James Fallows

James Fallows is a national correspondent for The Atlantic and has written for the magazine since the late 1970s. He has reported extensively from outside the United States and once worked as President Carter's chief speechwriter. His latest book is China Airborne. More

James Fallows is based in Washington as a national correspondent for The Atlantic. He has worked for the magazine for nearly 30 years and in that time has also lived in Seattle, Berkeley, Austin, Tokyo, Kuala Lumpur, Shanghai, and Beijing. He was raised in Redlands, California, received his undergraduate degree in American history and literature from Harvard, and received a graduate degree in economics from Oxford as a Rhodes scholar. In addition to working for The Atlantic, he has spent two years as chief White House speechwriter for Jimmy Carter, two years as the editor of US News & World Report, and six months as a program designer at Microsoft. He is an instrument-rated private pilot. He is also now the chair in U.S. media at the U.S. Studies Centre at the University of Sydney, in Australia.

Fallows has been a finalist for the National Magazine Award five times and has won once; he has also won the American Book Award for nonfiction and a N.Y. Emmy award for the documentary series Doing Business in China. He was the founding chairman of the New America Foundation. His recent books Blind Into Baghdad (2006) and Postcards From Tomorrow Square (2009) are based on his writings for The Atlantic. His latest book is China Airborne. He is married to Deborah Fallows, author of the recent book Dreaming in Chinese. They have two married sons.

Fallows welcomes and frequently quotes from reader mail sent via the "Email" button below. Unless you specify otherwise, we consider any incoming mail available for possible quotation -- but not with the sender's real name unless you explicitly state that it may be used. If you are wondering why Fallows does not use a "Comments" field below his posts, please see previous explanations here and here.
  • Where to Get Your Next Fix of MH370 News

    Chris Goodfellow, who has offered the so-far least-unlikely explanation of what happened, does a 90-minute Q&A.

    Evolving search areas for Malaysia Air 370. ( via VOA )

    Executive summary of what you'll find below: If you're looking for more discussion of MH370, please swap the first 90-minutes of this "Google Plus Week" (embed below) for the next 90 minutes you would spend with cable news. It features the person who came up with the at-the-moment-least-implausible explanation of what happened, and its BS/insanity quotient is practically nil, in stark contrast to the normal cable level.

    Now the details.


    Yesterday I was on CNN's Reliable Sourceswith Brian Stelter (and Poynter's Andrew Beaujon), talking about the way CNN, in particular, has decided to go wall-to-wall in covering the missing airplane. Stelter pointed out that when CNN dealt with MH370, its ratings went up; when it didn't, the ratings went down. Therefore the network had quite rationally decided to make itself into the Missing Plane Channel for the foreseeable future, much as it became the Gulf War Channel in the early 1990s, in the period that first established its worldwide role.

    I replied: I understand this business logic, which fits the reality of the modern highly diversified news ecology. If you want to find out, right now, what's up with sports, or weather, or the stock market, or political trends, you know where to go. If you want to find out about the MH370 search, you know you can go to CNN.

    But my main complaint was that CNN had been so undiscriminating in filling these hours with nutso speculation -- black holes, "radar shadow," attack on Israel -- right alongside people who kept their discussion within the realm of the plausible. It's one thing to say that almost nothing is known about what happened with the plane. It's something else to have people gas on about things with no evidence to support them and with strong common-sense obstacles to being true.

    Political analogy: no one knows who will be elected president in 2016. But if we treated electoral handicapping the way cable news has often treated MH370, we'd have panelists speculating how Megyn Kelly might do against Stephen Colbert in the crucial swing states. ("Kelly will help the Republicans with the youth vote, and women, without in any way depressing interest from their traditional base of older white men. But Colbert, who is from South Carolina, could open new possibilities...") After all, you can't prove they won't be the nominees.

    Which brings us to Chris Goodfellow. Nearly three weeks ago, when most discussion concerned hijacking or pilot criminality, he offered on Google+ a different MH370 hypothesis. In essence it was: that some mid-flight emergency (probably a fire) had broken out on the plane; that the pilots had immediately turned back toward the nearest big airport, which was on an island off Malaysia; that for some still-unknown reason they had become incapacitated or disabled; that also for unknown reasons, possibly fire that disabled their radios, they had not been able to communicate; and that the plane, on autopilot, had flown on until it either ran out of fuel or crashed for another reason.

    Soon thereafter, I wrote that this was the first hypothesis that made face-value sense to me. Maybe things didn't play out this way --  but this scenario started out with the Occam's Razor advantage of requiring fewer assumptions or suspensions of probability than others.

    An item in Slate immediately and with great certainty declared that Goodfellow's scenario could not be true. Its author, Jeff Wise, became a regular on CNN making that same point -- and meanwhile promoting the hypothesis that the plane had landed in Central Asia. Eg, "the 777 is capable of landing on small airstrips and on relatively unimproved surfaces, such as packed dirt and dry lake beds. In such a scenario, the odds are good that, unless they were murdered, the passengers remain alive." (Also here. For the record, in his original anti-Goodfellow item Wise included me among people who he thought had been taken in by Goodfellow. He knows that I disagree with him.)

    This weekend Chris Goodfellow did a Q-and-A session on the "Google Plus Week" channel on YouTube. The next time you're looking for 90 minutes' worth of discussion of what could have happened, what we know and don't, and why the plane's reported cargo of lithium ion batteries deserves attention, I'd recommend this over any comparable time with cable news.

    It could turn out that Goodfellow's view is entirely wrong, but his pattern of thinking about the puzzle is systematic and worth hearing.

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  • Electronic Medical Records: A Way to Jack up Billings, Put Patients in Control, or Both?

    "Digital records are also being aggressively used to maximize patient billings," and other imperfections on the route to a more sensible health care system.

    What we are leaving behind. ( Money and Medicine )

    Previously on this topic: my Atlantic Q&A with Dr. David Blumenthal, who supervised the Obama administration effort to move medical records into electronic form; and installments one, two, and three. Here is another round of reader responses.

    1) A new way to maximize billings. From Ronald Russell of Kenmore, Washington:

    As a member of Group Heath Cooperative in Puget Sound for over 20 years, I've seen first hand many positive aspects of computerizing patient records. Whomever you see, your records are instantly accessible- that's comforting when you land in the ER in the middle of the night.  Web access means you have access to some of those records yourself, and can communicate with your providers easily. 

    Unfortunately, I've also seen a negative aspect in how EMR's are being used that got only the slightest passing mention in this discussion, one that gets the incentives exactly backwards.  This is the reason I'm now a former GHC member. 

    Digital records are also being aggressively used to maximize patient billings. At GHC, it used to be the case that a standard office visit was a flat charge- most recently $80. Now, when your physician asks a question, responds to one of yours, and makes a note in your record, this becomes another billing code. The result is that a 15 minute office visit can easily run to several hundred dollars, perhaps just because you mention a concern or the physician asks another question.

    Every patient note entered in the digital record rings the cash register again in billing- and not in a way that anyone seems able to explain, or that physicians are aware of. The cynic in me wonders how long until they are compensated on commission, or get bonuses for entering more billing codes per visit. 

    The dollar amounts charged are often absurdly high, there is no accessible "price list" for consumers. My auto mechanic is legally required to explain his charges in advance, my health care provider never has to.

    Of course, for consumers with full coverage or copay-only plans, this would pass unnoticed, as just an accounting detial.  But for those of us with high deductibles that mean we essentially pay out of pocket for everything, this is a powerful disincentive  to discuss concerns with your doctor or interact beyond the minimum business at hand.  I don't believe this is good for patient care.  

    Fortunately, due to the ACA, I've been able to move to another insurance plan that mandates a flat charge for standard office visits, even before you meet the deductible. So perhaps that one small part of the market is working. Unfortunately, this brought up another problem with these records- ours are now locked up inside the Group Health system, and no longer accessible to me- at least, apparently, without paying for them. 

    These issues are not so much inherent problems with EMR's as they are symptoms of a broken health care system, in particular where the provider and the insurer are one and the same.  I put them out there to add to the discussion. 

    2) A way to get the doctor to look at you. In response to a previous complaint about doctors stare at their computers rather than their patients:

    [A previous reader says:] "No, at Kaiser, Northern California, they do not.  The computer is on a roll-around stand, and the doctor or nurse is facing me while using it."

    I'm in IT, and have worked at several hospitals where these stands are used, and the usual nomenclature is COW (computer on wheels, of course). I'm often reminded to be careful there are no women around when discussing the COWs in the room...

    3) Once again the VA is doing it right:

    I'm a 68 yr. old Vietnam vet (USMC) who is rated 90% 'Service Connected' disabled: hearing aids (I was in an artillery battery in Nam for 19 months); Type II Diabetes and Ischemic Heart Disease (Agent Orange exposure) and assorted other things.

    I can't praise the VA enough. Through HealtheVet I can re-order meds and have them mailed to me, same with hearing aid batteries. I can set up or cancel appointments or ask my Primary Care doc, or any of the physicians who treat me, questions and get an answer within 24 hours. I can go to ANY VA facility in the world (yes, there are VA clinics and hospitals outside the US) and they will have total access to my medical records.

    From the hell holes that VA hospitals were in the '70's, as depicted in the movie Born On The Fourth of July, they now are as good as it gets in the US. I give Bill Clinton props for the revamping he and his VA Secretary undertook that got the VA to where it is today. It may be struggling a little with the overwhelming influx from the Bush/Cheney/Rumsfeld fiascos but I have no complaints here in NYC. Semper Fi

    4) Promise from the patients' point of view:

    The use of EMR is obviously in early days, and flaws are easy to identify. My experience, however, shows the great promise of EMR to improve medical care and help patients make medical decisions.

    I have a mild case of MS, and go to [a major medical center] every year for a check-up. These include MRIs of my head every two years or so. I travel 200 miles to visit the clinic, so I want to get everything done on the same day. On MRI years, I’ll have the scan in the late morning at the imaging center that is allied with the clinic. When I see the nurse practitioner or physician’s assistant a few hours later, pictures of my brain are available in my electronic chart, and my medical professional looks at the scan with me, and explains what he or she sees. The reports of my last two scans are available to me right now on the MyChart website that [the center] makes available to its patients. And yes, my case is so boringly stable that there is no current need for me to see “the big man”.

    That’s cool, but the real power was revealed to me in 2011, when the radiologist who reviewed my scan discovered that I have a small benign brain tumor, a meningioma. I was referred to a neurosurgeon, also allied with Strong, where it was recommended that I should have my head screwed painfully into a frame so that a surgeon could aim what is essentially a killer death-ray at my brain.

    Except… when the medical professional and I looked together at the series of scans in my EMR dating back to 2002, there that pesky meningioma was, seemingly the same size as in the 2011 scan. This empowered me to turn down the surgery. I’d had that tumor for a decade or more with no ill effects. Prove to me that it’s growing, and I might consent to the surgery. A repeat scan a year later confirmed that the tumor is not growing.

    There’s one key element here, of course: all of the professionals involved are allied with the same large medical center, so communication between them is smooth and nearly instantaneous. My GP 200 miles away is not part of their system. Still, I’m very happy that I had access to a decent EMR system in this case, which helped me to make an informed decision.

    5) As long as the systems stay in touch:

    I have several chronic illnesses, and because of the specialized nature of them, I have a lot of doctors. I live in the San Francisco Bay area, and have specialists at Stanford, in San Francisco, and then my local team near home. Here’s the thing - all of these facilities have have state of the art EMR systems, but the systems don’t talk to each other.

    This means I spend a lot of my time bringing copies of records between various specialists, and communicating what one doctor said to another. As in telling my primary care  doctor “My rheumatologist is concerned that the medicine you want me to take will have an impact on my spine issue”.  Sometimes I get letters from one doctor that I have to carry to another. I keep my own records of my latest test results, culled from the various sources (included the online tools provided by some medical facilities), and bring them with me to appointments, so I can answer questions about when I last had a test, and what the results are.

    I also have a list of every medicine and treatments I have tried, and the outcomes, as new doctor often has a standard approach to the first thing they want to try. And they haven’t had time to go through all the records that were sent to them. Since the systems are designed around billing, they don’t have easy ways to extract care info, such “Show me the medicines to which this patient has had an adverse reaction”.

    Until there is a well integrated way for your doctors and their systems to communicate, coordination of care is going to be an issue. My career was in computer tech, and I know how hard it is to create interoperability standards.

    To me, yet another argument for single payer system, is that we could standardize on some basic data collection and exchange.

    6) From a Yank in Canada:

    I moved to British Columbia eight years ago from California.

    The first thing I had to get used to when I went to the doctor here was just... walking... out.  No stopping at the receptionist to deal with payment and/or insurance.  Just... walk... out.

    My clinic in California had started doing electronic records before I left, but I recall it as being kind of clunky.  Here, however it doesn't seem as clunky; it seems more integrated into the appointment.  Perhaps it is because I see young doctors (my clinic is a teaching clinic), but I think it's because the appointments are structured differently.  

    Here, the appointment starts with me sitting, fully clothed, in a chair, to the side of a desk.  The doctor sits at the desk with both me and the screen visible.  He or she asks me if anything has changed, and talk about why I came in.  Frequently, the doc will look something up on the web that is out of his/her area of expertise, and they are not shy about doing so.  (Usually not Wikipedia, something more like PubMed.)  If he/she needs to examine me, *then* I get given a gown.  

    By contrast, my recollection of appointments in the US is that they started with height/weight/blood pressure measurements by a nurse.  (This was true even when I was in my 20s and now seems like overkill.  Why did they need to take these measurements every time, when my measurements didn't budge for years at a time?)  Then the nurse would give me a gown, and I'd get undressed and sit on the exam table.  That meant that I would *start* the consultation sitting uncomfortably on the exam table.  (There often weren't even two chairs in the room; maybe there was a chair and a lower stool.)  In that configuration, it is not easy to position the computer so that the doc can see both the screen and the patient.

    Another thing that is different: I almost never fill out a form before my appointment at my regular clinic.  If I am going to a new practice (like an after-hours clinic), yes.  If I am getting some new and different procedure, yes. But they don't ask me to tell them who I am and where I live and what my insurance is and who my next of kin blah blah over and over again.  Occasionally they ask me verbally if anything has changed, and that's it.

    7) Allowing doctors to do more than just fill in the forms. From a librarian:

    One comment based on my experience, I appreciate the doctor who said the system would not let him record what he wanted to say. I think these systems should allow writing free-form notes, sketches, scanned items, etc. 

    I am a retired librarian and early in my career I worked on several of the early computer systems for recording the arrival of issues of magazines in libraries. I'm sure this is much less complex than medical records, but it is more complex than one might think. These early computer systems couldn't accommodate the creativity/inaccuracy of journal publishers and printers when there was an issue number 12 1/2, or, more often, the printer did not change the volume number in the new year until he discovered the mistake midway, so you have volume 14 for a year and a half but number 1-6 in one year were not the same as 1-6 in the next.

    In medicine, the doctor's free-form notes can express his knowledge of how complex things really are, in his best estimation at the time, or the questions he has (another issue, do you want this in a record that will be shared with the insurance company, and thus perhaps used out of context in litigation -- but if the electronic record is the only one you have, where else do you put the information?) 

    I'm all for having evidence-based guidance in medicine, but I want the doctor to be able to take all of this information and then see if I fit the profile the computer predicted. How is this going to happen if the information isn't even recorded?

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  • 'Career Technical' Education: More Middle in the Middle Class?

    Training students for jobs that are less likely to be outsourced, de-skilled, or stuck at minimum wage.

    Part of the Engineering, Architecture, and Industrial Academy at Camden County High School (James Fallows)

    Two days ago I mentioned what my wife and I had seen this month at Camden County High School, in southernmost Georgia. There all students, in addition to regular academic subjects and 20-plus AP offerings, are enrolled after freshman year in one of five "academies" emphasizing specific occupational skills. This approach used to be called "vocational ed," is now known as career technical education, and is designed to equip students, whether or not they are headed for college, with skills that will give them options and leverage for higher-paid jobs.

    Inside Marriage Special Report bug
    Reinvention and resilience across the nation
    Read more

    I am no one's idea of an education specialist, but from my book More Like Us onward I've tried to follow the ways American institutions equip people, or hamper them, for the endless process of reinvention and adaptation that is American economic and social life. College education is obviously valuable in its own right and, usually, as a path toward better career options. But not everyone will start or stay in college. The importance of skilled technical jobs, from machinists to construction engineers, is they're generally interesting in themselves, they're less likely to be outsourced or "de-skilled" than even some white-collar work, and they are better paid than retail or low-end service work. Everyone recognizes this when we look at, say, the successful apprenticeship programs in Germany. The news, for my wife and me, was the rise of such efforts in American schools.

    Readers weigh in on this and related points

    1) Another thing that Boomers must answer for. A reader writes:

    I think many baby boomer and younger parents in this country don't take vocational training seriously because that's not what we were steered into and the college path has now become the norm.  Too many feel that a vocational career isn't important/rewarding/prestigious.  The large majority of my high school graduating class had parents who were only high school graduates.  Earning a living was paramount and college wasn't available to them.  They pushed us into college "to be something". 

    Now we are seeing how difficult it is to find a great electrician or plumber or auto mechanic.  Luckily my husband and I finally found great ones, but only after much searching and asking neighbors for recommendations.  

    My dad was a tool and die maker.  He made parts for the space shuttle and the Verrazano Narrows Bridge, among other things, working predominantly in platinum and gold.  I regularly see want ads for people in this trade, and just recently found our local community college has expanded its curriculum to fill these positions.

    Probably the best thing about having a dad who worked with his hands was how much I learned from him.  I know my way around tools and am able to fix most things without calling for help. 

    I am not saying vocational training shouldn't include college. Higher education needs to be formulated around the requirements of society.  We need educated auto mechanics, electricians and plumbers.  

    2) The era of collars is over. A reader originally from southern Georgia writes:

    As an educator myself now--I completely agree with the [Camden County] approach.  College isn't the option for everyone--learning trades could change early gives more people a chance to thrive.

    The era of the "collars" is over.

    I wish I didn't go to school where vocational and "college prep" were segregated.

    3) Finding someone to teach what I know. James Walker, a metalsmith in southern California, writes:

    Yesterday [on Marketplace] you mentioned trade schools and I wanted to say that I believe they need to be emphasized a lot more in the school system. 

    Although I spent several years in college, I've made my living as a metalsmith, which derived from an apprenticeship I served while going to college. The area I chose in the metalsmith's world (repair, restoration, preservation of non-ferrous metals) is specialized enough that I draw work from around the country, with no advertising -- just a web site with examples of what I do. 

    I wish young people could realize that the trades and crafts are alive and well and offer many opportunities. For years I've tried to find someone to teach what I know, but I guess we live in a different world now.

    Different kinds of roofing, in the Engineering, Architecture, and Industrial Academy

    I wrote back to James Walker to get permission to name him and his company. He added, about a specific project:

    I would also like to mention a pet project of mine, Operation Rediscover, which seeks to foster a grass-roots involvement of people locating, caring for and sharing  information about bronze plaques and memorials. 

    Over the years I have often been asked to restore them, since their surface inevitably disintegrates from the weather, sunshine, pollution, etc., making them hard to read. It is a shame to see that happen, so to help deal with the problem I developed a simple process to preserve them and published it as an eBook, which people can download for free from my blog "Operation Rediscover."

     I feature stories about bronze plaques and memorials and another free eBook action plan that has specific step-by-step things people can do. A few days ago I also posted an essay/review of The Monuments Men, which has similar (though way more advanced) goals to mine.

    4) Scholarships for technical training. I got this note from Marty Stockdale of Florida, who has set up a foundation to provide scholarships for high school graduates who want to pursue further technical training.   

    I am the Founder & President of The Stockdale Foundation. Our motto is: A Bachelor's Degree may not be for everyone - Success is. 

    Each year we provide scholarships to current-year high school graduates who plan to continue their education at a vocational/technical/trade school, as well as fire academy attendees. 

    It is our sole focus and since 2009 we have awarded 14 scholarships totaling $31,200.00. 

    I called Marty Stockdale to ask if I could share his information, and about the background of his scholarship. He said that he set it up in honor of his daughter, who was ready to pursue non-college career training after she finished high school but was then killed in an accident. "There are so many young people who could do so much, with some help," he told me. He would of course be happy to hear from others interested in this cause. You can find more about his program at his site

    Map of AP scores in Georgia schools. Camden
    County (lower right) shows up better than others
    in the southern part of the state.

    5) How unusual is Camden County? Did my wife and I just happen to find the school in Georgia that had gone furthest with the "career academy" approach? I asked around yesterday, and the answer is Yes and No. 

    No, CCHS is not unique in Georgia, where many other schools have developed internal "academies" of their own. But Yes, it is unusual, in that most schools have a "Pull-Out" model, where they take students away from the main high school at certain times of day for courses at a technical center. CCHS is unusual in its "Wall-to-Wall" approach, of having everything about one large, integrated campus be built around its component academies.

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  • As the Search Goes On for the Plane That Disappeared, How Can So Many Flights Take Off and Land Safely Each Day?

    More on the details of designing for 1-in-a-billion accident rates.

    Representation of flights underway at any given moment. ( Flixxy.com )

    Earlier today, I quoted the longtime aviation writer J. Mac McClellan on the one-in-a-billion risk factor to which modern aircraft design is held. Someone familiar with such standards writes in:

    I'm a system safety engineer for a small-ish system supplier, so I'm pretty familiar with the 10^-9 standard. There are a number of issues with probabilistic risk assessment, but I think the history of the 1 in a billion standard is pretty interesting. This is an excerpt from the proposed rule change to FAA regulations regarding system design, referred to as the ARSENAL draft of 25.1309. [Excerpt begins:]

    The British Civil Airworthiness Requirements (BCAR) were the first to establish acceptable quantitative probability values for transport airplane systems.  The primary objective in establishing these guidelines was to ensure that the proliferation of critical systems would not increase the probability of a serious accident.  Historical evidence at the time indicated that the probability of a serious accident due to operational and airframe-related causes was approximately one (accident) per one million hours of flight.  Further, about 10 percent of the total accidents were attributed to failure conditions caused by the airplane’s systems. Consequently, it was determined that the probability of a serious accident from all such failure conditions should not be greater than one per 10 million flight hours, or “1 x 10 -7  per flight hour,” for a newly designed airplane.  Commensurately greater acceptable probabilities were established for less severe outcomes. 

    The difficulty with the 1 x 10 -7  per flight hour probability of a serious accident, as stipulated by the BCAR guideline, was that all the systems on the airplane must be collectively analyzed numerically before it was possible to determine whether the target had been met.   For this reason, the  (somewhat arbitrary) assumption that there would be no more than 100 failure conditions contributing to a catastrophe within any given transport category airplane type design was made. It apparently was also assumed that, by by regulating the frequency of less severe outcomes: 

     * only 'catastrophic failure conditions' would significantly contribute to the probability of catastrophe, and  

     * all contributing failure conditions could be foreseen. 

    Therefore, the targeted allowable average probability per flight hour of 1 x 10 -7  was apportioned equally among 100 catastrophic failure conditions, resulting in an allocation of not greater than 1 x 10 -9   to each.  The upper limit for the average probability per flight hour for catastrophic failure conditions became the familiar “1 x 10 -9 .”  Failure conditions having less severe effects could be relatively more likely to occur." [Excerpt ends.]   

    They basically worked backwards from the existing accident rate, made a few assumptions about contributions from complex systems and got us this number. There are a few questionable assumptions such as the number of catastrophic failure conditions. Thankfully, more goes into safety now than estimating probabilities such as human factors and common cause assessments. But it does point out that the standard was arbitrary to begin with, so changes in public perception may eventually change the standard.

    One minor correction on Mr McClellan's note. The 10^-9 standard is referred to as "extremely improbable" rather than just "improbable" and it is in terms of average probability per flight hour, not per average flight. See section 7c(1) of the arsenal draft of 25.1309 under "Probability Ranges."

    (1) Probability Ranges. 

          (i) Probable Failure Conditions are those having an Average Probability Per Flight Hour greater than of the order of 1 x 10-5 .  

          (ii) Remote Failure Conditions are those having an Average Probability Per Flight Hour of the order of 1x 10-5 or less, but greater than of the order of 1 x 10-7 . 

          (iii) Extremely Remote Failure Conditions are those having an Average Probability Per Flight Hour of the order of 1x 10-7 or less, but greater than of the order of 1 x 10-9. 

          (iv) Extremely Improbable Failure Conditions are those having an Average Probability Per Flight Hour of the order of 1x 10-9 or less. 

    I sent this to Mac McClellan, and he replies as shown below. (We added the photo, which is of a different engine failure from the one he mentions):

    Yes, the standard evolved over time and has some interesting twists. For example, passengers can be seated in a turbine engine rotor burst zone and would presumably be killed by a burst. A rotor burst energy is now treated as infinite and debris will pass through anything or anybody in the zone. However, no required crew can be located in the burst zone. The 10-9 standard doesn't necessarily apply to a passenger or passengers staying alive, but to the airplane and it's ability to reach a runway.

    Destroyed turbine engine from a Delta MD-88 with P&W engine, in 1996. (Wikipedia photo)

    Also, much of the historic data floating around is historic. Rules change constantly, and there was a big change after the DC-10 in Iowa where the center engine exploded. Douglas had installed triple hydraulic lines to the tail control surfaces but the lines were routed close together. The engine burst took out all three systems. Up to that time triplex was enough. After that triplex was only good enough when you could demonstrate that no single foreseeable event would take out all three.

    The 777 was certified under pretty current rules, as was its FBW which does meet the 10-9 through triple redundancy and several levels of computer participation. The final level is direct law where the cockpit controls command direct movement of a surface with no enhancement or protection for speed or CG [Center of Gravity] or other considerations.

    This is way more technical detail than most people will want to follow. But so much of this story, which continues to command interests, turns on precise technical details; and for those who are interested in the safety and redundant-design criteria of modern aircraft, this will be instructive.

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  • When a 1-in-a-Billion Chance of Accident May Not Seem 'Safe Enough'

    The very safety of modern air travel makes accidents both intellectually more difficult and emotionally more disturbing.

    Navy pilots fly a P-8A Poseidon during a mission to assist in search and rescue operations for MH370. (US Navy)

    As the mystery about the fate and location of MH370 continues, and as theories come and go about what might have happened, here is a note from J. Mac McClellan, long-time editor of Flying magazine, about a phenomenon I've mentioned frequently. First-world commercial air travel has become so extremely safe that when something does go wrong, figuring it out can be a huge challenge -- which heightens the mystery and, for many people, the terror of these episodes, by making them seem so random. You're sitting there grumbling about the discomforts of modern flight -- and then, for no apparent reason, your plane is the one headed into the sea. McClellan writes: 

    As you probably know the FAA standard, and pretty much the global standard, for certifying critical components and systems is one in a billion probability of failure, or 10 to the minus 9th. The FAA calls this standard "improbable."

    That means in a transport category airplane [JF note: this includes airliners] the certification standard for a failure, or combination of failures, that would prevent the airplane from successfully landing on a runway must be one in a billion flights. Not hours, flights.

    I remember that when the 777 was introduced it was such a sales success and was expected to live such a long service life that some people speculated the fleet could actually make a billion flights. Of course, you don't need to make a billion flights to draw the magic short one-in-a-billion straw. But it is something to think about. Transport flying is now so safe that the long time standard of 10 to the minus 9th may not satisfy the public.

    I'm sure you are also tired of hearing about all of the things a transponder does that it really can't. Every comment on a transponder says it reports course and speed, but we know a transponder, even a Mode S as you have and the 777 has, reports only an identification code and Mode C pressure altitude. Course and speed all must be calculated by observation by radar. I guess the media and experts have mixed up what ADS-B does with what a transponder does. [For more on transponders, here; on for ADS-B, here.]

    Also odd that the 777 FBW [fly-by-wire, or electronic system for directing the airplane's control surfaces] system has escaped almost all speculation. It was the first for Boeing. And it was failure of the pitot input that put the FBW system into "direct law." [That is, it disabled the normal automated limits on "control inputs" the pilots could give to the airplane. In "normal law," which prevails within normal flight circumstances, the autopilot impedes or buffers any control input thought to be unsafe, for instance too sharp a turn or too steep a climb at too low an airspeed.] This handed the Air France crew an airplane that the computer could no longer control while expecting the humans to quickly diagnose a problem the computers couldn't. I'm not saying FBW has anything to do with 370 but it must be on the list of considerations.

    This is not speculation, simply some basic info that I haven't seen touched on during the endless TV interviews and such.

    The sobering point here is again that the very safety of modern air travel makes these episodes both intellectually and emotionally even more difficult.

    One other aspect of the drama is the national reactions and tensions it has highlighted -- of course in Malaysia and China, also in Australia, even in Israel. Thanks to many people writing in with on-scene reports of reactions in China and Malaysia. Will sort them out and report as I can.

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  • High School in Southern Georgia: What 'Career Technical' Education Looks Like

    A school that is famous for football is notable in an entirely different way.

    Walkways over the marshland, and beneath Spanish-moss-draped trees, to Camden County High School (James Fallows)

    Earlier this month my wife and I spent about a week, in two visits, in the little town of St. Marys, Georgia, on the southernmost coast of Georgia just north of Florida and just east of the Okefenokee Swamp. It's a beautiful and historic town, which is best known either as the jumping-off point for visits to adjoining Cumberland Island National Seashore or for the enormous Kings Bay naval base, which is the East Coast home of U.S. Navy's nuclear-missile submarine fleet and which is the largest employer in the area.

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    St. Marys is known to our family for its complicated and often-troubled corporate history, which I described long ago in a book called The Water Lords and which we'll return to in upcoming posts. But it also highlights an aspect of American education which we've encountered repeatedly in our travels around the country and is well illustrated by the school shown above, Camden County High School, or CCHS from this point on.

    CCHS is the only high school in the county, drawing a total of some 2800 students from the cities of Kingsland (where it is located), St. Marys, and Woodbine plus unincorporated areas. Each year's graduating class is around 600 students. Its size gives it one advantage well-recognized in the area: it is a perennial athletic powerhouse and has won the state football championship three times in the past 10 years. It also has another advantage that I recognized from my own time as a student in a single-high-school community: it creates an enforced region-wide communal experience, across class and race, rather than the separation-by-suburb of many public schools. This part of Georgia has relatively few private or religious schools. 

    As a matter of statistics, the CCHS student body is more or less like the surrounding area: about one-quarter black, most of the rest white, and small numbers of other ethnic groups (including from Navy-related families). About 40% of the students qualify for reduced-price lunch, the main school proxy for income level, and about 60% go to post-high school training of any sort.  Each year, a small number go away to out-of-state schools, including selective ones. In 2001, only 50.5% of the school's students graduated from high school. Now that is up to 85%, a change that Rachel Baldwin, the CCHS Career Instructional specialist who showed us around, attributed mainly to the school's application of programs from the Southern Regional Education Board. CCHS has the best AP record of high schools in its part of the state.  

    That's the background. Now what struck us, which was the very practical-minded and well-supported embrace of what used to be called "vocational education," and now is called the "career technical" approach.

    Hallway sign showing stats for the six different "academies" at CCHS.

    In practice what this means is dividing a large, sprawling campus and student body into six "academies," with different emphases. One of them is the Freshman Academy, to get the new students acclimated. ("I don't know if you've seen ninth graders recently," one person there told us. "But some of them look big and old enough to be parents of some others. It's a big range, and it helps to have a special place for them.")

    The other five academies each have a "career technical" emphasis. After freshman year, all students enroll in one of the five. While they still take the normal academic-core range of subjects, they also get extensive and seemingly very-well-equipped training in the realities of jobs they might hold.

    A few examples:

    Rich Gamble, head of the CSI course at CCHS

    - In the "law and justice" curriculum, which is part of the Government and Public Service Academy, a former Navy-Kings Bay NCIS official named Rich Gamble (right) trains students in conducting mock crime investigations, and preparation for testimony in court.

    On the day we were there, he had staged a mock robbery, in which the perp grabbed a cashbox from an office, ran through the hallways, and dumped the box as he was escaping. (The students acting out the scenario wore their white CSI lab coats, so other teachers would know what they were up to.) Then Rich Gamble divided his students into three teams to investigate the crime -- making plaster casts of footprints (below), taking evidence, filing reports, preparing a case. "We emphasize a lot of writing," he said. "I give them issues where they have to defend themselves, in very few words, because courts don't like you to waste words. Some of these papers are as good as any written by NCIS."

    Plaster casts of three footprints, by three of Rich Gamble's CSI student-teams.

     In the Engineering and Industrial Technology Academy, students design and build doghouses and other structures, which they sell in the community; do welding (and compete in state and national welding competitions); run an auto-repair shop that handles county vehicles; do extensive electrical work, and other activities I'll suggest by the photos below. Wood-frame construction:

    Student-built houses.

    Inside the wood-and-electric shop:

    Masonry:

    Welding:

    Auto shop:

    This same academy also includes computer-aided design and robotics programs, under the direction of Fred Mercier. The houses in the first photo are ones his students had designed and built, sitting on top of a 3D printer they use. The contraption in the second is part of the school's entry in a national robotics competition. 

    3D printer above, catapult-throwing arm for robot (with Fred Mercier) below.

    (These photos show young men, but that is happenstance of where it was feasible to take pictures. The academies are diversified by gender and race.)

    In the Health and Environmental Sciences Academy, students were preparing for certification tests by administering care to dummies -- in this case, representing nursing-home patients. 

    There is more to show, including from the other two academies: Business and Marketing, and Fine Arts. CCHS has an industrial-scale kitchen and catering facility, overseen by a former Navy chef. It has a very large auditorium, where students not only perform plays, dances, and concerts but also learn to build scenery and make costumes. I'm running out of time, and you've got the point by now.

    Here is why we found this interesting and surprising. Among the non-expert U.S. public, the conventional wisdom about today's education system is more or less this:

      - At the highest levels, it's very good, though always endangered by budget cuts and other problems;

      - At the lower ends, it's in chronic crisis, for budgetary and other reasons;

     - And overall it's not doing as much as it should to prepare students for practical jobs skills, especially for the significant group who are not going to get four-year college degrees. Sure, the Germans are great at this, with their apprenticeship programs and all. But Americans never take "voc ed" seriously.

    Career poster from CCHS hallway

    I'm not trying now to address all levels of this perception, and one high school doesn't prove a national trend. But what struck us at Camden County High was its resonance with developments we have seen elsewhere,: schooling explicitly intended to deal with the third issue, serious training for higher-value "technical" jobs. This is theme that John Tierney has previously discussed regarding schools in Maine and Vermont, and Deb Fallows about South Carolina. "Non-college" often serves as a catchall, covering everything from minimum-wage-or-worse food-service jobs, to highly skilled hands-on technical and engineering jobs that may be the next era's counterpart to the lost paradise of assembly-line jobs that paid a family-living wage in the Fifties and Sixties.

    "In the past, we've encouraged all kids to go to college, because of the idea that it made the big difference in income levels," Rachel Baldwin told me on the phone this morning. She then mentioned a recent public radio series on the origins of success, and said: "The recent evidence suggests really goes back to something like 'grit.' I think you are more likely to learn grit in one of these technical classes. The plumber who has grit may turn out to be more entrepreneurial and successful than someone with an advanced degree. Our goal has been getting students a skill and a credential that puts them above just the entry-level job, including if they're using that to pay for college."

    And oh, yes: What the weight room looks like for a state-champion football team.

    Thanks to all at Camden County High. And Rachel Baldwin has written in with a closing thought on the career-technical/traditional-academic balance:

    As a naval community, Camden County appreciates the phrase “a rising tide raises all ships.” Our AP students at CCHS thrive in Career Technical options (we have more than 20 AP course offerings), along with students who would be considered traditionally  “vocational” in the past. Our administration and faculty, believing in "all ships rise," recognize and provide strong support for both achievement at higher academic levels and meeting the new technical demands of the workplace.

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  • The Freedom and Risk of Wingsuit Flying: Sean Leary

    When a man is tired of wingsuit videos ... 

    The "exit" of a flight ( Great Book of Base )

    I mentioned last week that I was admiringly fascinated by wingsuit videos but could never imagine leaping off those cliffs myself.

    In the video below, Sean "Stanley" Leary, a very well-known figure in the field, describes the exhilaration and freedom he has found in this pursuit. "The best part -- well, there's a lot of best parts, but the first best part..." he says late in this clip.

    Sean's Freedom from Chad Copeland on Vimeo.

    What he is describing sounds dangerous, and is. Earlier this month Sean Leary was killed, at age 38, during a wingsuit flight at Zion National Park in Utah. You can read more about his story here and here.


    The video above is of course all the more poignant in light of how his deliberate embrace of risk ended. But it is also very eloquent, just on its own. For instance, compare Leary's description, during the first minute of this clip, of the "exit" or moment of leaping off and beginning flight, with what you see starting at time 1:40 in the well-known clip below.

    Or with what you see starting at time 0:15 of this terrifying one, from Italy.

    This is posted to close the loop after previous wingsuit mentions, and to note the outlook with which Leary and his colleagues approach these risks, and with great sympathies for his wife, who is now pregnant with their first child.

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  • 'Where Do You Go to Church?' The Video and Mapping Versions

    More ways of taking the measure of this vast country.

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    Last month Deb Fallows did several popular posts -- here, here, and here -- about regional variations in the question you ask someone when you've first been introduced. "Where do you work?" "Who are your people?" "How long have you lived here?" and so on.

    I mention it now for two reasons. One is to tout the wonderful video that Katherine Wells, of the Atlantic's video team, has made about answers to just this question. She phoned people from around the country and recorded their responses, building on leads from Deb's items. I find it haunting and will be surprised if you don't think it worth a look. The direct link is here, and it is embedded below.

    This video also ends with a lovely presentation on the opening question that I have used when meeting people for as long as I can remember.

    Reason two is to highlight another Esri map that John Tierney has made to illustrate a linguistic/sociological point. Earlier, Deb reported that a standard opening question in St. Louis was "Where did you go to high school?" John's map showed why the question had such resonance there.

    In Greenville and surrounding upstate South Carolina, a standard opening question is "Where do you go to church?" This new map by John Tierney gives an idea why:  

    You can use the Plus and Minus keys to zoom in and out of the map; you can click on the Legend button to see how the color-coding matches the denomination, and you can click on any specific church to get more information about it. The background colors refer to the socio-economic "Tapestry" segmentation, so if you click on any neighborhood you'll get a popup about its social makeup. Of course there's at best a loose connection between neighborhood character and type/density of churches, since people don't necessarily attend services where they live. But the patterns are surprisingly interesting.  (This is a Greenville-specific church map, as the school one was St. Louis-specific, because of the hand-coding involved on John Tierney's part.)

    Now, a bonus third reason, which connects this to some previous posts. In my article on Greenville I mention that the surrounding county was the last one in the state, which itself was the last one in the union, to observe Martin Luther King's birthday as a holiday. Over the weekend I posted a note from Knox White, long-serving mayor of Greenville, saying that the city itself had voted for MLK long before the more-conservative county did. It turns out that there is an entire academic study of just this point. It is "Religious Interests in Community Conflict: The Case of Martin Luther King Jr Holiday in Greenville, South Carolina," by four scholars from Furman University in Greenville. It is interesting, especially about the complexities of class-based and race-based politics, and you can read it here. Thanks to John Tierney for recommending it.

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  • Bloomberg in China: It's Not About the Terminals, It's About the Data

    Either way, there's a tension with the company's journalistic operations.

    Bloomberg Terminal ( Museum of American Finance )

    In an item yesterday about the latest Bloomberg-in-China flap, I quoted a note I'd received late last year from someone inside the company:

    Outsiders think the worst explanation for this controversy is that it's concerned about selling terminals within China. It's bigger than that. Really it's about continuing sales all around the world, if Bloomberg can't promise having the fastest inside info from China.

    Just now this note arrived, in the same vein:

    I don't work for Bloomberg.  But I do work for a competitor.

    The primary reason for the suppressing China investigating reporting is not about terminals.  It is about DATA.

    Bloomberg terminals are clunky and old, but what makes the terminals valuable is the timeliness of information and data that the terminal delivers.

    The data part is the most important asset for financial professionals that use Bloomberg terminals.

    Bloomberg is afraid of being shut out of access to economic indicators and statistics for China.  Granted this information/data as of today is unreliable and sketchy, but as China is forced to become more transparent (i.e. globalization of the yuan as a currency) it is going to have to provide more transparency on economic/financial indicators and statistics.  

    Bloomberg pulling back is not primarily because of terminal sales, although this is important,  but access to financial information.

    For the record: I've asked for on-the-record responses from Bloomberg spokespeople or officials; the one person I have heard back from said that the company declined to comment. Also, check out this ChinaFile conversation on the topic. 

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  • Jimmy Carter on Colbert

    Our 39th president, at his relaxed best

    The X-Presidents ( Comic Collector Live )

    No doubt I'm biased, but I thought our 39th president did a great job on the show last night—as did Colbert, in being mock-disrespectfully jokey right up to the limit of what is seemly with an 89-year-old former president, but not beyond.

    What I really liked about this segment, apart from seeing Carter so relaxed and quick, was the glimpse it gave of the person with enough political instinct to have become president in the first place. For example, check out Carter's little deadpan retort in the time between 1:05 and 1:15 in this first part of the interview. Or approximately 1:45 through 2:15, in which Carter explains the circumstances in which he might stop being a Baptist and join the Catholic Church. (Pre-roll ads involved.)

    [UPDATE: The embedded videos seem not to be loading. As far as we can tell, this is a problem on Comedy Central's end rather than ours. For the moment, here's the link to Part 1 of the Carter-Colbert interview.]

    While you're at it, why not watch that whole clip, and this second installment of the interview too? It includes great riffs on Carter's home-building activity for Habitat for Humanity and whether the other X-Presidents consider him the odd man out. [Update: Here is the link to interview Part 2.]

    Politicians still bearing the obligations of office, especially presidents, can be only so informal, before the "but let's be serious" part kicks in. Politicians on the rise are often trying a little too hard to show that they are hip. This is a rare instance of someone far enough past those days (though not past the sting of losing, as Carter mentions several times) to be at his relaxed best, and still in good enough mental shape to pull it off. This was an unexpectedly nice moment, by Carter also Team Colbert. 

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  • Let's Talk Electronic Medical Records (Cont.)

    "I can certainly see how, as small business owners, physicians might resist this change. But as a patient, I see the benefits to my family far outweighing the risks of that loss of independence."

    Our new issue has an interview with Dr. David Blumenthal, who was in charge of the Obama administration's effort to promote the use of electronic medical records (EMRs). We've had two previous rounds of responses from doctors, technologists, patients, and others, one and two.

    Now another round. 

    1) It's generational. Previously I quoted Dr. Creed Wait, formerly of Texas and now of Nebraska. He enumerated the practical problems the EMR requirement created for him. A reply:

    I read [those] gripes and wanted to weigh in as well.

    I am a physician and have had the privilege of training and practicing in different places across the country.  I specialize in sports medicine.  My experience with EMR is greatly different from my fellow physician.  

    Some of his complaints are valid, but it seems as though many of his issues are related to his own inadequacies utilizing or adapting to technology.  My observation has been that practitioners above the age of 40 in general have problems adapting their practice habits to new technology.  People under 40 (myself included) are already familiar with computers and can adapt more readily.  Another point to consider is that older physicians (as I assume my colleague is) will eventually retire, and current medical students and residents who will take their places already find the "paper and pen" method quaint, if not antiquated.

    2) Is money the problem, or isn't it? Another rebuttal to Dr. Wait's report:

    I wonder why he doesn't notice the self-contradiction in his complaint about the medical records mandate.

     On the one hand, he complains that small practices like his don't have the big budgets that the VA and others use to make electronic medical records work well.  

    Then he complains about the $19B that the government has paid out to physicians for adopting electronic medical records, saying that if the systems worked well (like the cotton gin) no financial "carrots" would be necessary.  But if lack of money to implement the systems is the problem, why isn't government funding to those using the systems precisely the right policy?

    3) It's all about the software companies. From a doctor on the Gulf Coast of Florida:

    I would parrot the statements of most of the physicians that you have quoted:

    - EMR degrades the quality of information transfer in medical notes.

    - EMR increases time of documentation.

    - EMR costs more than our prior system.

    I would also point out that transcriptionists are part of the disappearing middle class.

    Who wins?  EMR software companies…who I would point out market to CFOs, not physicians.

    4) The driverless vehicle, a century before Google? From a non-physician:

    Some comments:

    - In 1985 I was teaching a group of state-level bureaucrats about our brand-new IBM System/36.  One of the men sitting at the rear was a man with 30 years or so in the agency (USDA-ASCS), very assertive. Midway through the lesson (entering name and address data) he beckoned me over and said: "I don't type."  

    All of the complaints of the first doctor could be echoed in an assessment of our initial automation efforts.  We basically automated what we were doing on paper, without rethinking what we did to use the hardware better.  Took us years before we (the Washington bureaucrats and systems designers) learned better so our applications actually helped the county offices.

    - I recommend this book to the doctor: Lakwete, Angela. Inventing the Cotton Gin: Machine and Myth in Antebellum America. The truth about the cotton gin is that it took a long time (i.e. 20 years or so) to work improve Whitney's gin and change the processing of the lint cotton downstream from the ginning to the point where it represented a great advance.

     -Finally, I'm old enough to remember the transition from horses to tractor on our farm.  Though the tractor then was a reliable machine, changing over was not a simple process--dad underestimated the time and cost.

    So my point is the transition always takes longer than predicted, and usually is complex than the advocates of change  concede.  And there's always a trade-off.  My mother could remember returning from Binghamton, NY after selling their farm produce, and letting the team find their way home--the driverless-car 100 years before Google. 

    5) "I'll choose a universal (electronic) record every time." From a reader in the Midwest.

    I have some experience with EMRs—I’m a technology and healthcare writer and have written about them for many years for provider groups and insurers, and at one point, for an independent EMR lab that allowed small practices to experiment with various solutions before buying. I’m also a patient, of course, and my family here in [a major university city] sees clinicians within the University of [xx] Health System, which uses a very sophisticated EMR.

    Your coverage of this issue has been fascinating. The criticisms of physicians from smaller independent practices do have an air of intransigence (we might call it whining), but many of the concerns are valid. The benefits of an EMR for a small, independent clinical practice are likely outweighed by the costs and complexity, certainly in the near term. But for larger practices and health systems, they’re indispensible. I can’t tell you how reassuring it is as a parent to know that any doctor or specialist we see has access to my daughter’s entire clinical history. If we have to run to the ER at 2am on a Saturday, god forbid, it is immensely comforting to know that the resident examining our child has exactly the same information as her primary care physician, and has a complete picture of her medical history since the day she was born. There is no scenario I can imagine in which the alternative leads to safer or more effective care.

    But the physician who writes that “technological fixes only work in the context of appropriate institutional structures” is correct. The value we see in our local system as patients and parents is not really observed during a regular checkup or sick visit to the doctor’s office. It’s in having clinical information shared across every provider we come into contact with through the course of our lives. The minute we see a doctor outside the university system (if we go to an independent urgent care clinic, for example), those benefits begin to erode, and the larger story is a much harder sell.

    But the market and regulatory regime do seem to be addressing this. The move toward accountable care organizations (ACOs) is very much an institutional framework under which EMRs make sense and begin to add tremendous value. ACOs are geared toward Medicare beneficiaries, but the consolidation happening in the larger industry is following the same path.

    In many parts of the country, smaller practices can have their EMRs partially or entirely subsidized by the larger hospital systems with which they work. This makes sense on many levels. Hospital systems benefit by having a more consistent, universal medical record of the patients they see, while smaller practices and physician groups gain much lower barriers to adoption, as well as ongoing support and training superior to what they could sustain on their own. The downside is the loss of independence of the small practice. I can certainly see how, as small business owners, physicians might resist this change. But as a patient, I see the benefits to my family far outweighing the risks of that loss of independence.

    Consolidation introduces its own challenges, and it’s not yet clear whether the financial incentive structures (especially in consolidation outside of ACOs) will counterbalance the higher prices that can result from fewer competitors in the marketplace. But in terms of quality and safety of the care provided, I’ll choose the larger provider group that’s embraced a universal medical record for my family every time.  

    6) A solution for staring at the computer. A reader in northern California writes:

    Re: information systems in medicine, I am a Kaiser patient, and am intrigued by one small comment made by several people, that doctors must turn their backs on the patient to enter data into the computer.    

    No, at Kaiser, Northern California, they do not.  The computer is on a roll-around stand, and the doctor or nurse is facing me while using it.  Simple solution.   Perhaps there are other simple solutions for some of the complaints. 

    7) Similarly positive experience in Seattle:

    My primary care physician works out of a small non-profit clinic here. An EMR system has been in use there since soon after I my first visit about 5 years ago and my experience has been entirely positive. Examination rooms are arranged so the doctor doesn’t have to turn away from the patient while viewing the screen. Patient history is available at all three locations, to the doctor, nurse, assistant, and front desk. Other information, for example background for interpreting test results, is available promptly. There is a patient portal where doctor and patient can exchange messages such as test results. What’s not to like? 

    I have no knowledge of the system in use nor of the staff’s opinion. My doctor, nurses, and assistants have keyboarded info during a visit and it doesn’t seem to me to be too distracting. The experience described by previous correspondents on this issue is amazingly poor and I can imagine their dislike of those systems. I can’t imagine this small non-profit clinic spending a great deal on an EMR several years ago unless they expected immediate benefit. From my point of view they got it.  

    8) Finally for now, reliance on medical records as category error:

    As an IT practitioner I have been following the slow-motion and entirely predictable train wreck of EMRs for some time now, starting with Microsoft HealthVault and the ill-fated Google Health in 2007

    A timeline, with some observations: 

    - March 2008: ars technica has a decent overview of the situation. The takeaway: "many of the reasons for poor US health outcomes have much deeper structural roots related to a lack of preventative care versus emergency care, issues that are tied in to the lack of a universal healthcare system and the nature of insurance companies, that are outside the scope of medical records databases".

    - March 2010: The announcement of $20 billion in the stimulus bill for electronic health records (EHR) has started a gold rush. There's excellent coverage of the IT issues by Andy Oram on the O'Reilly Radar weblog. It elides the political question unfortunately - with single-payer many of the complexities of the IT implementations simply disappear. The problem of interoperability of competing systems vanishes, for one.

    An IEEE Spectrum article covers some of the security implications. In particular my paranoia is confirmed by Dr. Deborah Peel, who writes

    "Today our [the patient's] lab test results are disclosed to insurance companies before we even know the results. Prescriptions are data-mined by pharmacies, pharmaceutical technology vendors, hospitals and are sold to insurers, drug companies, employers and others willing to pay for the information."

    EHR will only expedite this process. I'd like to see a blunt rule in the HIT regulations that gives ownership of the medical record to the patient and his heirs and assigns. Currently the ownership is vested somewhere in the aether.

    - July 2010: the HIT has released its "meaningful use" criteria for the adoption of EHR by doctors, etc. This offers a few thousand dollars (from the stimulus package) for implementation of an EHR. As Andy Oram observes,

    "The catch is that they can't just install the electronic system, but have to demonstrate that they're using it in ways that will improve patient care, reduce costs, allow different providers to securely share data, and provide data to government researchers in order to find better ways to care for patients. That's what "meaningful use" means."

    A few thousand isn't going to do it. The costs of EHR fall upon the doctor, the benefits accrue to society and the patient. The costs are much higher than a couple of thousand, especially considering the current wholly dysfunctional state of EHR. Many EHRs have no API at all, others have incompatible ones, and so depressingly on. Single-payer with a single EHR solves all these problems at once, but because it's politically impossible, we're left with hideous technical problems.

    Trying to solve US healthcare problems with EMR/EHRs is a category mistake, like trying to take the integral of a head of cabbage.. as your midwest doctor observed, " technological fixes only work in the context of appropriate institutional structures. "

    Thanks for these; more in the queue. 

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  • Bloomberg and China, TL;DR Version

    What would Bloomberg's best reporters make of an institution that tried to stonewall its way past a controversy?

    A little while ago I put up an extended Q-and-A with Ben Richardson, the latest member of the Bloomberg news team who has resigned in protest of the company's approach to stories that might offend the leadership in China.

    I hope you read it; its main payoff are Richardson's answers to the questions, and a timeline of how this story has evolved through the past four months.

    But here is the central point: fundamental questions about Bloomberg's integrity as a news organization have been raised by its own employees over these past few months. Its responsible leaders have -- so far -- refused to say anything in detail (apart from "it's not true"), or to entertain on-the-record questions about these allegations. And one of the rare on-the-record comments, by its chairman, has seemed to confirm assumptions that Bloomberg has decided to place its journalistic operation second to its financial-terminal business.

    On All Things Considered today, David Folkenflik said that ex-mayor Michael Bloomberg had told his staff that they should think of themselves as journalists first. Great! If so, how about saying that in public, and taking questions on it?

    I think I know what Bloomberg's best reporters would make of an institution that refused to answer questions about its decisions and relied on the stonewall policy.

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  • Another Bloomberg Editor Explains Why He Has Resigned, Over Its China Coverage

    "For the international press, there are many reasons for crimped ambitions."

    A graphic for "China's Red Nobility," from a 2012 investigative series on corruption among the country's leading families. ( Bloomberg )

    Four months ago, The New York Times ran a big story contending that Bloomberg editors had quashed an investigative report about corruption among leaders in China. The Times story was clearly based on informed comment from people inside Bloomberg who were unhappy about the result. It said that higher-ups at Bloomberg were worried that the story would hurt the company's sales of financial terminals—the mainstay of its business—inside China, since the main purchasers would be directly or indirectly subject to government control.

    Like the NYT and some other Western news organizations, Bloomberg was already "on probation" with the Chinese government, because of some very brave and probing official-corruption stories the previous year—including the one on "Red Nobility" that is the source of the graphic above.

    As a reminder, here are the main story steps since then:

    • The FT did a similar report (here, but paywalled), also clearly based on inside-Bloomberg sources and also saying that Matthew Winkler, Bloomberg's editor-in-chief, had ordered the story killed, for fear of ramifications inside China.
    • Bloomberg denied the reports, in categorical but not specific terms. I.e., variations on: Of course we didn't bow to political pressure, and the story was just not ready yet.
    • Amanda Bennett, a long-time editor and reporter with experience in China (she was co-author of Sidney Rittenberg's book, The Man Who Stayed Behind), promptly resigned as head of Bloomberg's investigative unit. She did not explicitly address the controversy but made her feelings clear in her resignation statement. It said: "I am totally proud of the work of the Bloomberg Projects and Investigations team over the past five years....  I’m also most proud of the groundbreaking June 2012 story that the team led, that for the first time exposed the wealth of the relatives of China’s top leaders. I’m proud of the courage it took from top to bottom in Bloomberg to make that happen."   
    • Michael Forsythe, the Bloomberg reporter who had worked for decades in China and was involved in these corruption-investigation stories, was quickly suspended by Bloomberg. He later joined the NYT staff.
    • Bloomberg continued to deny the allegation of knuckling-under but refused to address any specifics. The story that reportedly was underway has not yet appeared.
      Soon after the flap broke, I received several calls from people inside Bloomberg, all of them insisting that I say nothing that could identify them, or even about the fact that we had talked. One was from a person who warned me that it would be a big mistake to put too much faith in what this person said were competitively motivated attacks by Bloomberg rivals. The other calls were from Bloomberg reporters or staffers, who said that the NYT and FT reports were essentially accurate. I wrote to the man who reportedly gave the spiking order, editor-in-chief Matthew Winkler, and did not hear back.
    • Then, last week, the chairman of Bloomberg L.P., Peter Grauer, seemed to confirm the original accounts by saying that it had been a mistake for Bloomberg ever to deviate from its business-oriented coverage. 
    Ben Richardson,
    from Bloomberg.

    All this is prelude to the latest news, which is Ben Richardson's resignation as a Bloomberg editor. Jim Romenesko had the story yesterday, followed by this from Edward Wong of the NYT, who also had the story about Michael Forsythe back in November.  

    After I saw the item on Romenesko, I wrote to Richardson asking if he would say more about the situation. He agreed. What follows are my emailed questions to him and his replies:



    James Fallows: Four months ago, during the Mike Forsythe episode, Bloomberg officials contended that his stories just "weren't ready," and that the accounts in the NYT and elsewhere were misleading or incomplete. What was your understanding of the episode and whether the company's claims were correct?

    Ben Richardson: I was one of the two editors on the story that was spiked last year, and one of three who helmed the 2012 stories on the hidden wealth of China's Communist Party leaders, so I have a pretty intimate knowledge of what happened. Unfortunately, I am bound by a confidentiality agreement that prevents me from disclosing the details. That said, much has already become a matter of public knowledge. 

    I felt the NYT and FT articles were a fair account. As often happens in news coverage, the stories painted the picture in stark black and white when in reality it was more nuanced. However, the contention that the story "wasn't ready" is risible: the only proof of readiness is publication. The real question is whether the story had any merit, and if it did, how could we get it to press?

    That's a simple question. So if Bloomberg felt the story had no merit, then why has the company not explained its reasons? Four seasoned, veteran journalists (with help from many others on the periphery) laboured for months on this story. Were we all wrong? All of us deficient in news judgment?

    JF: Amanda Bennett left the company at that same time. I know you can't speak for her, but should outsiders see her departure and yours as similar reactions to a trend in coverage?

    BR: Amanda Bennett must speak for herself on this. The only comment I can make is that her departure coincided with the decision to spike the China wealth story and the effective dismantling of her Projects & Investigations team -- along with the sacking of a number of seasoned and award-winning journalists. At the same time, the company is shifting ever-more resources into the short, bullet-point end of the news spectrum. That trend isn't unique to Bloomberg and is undoubtedly sound business, but the overall direction is clear.

    JF: What happened, now, in March, 2014 to persuade you to leave the company, versus the controversy in November, 2013? 

    BR: Time. Like most Bloomberg staff, I have a family to support, credit card bills, taxes and a mortgage to pay. I timed my departure to the company's annual bonus. 

    JF: Is the main change that is afoot here on the Chinese side, in decreased tolerance for any investigation into (especially) leading-family corruption issues? Or is it on the Western-press side, in decreased willingness to run these risks?

    BR: It's hard to say. I'm not aware of any reporting of this nature up until Bloomberg and the New York Times stories of 2012, so there's little to gauge the government reaction against. Those stories were published against the backdrop of a power transition, the purge of Bo Xilai and incoming president XI Jinping staking his legitimacy on cleaning up graft. And on top of that, growing inequality and soaring home prices are stoking public resentment of corruption -- making the government even more sensitive.

    As for the international press, there are many reasons for crimped ambitions. The first is that these stories are immensely expensive to execute. Even if a news organisation has the money, it may not have enough people with the right skills. And then it needs the will.  I don't know whether it was bravado fueled by ignorance or true cold-steel nerves, but Bloomberg stood up to intense bullying by the Chinese government in 2012. Last week in Hong Kong, Chairman Peter Grauer made it clear that China is just too big a market to miss out on. The jury's still out on how most other big organisations would handle a similar situation.

    JF: If you were in charge, how would big Western news organizations set this balance? To be more precise, Bloomberg is in a different situation from NYT or WSJ, in that its main business is not reporting but financial services. How should Bloomberg set this balance? 

    BR: I'll combine this with your next question, "What is the main thing you would like people without experience in China to know about your situation and decision?"

    Bloomberg has to act with the interests of the majority of its employees at heart. The company provides a good living for thousands of people. The vast majority of its news is untainted by the kind of constraints you see in China. If that's the kind of news its clients want, give it to them. The world is full of news organisations that feed different parts of the spectrum -- including many trade and specialist publications that never write critical articles of any kind. I think the debate should now move beyond Bloomberg.

    Business and political power are inextricably linked everywhere. That's especially so in China, where both are largely in the hands of a single, unelected political party that forbids the free flow of information and ideas and operates behind a veil of secrecy. Lack of transparency and accountability fuel rampant corruption, human rights abuses and environmental crimes. As China goes global, those values and practices are in danger of gaining currency elsewhere.  

    The question is a bigger one for society as a whole. What value do we place on investigative journalism? If the world's best-resourced news organisation leaves the field, who will fill the gap?


    I'm grateful to Ben Richardson for his quick and forthcoming answers. This may be the time also to share something I received from a person inside Bloomberg at the time the news first broke, which is a useful complement to what Ben Richardson says. This Bloomberg employee said:

    There is a bigger contradiction for the company than most people perceive. Outsiders think the worst explanation for this controversy is that it's concerned about selling terminals within China. It's bigger than that. Really it's about continuing sales all around the world, if Bloomberg can't promise having the fastest inside info from China.

    Everyone knows that it's a company that exists on the terminals. But now that they have saturated the US market, all of the growth will come from areas with these deep contradictions between the company's financial-business interests and its journalistic aspirations. 

    Until very recently, the very fact that Bloomberg was not principally a journalistic company seemed to be its greatest strategic asset. It could use the stream from those financial terminals to bankroll ever-expanding coverage, while companies that were mainly or only in the troubled journalism biz kept cutting back. 

    From Citizen Kane onward (and beforehand), it's been obvious that these extra-journalistic business ties can complicate news coverage. It's time for someone with standing-to-speak for Bloomberg values—Winkler, Grauer, or the mayor himself—to address these concerns directly. 

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  • William of Occam, Thomas Bayes, and the Fate of MH370

    Some postings that begin to put the mystery in perspective.

    Thomas Bayes wondering whether a customer has said "I want four candles" or "I want fork handles" ( A Bayes Tutorial )

    Three perspectives worth mentioning this morning. 

    1) Mysterious disappearances were once the norm. A reader who runs a tech firm writes:

    It's interesting to remember that this sort of mysterious disappearance was completely normal until comparatively recently. I'm not sure, but I think theTitanic (1912) may have been the first shipping disaster that played out in the press in nearly real time. Before 1899, the first news of a ship lost at sea was likely to be no news at all.

    2) Eponyms of logic, Occam and Bayes. Most people easily grasp (though often stray from) the logical concept known as Occam's razor. It's the idea that, other things being equal, the simpler explanation for an event is more likely to be true. For instance, early in the MH370 mystery, one popular conjecture was that something terrible had gone wrong that impaired the pilots' ability to control the plane. And another popular one was that those pilots had found a way to sneak up underneath another plane, hide in its "radar shadow," and then peel off undetectably and land at a secretly arranged rendezvous site in Pakistan or Iran. Knowing nothing else, by Occam's razor sheer complexity made the second far less likely to be true. 

    I find that people have more trouble with the concept of Bayesian statistics or probability, or simply the name, even though the simplest version of its implications makes common sense. That simplest version is the idea that probability estimates can be continually improved and refined if they are adjusted to reflect past experience or new evidence.

    Thus the image at the top of the page (taken from here, as is the example that follows).  Acoustically, the phrases "I want four candles" and "I want fork handles" are practically identical, and if you listened to a recording with no other info, it would be 50/50 which statement the speaker had in mind. But if you're hearing this in a candle store, the probability changes in one way -- having nothing to do with the actual sound -- and in a cutlery store it changes the other way. There's much more to the concept, but that is the main idea. [Mea culpa! I did not know about the "Two Ronnies" episode on Fork Handles, but now I do.]

    My reason for bringing this up is to point toward an interesting short book I read last year, which is all about this history of Bayes's approach and its modern implications. (Plus, why it probably should have been named not for the English clergyman/mathematician  Thomas Bayes but for the French mathematician Pierre Simon Laplace.) The book is The Theory That Would Not Die, by Sharon Bertsch McGrayne.

    3) Clear thinking about MH370. Here are two examples. One is an article by Les Abend, a long-time 777 pilot whose sane-sounding judgments I have praised before. On the CNN site today he gives a chronology that discards some wild implausibilities and explains how a mechanical problem could have led to the evidence we now have.  

    The other is an update from Chris Goodfellow, who ten days ago offered the first plausible-seeming discussion of why mechanical/electrical error --rather than hijacking, terrorism, or suicide -- was the least-implausible explanation for what went wrong. His views got a churlish early dismissal from Slate and some TV pundits, but I think they have held up better than some other theories. Today he explains how the latest evidence affects his interpretation, and mentions the Les Abend post. (This is on Google+ rather than a normal blog so you may need to prowl around a little.)

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  • The Vermont Lake Monsters, and Other Updates From the Road

    Are people in smaller towns "nicer" than cosmopolitans? No. But their political structures are working better.

    Approaching downtown Greer (James Fallows)

    The photo above is from the small South Carolina city of Greer, which is midway between Greenville and Spartanburg and whose downtown-revitalization efforts I mention briefly in my article in our current issue. I will be reporting on Greer soon, and I mention it now as segue to three updates:

    Inside Marriage Special Report bug
    Reinvention and resilience across the nation
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    1) Are small towns "virtuous"? Not really. But they can be effective. Most of this article is about the specific ways in which some cities we've visited have addressed their civic problems, improved their economic prospects, and overall made themselves more attractive places to live. Those specifics matter, and as a relative newcomer to the thriving and crowded field of city-improvement studies (of which Atlantic Cities is an excellent chronicler), I've been fascinated by the ways in which successful tactics spread.

    But there is a general point I consider increasingly important, so let me hammer it home once again. It's this, which contrasts our willed, structural paralysis in presidential-congressional politics which what is feasible elsewhere:

    Once you look away from the national level, the American style of self-government can seem practical-minded, nonideological, future-oriented, and capable of compromise. These are of course the very traits we seem to have lost in our national politics.

    The sappy version of appreciating smaller-town effectiveness is the idea that away from the metropolis, people are nicer, more generous, godlier, and so on. I don't buy it. People are people. Romanticizing small-town virtue is like imagining that the reason Western research centers produce so many Nobel prize winners, and Chinese ones so few (none), is that Americans are more "creative"—as these same Chinese researchers miraculously become when relocated from Tsinghua to Berkeley. The real explanation in these cases, I think, is institutional: incentives reward people for getting things done at a local level, and often for not doing so at the national level.

    As another smaller-town mayor I quoted in the story, Don Ness of the (wonderful) town Duluth, Minnesota, put it:

    “Being a mayor, especially in a ‘strong mayor’ city system, gives you tremendous opportunities... It’s a job that requires—and allows—you to create and implement a tangible agenda. You can carry that out in a way that most positions in American politics just don’t permit.”

    That's true. And since we also need a functioning national government, it raises questions about how we could change the rules and incentives there.

     2) Greenville City, Greenville County, and Martin Luther King. I mention in my article that Greenville County was the last one in South Carolina, which itself was the last state in the union, to observe Martin Luther King's birthday as a holiday. I also quoted this reader on its racist past—and since have heard from many current residents, black and white, about changes since then. The longtime mayor of Greenville, Knox White, who is one of the protagonists of my story, writes in with this clarification about the holiday:

    I see that a former county council's public foot dragging on MLK came up. The City long, long ago declared a holiday and when the county council did not follow suit the perpetrators were all swept from office in the next election. Most were defeated in the GOP primary.

    Indeed there are important political and demographic differences between the city of Greenville and surrounding Greenville County. Like most cities compared with their rural areas, the city is politically more liberal. For instance, Mitt Romney trounced Barack Obama county-wide in Greenville, but the race was very close within the city. I take the mayor's point.

    3) Lake Monsters and Reds. My article points out that civic leaders in Greenville made a big push to build a downtown stadium for their minor-league baseball team, the Red Sox-affiliated Drive. (Named, it appears, for the local BMW and Michelin plants.) And Senator Bernie Sanders, in his days as a crusading mayor of Burlington, Vermont, made a big push to get a stadium for their minor-league team, which was then Cincinnati Reds-affiliated and was called the Vermont Reds. They have since left and are now known as the Akron Rubber Ducks.

    As anyone who has been to Burlington knows, the team that plays there now is called the Vermont Lake Monsters—logo below. Through an in-house jumble, we said that the local team "is called" the Reds, rather than "was called," thus presenting the name of the team Sanders brought in as if they were still there under current mayor Miro Weinberger.

    Sorry for the mix-up. Mayor Sanders cheered for the Reds-affiliate Vermont Reds; Mayor Weinberger, for the A's-affiliate Lake Monsters. Go team(s). 

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