Amazon Health

It’s pretty rare for the same company to feature in two consecutive Weekly Articles; yesterday’s announcement of a health care initiative involving Amazon, though, is not only incredibly intriguing, it also fits directly into some of the most important themes on Stratechery. I couldn’t resist.

THE ANNOUNCEMENT

From a joint press release:

Amazon, Berkshire Hathaway and JPMorgan Chase & Co. announced today that they are partnering on ways to address healthcare for their U.S. employees, with the aim of improving employee satisfaction and reducing costs. The three companies, which bring their scale and complementary expertise to this long-term effort, will pursue this objective through an independent company that is free from profit-making incentives and constraints. The initial focus of the new company will be on technology solutions that will provide U.S. employees and their families with simplified, high-quality and transparent healthcare at a reasonable cost. 

Tackling the enormous challenges of healthcare and harnessing its full benefits are among the greatest issues facing society today. By bringing together three of the world’s leading organizations into this new and innovative construct, the group hopes to draw on its combined capabilities and resources to take a fresh approach to these critical matters… 

The effort announced today is in its early planning stages, with the initial formation of the company jointly spearheaded by Todd Combs, an investment officer of Berkshire Hathaway; Marvelle Sullivan Berchtold, a Managing Director of JPMorgan Chase; and Beth Galetti, a Senior Vice President at Amazon. The longer-term management team, headquarters location and key operational details will be communicated in due course.

I’ve gotten more and more questions from readers about the possibilities of Amazon and health care, even before this announcement. I’ve been surprised, to be honest, but perhaps I shouldn’t be: I was the one who declared on The Bill Simmons Podcast that “Amazon’s goal is to basically take a skim off of all economic activity”, and given that health care was 17.9% of GDP in 2016, well, I guess that means I predicted this!

AMAZON HEALTH MARKETPLACE

What is “this”, though? It certainly is tempting to jump immediately to a possible end game predicated on the ideas I have laid out in The Amazon Tax, Amazon’s New Customer, and Amazon Go and the Future:

• Amazon builds out “interfaces” for its employees (as well as those of Berkshire Hathaway and J.P. Morgan Chase — I’ll just refer to Amazon from here on out), both digital and physical, to access basic healthcare needs; these sit in front of pharmacy benefit managers (PBMs), insurance administrators, wholesale distributors and pharmacies.

• Amazon starts building out infrastructure for those healthcare suppliers, requiring them to serve Amazon’s employees using a standard interface.

Amazon could then go in one of two directions. First, Amazon could start to backwards integrate into its suppliers’ business; there are hints the company is already exploring pharmaceutical sales, and the Wall Street Journal says the idea was broached. That said, I actually think this is less likely; insurance operates best at more scale, not less: first and foremost, the larger the pool, the more risk can be spread, as well as obvious efficiency gains in administration. More scale also gives more bargaining power over other parts of the healthcare chain. Three companies, large though they may be, aren’t going to be as effective as large insurers, no matter how well-managed they may be.

What would make more sense to me is that, having first built an interface for its employees, and then a standardized infrastructure for its health care suppliers, is that Amazon converts the latter into a marketplace where PBMs, insurance administrators, distributors, and pharmacies have to compete to serve employees. And then, once that marketplace is functioning, Amazon will open the floodgates on the demand side, offering that standard interface to every large employer in America.

AGGREGATION AND SUPPLIERS

This is certainly ambitious enough — basically intermediating U.S. employers and the U.S. healthcare industry — but in fact this only sets the stage for the wholesale disruption of American healthcare. First, Amazon could not only open up its standard interface to other large employers, but small-and-medium sized businesses, and even individuals; in this way the Amazon Health Marketplace could aggregate by far the most demand for healthcare.

Consolidating demand by offering a superior user experience is how aggregators gain power; given the scenario I just sketched out, Aggregation Theory has a prediction about what might happen next:

Once an aggregator has gained some number of end users, suppliers will come onto the aggregator’s platform on the aggregator’s terms, effectively commoditizing and modularizing themselves. Those additional suppliers then make the aggregator more attractive to more users, which in turn draws more suppliers, in a virtuous cycle. 

This means that for aggregators, customer acquisition costs decrease over time; marginal customers are attracted to the platform by virtue of the increasing number of suppliers. This further means that aggregators enjoy winner-take-all effects: since the value of an aggregator to end users is continually increasing it is exceedingly difficult for competitors to take away users or win new ones.

The key words there are “commoditize and modularize”, and this is where the option I dismissed above comes into play, but not in the way most think: Amazon doesn’t create an insurance company to compete with other insurance companies (or the other pieces of healthcare infrastructure); rather, Amazon makes it possible — and desirable — for individual health care providers to come onto their platform directly, be that doctors, hospitals, pharmacies, etc.

After all, if Amazon is facilitating the connection to patients, what is the point of having another intermediary? Moreover, by virtue of being the new middleman, Amazon has the unique ability to consolidate patient data in a way that is not only of massive benefit to patients and doctors but also to the application of machine learning.

Of course that leaves the insurance piece, which makes Berkshire Hathaway a useful partner; conveniently, Berkshire Hathaway is not in the health insurance business, but rather the health reinsurance business — that is, they insure the insurers. Or, to put it another way, they don’t provide any of the services that Amazon Health Marketplace might make obsolete, and specialize in the one thing Amazon Health Services would need.

Oh, and this will be really expensive, and take years to get off the ground. It certainly would be helpful to have access to financing and capital markets, which means it would be very helpful to partner with JPMorgan Chase & Company. The skills these three companies bring to bear seems far more relevant than the number of employees (and besides, the company alliance approach to traditional health care has been done).

by Ben Thompson, Stratechery |  Read more:

Image: uncredited

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Why CBT is Falling Out of Favour

Everybody loves cognitive behavioural therapy. It’s the no-nonsense, quick and relatively cheap approach to mental suffering – with none of that Freudian bollocks, and plenty of scientific backing. So it was unsettling to learn, from a paper in the journal Psychological Bulletin, that it seems to be getting less effective over time. After analysing 70 studies conducted between 1977 and 2014, researchers Tom Johnsen and Oddgeir Friborg concluded that CBT is roughly half as effective in treating depression as it used to be.

What’s going on? One theory is that, as any therapy grows more popular, the proportion of inexperienced or incompetent therapists grows bigger. But the paper raises a more intriguing idea: the placebo effect. The early publicity around CBT made it seem a miracle cure, so maybe it functioned like one for a while. These days, by contrast, the chances are you know someone who’s tried CBT and didn’t miraculously become perfectly happy for ever. Our expectations have become more realistic, so effectiveness has fallen, too. Johnsen and Friborg worry that their own paper will make matters worse by further lowering people’s expectations.

All this highlights something even stranger, though: when it comes to talk therapy, what does it even mean to speak of the placebo effect? With pills, it’s straightforward: if I swallow a sugar tablet, believing it to be an antidepressant, and my depression lifts, then there’s a good chance the placebo effect is at work. But if I believe that CBT, or any therapy, is likely to work, and it does, who’s to say if my beliefs were really the cause, rather than the therapy? Beliefs are an integral part of the process, not a rival explanation. The line between what I think is going on and what is going on starts to blur. Truly convince yourself that a psychological intervention is working and by definition it’s working.

Perhaps every era needs a practice it can believe in as a miracle cure – Freudian psychoanalysis in the 1930s, CBT in the 1990s, mindfulness meditation today – until research gradually reveals it to be as flawed as everything else.

Or it could be that we’re changing as people. In 1958, a US psychoanalyst, Allen Wheelis, published a book arguing that Freudian analysis had stopped working because the American character had altered. In Freud’s day, Wheelis argued, people didn’t understand why they felt sad; psychoanalysis gave them explanations, whereupon they found it easy to transform their lives. Modern people were better at self-understanding, but they lacked the gumption to do anything about it. “Lacking the sturdy character of the Victorians,” as Roy F Baumeister and John Tierney put it in their book Willpower‚ “people didn’t have the strength to follow up on the insight and change their lives.”

The old techniques weren’t completely wrong; they’d just outlived their usefulness. If the secret of happiness is hard to find, maybe that’s because the answer keeps changing.

by Oliver Burkeman, The Guardian |  Read more:

Image: uncredited

[ed. Nearly all therapists these days seem to be CBT practitioners. From Slate Star Codex: "The therapists I’ve seen ask patients to question whether their anxiety and their negative thoughts are rational, ever so tactfully, and the patients say “No shit, Sherlock, of course they aren’t, but just knowing that doesn’t help or make them go away, and I’ve been through this same spiel with like thirty people already. Now shut up and give me my Xanax.”. There's got to be something better. See also (from SSC): CBT in the Water Supply. And also: Powerless Placebos.]

HappyOrNot - Customer Satisfaction at the Push of a Button

In 2016, a European gas-station chain hired HappyOrNot, a small Finnish startup, to measure customer satisfaction at its hundred and fifty-plus outlets. One gas station rapidly emerged as the leader, and another as the distant laggard. But customer satisfaction can be influenced by factors unrelated to customer service, so, to check, the chain’s executives swapped the managers at the best and worst performers. Within a short time, the store at the top of the original list was at the bottom, the store at the bottom was at the top, and one of the managers was looking for work.

By the standards of traditional market research, HappyOrNot’s analysis was simplistic in the extreme. There were no comment cards, customer surveys, focus groups, or reports from incognito “mystery shoppers.” There was just crude data collected by customer-operated devices that looked almost like Fisher-Price toys: freestanding battery-powered terminals with four big push buttons—dark green and smiley, light green and less smiley, light red and sort of frowny, dark red and very frowny. As customers left a store, a small sign asked them to rate their experience by pressing one of the buttons (very happy, pretty happy, pretty unhappy, or very unhappy), and that was all.

What HappyOrNot’s gas-station data lacked in substance, though, they made up for in volume. A perennial challenge in polling is gathering responses from enough people to support meaningful conclusions. The challenge grows as the questions become more probing, since people who have the time and the inclination to fill out long, boring surveys aren’t necessarily representative customers. Even ratings on Amazon and on Walmart.com, which are visited by millions of people every day, are often based on so few responses that a single positive or negative review can affect customer purchases for months. In 2014, a study of more than a million online restaurant reviews, on sites including Foursquare, GrubHub, and TripAdvisor, found that the ratings were influenced by a number of “exogenous” factors, unrelated to food quality—among them menu prices (higher is better) and the weather on the day the reviews were written (worse is worse).

A single HappyOrNot terminal can register thousands of impressions in a day, from people who buy and people who don’t. The terminals are self-explanatory, and customers can use them without breaking stride. In the jargon of tech, giving feedback through HappyOrNot is “frictionless.” And, although the responses are anonymous, they are time-stamped. One client discovered that customer satisfaction in a particular store plummeted at ten o’clock every morning. Video from a closed-circuit security camera revealed that the drop was caused by an employee who began work at that hour and took a long time to get going. She was retrained, and the frowns went away.

Last year, a Swedish sofa retailer hired HappyOrNot to help it understand a sales problem in its stores. Revenues were high during the late afternoon and evening but low during the morning and early afternoon, and the retailer’s executives hadn’t been able to figure out what their daytime employees were doing wrong. The data from HappyOrNot’s terminals surprised them: customers felt the most satisfied during the hours when sales were low, and the least satisfied during the hours when sales were high. The executives realized that, for years, they’d looked at the problem the wrong way. Because late-day revenues had always been relatively high, the executives hadn’t considered the possibility that they should have been even higher. The company added more salespeople in the afternoon and evening, and earnings improved.

HappyOrNot was founded just eight years ago, but its terminals have already been installed in more than a hundred countries and have registered more than six hundred million responses—more than the number of online customer ratings ever posted on Amazon, Yelp, or TripAdvisor. HappyOrNot is profitable, and its revenues have doubled each year for the past several years; its clients have a habit of inquiring whether, by chance, the company is for sale—significant accomplishments for a still tiny enterprise whose leaders say that their ultimate goal is to change not just the way people think about customer satisfaction but also the way they think about happiness itself.

by David Owen, New Yorker |  Read more:

Image: HappyOrNot

Don’t Forget How the Soviet Union Saved the World from Hitler

In the Western popular imagination -- particularly the American one -- World War II is a conflict we won. It was fought on the beaches of Normandy and Iwo Jima, through the rubble of recaptured French towns and capped by sepia-toned scenes of joy and young love in New York. It was a victory shaped by the steeliness of Gen. Dwight D. Eisenhower, the moral fiber of British Prime Minister Winston Churchill, and the awesome power of an atomic bomb.

But that narrative shifts dramatically when you go to Russia, where World War II is called the Great Patriotic War and is remembered in a vastly different light. (...)

Starting in 1941, the Soviet Union bore the brunt of the Nazi war machine and played perhaps the most important role in the Allies' defeat of Hitler. By one calculation, for every single American soldier killed fighting the Germans, 80 Soviet soldiers died doing the same.

Of course, the start of the war had been shaped by a Nazi-Soviet pact to carve up the lands in between their borders. Then Hitler turned against the U.S.S.R.

The Red Army was "the main engine of Nazism’s destruction," writes British historian and journalist Max Hastings in "Inferno: The World at War, 1939-1945." The Soviet Union paid the harshest price: though the numbers are not exact, an estimated 26 million Soviet citizens died during World War II, including as many as 11 million soldiers. At the same time, the Germans suffered three-quarters of their wartime losses fighting the Red Army.

"It was the Western Allies’ extreme good fortune that the Russians, and not themselves, paid almost the entire ‘butcher’s bill’ for [defeating Nazi Germany], accepting 95 per cent of the military casualties of the three major powers of the Grand Alliance," writes Hastings.

The epic battles that eventually rolled back the Nazi advance -- the brutal winter siege of Stalingrad, the clash of thousands of armored vehicles at Kursk (the biggest tank battle in history) -- had no parallel on the Western Front, where the Nazis committed fewer military assets. The savagery on display was also of a different degree than that experienced farther west.

Hitler viewed much of what's now Eastern Europe as a site for "lebensraum" -- living space for an expanding German empire and race. What that entailed was the horrifying, systematic attempt to depopulate whole swaths of the continent. This included the wholesale massacre of millions of European Jews, the majority of whom lived outside Germany's pre-war borders to the east. But millions of others were also killed, abused, dispossessed of their lands and left to starve.

"The Holocaust overshadows German plans that envisioned even more killing. Hitler wanted not only to eradicate the Jews; he wanted also to destroy Poland and the Soviet Union as states, exterminate their ruling classes, and kill tens of millions of Slavs," writes historian Timothy Snyder in "Bloodlands: Europe between Hitler and Stalin." (...)

To be sure, as Snyder documents, the Soviet Union under Stalin also had the blood of millions on its hands. In the years preceding World War II, Stalinist purges led to the death and starvation of millions. The horrors were compounded by the Nazi invasion.

"In Soviet Ukraine, Soviet Belarus, and the Leningrad district, lands where the Stalinist regime had starved and shot some four million people in the previous eight years, German forces managed to starve and shoot even more in half the time," Snyder writes. He says that between 1933 and 1945 in the "bloodlands" -- the broad sweep of territory on the periphery of the Soviet and Nazi realms -- some 14 million civilians were killed.

By some accounts, 60 percent of Soviet households lost a member of their nuclear family.

For Russia's neighbors, it's hard to separate the Soviet triumph from the decades of Cold War domination that followed. One can also lament the way the sacrifices of the past inform the muscular Russian nationalism now peddled by Putin and his Kremlin allies. But we shouldn't forget how the Soviets won World War II in Europe.

by Ishaan Tharoor, Washington Post | Read more:
Image: Eduard Korniyenko
[ed. People have short memories. See also: Someday Donald Trump Will Be as Respected as Ronald Reagan]

James Hunter

[ed. ..bread without no meat.]

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The Secrets of Cruise Ships

At a time when travelers are feeling more precious than ever about “authentic experiences,” the cruise industry is doubling down on the exact opposite: completely manufactured fun. Leading the pack is Royal Caribbean Cruises Ltd., whose mega-ships are destinations unto themselves: Its restaurants, casinos, Broadway-caliber musicals, silent disco parties, skating rinks, karaoke, dance clubs, and escape-the-room experiences are such strong lures, some guests don’t even bother to look up where the ship is docking.

So when the cruise line invited me to join the ranks as temporary director of its largest ship, Harmony of the Seas—which is as big as five Titanics—I knew I was signing up for the most manic week of my life.

As cruise director, my primarily responsibility was seeing to the happiness of 6,322 passengers and 2,200-plus crew. Over the course of a week, I had my hands in every department, from ship activities and entertainment to onboard revenue, making sure that everyone and everything worked in, well, harmony. From stocking the world’s biggest buffet and staving off gastrointestinal disasters to hosting celebrity guests, everything is 10 times crazier when you’re mayor of a city that’s floating in the middle of the sea.

There Is Secret Cruise Code Language

It’s crucial for the staff to have code words so that passengers don’t get freaked out if something goes wrong. A “30-30” means the crew is asking maintenance to clean up a mess; three times during my stint I called in a “PVI” (public vomiting incident). An “Alpha” is a medical emergency, a “Bravo” is a fire, and “Kilo” is a request for all personnel to report to their emergency posts, which happens in the event of, say, a necessary evacuation. Be wary of “Echo,” which is called if the ship is starting to drift, or “Oscar,” which means someone’s gone overboard. A crew member told me he’s had only four or five “Oscars” in 10 years of cruising.

Drunk Guests Can't Outsmart the On-Board Bartenders

If you thought those all-you-can-drink beverage packages were directly correlated with drunk debauchery at sea, think again. Only eight to 10 percent of passengers purchase unlimited booze packages—Royal Caribbean’s guests are largely family travelers—and those who do are carefully monitored. Every single alcoholic beverage is poured with a jigger. Intoxicated passengers can have their SeaPasses (onboard credit cards) temporarily disabled, barring them from being served at any of the ship’s bars. As for the most popular alcoholic beverage ordered on board? It’s a cinnamon fireball shot.

According to Ivan De La Rosa, the ship’s senior doctor, the biggest issue involving alcohol is when the ship is docked in Cozumel, Mexico. Mix an afternoon of unregulated drinking on land at Señor Frogs with tropical heat and a few glasses of Mexican tap water, and you’ve got yourself a guaranteed “PVI.”

All Cruise Guests Basically Eat the Same Things

Freezers on board Harmony of the Seas are the size of New York studio apartments—and stocking them is an art form. Before each sailing, the inventory team receives enoughingredients for 20 different dining venues, plus servings for the 2,000-member crew. (The total cost, including such other consumables as paper towels, is about $800,000.) Overestimate the order, and the voyage becomes less-profitable (and wasteful); underestimate, and you’ll risk a riot over coconut shrimp.

Luckily, passengers’ eating habits are fairly predictable. On the average week-long cruise, Royal Caribbean estimates its guests will be 80 percent American, consuming around 3,000 bottles of wine, 7,000 pounds of chicken breast, and almost 100,000 eggs.

If more than 80 percent of the guests are American, the crew orders extra ketchup. When the percentage of Chinese passengers increases, they bump up the supply of sliced fruit, seafood, and rice. Latin Americans consume more red meat and Coronas (which also requires additional limes). And family-prone Spring Break cruises require three times as many chicken nuggets. The one thing that never changes no matter who is on board? Toilet paper. Around 9,600 rolls are used each week.

by Brandon Presser, Bloomberg |  Read more:

Image: Zohar Lazar

The Case Against Tom Brady

Perhaps the sight of Tom Brady’s chin dimple doesn’t blind you with seething rage. I guess you don’t have eyeballs.

Or maybe you’re not from Philadelphia. Eagles fans have recently been prevented from realizing a beloved postseason pastime—the city’s so-called “Crisco Cops” greased up downtown lamp posts to stop rowdy Philadelphians from scaling them. Perhaps now they can instead relish another classic activity: the great tradition of loathing the New England Patriots, everyone who holds them dear, and everything they represent.

The Patriots. Ugh. Even their team name is a lie. First of all, a bald eagle—so sleek! so majestic! so fierce!—is infinitely cooler than some dude wearing a tricorne hat. And can someone tell Robert Kraft that giving muskets to a bunch of LARPers in the endzone isn’t actually patriotic? Last time I checked, the cradle of liberty wasn’t in Foxborough, Massachusetts. Ben Franklin may have believed the nation’s premier bird was the turkey, but he still picked Philadelphia over Boston for a reason. (The reason: Philly’s better.)

Tom Brady. Ughhhhhh.

It isn’t the unrepentant cheating that makes him detestable—or even his thing with avocado “ice cream,”or that he’s from California, or that he wrote a bookcalled The TB12 Method: How to Achieve a Lifetime of Sustained Peak Performance, or that he tried to sell people $99 science-pajamas, or that he has a controversial bromance with Donald Trump, or that he’s so wishy-washy about that bromance, or that he married a mega-successful knockout supermodel, or that he has a $44 million salary, or his 66,159 passing yards, or his five Super Bowl rings, or the fact that he is some kind of football-savant Benjamin Button who ages in reverse and physically cannot stop winning.

Actually, wait, it is the winning thing. It’s totally all the winning.

Tom Brady is eminently hate-able because he’s so damned good. But there must be more to it than that. Philadelphians can’t be that petty, right? (Don’t answer that.)

People love an underdog, in part, because spectators are hedonists; they want an emotionally pleasurable experience. And, putting aside team loyalties, it turns out that rooting for a favorite like Brady to win is especially ho-hum if that favorite ends up losing. “Because it is unexpected, an underdog’s victory is more satisfying than a favorite’s and an underdog’s loss is much less traumatic,” wrote Jimmy Frazier and Eldon Snyder, the authors of a 1991 paper published in the Sociology of Sport Journal about the appeal of teams that are expected to lose. A utilitarian model would, they said, clearly predict the underdog effect. (...)

Their findings have implications that extend beyond the sporting world. Underdogs show up throughout the history, literature, and mythology of the Western world. Going back to ancient times, one of the most compelling kinds of stories people tell is fundamentally concerned with underdog status.

The novelist Kurt Vonnegut, for example, once observed that the arc of one classic story type—characterized by a protagonist’s steady climb in good fortune, sudden fall, and eventual ascension back to happily ever after—can be found in anything from creation stories across major religions to Cinderella. A couple years ago, I wrote about a group of computer scientists who studied the emotional path of this story pattern, compared with several others, and found that it’s among the top narrative arcs favored by readers.

This same story arc arguably mirrors the trajectory of Tom Brady’s career. It wasn’t always easy for him, back before he was the king of the Super Bowl and the husband of a supermodel. This is the same Tom Brady who got so little playing time at the University of Michigan that he nearly transferred. And the same Tom Brady who began his career as a starting player with a humiliating loss to Notre Dame. “No one expects that this guy was going to be the best football player of all time. Even him!” said Mark Snyder, who was one of the beat writers who covered Brady’s redshirt junior season for the University of Michigan’s college paper in 1998. “No one really knew who he was. He was definitely an underdog.”

by Adrienne LaFrance, The Atlantic | Read more:

Image: Wikipedia
[ed. See also: The Invention of Moral Narrative]

David Rudnick

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Amazon, Berkshire Hathaway and JPMorgan Team Up to Try to Disrupt Health Care

Three corporate behemoths — Amazon, Berkshire Hathaway and JPMorgan Chase — announced on Tuesday that they would form an independent health care company for their employees in the United States.

The alliance was a sign of just how frustrated American businesses are with the state of the nation’s health care system and the rapidly spiraling cost of medical treatment. It also caused further turmoil in an industry reeling from attempts by new players to attack a notoriously inefficient, intractable web of doctors, hospitals, insurers and pharmaceutical companies.

It was unclear how extensively the three partners would overhaul their employees’ existing health coverage — whether they would simply help workers find a local doctor, steer employees to online medical advice or use their muscle to negotiate lower prices for drugs and procedures. While the alliance will apply only to their employees, these corporations are so closely watched that whatever successes they have could become models for other businesses.

Major employers, from Walmart to Caterpillar, have tried for years to tackle the high costs and complexity of health care, and have grown increasingly frustrated as Congress has deadlocked over the issue, leaving many of the thorniest issues to private industry. About 151 million Americans get their health insurance from an employer.

But Tuesday’s announcement landed like a thunderclap — sending stocks for insurers and other major health companies tumbling. Shares of health care companies like UnitedHealth Group and Anthem plunged on Tuesday, dragging down the broader stock market.

That weakness reflects the strength of the new entrants. The partnership brings together Amazon, the online retail giant known for disrupting major industries; Berkshire Hathaway, the holding company led by the billionaire investor Warren E. Buffett; and JPMorgan Chase, the largest bank in the United States by assets.

They are moving into an industry where the lines between traditionally distinct areas, such as pharmacies, insurers and providers, are increasingly blurry. CVS Health’s deal last month to buy the health insurer Aetna for about $69 billion is just one example of the changes underway. Separately, Amazon’s potential entry into the pharmacy business continues to rattle major drug companies and distributors.

The companies said the initiative, which is in its early stages, would be “free from profit-making incentives and constraints,” but did not specify whether that meant they would create a nonprofit organization. The tax implications were also unclear because so few details were released.

Jamie Dimon, the chief executive of JPMorgan Chase, said in a statement that the effort could eventually be expanded to benefit all Americans.

“The health care system is complex, and we enter into this challenge open-eyed about the degree of difficulty,” Jeff Bezos, Amazon’s founder and chief executive, said in a statement. “Hard as it might be, reducing health care’s burden on the economy while improving outcomes for employees and their families would be worth the effort.”

by Nike Wingfield, Katie Thomas and Reed Ableson, NY Times | Read more:

Image: Bryan Anselm

[ed. If ever an industry/system were ripe for disruption, health care is it. Now predators are stalking predators. It's significant that Amazon is involved. See also: Amazon Health.]

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CHIP: Bone-Deep Risk for Heart Disease

It’s been one of the vexing questions in medicine: Why is it that most people who have heart attacks or strokes have few or no conventional risk factors?

These are patients with normal levels of cholesterol and blood pressure, no history of smoking or diabetes, and no family history of cardiovascular disease. Why aren’t they spared?

To some researchers, this hidden risk is the dark matter of cardiology: an invisible but omnipresent force that lands tens of thousands of patients in the hospital each year. But now scientists may have gotten a glimpse of part of it.

They have learned that a bizarre accumulation of mutated stem cells in bone marrow increases a person’s risk of dying within a decade, usually from a heart attack or stroke, by 40 or 50 percent. They named the condition with medical jargon: clonal hematopoiesis of indeterminate potential.

CHIP has emerged as a risk for heart attack and stroke that is as powerful as high LDL or high blood pressure but it acts independently of them. And CHIP is not uncommon.

The condition becomes more likely with age. Up to 20 percent of people in their 60s have it, and perhaps 50 percent of those in their 80s.

“It is beginning to appear that there are only two types of people in the world: those that exhibit clonal hematopoiesis and those that are going to develop clonal hematopoiesis,” said Kenneth Walsh, who directs the hematovascular biology center at the University of Virginia School of Medicine.

The growing evidence has taken heart researchers aback. Dr. Peter Libby, a cardiologist at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, calls CHIP the most important discovery in cardiology since statins.

“I’m turning part of my lab to work on this full time,” Dr. Libby said. “It’s really exciting.”

The mutations are acquired, not inherited — most likely by bad luck or exposure to toxins like cigarette smoke. But there is little that patients can do. (...)

Dr. Benjamin Ebert, chair of medical oncology a the Dana-Farber Cancer Institute, was the first to see the link. He turned for help to Dr. Sekar Kathiresan, a cardiologist and genetics researcher at the Massachusetts General Hospital and the Broad Institute, who had genetic data from four more large studies.

They confirmed that CHIP doubled the risk of a heart attack in typical patients — and increased the risk fourfold in those who had heart attacks early in life.

But how might mutated white blood cells cause heart disease? One clue intrigued scientists.

Artery-obstructing plaque is filled with white blood cells, smoldering with inflammation and subject to rupture. Perhaps mutated white cells were causing atherosclerosis or accelerating its development.

In separate studies, Dr. Ebert and Dr. Walsh gave mice a bone-marrow transplant containing stem cells with a CHIP mutation, along with stem cells that were not mutated. Mutated blood cells began proliferating in the mice, and they developed rapidly growing plaques that were burning with inflammation.

“For decades people have worked on inflammation as a cause of atherosclerosis,” Dr. Ebert said. “But it was not clear what initiated the inflammation.”

Now there is a possible explanation — and, Dr. Ebert said, it raises the possibility that CHIP may be involved in other inflammatory diseases, like arthritis.

by Gina Kolata, NY Times |  Read more:

Image: SPL/Science Source

Pain Tolerance Predicts Human Social Network Size

Abstract

Personal social network size exhibits considerable variation in the human population and is associated with both physical and mental health status. Much of this inter-individual variation in human sociality remains unexplained from a biological perspective. According to the brain opioid theory of social attachment, binding of the neuropeptide β-endorphin to μ-opioid receptors in the central nervous system (CNS) is a key neurochemical mechanism involved in social bonding, particularly amongst primates. We hypothesise that a positive association exists between activity of the μ-opioid system and the number of social relationships that an individual maintains. Given the powerful analgesic properties of β-endorphin, we tested this hypothesis using pain tolerance as an assay for activation of the endogenous μ-opioid system. We show that a simple measure of pain tolerance correlates with social network size in humans. Our results are in line with previous studies suggesting that μ-opioid receptor signalling has been elaborated beyond its basic function of pain modulation to play an important role in managing our social encounters. The neuroplasticity of the μ-opioid system is of future research interest, especially with respect to psychiatric disorders associated with symptoms of social withdrawal and anhedonia, both of which are strongly modulated by endogenous opioids.

Introduction

The origin of societies is considered one of the major evolutionary transitions. This has been accomplished by numerous species but arguably no society is as widespread, complex and technologically advanced as our own. The human brain has evolved to thrive in social environments, providing us with the cognitive processing power to deal with our dynamic and intricate personal relationships. However, there is limited understanding of the neurobiological processes underpinning human sociality. A growing number of studies highlight the important role played by endogenous opioid peptides, most notably β-endorphin, in affiliation and bonding in social animals such as rodents and primates, including humans. This neuropeptide is released from the CNS and has the highest binding affinity for μ-opioid receptors, which are widely distributed in the brain. Upon binding, β-endorphin induces analgesia and a sense of well-being. The brain opioid theory of social attachment postulates that the endogenous μ-opioid system is fundamental to the establishment and maintenance of social bonds. Indeed, μ-opioid neurotransmission has been shown to modulate social motivation and plays a key role in attributing positive value to social interactions. Specifically, the close relationship between the opioid and dopamine systems is integral to the rewarding nature of social interactions.

Until relatively recently, experimental evidence supporting the role of the endogenous opioid system in modulating social behaviour mainly derived from the administration of opioids and opioid blockers. For instance, humans given the μ-opioid antagonist naltrexone experience feelings of reduced social connection. With advances in genetics, knockout technology has revealed that mice lacking the μ-opioid receptor gene show severe deficits in numerous facets of social behaviour, including interactions with conspecifics, communication and infant attachment. Furthermore, there is increasing interest in the use of positron emission tomography (PET) scanning to measure activity of the μ-opioid system in relation to differences in social behaviour, both within individuals (Manninen et al. in prep) and between individuals.

Since β-endorphin is a potent analgesic, indeed more so than the pain-relieving opiate drug morphine, the primary hypothesis tested here was whether pain tolerance (as a proxy for activation of the μ-opioid system) predicts social network size. We tested this hypothesis in a population of healthy young adults (n = 101). The study involved a questionnaire relating to the two innermost social network layers (approximately corresponding to those individuals contacted at least once a week and once a month respectively), as well as collecting information on personality, sociodemographics and lifestyle. Since the blood-brain barrier is impermeable to β-endorphin, CNS endorphin levels can only be accurately determined by sampling cerebrospinal fluid via lumbar puncture, whilst measuring the μ-opioid system directly requires the use of PET scanning. Instead, pain tolerance was assessed by means of a non-invasive, physical pain test (see Methods). (...)

Discussion

Our results show that pain tolerance positively predicts social network size. This therefore supports our hypothesis that variation in the μ-opioid system underlies individual differences in sociality. These results are consistent with a recent PET imaging experiment demonstrating a correlation between μ-opioid receptor availability and attachment style, such that individuals showing greater avoidance of social attachment exhibit lower receptor densities. Our findings are also in agreement with previous pain tolerance studies indirectly implicating the endogenous opioid system in human social bonding activities such as music-making, dancing and laughter. In addition, laughter has since been shown to correlate with elevated μ-opioid activity, as measured by PET scanning (Manninen et al. in prep). This suggests that tests of pain tolerance like that used in our study may indeed serve as a useful proxy for assessing activation of the μ-opioid system.

Variation in μ-opioid receptor signalling may be due to underlying differences in both endogenous opioid release and receptor density, though their relative contribution is yet to be fully determined. However, studies of oxytocin and vasopressin signalling in rodents have shown that CNS receptor densities strongly modulate the influence of these neuropeptides, irrespective of neuropeptide abundance. In fact, analyses of post-mortem brain tissue and in vivo PET studies in humans have revealed a broad range of μ-opioid receptor densities within the population, differing by at least 30–50% (...)

Further research is required to understand the causality of this relationship between pain tolerance and network size. It may be that individuals with genetic variants conferring enhanced μ-opioid neurotransmission derive greater reward from social interactions, thereby seeking more company. An alternative, though not mutually exclusive, explanation is that individuals leading lives rich in social interactions may release higher levels of endogenous opioids and/or have elevated receptor expression. However, we currently lack knowledge regarding the neuroplasticity exhibited by the μ-opioid system. This is of particular interest in relation to psychiatric disorders. Indeed, healthy females asked to sustain a sad mood for only 30 minutes show a reduction in μ-opioid receptor activation. Thus prolonged sadness, as experienced by those suffering from depression, may over time lead to a significant fall in opioidergic signalling. We hypothesise that reduced μ-opioid activity may characterise the onset of conditions such as depression and schizophrenia, resulting in the common symptoms of anhedonia and social withdrawal. Indeed, endogenous opioids mediate hedonic experiences and are integral to our feelings of social connection. In support of this, there is evidence of compromised μ-opioid receptor signalling in patients suffering from depression and schizophrenia and studies using rodent models of depression also implicate the μ-opioid system. (...)

Understanding the biological causes of variation in social network size is of particular interest given the robust association between an individual’s social support and their health, ranging from functioning of their immune, endocrine and cardiovascular systems to myelin integrity. Interestingly, it is an individual’s perceived level of social support that may often be a more reliable indicator of their health status. Compared to other lifestyle factors, we have limited understanding of the mechanisms via which sociality influences morbidity and mortality risk, though reduced activation of the neuroendocrine stress response likely plays a significant role in both humans and animals. Since β-endorphin is known to alleviate the stress response and protect against inflammation and cancer, the activity of an individual’s endogenous μ-opioid system may have important consequences for their health. However, such a direct interaction between social and somatic health is yet to be explored.

In summary, there is substantial evidence that μ-opioid neurotransmission influences sensitivity not only to our physical environment but also our social one. This study adds to previous research implicating the μ-opioid system as a key neural substrate upon which human sociality has evolved.

by Katerina V.-A. Johnson and Robin I. M. Dunbar, Nature |  Read more:

[ed. Wow, μ-opioid receptor densities among individuals can vary up to 30-50 percent, further discrediting the "chemical imbalance" theory of depression. More to the point (of this study), now I know why I quit Facebook - low tolerance to pain.]

Good Arguing: How to Steelman (and Why It's Hard)

The tactic of constructing an inaccurate version of an argument in order to demolish it is called strawmanning.

Strawmanning is easy to do, and advantageous when the only people you care about impressing are people who already agree with you, and who also aren't particularly concerned about you representing your opponent fairly-- they just want to see you rip him/her apart, or at least a sufficiently convincing facsimile thereof. And since it's very likely that the image of your opponent is already more of a caricature in the eyes of those who agree with you (that's tribalism, in a nutshell), the chances are relatively low that someone on your side is going to pull back from basking in the warmth and comforting glow of the effigy which you've just set ablaze to tug at your sleeve and point out-- hey man, that's an effigy.

A strawman version of your opponent's argument is easier to demolish for precisely the same reasons that the first little pig's straw house was easy for the big bad wolf to demolish-- it's flimsy. It was constructed in haste with little thought put into it (who lives in a house made of straw, anyway?), and takes but a few forceful huffs and puffs and logic to blow it to smithereens. So if you, rhetorical big bad wolf that you are, could actually choose to have the person you're arguing against live in a straw house rather than something sturdier, you would, wouldn't you? It makes everything so. Much. Easier. And you're angry, because damn that pig for having the gall to say...whatever horrible thing pigs say. Why should he get the benefit of a charitable, sturdy interpretation of his house I mean, argument?

Well, because that's what logic-- and fairness-- demand. You want your opponent to engage the argument you're actually making, rather than some shoddy imitation that's easier to dismantle, so shouldn't you extend the same consideration? And if his/her argument is really so pernicious and threatening, doesn't that make it especially important to make sure that you're addressing it accurately, in order to publically demonstrate its problems to every witness, so that they can avoid being taken in by it? Does the group of people you care about convincing of the problems with your opponent's argument include the opponent him/herself? And if not, shouldn't it?

This is why steelmanning is so important. And so difficult. And so important.

Steelmanning is exactly what it sounds like-- you turn the analogy of the strawman on its head, and imagine constructing a stronger, better version of your opponent's argument. Perhaps even better than the one he/she initially constructed. You take the time to contemplate your opponent's concerns, including the unspoken ones, and address them. You create the most convincing, best possible version of your opponent's argument, and you lay it out for everyone to see. And then-- only then-- do you you show why it's wrong.

To the best of my knowledge, use of the term "steelmanning" to refer to this practice originated with Chana Messinger. To quote her on the subject:

But Chana, you might say, I’m actually trying to get something done around here, not just cultivate my rationalist virtue or whatever nonsense you’re peddling. I want to convince people they’re wrong and get them to change their minds. 

Well, you, too, have something to gain from steelmanning. 

First, people like having their arguments approached with care and serious consideration. Steelmanning requires that we think deeply about what’s being presented to us and find ways to improve it. By addressing the improved version, we show respect and honest engagement to our interlocutor. People who like the way you approach their arguments are much more likely to care about what you have to say about those arguments. This, by the way, also makes arguments way more productive, since no one’s looking for easy rebuttals or cheap outs. 

Second, people are more convinced by arguments which address the real reason they reject your ideas rather than those which address those aspects less important to their beliefs. If nothing else, steelmanning is a fence around accidental strawmanning, which may happen when you misunderstand their argument, or they don’t express it as well as they could have. Remember that you are arguing against someone’s ideas and beliefs, and the arguments they present are merely imperfect expressions of those ideas and beliefs and why they hold them. To attack the inner workings rather than only the outward manifestation, you must understand them, and address them properly.

Now, of course, the concept of taking on the most robust version of your opponent's argument, even if you have to construct it yourself, has been around a lot longer than the term "steelmanning" itself. You could simply call it arguing charitably. You could, as philosopher Daniel Dennett has been known to do, actually insert a stand-in for your opponent in the text of your own elucidation of your position, to fire objections and criticisms of that position in "real time," giving you the opportunity to answer those criticisms. Of course, when you have multiple opponents, this means you probably won't have the time and space to answer all of their potential criticisms. But again, you can choose the best of these and answer them-- or at least, the best of them so far as you can honestly assess.

Dennett outlines the practice of charitable criticism in his recent book Intuition Pumps and Other Rules for Thinking, attributing it to Russian-American psychologist Anatol Rapoport:

Anatol Rapoport… once promulgated a list of rules for how to write a successful critical commentary on an opponent’s work. First, he said, you must attempt to re-express your opponent’s position so clearly, vividly and fairly that your opponent says “Thanks, I wish I’d thought of putting it that way.” Then, you should list any points of agreement (especially if they are not matters of general or widespread agreement), and third, you should mention anything you have learned from your opponent. Only then are you permitted to say so much as a word of rebuttal or criticism. I have found this a salutary discipline to follow– or, since it is challenging, to attempt to follow. When it succeeds, the results are gratifying: your opponent is in a mood to be enlightened and eagerly attentive.

Sounds good, right? Sounds like a total "best practice" for argumentation. This is something everybody should be doing right? So....why is, when we look around, we see so few people actually doing it? So few people, when deciding how to depict a position they oppose, selecting materials by reaching immediately for the straw rather than the steel?

Well, I know one thing with certainty-- it's not because they're incapable.

There is no level of intelligence or education at which a person moves beyond having the incentive to strawman. The incentives, as I've described, include that that it's easier and faster, but also there is the fact that it's simply more satisfying to pin down and torture a good straw man when you're angry, and when you're speaking to people who are already angry for the same reason that you are, or whom you would like to make angry for the same reason.

by Gretchen Koch, Cheap Signals |  Read more:

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The Book That Colored Charles Darwin’s World

I had been struck by the beautiful colour of the sea when seen through the chinks of a straw hat,” Charles Darwin wrote, in late March, 1832, as H.M.S. Beagle threaded its way through the Abrolhos Shoals, off the Brazilian coast. The water, he wrote, was “Indigo with a little Azure blue,” while the sky above was “Berlin with [a] little Ultra marine.”

Darwin, then twenty-three, was only three months into the nearly five-year adventure that would transform his life and, eventually, the way that humans saw themselves and other species. As the voyage’s so-called scientific person, he would collect masses of rocks, fossils, animals, and plants, periodically shipping his specimens to Cambridge in containers ranging from barrels to pillboxes. Like other naturalists of his time, though, his primary documentary tool was the written word, and during the voyage he drew many of his words from a slim volume called “Werner’s Nomenclature of Colours,” published in 1814 by the Scottish artist Patrick Syme.

Syme’s guide, a facsimile of which will be released in early February by Smithsonian Books, contains samples, names, and descriptions of a hundred and ten colors, ranging from Snow White to Asparagus Green to Arterial Blood Red to, finally, Blackish Brown. Based on a color-naming system developed in the late eighteenth century by the German mineralogist Abraham Werner, the guide is full of geological comparisons: Grayish White is likened to granular limestone, Brownish Orange to Brazilian topaz. Syme, a flower painter and art teacher, added comparisons from the living world. To Werner’s eyes, the Berlin Blue that Darwin saw in the Atlantic sky resembled a sapphire; to Syme, the wing feathers of a jay.

Darwin said that he always named the colors he saw “with the book in hand,” and, indeed, Syme’s terms are scattered throughout the diaries and notebooks that he filled while aboard the Beagle. Darwin describes cuttlefish as tinted with “hyacinth red and chestnut brown,” a sea slug as “primrose yellow,” and a type of soft coral as “light auricular purple.” Specimens could degrade, paintings could fade, and color photography was still a far-off dream, but with Syme’s help Darwin could encode the colors of an unfamiliar world—and carry them safely home. When his “Journal of Researches” (now known as “The Voyage of the Beagle”) was published, in 1839, one reviewer called Darwin “a first-rate landscape-painter with the pen.”

Syme’s guide was only one of the charts, wheels, and other color taxonomies that proliferated in nineteenth-century Europe. Produced mainly by artists and naturalists, they were intended to establish a standard set of labels for the visible spectrum, stabilizing the correspondence between what Tanya Kelley, a professor of languages at the University of Missouri–Kansas City, has called “word and world.” In some ways, these taxonomies only complicated human communication about color, greatly expanding the number of named colors and creating a multitude of conflicting categories. But, as Darwin found, they also allowed colors observed in one place to be reliably reproduced in another, and they drew attention to surprising similarities. Syme points out, for instance, that the spots on a tiger moth’s wings are the same shade of reddish black as the “Breast of [a] Pochard Duck.” The ultramarine blue that Darwin recorded on the Abrolhos Shoals is found not only in the wings of the heath butterfly but also in borage flowers and lapis-lazuli stones.

Kelley, who has studied the history of color nomenclatures, told me that she is often struck by their authors’ faith in the descriptive power of words. “What I come away with is the optimism that people had in our cognitive abilities, in the ability of language to capture something that we now describe with mechanized methods,” she said. Darwin’s modern-day successors have photographs and spectrographic readings to help them catalogue colors. But Kelley argues that language still matters, because it moves both the intellect and the emotions, often evoking qualities beyond hue. Consider Homer’s “wine-dark sea.” Scholars have suggested that oínopa, the ancient Greek word traditionally translated as “wine-dark,” may refer less to the Aegean Sea’s color than to the movement of its water, the shimmer of its surface, or the intensity of its depths. Though today’s Pantone color system—which traces its origins to an 1886 color nomenclature by the ornithologist Robert Ridgway—uses numerical codes to identify its more than twenty-three hundred colors, its curators appear to be well aware of the value of language. Pantone’s 2018 color of the year, 18-3838 Ultra Violet, is characterized by the company as a “dramatically provocative and thoughtful purple shade” that evokes the “experimentation and non-conformity” of Prince, David Bowie, and Jimi Hendrix. (Syme, given to more modest comparisons, finds one of his violet hues in a flesh-fly egg.)

Kelley told me that the discernment of Syme and his contemporaries has helped draw her own gaze to less dramatic shades, and to distinctions that she might not otherwise perceive. “We think of dogwoods as just ‘green,’ but really their leaves are gray underneath, and poplar leaves are silver,” she said. “And there are so many things you’d never think are the same color—like a mushroom and a mallard’s wing—but when you look closely you can see that, yes, they really are.” As Werner’s nomenclature reminds us, sometimes a word is worth a thousand pictures.

by Michelle Nijhuis, New Yorker | Read more:
Image: Smithsonian Books

Illuminated frame for potted plants (Greenframe by Glimakra of Sweden)

Images: kauppi & kauppi

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[See also: Jenny]