Multipurpose soundbite (1): apply as necessary

From Jonah Goldberg’s brief precis of Trump’s plan to actually move the US embassy in Israel to Jerusalem:

The only people who bought the idea that the Middle East conflict began and ended with Israel were those guys in the control booth describing the wrong game — i.e., Western experts and activists deeply invested in the “peace process.”  In a sense that’s understandable. If you’ve dedicated your entire professional life to a moveable feast that covers your airfare and lodging in Paris or Geneva while you discuss grave matters, it’s probably hard not to cling to fictions.

Good article, but it’s the second half of the quote that is so handy:

If you’ve dedicated your entire professional life to a moveable feast that covers your airfare and lodging in Paris or Geneva while you discuss grave matters, it’s probably hard not to cling to fictions.

It’s possibly the best explanation for nearly all climate change activity, numerous medical ‘conferences’, the EU, various peace processes (see above), the G7, the G20 and much much more. Nobody holds these boondoggles in Detroit or Dundee.

I wouldn’t care except when I end up paying for all this nonsense, directly or indirectly.

Here’s the reliable Lou Donaldson to celebrate what’s actually going on:

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We have to talk about nationalists, AKA Bigger Than Brexit

tibidabo2
On Tibidabo, gazing down on the chaos..

As someone with an intimate knowledge of secessionist lunatics and the trouble they cause – with complete indifference to its effects and an utter disregard of those who might demur from their obsessive worldview – I have watched the Catalonia situation with a mix of deja vu and disgust.

In retrospect, lancing the SNP boil by giving them their referendum might have been David Cameron’s signature achievement. Scotland, despite the SNP hype, is not ruefully regretting the majority rejection of the SNP raison d’etre.

And also, as someone with a pretty good knowledge of Spain, including Catalonia, over many years, I can observe that Puigdemont’s mob, in common with the SNP, don’t really have anything tangible in the way of active grievances. Their gripes are historical, though in Spain I would concede, some of the bad stuff still lies within living memory. Not so Scotland, I would suggest.

Other things they have in common are a failure of serious planning – currency, defence, capital flight, all that stuff – and the thinnest of veneers when it comes to respecting democracy. It was almost inevitable that the floppy haired egomaniac Puigdemont would turn out to be an unelected demagogue, in that no Catalan actually voted for him to become president. That would be too risky. Here’s Wikipedia:

On 10 January 2016, he was invested as the 130th President of the Generalitat of Catalonia by the Parliament of Catalonia. This followed an agreement carried out the day before between Together for Yes and the CUP, in which it was announced that he would replace Artur Mas as president of the Generalitat in exchange for a guarantee of parliamentary stability for his Government

Nice deal guys

However, enjoyable sneering aside (the SNP similarities keep coming), there is a very serious aspect to all this, or aspects. Spain’s tumultuous history comes to the fore, from the epic of Covadonga in 722, through the Reconquista of 1492 to the civil war of the 1930’s. For the last 5 years and more there have been clear signs that Catalonian separatism was encouraging an Islamist enclave to form, in part as a further divide with the rest of Spain. The recent horrific terrorist attacks, conveniently airbrushed now, combined with any casual observation in Barcelona and environs, will tell you that it has changed immensely. This is in part hardcore Salafist Islam, a problem for everyone, including the vain and solipsistic Puigdemont.

By contrast, the beleaguered Mariano Rajoy has shown a decisiveness and maturity so far, that it provides a little ray of hope.

The best summary of all this right now, with hard hitting criticism of all parties,  is  from Iain Martin, a man who knows a mad secessionist when he sees one, over at Reaction (which is worth its tiny subscription fee). I feel compelled to quote it at length:

One of the more obscure aspects of the latest, tragic events in Catalonia is the way in which the constitutional emergency has brought together under one banner some unlikely allies in Britain. Not only are the separatists in Barcelona being cheered on by activists from the Scottish, Welsh and Northern Ireland nationalist parties, as should be expected.

They all support the potential break up of Spain for the obvious reason that separatists love separatism, and, because they want to break up countries on principle, they enjoy the spectacle of it happening elsewhere, probably because they expect the impulse to spread beyond the borders of Spain.

But alongside the SNP et al, the Catalans also have the support of the Faragists, that collection of tin-pot populists clustered around the former leader of UKIP, Nigel Farage. In that faction, judging by their comments today, the delight at the declaration by the Catalan parliament of independence from Spain is rooted instead in the potential for the Catalan business to damage the European Union, which they despise and want to fall apart. In this way the Catalans are cast as the latest exponents of the Trumpian impulse – breaking norms, smashing up the system, as though it is all a great laugh, Carry on Up the Sagrada Familia.

According to the twisted populist reading, the EU is trampling on the will of the Catalan people. That is nonsense. It is not clear there is anything like a majority for a split from Spain. Unlike the Brexit referendum in the UK in 2016, held legally in a nation state, the recent Catalan referendum was illegal, and the EU’s refusal to recognise the unilateral split is perfectly fair and sensible. National governments elsewhere across Europe are taking the same position, not because the EU told them to, but for the perfectly understandable reason that it is rooted in truth and respect for law. In the fantasy ultra-Brexiteer version of diplomacy, this is supposed to be cast aside, sanctioning the end of Spain when there is simply no majority for it.

There has always been a brainless, reckless strand at the Faragist end of the Brexit side of the argument, which operates on the assumption that anything bad for the EU, or Europe more broadly, is good fun and good for Brexit, as though this is a zero sum game and as though we are not all living in the same continent, in the shared space that is Europe. The temptation to mix the two up – Europe and the EU – must always be resisted. Europe is an old civilisation and an enduring concept. The EU is a relatively new political experiment.

In that context, what is happening in Spain is not a cause for celebration. It is a European catastrophe. After a difficult 20th century – and a return to democracy in the mid-1970s following the death of Franco in 1975 – Spain has re-emerged as a confident country with distinct economic strengths (in finance in particular) and restored pride. Catalonia is a disproportionately productive part of that success story. With only 16% of Spain’s population it nonetheless generates 20% of Spanish GDP and a quarter of national exports. It is, for now, a magnet for foreign inward investment.

Catalonia is, or was, doing well, and Spain is, or was, recovering strongly – with growth running just above 3%. The considerable difficulties that Spain encountered stemmed from joining the euro. They are being overcome after a robust programme of reforms.

Now, this weekend, the unity and economic health of that major European democracy is in peril. Direct rule will be imposed. Civil unrest seems certain and violence highly likely. In simple human terms, once the celebrations in Barcelona are matched by counter-demonstrations, a lot of people are at risk of being hurt.

There is another important and overlooked reason for non-Spaniards to fear the break up of Spain. It is on the European front-line against the Islamist war on Western civilisation. Islamic State talks of retaking the Iberian peninsula, and it was from radicalised communities in the Pyrenees that the cells emerged to perpetrate recent attacks. Spain falling apart in the face of such violence would signal to the enemies of European civilisation that great countries are disintegrating and the West is weakening.

Some things, you see, are bigger than Brexit. All Europeans – in or out of the EU – should be extremely concerned by the crisis in Catalonia and should hope for some statesmanship and compromise.

It is indeed a catastrophe, and no-one knows how it will end.

Science: it’s not rocket science (and climate change is not science)

Here’s a quote from the column that runs down the right side of this blog:

One of the great commandments of science is, “Mistrust arguments from authority.” … Too many such arguments have proved too painfully wrong. Authorities must prove their contentions like everybody else

The author is noted populariser of science – but also a real scientist – Carl Sagan.

What can he possibly be getting at? Let’s try another famous scientist: Einstein. In 1905 he’d proposed his Theory of Relativity, and worked on it until 1916 (the year of the Somme, which made communications tricky), and it immediately had a huge impact, with British scientists, notably Eddington, who publicised it through the Physical Society in London.

Here’s where the key point is. Despite the acclaim he was receiving, Einstein refused to accept it until the theory had been verified by empirical observation. Which makes sense, no? Here is the extract from Paul Johnson’s essential history of the 2Oth century, Modern Times:

einstein3
*

einstein1919Which is where Eddington came in, setting off to the coast of West Africa to photograph a solar eclipse, with all the vagaries of the weather. It worked. He proved two of the three tests were correct, and the third, related to the phenomenon of red shift, was confirmed in 1923 by the astronomers of Mount Wilson observatory. Four years earlier though, Einstein had received a huge amount of publicity following Eddington’s trip, which he disavowed, until all of the empirical observations had been made and had proven his theory.

So what’s my point?

I think it’s best made by a youthful Karl Popper, then at Vienna University, who ended up knighted and a doyen of British academia at the LSE and elsewhere, only dying in 1994. He knew Einstein personally. Here he is:

einstein1
*

None of this is remotely controversial. It demonstrates well two key requirements of real scientific endeavour:

  1. The role of observable, verifiable data in proving – or disproving – a theory
  2. Humility

Of course, point 1 is routinely abused with a cornucopia of computer modelling (the most easily abused of all the techniques), surrogate endpoints and allowing one’s politics, emotions and beliefs to play with whatever data you’ve got.

Point 2 is a rare quality in humans (me included).

In medicine there are quite a few examples. For instance, death from a pulmonary embolus after a hip replacement is self-evidently a bad outcome. it’s also very rare, despite the huge number of joint replacements performed. It is ‘prevented’ by the routine use of chemical agents which reduce the body’s capacity to clot blood. As you might imagine, an undesirable consequence of this is bleeding – from the wound, the gut etc – which can lead to all sorts of problems. The ‘cure’ might lead to other serious complications. It does, in practice, to a degree.

So why do we use these drugs? Well, they actually don’t reduce the risk of fatal pulmonary embolus. They may not even reduce the risk of a symptomatic deep vein thrombosis. They do, in relatively small studies, reduce the risk of clots in the leg visible on some sort of sophisticated imaging. That is the basis of the ‘big pharma’ marketing that everyone buys into, for fear of being sued. Yes, fear and loathing stalk the NHS too.

A surrogate endpoint like that (a leg clot visible on an ultrasound scan, whether or not it’s symptomatic), with no definite link to fatal pulmonary embolus, is bad science, yet it’s out there.

None of us is immune to such dodgy data. Einstein’s ‘purity’ is getting rarer in medicine, and it’s very rare in another area of Big Science: climatology as it relates to ‘anthropogenic global warming’ (AGW).

I won’t rehearse all the very justified arguments as to why #climatechange is chock full of bad science and histrionics, I’d rather show good scientific papers, which helpfully debunk a lot of the propaganda.  So here you are, courtesy of the much-attacked James Delingpole. These are from the recent literature, and the usual climate change mob are not enamoured of them:

  1. The alleged ‘pause’ in AGW that the computer models mysteriously allow for is actually more than a pause. The warmists tend to ignore the well recognised El Nino phenomenon. Astronomical influences and empirical observations tend to point away from the AGW claims. Read it here.cc3
  2. Flooding in the USA and Europe is a random event with no relation to alleged        AGW/’extreme weather’ etc etc. Or as they put it “The number of significant trends was about the number expected due to chance alone”. Read it here.cc1
  3. The confident predictions of a global 1.5 degrees C temperature rise by 2022, upon which most of the hype, whining, government virtue signalling and overreaction is predicated, cannot possibly happen by all the postulated mechanisms. It’s really not going to happen. And these researchers are far from being AGW sceptics. Read it here. And if it seems a bit abstruse, here’s Delingpole’s very neat summary.cc2

…and if that wasn’t enough, despite the utterly pathetic attention seeking underwater cabinet meeting by the Maldives government in 2009, sea levels are dropping, much to NASA’s disappointment. Of course, if the Maldives’ dismal excuses for politicians meant what they said, they wouldn’t be building 5 new airports, to add to the 11 they already have.

Ibrahim Didi
Sad!

I won’t even mention the news that the much maligned Great Barrier Reef is in fact doing just fine, despite predictions of doom. Or that the now disappearing Independent newspaper’s famous  news story from the year 2000, that snow would ‘soon be a thing of the past’, has been quietly erased from their website – but not from others (read it here). Who’dathunkit?

Note that the above references that I have provided are refutations of the AGW hysteria and associated hype, not mere denials. The Warmists’ favoured meme of Deniers v Scientists just took a big hit.

It’s all a scam. I could live with the propaganda, it’s the abuse of  the scientific process that I can’t stomach (plus the outrageous expense). I’ve written on this before. The wise doctor and writer Michael Crichton had these guys sussed.

By a strange quirk, where this post began, with Einstein insisting on observational proof of his Theory of Relativity, has been repeated in this last couple of weeks, about 100 years later. The news was rightly full of the observation of gravitational waves – predicted by Einstein – following the remote collision of two neutron stars.  Hard observational data, not a computer simulation.

As Lord Rutherford, splitter of the atom said, with some truth: if your experiment needs statistics**, you should have done a better experiment.   

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I feel fine, thanks

 

**to update this, I would add ‘and computer simulation’

 

Weinstein – the Hobbesian revolutionary soothing the middle classes

It’s always a cop out, on the face of it, to use a blog to just reprint someone else’s piece. This, however is so good by John Podhoretz that I’ve broken that rule. It’s exceptional on every level: literary, philosophically, morally and even as entertainment.

Hobbes (and Original Sin) come out of it pretty well too. Read and savour it, wondering how such a monstrous and evil scenario can produce an unexpected delight.

Given Hobbes’ famous phrase (“the life of man, solitary, poore, nasty, brutish, and short”) I thought I’d conclude with one of the great Tom Waits’ best songs, in which he co-opts it to his usual effect.

In man’s natural state, with no social or religious order to impose limits upon his hungers and passions, “notions of right and wrong, justice and injustice have there no place. Where there is no common power, force and fraud are…the cardinal virtues.” Thus did Thomas Hobbes, in 1651, anticipate and describe the sordid story of the film producer Harvey Weinstein.

The reason Weinstein’s three decades of monstrous personal and professional conduct are so appalling and fascinating in equal measure is that he was clearly functioning outside the “social compact” Hobbes said was necessary to save men from a perpetual state of war they would wage against one another in the state of nature. For that is what Weinstein was doing, in his own way: waging Hobbesian war against the women he abused and finding orgasmic pleasure in his victories.

And Weinstein did so while cleverly pretending to leadership within the social compact and disingenuously advocating for its improvement both through political change and artistic accomplishment. Hobbes said the life of man in the state of nature was nasty, brutish, and short, but he did not say the warrior could not be strategic. Rochefoucauld’s immortal declaration that hypocrisy is the tribute vice pays to virtue is entirely wrong in this case. Weinstein paid off feminists and liberals to extend his zone of protection and seduction, not to help support the virtues he was subverting with his own vices.

Hobbes said that in the state of nature there was “no arts; no letters; no society.” But if the man in the state of nature, the nihilistic warrior, coexists with people who live within the social compact, would it not be a brilliant strategy to use the arts, letters, and society as cover, and a means of infiltrating and suborning the social compact? Harvey Weinstein is a brutal thug, a man of no grace, more akin to a mafioso than a maker of culture. And yet as a movie producer he gravitated toward respectable, quality, middlebrow, elevated and elevating fare. 

People wanted to work with him because of the kinds of movies he made. I think we can see that was the whole point of the exercise: It was exciting to be called into his presence because you knew you would do better, more socially responsible, more praiseworthy work under his aegis than you would with another producer.

And then, garbed only in a bathrobe, Weinstein would strike.

Weinstein was universally known to be a terrible person long before the horrifying tales of his sexual predation, depredation, and assault were finally revealed. And—this is important—known to be a uniquely terrible person. His specific acts of repugnant public thuggishness were detailed in dozens of articles and blog items over the decades, and were notable precisely because they were and are not common currency in business or anywhere else. It was said of him after the latest revelations that he had mysterious abilities to suppress negative stories about himself, and perhaps he did; even so, it was a matter of common knowledge that he was the most disgusting person in the movie business, and that’s saying a lot. And that’s before we get to sex.

To take one example, Ken Auletta related a story in the New Yorker in 2001 about the director Julie Taymor and her husband, the composer Eliot Goldenthal. She had helmed a movie about Frida Kahlo produced by Weinstein. There was a preview screening at the Lincoln Square theater in Manhattan. The audience liked it, but some of its responses indicated that the plotline was confusing. Weinstein, whose hunger to edit the work of others had long since earned him the name “Harvey Scissorhands,” wanted to recut it to clarify the picture. Taymor didn’t, citing the audience’s favorable reaction. Then this happened:

He saw Taymor’s agent…and yelled at him, “Get the fuck out of here!” To Goldenthal, who wrote the score for Frida, Weinstein said, “I don’t like the look on your face.” Then, according to several witnesses, he moved very close to Goldenthal and said, “Why don’t you defend her so I can beat the shit out of you?” Goldenthal quickly escorted Taymor away. When asked about this incident, Weinstein insisted that he did not threaten Goldenthal, yet he concedes, “I am not saying I was remotely hospitable. I did not behave well. I was not physically menacing to anybody. But I was rude and impolite.” One member of Taymor’s team described Weinstein’s conduct as actually bordering on “criminal assault.”

Weinstein told the late David Carr in 2002 that his conduct in such cases had merely been the result of excess glucose in his system, that he was changing his diet, and he was getting better. That glucose problem was his blanket explanation for all the bad stories about him, like this one:

“You know what? It’s good that I’m the fucking sheriff of this fucking lawless piece-of-shit town.” Weinstein said that to Andrew Goldman, then a reporter for the New York Observer, when he took him out of a party in a headlock last November after there was a tussle for Goldman’s tape recorder and someone got knocked in the head.

Goldman’s then-girlfriend, Rebecca Traister, asked Weinstein about a controversial movie he had produced. Traister provided the predicate for this anecdote in a recent piece: “Weinstein didn’t like my question about O, there was an altercation…[and] he called me a c—.”

Auletta also related how Weinstein physically threatened the studio executive Stacey Snider. She went to Disney executive Jeffrey Katzenberg and told him the story. Katzenberg, “one of his closest friends in the business,” told Weinstein he had to apologize. He did, kind of. Afterward, Katzenberg told Auletta, “I love Harvey.”

These anecdotes are 15 years old. And there were anecdotes published about Weinstein’s behavior dating back another 15 years. What they revealed then is no different from what they reveal now: Weinstein is an out-and-out psychopath. And apparently this was fine in his profession…as long as he was successful and important, and the stories involved only violence and intimidation.

Flash-forward to October 2017. Katzenberg—the man who loved Harvey—publicly released an email he had sent to Weinstein after he was done for: “You have done terrible things to a number of women over a period of years. I cannot in any way say this is OK with me…There appear to be two Harvey Weinsteins…one that I have known well, appreciated, and admired and another that I have not known at all.”

So which Weinstein, pray tell, was the one from whom Katzenberg had had to protect Stacey Snider? The one he knew or the one he didn’t know? Because they are, of course, the same person. We know that sexual violence is more about power than sex—about the ultimate domination and humiliation. In these anecdotes and others about Weinstein, we see that his great passions in life were dominating and humiliating. Even if the rumors hadn’t been swirling around his sexual misconduct for decades, could anyone actually have been surprised he sought to secure his victory over the social compact in the most visceral way possible outside of murder?

The commentariat’s reaction to the Weinstein revelations has been desperately confused, and for once, the confusion is constructive, because there are strange ideological and moral convergences.

The most extreme argument has it that he’s really not a unique monster, that every working woman in America has encountered a Weinstein, and that the problem derives from a culture of “toxic masculinity.” This attitude is an outgrowth of the now-fashionable view that there have been no real gains for women and minorities over the past half-century, that the gains are illusory or tokenish, and that something more revolutionary is required to level the playing field.

As a matter of fact in the Weinstein case, this view is false. Women have indeed encountered boors and creeps in their workplaces. But a wolf-whistler is not a rapist. Someone who leers at a woman isn’t the same as someone who masturbates in front of her. Coping with grotesque and inappropriate co-workers and bosses is something every human being, regardless of gender, has had to deal with, and will have to deal with until we are all replaced by robots. It’s worse for women, to be sure. Still, no one should have to go through such experiences. But we all have and we all do. It’s one of the many unpleasant aspects of being human.

Still, the extreme view of “toxic masculinity” contains a deeper truth that is anything but revolutionary. It takes us right back to Hobbes. His central insight—indeed, the insight of civilization itself—is that every man is a potentialWeinstein. This clear-eyed, even cold-eyed view of man’s nature is the central conviction of philosophical conservatism. Without limits, without having impressed upon us a fear of the legal sanction of punishment or the social sanction of shame and ostracism, we are in danger of seeking our earthly rewards in the state of nature.

The revolutionary and the conservative also seem to agree there’s something viscerally disturbing about sex crimes that sets them apart. But here is where the consensus between us breaks down. Logically, if the problem is that we live in a toxic culture that facilitates these crimes, then the men who commit them are, at root, cogs in an inherently unjust system. The fault ultimately is the system’s, not theirs.

Harvey Weinstein is an exceptionally clever man who spent decades standing above and outside the system, manipulating it and gaming it for his own ends. He’s no cog. Tina Brown once ran Weinstein’s magazine and book-publishing line. She wrote that “strange contracts pre-dating us would suddenly surface, book deals with no deadline attached authored by attractive or nearly famous women, one I recall was by the stewardess on a private plane.” Which means he didn’t get into book publishing, or magazine publishing, to oversee the production of books and articles. He did it because he needed entities through which he would pass through payoffs both to women he had harassed and molested and to journalists whose silence he bought through options and advances. His primary interest wasn’t in the creation of culture. It was the creation of conditions under which he could hunt.

Which may explain his choice of the entertainment industry in the first place. In how many industries is there a specific term for demanding sexual favors in exchange for employment? There’s a “casting couch”; there’s no “insurance-adjustor couch.” In how many industries do people conduct meetings in hotel rooms at off hours anyway? And in how many industries could that meeting in a hotel room end up with the dominant player telling a young woman she should feel comfortable getting naked in front of him because the job for which she is applying will require her to get naked in front of millions?

Weinstein is entirely responsible for his own actions, but his predatory existence was certainly made easier by the general collapse of most formal boundaries between the genders. Young women were told to meet him in private at night in fancy suites. Half a century earlier, no young woman would have been permitted to travel alone in a hotel elevator to a man’s room. The world in which that was the norm imposed unacceptable limitations on the freedoms of women. But it did place serious impediments in the paths of predators whose despicable joy in life is living entirely without religious, spiritual, cultural, or moral impediment.

Hobbes was the great philosopher of limits. We Americans don’t accept his view of things; we tend to think better of people than he did. We tend to believe in the greater good, which he resolutely did not. We believe in self-government, which he certainly did not. But what our more optimistic outlook finds extraordinarily difficult to reckon with is behavior that challenges this complacency about human nature. We try to find larger explanations for it that place it in a more comprehensible context: It’s toxic masculinity! It’s the residue of the 1960s! It’s the people who enabled it! The truth is that, on occasion—and this is one such occasion—we are forced to come face to face with the worst of what any of us could be. And no one explanation suffices save Hamlet’s: “Use every man after his desert, and who should ’scape whipping?”

Twattish comments: an occasional series – Ryan Gosling

The goofy faced Hollywood superstar seems like a charming fellow, I would concede that. But rather in keeping with the post below, he seems to have decided that we’re all a problem, and that all our workplaces are equally afflicted by Harvey Weinstein tendencies. He feels the need to shoulder the heavy burden of scolding the rest of us accordingly.

Ryan, you guys are the ones with the problem, and frankly it’s a little late in the day to start lecturing us all. Here’s his statement:

“He is emblematic of a systemic problem. Men should stand with women and work together until there is real accountability and change.”

Broadly true, but the implication that ‘men’ in general needed to be told this, because we are all guilty (copyright Dr Heinz Kiosk, and Michael Wharton), is more than annoying.

Here’s a now famous pic of Ryan advising Harvey to “stand with women and work together until there is real accountability and change”….

harvey1

 

 

 

Most people are normal (AKA politics today)

Harvey Weinstein Hosts a Private Dinner and Screening of "Bobby" for Senators Obama and SchumerGiven numerous news ledes, most recently Theresa May’s ludicrous claims about racism – which indicate she leads a pretty closeted existence  – here is a nice summary of what it is to be a normal citizen in the UK today:

        chancers4  To be a normal  UK citizen is to constantly be scolded, to be lectured, to be treated as a morally bankrupt simpleton in need of the guidance and direction provided by an urban elite ruling class notable for its empty academic credentials, its track record of incompetence, and its idolization of people who erotically abuse the foliage.

chancers3If we are to have betters, is it so wrong for us to demand that they actually be better? Superiors should be distinguished by their superiority – if you presume to take charge shouldn’t you demonstrate tactical, technical, and moral mastery? So what has our ruling class mastered lately? What is the skill set that sets the smart set apart?

chancers1
…still a classic

As you may have twigged from the foliage reference, this otherwise accurate take is actually from the US, by the impeccably grounded Kurt Schlichter.

What did we do to deserve these people? As Kurt correctly goes on to point out:

Where are the elite’s achievements? Our betters have been running things and yet they are the ones crying loudest about how awful things are. It’s another scam, of course. Things are awful, but not for them

Thank God things are slowly changing.

The SNP: decline and fall (15 and a half)

I  think this should wait till the Nats’  less than enticing conference in Glasgow is finished, next week. There’s a bit to talk about, not least their ahistorical and opportunistic alliance with the reckless and mad Puigdemont (and the more reasonable Catalan separatists).

They’re still on the way down though. Read Stephen Daisley in the meantime, here.

salmstur
…we were happy once

Surgery will always be a matter of life and death

I’ve nothing against him personally, but when I’m urged to read Atul Gawande’s books about aspects of surgical practice, particularly outwith the technical skills, I wonder what makes him such an expert. Here’s the evidence:

Qualified in Medicine at Harvard in 1995 aged 30

Master of Public Health degree in 1999, then 6 years of residency training in surgery – ie. junior doctor acquiring experience – till 2003.

He spent quite a bit of time from the late 80’s involved in writing magazine articles and working in Democratic politics.

His first book, Complications: A Surgeon’s Notes on an Imperfect Science, came out in 2002, when he was still a junior doctor in training, far from the finished product. The next one Better: A Surgeon’s Notes on Performance, was released 5 years later. I assume he’d been busy in clinical practice for this time, with possibly some of the previously noted extracurricular activities getting in the way occasionally.

w-eugene-smith-dr-ernest-ceriani-following-the-loss-of-a-mother-and-child-during-childbirth-1948
…still a role model

An NHS consultant surgeon, 5 years in, working in a busy hospital is, in my view still very much on the learning curve. ‘Surgical maturity’, I would say, is at least 10 years in. Some people never get there.

Gawande’s Wiki entry implies that from about 2009 onwards he was doing more and more non-surgical things, fair enough, he seems an interested and accomplished fellow, but I feel very strongly that the way you get better in medicine is, I’m afraid, long hours, year in year out, in the wards, the theatres and the clinics. It’s a lifelong thing, even if – as I do – one has plenty of other interests.

One of the classic scenarios in the NHS is the consultant who having got to the top – as it was perceived in the old days – realises that he or she wants to get out. Often ‘management’ and ‘governance’ are the dubious beneficiaries of their career move, which amazingly usually involves telling working clinicians what to do. Not that I’m accusing Gawande of that, but some individuals closer to home, certainly.

Anyway, this preamble is to praise the benefits of long, hard won clinical experience, especially of the surgical kind. There is a significant difference between prescribing a drug – which could do harm – and opening someone up with a knife, which is intrinsically harmful before it gets better, even if everything goes well.

Is there a plausible alternative to working the hours? I think not. Don’t get me started on the world of ‘simulated surgery‘.

All of which brings me to a fascinating interview with both Stephen Westaby (69), heart surgeon and Henry Marsh (67), neurosurgeon. Both have a public profile, both have performed thousands and thousands of challenging high end operations, for the NHS. With respect to the aforementioned competition, these are the guys that I want to hear from. They’ve also written books for the general public, as it happens.

There are numerous gems in the interview, here’s some tasters:

HM:  We have this very complex relationship with patients. It’s not one of straightforward altruism at all; it’s a very difficult relationship. You have to be both hard and soft at the same time. You certainly don’t want to be empathetic. If empathy means you actually feel what your patients are going through, actually . . . you can’t do it.

…the problem is you could spend the entire national income on healthcare and everybody still dies — there is 100 per cent mortality — so you have to decide somehow where to set your artificial floor on that bottomless pit.

…[When he was PM] David Cameron made this speech about we must have “zero harm” in the NHS, which struck me as the most incredibly stupid thing to say because it suggests that when anything goes wrong, therefore somebody’s to blame. The whole point about medicine is it often goes wrong. The decision whether to operate or not, to recommend an operation or not, is all about probabilities, and these are very subjective, difficult judgments. Everything we do is in the face of uncertainty and a lot of the time patients come to harm. It doesn’t necessarily mean that anybody’s at fault. So I thought that was a very, very naive and rather silly thing to say.

SW:  The job is difficult enough without having the press and everybody else on your back. A British heart surgeon had the idea when he became the medical director of the NHS that surgeons’ death rates should be published and available for the newspapers. Let me ask you: which surgeons would have the highest death rates, the worst ones or the best ones? The best surgeons attract the worst patients like a magnet. So if you want to make your best surgeons defensive, you start counting the bodies and putting it into the public arena. My particular branch of the profession is now risk-averse. Fewer heart surgeons want to come to Britain to do heart surgery and the British especially don’t want to do heart surgery. They’re long operations, you can end up operating all night, every day of the week, and it’s taxing and it’s rotten when people die. It’s totally rotten to have to go out of an operating theatre and tell a couple of young parents that their baby’s just died on the operating table. It’s misery. None of us lose patients because we’re careless or don’t care. So I’ve seen my profession wrecked, I’m afraid.

HM:  Forty years ago, the power structure in hospitals in this country was very simple. There was a senior doctor, a senior nurse and one manager, and basically the hospitals are run more or less by the senior doctors, for better or for worse. Now you have a whole series of competing pyramids. The management, the doctors, the nurses — more or less autonomous now — the other paramedics and physios and people like that, so there’s a real sense of nobody being in charge. I would go to work in the morning and I wouldn’t know what I was going to do that day because it all depends. Is there a bed? Is there an intensive-care unit bed? Is there a bed on the high-dependency unit? You have to negotiate with each of these individual power structures, it’s deeply chaotic

…Another example is that, after the Stafford scandal [over nursing care] and the Francis inquiry [into it], the General Medical Council wrote to all the doctors saying that when a mistake is made you must apologise and then it said that this is usually the duty of the senior clinician; in other words, whoever makes the mistake, muggins here has to go and say sorry. And then thirdly it added that for an apology to be meaningful, it must be genuine. If the GMC can’t see there’s a problem here — if an apology is compulsory, how can you force it to be genuine? Well, the answer is that it is genuine if the senior doctors have a sense of authority, if they feel they’re trusted and then they do feel responsible for what happens in their department.

Just superb, and not calculated or self-serving, simply real world experience of something very important. Westaby’s line “The best surgeons attract the worst patients like a magnet” is very very true.

I’ll give him the final word:

 

The future of the NHS, AKA “stopping doing some things”

ab1
…he has a point

Nearly 70 years ago,  the declared bases of the NHS, were the much-quoted three founding principles, courtesy of Aneurin Bevan, a remarkable politician:

  • that it meet the needs of everyone
  • that it be free at the point of delivery
  • that it be based on clinical need, not ability to pay

This nice summary from the NHS’ 60th birthday in the BMJ provides the narrative:

The three principles stand up well. American patients admitted as emergencies often can’t believe how good things can be in a quality NHS unit. It’s true though that maintaining such quality without financial incentives/disincentives (unlike most developed countries) is getting harder to do.

Did we need to add to these three principles? I don’t think so, but in the time honoured manner of bored self important managers and clinicians drifting away from the frontline, we have. Try this, from a big cheese Welsh NHS seminar in 2011:

Universal access, based on need
Comprehensiveness, within available resources
Services free at the point of delivery
A shared responsibility for health between the people of
Wales and the NHS
A service that values people
Getting the best from the resources available
A need to ensure health is reflected in all policies
Minimising the effects of disadvantage on access and outcome
A high quality service that maximises patient safety
Patient and public accountability
Achieving continuous performance improvement across all
dimensions of healthcare

I’ve italicised the ones that I would call mission creep – they’re not strictly NHS issues – and also the ones that are platitudinous and glaringly obvious. I’ve put in bold the bits with which I agree, but nobody really means, as ‘within available resources’ in practice means rationing. I have yet to hear a sensible debate on real rationing of NHS services, which means stopping doing some things. The Scottish NHS goes on about ‘realistic medicine’, but despite lots of hype, it remains somewhat undefined in terms of stopping doing some things.

Principle 6 in the now seven principles of the NHS spelt out in the NHS Constitution, also from 2011, alludes to this:

nhs6

Which actually is worth spelling out. It’s the only way to keep the NHS viable. And what that means is….stopping doing some things. There are plenty of things that would have appalled Bevan and his colleagues, had he realised that’s what the NHS smorgasbord would end up providing. I have my particular favourites, you may too, and I include in my unpublished list quite a few of the elective procedures offered by my own specialty.

Bevan was following on from the flawed intellectual William Beveridge, who had a slightly broader remit looking at the role of the postwar state in more general terms:  “five giants on the road to reconstruction” that needed to be slayed: want, disease, ignorance, squalor, and idleness.

Beveridge was on to something then and now.

None of this is new of course, but my suggestion is that these admirable and clear principles have been abused by the sprawling megacity of the welfare state of 2017, the most loved component of which is the NHS.

For the record, I’ve worked in the NHS for decades, I don’t do private work. What we badly need, as taxpayers, patients, healthcare workers, rational human beings etc, is to restructure what the NHS does (which means stopping doing some things). It’s not hard in principle. Here’s the order of priorities:

  1. Lifesaving emergency treatment
  2. Pragmatic management of life-threatening conditions, mainly cancer
  3. Rapid access General Practice that includes real out of hours care
  4. Elective procedures that work – so stop doing things that don’t have proven benefit of adequate clinical significance. That’s actually quite a lot of things that currently go unquestioned.
  5. Appropriate public health/screening. So more colonoscopies, fewer stupid campaigns against booze (just to be topical).
  6. Better end of life care

There are lots of other areas of neglect – for example the adult physical handicapped – but many of these are primarily social care issues, and I would like to see that separated from the NHS conceptually and financially, whilst accepting that the much neglected interface between the two is very important.

Where Beveridge, Bevan and the modern welfare state collide is in at least two areas. Firstly, it would have been impossible for them to foresee the exponential expansion of high quality, effective but costly medical interventions. The human race got good at this very quickly. Affordability became difficult within a few decades of  the 1948 landmark.

Secondly, note Beveridge’s specific mention of ‘idleness’, which is effectively a codeword for what is loosely referred to as the Benefits Culture. Guardianistas don’t tend to focus on it. It is equally unaffordable in its current iteration. I’m not going to explore it, but interested readers will find illuminating references to it throughout the works of a master medical chronicler of these two centuries, Theodore Dalrymple (1, 2). Anyone with their eyes open in the developed world, particularly the UK, will know what I mean. As would Beveridge.

It’s fascinating to learn from the acerbic and erudite Geoffrey Wheatcroft something that may seem minor, but isn’t: Beveridge detested the expression “welfare state”.

wb1
…another zinger

 

 

The SNP: decline and fall (15)

Things are ticking over nicely. Three little gems:

48. Unfunny ex MP Eck could be going on tour

What is it about the bullying despotic politically inclined type that makes them want to go on stage? Eck is possibly following in the footsteps of gruesome thug Alastair Campbell (1, 2), in selling his tedious schtick for cash and adulation once the political spotlight has begun to fade.  German journalist Matthias Matussek, reviewing Campbell’s nonsense thirteen years ago said: He provided a strange white noise, two hours long. Sounds about right for Eck. What could go wrong?

49. Well this could..

Eck continues (see 47) to damn his successor with faint praise, knowing exactly what the headlines will say.

DISLOYALECK
…with friends like these…

 

50.  More seriously though. Money.

There is now a more open, and less adulatory mood in parts of the Scottish media when it comes to following whatever the SNP party line is this week.  Former Salmond adviser, Alex Bell, transformed himself into a sharp and knowledgeable critic of Salmond and the Nats some time ago. Here he is this week:

There are days when Nicola Sturgeon must wish Alex Salmond gone. Not for the sexist gags or the disloyalty to her (though how he would have hated that in return). It is the legacy which leaves her trapped between hard numbers and soft promises, destined to disappoint the nation…

….But she is never free of the legacy, the memory of her political mentor, as Salmond is built into every atom of the modern SNP. She can no more be free than start a new party – a thought that must have crossed her mind in darker moments. Her dilemma is when the annual round of economic figures (GERS) come out showing a big gap between what Scotland earns and what it spends within the UK.

If she admits the truth, that Scottish spending would have to be different to the UK budget, she exposes Salmond’s trickery. If she defends it, she holds the movement back from seeing the truth and facing questions about spending priorities and tax increases…

….Most of all, she has wrestled with the SNP belief that Scotland can afford what it wants because Salmond told them so. Whether Salmond ever believed this, I can’t tell. But it seems unlikely as the man isn’t stupid.

The numbers are the numbers – and they show that UK spending attached to Scotland is greater than Scotland could afford if it was detached. Salmond was smart enough to realise that admitting this would end up irritating voters so he never did. And because of what Salmond spun and the SNP believed, the party are based on an illusionist trick – that anything is affordable.

Painful stuff  for true believers, although evident to sentient thinking punters for years. If you want to know what those GERS actually show in their cold, uncomfortable detail, then visit the indispensable @kevverage over at Chokkablog.

Scottish National Party Hold Their Annual Conference
…keep him where you can see him Nicola…