuum of care" and dominated by the safety and survival priorities of medicine, residents soon once again found themselves limited in how they could live, what they could have, what they could do and when they could do it--treated like children for their own good. By 2003 the trademark combination of privacy, autonomy and support for the frail was only present in 11% of places labelled as assisted living. Wilson is still working on this problem, as are many care homes.
It is a lot of work for staff to understand how each resident defines life and what kind of assistance they might need to achieve their goals. Doing for residents-- turning them into patients-- is more efficient than allowing them to do what they can for themselves, even when it comes to something as simple as dressing in the morning. The matter is made more complicated by the fact that we ourselves are not always good at gauging our own abilities. Some people will fold at the first symptom of old age, begging others to take over responsibilities they could really still manage themselves. More commonly, people who were used to walking for miles or cooking for themselves or managing their own medical care insist on doing so long after it's clear to everyone else that they no longer have the ability to do so. Thus, staff is in a dance between what residents want to do and what they can do and what can be reasonably accommodated in compliance with the regulatory and financial environment of the institution.
After all, helping people really live is harder to measure than health and safety. Worst of all, the people staff are helping are not the real customers-- it's their kids! Wilson and other advocates for the "living with assistance" model know that "we want autonomy for ourselves and safety for those we love." Who can leave their parents in a situation that isn't really safe-- even if it's the parents' pursuit of their own best life that exposes them to risk?
A Better Life: But what is autonomy? Is it free action? For almost no one is that true. "Our lives are inherently dependent on others and subject to forces and circumstances well beyond our control." So regardless of the architecture or affiliation of the place we may find ourselves, we will still have to balance on the curb that lies between the story we have been writing all our lives and the bodies and minds we find ourselves in today. And for those whose stories have until now been built on productivity and action, that balance may be very difficult to find.
In 1991 Bill Thomas interested himself in how to lick "the Three Plagues of nursing home existence: boredom, loneliness and helplessness." He wanted to run a home, not an institution. He concluded that the answer was more life: plants, animals, a garden-- innovations he dubbed "the Eden project". He found that "the light turned back on in people's eyes." They walked the dog, they kept journals about their birds. The nursing staff resented the extra work, but the residents were excited to do it. Prescription meds dropped by half, deaths decreased 15%, and people who had been just sitting around started getting up and about. They had purpose. They were needed to tend the garden or walk the dog or watch the bird, so they exerted themselves.
It felt like my mother stayed at every facility in the county at some point, and the one amenity she would always choose to spend time with would be the aviary, or the fishtank, or, failing all else, the garden. Watching the behavior of the animals indeed turned her lights on. Another innovation Thomas spearheaded is the Green House Project, which is now in use across the country. It is based on home design that involves literally self-contained homes, with no more than 20 residents, all of whose rooms center on a dining room, living room, kitchen and family room. Residents are encouraged to conduct their daily life in the public areas, and caregivers are also encouraged to become part of the family, eating and relaxing with the residents as their schedules allow.
The principle that "simply existing--being merely housed and fed and safe and alive--seems empty and meaningless to us... we all seek a cause beyond ourselves," was well known before Josiah Royce articulated it in 1908. Victor Frankl, author of Man's Search for Meaning, famously founded a whole school of psychotherapy around this principle. Gawande observes that as we sense death approaching, "while we may feel less ambitious, we also become concerned for our legacy. And we have a deep need to identify purposes outside ourselves that make living feel meaningful and worthwhile." And yet, as Gawande observes, "For more than half a century now, we have treated the trials of sickness, aging, and mortality as medical concerns. It's been an experiment in social engineering, putting our fates in the hands of people valued more for their technical prowess than for their understanding of human needs."
Letting Go: Here are some fun facts for you: 25% of all medicare spending is for the 5% of subscribers in their last year of life, mostly for the couple of weeks or months where they are closest to death. 63% of doctors overestimate their patients' survival time, and those estimates average more than 5 times too long. We ask why people and their families have such a hard time accepting that they are at the end of the road, and maybe this is why: their doctors also can't accept that there is nothing left to do that is worth doing. As individuals, as families, we think we'll know when "there's nothing more they can do," but in a modern hospital, there's always something more that can be done.
"We pay doctors to give chemotherapy and to do surgery but not to take the time required to sort out when to do so is unwise.... in a war that you cannot win, you don't want a general who fights to the point of total annihilation." Gawande states that, based on outcomes, "If end-of-life discussions were an experimental drug, the FDA would approve it," because "you live longer only when you stop trying to live longer." He goes on to say that "A family meeting is a procedure, and it requires no less skill than performing an operation." It's a procedure doctors need to learn, because it shouldn't be the family's job to decide when the war is over. We are desperate, and we are ignorant and we have believed that medicine is Science when it's really half art and half voodoo. By the time a doctor is running down our odds and our options, we are sleep-deprived, we are in pain, we are running scared, and we are in no condition to understand our condition.
After a couple of hours, the surgeon came out to update me with bad news. The ugliest images were the accurate ones. Our options were a "heroic" surgery attempt that had a very high probability of killing my father on the table or leaving him completely crippled, or hospice. He didn't advise continuing the operation, but he offered it, and if I had insisted, he would have spent the rest of his day trying to pick cancer out of my dad's guts. Instead, I let him sew Dad up, wake him up and tell him the whole thing had been for nothing. He was now back to square one, but worse, because now he had a big surgery wound to heal from. Takeaway: Sometimes we can't even get a clear image of the problem until we open the patient up-- in the 21st century!
But here's the thing: my dad then proceeded to have three great months on hospice service. He went from being the terror of the retirement home to being "a marshmallow." He refused PT because he could-- he was on hospice! He lay in the bed, deconditioning, because he was dying anyway! He spent his waking hours watching movies, eating chocolate, drifting in and out of hallucinations that he obviously found intriguing, and receiving visits from pretty nurses and chaplains. He died more at peace than I had ever seen him before.
No doctor had known how to find out from him whether he really valued the life he found himself in at that time, where he struggled and strove to hang onto his identity, his activities, his accomplishments, losing ground almost weekly. He himself was ambivalent about whether he wanted to live or die. He had to go all the way, go under the knife, to realize that he was ready to crawl into bed and surrender to the death process.
Surgeons talk about "buying you more time"-- how much time are they talking about, exactly? or about a "60% chance of success"-- what is success, exactly? How did the doctor arrive at this percentage? What does failure look like? What does doing nothing look like? What is the shortest and the longest time a person with no treatment has lived? How about if they did get treatment? It would be nice if doctors could answer these questions even if we don't know to ask them.
Ezekiel and Linda Emanuel have identified three styles of medical communication. Some doctors act like priests and just tell you enough to get you to comply with what they have decided is best for you -- which is, of course, nearly always survival for one more day, one more month or one more year. Others dispense information-- too much information, indecipherable information, data delivered at 100 wpm-- and leave the decision to you, but the more you know, the worse all your options seem. How many doctors have the time and the inclination to be "interpretive," as Ezekiel and Linda Emanuel called it? They will ask questions until they understand your goals-- until you understand your goals-- and then inform you about the options and how they compare to the results you say you want. They are not generals on the battlefield or technicians under the hood of a car but counselors and contractors. And sometimes, they are life coaches, challenging your priorities and beliefs, pushing you to make better choices, and exposing what you really want, as opposed to what you want to want.
When we reach the stage where life becomes nothing but a series of medical crises and hospital visits, clarity on the actual probable length of one's remaining lifespan can be useful to narrow our focus and alter our activities in a way that is both freeing for ourselves and helpful for our material and spiritual heirs. We redefine our identity. We move our red lines. We stop butting our heads against the immovable object of chronic or terminal disease and decide what to do with our reduced circumstances. We find the realm where we still have autonomy.
By the time my mother found herself in this stage of life, experiencing what Gawande calls "One Damn Thing After Another" syndrome, I had not only my experience with my father, but a number oF other people's end-of-life journeys to draw from. I was starting to notice that most of the "damn things" that were following in rapid succession started with a hospital visit: deconditioning, MRSA, improper wound treatment, medical errors. And my mother knew that spending 20% of her year and $55,000 in medical facilities was no kind of life, and that she was tired of chasing cures. She fell again while I was out of town, and the assisted living called the ambulance, as procedure required, and I got on the phone with her and with them, and she refused treatment, and within the week she was on hospice status.
For nine months we went to the movies and to art shows and to the Olive Garden, and she read her Anthony Trollope collection. And when she fell off her scooter, probably as the result of a heart event, and realized she might die of complications, she literally said, "Whoopee." I knew if we agreed to get in the ambulance, and anything was broken, we would probably be talked into surgery, and that if she survived that, she would spend 6 weeks in a rehab hospital, and if she survived that, she would never be the same again. So instead, we sent the EMTs away again, and she spent her last two weeks sleeping, receiving visitors, listening to music and looking at her spectacular view. The last words she said to me were, "I love you too," and her last coherent conversation was a few days later, with a granddaughter she hadn't seen in a couple of years. Like my father, she was as much at peace as I had ever seen her, because she was allowed to exercise that one last slice of autonomy: choosing the way she died.
Courage: Gawande asks: "What mistake do we fear most? The mistake of prolonging suffering or the mistake of shortening life?" When we are terrified of losing one day we might have been able to save, we sometimes rob ourselves of the days we have in our hands. The dying role is important both to the terminal individual and to his or her community. As Gawande says: "People want to share memories, pass on wisdom and keepsakes, settle relationships, establish their legacies, make peace with God, and ensure that those who are left behind will be okay." They can't do those things very well with tubes in their mouths and heavy doses of morphine in their veins. The dying role becomes the role of the "fighter," who went down swinging... the general who led his troops to total annihilation in an unwinnable war.
Recently, I spent a weekend in the country with my extended family, celebrating my son's graduation. It rained most of the time, and my husband and I were both pretty sick, and the cabin I had rented sight unseen was moated with mud and beseiged by bees and really just too small. But it was a lovely weekend. Why? Because, as Daniel Kahneman tells us in Thinking, Fast and Slow, we seem to be literally of two minds. While we are experiencing something, every moment has equal weight-- the moment when we introduce Great-Grandma to the newest grandbaby, the moment when we realize that this commencement speaker is going to take the cake as the absolutely worst commencement speaker we have ever heard, the moment when we can't sleep because we can't stop coughing, the moment when 12 people crowd into a cabin living room and take turns reading Oh, the Places You'll Go to the graduate-- they all run together and all last forever. But when it's over, we evaluate the experience by two points: the best or the worst part, and the last part. And I was lucky enough to have several really great parts to look back on, and that the last thing we did on the trip was go to an Italian buffet for lunch. So, yeah, it was a lovely weekend. As Gawande says, "In stories, endings matter, and your remembering self is attempting to recognize not only the peaks of joy and valleys of misery but also how the story works out as a whole."
What kind of ending will bring sense to our life story? What makes life worth living? What will we pursue at any cost, and what is worthless to us? When is longevity the last priority? Is our goal just to make life longer, or to make it better? Endings matter-- are we holding the space for ourselves and each other to make good endings to the stories of our lives?
Sunday, May 5, 2019
How Not to Be Wrong: The Power of Mathematical Thinking, by Jordan Ellenberg
Who wants to be wrong? What a great reason to learn math! How Not to Be Wrong is excellently summarized in this review, so take a minute and read that so you can not be wrong anymore. Then you can come back here, and I'll give you some of my examples. (NB: the math herein is very rough. Numbers have been wildly approximated. I tried not to write about anything I didn't understand, but I may have failed. If you want really elegant, clean math and blameless explanations, read the book.)
First of all, math is everywhere, and it turns out that if you know just as much math as you did in the fourth grade, it can be a great party trick. If there are 20 people in the room, and we want to divide into groups that are not too big and not too small, what are our options? What if there are only 19? If your lunch was $7.50 plus tax and tip, what do you owe the person who put down her credit card? If you are having an Easter egg hunt with three kids, and it turns out you have 31 eggs, how many should each one find?
All of these everyday math problems hinge on the beautiful way numbers separate and combine. 4 groups of 5 people can be reorganized into 5 groups of 4 people, and once you know that, you know that 19 people will make 3 groups of 5 and one group of 4, or 4 groups of 4 and one group of 3. $2 is kind of a minimum tip and tax exists and is always more than you think it should be, so $10 would not be too much to contribute towards your $7.50 lunch. And the oldest kid can have the extra Easter egg, because he's the only one who can reliably count that high anyway.
On a more sophisticated level, there's a discussion somewhere in the middle of the book about probabilistic situations that divide into four categories rather than two. For example, there are people who are terrorists and people who are not terrorists, and there are people Facebook flags as possible terrorists and people it does not. In such a situation, the question, "What are the chances that my neighbor is a terrorist?" is completely different from the question, "What are the chances that my neighbor, who was flagged as a possible terrorist, actually is one?" The first question is binary: She is or she isn't. The second is only looking at one quadrant of a four-way possibility matrix, because I am looking at the intersection of people who are actually terrorists and people Facebook identifies as suspicious.
One reason this situation is interesting is the principle that the more extreme a number is, the less useful it's going to be to try to change it by what sounds like an impressive proportion. In our home, that's sometimes known as the Ralph Lauren effect. A half-price sale sounds amazing until you realize that regular price is $125. Even half off just isn't enough to make the shirt affordable.
In our example about terrorists, the chances that anyone is a terrorist are tiny-- like there are 7 billion people in the world, and by the broadest definition there might not be more than a few million terrorists among us. That's if most of them are pretty ineffectual: according to my minutes of research, in 2014, there were about 44,000 deaths and 16,000 injuries as a result of terrorist attacks worldwide. Out of 7 billion people. So the chances of finding a terrorist just by picking a person at random is, let's say, 1 million out of 7 billion, or 1/7000, or .00014%. If I say I can double your chances of picking a terrorist out of the crowd, that sounds great, right? But sadly, that only puts your chances up to 2/7000 or .00028%, which are still terrible odds. Now you see why we have the NSA and so forth.
So here's some more fun with percents. If I say I'm "doubling" your chances, they will go up by 100%. Which is not the same as going up to 100%! A percent is only as good as its starting point-- remember the Ralph Lauren problem? Here's another example. I have to write surveys for work. Getting people to fill out the surveys is a big problem. My survey provider sent me an email recently asking, "If you could improve survey response rates by 50%, would you do it?" Wow! That sounded great! But when I looked more closely, here's what was really happening, more or less (remember, my numbers are rough). Typical survey response rate was only 25%. So, add 50% of 25% (12.5%), and that new, improved shiny response rate was now... 37.5%! That's not so exciting. Less than half my group would be responding, even with my snazzy new strategy. Furthermore, watch this trick: I still have 62.5% not responding (because P plus NOT P equals 100%). Previously I had 75% not responding. So I only reduced not responding rates by 16.67%! Only 16.67% of my not-responders responded to my new bells and whistles! So here's where things get weird: Increasing the response rate by 50% only decreased the non-response rate by 16.67%! That's because so few people were responding in the first place. If half the people were responding, it would work out more nicely: I would go from 50/50 answer/no answer to 75/25, which would be a tidy 50% increase in what we want and 50% decrease in what we don't want. But a percent is only as good as its starting point!
Isn't math fun? Now go read that review, at least, so you can learn more!
Ellenberg closes with a wonderful quote from W.V. Quine that I have used a lot since I read it: "To believe something is to believe that it is true; therefore a reasonable person believes each of his beliefs to be true; yet experience has taught him to expect that some of his beliefs, he knows not which, will turn out to be false. A reasonable person believes, in short, that each of his beliefs is true and that some of them are false." Isn't that great! It doesn't make much sense going around saying, "I could be wrong." For crying out loud, if you think you're wrong, do some more research until you either are pretty sure you're right or have realized the answer is unknowable! But, at the same time, realize that you are perfectly capable of all kinds of errors, even while you are doing your best due diligence to avoid them. That's mathematical thinking!
First of all, math is everywhere, and it turns out that if you know just as much math as you did in the fourth grade, it can be a great party trick. If there are 20 people in the room, and we want to divide into groups that are not too big and not too small, what are our options? What if there are only 19? If your lunch was $7.50 plus tax and tip, what do you owe the person who put down her credit card? If you are having an Easter egg hunt with three kids, and it turns out you have 31 eggs, how many should each one find?
All of these everyday math problems hinge on the beautiful way numbers separate and combine. 4 groups of 5 people can be reorganized into 5 groups of 4 people, and once you know that, you know that 19 people will make 3 groups of 5 and one group of 4, or 4 groups of 4 and one group of 3. $2 is kind of a minimum tip and tax exists and is always more than you think it should be, so $10 would not be too much to contribute towards your $7.50 lunch. And the oldest kid can have the extra Easter egg, because he's the only one who can reliably count that high anyway.
On a more sophisticated level, there's a discussion somewhere in the middle of the book about probabilistic situations that divide into four categories rather than two. For example, there are people who are terrorists and people who are not terrorists, and there are people Facebook flags as possible terrorists and people it does not. In such a situation, the question, "What are the chances that my neighbor is a terrorist?" is completely different from the question, "What are the chances that my neighbor, who was flagged as a possible terrorist, actually is one?" The first question is binary: She is or she isn't. The second is only looking at one quadrant of a four-way possibility matrix, because I am looking at the intersection of people who are actually terrorists and people Facebook identifies as suspicious.
One reason this situation is interesting is the principle that the more extreme a number is, the less useful it's going to be to try to change it by what sounds like an impressive proportion. In our home, that's sometimes known as the Ralph Lauren effect. A half-price sale sounds amazing until you realize that regular price is $125. Even half off just isn't enough to make the shirt affordable.
In our example about terrorists, the chances that anyone is a terrorist are tiny-- like there are 7 billion people in the world, and by the broadest definition there might not be more than a few million terrorists among us. That's if most of them are pretty ineffectual: according to my minutes of research, in 2014, there were about 44,000 deaths and 16,000 injuries as a result of terrorist attacks worldwide. Out of 7 billion people. So the chances of finding a terrorist just by picking a person at random is, let's say, 1 million out of 7 billion, or 1/7000, or .00014%. If I say I can double your chances of picking a terrorist out of the crowd, that sounds great, right? But sadly, that only puts your chances up to 2/7000 or .00028%, which are still terrible odds. Now you see why we have the NSA and so forth.
So here's some more fun with percents. If I say I'm "doubling" your chances, they will go up by 100%. Which is not the same as going up to 100%! A percent is only as good as its starting point-- remember the Ralph Lauren problem? Here's another example. I have to write surveys for work. Getting people to fill out the surveys is a big problem. My survey provider sent me an email recently asking, "If you could improve survey response rates by 50%, would you do it?" Wow! That sounded great! But when I looked more closely, here's what was really happening, more or less (remember, my numbers are rough). Typical survey response rate was only 25%. So, add 50% of 25% (12.5%), and that new, improved shiny response rate was now... 37.5%! That's not so exciting. Less than half my group would be responding, even with my snazzy new strategy. Furthermore, watch this trick: I still have 62.5% not responding (because P plus NOT P equals 100%). Previously I had 75% not responding. So I only reduced not responding rates by 16.67%! Only 16.67% of my not-responders responded to my new bells and whistles! So here's where things get weird: Increasing the response rate by 50% only decreased the non-response rate by 16.67%! That's because so few people were responding in the first place. If half the people were responding, it would work out more nicely: I would go from 50/50 answer/no answer to 75/25, which would be a tidy 50% increase in what we want and 50% decrease in what we don't want. But a percent is only as good as its starting point!
Isn't math fun? Now go read that review, at least, so you can learn more!
Ellenberg closes with a wonderful quote from W.V. Quine that I have used a lot since I read it: "To believe something is to believe that it is true; therefore a reasonable person believes each of his beliefs to be true; yet experience has taught him to expect that some of his beliefs, he knows not which, will turn out to be false. A reasonable person believes, in short, that each of his beliefs is true and that some of them are false." Isn't that great! It doesn't make much sense going around saying, "I could be wrong." For crying out loud, if you think you're wrong, do some more research until you either are pretty sure you're right or have realized the answer is unknowable! But, at the same time, realize that you are perfectly capable of all kinds of errors, even while you are doing your best due diligence to avoid them. That's mathematical thinking!
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