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.

James Fallows: Public health

  • But Seriously Now, Why Do Doctors Still Make You Fill Out Forms on Clipboards?

    "Meditative practices emphasize returning to one’s breath. The clinical equivalent of this is to return to one’s patient. "

    Growth of "Hospitalists," a relatively new medical specialty discussed in the last note below. ( Society of Hospital Medicine )

    We'll get back to St. Marys, Georgia, later today. For now, let's dip back into the mailbag for the latest array of views -- most from doctors or other medical professionals, some from technologists, some from "ordinary" patients -- on the pluses and minuses of the shift to electronic medical records. For background: my original Q&A with Dr. David Blumenthal, who directed the electronic-records program at the start of the Obama administration. That article also has links to four previous rounds of discussion -- and, why not, here they are again. One, two, three, and four. Now, eight more ways of looking at electronic medical records.

    1) "Unremitting folly" and "lack of leadership," and apart from that it has some problems. A negative verdict:

    I am a recently retired family physician and was formerly a physicist. Fifty years ago I was programming a mainframe computer in Fortran and am currently using the Python language to pursue several interests. I have experience with 4 different EHRs. Though not a computer expert, I am neither a technophobe nor a Luddite. 

    My purpose in writing to you is to draw your attention to the elephant in the room. In brief, the rollout of electronic health records (“EHRs”) in the United States is a story of unremitting folly, lack of leadership, opportunities wasted, and a stiff dose of medical academic hubris.

    Anyone involved with medicine or information technology (“IT”) has surely been aware for 3 decades or more that EHRs were coming, someday, somehow. The potential advantages were always clear enough. Broadly speaking, they were ready access to individual patient data at the point of care and aggregated patient data, “big data", to be mined somehow for new medical knowledge.

    Standards for medical records were developed, but were overly broad and insufficiently specific (see, for example, HL-7).  The Department of Defense and the Department of Veteran Affairs were interested in developing a systems-wide EHR, which probably discouraged any entrepreneur reluctant to develop a product only to see the government version become a national standard. 

    The lack of a clear standard is a major issue. EHRs, like computer operating systems, are a highly path-dependent technology.  The system you buy today will be yours to live with for the next 20 years, even if no system available today meets your needs.  A good example of this path dependence is the history of Unix-like versus Microsoft versus Apple operating systems.  Unfortunately, the EHR mandate ignores the lesson.

    We now see a technology not ready for deployment being imposed on hospitals and other health care systems. They can buy in with some help from the federal treasury or wait and be penalized for not being on line, an interesting new form of under funded federal mandate. Health care systems are scrambling to enlarge IT departments. Different vendors’ systems are largely not interoperable. This is more than a nuisance when patients self-refer between health care providers.

    For a physician seeing patients in clinic an EHR can be an astonishing impediment. We are rebuked, often deservedly, for being insufficiently engaged with our patients, yet now must spend more time in front of computer displays. (“Why can’t I find a nurse? They are in the patients’ rooms because the computer system is down.”)  

    The practice of medicine involves intensely personal encounters; indeed the patient-physician relationship is what makes being a primary care physician such a privilege.  The EHR does not accommodate narrative analysis of a patient encounter, also known as the personal touch. 

    Voice recognition requires time-consuming, highly distracting concurrent proofreading, quite unlike dictation transcribed by human intelligence.  

    Examination rooms are small (and are not going to grow), requiring that the physician’s back be toward the patient when addressing the computer. [JF note: several previous reader-messages have suggested solutions to this problem.] In the examination room the EHR is marginally effective and utterly inefficient. The human-machine interface is crude and by itself should have precluded widespread deployment of EHRs at this time. 

    EHRs have real potential for “encouraging” adherence to guidelines purported to improve “quality of care.” This is at best a mixed blessing. Many, probably most, guidelines are not solidly grounded in evidence or serve the self-interests of their authors. Until the guidelines industry is brought to heel, patients are at risk of negative benefit.  The diabetes-industrial complex is a good illustration of this. 

    The entire history of EHRs in the United States is worthy of a full-length book. An overdue technology, it is here to stay, as it should.  However, the fact remains that it was overpromised and recklessly deployed.  There are lessons to be learned, if and only if analyzed and reported by persons without a personal stake in the matter.

    2) "A patient's visit to the doctor is morphing into a billing session." From another practitioner:

    Maybe I’m late to the party here, but I thought I’d add a few additional perspectives regarding the matter of electronic medical record systems (EMRs).

    First, the good: A tremendous upside to EMRs is that they make the record so easily accessible. When I was a resident, I seemingly spent half of my time running around the hospital searching for patient charts and scans. Scans were the most maddening—the radiology file room was far from where my patients mostly were. Often, the file clerk wasn’t there. Other times, there were several teams ahead of me, and I’d waste 20 minutes standing there waiting for my turn. And then the scan may or may not even have been there—another team may have checked it out and taken it to their work room or the operating room.

    At my current institution (a large academic center) all of our scans are digital and can be viewed from any terminal in the complex and, via an encrypted connection, from any internet-connected computer anywhere. If one of my residents or a radiologist calls me regarding an important finding, I can be looking at the images and discussing the case in under a minute. I can show the images to colleagues, display them at a teaching conference, and use them to educate the patient and his family without worrying whether I’ll be able to get my hands on the films when I need them and without impeding anyone else’s access.

    Now the bad: Others have mentioned that EMRs make it easier to bill for higher levels of service. The larger issue is that, sadly, the patient’s visit to the doctor is morphing into a billing exercise with a clinical encounter appended to it. EMRs facilitate this process, but I think the causes lie upstream—with physicians, with the hospitals that increasingly employ us, and with our political choice to largely preserve a fee-for-service medical system.

    More recently, the billing imperative has been joined by the safety and quality imperatives. These are sorely needed, but they do sometimes distort medical practice and can even strain the doctor-patient relationship. Again, EMRs potentiate this but aren’t the cause. For example, one commonly used quality metric is a hospital or program’s ratio of observed to expected mortality. The numerator is straightforward, but arriving at the denominator requires prognostication based on the patients’ ages and the number, type, and severity of their various morbidities. Just as EMRs make it easier to document in such a way as to capture the highest possible charges, they also make it easier to document in such a way as to portray the highest possible severity of illness (and hence mortality risk). The hospital’s coders are constantly asking me to clarify various diagnoses that are unrelated to the patient’s presentation and that are often outside of my area of expertise. This diverts my attention away from direct patient care and instead toward the practice of massaging electronic medical records in order to optimize mortality ratios.

    For many physicians, the result of this pivot away from the individual patient and his clinical needs and toward the increasingly complex documentation of such is that medicine ceases to be an emotionally and intellectually fulfilling practice and becomes instead clerical work. We no longer spend a few extra minutes getting to know the patient and his family, perhaps learning something seemingly small but ultimately clinically important in the process. We instead spend unsatisfying time asking irrelevant questions (the review of systems) that allow us to check more boxes, bill a higher level of service, and make the patient appear as sick as possible.

    There’s a mental antidote to this pessimistic mindset, which is easier said than done given the cognitive loads under which we all labor—loads that are increased not only by the demands of using EMRs, but also by pagers, cell phones, various inboxes, etc. The antidote is to listen deeply and re-connect with the person in front of you. Meditative practices emphasize returning to one’s breath. The clinical equivalent of this is to return to one’s patient. A corollary to this is that my generation of medical educators, witnessing the end of the paper chart era while having many years of service ahead, must practice and teach the fundamentals of clinical medicine while helping trainees learn to marshal EMRs and other technologies appropriately.

    3) Comparison from France, and from Seattle

    Quote from one of your other readers: "[At] Group Health Cooperative in Puget Sound, electronic medical records were adopted decades ago, and are widely used and highly effective."

    Response: When I lost my insurance and the ability to stay with Group Health, I wanted to take my medical records. But they charged $45 to put them on a CD. Inexcusable even five years ago. They could just as easily have written a simple program to route records to a printer and handed me the stack of paper at nearly zero cost. Let alone providing the option to buy a USB stick for $5, with all records on it.... 

    Of (possible) interest: "The French way of cancer treatment", by Anya Schiffrin, from February 12, 2014.

    "In New York, my father, my mother and I would go to Sloan Kettering every Tuesday around 9:30 a.m. and wind up spending the entire day...feeling woozy, we'd get home by about 5:30 p.m.

    "[In Paris] A nurse would come to the house two days before my dad's treatment day to take his blood. When my dad appeared at the hospital, they were ready for him. The room was a little worn and there was often someone else in the next bed but, most important, there was no waiting. Total time at the Paris hospital each week: 90 minutes."...

    "When my dad needed to see specialists, for example...the specialists would all come to him. The team approach meant the nutritionist, oncologist, general practitioner and pharmacist spoke to each other and coordinated his care. As my dad said, 'It turns out there are solutions for the all the things we put up with in New York and accept as normal.' "

    Competition cannot provide these results, nor any market forces whatsoever. Regarding people as fellow humans can.

    4) And from Vietnam:

    [How it works there.] Go to the doctor. Begin the discussion at his/her desk. Your previous records have been reviewed in the data base. The doctor's hands rest on the desk.  She/he looks you in the eye and asks questions. Diagnosis made. Treatment recommended. If prescriptions are needed, they are input and transmitted electronically to the receptionist and the pharmacy. You make your co-pay pick up your drugs and depart.

    The efficiency is remarkable. I once had a CT scan at a gigantic clinic with a branch here and in California. The radiologist finished and said

    "Go get a cup of coffee and come back. I'll have your films in half an hour."

    EMR is a tool. A hammer is a tool. In the hands of persons with evil or avaricious intent, either one can do tremendous damage.

    5)  And Boston:

    About 4 years ago I changed health insurance plans and moved my business to a doctor who was a member of Partners Healthcare in the Boston area. I eventually discovered that the practice was connected to a medical records system that would allow any practitioner connected to that system to have immediate access to doctor’s notes, lab results, etc. related to my care. I could also email doctors, make appointments, obtain referrals, request subscriptions over the internet. I grew very comfortable with this. 

    Then my wife had a brain seizure and the EMTs took her to the nearest hospital. The hospital and the doctors who worked at that hospital were not connected to the EMR system we had been using. Problems ensued. 

    The hospital had no access to her history of care.

    I had to track down a doctor on a Sunday night and request complete information about my wife’s medications. The doctor had to send an email to my cell phone so that I could verbally communicate this critical information to the attending physician. 

    Drastic changes in medication were made with negative consequences. 

    I had not realized how much better care could be when you are using doctors who have access to an EMR system. But it is important that every doctor and hospital you use be connected to that system. 

    I will not consider using any medical service that is not connected to this EMR system in our area.

    6) And from a doctor's perspective in Boston:

    I am a surgeon who practiced in a solo private practice in a low income area in Massachusetts for 30 years. I bought an EHR in 2011 and participated in the incentive payment program from CMS and a subsequent audit in which the payment was recouped.

    As other physicians have pointed out , the EHR increased my workload by at least 20%.Dr Blumenthal and his team could have worked to make the VA EHR system, that the taxpayers paid to develop, available universally. Instead perhaps thousands of vendors were certified by the government . The price of these systems was always magically about the same: the $45000 in incentive payments that were promised by the CMS over 5 years.

    Once purchased, myriad other charges arose. The systems were clearly designed to maximize billing through justifying documentation modules. They also were set up to create reports to be forwarded to the government regarding "quality of practice." These mostly involved fairly crude measures like  bean counting how many patients had mammograms or colonoscopies.  With all this crammed in, the goal of creating  clear, informative documentation across a variety of specialties was bound to be lost .

    When these systems failed to serve particular practices or specialties well, , physicians were encouraged to develop their own templates and modifications. More time away from patient care and expense loomed.

    In Boston, there are three major hospital and physician practice systems based on the three medical schools: Tufts, Harvard, and BU. When a patient gets chest pain acutely , he will be taken by ambulance to the nearest facility.He may be transferred during his treatment to a different facility that may or may not be part of the hospital system where he was initially brought. His subsequent outpatient may again be not necessarily with physicians who work for the hospital system where he was treated. It is very likely that the various computer systems involved with the documentation of his care have no interconnectivity.

    At one of the many dinner meetings that we were invited to in 2010 and 2011 exhorting us to adopt the EHR , I queried an employee of the Mass ecolloborative, a federal  grant funded entity, about what priority CMS and the government were giving to the issue of interconnectivity. It seemed unlikely that the big, fiercely competitive  hospital systems and  the IT vendors would pursue this on their own . I specifically asked, when would an ER doctor seeing a patient at BU be able to see the records of the patient's previous care at Tufts or Harvard and she shook her head. So I ask if it would be in five years and she shook her head again . I tried ten years and she said "maybe" and then ,on prompting, said "they are talking about this."

    It seems: you are what you mandate, and the approach of Dr Blumenthal and his team, in my view, has  endorsed and augmented the free market model as regards IT and the large hospital chains and their internecine rivalries. The consequences to patients and independent practitioners are enfolding .

    So, what's a patient to do? In China, in the barefoot doctor days, they gave the paper charts to the patients  and let them carry them around.Not unlike in  the third world, many of my low income patients have smart phone access. In France, as TR Reid has reported, you can go to a doctor in their system and put your ID card through their reader and your updated EHR can be read off your chip. Patients need apps that can download and store these various differently configured EHRs. Like a lot of things regarding your health, when patients are empowered, things really can change.

    7) The technology has problems similar to the Pentagon's:

    1. Yes, some of the large health care systems such as Kaiser Permanente have deployed relatively effective electronic health record systems but what is seldom discussed are the huge cost-overruns associated with these deployments. 

    Health care IT procurement in the large delivery systems is similar to the problems that the Pentagon experiences when it buys weapons systems---the systems usually work, but the costs are often much higher than expected (therefore, the net benefits are lower than expected).  This problem is not unique to the health care sector---as you know, development and installation of enterprise software systems is notoriously complex and even some of the most IT savvy corporations and government agencies have experienced huge cost overruns and outright failures in this area. 

    Unfortunately, there is sort of a conspiracy of silence in the health care sector about cost overruns.  Both the software vendors and the executives who run these organizations are loathe to acknowledge this problem, instead they would rather focus on the benefits (which to be sure are real in many instances) and not talk about the costs---for example, Kaiser Permanente's staff has published 3 books touting the benefits of its electronic health records system, but none of the books discuss the costs or many of the daunting technical and organizational challenges they confronted in building their system.  

    2.  The interoperability problem in health care IT has two dimensions.  The first dimension (and the one that gets the most attention) is the lack of interoperability across health care organizations (as noted by the one of the physicians who commented on the VA's system).  The other dimension, which receives relatively little attention, is the lack of interoperability within organizations. 

    Most large health care delivery organizations decide to keep some of their legacy systems when they decide to implement a new EHR---for example, they may decide to keep their existing radiology and lab order systems, which means they have to spend alot of money creating middleware that can facilitate communication between the old systems and the new EHR.  The cost of developing the middleware is often huge because of the absense of industry standards---this is major reason why cost overruns in this space are so common.

    8) And to round things out, illustrating the complexity of working any change in today's health-care system, the complicating fact of that rapidly growing medical specialty, the "hospitalist":

    After years of only needing to see my doctor (the same one since 1977 until 2013) I've had an up close and personal experience with the new system that has required new doctors (a new medical condition and the retirement of my family physician). 

    What has that meant to me as a patient?  Like the doctor you quoted, when I see my new family physician (still the same practice that is the home of thirty some years of handwritten charts), she is looking at the computer instead of me.  She's also asking the same redundant questions over and over again.  There is a third party in the room--the computer--that is getting the major share of the attention. 

    On the other hand, I love having prescriptions entered immediately.  The scary part: I have caught a number of mistakes: which prescriptions I'm actually taking, what the dosages are, what diagnoses I've had in the distant past at another medical facility.  As they say: garbage in, garbage out. The only good thing is that people are mentioning the "garbage" and asking me if it is true because it is more obvious.

    But the computer is just one part of the problem.  Here's a much scarier thing.  An elderly man with Parkinson's is admitted for emergency surgery that has nothing to do with the Parkinson's.  He suffers from constipation--a common side effect of the disease.  He has a regular routine of over the counter medication to help with the problem.  His wife explains to the medical staff that this is what is prescribed by his regular physician. 

    But his care is now overseen by a hospitalist.  His wife is told that the constipation issue is being handled as usual.  It isn't.  After five days, he is extremely bloated and uncomfortable and nothing has been done.  His wife pleads for help for him in the form of an enema. Did I mention that she is the kind of person who doesn't like to be demanding? The hospitalist (who has almost never visited him and operates through the computer and the nursing staff) orders an x ray and then an enhanced x ray.  Meanwhile the patient gets more and more uncomfortable.

    Eventually, relief is prescribed in the form of--an enema.  A human  conversation in the form of a doctor to doctor discussion of the patient's prior conditions and accommodations would have made his recovery from the surgery so much more comfortable.  Instead the inevitable discomfort of the surgery was made worse by adding more discomfort.

    My conclusion: medicine human to human connection as well as technology. I want my doctors to use technology effectively, but I also want them to listen to me and connect with me as a patient rather than as a disease.  I am very fortunate to have found a new doctor who has this combination, but I worry for all those who aren't getting that kind of care.  I'm also convinced that a human connection with doctors and nurses and other medical people helps us trust our care better and helps us follow through with our treatments.  It's not just warm and fuzzy stuff; it's part of our healing.

    Thanks to all. This is about 5% of the mail that has arrived on the topic. Will keep looking through it. 

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  • Back to 'Throwing Like a Girl'

    Most females 'throw like girls,' but not for the reason you think.

    Fig10.gif

    I was traveling so didn't get on the much- commented-upon Washington Post feature about "throwing like a girl" when it first appeared. I am reminded by Andrew Sullivan that the topic is still bouncing around, so here goes:

    1) I am weirdly heartened to have other people treat this as a "real" subject. As I've mentioned elsewhere, the article I've most enjoyed doing in my Atlantic career was one called "Throwing Like a Girl," from some 15 years ago.

    2) As you'll see if you compare my piece and the Post's, we come to somewhat different conclusions. We both agree that there is a such a thing as the throwing-like-a-girl motion. We disagree on its fundamental cause.

    3) The Post piece talks about a variety of differences between the genders. Eg, "[a professor of psychology and women's studies] found what she defined as a 'very large' difference in only two skills: throwing velocity and throwing distance." I ended up being convinced that, apart from obvious gaps in size and strength, the only difference that mattered between men and women is that more males than females have spent time learning how to throw.

    4) Learning how is the crucial concept, because throwing a ball "correctly" is like riding a bike, in this way. Virtually anyone can learn to do it, but virtually no one starts out knowing how. Once people learn, gender differences in strength take over. The average male bike rider will be stronger than the average female; the strongest male ball-thrower, like Randy Johnson, above, will throw faster than the strongest female. But they all can ride bikes the same way, or throw balls the same way, once they learn how.

    5) Check my article for details (and this follow up), but here's the simplest try-it-right-now proof that throwing motion is a learned rather than an innate skill. Pick up a ball with your "off" hand -- for me, the south paw, since I am right-handed. Throw the ball with that hand. You will throw it "like a girl." And it will take you hundreds, probably thousands, of throws before you feel as if you can do it naturally. As part of my article research, I threw left-handed with my sons and my wife. It was revealing and character-building.  UPDATE! Here is a fabulous Vimeo clip of men throwing with their "off" hands. Every one of them throws like -- well, see for yourself. [Thanks to reader ER.]

    6) Now we get to the other realm of gender differences. For whatever reason, most little boys spend more of their early years learning how to throw than most little girls do. They get better at it -- as they would be at bike riding, if only boys rather than girls were taken through the inevitable shakiness and falls of those first few rides. But that's where the boy/girl difference emerges -- from the thousands of instances of a boy picking up a rock to skip it across a pond and learning how the "kinetic chain" of a throw feels, while a girl, for whatever reason, is doing something else.

    Below, as discussed in another item, is a great super slo-mo video with the Giants' Tim Lincecum, showing the "kinetic chain" of an effective throw. And after that, continued after the jump, is a note that came in just now on the very topic of learned rather than innate skills.



    Now, below and after the jump, a touching letter that has just arrived, on this very topic. It is long but to me very interesting:

    I loved your article, "Throwing Like a Girl." it.  I loved that you even dared to point out this stinging little "euphemism"  and all that it implies.   I am personally guilty of using the expression (along with "you scream like a girl") and I AM a girl.
     
    I think the part of this article that interested me most, however, was not that  you pointed this out, but that  you pointed out that throwing properly is something that can be learned by adults - and more importantly to me, by children. 

    I'm sure the reason my husband brought this article to my attention was to sooth my worried and inherently UN-athletic soul.  I have managed to pass this inherent lack of athleticism down to my oldest son, despite ALL of the opposite genetic material encoded in my husband and his side of the family.  It runs deep and strong on his side, but apparently not deep and strong enough. 

    When I realized that my tall and naturally strong boy, a boy who even looks graceful in repose, was not actually gifted with any grace when it came to running, throwing or hitting, I got very sad about it.

    More »

  • Pushback on CIA and Fake Vaccinations: Maybe Not So Lame?

    A defense of letting the CIA piggyback on public health workers

    Recently I argued that the CIA's scheme of luring Abbottabad families in for vaccinations, and as part of the process collecting their DNA to see if any were related to Osama bin Laden, was a bad idea.

    For the record, two arguments on the other side. First, from a reader not in the CIA:

    >>On the matter of vaccinations, I think there are two distinct issues:
    1. Whether it's right for the CIA to use vaccinations as one of their tools for gathering data.
    2. Whether it's right for the CIA to allow the world to find out that they're doing it. 
    That might sound like a duplicitous approach, but this is espionage, some two-facededness is expected - right?

    For me, the answers are: 1 - probably, 2 - certainly not - put it in a 50 year file and if we're still doing it in 50 years put it in a 100 year file. And if we think we're not capable of #2 then hire some people who are, they surely exist.

    My understanding/assumption is that the intelligence community has a good track record of keeping tactics secret - based on what we find out when the 25 year files are opened. Shame they gaffed this one - I imagine there are some people in the CIA who feel this operations just went from an A+ to an A-.  <<

    And from someone who used to be a CIA officer:<

    >>As we approach the tenth anniversary of the 9/11 terrorist attacks, it's worth remembering how we felt on that day as we evaluate an American operation to bring the perpetrator to justice...  [The fake vaccine] operation could do long-term damage and it absolutely crosses the line of ethical behavior. But it's also true that this is exactly the kind of thing we pay our spies to do, and it's clear by now that this is what we want as a society given the absence of outrage over the intelligence community's growth following 9/11. During the entirety of the debt ceiling and deficit reduction debate, how often have you heard any politician--from either party--suggest that we need cuts in intelligence spending?...

    The flip side of this story is just as important, and it suggests a trend with which intelligence operators must increasingly contend: the fact that the operation became public. As I said above, I was not an operations guy, but I can only imagine how tightly held the details of this vaccination program must have been given the sensitivity of the target. And yet only several weeks after the Navy SEAL raid the Guardian is printing details and senior U.S. officials are essentially confirming the story in the Washington Post.<<

    More at his site.

    More »

  • First-hand experience with Chinese air, pro and con

    Following this item yesterday, about this article in the current issue on the health effects of living in China, good-news and bad-news reports from American friends with long experience in Asia.

    First, the bad news.

    "I check the BeijingAir Twitter every time I'm headed there for work. I thought I'd report an anecdote from a friend who has worked in China since the 1970s and lived there for many years (though moved back partly to raise children in a more healthy environment!). She had MRIs performed on her lungs some time ago and they indicated significant scarring and other damage, despite the fact that she has never been a smoker. She has never complained of any symptoms or health problems but clearly some damage was done."

    FWIW, I heard similar stories from a variety of people who had been in and out of China since the 1980s, but I don't know of any systematic data. Maybe I'll have another data point two weeks from now, when my appointment with my own doctor for a welcome-home physical exam finally rolls around. Only has taken three months to get on his schedule! Good thing we don't have Canadian-style socialized medicine in this country, what with its long waiting lists and rationing-by-delay etc.

    Now, the better news:

    "We were back in China for a couple of weeks this past summer to visit my former students in Beijing and then to travel in Hunan for a week or so.  I think the air has improved.  It was mostly blue skies, even in Beijing, which I rarely saw when we lived there for 10 months in 2003-04.  I think you are right to conclude that expats do get over the problems once they leave.  At least we haven't had lasting health problems -- at least not yet."

    As a side note, based on my experience anyone who wants to visit Beijing in particular should go in October. Even though the current BeijingAir Twitter reading is deep into the "unhealthy" zone, this seems reliably the nicest time of the year.

  • Festival of links, part 1

    Before an impending "real," as opposed to false-alarm, absence from this site for a while, because of impending "real" writing, a variety of links about things I've meant to mention. Two now, two or three later in the day.

    - Everyone on the China-media beat is aware of the turmoil at Caijing, a unique and important magazine in China. The title means "Finance and Economics"; an English site is here. (Disclosure: one of my sons worked there right out of college, during the SARS epidemic, and I know many of the staff.) Caijing has become a powerhouse in both the business and the journalistic sense. It publishes thick issues and holds big, influential conferences -- but it has also been a crucial leader in real business/financial reporting and exposes of financial chicanery, corruption, pollution, and other topics usually hard for the Chinese press to cover. Evan Osnos, who wrote a New Yorker profile of the founder and sparkplug of the magazine, Hu Shuli, has an update on the turmoil here. Other info from the FT here, from the AP here, from the WSJ (subscription wall) here, from the Guardian here, from the NYT here, and from Yahoo news here. None of this is good news.

    - In their respective parts of the Atlantic's site, my colleagues Corby Kummer and Megan McArdle make opposite cases about the effects of New York City's calorie-labeling law. McArdle says it hasn't done any good; Kummer argues that it has already done something and, over time, will undoubtedly do much more. Read and judge for yourself, but one part of Kummer's argument seems obviously true and worth underscoring. He stresses (as did the authors of the original study) that calorie labels -- like mileage labels on cars or electric-consumption labels on appliances -- can make a difference even if customers don't think they're paying attention to them. As the original study said:

    "Calorie labeling could result in changes that do not rely primarily on alterations in consumers' food choices. Menu labeling regulations may encourage chain restaurants to offer more nutritious or otherwise improved menu offerings, which could be profoundly influential. [italics Kummer's] Public health experts have shown that creating "default" incentives to improve well-being is essential to improving public health. By indirectly influencing restaurants to offer more lower-calorie items, menu labeling regulations could help encourage such default options for consumers."

    As Kummer added:

    "Yuppie avatar Starbucks immediately changed its default milk from whole to 2 percent, so it wouldn't have to admit that a Frappuccino could amount to practically as many calories as you should eat in a whole day... Just this week, [a NYC official] told me... Burger King began a new ad campaign telling how customers could eat a full meal for 650 calories or less. McDonalds took .7 ounces and 70 calories out of its standard portion of french fries. Dunkin Donuts introduced an egg-white breakfast. KFC put grilled skinless chicken on its menu--not something anyone expected to see at KFC."

    Again, decide for yourself, but this corresponds to effects I've seen in other areas over the years. Labeling and disclosure in itself has an influence, in encouraging organizations to offer more of what they think will look "good" and less of what looks "bad."

  • Emptying the obesity-and-class mailbag

    I will say goodbye for now to this topic, which began with an offhand mention that America didn't seem as fat as I "expected" after three years away. An unprecedented amount of mail came in; below and after the jump, samples of some of the themes I hadn't previously gotten to. Thanks for the responses.

    Eating as an available pleasure. From a reader in South Dakota:

    "An overlooked connection between obesity and class, I believe, stems from varying quantity of personal enjoyment and anticipation of enjoyment.

    "It is one thing for a successful, financially comfortable, socially accepted and respected person who has multiple things happening every day that are pleasurable (golf, driving a nice car, nice home, stylish clothing, success at work, interesting social events, kids doing well, planning vacations, etc) to take just one pleasurable aspect of life (overeating) and sacrifice some of that pleasure for the good result of losing weight.

    "Now, for people struggling financially and socially, trying to just get through the day and keep their lives together to varying degrees...their meals are often the only consistently happy and pleasurable events they can count on each day. 

    "Obviously, a generalization.  But, if one gets up and faces a day with a tedious and unfulfilling job, not much money to spend on anything but necessities, and no "fun" things ahead, how much more difficult it is for that person to also think ahead to a day of denying themselves the pleasure of their mealtimes...."

    The processed-food factor:

    "I was quite surprised to note the glaring lack of an obvious contributing major factor in your recent post on obesity: processed foods.

    "I was first struck by the weight of this factor (pun intended) during a trip to Buenos Aires a couple of years ago. During my stay, I was absolutely astonished to find such a small percentage of fat people given that:

    "a) the per-capita consumption of meat (in Argentina) is the highest in the world.

    More »

  • A whole bunch more on obesity theories

    After the jump, an American-style cornucopia of observations and theories about which Americans are overweight and why. I have been fascinated to read this mail and am trying to share some of the most interesting or representative parts.

    First, why med students aren't fat, from a fourth-year med student from Indiana:

    "1)  From what I've seen, class is a massive factor when it comes to obesity.  For us, it's actually frighteningly easy to quantify class when seeing patients -- we rotate through 4 different hospitals here and the term "Wishard Patient" is a well worn code among students/doctors/nurses/etc.  Typically, it's used in the context of trauma (gun and knife club) but it's depressing how routine it is to see diabetic patients 50/100/150 lbs overweight in the populations that can least afford care.  When working in a clinic for the local indigent population I saw a whole family where I'm certain every member was at least 100 lbs overweight, and a 14 year old girl already weighed over 250 lbs.

    2)  For some reason, there are very few fat medical students or residents.  Undoubtedly some of this is class, but the number of overweight students is too low to be attributed solely to that.  This actually kind of surprised me, because I've known my share of fat doctors.  My dad was a physician and could have stood to lose 30-40 lbs for most of his life...  But I'm constantly amazed at how fit my class is.  I can think of maybe 5 people I'd call "overweight" (let alone obese) in a class of 280.  I probably work out less than the mean, and I'm 6'2, 200 lbs, lift/run sporadically but play tennis once a week minimum.  I have friends who literally look like they can bench press trucks.  Some people just never NOT go to the gym, even on their most brutal rotations (sometimes that can mean 100+ hour weeks).  That's really inspiring to me. 

    "But the moral of the story is why that's the case?  Undoubtedly some of that is self selection, but I think a lot of it is that the medical hierarchy can be incredibly cruel to the overweight.  I suspect it's much harder than an overweight candidate all else being equal to get admitted to medical school to get admitted (maybe even relative to other professional schools or graduate schools).  I've seen superiors (staff, residents) just blatantly insult the weight of subordinates -- what comes to mind in particular is a staff physician constantly berating an extremely overweight resident to his face.  And honestly, I sometimes wonder how patients would react to an obese physician -- is it tough to tell someone to quit smoking when you're a 100 pounds overweight?  I'm not sure."

    Are cars the problem,  or suburbs? A view from Austria:

    "Interesting last post about the perils of car culture. I think it's dead on, but I wanted to emphasize that it's not just cities that come out looking good. The lesson is closer to, it's suburbs that are bad.

    More »

  • Obesity and politics

    A reader notes the thematic resemblance between two maps. First, the famous NYT map showing the counties that voted more Republican in the 2008 presidential election than in 2004. The areas in red show where Barack Obama, while winning nationally, got less of the vote than John Kerry did while losing.
    ElectoralMap1.jpg


    Then, the previously-mentioned map showing the states with greatest number of people who are both poor and obese.
    Thumbnail image for ObesityMap1.jpg

    What this means, if anything, is hard to say, because of the state-versus-county difference in scale and other anomalies. Still, it's interesting. The reader says:

    "You brought up the voting map, but even before I saw your mention of it, it struck me that the obesity/median income map strongly resembled maps that showed percentages of people voting for McCain and Obama. There is a V, with its bottom point in Arkansas and extending an arm NE to West Virginia and NW to Montana, that covers both McCain voters and the poor-and-fat. So the GOP is not just the natural home now of evangelical whites but also the disproportionatlely poor and heavy? Wow. That's a lot of cultural signifiers for rednecks conservatives all rolled up into one.."

    Here, also from the NYT, is a map of the states McCain actually carried, showing the reach up toward Montana.
    ElecMap2.jpg


  • Obesity and class: the "hotness" factor

    An additional view on the relationship among education, income, and weight:

    "I am currently enrolled in an MBA program in a large city in the South.  On the weekends, I drive 80 miles and work as a paramedic for 48 straight hours for an emergency medical service that covers a bunch of rural small towns.  I am about 50 pounds over my ideal weight.  In my classes and in my neighborhood, which is very "creative class," my weight is definitely irregular.  In a b-school class of 50 or a full trendy neighborhood restaurant, there might be one other person who is more than 20 pounds overweight.  In the more rural area where I work, however, I'm damn close to the median.

    "A couple of thoughts:
    "1. Very broadly, American culture trends to stereotype those who get good grades as unathletic nerds.  Might be true in engineering, computer sciene and the natural sciences.  But in the professional classes, the same people I went to school with who had the discipline to put in the study time necessary to get into the good law schools, med schools or grab the investment banking or management consulting jobs also had the willpower to put in the time at the gym.  I'd bet that many current 22-year-olds would consider maintaining or obtaining "hotness" as as important as career success.  D.C. is full of these types of successful grads of good schools.

    "2. Car culture is terrible for public health.  Again, I'm significantly overweight.  Always trying new exercise and diet programs that never result in sustained weight loss.  What has?  Spent two months in London without car, relying on public transit and walking, no attempt at dieting or exercising.  Weight loss: 22 lbs. Six weeks in NYC without car, relying on public transit and walking, no attempt...  Weight loss: 19 lbs.  D.C. also benefits from this.

    "I had a friend from my paramedic job come visit me in the city a couple months back and bring his brother and a few of his brother's friends, who all work physically demanding construction jobs.  The construction guys, who are all stocky but in various stages of growing beer guts, somehow got into a fight with this group of guys who were built like lumberjacks.  It was a draw.  I later found out that the lumberjack guys were all "Big 4" accountants - CPAs who somehow had better arms and fitness levels than those who actually used their bodies for a living."

    More in the queue.

  • From Sudan, the Arctic, Shanghai: last takes on obesity

    ... at least for a while. Previously here, and with backward-reaching links here. Today's themes:

    Role of psychological factors, beyond class and geography:

    "Earlier this year, I spent a month in Southern Sudan. Returning to the US has many culture shocks - overpowering media environment being one. But the most striking was the preponderence not only of obese people, but people of all classes who were clearly overweight.

    "I live in Rochester, upstate NY which I consider a small midwestern city. The class lines referred to in your post are easily visible and confirmed. But I'd add one other possible obesity factor that likely traverses class lines: depression. No data, but I would guess that people who are depressed or anxious most often turn to food to soothe those beasts. Perhaps there's also a subtle factor of reaction to our Calvinist, repressive cultural history when it comes to sensual pleasure; food is allowed."

    The Eskimo angle:

    "I live in a predominantly Yup'ik Eskimo part of the world, where education levels are typically lower and the consumption of junk food has led to rapidly increasing rates of diabetes.Overweight and obese are the norm here, and not just among Yup'iks....

    "Another indicator from here: the used-clothes boutique has literally tens of feet of rack space for large, large clothes, about one foot or less for what one would consider small sizes.A doctor friend says the medical community has to redefine normal, since official normal does not represent most people...

    "I recently took a trip to Kansas City - which appears periodically in those lists generated somewhere of most-obese cities - and was struck by how few overweight people I was seeing. In fact, it was notable to me how fit most people looked, whereas here it is just the opposite. I was surprised."

    From a British friend in Shanghai:

    "I'm not surprised you are surprised not to see so many obese people. The world is enjoying the conversation about an 'obesity epidemic' and technically America tops the scales which gives the rest of us a chance to enjoy a seeming superiority. Whether or not that situation has changed in America and whether or not the situation for the rest of us has changed (in Europe, China or wherever getting fatter) doesn't matter. It's become a truism that Americans are fatter in greater numbers. This belief is held on to by both a) foreigners who like to have a dig at the US whenever we get a chance and b) ex-pat Americans who take the ex-pat view of all ex-pats that the country they come from has gone to the dogs since they left it. As you've been mixing with both foreigners and ex-pat Americans for several years in China you've probably let your guard down a bit and allowed it all to seep into your consciousness as it sort of seems right. Therefore when you return and are re-immersed in American life your unconscious assumption made while overseas is challenged.

    "Or, maybe you just need glasses!

    "Seriously though, it is interesting how many myths, stereotypes and assumptions you make about your own society while out of it for even a relatively short time.

    "Therefore the question is not really what happened to America's weight, good or bad, but what happened to James Fallows while he was away!"

    Ah, that last line opens up some questions that reach far beyond the obesity theme...  For now I'll say that I will return shortly to the ever-pressing boiled frog and slippery slope debates. And I will add, after yesterday's set of obesity maps, that a wonderful site for visualized data in general is FlowingData.com -- eg with this set of charts about making sense of flight delays. Nothing to do with body weight but interesting nonetheless. Thanks to Parker Donham for this lead.

  • More on obesity, geography, and class

    Gary Chapman, of the University of Texas, has created this way of envisioning the relationship between income and obesity. Concept: the shading varies with the obesity rate divided by median household income. This is a not-immediately-obvious way to present the data, in order to highlight one particular phenomenon: The darker the shade, the likelier you are to find people who are both poor and obese. Map created via Datamasher.org.

    ObesityMap1.jpg


    And here is a map of simple state-by-state obesity rates, from the Centers for Disease Control, highlighting among other things Colorado's claim to be trimmest state in the union.

    ObesityMap2.jpg

    Obviously, state-by-state comparisons are crude at best. The real sociological differences are within states -- county by county, neighborhood by neighborhood, as we see in Red/Blue voting maps. Still, as with voting there are large-scale state-by-state variations, and here the difference between Mississippi and, say, Vermont or Utah says something about racial mix, income and education levels, etc.
     
    After the jump, another map and a few more hypotheses.
    ____

    More »

  • Weight, class, and Wal-Mart

    From a friend in Boston, a note that gives an extended version of a theme in many responses I've received. Background here and here. Charts and data on this point shortly. The argument here -- that, along with smoking, obesity has become a class-bound marker and problem in America -- is hardly surprising, but the power of the connection is what many people emphasize.

    "i wonder if your seeing fewer overweight people than you expected when you got back to the states might be, at least in part, a function of class. this is a point i'm somewhat uncomfortable making, but it shouldn't be ignored. people who, just as a for instance, run and listen to npr and read (not to mention write for) the atlantic are both likelier to be fit and likelier to associate with people of the same ilk. (as a nation, we've not only gotten fatter but also, as you know, much less likely to mix with people who don't share our educational or cultural background.)

    "i remember walking  through harvard yard back in 1986 during the university's celebration of its 350th anniversary. the place was awash in alums, and there was something noticeably different about most of these people. it wasn't that they were expensively dressed or looked like preppies, i realized. it's that almost everyone was so *trim.* none of  these people would likely be found shopping in wal-mart, where waistlines look a lot different.

    "as an aside: i've long thought it would be an interesting commentary on the stratification in this society to have political candidates asked during a debate if they'd ever shopped at a wal-mart. i have to think that very few could honestly answer yes--and the higher the office the fewer the yeses. to think that a democracy's leadership class should  have no connection (other than owning stock--or, in hillary clinton's case, being once on its board) to the biggest corporation in the country, how strange! back when the biggest corporation was gm or exxon, even the wealthiest people likely had *some* dealings with it, even only being chauffered in a cadillac."

    To answer the last question: I'm not a political candidate, but I have not only shopped in W-Ms around the US but have also been to many outlets inside China. That's a story on its own -- the one in Shanghai has whole pig carcasses suspended by hooks right inside the front door, and tanks full of live carp, which the shopper-housewives let flop around on the floor to see which ones look best for the evening's dinner. No one will ever convince me that W-M doesn't know how to globalize/localize.

    But I digress. To sharpen my friend's question: a candidate should be asked when was the most recent time he or she enjoyed Every Day Low Prices.

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