April 26, 2009
Epistemology, Irony, and a ParadoxEpistemology is a technical term for the study of knowledge; the basic questions dealt with are, “what do we know and how do we know it?” Thus, although it’s a term few use comfortably, many of us devote considerable time and energy to its basics, a fact underscored by the frequency of certain constructions: “to tell the truth,” “in truth,” In point of fact,” as a matter of fact,” etc..
Nevertheless, most of what we humans now know reliably about our home planet and its universe has only been learned over the last five centuries. Among the more salient epistemic facts is that although we know we’re not the only cognitive species, we’re the only one capable of accumulating and retrieving today’s vast array of useful knowledge. Less well appreciated is that profligate exploitation of that knowledge has trapped us in a series of problems requiring urgent resolution, but sadly, our chronic inability to reach agreement casts doubt on whether we can even define them in time to solve them .
To use an overworked medical metaphor: without an accurate diagnosis, effective treatment is unlikely. An equally critical corollary is that it’s better to begin definitive therapy short of cardiac arrest. Several of the most pressing problems we now face as a species, climate change and the global economy, to name but two, have progressed to points that demand action, yet a host of unsettled problems preclude constructive international discourse, even as disruptive unconventional warfare is being waged on a global scale by non-national actors .
At this point, one might reasonably ask what gives a lone, obscure physician the chutzpah to discuss such issues? My answer is one Darwin could have offered: after starting from a series of chance observations in 1831, he’d followed an obsessive train of thought that led him to several novel conclusions he felt impelled to share with the the world in 1859.
150 years after publication of The Origin of Species, Darwin’s basic insights are still probably unknown to a majority of living humans and would likely be rejected by most who know something of them; yet they have been essential guides for the generations of scientists who have reduced biological inheritance into ever smaller, yet exquisitely related, components retaining an innate coherence at the molecular level.
Thus does Darwin’s life work also resemble that of another great scientist who preceded him by less than two centuries and famously noted that he'd stood “on the shoulders of giants” in ways that are (ironically) still disputed.
To return to my chutzpah, it comes from seven years of doing something that’s been actively discouraged for almost forty: discussing drugs with scorned drug users in an effort to understand their behavior. To my great surprise, that activity and the conclusions it leads to have elicited little overt interest from the very people one would expect to be curious, a circumstance that itself demands an explanation.
In essence, those same histories, and the lack of response they have provoked, add up to a refutation of America’s “war” on drugs that will be outlined in the next issue of O’Shaughnessy’s, a journal chronically on life support, but with an '09 issue almost ready for the printer.
An ironic, even paradoxical, item suitable for interim consideration appeared in today's column by a local pundit, one I’ve praised for her support of medical marijuana and criticized for her (doctrinaire) scorn of “tree huggers.”
April 25, 2009
Progress, too late for someJust as I was starting to lose all hope, the following link was forwarded to me in this morning’s e-mail. It leads to the abstract of an about-to-be-published Canadian study that sounds like it will substantially confirm that adolescents become cannabis users because it relieves symptoms of anxiety.
What that represents to me is the first small crack in the huge dam of official denial that exists on this issue. I’m now more confident than ever that it will eventually have to give way. The (bitter) irony is that I know of die-hard state and federal prosecutions of bona-fide medical users in my study that are still grinding away in California, even as this is written.
April 19, 2009
Rehab for Pot Smokers? Say it isn’t So, Barack!!It’s becoming increasingly difficult to remember that back in November, I was actually hopeful that we’d see some intelligent changes in the corrupt and destructive American policy known as the "War" on Drugs. It’s not as if the drug war had ever done anything but fail in the nearly four decades since Richard Nixon’s unexpected election and a surprising Supreme Court decision combined to allow his administration to rewrite what had been a bad drug policy to begin with. The rewrite produced a greatly expanded version of the old policy that soon made things infinitely worse by retaining and intensifying all its erroneous assumptions while creating several new illegal markets for agents that had become available during and after the Second World War.
The result has been been an unmitigated disaster; by expanding the role of police agencies in the practice of Medicine, the Omnibus Controlled Substances Act (CSA) has been responsible for countless deaths and blighted lives; it has corrupted law enforcement, Psychiatry, and the Behavioral Sciences, while quadrupling our prison population, debasing Education and creating business opportunities for powerful transnational criminal organizations that now have the power to destabilize sovereign nations.
Sadly, since taking office in January, the Obama Administration's drug policy initiatives have been disappointing; first, it sent a confusing series of mixed signals on medical marijuana in California; more recently, when faced with resurgent Mexican drug cartels, it dusted off all the old shibboleths favored by past administrations.
The latest is an announcement, seconded by his new drug czar, that we will be relying on rehab to “control” the murderous cartels now competing for a share of the lucrative US marijuana market.
A far more intelligent approach might be to ask why that market has grown so steadily since the Sixties despite all the money spent to suppress it.
Because our study of chronic users in California strongly suggests that inhaled cannabis protects troubled teens from problematic use of alcohol and other drugs, I can't imagine a move more likely to fail. Talk about being trapped in the ignorance of the past!
Nevertheless, our new President was (by far) the most intelligent and open of all candidates in the last election, as he demonstrated again today at a press conference in Trinidad. Perhaps what would help most would be for some members of the press to ask some intelligent questions about pot for a change.
How Drug War Lies Threaten the PolicyYesterday evening as I was driving home on the Nimitz Freeway, a DEA stooge I’d never heard of was interviewed by an NPR person ( Robert Siegel on All things Considered, I think) about the recent flare-up in Mexican border violence. My jaw dropped when he announced that not only was -marijuana the most commonly smuggled drug, despite its bulk and tell-tale odor, it also rewards its distributors with the highest profit margins. Think about that for a while: pot, the pacifist drug of peaceful stoners and the subject of inane word play has matured as the bloodiest illegal drug market and earns Mexican cartels, their biggest profits.
A few moments later I nearly went ballistic when the DEA stooge claimed that overall illegal drug use in the US is down significantly and only 4 percent of all Americans are repeat users. I became even more upset when Siegel seemed to accept those answers without question. I remained angry for most of the evening over what I’d heard because I’d just had my own beliefs reinforced by a second straight day of patient histories and was thus acutely aware of just how lame the federal position really is.
By this morning, I’d calmed down enough to think a little more constructively and could discover no mention of either the DEA stooge or his message. That allowed me to realize the potential for pot’s popularity, it’s role in provoking bloodshed, or the illegal profits it generates for turning both the drug war and the DEA into objects of ridicule. All it would take is for someone to begin asking the right questions; like “how long can you guys miss stuff that’s right out in front of you?”
At some point DEA absurdity has to embarrass its academic defenders; whether it’s the phony Pharmacology, imaginative Economics, or Psychiatry’s reliance on the absurd DSM is less important than breaking a malignant policy’s grip on power,
April 18, 2009
Enough, Already!For almost four years, I’ve been using this blog to describe an ongoing study of Californians applying for “recommendations” to use marijuana as allowed by Proposition 215 in 1996. When the study began in late 2001, I was almost as clueless as everyone else then arguing over whether there was "valid' medical use, let alone how to define it. What I soon learned was a result of following a long established clinical technique of treating applicants as patients. Thus I soon discovered that the great majority had been self-medicating their emotions safely and effectively with pot for years–– which was the very reason it had become so popular with baby boomers in the Sixties. That part was relatively easy to understand and paved the way for many additional, and equally unexpected, insights.
What soon became much more difficult for me to grasp was why my attempts at relaying that information to colleagues in the medical marijuana "movement” were almost immediately and uniformly rebuffed without explanation. I would only later discover that most people, (I have to include myself in the indictment), would rather shrink from “inconvenient” facts than deal with intense disagreement. There is also a smaller minority who apparently can't bring themselves to admit ever being wrong.
A related reason was that the earliest "pot docs," had entered the federally contested pot recommendation arena long before I had. As heads themselves, they were largely unaware that they had been suggesting the conditions I would find in vogue as acceptable excuses for pot use when I started. My sin had been the (largely unconscious) invasion of an alien culture. That I was also unschooled in that culture didn't help my credibility.
A variety of denial devices are illustrated by the “good" Germans of the Thirties most of whom eventually discovered during the war, but others were never able to admit, that all Germans had become victims of Hitler’s earliest rhetoric. In other words, the transient comfort provided by denial may someday command an enormous price.
That same weakness has allowed America’s Drug War to evolve incrementally from a relatively small 1914 exercise in legislative chicanery into today's transnational disaster, one of very few laws being enforced across all political boundaries in today's divided world. Possession of pot in any International port of entry risks being identified as a “druggie” and treated as harshly as local custom allows. While we can't be certain all die-hard drug warriors believe their own dogma, we can be reasonably sure most never got high on pot, and those who did can't admit it.
I'm considering publishing a list of those I think are most culpable in America's drug war follies, along with my reasons. I have been moved to speak out this forcefully by an NPR broadcast to be described in the next entry.
April 16, 2009
More on Pot LegalizationContinuing interest in a possible change in the status of marijuana was reflected by two more items in yesterday’s San Francisco Chronicle. On the front page, but probably of less immediate interest, was one about a local politician urging the City to go into business as a pot distributor. He's a well known advocate who is also considered out in front of his support, even in San Francisco.
For me, the story on ASA’s suit and the Ninth Circuit has greater potential for positive change because what my clinical study of pot applicants shows so clearly is that as soon as large numbers of adolescent baby boomers were able to try pot in the mid-Sixties, many of them began using it for its anxiolytic (anxiety relieving) properties. That many continued using it safely and with satisfactory results for over thirty years was the reason they eventually discovered its additional medical benefits.
Thus the dirty little secret neither side of the “debate” that sustains the drug war is one they've both been unwilling to acknowledge: virtually all chronic repetitive use of cannabis could easily qualify as “medical.”
At some point, hopefully sooner than later, there will be a lot of red faces. The great tragedy is that so many lives have been lost or ruined by ignorance, malice, or misplaced self-righteousness.
That such a situation has long been recognized as a Mexican Standoff simply adds a degree of irony that’s nearly unbearable to someone who remembers Juarez and El Paso as they were when he last saw them in August, 1963. The big local news was that then- President Kennedy had just visited to meet with President Lopez-Mateos of Mexico and the two had agreed to settle the long-standing Chamizal Dispute between the two nations.
April 15, 2009
Somali Piracy and Mexican CartelsAt first glance, the disturbing news from two widely separated parts of the world may not seem that closely related; but both are, in fact, good examples of why crime is becoming the world’s most successful business model, one with the power to drag our overheating and overpopulated planet into a high-tech reprise of the Dark Ages from which emergence will be difficult at best and certainly can’t be assured.
The US is widely acknowledged to be both the richest, and militarily, most powerful nation on earth; yet many of our most successful corporations are teetering on the brink of bankruptcy, we are squabbling over an ad-hoc “bail out” with dubious prospects of success, and pundits from both extremes of the political spectrum are finding it difficult to avoid the D word.
While our European colleagues may blame us for many of their own woes, the more responsible ones are forced to admit a degree of complicity and the others have to admit to another harsh reality: their own prosperity is unlikely in a world dominated by American economic failure.
How does crime fit into all this? Economic hard times favor it and the pirates have just discovering a secret drug traffickers exploited with increasing success throughout the entire Twentieth Century: Law Enforcement simply can’t win. The reasons are multiple, complex, and will certainly be disputed, but, in the end, it comes down to the competition for survival first articulated by Charles Darwin in The Origin of Species in 1859 and has most to do with the function of the human brain, which is clearly our principal survival organ and the source of all our aggregated culture.
One way of stating my admittedly unwelcome conclusion would be to phrase it in terms of the just-discovered (by me) concept of Path Dependence: the sun total of human culture cannot change (or be changed) quickly enough to avoid several looming catastrophes. In more colloquial terms, we have simply painted ourselves into a corner we are unlikely to escape from.
Both Mexico and Somalia represent failed states in which criminal gangs are ascendant. The lawlessness is further advanced in Somalia, but that’s only because it’s much further from the US and surrounded by other poor nations in the process of failing. Is there any historical example of a successful wall between neighboring states? Do we really think it would be possible to distinguish impoverished job seekers from drug smugglers, or that our overstretched military would be capable of shooting to kill at civilians while also resisting the temptation to sell out?
The truth may not be that palatable, but the time for denial is over: we’re not likely to escape the consequences of our own past history.
April 13, 2009
An Illustrative Case?As someone who started with a study of marijuana use, only to eventually become obsessed by the entire spectrum of human behavior, I found the following item an irresistible example of how large organizations–– in this case, the Chinese government–– manage to foolishly paint themselves into corners by passing laws with outcomes that were (or should have been) eminently predictable .
The following item, from Discover Magazine, even has a bonus: the exchange of comments that follows is another unwitting example of the same futile authoritarian dynamic.
In other words, I'm not claiming to have a solution; only offering the suggestion that we started creating our own unintended consequences by creating “illegal drug" crime with the 1914 Harrison Act and then made it a lot worse by expanding its futility as a "war" with Nixon’s CSA in 1970.
It doen't take a lot of imagination to apply the same lessons to Somalian piracy, but I'm reasonably sure most won't care to do so.
Is this just another complaint? No. Rather, it's a reiteration of the idea that until we grasp the problem, we're unlikely to come up with a solution. A good example of classic drug war futility was aired only this morning on CNN.
April 12, 2009
The Beginning of the End?I must admit that although I’ve been buoyed recently by increasing evidence that the idea of legal pot is making headway, I still considered it a long way over the horizon.
Thus another newspaper item, one I hadn't known of in advance, and on the front page of today’s SF Chronicle, really caught me by surprise. The author isn’t that well known to me, but she had always struck me as a seasoned political writer, one not not given to idle speculation. I was also impressed by a negative: the Chronicle's editorial policy toward medical pot had always been so conservative for the Bay Area, I assumed that if they opted for page one, it must be more than a rumor.
Before getting too carried a way however, it’s well to remember that the inroads 40 years of aggressive pot prohibition have already made on intelligent behavior in America argue against a smooth transition. In fact, trouble is almost guaranteed from correctional officers who will be looking at job cuts and those who will have to sort out which prisoners should be granted either amnesty or early release.
I've also been so sickened by the unfair and punitive convictions that have been handed out by both federal and state courts to some medical users in California, it makes me almost physically ill to think about them and the casual cruelty traceable to a stupid law. Nor is my contempt for punitive types who remain insistent on punishing pot “criminals” severely liable to go away in a hurry.
But I'm also ready for change; it's way overdue.
April 11, 2009
Path Dependence in the NewsOnce one realizes how past decisions inevitably influence the course of current events (and thus limit options for change) the applicability of Path Dependence becomes even more obvious, as does the fatuous nature of most political rhetoric and the inconsistency of cherished notions of “justice,” as they relate to “fair” and “equal.”
A prime example of fatuous political rhetoric is the wave of complaints from the political Right charging President Obama with irresponsibly plunging the nation into debt in his efforts to save big banks from bankruptcy. Just how does one replace an admittedly dishonest system overnight? Weren’t these same banks' recent sales of “toxic” sub-prime mortgages and resales of their complex “derivatives” to gullible investors (including European central banks) what is most responsible for the world's financial crisis? I haven’t heard any suggestions from either Fox News or Congressional Republicans on how to replace the complex international banking system while saving it from itself.
That's an undertaking that may not even be possible, a contingency for which there is no precedent and of which there is little mention.
As for the Department of “Justice,” now headed by Eric Holder, it’s another human bureaucracy that doesn’t always interpret directives exactly as intended. A number of people– several of whom have already been mentioned here, and others I know personally– who find themselves caught somewhere between arrest and prosecution. The detailed reality of their situations is even more complex than suggested by Bob Egelko’s article in today’s Chronicle.
If there’s any good news, it’s that their plight, like that of others detained by the US, is finally receiving some long-overdue attention. The bad news about drug policy, made clear by a study of pot use, but still denied by both the federal government and “reform," is that unjust policies based on years of false assumptions are difficult to change and continue to have their own destructive consequences, which may not even be revealed until years later.
April 09, 2009
Guerrilla War UpdateDespite the recent spate favorable interest in medical marijuana, I was still referring to a “tax-supported alliance of federal and local police agencies” being engaged in “guerrilla war” against Proposition 215.
In fact, I had long been reasonably certain that similar collusion between state and federal law enforcement entities was behind the rash of prosecutorial “hand-offs” that followed the unfavorable Raich decision by SCOTUS in June of 2005, of which the prosecution of Dustin Costa in the Eastern District of California is merely one example.
Today, Google led me to the closest candidate I've found for a smoking gun , linking Raich to the "hand offs."Because I know the account by Pat McCartney and Martin Lee is accurate and their link is still active, I’ll post it without comment because I'm busy and also I know it will (only) be read by those with an interest.
April 07, 2009
Path Dependence, ContinuedThe last entry suggesed that the time may have come for humanity to take a more species-oriented approach to its intrinsic problems; particularly those that have evolved past a point that threatens its (our) existence. I also implied that a reasonable first step would be standardization of an analytical method that would allow a clear understanding of how several of our more vexing contemporary problems have actually evolved. The concept known as Path Dependence was identified as a reasonable candidate because its core concept is well suited to the analysis of any evolving process. Also, thanks to Google and the internet, we may now possess the data management tools such a process would need to eventually become fast, accurate, and transparent enough to be taken seriously.
Given our worsening global financial crisis and the slowly dawning awareness of its long term implications, a good subject for an early study might be our own dishonesty, a trait that was clearly one of the current economic panic's more important, yet frequently overlooked, causes. That individual humans lie and cheat is obvious; nevertheless, our large organizations–– both governments and successful businesses of a certain perceived importance–– are normally able to exempt themselves from such suspicions. Major exceptions to that general rule are times of extreme crisis.
Current events also illustrate, often dramatically, how a combination of deception by an accomplished cheat and denial by his victims, when undetected for long intervals, can do enormous harm. Were it not for the market crash in December ‘08, Bernard Madoff’s epic Ponzi scheme might still be paying the modest regular dividends his socially prominent victims had come to expect. Many of those victims were themselves reputed to be canny investors (just as many Madoff-ruined charities had been assumed to be well run). In the face of such evidence, our failure to recognize that both dishonesty and denial are intrinsic human behaviors, capable of becoming major problems for our species, should be unlikely. Unfortunately, examples of that same phenomenon abound, both in history and in the daily press.
My structured interviews of pot smokers were not what led me to see dishonesty as a key human flaw; rather it was the unwitting serial revelations of federal agencies charged with defending the drug war against medical marijuana in California, in combination with the almost-reflex denial exhibited by so many of the activists who had worked so hard to place Proposition 215 on the ballot.
The arrogance of the drug war bureaucracy is consistent with its uninterrupted dominance of American (and global) drug policy and the success of its central dogma (fear of addiction). Although one can hardly blame them for using tactics that have been successful since modern Pharmacology was in its infancy, one can certainly blame modern pharmacologists, other scientists, and knowledgeable scientific popularizers, all of whom have been tacitly endorsing drug war rhetoric with their silence since (at least) 1975.
Polls now show that “medical marijuana” has even greater voter appeal than when Proposition 215 surprised the world in 1996; however, data provided since then by users who had been self-medicating with pot in the face of considerable personal risk have been ignored by both sides of the political argument, neither of which ever had access to similar data, and both of which have their own doctrinaire agendas.
In any case, I’m quite sure a majority of the applicants I’ve interviewed have given honest answers to most of my questions. My reasons are:
1) The remarkable internal consistency of their data; not only do family backgrounds coordinate well with generational age (YOB data), drugs tried, and other information not usually obtainable in more restricted settings; so do racial/ethnic backgrounds.
2) Applicants who had received recommendations from other screening physicians (none of whom ask my questions) turn out to have similar profiles when those questions are asked.
The most striking feature of a comparison of my data with federal assertions about cannabis is the complete lack of agreement on almost every aspect of pot use, a difference that can best be accounted for by realizing that the government position is based a combination of unproven assumptions and clinical ignorance. There has not been a comparable period since 1967 when physicians could take histories from admitted pot users who weren’t also being categorized as either "druggies" or criminals. The situation becomes even more implausible when one considers the near total lack of congruence between my study and those published thus far by other “pot docs” in California after what is now over twelve years of possible clinical contact.
This essay only scratches the surface of the role human dishonesty has played, and still plays, in our problems as a species. Once one sees that dynamic from the required perspective, good examples become almost too common to list and the most critical question then becomes, how do we deal with it?
April 05, 2009
Some Additional Thoughts on Path DependenceWhen Claude Shannon’s General Theory of Communication was first published in 1948, it struck some contemporaries as so simplistic that it evoked a “so what” reaction. However, it’s now recognized by insiders as one of the Twentieth Century’s most important insights, if for no other reason than its facilitation of both the digital and communication “revolutions;” not to mention its applicability to a host of biological processes, most of which it clearly anticipated, a fact seldom mentioned by biologists themselves, probably because they never heard of Shannon.
Shannon, himself, in common with most of Science’s pioneers, could not possibly have predicted all the ripple effects of his many contributions, even though he did live to witness much of their early trajectory.
Which brings me to my main point: an intellectual formulation (idea) is now evolving under the rubric of Path Dependence (Path Dependency). Although still so poorly defined as to be more confusing than helpful, it has the potential to meet a human need that’s becoming more critical by the month: that of a quick, reliable method for analysis of the planet's most troublesome issues, and yet authoritative and transparent enough for its results to become starting points for attempted solutions. A growing list of such problems now threaten either the welfare, or the outright survival, of a majority of the Earth’s human inhabitants; yet the problems themselves are so divisive they defy agreed definitions, let alone any concerted efforts at solution.
Two of the most obvious at this writing are a rapidly crashing global economy and unresolved climate change issues. Multiple others lurk in the background: territorial disputes, international criminal markets, cheating in global financial markets, human dishonesty in general, looming oil and fresh water shortages, depleted fisheries and the accelerated extinction of species, to mention only some of the more troublesome.
At this point, the history of Path Dependence as economic theory is not particularly important because its original conceptualization predated the availability of resources and tools that might make it practical today: a growing repository of data on the internet, powerful search engines to retrieve them rapidly, and database technology with which to analyze them. All that's needed is the funding and will for a feasibility study to explore PD's ability to bring some clarity to a range of current problems.
What made the concept of PD so immediately attractive to me when I first encountered it in Atul Gawande's article on evolving health care systems, was the structural resemblance to (biological) Evolution: an original idea inspired by a perceived need in business or public policy can be seen as analogous to an environmental change that will ultimately produces a new species. Any new species is limited (constrained) to certain possibilities for meeting a challenge; the more known about the genetic endowment of the threatened species, the better the potential success of an adaptation can be understood. The same is true of any addition environmental influences.
Just as we now know that most species go extinct, most governments under which humans have ever lived have been replaced. One less obvious corollary is that our brain and its cognitive prowess are both products of biological evolution. Since the appearance of Science about 500 years ago, human culture has evolved much more rapidly in directions which are still poorly understood, but are, nevertheless, more competitive than ever.
Therein lies our most threatening cultural problem: how to restrain the human appetite for control of the planet's limited resources now causing so many problems? One way of asking that question is: can humanity find a way to cooperate as a species so as to allow survival in harmony with a constantly changing universe? Another is how big a catastrophe would be required for enough humans to live in enough harmony to reverse current destructive trends?
At this point, I'm forced to fall back on the clinical wisdom of my profession: an accurate diagnosis is far more likely to lead to effective treatment than a guess; especially a guess based on a false assumption.
April 04, 2009
In the NewsYesterday's hot story was the mass shooting of recent immigrants in Binghamton, NY. It was over in minutes, but heavily armed SWAT teams waited outside for three hours before entering. Judging from details in today's NYT story, those in charge should have been able to deduce from the 911 calls that it was a lone shooter. What distresses me is the probability that, as at Columbine, police reticence to enter such a scene almost certainly risked adding avoidable mortality and morbidity to a tragic situation.
Such a policy stands in stark contrast to the aggressive tactics SWAT teams routinely use on drug busts, in which raiding the wrong address occasionally leads them to shoot surprised home owners, their dogs, or even their children.
April 02, 2009
Dual Diagnosis and Appropriate TherapyI’ve just watched Obama answer questions form the press in real time at the conclusion of the G-20 Summit in London. I’m now more conviced than ever that he is the most articulate, hopeful, and honest American President since Lincoln.
Hopefully, he will be as able to meet his historic challenges. Depression is a word that applies to both economics and emotions. The world desperately needs effective therapy for both.
Learning from GawandeIt’s now less than a week since the casually overheard portion of an NPR radio interview made me aware of Harvard surgeon Atul Gawande, who happens to be one of two Harvard physicians writing regularly for the New Yorker. Ironically, both became regular contributors to the magazine in 1998; but although I’d read several articles by Jerome Groopman, and only two written recently by Gawande, I’m quite confident I’ve detected critical differences between them.
For one thing, Gawande is not only considerably younger, he also writes analytically about a variety of social issues in ways that make him unique and have little to do with his calling as a surgeon. Indeed, his early career was distinguished by the great aptitude he displayed for social issues. Despite interruptions to pursue them before and during medical school and again during his surgical training, the medical skills he ultimately displayed placed him, almost at once, in a position to practice surgery close to a well established academic pinnacle. That he still finds enough time to pursue his interest in broader social issues and write about them so clearly and in depth, has convinced me he’s a genuine medical polymath, someone with a lot to offer today’s world.
My first evidence was this week’s New Yorker article on the cruelty of American prisons. Our increasing reliance on incarceration, particularly as enhanced by punitive solitary confinement, is an issue which, much like our relentless punishment of those using cannabis for any reason (and especially for medical purposes), can be thought of as both institutionalized injustice and needless cruelty. Nevertheless, as Gawande points out in Hellhole, even tentative efforts at reform from within “the system” of incarceration have been so politically unpopular that those making them have been forced to desist. It was that nugget of information that led me to hope Gawande might be a guru from whom I could learn other helpful truths.
I didn’t have long to wait; his penetrating analysis of several national health systems in developed nations had just been published in January; not only does it comport with my own knowledge of those systems, it added to it. More importantly, it provided me with a concept that may turn out to be one of those disarmingly simple key insights with the power to change the world, at least for a little while.
That concept is Path Dependence; an idea that seems seems to have arisen among those primarily concerned with Economic system analysis and has been around long enough that its exact provenance has already been hopelessly confused. In any event, it doesn’t seem io have been comprehensively applied to either biological systems or their evolution.
Briefly stated, Path Dependence, as applied to Economics, is the notion that the developmental trajectories of new products competing for market share are already constrained by conditions that existed when they were first conceived, and are then shaped by new conditions that develop over time. The examples referred to in most iterations of PD are repetitive: the VCR versus Betamax and QWERTY versus Dvorak keyboards. The usual conclusion is that what might now appear to have been a better design often didn’t win out in the marketplace for good reasons that can only be understood in retrospect, and with enough specific information.
Current definitions of PD turned up on several Google searches were not nearly as informative as the one I was able to derive from Gawande’s invocation of the concept in his comparison of modern national health plans as they had evolved in Britain, France, Canada, and other nations, with the hodgepodge non-system now failing so expensively in the United States.
This is all I have time for now. I plan to return to both Atul Gawande’s writing and the pivotal concept of Path Development at my earliest opportunity.