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Links 12/16: Site Makes Right

The town of Monkey’s Eyebrow, Kentucky is supposedly named because it’s in a county whose shape looks like a monkey’s head, and the town is around where the eyebrow would be.

A man involved in a homophobic hate killing and a fellow prisoner who also murdered a gay man have become the first couple to gay marry in prison.

Claritas Prizm helps companies analyze consumer demographics using their system of 66 US social classes with cutesy names.

Ribbonfarm offers a live video blogging course aimed at “beefing up [their] pipeline of potential contributors”, complete with assigned reading, homework, and a fee. It’s already over, so don’t bother applying. I guess I’m just linking this so that one day, when I get put in jail for blogging without the appropriate licenses and certifications, I know where things started to go wrong.

NASA is publishing their paper finding that the EMDrive produces meaningful thrust; more skeptical friends have recommended this and this picking-apart of some of their methods. I know nothing about physics, but the little I know of social sciences recommends extreme skepticism about effects so small that it takes heroic effort to distinguish them from noise, especially when they don’t respond to manipulations in predictable ways.

Time-waste subreddits for the week: /r/nononoyes, /r/yesyesyesno, /r/nononoawwww, /r/nonono, and various things along those veins.

Prescient Marginal Revolution post from last year on how celebrities and CEOs make better politicians than politicians

One of the better post-election-handwringing pieces: Nathan Robinson, What This Means, How This Happened, What To Do Now?

The Atlantic: are transgender people more autistic? If so, why? My thoughts on this deserve a full blog post, but for now I’ll just leave this paper on autism in congenital adrenal hyperplasia and let you draw your own conclusions.

Ben Carson declines a role in Trump’s cabinet on the grounds that he is a doctor and knows nothing about politics and would probably screw it up. On the one hand, this is admirably humble and clear-thinking. On the other, I am kind of confused what he thought he was doing when he ran for President. Update: Trump picks Carson to lead HUD.

Reddit asks people who randomly ran into Donald Trump before he was President what he was like in real life. A surprising number of New Yorkers had encounters with him, and all gave pretty much the same picture.

Kanye West: I didn’t vote, but if I did I would have voted for Trump. Possibly related: Kanye West hospitalized, placed on psychiatric hold. Old, but relevant under the circumstances: Scott Adams: The Odds Of A Kanye West Presidency Are 90 Percent.

The North Pole is 36 degrees warmer than usual right now, with extreme effects on sea ice.

Chinese scientists claim they can use machine learning to predict criminality from facial appearance. Still needs a lot of double-checking before accepted, but basically believable. Maybe related to mutational load: “The variation among criminal faces is significantly greater than that of the non-criminal faces. The two manifolds consisting of criminal and non-criminal faces appear to be concentric, with the non-criminal manifold lying in the kernel with a smaller span”.

Less Wrong is trying to regain its status as a good discussion hub and it’s actually going pretty well. Among the posts there worth checking out: A Return To Discussion, Double Crux: A Strategy For Resolving Disagreement, and Sample Means: How Do They Work?

Related to the Return To Discussion post: is an intentionally confusing interface the secret of Tumblr’s success?

Ozy at Thing of Things did a social justice Intellectual Turing Test.

NEJM: genetic risk and healthy lifestyles are independent determinants of cardiac disease. That is, whether you have a high or a low genetic risk, living a healthy lifestyle will decrease your risk of heart disease about the same relative amount.

SSC reader Fiona van Dahl, some of whose other work has been mentioned here, has a new novel out, New Night.

Remember Trump’s claim that millions of non-citizens voted in the election? It comes from a journal article in Electoral Studies (article, popular summary) calculating that several hundred thousand non-citizens probably voted in the 2008 election. But further research has challenged that claim (study, popular article), and it now seems to be very much in doubt. [EDIT: National Review defends the study, and relevant SSC]

Related: the studies above form part of the backdrop of Nathan Robinson’s excellent article The Necessity Of Credibility: To Prevent Fake News You Have To Offer Real News. I think it says a lot of important things, but it does miss the important question of when you should or shouldn’t report on exciting-sounding but not-yet-replicated studies – and so fails to have a good theory of whether the villains of the piece even did anything wrong.

In my post on Daraprim (the toxoplasma drug Martin Shkreli hiked the price of), I noted that the Daraprim molecule looks easy to make and somebody could probably cook up a batch for pretty cheap as an act of civil disobedience. Now it’s been done: Daraprim Drug’s Key Ingredient Recreated By High School Students In Sydney For Just $20.

Looking for a good charity to give to over the holidays? Aceso Under Glass makes the case for Tostan.

The wit and wisdom of new Defense Secretary pick James Mattis: “Be polite. Be professional. But have a plan to kill everyone you meet.”

Andrew Gelman: How Can You Evaluate A Research Paper?

A lot of Castro retrospectives were along the lines of “Cuban communism could be brutal, but at least it brought people good affordable healthcare”. But Cuban healthcare and other public services actually underperformed most other Latin American countries during the Castro period.

Big Macs vs. The Naked Chef – on problems of scalability. And Miranda applies this to nursing.

Today in “forced to have grudging admiration for people I don’t respect very much for speaking out unexpectedly eloquently against people I respect even less”: Sarah Palin denounces Trump Carrier deal as crony capitalism. I have a really bad feeling that this ends with every company that was planning to do something good anyway crediting Trump in exchange for free Presidential goodwill, and we get a neverending string of apparent Trump victories that are very hard to disprove.

The surprising popularity of the (American) far right in China

Internationally Comparable Math Scores For Fourteen African Countries. African countries’ math scores are “significantly lower than predicted by African per capita GDP levels, and converging slowly, if at all, to the rest of the world during the 2000s.” Apparently the African economic boom is not going to solve educational problems on its own. Best case scenario: we just need more deworming.

Also in bad news: South Sudan “on the brink of genocide”

kontextmachine on the history of county power in the US.

I’ve previously criticized Vox in general and Sarah Kliff in particular for their pieces on drug regulation, so I should give credit where credit is due: their latest article, The True Story Of America’s Sky-High Prescription Drug Prices, is pretty good and well-balanced (aside from using stick figures, which I find condescending and annoying). It also uses the word “trade-off” seven times, which is how you know you should trust it.

Globalization Not To Blame For Income Woes, Study Says. But you can mostly skip the article itself in favor of this convincing re-imagining of the famous “elephant graph”.

US labor productivity still increasing at same rate as always, apparently.

The new King of Thailand, Vajiralongkorn Borommachakkrayadisonsantatiwong Thewetthamrongsuboriban Aphikhunuprakanmahittaladunladet Phumiphonnaretwarangkun Kittisirisombunsawangkhawat Borommakhattiyaratchakuman (Vaj to his friends). Interesting fact: he got second-class honors (= a B grade) on his law degree in a Thai university. I feel like when someone feels safe giving the Crown Prince a ‘B’, that’s a good sign that your country is sufficiently non-corrupt.

New study on Swedish intergenerational mobility finds somewhere in between Clark and his critics.

Trump’s election victory raised interest in epistocracy, a hypothetical system of government where only well-informed people can vote. A new blog post pops that bubble, calculating that Trump beat Clinton among well-informed voters by an even bigger margin than among the general public, although note that the methodology uses broad demographic bins and can’t prove this is true of individual voters.

Lord Dunsany wrote a sequel to The Tortoise And The Hare, where there’s a forest fire and the animals need to send warning quickly. Since they have already determined that the tortoise is faster than the hare, they send him to spread the message, and everybody burns to death. This is probably a metaphor for life.

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Thin Air

The International Journal of Obesity (h/t amaranththallium) points out a correspondence between US topography and US obesity rates:

It’s easy to see the Rocky Mountains on the obesity map. Not too hard to see the Appalachians either. Squint a little and you can even see California’s Central Valley vs. its coastal ranges.

This doesn’t seem to be related to poverty or population density. It does look a lot like the map of exercise level, but apparently it stays significant even when you control for that.

The IJO study finds that people living at sea level are five times more likely to be obese than people living at 500m elevation, even after controlling for “temperature, diet, physical activity, smoking, and demographic factors”. I don’t always trust controlling for things, but in this case the effect is big enough, and similar enough to the results of eyeballing, that it seems pretty plausible. Also, European studies find the same effect in high-altitude areas there, as do studies in Tibet. And someone did a study on US soldiers, who are randomly assigned (via deployment) to different areas, and found the same effect controlling for BMI at enlistment.

(on the other hand, a study in Saudi Arabia finds the opposite. Whatever. I didn’t even know Saudi Arabia had mountains.)

So what’s going on? There’s a well-known phenomenon called altitude anorexia where lowland people going to a high altitude suddenly can lose a lot of weight. Unfortunately most of the studies just stop at showing an acute effect; it’s not clear how long it lasts or whether there are more general principles involved. One study on rats found that they ate 58% less one day after being transported to Pike’s Peak, and were still eating 16% less per day two weeks afterwards. An article in High Altitude Medicine noted without further details that altitude anorexia seemed to persist after initial acclimatization. Pugh et al note weight loss of 1 kg/week up to 5-10 kg over a several week Everest ascent, reversing quickly as the climbers descended. A controlled experiment where obese subjects were ferried to the Swiss Alps, told to eat as much as they want, and banned from exercising resulted in weight loss of three pounds after a week, mostly sustained (?!) after a month at low altitude. It seemed mediated by eating less, which was independent of altitude sickness and persisted after people were no longer altitude-sick.

The active ingredient of altitude seems to be hypoxia. The air is thin at high altitudes so the body gets less oxygen. Being in low oxygen conditions in normal pressure seems to cause weight loss too – see here and here for studies of people exercising in low oxygen conditions. I don’t know of any studies where people were just kept in low-oxygen environments for a long time without exercise to see what happened to their weight. It’s not really clear how reduced oxygen makes people eat less. A lot of people mention leptin, but the studies seem pretty unconvincing, and people try to work leptin into everything.

This BMJ editorial suggests that hypoxia should get credit for smoking-related weight loss. But it reads like a completely unhinged screed from the tobacco lobby of an alternate dimension (“Might the aggressive anti-smoking lobby have contributed to the costly epidemic in obesity and type 2 diabetes that Professor Sir George Alberti have warned us about?”) so maybe we shouldn’t take it too seriously. Also, nicotine gum works just as well as cigarettes here, so it’s probably an effect of the nicotine itself, and in fact we have some pretty good ideas how this happens. Maybe unhinged screeds by alternate-universe tobacco lobbies aren’t the most trustworthy source of information.

Anyway, this is boring. Let’s move on to a more interesting question – did global warming cause the obesity epidemic?

The arguments in favor: there’s a lot more carbon dioxide in the air now than there was just a few decades ago. The obesity epidemic began around the time carbon dioxide concentrations really started getting worrying. And there are various body functions that are exquisitely dependent on CO2 levels. Bierworth (2014) has a good run-down of some of these and how they might be affected by increasing atmospheric CO2 levels (dear conservatives who always talk about Chesterton’s Fence and principle of precaution – has it occurred to you that doubling the concentration of a major bioactive atmospheric gas might be a bad thing?). I see some conflicting claims about how much atmospheric CO2 could affect average blood pH. Neurons that produce obesity-regulating chemical orexin are potentially very sensitive to blood pH, so maybe this could be involved?

Wild animals are affected by the obesity epidemic too, even though they eat far fewer Big Macs. Even lab rats and zoo animals, supposedly kept on a well-monitored diet, are heavier now than they were decades ago. It’s hard to think of some obesogenic factor so prevalent that it could seep into laboratories and zoos unnoticed by scientists and zookeepers. If it were a chemical, it would have to be really prevalent. The xenoestrogens in the water are one possiblity. But the other is the atmospheric gas breathed in by every living thing which we already know has been increasing for decades.

This at least is the theory of epidemiologist Lars George Hersoug. He did a study where he put some people in a high-CO2 room and found that they gained weight. It got a decent amount of press.

I really like this theory. It’s elegant. It’s clever. It’s at exactly the right level of contrarianism to be fun. If it were true, it would solve global climate change – once tabloids covers trumpet THE ONE SECRET TO A TIGHT BELLY DOCTORS DON’T WANT YOU TO KNOW – TELL YOUR CONGRESSMAN TO PASS THE PARIS AGREEMENT TO LIMIT CLIMATE CHANGE TO WITHIN 2 DEGREES CENTIGRADE OF PRE-INDUSTRIAL LEVELS, we will finally get Middle America on board. Insofar as scientific theories can be “fun”, this theory is fun.

But I grudgingly acknowledge that it’s probably not true.

For one thing, the study involved kind of sucks. It has a sample size of six. The six people were in a chamber that elevated CO2 levels about 50x higher than human industrial activity has elevated them in the atmosphere. And it got a non-significant result. In fact, food intake decreased in three of the six subjects, with almost all of the (nonsignificant) positive trend coming from one guy who apparently was just really hungry that day. There is a decent study showing CO2-related orexin effects in mice, but it’s at 2000x atmospheric concentrations. Also, when I look at the orexin neuron calculations, even if their hypothesis is true it suggests that orexin neurons might fire a little less than 1% more often now than they did 100 years ago. Unless there’s something really nonlinear going on, this is not enough to cause an epidemic.

For another, it doesn’t seem to line up geographically. Zheutlin, Adar, and Park try to correlate the geography of US obesity with the geography of US atmospheric CO2 in the same way that some of the studies above successfully correlated US obesity with US altitude. Here they fail. After adjusting for appropriate confounders, there is no clear relationship between CO2 levels and obesity. I think this might also reflect a more general point, which is that CO2 has been rising all over the world but obesity hasn’t; Japan, for example, is a very high CO2 emitter but has almost totally avoided a US-level obesity crisis.

(but while we’re talking about this study, it did find that serum bicarbonate has been increasing over the past decade or two. No proof as yet that this is a real effect or related to CO2, but have I mentioned that increasing the concentration of a bioactive atmospheric gas worldwide is a really bad idea?)

One last counterargument. A global warming skepticism blog points out that submarines are a natural laboratory for the effect of high CO2 on human health, since they usually have CO2 levels up to ten times atmospheric (and several times worse than even a poorly-ventilated building). I don’t see any formal tests of their own argument, which is that submariners don’t suffer any cognitive problems, and I’m not sure they’re right to use intuition and failure to notice gross impairment – after all, the original studies showing impairment were done in office buildings, and there’s no grossly noticeable differences there. But in any case, the Navy actually did a formal study and found that submariners do not gain weight. This seems pretty fatal for a CO2 = weight gain theory.

So my guess is that Hersoug is wrong and CO2 doesn’t cause appreciable weight gain in normal concentrations. We should abandon the beautiful theory of climate-change-induced obesity and go down a level of contrarianism to blaming boring normal-person things like xenoestrogens and gut microbiota.

(I’ve heard there are theories of obesity even less contrarian than those, but I’ve never been to such low contaranianism levels and wouldn’t be able to tell you what they might be.)

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OT64: Openn Thread

This is the bi-weekly visible open thread. There are hidden threads every few days here. Post about anything you want, ask random questions, whatever. Also:

1. Thanks to Brendan Long for doing some work to make the blog appear better on cell phones. Cell phone users, please let me know whether it’s actually better now.

2. I would like to do a new SSC Survey soon. If you have any ideas for interesting questions, let me know. I’m not going to include very many reader-requested questions, but if someone comes up with a really good one I find really interesting it might make it in.

3. I will be at this meetup in New York City on December 18. If anyone else wants to come, I’ll see you there. ADDED: Also, we are still looking for a location, so if anyone has a big house in New York City and wants to help us, we can figure out some way to make it worth it for you. Please let me know or email schnaigs@gmail.com

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Highlights From The Comment Thread On School Choice

Several people including Yehoshua K and Freddie deBoer point out that “nonprofit” and “for-profit” are potentially meaningless terms in situations like these.

IrishDude adds some context to the for-profit hospital scene by noting that companies are not allowed to open new hospitals until they apply for and are granted a Certificate Of Need, apparently on the basis of a theory that an oversupply of hospitals would increase (?!) costs.

Algorizmi describes his work with a private school that costs less than half as much as most public schools, including how it saves money

Half a dozen people yell at me for saying that the grocery industry worked well for the poor, objecting that I had forgotten about Food Deserts. Various other people save me some time by pointing out that most of the claims about Food Deserts are kind of fake (1, 2, 3). There’s a defensible version of the term, which is that in very poorly planned car-centered zoning-regulated cities without good public transportation it’s not always possible for someone without a car to easily get to the stores they want, but just posing the problem that way makes the solution pretty obvious.

Spotted Toad is great as usual, pointing out among other things that Obama has already led the most pro-charter administration in history.

Douglas Knight proposes that college demand curves are upward-sloping, which is kind of terrifying but seems to have at least anecdotal support.

Robinson: “The things needed by poor people, if done well, will never be money-makers.” Matt M: “A bold claim considering that the biggest company on Earth, more than double #2, serves the needs of poor people almost exclusively.”

MDP has worked in the payday loan industry and explains how their interest rates can be so high and their profits so low.

Many people (1, 2, 3) point out the high cost to schools of misbehaving kids, and try to explain the rise in education costs by saying that kids today are raised wrong (or not at all) which makes them harder to control. But everybody who looks for this kind of thing finds the opposite – kids today have less teenage pregnancy, crime, dropouts, et cetera. I don’t know if anyone has specifically looked at classroom misbehaving, but it would be weird for that to be getting worse in such an isolated way.

Lots of people are very angry at me for posting the graph from the Cato Institute for various reasons. A few people object that it is dishonest because it didn’t adjust for inflation, even though it did adjust for inflation and is very clear about that. A few people object that it is dishonest because it puts cost increases and score increases on the same scale as each other, instead of skewing them to make the effect look bigger than it really is – this is a definition of “dishonest” I haven’t heard before (maybe I am being uncharitable here?). Several others say that test scores have increased more than they give credit for. You can look at a very good summary of test score changes here. You’ll see there are some gains among younger students, but much fewer among older kids – for example, 17 year olds’ math scores went from 304 in 1971 all the way to 306 in 2012. This is not just a race-related Simpson’s Paradox – among white students alone, for example, the gain was 4 points (though blacks did gain 18, as I mentioned before). I am not sure what good it is to have high gains in early years if those gains are all lost by the time kids leave school. Overall I think the Cato graph comes out looking pretty good. But even if you disagree, I would ask you to pick whatever metrics you want – your favorite test, racial group, axis scheme, whatever – and tell me whether it really looks like the doubling-to-tripling of education costs during the relevant time period has been money well-spent. If not, then as happy as I am to debate details in the comments, it all seems like basically nitpicking.

Jonah Katz brings up a really complete analysis of increasing costs in higher education:

The rising cost of higher education isn’t quite so mysterious, at least for the last 10-15 years. The Delta Cost Project has put together some fairly comprehensive data about this. What you see across most categories of post-secondary institutions is that basically *everything* is becoming more expensive, but ‘student ‘life’ and ‘academic support’ are rising fastest, followed by ‘institutional support’. Student life is all of the bells and whistles (athletic centers, movie theaters, etc.) that colleges use to try to entice prospective students into paying huge amounts of money to enroll in their institutions, and I believe it also includes health and mental health services, which I would imagine have become exponentially more expensive over the past couple decades (this is probably unavoidable, because health costs are going up in general and universities are enrolling a far wider range of students with more mental and physical health issues who wouldn’t have gone to college in the past). Academic support includes a mix of stuff that is crucial to the academic mission of a university (libraries, IT systems), stuff that is arguably not part of the core academic mission at all (Dean’s Office personnel, museums), and stuff that is well intentioned but tends to be useless in practice (central offices for teaching and curriculum development). Institutional support is administration proper. Note that these data come from 2003-2013, so they don’t capture the explosion in university administration that is generally agreed to have occurred from roughly the 1970s to 1990s. I’ve never been able to find categorized data that goes back that far, but I imagine the change in spending on administration during that period must have been astronomical. The cost of instruction is still the largest single category of expenditure, and accounts for the majority of absolute price increases, but proportionally it is not rising as fast as these other categories. Also, the NY times Op-ed piece you link to is either selectively pulling misleading data or is just plain ignorant about the state of public financing for higher ed. There has not been a ‘modest’ reduction in per-student funding: it has dropped around 30% in inflation-adjusted dollars since 2000.

Static brings up the role of pensions as a driver of schooling cost increases.

Swing finds there have not been similar cost increases in the Netherlands. And Politifact rates as true a similar claim – that we greatly outspend other First World countries in per pupil spending. This article notes that we spend about 25% more than Britain and almost 50% more than Germany. On the other hand, the Netherlands is only a little better than we are, so this doesn’t match a scenario where the Netherlands’ spending goes up by only a little but America’s goes up by 200%. I don’t know where the discrepancy comes from. {EDIT: Douglas Knight points out that most countries have per pupil spending as a similar percent GDP)

Various people chime in with their favorite anecdotes about school vouchers working very well (DC) or working very poorly (Sweden). Murphy describes a personal bad experience with school privatization. At some point I do want to go through and sum up all the empirical literature on this, but not now.

Many people mention the possibility for bad incentives or market failures in schooling. 1soru1 thinks that, absent better signals of quality, schools will compete on shininess and raise prices to have the biggest and most breathtaking stadium (which I think is what the post above was saying happened to colleges, so certainly plausible). Tanagrabeast describes finding the private schools in Arizona heavily politicized: “What Scott worries about is already happening. I was skeptical until I took my son to an open-house at a fast-growing chain of charters where they tried very hard to play conservative buzzword Bingo and did all but lead us in a prayer to the Founding Fathers.” In contrast, Doctor Mist says that as a rightist, he feels like going to a private school lets him escape what he sees as public schools’ existing liberal politicization.

EarthSeaSky is a purist and reminds us that the free market which can be named is not the eternal free market.

Steve Sailer argues that for-profit colleges are a natural comparison group for for-profit primary schools, and they are very bad.

I talked to Education Realist on Twitter. Their position is complicated but they recommend their posts The Fallacy At The Heart Of All Reform and Charters: The Center Won’t Hold as introductions/summaries. I am still not entirely clear on their position – the objection seems to be that successful charters succeed only by taking the best students who would get good test scores anywhere, then claiming charters raise test scores. Obviously charters are trying this, but every halfway-decent study on charter schools has tried to control for this possibility. Also, none of my points involved empirical claims that charter schools raise test scores, so I don’t see why this discredits me in particular. They also note that US education is already pretty good both compared to other countries and compared to its own past, something else I agree is true and have never denied.

Levarkin brings up James Tooley’s fascinating work on private schools for the poor in Third World countries.

And Justreggedthis on the subreddit makes what I find the most convincing argument in this whole discussion:

Sweden’s experiment with school vouchers showed a different problem: the market delivers what you want, not what you need. What (stupid) parents want is good grades. What kids need is good education. So precdictably, voucher schools ended up diluting grades. You can probably imagine how it works. We live in an age of narcissism. Many parents want to hear their kids is super, special, and a genius, and get straight-A grades for a performance that is at best average. Few parents have the character left to stand up to it, and want challenging education and honest grading.

Of course this is a problem with people, not vouchers. I am sure the very same narcissism in modern culture also rears its head in public schools as well.

The classic solution was school principals having low time preference and interested in preserving the long-term good name of their school. So they would not agree to grade dilution, they would not encheapen the brand of their school.

Seems like today time preferences are high.

Grocery stores are a good parallel. You need healthy food. You want (a stupider version of you wants) gallon buckets of ice cream. Hence, you get all kinds of special offers and discounts on tasty and cheap gallon buckets of ice cream. The market delivers what you want. Hence, obesity epidemic.

I don’t really know any solution that is acceptable within a democratic framework. Obvious someone somewhere should override personal preferences, but that someone should have a very good set of incentives and that is what we don’t get in this framework.

Overall reading this has made me somewhat more pessimistic about charter schools. But I’m still uncertain enough that I want to look into the empirical literature more, and I still think careful experimentation is the way to go.

…so maybe I should end with shadypirelli’s comment from the subreddit pointing out that Betsy DeVos’ policies cannot be described as “careful experimentation”.

Contra Robinson On Schooling

I.

Nathan Robinson argues against school vouchers: Why Is The Decimation Of Public Schools A Bad Thing?

(note that despite the inflammatory title, he’s arguing that the decimation of public schools is, indeed, a bad thing)

He starts with a meta-level point: most criticisms of Trump’s Education Secretary nominee Betsy DeVos merely point out that she will promote schools vouchers instead of public schools, expecting their audience to be suitably turned off. But this won’t change the minds of DeVos supporters, whose whole point is that they want more school vouchers. In order to convince people, you’ve got to convince people. If this doesn’t seem like a suitably profound insight to you, the click the link, read the piece, and notice how there’s something weird about it. Is it written in a funny font? Is the computer screen flickering or something? Finally, you realize with dawning horror that this is the first time you’ve read a logical argument, written in good faith and intended to convince someone, in the past you-can’t-remember-how-many months.

But anyway, let me explain why I think it’s wrong.

Robinson says:

Introducing profit into the school system is very dangerous, for a simple reason: it creates a terrible set of incentives. If we hand a voucher to a for-profit private school, or give a large grant to a for-profit charter school, there is a strong incentive for the school to give as little in return as possible. After all, since a for-profit corporation exists to maximize value to shareholders (not value to students), for-profit schools should try to spend as little money educating students as possible, in order to reap the largest financial gains. If you don’t have to spring for new lab equipment or new textbooks, you have no incentive to do so merely because it would benefit the students.

He does note the obvious counterargument, but he’s not convinced:

Privatization advocates have a compelling response to this argument. They reply that it misses the full picture. Yes, corporations have an incentive to maximize shareholder value. But they can’t do that without satisfying their customers. The interests of shareholders and consumers are brought into alignment through the existence of choice. In the case of schools, because parents have a voucher, if the school is not prioritizing its students, parents can simply go elsewhere. Nobody is making them send their students to this particular school. The theory of school choice is about choice, and choice creates competition, which creates quality. A school that simply funneled money to its executives and shareholders would not long maintain its enrollment.

But the theory of choice here is a romantic fiction. In reality, parents will not have many options among which to choose (there are only so many schools within a feasible distance of one’s home, after all) and moving schools can be an extraordinarily disruptive and complicated process that hurts the child. We can also see how, even in theory, it is easy for a privatized school system to simply enrich the wealthy, while making schooling for poor children worse. In a public school system, all money is spent on the schools. In a for-profit school system, at least some portion of that money is directed instead toward the pockets of shareholders (if it wasn’t, the for-profit schools couldn’t continue to exist). And if we have a school district comprised in total of three for-profit elementary schools, and all of them simply pocket most of the voucher money while failing to educate the children, then no matter what “choices” among schools parents make, they won’t be able to improve the quality of the schools. One might expect new operators to enter the market, but if the only way to make any real money on the children is to neglect them, then new operators won’t be any better than the old ones.

This is a good point, made somewhat weaker by failure to consider why it doesn’t apply to everything else.

Robinson compares school vouchers to foodstamps, which are basically “food vouchers” to be redeemed at grocery stores. I often see poor people using food stamps at my own grocery store, so I know the quality of service these poor people get for their money. And it is really good. Practically all grocery stores are really good. There’s a story about Boris Yeltsin coming to America for the first time, walking into a random grocery store, seeing that random middle-class Americans had a better selection of goods than the highest-status Soviet officials, and freaking out that this was some kind of weird Potemkin economy that the Americans had set up to demoralize him. Grocery stores don’t just have fifty different kinds of cereal and a hundred different kinds of soda, they’re also really cheap. You can buy a day’s worth of food for an hour’s minimum-wage work, maybe two hours if you want a little quality and variety.

So why don’t grocery store shareholders leech off so much money that everything is overpriced and has terrible service? Why aren’t stores dingy and full of rats? Why don’t we have a world where, as Robinson argues, the theory of choice is a romantic fiction because all of the grocery-related options available to poor people are terrible, and no new operators can do a better job because the only way to make money in the grocery business is to shaft customers and have a terrible store selling rice mixed with sawdust?

Something like 48% of Americans are satisfied with the education system in the US. My guess is 100% of Americans are satisfied with the grocery system in the US. Why should this be?

My guess: the loss from profits matters less than the gain in efficiency.

Profit margins are a specific number. You can just look them up. Usually they’re not very big. Once you look up that number, you know how much profit the company is making. After that, you’ve circumscribed “the dangers of profit” to a relatively small amount.

An example: Health care in this country is overpriced and everyone knows it. Some people think this is because greedy insurance companies are charging too much in order to make a profit.

But health insurance companies have a profit margin of about 3% (see caveats here, but I do think the 3% number is the one relevant to this discussion). This is a big deal in terms of absolute number of dollars. But it’s not a big deal if you’re wondering how much they affect health care costs. If you’re paying $5,000 a year for health insurance, then take away all profit motive from the insurance companies and you would pay $4850 a year for health insurance. This is less than year-to-year variation, let alone any of the components that actually matter.

Insurance companies aren’t callously throwing sick people out on the street for profitability reasons, they’re callously throwing sick people out on the street because they can only pay as much money as their customers give them and that isn’t enough to fund as much health care as people need. Or, well, maybe out of the people they callously throw out on the street, 3% are for profit and the other 97% are of necessity.

The same is true of other famously predatory businesses like payday lenders. Wikipedia notes:

In a profitability analysis by Fordham Journal of Corporate & Financial Law, it was determined that the average profit margin from seven publicly traded payday lending companies (including pawn shops) in the U.S. was 7.63%, and for pure payday lenders it was 3.57%. These averages are less than those of other traditional lending institutions such as credit unions and banks. Comparatively the profit margin of Starbucks for the measured time period was just over 9%, and comparison lenders had an average profit margin of 13.04%. These comparison lenders were mainstream companies: Capital One, GE Capital, HSBC, Money Tree, and American Express Credit.

Payday lenders aren’t charging outrageous interest rates so they can get fat off the profits. They’re charging outrageous interest rates because loaning money to poor people who often fail to pay back their loans is a hard business to break even on.

Now apply this logic to private schools. You think they’re going to ruin everything by funneling more and more money into their own profitability? I propose that about 11% of their funding would go to profit, the same as current private schools. Actually less than that, since most current private schools serve rich people who don’t care about outrageous markups as long as they can buy prestige.

But isn’t 11% still more than nothing? If private schools cost the same amount of money as public schools, but 11% of that went to shareholder profits, wouldn’t our children receive an 11% worse education?

Or to put it another way – what are we buying with that 11% of the education budget?

The hope would be that we’re buying efficiency.

Robinson writes:

Let’s consider what the conservative argument on schooling actually is. It goes like this: government-run institutions tend to function poorly. They are not efficient, like businesses are, because they do not have incentives to perform well. Businesses, because they must compete for customers in a market environment, must offer the best products if they want to stay profitable. Governments, on the other hand, can offer crappy products, and because they are state-imposed monopolies, there is no way for consumers to go elsewhere. School choice will improve schools, because instead of forcing students to attend whatever school the government happens to offer, choice allows parents to decide which school they prefer. Schools will have to strive to be better and better, because parents can pull their students out and go elsewhere if they don’t like them. Introducing a profit motive into schooling offers a powerful incentive for schools to offer a great product. If there is money to be made on being a good school, you can bet businesses will want to provide great schools. Thus private, for-profit schools with vouchers are a highly efficient way of delivering the best-quality education.

He counters that “introducing profit into the school system is very dangerous”, but never really says that the argument above is wrong. So we’re looking at a tradeoff here. There’s the dangers of profit and the promises of better efficiency. If profits aren’t going to take too much money out of the system, might the gain from efficiency be worth the small cost?

Here is a graph by the Cato Institute – note that this is already adjusted for inflation:

In case you don’t trust them, here’s Politifact rating a similar claim mostly true, although they get slightly different numbers using a different methodology.

What are we to make of this? It’s not that teachers are getting paid any more – their salaries have remained stagnant over the time involved and they may even have lost ground compared to other professions. It’s not that school buildings cost more – I don’t have good data on schools in particular, but I looked into skyscrapers and found there wasn’t any general rise in construction prices. So how is an activity which basically involves getting a bunch of kids into a building and throwing a teacher at them rising so dramatically in the absence of changes in building or teacher prices? I’ve only heard three theories:

The first theory is that student test scores are improving, but we’re stuck in a Simpson’s Paradox. That is, students of some racial groups get higher scores than others, every racial group’s score is improving, but a higher percent of students are in low-performing racial groups now which is bringing the average down. But it looks like race-specific scores are also stagnant (1, 2), with the possible exception of a jump for blacks between 1980 and 1990. Given that no other ethnic group had this jump and school spending has increased at a constant rate the whole time, I think this is more likely socioeconomic factors than education spending.

The second theory is that all this extra money has been used to help previously underserved special needs kids. But these kids apparently cost about twice as much as average to educate. Up to 13% of students are special needs, although I don’t know if that’s the same definition of “special needs” as the people calculating the cost used. But if we take that as our estimate, then providing extra services to special needs kids can explain a rise of 13% in education costs, but not the 150% we actually see.

The third theory is Wilde’s Law: “The bureaucracy is expanding to meet the needs of the expanding bureaucracy.”

One argument in favor: the same thing that’s happening to primary education is happening to college education. College costs about 4x as much (inflation-adjusted) as it did in 1980.

This is not because of decreased government subsidization. It’s not going to shareholders – most colleges are nonprofits and even public institutions have seen outsized increases. And although I don’t have any equivalent to the flat-lining test scores from primary school, today’s college students don’t seem to be four times better-educated than those of yore. So where did all that money go?

I don’t think anybody knows. There are whole studies that have been done on this. Every so often people argue about it on the editorial pages. Some people say “administration”, other people say it’s not exactly administration but it’s something else. I don’t know. But it doesn’t seem to be Simpson’s Paradox or special needs kids.

A lot of smart people think that easy availability of student loans fueled college cost increases – see eg here. The theory was that colleges could charge more money, so they did. I definitely don’t understand how this works economically, but it seems like somehow easy availability of money combined with lack of real competitive pressure caused colleges to increase administration and pass the cost on to students. Maybe something similar happened in primary schools?

If this third hypothesis of increased primary school costs is true, then going back to the level of bureaucracy we had in 1970 would cut costs by 75% while maintaining similar test scores. Or it would allow us to keep costs constant and pay for things that actually work.

The point is, private schools lose 11% of their funding to shareholder profit, and public schools apparently lose 75% of their funding to, uh, nobody really knows.

Do private schools also lose 75% of their funding to nobody-knows, since I don’t see many of them around as cheap as schools were in 1980? I’m not sure. Arnold Kling does some calculations here and suggests that private schools should have really big profit margins. But they apparently don’t. Overall I admit I am confused on this issue. But I am a little more hopeful that private schools might be able to work this issue out than that public schools can. [EDIT: see note at bottom of post]

It may seems kind of bloodless to focus on cost. But the amount of money added to the public school budget without any change in outcomes is more than enough to house every homeless person in the country in style and comfort. Money matters. And when we talk about private schools being obsessed with profit, that’s an argument about money. It’s acknowledging that every dollar diverted to shareholders is a dollar that isn’t going to improving education, housing the homeless, or something else useful.

Robinson writes:

It’s because the things needed by poor people, if done well, will never be money-makers. Introducing an incentive to make money will necessarily mean exploiting and neglecting the poor, whose “choices” are highly constrained by their circumstances. I fear privatization not because of some mystical devotion to the inefficiencies of government but because I fear the erosion of the idea of education as something that isn’t win-win, that we give to children because they deserve it rather than because we can profit from it. I worry that the sort of people who run things “like a business” do not really care about children very much, and are motivated by the wrong incentives. I am concerned about what would happen if they ever faced a choice between doing the right thing and doing the lucrative thing.

With all due respect, I think there is something mystical in this thought process, some demon best exorcised with a bell, candle, and Public Choice Theory textbook. There’s no object called The System, which is focused on profit in businesses and focused on education in public services. There’s just a bunch of people motivated by a combination of ethics, incentives, and trying not to get fired. Business isn’t antithetical to caring – the average family doctor is motivated by desire to help patients, even though she’s also a small business. And lack of a profit motive doesn’t guarantee good behavior – it looks like the administrators of nonprofit colleges decided to spend their windfall on prestige and empire-building rather than on keeping costs low.

I have very low confidence in this. I know many people who are involved in education, and they are all very good people who are very passionate and definitely would never skim 75% off the top and use it to buy gold-plated yachts for themselves. In my home state of California, there was a big funding shortfall ten years ago, and schools tried to cut everything they could, but finally they said there was nothing left to cut and they had no more ideas, and I believe that they tried as hard as they could. If bureaucracy is inflating the price of schooling, it’s not doing so in an obvious way where you can point a finger at the exact bureau involved.

But it might be a general ethos of inefficiency that makes a lot of little things add up – I know it is in health care. And I at least think it would be worth trying the experiment.

(I realize the experiment is already being tried, with wildly varying results based on the specifics. I want to look into this research in more depth soon to see if there are any consistent trends.)

II.

A digression to support my point that sometimes increased efficiency can compensate for money diverted into profits – what about hospitals?

Hospitals are about evenly split between for-profit and not-for-profit institutions. Measuring “hospital quality” is even harder than measuring school quality, but researchers have tried to do this on various metrics. The results are hard to sum up, and I was only able to find a few studies and not anyone’s magisterial summation of the field, but it looks like there are minimal differences between for-profit and non-profit private hospitals, with government hospitals doing worst of all:

— A team from Harvard finds that for-profits and non-profits have about equal quality, and government-owned hospitals are worse than either. A follow-up study by the same team finds non-profit hospitals becoming for-profit is not associated with a drop in care.

Truven Health Analytics finds some advantages for church-owned nonprofit hospitals, with secular nonprofit hospitals and for-profit hospitals in the middle, and government-owned hospitals worst of all. Note that this is my interpretation of a lot of different data and you might want to look at the particular metrics they use to draw your own conclusions.

A textbook on the hospital industry finds that “on average, the performance of non-profit hositals in treating elderly patients with heart disease appears to be slightly better than that of for-profit hospitals, even after accounting for systematic differences…however, this small average difference masks an enormous amount of variation in hospital quality within the for-profit and not-for-profit hospital groups.”

— A study in a cardiology journal found “no evidence that for-profit hospitals selectively treat less sick patients, provide less evidence-based care, limit in-hospital stays, or have patients with worse acute outcomes than nonprofit centers”.

— As per the Handbook Of Health Economics:

The most rigorous and extensive study of large-scale empirical study of quality published to date that permits comparisons of quality by hospital ownership is by Keeler and co-authors (1992). They used two process measures of quality based on reviews of 14,000 medical record for five diseases in five states. One of this “explicit process” gauged the extent to which the charts showed that specific diagnostic and therapeutic procedures were performed competently. Rather than focus on particular elements of care as explicit process did, a second process measure, “implicit process,” measured the care process overall. For example, one of their implicit process questions to physician reviewers was: “Based on what you now know about this case, would you send your mother to this hospital?” In addition, they gauged quality on an outcome measure — the difference between actual mortality and the rate that would be expected based on the patient’s characteristics.

They found no difference in quality between private not-for-profit and for-profit hospitals on two indicators, excess mortality and explicit process; public hospitals fared worse on both criteria. However, on a third measure, implicit process, there was a statistically significant difference between quality of care of private not-for-profit hospitals and the other two ownership types, indicating higher quality levels for the for profits. The authors appear to have been more persuaded by the results on the first two indicators, stating that “nonprofit and for-profit hospitals provide similar quality overall”

In their national study of 981 hospitals in 1983-84, Shortell and Hughes (1988) found no difference in quality measured in terms of mortality by ownership. However, using fewer covariates, Hartz et al. (1989) did find that mortality was higher in for-profit than in private not-for-profit hospitals.

Sloan and co-authors (1998a,1998b, 1998c) examined outcomes of care of elderly persons hospitalized for one of four conditions: hip fracture; stroke; coronary heart disease; and congestive heart failure. They analyzed the first admission for these conditions since patients with a first unanticipated major health shock are less likely to shop among hospitals. Their outcome measures were survival, functional status, cognitive status, and living arrangements (probability of living in a nursing home). Although, on some measures, patients admitted to major teaching hospitals did better, a result consistent with Keeler et al. (1992), there were no statistically significant differences in outcomes between non-teaching private not-for-profit and for-profit hospitals. On some measures, elderly patients admitted to non-teaching government hospitals had worse outcomes, holding a large number of other factors constant.

So it looks like the differences between for-profit and not-for-profit hospitals are pretty slight, and that government hospitals are likely worse than either. This should be equally confusing to people who believe that the profit motive is invariably destructive and to people who believe it invariably results in better service.

This would be a good time to note that, contrary to the impression one might get from the Current Affairs article, only 13% of charter schools are for-profit. So a system with vouchers and charter school would probably be most like private non-profit hospitals, which these studies also show as doing well, and as decisively better than government-run hospitals. Also, everything I’ve talked about up to this point is mostly irrelevant. Maybe I should have started by mentioning this.

III.

From the same article:

There are other serious problems with the “gutting” of public schools. As we have argued before in Current Affairs, converting public schools to a voucher system makes education operate similarly to food stamps. After all, SNAP benefits operate roughly the same way: instead of giving people food, we give them the equivalent of money, which they then use to go and buy food. A voucher program does the same for schooling: instead of giving them schools, we give them a voucher, which they can use to go and find a private school. But look what happens with food stamps: the moment you start handing out a “voucher,” conservatives start seeing it as some kind of unearned “handout.” Pressure then develops to cut the handout. Is there any reason to think that “education stamps” would be subjected to less cost-cutting political pressure than food stamps? A serious problem with voucher programs is that they erode the idea of education as a fundamental right, instead making it seem like a privilege that one does not necessarily deserve. But education should be a right, because children cannot help the circumstances of their birth, and should therefore not be punished for their parents’ poverty.

I think this is drawing the wrong lesson from education’s popularity relative to food stamps. Robinson thinks conservatives like one-size-fits-all handouts, but not voucher handouts. I think conservatives like universal handouts, but not handouts to the poor.

Imagine a world where food stamps are replaced by the Federal Food Agency. Every week, a truck comes to poor people’s houses and gives them a one-size-fits-all food package that the government believes satisfies their nutritional needs. Do you think conservatives would be any happier with this than they are with food stamps? For that matter, did conservatives support public housing projects any more or less than they support housing vouchers now?

On the other hand, Medicare remains popular even though it’s essentially a voucher. Patients with Medicare choose their doctor, choose their hospital, and then Medicare pays for it. But because everyone expects to benefit someday, it has pretty broad bipartisan support; even its critics mostly want to change rather than eliminate it.

I don’t think changing public education from a service to a voucher would change whether people support it or not.

IV.

So I disagree with Robinson’s specific arguments. But there are some things that worry me about school vouchers.

First, the hospital case study is kind of ambiguous. Although for-profit hospitals aren’t noticeably worse than not-for-profit, they’re also not noticeably better. And the existence of for-profit hospitals hasn’t started some kind of virtuous cycle where all hospitals compete to save money and provide better care that ends up with hospitals being lean and inexpensive and just as accessible as grocery stores. Having a field be open to competition isn’t necessarily incompatible with it being overpriced and inefficient. And commenters point out that existing private schools are not generally 75% cheaper than public schools, suggesting that cost-cutting is hard.

Second, Robinson notes later that:

Privatization schemes are also heavily dependent on the existence of highly astute parents, who have the time and inclination to carefully study schools. The most vulnerable children are unlikely to have such parents. And we can imagine a system in which private schools offer parents $100 out of the voucher money if they agree to enroll their children. Desperate and uncaring parents might snap up the cash, with the neediest children ending up in the most vicious, uncaring, profit-grubbing schools.

I doubt there would be such blatant kickbacks – they’d be illegal and I don’t think they’ve happened on other voucher programs like food stamps – but his point that many parents are ignorant or malicious is well-taken. You don’t need literal bribery to get schools which are very good at having flashy ad campaigns but not very good at education. Parents might not check the test scores of a smooth-sounding school any more than they check the health care grades of their local hospital. The worst-case scenario is schools associated with cults or fringe political ideologies that prey on the children of people who believe them, either out of genuine fanaticism or a cynical calculation that fanatics are easy to milk.

Third, the whole point of Trumpism is that once we have fewer immigrants we can create a culturally cohesive community where everybody shares some core values. But the school system – as fractured and diverse as it is – is really one of the only institutions responsible for instilling some basic civic values in everyone and making sure they’re all on the same page. I do not put it past people to start sending their kids to schools that teach liberal values or conservative values in particular, and then one of the few (albeit mostly ineffective) brakes on further polarization is removed. On the other hand, Catholic school is already sort of like this and they don’t seem to be some weird foreign cancer on the body politic, so maybe it’s not such a big deal?

Fourth, vouchers could worsen class segregation. Maybe not too much, because everyone already goes to public schools in their own class-segregated neighborhood anyway. But at least there’s a little socioeconomic diversity now. And with vouchers, there’s a risk of deliberate sorting/signaling, where if everyone gets a voucher for $10,000, decent schools will charge $15,000 just to sell the “privilege” of going to a school without poor students. That is, in the same way people will pay extra for a house in a gated community because they worry poor people make bad neighbors, they might pay extra for a spot in a more-expensive school because they worry poor people will make bad classmates. A little bit of this segregation goes a long way, because if enough people do this then the exactly-$10,000 schools will only have poor people, in much the same way that a little bit of racial segregation goes a long way.

(I don’t know much about proposed voucher systems, but I wonder if it would be possible to have a system where you’re not allowed to combine the voucher with your own money. That is, if you get a $10,000 voucher, you can go to a school charging $10,000. But if you want to go to a school charging $11,000, you have to throw away the voucher and pay the whole price out of pocket.)

To all these downsides we would have to add one very big upside – it destroys the incentive to overspend on/segregate housing in order to get into a “good school district”. Elizabeth Warren has argued this is primarily behind the secular rise in real estate prices that has undermined the economic position of the middle class for the past fifty years. This factor could easily be more important than everything else combined and might make school vouchers a plus even if they seriously worsened the quality of education.

Overall my thoughts on school vouchers are the same as my thoughts on pretty much everything in this category: let’s experiment. Figure out a window of acceptable possibilities that are reversible and don’t have too much risk, and let different states and areas try different ones. As we start to understand things better, extend the window of possibilities in the relevant direction. Check results. Rinse. Repeat. Then figure something out.

V.

Finally, one more point from the article that deserves its own discussion:

If we have a school district comprised in total of three for-profit elementary schools, and all of them simply pocket most of the voucher money while failing to educate the children, then no matter what “choices” among schools parents make, they won’t be able to improve the quality of the schools. One might expect new operators to enter the market, but if the only way to make any real money on the children is to neglect them, then new operators won’t be any better than the old ones.

It’s important because lack of good competition is indeed the bane of all of these sorts of industries. Economic theory predicts that in a perfectly competitive environment businesses will be pretty good; it is much less sure of itself in these sorts of three-school districts without enough competition to have much effect.

In the real world, someone will have to empirically determine how much this matters. In my own fantasy world, I have a solution that the new Education Secretary probably won’t be on board with: Let’s let random people open tiny schools.

Something like 3% of parents home-school their children. This cuts across class and racial lines better than you’d think. All the research shows that home-schooled students do much better than traditionally schooled students on standardized tests, college admission exams, college GPAs, and general life satisfaction as adults. This is probably unfair, because home-schooled students are the descendents of the sort of thoughtful conscientious parents who want to home-school their children, so they probably have a big genetic advantage. But there is at least absolutely no evidence that home-schooling makes anyone do any worse.

The average cost per pupil per year in the US is something like $10,000. So suppose we give everyone $10,000 school vouchers. A parent who wants to make the median US yearly income of $30,000 would have to teach three students. Add in some overhead and curriculum costs, and maybe it’s more like five students.

So imagine. A woman has a kid and decides she doesn’t want to go back to work and leave the kid in daycare for eighteen years. She takes some test, clears some regulatory hurdle, promises that she’ll clear a certain bar on her kids’ standardized test scores, and registers as an approved school. Then she gets a couple of friends and neighbors who trust her to send their kids to her too. Maybe her husband works outside the home, so she doesn’t even need five. She’s happy with two or three (I think it would be important that you can’t make any money by educating your own kid; otherwise the incentive is to keep them out of school and pretend to be educating them yourself). Then she tutors them in a class a fifth the size of comparable public school classes.

If you’re an actual, qualified teacher, maybe you can get ten or twenty kids who are interested. That’s $100,000 to $200,000, minus your overhead, much more than qualified teachers make today with a much lower class size. Remember, for the majority of American history, kids were taught by a member of the community in a one room schoolhouse, and that was the system that produced Benjamin Franklin, Thomas Edison, et cetera.

(and remember that all the research shows that formal teacher training and level of teacher credentialing has zero effect on how well teachers teach kids)

This would provide provide a means of self-directed, boss-free income for millions of people, including undercredentialled poor people, disabled people who can’t leave the home, people in rural areas, and especially young mothers. It would rebuild community ties. And it would ensure no one ever has to worry about districts with only three schools, or even districts with only thirty schools.

I don’t know. Probably there’s some sort of horrible flaw that I’m missing. But I still think the moral of the story is to experiment more. And school vouchers might be a good start.

EDIT: From the comments: “At my independent non-profit high school we have reduced the cost per student-year down to $3,000. Despite this budget we are able to offer the students many opportunities that public schools don’t. Art classes like glassblowing and copper and silversmithing, advanced science curricula like organic and biochemistry, health class vastly more informative that the state requirements, zero bullying enforced by a self-organized student culture, I could go on all day. For comparison the average cost for nearby school districts is $17,000 per high schooler-year and offer a fraction of the services we provide.”

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SSC Journal Club: Expert Prediction Of Experiments

I.

It’s been a good month for fretting over failures of expert opinion, so let’s look at DellaVigna & Pope, Predicting Experimental Results: Who Knows What?

The authors ran a pretty standard behavioral economics experiment where they asked people on Mechanical Turk to do a boring task while being graded on speed and accuracy. Then they offered one of fifteen different incentive schemes, like “we’ll pay you extra if you do well” or “your score will be publicly visible”.

But the point of the study wasn’t to determine which incentive scheme worked the best, it would determine who could best predict which incentive scheme worked the best. The researchers surveyed a bunch of people – economics professors, psychology professors, PhD students, undergrads, business students, and random Internet users on Mechanical Turk – and asked them to predict the experimental results. Since this was a pretty standard sort of behavioral economics experiment, they were wondering whether people with expertise and knowledge in the field might be better than randos at figuring out which schemes would work.

They found that knowledgeable academics had some advantage over randos, but with enough caveats that it’s worth going over in more detail.

First, they found that prestigious academics did no better (and possibly slightly worse) than less prestigious academics. Full professors did no better than associate professors, assistant professors, or PhD students. People with many publications and citations did no better than people with fewer publications and citations.

Second, they found that field didn’t matter. Behavioral economists did as well as microeconomists did as well as experimental psychologists did as well as theoretical psychologists. To be fair, this experiment was kind of in the intersection of economics and psychology, so all of these fields had equal claim to it. I would have liked to see some geologists or political scientists involved, but they weren’t.

Third, the expert advantage was present in one measure of accuracy (absolute forecast error), but not in another (rank-order correlation). On this second measure, experts and randos did about equally well. In other words, experts were better at guessing the exact number for each condition, but not any better at guessing which conditions would do better or worse relative to one another.

Fourth, the expert advantage was pretty small. Professors got an average error of 169, PhD students of 171, undergrads of 187, MBA students of 198, and MTurk users of 271 (random guessing gave an error of about 416). So the difference between undergrads and experts, although statistically significant, was hardly overwhelming.

Fifth, even the slightest use of “wisdom of crowds” was enough to overwhelm the expert advantage. A group of five undergrads averaged together had average error 115, again compared to individual experts’ error of 169! Five undergrads averaged together (115) did about as well as five experts averaged together (114). Twenty undergrads averaged together (95) did about as well as twenty experts averaged together (99).

Sixth, having even a little knowledge of individuals’ forecasting ability screened off expert status. The researchers gave forecasters some experimental data about the effects of a one-cent incentive and a ten-cent incentive, and asked them to predict the scores after a four-cent incentive – a simple, mechanical problem that just requires common sense. Randos who can do well on this problem do just as well as experts on the experiment as a whole. Likewise, randos who are noticed to do well on the first half of the experiment will do just as well as experts on the second half too. In other words, we’re back to finding “superforecasters”, people who are just consistently good at this kind of thing.

None of this seems to be too confounded by effort. The researchers are able to measure how much time people take on the task, whether they read the instructions carefully, etc. There is some advantage to not rushing through the task, but after that it doesn’t seem to matter much. They also try offering some of the Mechanical Turkers lots of money for getting the answers right. That doesn’t seem to help much either.

The researchers ask the experts to predict the results of this experiment. They (incorrectly) predict that prestigious academics with full professorships and lots of citations will do better than mere PhD students. They (incorrectly) predict that psychologists will do better than non-psychologists. They (correctly) predict that professors and PhD students will do better than undergrads and randos.

II.

What do we make of this?

I would tentatively suggest it doesn’t look like experts’ expertise is helping them very much here. Part of this is that experts in three different fields did about equally well in predicting the experimental results. But this is only weak evidence; it could be that the necessary expertise is shared among those three fields, or that each field contains one helpful insight and someone who knew all three fields would do better than any of the single-field experts.

But more important, randos who are able to answer a very simple question, or who do well on other similar problems, do just as well as the experts. This suggests it’s possible to get expert-level performance just by being clever, without any particular expertise.

So is it just IQ? This is a tempting explanation. The US average IQ is 100. The undergrads in this experiment came from Berkeley, and Berkeley undergrads have an average SAT of 1375 = average IQ of 133 (this seems really high, but apparently matches estimates from The Bell Curve and the Brain Size blog; however, see Vaniver’s point here). That same Brain Size post proposes that the average professor has an IQ of 133, but I would expect psychology/economics professors to be higher, plus most of the people in this experiment were from really good schools. If we assume professors are 135-140, then this would neatly predict the differences seen from MTurkers to undergrads to professors.

But the MBA students really don’t fit into this model. The experiment gets them from the University of Chicago Booth School of Business, which is the top business school in the country and has an average GMAT score of 740. That corresponds to an IQ of almost 150, meaning this should be the highest-IQ sample in the study, yet the MBAs do worse than the undergrads. Unless I’m missing something, this is fatal to an IQ-based explanation.

I think that, as in Superforecasting, the best explanation is a separate “rationality” skill which is somewhat predicted by high IQ and scientific training, but not identical to either of them. Although some scientific fields can help you learn the basics of thinking clearly, it doesn’t matter what field you’re in or whether you’re in any field at all as long as you get there somehow.

I’m still confused by the MBA students, and expect to remain so. All MBA students were undergraduates once upon a time. Most of them probably took at least one economics class, which was where the researchers found and recruited their own undergraduates from. And most of them were probably top students from top institutions, given that they made it into the best business school in the US. So how come Berkeley undergraduates taking an econ class outperform people who used to be Berkeley undergraduates taking an econ class, but are now older and wiser and probably a little more selected? It might be that business school selects against the rationality skill, or it might be that business students learn some kind of anti-insight that systematically misleads them in these kinds of problems.

(note that the MBAs don’t put in less effort than the other groups; if anything, the reverse pattern is found).

III.

Does this relate to interesting real-world issues like people’s trouble predicting this election?

One important caveat: this is all atheoretical. As far as I know, there’s no theory of psychology or economics that should let people predict how the incentive experiment would go. So it’s asking experts to use their intuition, supposedly primed by their expertise, to predict something they have no direct knowledge about. If the experiment were, say, physicists being asked to predict the speed of a falling object, or biologists being asked to predict how quickly a gene with a selective advantage would reach fixation, then we’d be in a very different position.

Another important caveat: predictive tasks are different than interpretative tasks. Ability to predict how an experiment will go without having any data differs from ability to crunch data in a complicated field and conclude that eg saturated fat causes/doesn’t cause heart attacks. I worry that a study like this might be used to discredit eg nutritional experts, and to argue that they might not be any better at nutrition than smart laymen. Whether or not this is true, the study doesn’t support it.

So one way of looking at it might be that this is a critique not of expertise, but of “punditry”. Engineers are still great at building bridges, doctors are still great at curing cancer, physicists are still great at knowing physics – but if you ask someone to predict something vaguely related to their field that they haven’t specifically developed and tested a theory to cope with, they won’t perform too far above bright undergrads. I think this is an important distinction.

But let’s also not get too complacent. The experts in this study clearly thought they would do better than PhD students. They thought that their professorships and studies and citations would help them. They were wrong. The distinction between punditry and expertise is pretty fuzzy. Had this study come out differently, I could have argued for placing nice clear lab experiments about incentive schemes in the “theory-based and amenable to expertise” category. You can spin a lot of things either direction.

I guess really the only conclusion you can draw from all of this is not to put any important decisions in the hands of people from top business schools.

OT63: Open Pit Mining

This is the bi-weekly visible open thread. There are hidden threads every few days here. Post about anything you want, ask random questions, whatever. Also:

1. The Report Comment button is back. Thanks to 75thTrombone for fixing things up.

2. New advertisement on the sidebar, for the Secular Solstice celebration. I’ll be at the one in New York City, so if you’re coming too I’ll see you there.

3. Thanks to everyone who emailed me with your thoughts on Trump. I got hundreds of emails and can’t reply to all of them, especially the ones trying to engage me in debate. I’m sorry, I just can’t debate a hundred people at once.

4. Thanks to everyone who disagreed with my predictions and offered to bet on them. I’ve accepted a few offers already, but I won’t be accepting any more until I can get a Bets/Predictions post up where I record all of them so I can keep track.

5. A few people emailed me to say that they have friends or family members who attempted suicide for Trump-related reasons. I’m really sorry about that and I hope they’re okay. If you or someone you know is considering suicide, consider checking out the National Suicide Hotline at 1-800-273-8255, which also has a special webpage on election-related suicidality. Please note that in a few rare cases, if you’re really serious about commiting suicide immediately and won’t back down, calling a hotline can end with them picking you up for psychiatric hospitalization.

6. If you’re looking for a more productive way to deal with the election results, some friends have pointed out some good opportunities for activism:

— The National Popular Vote is a really cool and game-theoretically interesting way to get rid of the Electoral College without a Constitutional amendment. It’s pretty close to being passed and the site gives you some ways to help push it forward.

— Trump has posted an online survey asking which of his plans he should prioritize during his first 100 days in office. You might not find anything super-great on there, but some of them are definitely worse than others, and it might be that by telling him to prioritize the less bad ones you can do a lot of good. Disclaimer: I have no idea if Trump plans to take the survey results seriously.

— Apparently the new administration didn’t realize that all of Obama’s staffers are leaving, and now they have a few thousand executive branch jobs to fill. Because of their commitment to avoid lobbyists they can’t use the preferred method of just giving all the positions to lobbyists, and they’ve been reduced to the indignity of having to accept applications from real citizens. Bloomberg notes that There’s No Shame In Joining The Trump Administration if your goal is harm reduction, and if you agree you can apply here. If you have some kind of useful political/administrative experience, this might be an unusually easy route to getting a position of power where you can do useful things like lobby for foreign aid and alleviate the effects of various Trump policies. Curious what the EA peoples’ opinion on this is.

— Here is a very complete spreadsheet about how best to contact your representatives and senators.

7. If you want to change (or add a link to) your username on this blog, you can do it at http://slatestarcodex.com/wp-admin/profile.php

8. My Amazon affiliate link no longer works. Please don’t buy things through it and expect me to get any money.

9. In an effort to keep my Trump-related traffic spike around for more useful things, I’ve added a “Subscribe via email” button to the side of the blog. If you really want to get emails every time SSC updates, now you can.

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The Alzheimer Photo

A professor recently brought my attention to this photo of Alois Alzheimer and his colleagues in Munich (source):

Alzheimer is the very-German-looking guy with the silly mustache third from the right on the top. Far right is Friedrich Lewy, discoverer of Lewy bodies and Lewy body dementia. Bottom, second from the left, looking kind of like Petyr Baelish, is Ugo Cerletti, inventor of electroconvulsive therapy.

Other members of Alzheimer’s team didn’t make it to the group photo. These include Alzheimer’s mentor, Emil Kraepelin, who discovered bipolar disorder, schizophrenia, etc, etc, etc (there’s a reason modern psychiatry calls itself “neo-Kraepelinian”). They include two of Alzheimer’s assistants, Hans Creutzfeldt and Alfons Jakob, who discovered Creutzfeldt-Jakob disease, the human version of mad cow. They include Alzheimer’s collaborator Franz Nissl, who discovered Nissl bodies and the Nissl stain at the same lab.

If you come across a neurological disease that sounds like a guy’s name, there’s a not insignificant chance that guy is either in this picture or else just barely missed it.

This made me think of a lot of the discussion around when fields of science prosper versus when they go stagnant. The last few decades haven’t really been great for neuropsychiatry. But one group of people in one lab came up with entire textbooks worth of advances. Why? Do we need to resurrect Alois Alzheimer and put him in charge of NIMH?

Part of it was that good histological staining had just been invented and Alzheimer’s lab was on the bleeding edge, so they were just sitting around picking off the low-hanging fruit that could be discovered by staining stuff. But Kraepelin’s and Cervetti’s discoveries didn’t have much to do with staining.

Part of it was that Alzheimer was in the right place at the right time. If he’d really wanted an impressive photo, he could have gotten together with his chief competitors, a group centered around Carl Westphal (cf. Westphal’s sign, Edinger-Westphal nucleus) which included his students Arnold Pick (cf. Pick’s dementia) and Karl Wernicke (cf. Wernicke’s area, Wernicke-Korsakoff syndrome). Heck, if he wanted to go further, the number of people within a day’s train journey staggers the imagination. Rudolph Virchow, Eugen Bleuler, Robert Koch, Sigmund Freud. Fin de siecle Central Europe was just a really good place for neurology and psychiatry.

Part of it was that the whole thing was arranged by Kraepelin, who besides being a scientific genius, was apparently an organizational genius as well. According to Wikipedia, “Kraepelin has been described as a ‘scientific manager’ and political operator, who developed a large-scale, clinically oriented, epidemiological research programme.” See also Psychiatric Governance And The German Institute Of Psychiatry In Munich. Kraepelin grabbed all these people, threw them at the most interesting problems, and made sure they always had all the funding they wanted – although the final form of all of this as the Institute for Psychiatric Research didn’t coalesce until after Alzheimer’s death.

And part of it is the natural tendency for some institution to gain a reputation for being the best, and then attract the best people. I’m sure you could find some pretty impressive conjunctions of people if you looked at photos of Harvard departments.

My theory of apparent scientific stagnation has always been that it’s easier to pick low-hanging fruit in one paradigm than to get entirely new ones – in other words, the problem is at least as much in the territory itself as in our engagement with it. I was interested to learn that one of the big hurdles to faster aircraft is a nonlinearity in fuel costs, which grow exponentially for physics reasons right when you start getting faster than modern planes. I think something similar might be going on here. Through painstaking trial-and-error, psychiatric hit upon a really fruitful paradigm of combining clinical observation, histopathology, and and random wacky ideas, right about when Alois Alzheimer opened his lab. Anybody who happened to be in the vicinity when the new paradigm was invented ended up getting a disease named after him. Eventually all the stuff that was easy to discover this way got discovered, and right now there just aren’t any equally fruitful paradigms coming to our attention.

This story has a sad ending. Alzheimer (ironically) died young. He was succeeded by his student Walther Spielmeyer (cf. Spielmeyer-Vogt-Sjögren-Batten Disease), and then Kurt Schneider (cf. Schneider’s first-rank symptoms). Schneider invented the modern concept of psychopathy, but unfortunately he was probably working from personal experience – this was in the middle of the rise of the Nazis. He was fired for political reasons and got replaced with Alzheimer’s fellow Kraepelin protege, Ernst Rudin, who re-centered the whole thing around the role of psychiatry in sterilizing the feeble-minded. The chain that started with Kraepelin and Alzheimer ended in Rudin’s own student, Josef Mengele.

After the war, Rudin was fined 500 deutschmarks, apparently the going penalty for leading a Nazi eugenics program at the time, and Kraepelin/Alzheimer’s institute was re-founded as the Max Planck Institute of Psychiatry. As far as I know they’re still around, but I haven’t heard of them discovering any interesting new diseases lately.

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You Are Still Crying Wolf

[Content warning: hate crimes, Trump, racism. I have turned off comments to keep out bad people who might be attracted by this sort of thing. Avoid sharing in places where this will attract the wrong kind of attention, as per your best judgment. Please don’t interpret anything in this article to mean that Trump is not super terrible]

[Epistemic status: A reduction of a complicated issue to only 8000 words, because nobody would read it if it were longer. I think this is true but incomplete. I do not deny that Trump is being divisive and abusing identity politics in more subtle ways. I will try to discuss missing parts at more length later.]

I.

A New York Times article from last September that went viral only recently: Crying Wolf, Then Confronting Trump. It asks whether Democrats have “cried wolf” so many times that nobody believes them anymore. And so:

When “honorable and decent men” like McCain and Romney “are reflexively dubbed racists simply for opposing Democratic policies, the result is a G.O.P. electorate that doesn’t listen to admonitions when the genuine article is in their midst”.

I have a different perspective. Back in October 2015, I wrote that the picture of Trump as “the white power candidate” and “the first openly white supremacist candidate to have a shot at the Presidency in the modern era” was overblown. I said that “the media narrative that Trump is doing some kind of special appeal-to-white-voters voodoo is unsupported by any polling data”, and predicted that:

If Trump were the Republican nominee, he could probably count on equal or greater support from minorities as Romney or McCain before him.

Now the votes are in, and Trump got greater support from minorities than Romney or McCain before him. You can read the Washington Post article, Trump Got More Votes From People Of Color Than Romney Did, or look at the raw data (source)

Trump made gains among blacks. He made gains among Latinos. He made gains among Asians. The only major racial group where he didn’t get a gain of greater than 5% was white people. I want to repeat that: the group where Trump’s message resonated least over what we would predict from a generic Republican was the white population.

Nor was there some surge in white turnout. I don’t think we have official numbers yet, but by eyeballing what data we have it looks very much like whites turned out in equal or lesser numbers this year than in 2012, 2008, and so on. [EDIT: see counterpoint, countercounterpoint]

The media responded to all of this freely available data with articles like White Flight From Reality: Inside The Racist Panic That Fueled Donald Trump’s Victory and Make No Mistake: Donald Trump’s Win Represents A Racist “Whitelash”.

I stick to my thesis from October 2015. There is no evidence that Donald Trump is more racist than any past Republican candidate (or any other 70 year old white guy, for that matter). All this stuff about how he’s “the candidate of the KKK” and “the vanguard of a new white supremacist movement” is made up. It’s a catastrophic distraction from the dozens of other undeniable problems with Trump that could have convinced voters to abandon him. That it came to dominate the election cycle should be considered a horrifying indictment of our political discourse, in the same way that it would be a horrifying indictment of our political discourse if the entire Republican campaign had been based around the theory that Hillary Clinton was a secret Satanist. Yes, calling Romney a racist was crying wolf. But you are still crying wolf.

I avoided pushing this point any more since last October because I didn’t want to look like I was supporting Trump, or accidentally convince anyone else to support Trump. I think Trump’s election is a disaster. He has no plan, he’s dangerously trigger-happy, and his unilateralism threatens aid to developing countries, one of the most effective ways we currently help other people. I thought and still think a Trump presidency will be a disaster.

But since we’re past the point where we can prevent it, I want to present my case.

I realize that all of this is going to make me sound like a crazy person and put me completely at odds with every respectable thinker in the media, but luckily, being a crazy person at odds with every respectable thinker in the media has been a pretty good ticket to predictive accuracy lately, so whatever.

II.

First, I want to go over Donald Trump’s official, explicit campaign message. Yes, it’s possible for candidates’ secret feelings to differ from their explicit messages, but the things they say every single day and put on their website and include in their speeches are still worth going over to see what image they want to project.

Trump’s official message has been the same vague feel-good pro-diversity rhetoric as any other politician. Here’s Trump on African Americans:

It is my highest and greatest hope that the Republican Party can be the home in the future and forevermore for African-Americans and the African-American vote because I will produce, and I will get others to produce, and we know for a fact it doesn’t work with the Democrats and it certainly doesn’t work with Hillary.

When I am President, I will work to ensure that all of our kids are treated equally, and protected equally. Every action I take, I will ask myself: does this make life better for young Americans in Baltimore, Chicago, Detroit, Ferguson who have as much of a right to live out their dreams as any other child in America?

African-American citizens have sacrificed so much for this nation. They have fought and died in every war since the Revolution, and from the pews and the picket lines they have lifted up the conscience of our country in the long march for Civil Rights. Yet, too many African-Americans have been left behind.

No group in America has been more harmed by Hillary Clinton’s policies than African-Americans. No group. No group. If Hillary Clinton’s goal was to inflict pain on the African-American community, she could not have done a better job. It’s a disgrace. Tonight, I am asking for the vote of every African-American citizen in this country who wants a better future.

And at the end of four years I guarantee that I will get over 95% of the African-American vote. I promise you. Because I will produce for the inner-cities and I will produce for the African-Americans.

America must reject the bigotry of Hillary Clinton who sees communities of color only as votes, not as human beings worthy of a better future.

On Hispanics:

I have just landed having returned from a very important and special meeting with the President of Mexico…we discussed the great contributions of Mexican-American citizens to our two countries, my love for the people of Mexico, and the close friendship between our two nations.

I employ thousands and thousands of Hispanics. I love the people. They’re great workers. They’re fantastic people and they want legal immigration. I’ll take jobs back from China, I’ll take jobs back from Japan. The Hispanics are going to get those jobs, and they’re going to love Trump.

On his campaign:

It’s a movement comprised of Americans from all races, religions, backgrounds and beliefs who want and expect our government to serve the people, and serve the people it will.

Trump’s campaign photos are consistent with a desire to present the same message:

This wasn’t a scripted appearance forced by his campaign staff. According to the Washington Times:

Trump walked on stage in Greeley, Colorado to a large cheering crowd when he spotted a rainbow flag in the audience. As the music blasted through the speakers, Mr. Trump pointed to a supporter as if to ask if he could see his flag and then motioned for a campaign worker to help retrieve the LGBT symbol of equality from the attendee.

Within seconds, Mr. Trump was walking around the platform with the rainbow flag in his hands and moments later unfurled it in full display. You could see a huge smile on Mr. Trump’s face as he walked to both sides of the stage to proudly hold up the rainbow flag announcing support from the gay and lesbian community.

Trump campaign spokesman Jason Miller told me, “Mr. Trump is campaigning to be President for ALL Americans and was proud to carry the ‘LGBT for Trump‘ rainbow flag on stage in Greeley, CO yesterday.

This is just a tiny representative sample, but the rest is very similar. Trump has gone from campaign stop to campaign stop talking about how much he likes and respects minorities and wants to fight for them.

And if you believe he’s lying, fine. Yet I notice that people accusing Trump of racism use the word “openly” like a tic. He’s never just “racist” or “white supremacist”. He’s always “openly racist” and “openly white supremacist”. Trump is openly racist, openly racist, openly racist, openly racist, openly racist, openly racist, openly racist. Trump is running on pure white supremacy, has thrown off the last pretense that his campaign is not about bigotry, has the slogan Make American Openly White Supremacist Again, is an openly white supremacist nominee, etc, etc, etc. And I’ve seen a few dozen articles like this where people say that “the bright side of a Trump victory is that finally America admitted its racism out in the open so nobody can pretend it’s not there anymore.”

This, I think, is the first level of crying wolf. What if, one day, there is a candidate who hates black people so much that he doesn’t go on a campaign stop to a traditionally black church in Detroit, talk about all of the contributions black people have made to America, promise to fight for black people, and say that his campaign is about opposing racism in all its forms? What if there’s a candidate who does something more like, say, go to a KKK meeting and say that black people are inferior and only whites are real Americans?

We might want to use words like “openly racist” or “openly white supremacist” to describe him. And at that point, nobody will listen, because we wasted “openly white supremacist” on the guy who tweets pictures of himself eating a taco on Cinco de Mayo while saying “I love Hispanics!”

III.

A rundown of some contrary talking points:

1. Is Trump getting a lot of his support from white supremacist organizations?

No, because there are not enough organized white supremacists to make up “a lot” of anyone’s support.

According to Wikipedia on KKK membership:

As of 2016, the Anti-Defamation League puts total Klan membership nationwide at around 3,000, while the Southern Poverty Law Center puts it at 6,000 members total

The KKK is really small. They could all stay in the same hotel with a bunch of free rooms left over. Or put another way: the entire membership of the KKK is less than the daily readership of this blog.

If you Google “trump KKK”, you get 14.8 million results. I know that Google’s list of results numbers isn’t very accurate. Yet even if they’re inflating the numbers by 1000x, and there were only about 14,000 news articles about the supposed Trump-KKK connection this election, there are still two to three articles about a Trump-KKK connection for every single Klansman in the world.

I don’t see any sign that there are other official white supremacy movements that are larger than the Klan, or even enough other small ones to substantially raise the estimate of people involved. David Duke called a big pan-white-supremacist meeting in New Orleans in 2005, and despite getting groups from across North America and Europe he was only able to muster 300 attendees (by comparison, NAACP conventions routinely get 10,000).

My guess is that the number of organized white supremacists in the country is in the very low five digits.

2. Is Trump getting a lot of his support from online white nationalists and the alt-right?

No, for the same reason.

The alt-right is mostly an online movement, which makes it hard to measure. The three main alt-right hubs I know of are /r/altright, Stormfront, and 4chan’s politics board.

The only one that displays clear user statistics is /r/altright, which says that there are about 5,000 registered accounts. The real number is probably less – some people change accounts, some people post once and disappear, and some non-white-nationalists probably go there to argue. But sure, let’s say that community has 5,000 members.

Stormfront’s user statistics say it gets about 30,000 visits/day, of which 60% are American. My own blog gets about 8,000 visits/day , and the measurable communities associated with it (the subreddit, people who follow my social media accounts) have between 2000 – 8000 followers. If this kind of thing scales, then it suggests about 10,000 people active in the Stormfront community.

4chan boasts about 1 million visits/day. About half seem to be American. Unclear how many go to the politics board and how many are just there for the anime and video games, but Wikipedia says that /b/ is the largest board with 30% of 4Chan’s traffic, so /pol/ must be less than that. If we assume /pol/ gets 20% of 4chan traffic, and that 50% of the people on /pol/ are serious alt-rightists and not dissenters or trolls, the same scaling factors give us about 25,000 – 50,000 American alt-rightists on 4Chan.

Taking into account the existence of some kind of long tail of alt-right websites, I still think the population of the online US alt-right is somewhere in the mid five-digits, maybe 50,000 or so.

50,000 is more than the 5,000 Klansmen. But it’s still 0.02% of the US population. It’s still about the same order of magnitude as the Nation of Islam, which has about 30,000 – 60,000 members, or the Church of Satan, which has about 20,000. It’s not quite at the level of the Hare Krishnas, who boast 100,000 US members. This is not a “voting bloc” in the sense of somebody it’s important to appeal to. It isn’t a “political force” (especially when it’s mostly, as per the 4chan stereotype, unemployed teenagers in their parents’ basements.)

So the mainstream narrative is that Trump is okay with alienating minorities (= 118 million people), whites who abhor racism and would never vote for a racist (if even 20% of whites, = 40 million people), most of the media, most business, and most foreign countries – in order to win the support of about 50,000 poorly organized and generally dysfunctional people, many of whom are too young to vote anyway.

Caring about who the KKK or the alt-right supports is a lot like caring about who Satanists support. It’s not something you would do if you wanted to understand real political forces. It’s only something you would do if you want to connect an opposing candidate to the most outrageous caricature of evil you can find on short notice.

3. Is Trump getting a lot of his support from people who wouldn’t join white nationalist groups, aren’t in the online alt-right, but still privately hold some kind of white supremacist position?

There are surprisingly few polls that just straight out ask a representative sample of the population “Are you white supremacist?”.

I can find a couple of polls that sort of get at this question in useful ways.

This poll from Gallup asks white Americans their support for school segregation and whether they would move out if a black family moved in next door. It declines from about 50% in 1960 to an amount too small to measure in the 1990s, maybe 1-2%, where it presumably remains today.

(this graph also seems relevant to the stories of how Trump’s father would try to keep blacks out of his majority-white real estate developments in the late 60s/early 70s – note that at that time 33% of white families would move out if a black person moved in next door)

Here’s a CBS News poll from 2014 asking Americans their opinion on the Civil Rights Act that legally prohibited discrimination. Once again, the number of whites who think it was a bad thing is too small to measure meaningfully, but looks like maybe 1-2%. Of note, whites were more convinced the Civil Rights Act was good than blacks were, though I guess it depends on the margin of error.

Another Gallup graph here, with the percent of people who would vs. wouldn’t vote for an otherwise-qualified black candidate for President. It goes from 54% in 1968 to 5% in 1999; later polls that aren’t included on the graph give numbers from 4% to 7%, which sounds probably within the margin of error.

This is a Vox poll asking how many people had favorable vs. unfavorable views of different groups. 11% admit to “somewhat unfavorable” or “very unfavorable” views of blacks, which sounds bad, except that 7% of people admit to unfavorable views of heterosexuals by the same definition. This makes me think “have an unfavorable view about this group” is not a very high bar. If we restrict true “white supremacists” to those who have only “very unfavorable” views of blacks, this is 3%, well in line with our other sources.

(of note, 1% of respondents had “never heard of” blacks. Um…)

Maybe a better way of looking for racists: David Duke ran for Senate in Louisiana this year. He came in seventh with 58,000 votes (3%). Multiplied over 50 states, that would suggest 2.5 million people who would vote for a leading white supremacist. On the other hand, Louisiana is one of the most racist states (for example, Slate’s investigation found that it led the US in percent of racist tweets) and one expects Duke would have had more trouble in eg Vermont. Adjusting for racism level as measured in tweets, it looks like there would be about 1 million Duke voters in a nationwide contest. That’s a little less than 1% of voters.

So our different ways of defining “open white supremacist”, even for definitions of “open” so vague they include admitting it on anonymous surveys, suggest maybe 1-2%, 1-2%, 4-7%, 3-11%, and 1-3%.

But doesn’t this still mean there are some white supremacists? Isn’t this still really important?

I mean, kind of. But remember that 4% of Americans believe that lizardmen control all major governments. And 5% of Obama voters believe that Obama is the Antichrist. The white supremacist vote is about the same as the lizardmen-control-everything vote, or the Obama-is-the-Antichrist-but-I-support-him-anyway vote.

(and most of these people are in Solid South red states and don’t matter in the electoral calculus anyway.)

4. Aren’t there a lot of voters who, although not willing to vote for David Duke or even willing to express negative feelings about black people on a poll, still have implicit racist feelings, the kind where they’re nervous when they see a black guy on a deserted street at night?

Probably. And this is why I am talking about crying wolf. If you wanted to worry about the voter with subconscious racist attitudes carefully hidden even from themselves, you shouldn’t have used the words “openly white supremacist KKK supporter” like a verbal tic.

5. But even if Donald Trump isn’t openly white supremacist, didn’t he get an endorsement from KKK leader David Duke? Didn’t he refuse to reject that endorsement? Doesn’t that mean that he secretly wants to court the white supremacist vote?

The answer is no on all counts.

No, Donald Trump did not get an endorsement from KKK leader David Duke. Duke has spoken out in favor of Trump, but refused to give a formal endorsement. You can read the explanation straight from the horse’s mouth at davidduke.com: “The ZioMedia Lies: I Have Not Endorsed Donald Trump” (content warning: exactly what you would expect). If you don’t want that site in your browser history, you can read the same story at The International Business Times.

No, Donald Trump did not refuse to reject the endorsement. From Politico.com:

Donald Trump says he isn’t interested in the endorsement of David Duke, the anti-Semitic former Ku Klux Klan leader who praised the GOP presidential hopeful earlier this week on his radio show.

“I don’t need his endorsement; I certainly wouldn’t want his endorsement,” Trump said during an interview with Bloomberg’s Mark Halperin and John Heilemann. He added: “I don’t need anyone’s endorsement.”

Asked whether he would repudiate the endorsement, Trump said “Sure, I would if that would make you feel better.”

From Washington Post:

ABC NEWS: “So, are you prepared right now to make a clear and unequivocal statement renouncing the support of all white supremacists?”

TRUMP: “Of course, I am. I mean, there’s nobody that’s done so much for equality as I have. You take a look at Palm Beach, Florida, I built the Mar-a-Lago Club, totally open to everybody; a club that frankly set a new standard in clubs and a new standard in Palm Beach and I’ve gotten great credit for it. That is totally open to everybody. So, of course, I am.”

From CNN:

“David Duke is a bad person, who I disavowed on numerous occasions over the years,” Trump said on MSNBC’s “Morning Joe.”

“I disavowed him. I disavowed the KKK,” Trump added. “Do you want me to do it again for the 12th time? I disavowed him in the past, I disavow him now.”

The concern comes from a single interview February 28, where Trump was asked to renounce support from David Duke and the KKK, where he gave a non-answer:

“I have to look at the group. I mean, I don’t know what group you’re talking about,” Trump said. “You wouldn’t want me to condemn a group that I know nothing about. I’d have to look. If you would send me a list of the groups, I will do research on them and certainly I would disavow if I thought there was something wrong. You may have groups in there that are totally fine — it would be very unfair. So give me a list of the groups and I’ll let you know.”

This is pretty bad. But the next day Trump was saying that of course he denounced the KKK and blaming a “bad earpiece” for not being able to understand what the interviewer was saying.

Trump’s bad earpiece explanation doesn’t hold water – he repeated the name “David Duke” in his answer, so he obviously heard it. And his claim that he didn’t know who David Duke was doesn’t make sense – he’s mentioned Duke before in various contexts.

But it’s actually worth taking a look at those contexts. In 2000, Trump was already considering running for President. His friend Jesse Ventura suggested he seek the Presidential nomination of Ross Perot’s Reform Party. Trump agreed and started putting together a small campaign (interesting historical trivia: he wanted Oprah Winfrey as a running mate). But after some infighting in the Reform Party, Ventura was kicked out in favor of a faction led by populist Pat Buchanan, who had some support from David Duke. Trump closed his presidential bid, saying: “The Reform Party now includes a Klansman, Mr. Duke, a neo-Nazi, Mr. Buchanan, and a communist, Ms. Fulani. This is not company I wish to keep.” Later he continued to condemn the party, saying “You’ve got David Duke just joined — a bigot, a racist, a problem. I mean, this is not exactly the people you want in your party.”

So we have Trump – who loudly condemned Duke before February 28th, and who loudly condemned Duke after February 28th – saying on February 28th that he wanted to “look into” who David Duke was before refusing his (non-existent) endorsement. I’m not super sure what’s going on. It’s possible he wanted to check to see whether it was politically advantageous to officially reject it, which I agree is itself pretty creepy.

But notice that the evidence on the side of Trump being against David Duke includes twenty years of unambiguous statements to that effect. And the evidence of Trump not being against David Duke includes one statement along the lines of “I don’t know who he is but I’ll look into it” on an interview one time which he later blamed on a bad earpiece and said he totally disavowed.

This gets back to my doubts about “dog whistles”. Dog whistling seems to be the theory that if you want to know what someone really believes, you have to throw away decades of consistent statements supporting the side of an issue that everyone else in the world supports, and instead pay attention only to one weird out-of-character non-statement which implies he supports a totally taboo position which is perhaps literally the most unpopular thing it is possible to think.

And then you have to imagine some of the most brilliant rhetoricians and persuaders in the world are calculating that it’s worth risking exposure this taboo belief in order to win support from a tiny group with five-digit membership whose support nobody wants, by sending a secret message, which inevitably every single media outlet in the world instantly picks up on and makes the focus of all their coverage for the rest of the election.

Finally, no, none of this suggests that Donald Trump is courting the white supremacist vote. Anybody can endorse anybody with or without their consent. Did you know that the head of the US Communist Party endorsed Hillary, and Hillary never (as far as I know) “renounced” their endorsement? Does that mean Hillary is a Communist? Did you know that a leader of a murderous black supremacist cult supported Donald Trump and Trump said that he “loved” him? Does that mean Trump is a black supremacist? The only time this weird “X endorsed Y, that means Y must support X” thing is brought out, is in favor of the media narrative painting Trump to be a racist.

This, to me, is another form of crying wolf. One day you might have a candidate who openly courts the KKK, in the sense of having a campaign platform saying “I like the KKK and value their support”, speaking at Klan meetings, et cetera. And instead, you’ve wasted the phrase “openly courts the KKK” on somebody with a twenty year history of loudly condemning the KKK, plus one weird interview where he said he didn’t know anything about it, then changed his mind the next day and said he hates them.

6. What about Trump’s “drugs and crime” speech about Mexicans?

Trump said that:

When Mexico sends its people, they’re not sending their best. They’re not sending you. They’re sending people that have lots of problems, and they’re bringing those problems with us. They’re bringing drugs. They’re bringing crime. Their rapists. And some, I assume, are good people.

Note how totally non-racist this statement is. I’m serious. It’s anti-illegal-immigrant. But in terms of race, it’s saying Latinos (like every race) include both good and bad people, and the bad people are the ones coming over here. It suggests a picture of Mexicans as including some of the best people – but those generally aren’t the ones who are coming illegally.

Compare to eg Bill Clinton’s 1996 platform (all emphasis mine):

We cannot tolerate illegal immigration and we must stop it. For years before Bill Clinton became President, Washington talked tough but failed to act. In 1992, our borders might as well not have existed. The border was under-patrolled, and what patrols there were, were under-equipped. Drugs flowed freely. Illegal immigration was rampant. Criminal immigrants, deported after committing crimes in America, returned the very next day to commit crimes again. President Clinton is making our border a place where the law is respected and drugs and illegal immigrants are turned away.

Or John McCain in 2008:

Border security is essential to national security. In an age of terrorism, drug cartels, and criminal gangs, allowing millions of unidentified persons to enter and remain in this country poses grave risks to the sovereignty of the United States and the security of its people.

Trump’s platform contains similar language – and, like all past platforms, also contains language praising legal immigrants:

Just as immigrant labor helped build our country in the past, today’s legal immigrants are making vital contributions in every aspect of national life. Their industry and commitment to American values strengthens our economy, enriches our culture, and enables us to better understand and more effectively compete with the rest of the world.

We are particularly grateful to the thousands of new legal immigrants, many of them not yet citizens, who are serving in the Armed Forces and among first responders. Their patriotism should encourage all to embrace the newcomers legally among us, assist their journey to full citizenship, and help their communities avoid isolation from the mainstream of society. We are also thankful for the many legal immigrants who continue to contribute to American society.

When Democrats and Republicans alike over the last twenty years say that we are a nation of immigrants but that illegal immigrants threaten our security, or may be criminals or drug pushers, they’re met with yawns. When Trump says exactly the same thing, he’s Literally the KKK.

7. What about the border wall? Doesn’t that mean Trump must hate Mexicans?

As multiple sources point out, both Hillary and Obama voted for the Secure Fence Act of 2006, which put up a 700 mile fence along the US-Mexican border. Politifact says that Hillary and Obama wanted a 700 mile fence but Trump wants a 1000 mile wall, so these are totally different. But really? Support a 700 mile fence, and you’re the champion of diversity and all that is right in the world; support a 1000 mile wall and there’s no possible explanation besides white nationalism?

8. Isn’t Trump anti-immigrant?

He’s at least anti-undocumented immigrant, which is close to being anti-immigrant. And while one can argue that “anti-immigrant” is different than “racist”, I would agree that probably nobody cares that much about British or German immigrants, suggesting that some racial element is involved.

But I think when Trump voters talk about “globalists”, they’re pointing at how they model this very differently from the people they criticize.

In one model, immigration is a right. You need a very strong reason to take it away from anybody, and such decisions should be carefully inspected to make sure no one is losing the right unfairly. It’s like a store: everyone should be allowed to come in and shop and if a manager refused someone entry then they better have a darned good reason.

In another, immigration is a privilege which members of a community extend at their pleasure to other people whom they think would be a good fit for their community. It’s like a home: you can invite your friends to come live with you, but if someone gives you a vague bad feeling or seems like a good person who’s just incompatible with your current lifestyle, you have the right not to invite them and it would be criminal for them to barge in anyway.

It looks like many Clinton supporters believe in the first model, and many Trump supporters in the second model. I think this ties into deeper differences – Clinton supporters are more atomized and individualist, Trump supporters stronger believers in culture and community.

In the second model, the community gets to decide how many immigrants come in and on what terms. Most of the Trump supporters I know are happy to let in a reasonable amount, but they get very angry when people who weren’t invited or approved by the community come in anyway and insist that everyone else make way for them.

Calling this “open white supremacy” seems like those libertarians who call public buses Communism, except if “Communism” got worn out on the euphemism treadmill and they started calling public buses “overt Soviet-style Stalinism”.

9. Don’t Trump voters oppose the Emancipation Proclamation that freed the slaves?

This was in New York Times, Vox, Huffington Post, Time, et cetera. It’s very misleading. See Snopes for full explanation.

10. Isn’t Trump anti-Semitic?

I feel like an attempt to avoid crying wolf might reserve that term for people who didn’t win an Israeli poll on what candidate would best represent Israel’s interests, or doesn’t have a child who converted to Judaism, or hasn’t won various awards from the American Jewish community for his contributions to Israel and American Judaism, or wasn’t the grand marshal of a Salute To Israel Parade, or…

11. Don’t we know that Trump voters are motivated by racism because somebody checked and likelihood of being a Trump voter doesn’t correlate with some statistic or other supposedly measuring economic anxiety?

Although economic issues are only one part of Trump voters’ concerns, they certainly are a part. You just have to look in the right places. See also:

12. Don’t we know that Trump voters are motivated by racism because despite all the stuff about economic anxiety, rich people were more likely to vote Trump than poor people?

I keep hearing stuff like this, and aside from the object-level question, I think it’s important to note the way in which this kind of thing makes racism the null hypothesis. “You say it’s X, but you can’t prove it, so it’s racism”.

Anyway, in this particular case, there’s a simple answer. Yes, Republicans are traditionally the party of the rich. What’s different about this election is that far more poor people voted Republican than usual, and far more rich people voted Democrat than usual.

Poor people were 16 percentage points more likely to vote Republican this election than last time around, but rich people (well, the richest bracket NYT got data about) were 9 percentage points more likely to vote Democrat. This is consistent with economic anxiety playing a big role.

13. Doesn’t Trump want to ban (or “extreme vet”, or whatever) Muslims entering the country?

Yes, and this is awful.

But why do he (and his supporters) want to ban/vet Muslims, and not Hindus or Kenyans, even though most Muslims are white(ish) and most Hindus and Kenyans aren’t? Trump and his supporters are concerned about terrorism, probably since the San Bernardino shooting and Pulse nightclub massacre dominated headlines this election season.

You can argue that he and his supporters are biased for caring more about terrorism than about furniture-related injuries, which kill several times more Americans than terrorists do each year. But do you see how there’s a difference between “cognitive bias that makes you unreasonably afraid” versus “white supremacy”?

I agree that this is getting into murky territory and that a better answer here would be to deconstruct the word “racism” into a lot of very heterogenous parts, one of which means exactly this sort of thing. But as I pointed out in Part 4, a lot of these accusations shy away from the word “racism” precisely because it’s an ambiguous thing with many heterogenous parts, some of which are understandable and resemble the sort of thing normal-but-flawed human beings might think. Now they say “KKK white nationalism” or “overt white supremacy”. These terms are powerful exactly because they do not permit the gradations of meaning which this subject demands.

Let me say this for the millionth time. I’m not saying Trump doesn’t have some racist attitudes and policies. I am saying that talk of “entire campaign built around white supremacy” and “the white power candidate” is deliberate and dangerous exaggeration. Lots of people (and not just whites!) are hasty to generalize from “ISIS is scary” to “I am scared of all Muslims”. This needs to be called out and fought, but it needs to be done in an understanding way, not with cries of “KKK WHITE SUPREMACY!”

14. Haven’t there been hundreds of incidents of Trump-related hate crimes?

This isn’t a criticism of Trump per se (he’s demanded that his supporters avoid hate crimes), but it seems relevant to the general tenor of the campaign.

SPLC said they have 300 such hate incidents, although their definition of “hate incident” includes things like “someone overheard a racist comment in someone else’s private conversation, then challenged them about it and got laughed at”. Let’s take that number at face value (though see here)

If 47% of America supports Trump (= the percent of vote he got extrapolated to assume non-voters feel the same way), there are 150,000,000 Trump supporters. That means there has been one hate incident per 500,000 Trump supporters.

But aren’t there probably lots of incidents that haven’t been reported to SLPC? Maybe. Maybe there’s two unreported attacks for every reported one, which means that the total is one per 150,000 Trump supporters. Or maybe there are ten unreported attacks for every reported one, which means that the total is one per 45,000 Trump supporters. Since nobody has any idea about this, it seems weird to draw conclusions from it.

Oh, also, I looked on right-wing sites to see if there are complaints of harassment and attacks by Hillary supporters, and there are. Among the stories I was able to confirm on moderately trustworthy news sites that had investigated them somewhat (a higher standard than the SLPC holds their reports to) are ones about how Hillary supporters have beaten up people for wearing Trump hats, screamed encouragement as a mob beat up a man who they thought voted Trump, knocked over elderly people, beaten up a high school girl for supporting Trump on Instagram, defaced monuments with graffiti saying “DIE WHITES DIE”, advocated raping Melania Trump, kicked a black homeless woman who was holding a Trump sign, attacked a pregnant woman stuck in her car, with a baseball bat, screamed at children who vote Trump in a mock school election, etc, etc, etc.

But please, keep talking about how somebody finding a swastika scrawled in a school bathroom means that every single Trump supporter is scum and Trump’s whole campaign was based on hatred.

15. Don’t we know that Trump supports racist violence because, when some of his supporters beat up a Latino man, he just said they were “passionate”?

All those protests above? The anti-Trump protests that have resulted in a lot of violence and property damage and arrests? With people chanting “KILL TRUMP” and all that?

When Trump was asked for comment, he tweeted “Love the fact that the small groups of protesters last night have passion for our great country”.

I have no idea how his mind works and am frankly boggled by all of this, but calling violent protesters “passionate” just seems to be a thing of his.

16. But didn’t Trump…

Whatever bizarre, divisive, ill-advised, and revolting thing you’re about to mention, the answer is probably yes.

This is equally true on race-related and non-race-related issues. People ask “How could Trump believe the wacky conspiracy theory that Obama was born in Kenya, if he wasn’t racist?” I don’t know. How could Trump believe the wacky conspiracy theory that vaccines cause autism? How could Trump believe the wacky conspiracy theory that the Clintons killed Vince Foster? How could Trump believe the wacky conspiracy theory that Ted Cruz’s father shot JFK?

Trump will apparently believe anything for any reason, especially about his political opponents. If Clinton had been black but Obama white, we’d be hearing that the Vince Foster conspiracy theory proves Trump’s bigotry, and the birtherism was just harmless wackiness.

Likewise, how could Trump insult a Mexican judge just for being Mexican? I don’t know. How could Trump insult a disabled reporter just for being disabled? How could Trump insult John McCain just for being a beloved war hero? Every single person who’s opposed him, Trump has insulted in various offensive ways, including 140 separate incidents of him calling someone “dopey” or “dummy” on Twitter, and you expect him to hold his mouth just because the guy is a Mexican?

I don’t think people appreciate how weird this guy is. His weird way of speaking. His catchphrases like “haters and losers!” or “Sad!”. His tendency to avoid perfectly reasonable questions in favor of meandering tangents about Mar-a-Lago. The ability to bait him into saying basically anything just by telling him people who don’t like him think he shouldn’t.

If you insist that Trump would have to be racist to say or do whatever awful thing he just said or did, you are giving him too much credit. Trump is just randomly and bizarrely terrible. Sometimes his random and bizarre terribleness is about white people, and then we laugh it off. Sometimes it’s about minorities, and then we interpret it as racism.

17. Isn’t this a lot of special pleading? Like, sure, you can make up various non-racist explanations for every single racist-sounding thing Trump says, and say a lot of it is just coincidence or Trump being inexplicably weird, but eventually the coincidences start adding up. You have to look at this kind of thing in context.

I actually disagree with this really strongly and this point deserves a post of its own because it’s really important. But let me try to briefly explain what I mean.

Suppose you’re talking to one of those ancient-Atlantean secrets-of-the-Pyramids people. They give you various pieces of evidence for their latest crazy theory, such as (and all of these are true):

1. The latitude of the Great Pyramid matches the speed of light in a vacuum to five decimal places.
2. Famous prophet Edgar Cayce, who predicted a lot of stuff with uncanny accuracy, said he had seen ancient Atlanteans building the Pyramid in a vision.
3. There are hieroglyphs near the pyramid that look a lot like pictures of helicopters.
4. In his dialogue Critias, Plato relayed a tradition of secret knowledge describing a 9,000-year-old Atlantean civilization.
5. The Egyptian pyramids look a lot like the Mesoamerican pyramids, and the Mesoamerican name for the ancient home of civilization is “Aztlan”
6. There’s an underwater road in the Caribbean, whose discovery Edgar Cayce predicted, and which he said was built by Atlantis
7. There are underwater pyramids near the island of Yonaguni.
8. The Sphinx has apparent signs of water erosion, which would mean it has to be more than 10,000 years old.

She asks you, the reasonable and well-educated supporter of the archaeological consensus, to explain these facts. After looking through the literature, you come up with the following:

1. This is just a weird coincidence.
2. Prophecies have so many degrees of freedom that anyone who gets even a little lucky can sound “uncannily accurate”, and this is probably just what happened with Cayce, so who cares what he thinks?
3. Lots of things look like helicopters, so whatever.
4. Plato was probably lying, or maybe speaking in metaphors.
5. There are only so many ways to build big stone things, and “pyramid” is a natural form. The “Atlantis/Atzlan” thing is probably a coincidence.
6. Those are probably just rocks in the shape of a road, and Edgar Cayce just got lucky.
7. Those are probably just rocks in the shape of pyramids. But if they do turn out to be real, that area was submerged pretty recently under the consensus understanding of geology, so they might also just be pyramids built by a perfectly normal non-Atlantean civilization.
8. We still don’t understand everything about erosion, and there could be some reason why an object less than 10,000 years old could have erosion patterns typical of older objects.

I want you to read those last eight points from the view of an Atlantis believer, and realize that they sound really weaselly. They’re all “Yeah, but that’s probably a coincidence”, and “Look, we don’t know exactly why this thing happened, but it’s probably not Atlantis, so shut up.”

This is the natural pattern you get when challenging a false theory. The theory was built out of random noise and ad hoc misinterpretations, so the refutation will have to be “every one of your multiple superficially plausible points is random noise, or else it’s a misinterpretation for a different reason”.

If you believe in Atlantis, then each of the seven facts being true provides “context” in which to interpret the last one. Plato said there was an Atlantis that sunk underneath the sea, so of course we should explain the mysterious undersea ruins in that context. The logic is flawless, it’s just that you’re wrong about everything.

This is how I feel about demands that we interpret Trump’s statements “in context”, too.

IV.

Why am I harping on this?

I work in mental health. So far I have had two patients express Trump-related suicidal ideation. One of them ended up in the emergency room, although luckily both of them are now safe and well. I have heard secondhand of several more.

Like Snopes, I am not sure if the reports of eight transgender people committing suicide due to the election results are true or false. But if they’re true, it seems really relevant that Trump denounced North Carolina’s anti-transgender bathroom law, and proudly proclaimed he would let Caitlyn Jenner use whatever bathroom she wanted in Trump Tower, making him by far the most pro-transgender Republican president in history.

I notice news articles like Vox: Donald Trump’s Win Tells People Of Color They Aren’t Welcome In America. Or Salon’s If Trump Wins, Say Goodbye To Your Black Friends. MSN: Women Fear For Their Lives After Trump Victory.

Vox writes about the five-year-old child who asks “Is Donald Trump a bad person? Because I heard that if he becomes president, all the black and brown people have to leave and we’re going to become slaves.” The Star writes about a therapist called in for emergency counseling to help Muslim kids who think Trump is going to kill them. I have patients who are afraid to leave their homes.

Listen. Trump is going to be approximately as racist as every other American president. Maybe I’m wrong and he’ll be a bit more. Maybe he’ll surprise us and be a bit less. But most likely he’ll be about as racist as Ronald Reagan, who employed Holocaust denier Pat Buchanan as a senior advisor. Or about as racist as George Bush with his famous Willie Horton ad. Or about as racist as Bill “superpredator” Clinton, who took a photo op in front of a group of chained black men in the birthplace of the KKK. Or about as racist as Bush “doesn’t care about black people!” 43. He’ll have some scandals, people who want to see them as racist will see them as racist, people who don’t will dismiss them as meaningless, and nobody will end up in death camps. He probably won’t do a great job fighting to end voter suppression, or helping people caught in the criminal justice system, but I’m not sure that makes him too different from the average member of the Republican Congress we have already.

Since everyone has been wrong about everything lately, I’ve started thinking it’s more important than ever to make clear predictions and grade myself on them, so here are my predictions for the Trump administration:

1. Total hate crimes incidents as measured here will be not more than 125% of their 2015 value at any year during a Trump presidency, conditional on similar reporting methodology [confidence: 80%]
2. Total minority population of US citizens will increase throughout Trump’s presidency [confidence: 99%]
3. US Muslim population increases throughout Trump’s presidency [confidence: 95%]
4. Trump cabinet will be at least 10% minority [confidence: 90%], at least 20% minority [confidence: 70%], at least 30% minority [30%]. Here I’m defining “minority” to include nonwhites, Latinos, and LGBT people, though not women. Note that by this definition America as a whole is about 35% minority and Congress is about 15% minority.
5. Gay marriage will remain legal throughout a Trump presidency [confidence: 95%]
6. Race relations as perceived by blacks, as measured by this Gallup poll, will do better under Trump than they did under Obama (ie the change in race relations 2017-2021 will be less negative/more positive than the change 2009-2016) [confidence: 70%].
7. Neither Trump nor any of his officials (Cabinet, etc) will endorse the KKK, Stormfront, or explicit neo-Nazis publicly, refuse to back down, etc, and keep their job [confidence: 99%].
8. No large demographic group (> 1 million people) get forced to sign up for a “registry” [confidence: 95%]
9> No large demographic group gets sent to internment camps [confidence: 99%]
10. Number of deportations during Trump’s four years will not be greater than Obama’s 8 [confidence: 90%]

If you disagree with me, come up with a bet and see if I’ll take it.

And if you don’t, stop.

Stop fearmongering. Somewhere in America, there are still like three or four people who believe the media, and those people are cowering in their houses waiting for the death squads.

Stop crying wolf. God forbid, one day we might have somebody who doesn’t give speeches about how diversity makes this country great and how he wants to fight for minorities, who doesn’t pose holding a rainbow flag and state that he proudly supports transgender people, who doesn’t outperform his party among minority voters, who wasn’t the leader of the Salute to Israel Parade, and who doesn’t offer minorities major cabinet positions. And we won’t be able to call that guy an “openly white supremacist Nazi homophobe”, because we already wasted all those terms this year.

Stop talking about dog whistles. The kabbalistic similarities between “dog-whistling” and “wolf-crying” are too obvious to ignore.

Stop writing articles breathlessly following everything the KKK says. Stop writing several times more articles about the KKK than there are actual Klansmen. Remember that thing where Trump started out as a random joke, and then the media covered him way more than any other candidate because he was so outrageous, and gave him what was essentially free advertising, and then he became President-elect of the United States? Is the lesson you learned from this experience that you need 24-7 coverage of the Ku Klux Klan?

Stop using the words “white nationalist” to describe Trump. When you describe someone as a white nationalist, and then they win, people start thinking white nationalism won. People like winners. This was entirely an own-goal and the perception that white nationalism is now the winning team has 1% to do with Trump and 99% to do with his critics.

Stop responding to everyone who worries about Wall Street or globalism or the elite with “I THINK YOU MEAN JEWS. BECAUSE JEWS ARE THE ELITES. ALL ELITES AND GLOBALISTS ARE JEWS. IF YOU’RE WORRIED ABOUT THE ELITE, IT’S DEFINITELY JEWS YOU SHOULD BE WORRIED ABOUT. IF YOU FEEL SCREWED BY WALL STREET, THEN THE PEOPLE WHO SCREWED YOU WERE THE JEWS. IT’S THE JEWS WHO ARE DOING ALL THIS, MAKE SURE TO REMEMBER THAT. DEFINITELY TRANSLATE YOUR HATRED TOWARDS A VAGUE ESTABLISHMENT INTO HATRED OF JEWS, BECAUSE THEY’RE TOTALLY THE ONES YOU’RE THINKING OF.” This means you, Vox. Someday those three or four people who still believe the media are going to read this stuff and immediately join the Nazi Party, and nobody will be able to blame them.

Stop saying that being against crime is a dog whistle for racism. Have you ever met a crime victim? They don’t like crime. I work with people from a poor area, and a lot of them have been raped, or permanently disabled, or had people close to them murdered. You know what these people have in common? They don’t like crime When you say “the only reason someone could talk about law and order is that they secretly hate black people, because, y’know, all criminals are black”, not only are you an idiot, you’re a racist. Also, I judge you for not having read the polls saying that nonwhites are way more concerned about crime than white people are.

Stop turning everything into identity politics. The only thing the media has been able to do for the last five years is shout “IDENTITY POLITICS IDENTITY POLITICS IDENTITY POLITICS IDENTITY POLITICS IDENTITY POLITICS!” at everything, and then when the right wing finally says “Um, i…den-tity….poli-tics?” you freak out and figure that the only way they could have possibly learned that phrase is from the KKK.

Stop calling Trump voters racist. A metaphor: we have freedom of speech not because all speech is good, but because the temptation to ban speech is so great that, unless given a blanket prohibition, it would slide into universal censorship of any unpopular opinion. Likewise, I would recommend you stop calling Trump voters racist – not because none of them are, but because as soon as you give yourself that opportunity, it’s a slippery slope down to “anyone who disagrees with me on anything does so entirely out of raw seething hatred, and my entire outgroup is secret members of the KKK and so I am justified in considering them worthless human trash”. I’m not saying you’re teetering on the edge of that slope. I’m saying you’re way at the bottom, covered by dozens of feet of fallen rocks and snow. Also, I hear that accusing people of racism constantly for no reason is the best way to get them to vote for your candidate next time around. Assuming there is a next time.

Stop centering criticism of Donald Trump around this sort of stuff, and switch to literally anything else. Here is an incompetent thin-skinned ignorant boorish fraudulent omnihypocritical demagogue with no idea how to run a country, whose philosophy of governance basically boils down to “I’m going to win and not lose, details to be filled in later”, and all you can do is repeat, again and again, how he seems popular among weird Internet teenagers who post frog memes. In the middle of an emotionally incontinent reality TV show host getting his hand on the nuclear button, your chief complaint is that in the middle of a few dozen denunciations of the KKK, he once delayed denouncing the KKK for an entire 24 hours before going back to denouncing it again. When a guy who says outright that he won’t respect elections unless he wins them does, somehow, win an election, the headlines are how he once said he didn’t like globalists which means he must be anti-Semitic.

Stop making people suicidal. Stop telling people they’re going to be killed. Stop terrifying children. Stop giving racism free advertising. Stop trying to convince Americans that all the other Americans hate them. Stop. Stop. Stop.

Book Review: House of God

I’m not a big fan of war movies. I liked the first few I watched. It was all downhill from there. They all seem so similar. The Part Where You Bond With Your Squadmates. The Part Where Your Gruff Sergeant Turns Out To Have A Heart After All. The Part Where Your Friend Dies But You Have To Keep Going Anyway. The Part That Consists Of A Stirring Speech.

The problem is that war is very different from everything else, but very much like itself.

Medical internship is also very different from everything else but very much like itself. I already had two examples of it: Scrubs and my own experience as a medical intern (I preferred Scrubs). So when every single personin the medical field told me to read Samuel Shem’s House of God, I deferred. I deferred throughout my own internship, I deferred for another two years of residency afterwards. And then for some reason I finally picked it up a couple of days ago.

This was a heck of a book.

On some level it was as predictable as I expected. It hit all of the Important Internship Tropes, like The Part Where Your Attendings Are Cruel, The Part Where Your Patient Dies Because Of Something You Did, The Part Where You Get Camaraderie With Other Interns, The Part Where You First Realize You Are Actually Slightly Competent At Like One Thing And It Is The Best Feeling In The Universe, The Part Where You Realize How Pointless 99% Of The Medical System Is, The Part Where You Have Sex With Hot Nurses, et cetera.

All I can say is that it was really well done. The whole thing had a touch of magical realism, which turns out to be exactly the right genre for a story about medicine. Real medicine is absolutely magical realist. It’s a series of bizarre occurrences just on the edge of plausibility happening to incredibly strange people for life-and-death stakes, day after day after day, all within the context of the weirdest and most byzantine bureaucracy known to humankind.

Just in the past week, for example, I had to deal with an aboulomaniac patient – one with a pathological inability to make up his mind. He came to my clinic for treatment, but as soon as he saw me, he decided he didn’t want treatment after all and left. The next day, he was back on my calendar – he’d decided he needed treatment after all – but when his appointment came around, he chanegd his mind and left again. This happened five times in five days. Every day he would phone in asking for an appointment. Every day I would give it to him. Every day he would leave a minute or two before it began. Unsure how to proceed, I sought out my attending. He ignored my questions, pulled me into a side office, took out his cell phone, and started playing me a video. It’s a scene from his musical, The Phantom Of The Psychiatric Unit, which he’s been forcing his interns to rehearse after rounds. I watched, horrified. It was weirdly good.

If I were to write a book about this kind of thing, people would criticize me for being unrealistic. The only way to get away with it is to pass it off as “a touch of magical realism”, and this The House of God does to excellent effect.

The story revolves around an obvious author-insert character, Roy Basch MD, who starts his internship year at a hospital called the House of God (apparently a fictionalized version of Beth Israel Hospital in Boston). He goes in with expectations to provide useful medical care to people with serious diseases. Instead, he finds gomers:

“Gomer is an acronym: Get Out of My Emergency Room. It’s what you want to say when one’s sent in from the nursing home at three A.M.”

“I think that’s kind of crass,” said Potts. “Some of us don’t feel that way about old people.”

“You think I don’t have a grandmother?” asked Fats indignantly. “I do, and she’s the cutest dearest, most wonderful old lady. Her matzoh balls float – you have to pin them down to eat them up. Under their force the soup levitates. We eat on ladders, scraping the food off the ceiling. I love…” The Fat Man had to stop, and dabbed the tears from his eyes, and then went on in a soft voice, “I love her very much.”

I thought of my grandfather. I loved him too.

“But gomers are not just dear old people,” said Fats. “Gomers are human beings who have lost what goes into being human beings. They want to die, and we will not let them. We’re cruel to the gomers, by saving them, and they’re cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them.”

This is where the magical realism starts to come in:

Rokitansky was an old bassett. He’d been a college professor and had suffered a severe stroke. He lay on his bed, strapped down, IV’s going in, catheter coming out. Motionless, paralyzed, eyes closed, breathing comfortably, perhaps dreaming of a bone, or a boy, or of a boy throwing a bone.

“Mr. Rokitansky, how are you doing?” I asked.

Without opening his eyes, after fifteen seconds, in a husky slurred growl from deep down in his smushed brain he said: PURRTY GUD.

Pleased, I asked, “Mr. Rokitansky, what date is it today?”

PURRTY GUD. .

To all my questions, his answer was always the same. I felt sad. A professor, now a vegetable. Again I thought of my grandfather, and got a lump in my throat. Turning to Fats, I said, “This is too sad. He’s going to die.”

“No, he’s not,” said Fats. “He wants to, but he won’t.”

“He can’t go on like this.”

“Sure he can. Listen, Basch, there are a number of LAWS OF THE HOUSE OF GOD. LAW NUMBER ONE: GOMERS DON’T DIE.”

“That’s ridiculous. Of course they die.”

“I’ve never seen it, in a whole year here,” said Fats.

“They have to.”

“They don’t. They go on and on. Young people – like you and me – die, but not the gomers. Never seen it. Not once.”

“Why not?”

“I don’t know. Nobody knows. It’s amazing. Maybe they get past it. It’s pitiful. The worst.”

Potts came in, looking puzzled and concerned. He wanted the Fat Man’s help with Ina Goober. They left, and I turned back to Rokitansky. In the dim half-light I thought I saw tears trickling down the old man’s cheeks. Shame swept over me. My stomach churned. Had he heard what we’d said?

“Mr. Rokitansky, are you crying?” I asked, and I waited, as the long seconds ticked away, my guilt moaning inside me.

PURRTY GUD.

“But did you hear what we said about gomers?”

PURRTY GUD.

Someone once said that the point of art is to be more real than reality. The House Of God is way more real than reality. Reality wishes it could be anywhere close to as real as The House of God. This is a world where young people – the kid just out of school, the blushing new mother – die. Even normal old people – your grandmother, your grandpa – can die. But the most decrepit, demented people, the ones for whom every moment of artificially-prolonged life is a gratuitous misery and you pray at every moment that God will just let them find some peace – somehow they never die. They come into the hospital, they go back out to nursing homes, a few weeks later they’re back in the hospital, a few weeks later they’re back in their nursing homes, but they never die. This can’t be literally true. But it’s the subjective truth of working in a hospital. The Fat Man is right. I’ve been working in medicine for three years now, and I have seen my share of young people tragically cut off in the prime of life, and yet as far as I can remember I have never seen a gomer die. The magical realism of House of God describes the reality of medical professionals infinitely better than the rational world of hospital mortality statistics.

In the world of The House of God, the primary form of medical treatment is the TURF – the excuse to get a patient out of your care and on to somebody else’s. If the psychiatrist can’t stand a certain patient any longer, she finds some trivial abnormality in their bloodwork and TURFs to the medical floor. But she knows that if the medical doctor doesn’t want one of his patients, then he can interpret a trivial patient comment like “Being sick is so depressing” as suicidal ideation and TURF to psychiatry. At 3 AM on a Friday night, every patient is terrible, the urge to TURF is overwhelming, and a hospital starts to seem like a giant wheel uncoupled from the rest of the world, Psychiatry TURFING to Medicine TURFING to Surgery TURFING to Neurosurgery TURFING to Neurology TURFING back to Psychiatry again. Surely some treatment must get done somewhere? But where? It becomes a legend, The Place Where Treatment Happens, hidden in some far-off hospital wing accessible only to the pure-hearted. This sort of Kafkaesque picture is how medical care feels, and the genius of The House of God is that it accentuates the reality just a little bit until its fictional world is almost as magical-realist as the real one.

In the world of The House of God, medical intervention can only make patients worse:

Anna O. had started out on Jo’s service in perfect electrolyte balance, with each organ system working as perfectly as an 1878 model could. This, to my mind, included the brain, for wasn’t dementia a fail-safe and soothing oblivion of the machine to its own decay?

From being on the verge of a TURF back to the Hebrew House for the Incurables, as Anna knocked around the House of God in the steaming weeks of August, getting a skull film here and an LP there, she got worse, much worse. Given the stress of the dementia work-up, every organ system crumpled: in a domino progression the injection of radioactive dye for her brain scan shut down her kidneys, and the dye study of her kidneys overloaded her heart, and the medication for her heart made her vomit, which altered her electrolyte balance in a life-threatening way, which increased her dementia and shut down her bowel, which made her eligible for the bowel run, the cleanout for which dehydrated her and really shut down her tormented kidneys, which led to infection, the need for dialysis, and big-time complications of these big-time diseases. She and I both became exhausted, and she became very sick. Like the Yellow Man, she went through a phase of convulsing like a hooked tuna, and then went through a phase that was even more awesome, lying in bed deathly still, perhaps dying. I felt sad, for by this time, I liked her. I didn’t know what to do. I began to spend a good deal of time sitting with Anna, thinking.

The Fat Man was on call with me every third night as backup resident, and one night, searching for me to go to the ten o’clock meal, he found me with Anna, watching her trying to die.

“What the hell are you doing?” he asked.

I told him.

“Anna was on her way back to the Hebrew House, what happened – wait, don’t tell me. Jo decided to go all-out on her dementia, right?”

“Right. She looks like she’s going to die.”

“The only way she’ll die is if you murder her by doing what Jo says.”

“Yeah, but how can I do otherwise, with Jo breathing down my neck?”

“Easy. Do nothing with Anna, and hide it from Jo.”

“Hide it from Jo?”

“Sure. Continue the work-up in purely imaginary terms, buff the chart with the imaginary results of the imaginary tests, Anna will recover to her demented state, the work-up will show no treatable cause for it, and everybody’s happy. Nothing to it.”

“I’m not sure it’s ethical.”

“Is it ethical to murder this sweet gomere with your work-up?”

There was nothing I could say.”

After learning these medical secrets, Dr. Basch uses hook and crook to prevent his patients from getting any treatment. They end up healthier than anyone else in the hospital, and Basch becomes a contender for “Most Valuable Intern” – in typical House of God style, nobody knows if this award really exists or is just a rumor. His colleagues compete for another award, the “Black Crow”, which goes to the intern who gets the most autopsy consents from grieving families – and which the administration doesn’t realize incentivizes doctors to kill their patients. This is so reminiscent of the bizarre incentive systems in real hospitals that it hurts.

But as the year goes on, everyone gets more and more frazzled. One intern has a mental breakdown. Another commits suicide by jumping out of a hospital window (this isn’t dramatic exaggeration by the way; three junior doctors have committed suicide by jumping out of windows in the past three years in New York City alone). Dr. Basch runs through all sorts of interesting forms of neurosis. Finally, the end of the year approaches, the original crop of interns thinned-out but triumphant – and then they realize they have to do the whole thing again next year as residents, which is maybe a little less grueling but still in the same ballpark.

So they decide, en masse, to go into psychiatry, well-known to be a rare non-terrible residency. The author of House of God is a psychiatrist, so I guess this is only a spoiler insofar as you aren’t logically omniscient. When the Chief of Medicine learns that every single one of his hospital’s interns are going into psychiatry and there aren’t going to be any non-psychiatry residents in the whole hospital…

…okay, fine, I won’t spoil the ending. But suffice it to say I’m feeling pretty good about my career path right now.

II.

House of God does a weird form of figure-ground inversion.

An example of what I mean, taken from politics: some people think of government as another name for the things we do together, like providing food to the hungry, or ensuring that old people have the health care they need. These people know that some politicians are corrupt, and sometimes the money actually goes to whoever’s best at demanding pork, and the regulations sometimes favor whichever giant corporation has the best lobbyists. But this is viewed as a weird disease of the body politic, something that can be abstracted away as noise in the system.

And then there are other people who think of government as a giant pork-distribution system, where obviously representatives and bureaucrats, incentivized in every way to support the forces that provide them with campaign funding and personal prestige, will take those incentives. Obviously they’ll use the government to crush their enemies. Sometimes this system also involves the hungry getting food and the elderly getting medical care, as an epiphenomenon of its pork-distribution role, but this isn’t particularly important and can be abstracted away as noise.

I think I can go back and forth between these two models when I need to, but it’s a weird switch of perspective, where the parts you view as noise in one model resolve into the essence of the other and vice versa.

And House of God does this to medicine.

Doctors use certain assumptions, like:

1. The patient wants to get better, but there are scientific limits that usually make this impossible
2. Medical treatment makes people healthier
3. Treatment is determined by medical need and expertise

But in House of God, the assumptions get inverted:

1. The patient wants to just die peacefully, but there are bureaucratic limits that usually make this impossible
2. Medical treatment makes people sicker
3. Treatment is determined by what will make doctors look good without having to do much work

Everybody knows that those first three assumptions aren’t always true. Yes, sometimes we prolong life in contravention of patients’ wishes. Sometimes people mistakenly receive unnecessary treatment that causes complications. And sometimes care suffers because of doctors’ scheduling issues. But it’s easy to abstract away to an ideal medicine based on benevolence and reason, and then view everything else as rare and unfortunate deviations from the norm.

House of God goes the whole way and does a full figure-ground inversion. The outliers become the norm; good care becomes the rare deviation. What’s horrifying is how convincing it is. Real medicine looks at least as much like the bizarro-world of House of God as it does the world of the popular imagination where doctors are always wise, diagnoses always correct, and patients always grateful.

There have been a couple of studies finding that giving people health insurance doesn’t make them any healthier – see for example the RAND Health Insurance Experiment and the Oregon Medicaid Experiment. I’ve always been skeptical of these studies, because it seems logical that people who can afford health care will get more of it, and there are ten zillion studies showing various forms of health care to help. Insulin helps diabetes. Antibiotics help sepsis. Surgery helps appendicitis. To deny claims like these would be madness, yet the studies don’t lie. What is going on?

And the answer has to be somewhere in the bizarro-world of House of God. Real medical treatment looks precious little like the House MD model of rare serious disease -} diagnosis -} cure. At least as often, it’s like the House of God model where someone becomes inconvenient -} send to hospital -} one million unnecessary tests. Everyone agrees this is part of the story. House of God is a brilliant book in that it refactors perception to place it in the foreground.

But it’s brilliant because in the end it’s not just a romp through hilarious bureaucratic mishaps. There is as much genuine human goodness and compassion in this book as there is in any rousing speech by a medical school dean. The goodness is often mixed with horror – the doctor who has to fight off hordes of autopsy-consent-form-seekers to let a dying patient spend his last few seconds in peace, or the one who secretly slips euthanasia to a terminal patient begging for an end to the pain because he knows it’s the right thing to do.

The question posed here is “what do you do in a crazy cannibalistic system where it’s impossible to do good work and everyone is dying all around you?”, and the answer is “try as hard as you can to preserve whatever virtue you can, and to remain compassionate and human”. The protagonist swings wildly between “this is all bullshit and I’ll just make fun of these disgusting old people and call it a day” and “I need to save everybody and if I don’t I should hate myself forever”, and eventually like everybody, comes to some kind of synthesis where he recognizes he’s human, recognizes that his patients are human, and tries to deal with it with whatever humor and grace he can manage.

It’s hard enough for a book to be funny, and it’s hard enough for one to be deep, but a book like House of God that can be both at once within the space of a few sentences is an absolute treasure.

III.

I talked to my father about House of God, and I told him a few parts that seemed unrealistic. He told me that those parts were 100% true in 1978 when the book was written. I looked into it more, and ended up appreciating the work on a whole new level.

Uncle Tom’s Cabin is credited with kickstarting the emancipationist movement and maybe even causing the Civil War. The Jungle is famous for launching a whole new era of safety regulations. House of God has a place beside them in the pantheon of books that have changed the world.

The book’s “Second Law” is “GOMER GOES TO GROUND”: demented old people will inevitably fall out of their hospital bed and injure themselves. The book has a whole funny/horrifying scene where the senior resident explains his strategy for this eventuality: He leaves their beds low enough that patients won’t kill themselves when they fall, but high enough that they’ll probably break a bone or two and have to go to orthopaedic surgery – which takes them off his hands. Later, a medical student apes this procedure, a patient falls and breaks a bone or two, and everyone freaks out and tells him that it was a joke, that of course you don’t really arrange skeletal fractures for old people just to save yourself time, what kind of heartless moron could think such a thing? This is some nth-level meta-humor: the reader probably mistook it for real advice because it meshes so seamlessly with all of the other madness and horror, yet most of the other madness and horror in the book is easily recognizable by practicing doctors as a real part of the medical system. Actually, on the n+1st meta-level, I’m not at all sure that the resident wasn’t meant to be completely serious and then backtracked and called it a joke when it went wrong. For that matter, I’m far from sure this wasn’t a real medical practice in the 1970s.

I see enough falls that I wasn’t surprised to see them as a theme, but I thought the book exaggerated their omnipresence. My father said it didn’t – there were just far more falls back in the Old Days. Now hospitals are safer and falls are comparatively rare. Why? Because the government passed a law saying that insurance wouldn’t pay hospitals extra money for the extra days patients have to stay due to fall-related injuries. I am so serious about this. This, I think, is the n+2nd meta-level; amidst all its jokes-played-straight the book treats encouraging falls as an actual in-universe joke, and yet in the real world once hospitals were no longer incentivized to let patients fall the falls stopped.

How did people become aware of this kind of thing? How did the movement against it start? A lot of it seems to be because of House of God. Everyone in medicine knew about this sort of thing. But House of God made it common knowledge.

People were scared to speak up. Everyone thought that maybe they were just a uniquely bad person, or their hospital a uniquely bad institution. Anyone who raised some of these points was met with scorn by prestigious doctors who said that maybe they just weren’t cut out of medicine. House of God shaped medicine because it was the first thing to say what everybody was experiencing. Its terms like “gomer” and “turf” made it into the medical lexicon because they pointed to obvious features of reality nobody had the guts to talk about before.

Shem writes an afterword where he talks about the reaction to the book. Junior doctors and the public loved it. Senior doctors hated it. He tells the story of going to a medical conference. Someone asked who he was, and he said jokingly “I’m the most hated doctor here”. His interlocutor answered “Oh, don’t worry, I’m sure you’re not as bad as the guy who wrote that House of God book.”

But House of God gets credit for helping start movements to cut intern work hours, protect doctors from sleep deprivation, reduce patient falls, and teach empathy and communication skills. The moral of the story is: the courage to tell the truth is rare and powerful. More specifically: the courage to tell the truth is rare and powerful not just in Stalinist dictatorships and violent cults, but in apparently normal parts of everyday First World life. All of these differently loaded terms like “culture of silence” and “political correctness” point at a fear of rocking various boats with nothing but your imperfect first-person knowledge to go on. But a tiny crack in the wall can make a big difference.

IV.

In a closing scene, Dr. Basch and all of his fellow interns – interns who had broken into tears weekly, gotten burnt out, starting seeing psychiatrists, considered suicide, all this stuff, these interns who had smashed up against the unendurable horrors of medicine and held themselves together only by the promise that it would soon be over – the minute they graduate internship they change their tune:

It looked like all but two or three [interns] would stay. The Runt and I were definitely leaving; Chuck hadn’t yet said. The others were staying. In years to come they would spread out across America into academic centers and Fellowships, real red-hots in internal medicine, for they had been trained at the Best Medical School’s best House, the House of God. Although a few might kill themselves or get addicted or go crazy, by and large they’d repress and conform and perpetuate the Leggo [the Chief of Medicine] and the House and all the best medical stuff. [Eddie] had been praised by the Leggo that he could start off the second year as ward resident, with “a free rein” on his interns. And so, saying already that the internship been “not so bad,” he was preparing to indoctrinate his new charges: “I want them on their knees from day one.”

Shem’s author mouthpiece character Berry says:

It’s been inhuman. No wonder doctors are so distant in the face of the most poignant human dramas. The tragedy isn’t the crassness, but the lack of depth. Most people have some human reaction to their daily work, but doctors don’t. It’s an incredible paradox that being a doctor is so degrading and yet is so valued by society. In any community, the most respected group are doctors. [It’s] a terrific repression that makes doctors really believe that they are omnipotent healers. If you hear yourselves saying, ‘Well, this year wasn’t really that bad,’ you’re repressing, to put the next group through it. [But] it’s hard to say no. If you’re programmed from age six to be a doctor, invest years in it, develop your repressive skills so that you can’t even recall how miserable you were during internship, you can’t stop.

Shem’s thesis is that it isn’t just about not wanting to make waves or offend the Chief of Medicine. It’s about denying your own pain by identifying with the system.

This puts me in a weird spot. My internship (I find myself saying) wasn’t so bad. I can give you some arguments why this might be true – things have gotten a lot better since The House of God was published (with no small credit to Shem himself), a small community hospital in Michigan is less intense than Harvard Medical School’s training hospital, psychiatry interns sometimes have it easier than internal medicine interns since everyone knows this isn’t a permanent deal for them.

And yet I distinctly remember one night a long time ago, coming home from high school. I had noticed that all of the adults around me said high school was some of the best years of their lives and I would miss it when I was gone, and yet high school seemed objectively terrible. I wondered if there might be some bias or bizarre shift in memory that happened sometime in people’s twenties and gave them a localized amnesia or insanity. So I very distinctly recall telling myself “My current assessment is that high school is terrible, and if you ever find yourself remembering that high school was lovely, please be aware that your memories have been hijacked by some malevolent force.”

And God help me, but every single part of my brain is telling me that high school was lovely. I fondly remember all the friends I made, the crazy teachers I had to put up with, the science competitions I won, the lunches spent in the library reading whatever random stuff I could get my hands on. It seems like it was a blast. It’s hard for me to even trust that one memory as anything more than imagination or the product of a single bad day. But although high-school-me had a lot of issues, he generally had a decent head on his shoulders, and if he says my memories have been hijacked, then I grudgingly believe him.

So was my intern year a good learning experience? I have no idea and I’m not sure anyone else does either. It’s another type of figure-ground inversion: parade of horrors broken only by the occasional triumph, or clear sailing with a few bad moments?

On my last day of internship, one of my colleagues who was moving on said “I’m going to miss hating this place”. I’ve always remembered that phrase. Now I wonder if it’s some kind of weird snapshot of the exact moment of transition, the instant when “nightmarish ordeal” morphs into “halcyon days of youth”. This is why medicine has to be written as magical realism. How else to capture a world where people reliably go from agony to Stockholm Syndrome in the space of a day, and where the transition is so intermixed with the general weirdness that it doesn’t even merit special remark?

I found myself having more emotions reading House of God than I’ve had about anything in a long time. I don’t really know why. But I think it has something to do with this resignation to the general incommunicable weirdness all around anyone who works in medicine. Somehow Shem manages to avoid the normalization of insanity that happens to every young doctor, capture the exact subjective experience and write it down in a way that makes sense. And then, having put his finger right on the unbearable thing, he makes it funny and beautiful and poignant.

I tell her. Again I tell her about Dr. Sanders bleeding out in my lap, about the look in Potts’s eyes that night before he jumped, about my pushing the KCl into poor Saul. I tell her how ashamed I am for turning into a sarcastic bastard who calls the old ones gomers, how, during the ternship, I’d ridiculed them for their weaknesses, for throwing up their suffering in my face, for scaring me, for forcing me to do disgusting things to take care of them. I tell her how I want to live, compassionately, with the idea of death clearly in sight, and how I doubt I can do that, ever again. As I think back to what I’d gone through and what I’d become, sadness wells up and mixes with contempt. I put my head into Berry’s folds and weep, and curse, and shout, and weep.

“. . . and in your own way, you did. Someone had to care for the gomers; and this year, in your own way, you did.”

“The worst thing is this bitterness. I used to be different, gentle, even generous, didn’t I? I wasn’t always like this, was I?”

“I love who you are. To me, underneath it all, you’re still there:” She paused, and then, eyes sparkling, said, “And you might even be better.”

“What? What do you mean?”

“This might have been the only thing that could have awakened you. Your whole life has been a growing from the outside, mastering the challenges that others have set for you. Now, finally, you might just be growing from inside yourself.

He also frames all of it in the language of psychoanalysis, which is jarring and sounds preachy. I’ve ordered the sequel, Mount Misery, about his training as a psychoanalyst. Expect a review of that soon.