Tuesday, March 22, 2016

Uncertain Health in an Insecure World – 78

“The Prisoner”

A British TV show of this name starred Patrick McGoohan as former secret agent, Number Six. Over just 17 episodes in 1968, the show previewed the modern Netflix and HBO miniseries genre. It was shot with a feature film feel and Orwellian sensibility.

After being gassed into unconsciousness in his flat, Number Six finds himself trapped in The Village, where he repeatedly confronts surreal situations set amid psychological threats, science fictional events and allegorical themes. Escape attempts are thwarted by a sinister balloon called Rover, controlled by Number Two. Rover is programmed to prevent general unruliness among the populace and to restrict Number Six's personal egress.

Simply put, Number Six cannot escape The Village, and cannot cope with its madness.

Shot at a secret location in a seaside community (later revealed as Portmeirion, Wales), the show’s writers followed the old adage, “Be witty, be brief, and be gone.” In the final episode, Fallout, the combined effects of hallucinogens, mind control, dream manipulation, and social indoctrination – psychological warfare and spy craft – took their toll on Number Six (below). The final twenty minutes of Fallout baffled inveterate viewers to the point where McGoohan had to go into hiding. Critics nominated the episode for a sci-fi Hugo Award (1969), and it won a Prometheus Award (2002).

Solitary confinement is socially accepted as an extreme form of personal segregation.

Typically, prisoners in solitary confinement spend 23 hours of every day without any human contact, usually in a cell smaller than a horse stable. For much of the 20th century, this punishment lasted days or weeks, but today, it is not uncommon for inmates in “supermax” prisons to spend years in solitary. While corrections officials view the practice as an accepted protocol for general prison population safety, the medical literature shows that caging a person for months to years takes a heavy individual mental and physical toll.

In the 1950’s, University of Wisconsin psychologist Harry Harlow placed lone rhesus monkeys in a chamber nick-named “the pit of despair.” Its slippery sides made it impossible to climb out. After a day or so, the monkeys retreated into a corner, sitting hunched over, apparently hopeless. In time, they rocked, circled, stared and self-mutilated. “Twelve months of isolation almost obliterated the animals socially,” observed Harlow. An infamous 1951 study of McGill graduate students by psychologist Donald Hebb showed that within seven days, extreme sensory deprivation caused loss of the ability to think clearly and hallucinations.

Such research is no longer permitted by modern bio-medical ethics.

Studies of prisoners in solitary confinement are practically and ethically challenging. Prison systems are diverse and unique in many ways, making multi-institution cross-sectional comparisons difficult. Since the 1980’s Harvard’s Stuart Grassian has reported high rates of hallucinations, panic attacks, paranoia, poor concentration, impulsivity, obsessiveness, suicidal ideation and frank psychosis. As much as two-thirds of inmates in solitary confinement have a pre-existing psychiatric condition. Of interest, some research shows that such inmates did not worsen in solitary at rates higher than those without a prior mental illness diagnosis.

The more common outcome is social atrophy - a disabling anxiety about social interactions.
Since the 1990’s, University of California Santa Cruz psychologist Craig Haney has carried out studies of multi-year confinement in “The Hole.” His findings correlate solitary with higher self-mutilation and suicide rates; 63% of all 1995 prison suicides in the U.S. occurred in solitary lock-up. His experience with survivors of multi-decade solitary confinement at Pelican Bay State Prison is “shocking, frankly.”

This is Joseph Harmon, after 8 years in solitary at Pelican Bay.

Haney points out that, “So much of what we do and who we are is rooted in a social context.”  His findings are part of a lawsuit, which revealed that those exposed to such cruelty undergo “social death.” Social scientists agree that the eventual release of these inmates back into society renders solitary confinement counterproductive outside of prison confines.

A parakeet, when finally taken out of its cage, often quickly dies.

U.S. Supreme Court Justice Anthony M. Kennedy wrote a 2015 minority opinion on the practice, in response to the California case of Mr. Hector Ayala, concluding that “near-total isolation exacts a terrible price.” Barack Obama’s July 2015 visit to an Oklahoma federal prison (above), the first by a U.S. President, questioned whether, “We really think it makes sense to lock up so many people alone in tiny cells for 23 hours a day, sometimes for months or even years at a time.” An increasing number of top U.S. corrections officials agree.

Human rights groups consider solitary confinement a form of torture.

In a 2012 survey, twenty of the world’s 25 worst prisons are located outside of the U.S. But five of the world’s 10 worst prisons were situated in the U.S. 
An acclaimed TV series is the sum of all its episodes, not just the finale.

A movement is reflected in the acts of its followers, not just the words of its leader.

Whether in The Village or in a super-max prison, relegation of a person to a number begins a by-design de-socialization process.

In the end, individualism loses out to collectivism.

We in the Square follow good TV mini-series, and believe in progressive social movements.

But in doing so, we must guard against such warmth & fuzziness obscuring concern about the plight of one person.     

Tuesday, March 15, 2016

Uncertain Health in an Insecure World – 77


The word alien has its roots in the Latin word alienus (belonging to another). In that ancient era, this term referenced one of another noble house or those living outside Rome, and eventually persons from beyond the bounds of the Roman Empire.

Homo sum, humani nihil a me alienum puto…” I am a man, I consider nothing that is human alien to me.

This enlightened prose appeared in Heauton Timorumenos, a play written by Publius Terentius Afer (BC 195 – 159). Ironically, Terence was was brought to Rome as a slave from North Africa. As the Roman Empire grew across what is now modern Europe and Northern Africa, derivative meanings for alien emerged – unfriendly, hostile, unsuitable, strange, foreign and inconsistent. By circa AD 1500, the term “alien priority” referred to owing one’s obedience to a mother abbey in a foreign country.

In the 1940’s, the “alienation effect” grew from the works of poet/playwright Bertolt Brecht (1898 – 1956). The term was derived from the German Verfremdungseffekt, reflecting a theater audience’s estranged point of view. Some etymologists connect the word alien to incompatibility – multiple gods being alien to monotheistic peoples, for example.

H.G. Wells used the term Martians, not aliens, in War of the Worlds (1898). “Not of the Earth” meaning for alien was first recorded in the 1920’s. But it was not until the post-Roswell New Mexico 1950’s (below) that the term was commonly used in reference to beings from another planet – extraterrestrials.

In the science fiction that is modern politics, the adjective-added term, “illegal alien”, has taken on an especially pejorative meaning. It reflects foreigners who are not naturalized citizens in their country of residence. It engenders fear among some... hatred in others.

But before aliens invaded Earth, immigrants came ashore. These intraterrestrials looked like "Us", but weren't treated like "Us".

New York City’s harbor is peppered with islands that were used as immigrant quarantine stations between 1758 and 1954. Bedloe’s (now Liberty) Island housed ships’ crews infected with small pox, cholera, yellow fever and other contagions. Nutten’s (now Governor’s) Island held yellow fever incubators until an epidemic overcame it in 1799. Staten Island’s Tompkinville housed ship-fever victims, before it was burned down by local vigilantes in 1858. Its survivors were transferred to Blackwell’s (now Roosevelt) Island for small pox risk, or Ward’s Island for destitute males, or to the floating hospital steamships like The Falcon.

The passage of the U.S. General Quarantine Act in 1863 created a system of immigrant screening and facility allocation. From 1892 to 1954, Ellis Island (above) processed 70% of all immigrants entering the United States. Third-class passengers with suspected contagious diseases were housed there until they were finally examined by medical inspectors on “the line” (below). Immigrants marked (literally) by public health officers with a ‘C’, ‘X’ or ‘S’ who were granted hospital treatment at Ellis Island and other NYC Port facilities were often deported for their inability to pay all medical expenses.

Deporting is derived from circa 1640 French (déporter) and Latin (deportare), and can be traced back to the folk etymology of leaving harbor (portus).

Many American communities’ European roots flowed through Ellis Island’s quarantine houses. And if “America was built by immigrants”, then most of those immigrants were, by current definition, aliens.

The same fears of 1880's and 1890's immigrants entering the United States carrying “loathsome and dangerous” infectious diseases allowed public health officers to not admit undesirables “who would not make good citizens.” By 1903, there were widespread U.S. fears that these immigrants would “likely become a public charge.”

Similar dynamics are prompting present day concerns about importing SARS, Ebola, and Zika -  diseases that begin elsewhere and are carried into The Homeland by migrants. Unlike stowage on ships that took weeks to cross the ocean, these epidemics emerge but before they become clinically evident. Jets full of carriers travel in mere hours from one end of Earth to the other.

Border patrols of many countries are now faced with a human tsunami of illegal aliens and war refugees. Minors are known to carry “severe and dangerous” diseases including swine flu, dengue fever, Enterovirus D68 and multidrug resistant tuberculosis. Immigration nihilists point out that these unaccompanied children (UAC) often lack basic vaccinations, putting the indigenous population at risk of chicken pox and measles. These worries feed the blogosphere and fuel the xenophobic rhetoric of many politicians.

The British Empire had its own sad story of alien abuse.

Between 1860 and 1948, the forced emigration of >100,000 children to Canada – so-called Home Children – was a legal open secret. Over fifty organizations, including The Salvation Army, scooped up orphans, single-parent influenza survivors, street urchins & paupers (above) to become indentured farm hands and household domestics across Canada. Seen at the time as a social engineering solution to the Industrial Revolution’s wretched poverty, most Home Children never saw their British families again. Some died and committed suicide. Many were injured and abused. And most survivors were left suffering from PTSD.

These Home Children should not be confused with World War II’s Guest Children, who came to Canada to escape the Nazi Blitz. Another 50,000 Home Children went to Rhodesia, South Africa, New Zealand and Australia. In 2009 and 2010, Australian PM Kevin Rudd and British PM Gordon Brown offered their countries’ long overdue apologies. More than 10% of the current Canadian population can trace its roots back to Home Children.

But Canada’s government of the day failed to follow suit with a public apology. In 2010, then Immigration Minister Jason Kenney stated that, “Canadians don’t expect their government to apologize for every sad event in our history.” Newly elected Canadian PM Justin Trudeau recently greeted some of the 25,000 refugees escaping from the Syrian war zone (below). One can hope that Trudeau’s progressive government will finally acknowledge Home Children mistreatment.

In modern usage, these children might be politely miscast as “guest workers.” But the U.S. Southern Poverty Law Center (est. 1971) has called such children “slaves.”

The brutal mistakes of ancient and modern empires are symptoms of their imminent decay and eventual failure.

Waves of illegal aliens fleeing abject poverty, wars and brutal genocides cannot all be one country’s problem to solve. Within reason, all countries must share the economic and societal burden of such refugees. Once inside their borders, these people must be afforded asylum and the protection of law.

Progressives and protectionists alike in all countries must find humanistic common ground. Most of us are descended from aliens… immigrants… émigrés.

What’s in a name? Increasingly, it’s mean-spirited labels that count against them.

Migrants and refugees are still treated like alien intraterrestrials.

We in the Square appreciate that there are limits to human generosity - to our humanity.

But a blind eye is still open. And the other eye cannot simply be averted from these issues.

Tuesday, March 1, 2016

Uncertain Health in an Insecure World – 76

“Health Suffrage”

Elections anoint country leaders.

Their politics and policies dramatically influence many aspects of our lives. The economy and terrorism are often the biggest issues on voters’ minds these days. Around the world, people exercise their franchise with remarkable commonality when it comes to such matters. Healthcare is another day-to-day reality for most citizens, and a key issue for the general electorates of the world. Different countries still vote their consciences on healthcare, with diverse outcomes.

Over the course of history, suffrage has rightly expanded to include women and younger voters. Politicians have increasingly been forced to respond to their pressing health issues – vaccination, reproductive rights, legal marijuana, suicide, childcare, addiction, and mental illness (including gun control).

Another seismic shift has occurred in recent years – the dramatic growth of millennial and senior voting blocs. The former population is characterized by perceived health invincibility, while the latter is increasingly burdened by chronic diseases.

In every developed world jurisdiction, the ever-rising cost of drugs and medical technologies has become a troubling issue for both politicians and patients. In many countries, the pharmaceutical and device lobbies are mighty, often citing this sector’s economic impact (jobs) as rationale for being afforded protected status. Their campaign donations are permitted, Hell encouraged, and this flow of dollars is highly influential among mainstream politicians.

Diseases do not favor poorer liberals or monied conservatives.

Whatever a government’s social policy bent or economic forecast, the core demands of the healthcare sector remain immutable. Public payer and private insurance systems are essential job creators, and a hospital is as critical to a community as a school. The social and economic fabric of many communities is inexorably linked to healthcare – its providers, clinics and facilities.
Generational change is an undeniable force in both politics and healthcare. But some politicians ignore healthcare in favor of other popular issues, viewing young voters as generally healthy and unconcerned, and older voters as locked-in. Politicians do this at their own considerable risk.

In 1988, the two most populous countries on their respective continents passed constitutional amendments reducing the voting age from 21 to 18.


There were 309M voters in India’s 1989 Parliamentary election. In 2014, 554M voters vied to elect Prime Minister Narendra Modi (above). With 50% of its current 1.3B population aged <30 years, India is the world’s most youthful democracy. Their support was wooed by parties from across the entire political spectrum. While young Indian voters are far from apathetic, the proactive Youth Elect 2014 drive was designed to get out their vote. It worked – 150M votes were cast by 18 to 23 year olds!  The primary youth voting issues were sexual violence against women (rape), basic human rights (child labor & trafficking, gay rights) and economic inflation.

India’s present healthcare system is predominantly private, with high (~70%) out-of-pocket costs. Less than 10% of the population has healthcare insurance. The quality of care in the largely rural public sector and primary care programs is considered poor (India ranks 112 of 190 countries overall). Universal health coverage is being actively discussed as a focus of India’s twelfth 5-year plan.


The same year that Brazil reduced the voting age from 18 to 16 years, constitutional reforms enshrined health as a citizens’ right, requiring universal equal access to healthcare.  There were 71M voters in 1990, and 113M voters in 2014 when Dilma Rousseff (above) won the Presidential election in a runoff. Of 205M Brazilians, 2.3% of the total electorate was aged 16 and 17 years, turning out from Sao Paolo to Amazonia to vote. Unlike 18-69 year old Brazilians, voting is not compulsory for this teenage cohort. Before the election, youth activist and protesters (below) focused on issues like education (cost, access, quality), the environment (Green movement), progressive social programs (legalizing marijuana, anti-crime) and political corruption (the World Cup).

According to Deloitte, in 2015 Brazil had a mixed public (75%) and private (25%) healthcare system. Most inpatient facilities are privately run, and most outpatient care is provided by the “free” universal public healthcare system (SUS). Care is rated as bad to mediocre by 80-90% of the population, with lengthy waiting times and difficult access to complex medical procedures. Governmental policy is now turning to a revamped family healthcare strategy that primarily targets the poor.

In the 1970’s, the world’s biggest and oldest democracies (U.S., U.K., Canada, Australia, and France) reduced the voting age from 21 to 18 years (Japan has yet to follow suit).

United States

 In the U.S., this change was prompted by the Viet Nam draft anti-war movement (see SCOTUS’ Oregon v Mitchell, 1970); the U.S. Congress passed the 26th Amendment in 1971. Several U.S. states (California, Florida, and Alaska) and some European countries (Denmark, Austria, Scotland, and Germany) have recently dallied with 16 year olds voting.

Twenty U.S. states (above) permit 17 year olds to vote in Presidential primary & caucus elections if they will turn 18 by Election Day. Many of these states are early momentum changers for both Democratic and Republican candidates. As such, the ‘youth vote’ is curried with great ardor. One of the key youth-oriented planks of the 2010 Accountable Care Act was the extension of parental insurance coverage to 26 year olds.

In the 2016 U.S. political cycle, adversaries from opposite ends of the spectrum – Donald Trump and Bernie Sanders – are to varying degrees, both embracing the ‘mandate’ for healthcare insurance enrollment. Sanders wants a “universal” national healthcare plan, as supported by 58% of Americans in a 2015 Kaiser Family Foundation poll. And while Trump would repeal Obamacare (“a disaster”), Hillary Clinton is doubling down on it. As college aged debt-burdened voters now consider the cost of Obamacare-mandated private insurance, they are getting sticker shock!

In both 2010 and 2014 Pew Research Center surveys of likely U.S. Presidential voters, 77% identified healthcare as a priority. In 2014, 69% of 18-29 year olds identified healthcare as “very important” to their vote, as compared to 79% of those >65 years of age. Similar >10% age splits were observed for terrorism (68% vs 82%), foreign policy (51% vs 71%), immigration (49% vs 69%), economic inequality (68% vs 55%) and the environment (64% vs 48%).

A 2015 Fusion Massive Millennial Poll of 1,000 Americans aged 18-34 (born in 1981 to 1999) showed greater engagement; 90% intend to vote in 2016! They listed the following as “important” in selecting the next U.S. President: economy/jobs (19%), healthcare (11%), education (7%), budget deficit (6%), and border security/immigration (4%). These domestic issues far outweighed millennial's interest in foreign policy (3%), terrorism (2%), and defense (1%).  Conventional wisdom aside, 74 year old Bernie Sanders’ movement has masterfully leveraged these age splits.

In European countries like Austria, lowering the national election voting age to below 18 was proposed in 2007 as a way to acutely reverse declining election participation, while creating a future voting habit. Critics of the under 18 vote argue that teenagers lack the maturity and motivation to participate effectively in the electoral process. They point to relatively low turnout in this demographic group. While teenage cognitive neuro-developmental maturity is comparable to that of young adults, their engagement may be lower due to the early phase of their life-cycle. 

After the stunning 2007 electoral defeat of President Mahmoud Ahmadinejad (above), Iran’s hard-line Guardian Council reversed the voting age from 15 to 18 years. In totalitarian states with a vote, politicians are more interested in suffering than suffrage. Ahmadinejad is gone, but Iran’s youthful voters courageously remain.

"What's the point?", you ask.

Millennial voters are more independent, tech-savvy and diverse than the general population.

Leading up to a big vote, politicians shamelessly shill for these youthful supporters. Sadly, once general election polls close, regardless of age, healthcare for the poor remains generally poor.

Whether evolving subtly or extremely, youthful electorates are increasingly impactful. As a direct result of their growing political power, national healthcare policies around the world are in flux.

With their first ballot, youthful voters begin a lifelong civics experiment that favors future social change. And like older voting blocs, these young people will legitimately vote in their self-interest.

Youthful idealism aside, it's in the enlightened self-interest of this cohort to foster future economic growth and societal stability by casting a vote for health today.

If the youth of the world so choose, they can make health suffrage their New Day social cause. We in the Square are pragmatic enough to believe in the power of such a political movement.