Thoughts on economics and liberty

Tag: My book reviews

Review of Geoffrey Miller’s Spent

As usual, I seem to get these world best-sellers at the fag end of their season, when they are in the clearance bin. The most "entertaining" places (to me!) are these clearance book shops which temporarily sprout across the Melbourne city, and "Opshops" (used goods shops). A couple of weeks ago I found three great books and want to report on this one which is an excellent eye-opener:  Spent: Sex, Evolution, and Consumer Behavior by Geoffrey Miller.

A new personality test (GOCASE)

There is now apparently a growing consensus re: personality types. A 6-factor personality assessment tool called GOCASE has now been developed and has superseded the Myer-Briggs inventory (on which I wrote this blog post some time ago). The six factors, outlined by Prof. Geoffrey Miller, are:

a) G or general intelligence (usually called IQ)

b) O or openness

c) C or conscientiousness

d) A or agreeableness

e) S or stability

f) E or extraversion

Apparently the last five of these are totally independent, and a) and b) are mildly correlated. More importantly, these can be tested through just 10 questions (excluding IQ which is best tested independently). I quote directly from the book: 

Measuring Your Big Five

The Big Five can now be measured with moderate accuracy, using a self-rating scale, in about one minute. The psychologists Beatrice Rammstein and Oliver John published a Big Five scale in 2007 called the BFI-10 that uses just ten questions. They found that people's scores on this very short scale were very reliable across a two-month period (with test-retest correlations about .84), and correlated very highly (about .82) with their scores on much longer personality scales.
Their BFI-10 scale is reprinted below in a slightly clearer form; try it and see how you score.
After each statement below, write down a number from 1 to 5 to represent how well the statement describes your personality, where
1 = disagree strongly,
2 = disagree a little,
3 = neither agree nor disagree,
4 = agree a little,
5 = agree strongly.
I See Myself as Someone Who
1. has an active imagination ________
2. has few artistic interests _________
3. does a thorough job _____________
4. tends to be lazy ________________
5. is generally trusting _____________
6. tends to find fault with others ______
7. is relaxed, handles stress well _____
8. gets nervous easily _____________
9. is outgoing, sociable ____________
10. is reserved ___________________.
Here's how to score yourself. Items 1 and 2 concern openness; 3 and 4 concern conscientiousness, 5 and 6 concern agreeableness, 7 and 8 concern emotional stability, and 9 and 10 concern extraversion. For each successive pair of items, subtract the number you wrote for the even-numbered item from the number you wrote for the odd-numbered item, and that gives your score for the corresponding Big Five trait. Scores can range from -4 (very low on the trait) to +4 (very high on the trait), with 0 being about average.
For example, if you "agree a little" with "I see myself as someone who has an active imagination," you should have written a 4 for item 1. If you "disagree strongly" with "I see myself as someone who has few artistic interests," you should have written a 1 for item 2. Then you'd subtract your response to the even-numbered item (1) from your response to the odd-numbered item (4), yielding a score of 3 which would mean you are quite high on openness, given that the average is 0 and the maximum is 4. (p.162-3)
[You can get yourself tested on a slightly different scale here. Also see this.]
My score: OCASE = 2 : 1 : 2 : 0 : 0. In other words, I am pretty much a 'normal' person (closer to 0 represents the statistical mean). Compare this with my MBT inventory here. The closest fit between the two relates to extraversion, and I come out as neither extroverted nor introverted in both tests (the fact that I'm disclosing my results means I'm slightly extroverted?). Judging and conscientiousness seem to be closely related, but I score somewhat more moderately on that with OCASE. Overall I'm more a 'common man' on OCASE than I am with MBTI.
What's the validity of these results? Don't know. All I know is that Miller states somewhere that those who have all 4's are strongly likely to be super-successful!

Bell curve of human nature

I like the idea that the GOCASE model confirms the bell-shaped model of human nature I've outlined in Discovery of Freedom. I will now cite Miller in support of 'my model' – noting that I have a more extensive model than GOCASE, and focus more on the tail.
In particular, the GOCASE model doesn't show what Hitler's personality type would be, or that of a Gandhi. To be truly successful a human nature (personality) model should be able to ALWAYS identify a Hitler, or a sociopath. And what is the relationship between this and the 5-level Jim Collins model that I believe best represents human leadership? 
I'd say that the jury is out on whether GOCASE is the ultimate word on human personality testing. But it is nice to learn about this advancement.

Further additions to human bias and heuristics

This book, which focuses on the impacts of sexual selection on human nature, provides fascinating insights on how men and women can be biased in their decisions and actions, based on their state in the natural cycle of fertility.
Men who want to impress women are more likely to be non-confirmists "as long as the anticonfirmity doesn't make them look more negative and closed-minded than their rivals, and doesn't lead them to make an embarrassing factual error." (p.245) This, and a wide range of experimental conclusions cited in this book demonstrate that our preferences (even political views) can be influenced strongly by the state of our hormones! This is very provocative conclusion, but likely to be true.
By discussing such biases in human nature, this book advances the direction of work initiated by Kahneman and Tversky. He cites Robert Frank quite a bit, and that is a good thing. Frank is, generally speaking, a very good economist.

Rational irrationality

Most interestingly, I now better understand gaps in our rationality that I've sometimes struggled with. There is a lot of seeming irrationality in the world. 
For instance, it is OBVIOUS to even the most stupid student of economics that free trade generates wealth, that political freedom is beneficial. But then why do millions of people refuse to implement these basic ideas in practice?  The caste system is another classic case. It might have been rational in the past. Why is it still in place?
The reason he offers is very potent: that we promote irrational ideas because OTHERS whom we desire (not admire intellectually!), believe in them. If you want to marry a bright young thing and her parents are devout Hindus who believe in the caste system, you are better off by believing in it (and by belonging to the right caste!). One fool with a beautiful daughter creates another fool. Irrationality survives because it is INDIVIDUALLY rational to be irrational!
Miller provides a number of illustrations to demonstrate why people have "righteous contempt for any empirical evidence that would undermine them". You clearly can't out-argue anyone in this world on the basis of facts. I've never succeeded in doing so, at least. So why is it that people are so irrational that they reject evidence? Because we benefit by belonging to a 'biradari' that promotes our personal (reproductive) interests! – A very challenging idea, but possibly true.
Here is Miller's most profound sentence (which closely matches the social contract I've outlined in DOF): "More subtly, because mating is a social game in which the attractiveness of a behaviour depends on how many other people are already producing that behaviour, political ideology evolves under the unstable dynamics of social imitation and strategizing, not just as a process of simple optimization, given a particular set of self-interests." My Nash Equilibrium social contract model would actually endogenise these mating strategies. But this is a profound conclusion, and makes Miller's book a worthy contribution to the literature. 

Miller is often very, very wrong

Miller then moves on to areas where he not only has no specialisation but no theory. I refer particularly to his advocacy of the consumption tax. His concern is to reduce "consumerism". But sorry, Geoff, you are wrong on this. Your job to DESCRIBE the reasons why people behave the way they do; not to try to change them. That idea of intervening in people's choices – regardless of what their reasons are – is a huge problem! Is Miller or any economist a God that he/she sits separately from the 'people'? What gives us the right to change people's consumption choices? (I don't have any issues with charging a Pigovian tax for negative externalities, though.)
The theory of the state must be founded on a set of clear and consistent principles. A consistent theory of the state requires INCOME taxation – not taxation of consumption (see details here and here).
I don't care how many "economists" Miller cites in favour of his views about the consumption tax. The idea of asking a government to deliberately act to reduce 'consumerism' and increase savings is wrong. This whole idea about dabbling with people's incentives is a real issue. Already the central banks have made a mess. You don't want to confound things totally. These so-called "economists" have no underlying model of the state, and so they superficially prescribe "solutions" by meddling with, and disrupting, the clear link between the citizen and state. To Miller, I'd say: "Please build a CONSISTENT theory of the state before you prescribe a tax model." 
Miller is also very wrong in his comments regarding Hayek and the classical liberals (which are peppered throughout the book). I won't go into that in detail, since knowledge about such things is not expected of him, anyway.

Is Miller a racist?

Miller has great "faith" in the idea of IQ, as a kind of fixed number (which it is NOT – it continuously varies over time), and that 'groups' have different IQs or other personality traits. Thus, at p. 165 he notes, "Nation, region, langauge, culture, …. may predict consumer behaviour mainly because they are directly correlated with some of the Central Six traits". But how? The traits are supposed to be normalised. ALL nations must have the same mean. The law of large numbers must prevail. 
I believe that IQ is largely (not entirely!) determined by culture and by the level of freedom (see my model in Chapter 2 of BFN). Miller himself notes this, at p.198: "my Latin teachers … were open about why we had to learn to read Virgil: familiarity with Latin roots, prefixes, and suffixes would boost our SAT vocabulary test scores". And he admits that SAT is a proxy for IQ. Clearly a PARTICULAR type of education is influencing "IQ" scores!
Miller needs to read and think more widely. His understanding about IQ and the causes of its variations (and that of other traits) is poor. He does talk about how parasitic infection risk might influence openness, and that is not a 'racial' determinant of group variation. But overall I get the strong sense that Miller is a racist.

Overall rating

The book is far more long-winded than it should be. I had to skip solid chunks of idle chatter. The book should be shrunk into half.
However, Miller does come with a unique perspective on human nature that I've learnt a lot from: the elaboration of how sexual selection might work in humans. Overall, I'd say this book is a GOOD READ. Worth reading – but WITH AN OPEN EYE!
I believe that economists and marketing professionals will particularly benefit from this book. But they should never let down their guard. Much of what Miller writes is untested or not fully proven..
Continue Reading

The Checklist Manifesto – the crucial value of some red tape

I came across an advertisement for a book by Atul Gawande which received high praise from Steven Levitt. The book is entitled, ‘The Checklist Manifesto: How to Get Things Right’.

Intrigued, I explored the internet and found a 2007 New Yorker article by Gawande that explains the concept. It is such a fascinating piece that I’ve taken the liberty of copying it on to my blog – with due acknowledgements and referencing.

What the article talks about is a perfect example of critical thinking. I can’t find words to praise Dr. Peter Pronovost (if God exists, may He bless Peter!).

This feat of process innovation represents the heart of critical thinking: which requires us to find the truth through attention to detail. In reading this article I was reminded of Anil Kumar Lakhina’s revolution as a Deputy Commissioner in Ahmednagar. Not many people know of his work, but I had the privilege of visiting his office when he was DC and understanding his work. His simple but focused process innovations not only dramatically cut down corruption but increased efficiency dramatically.
I adopted his work when I became Deputy Commissioner in Barpeta, and in addition made extensive use of computerisation (in which I have had the privilege of being at the forefront in Indian government from 1986-2000, particularly in the 1980s when few cared to learn about or use these 'new fangled' gadgets). The computerised grievance system meant that ANYONE in Barpeta district who complained to me was guaranteed a comprehensive written response – including report on action taken – within a maximum of three months. Corruption and incompetence dramatically declined. ‘Do numbari’ ration cards were weeded out (of course, that begs the question: why ration cards – and that thinking is even more important).
I have always believed  that the devil is in the detail. That is why in BFN I focus extensively on the details of how our electoral system functions. I also spend inordinate time, in my life, investigating incentives, for once we understand incentives we can predict the outcomes.
Anyway, let me stop wandering around – and revert to this article by Gawande. Please enjoy. More importantly, let's applaud the critical thinking of Dr. Pronovost which has saved thousands of lives and could well save yours, in India or elsewhere in the world – if checklist systems are more widely adopted.

The Checklist

The damage that the human body can survive these days is as awesome as it is horrible: crushing, burning, bombing, a burst blood vessel in the brain, a ruptured colon, a massive heart attack, rampaging infection. These conditions had once been uniformly fatal. Now survival is commonplace, and a large part of the credit goes to the irreplaceable component of medicine known as intensive care.
It’s an opaque term. Specialists in the field prefer to call what they do “critical care,” but that doesn’t exactly clarify matters. The non-medical term “life support” gets us closer. Intensive-care units take artificial control of failing bodies. Typically, this involves a panoply of technology—a mechanical ventilator and perhaps a tracheostomy tube if the lungs have failed, an aortic balloon pump if the heart has given out, a dialysis machine if the kidneys don’t work. When you are unconscious and can’t eat, silicone tubing can be surgically inserted into the stomach or intestines for formula feeding. If the intestines are too damaged, solutions of amino acids, fatty acids, and glucose can be infused directly into the bloodstream.
The difficulties of life support are considerable. Reviving a drowning victim, for example, is rarely as easy as it looks on television, where a few chest compressions and some mouth-to-mouth resuscitation always seem to bring someone with waterlogged lungs and a stilled heart coughing and sputtering back to life. Consider a case report in The Annals of Thoracic Surgeryof a three-year-old girl who fell into an icy fishpond in a small Austrian town in the Alps. She was lost beneath the surface for thirty minutes before her parents found her on the pond bottom and pulled her up. Following instructions from an emergency physician on the phone, they began cardiopulmonary resuscitation. A rescue team arrived eight minutes later. The girl had a body temperature of sixty-six degrees, and no pulse. Her pupils were dilated and did not react to light, indicating that her brain was no longer working.
But the emergency technicians continued CPR anyway. A helicopter took her to a nearby hospital, where she was wheeled directly to an operating room. A surgical team put her on a heart-lung bypass machine. Between the transport time and the time it took to plug the inflow and outflow lines into the femoral vessels of her right leg, she had been lifeless for an hour and a half. By the two-hour mark, however, her body temperature had risen almost ten degrees, and her heart began to beat. It was her first organ to come back.
After six hours, her core temperature reached 98.6 degrees. The team tried to put her on a breathing machine, but the pond water had damaged her lungs too severely for oxygen to reach her blood. So they switched her to an artificial-lung system known as ECMO—extracorporeal membrane oxygenation. The surgeons opened her chest down the middle with a power saw and sewed lines to and from the ECMO unit into her aorta and her beating heart. The team moved the girl into intensive care, with her chest still open and covered with plastic foil. A day later, her lungs had recovered sufficiently for the team to switch her from ECMO to a mechanical ventilator and close her chest. Over the next two days, all her organs recovered except her brain. A CT scan showed global brain swelling, which is a sign of diffuse damage, but no actual dead zones. So the team drilled a hole into the girl’s skull, threaded in a probe to monitor her cerebral pressure, and kept that pressure tightly controlled by constantly adjusting her fluids and medications. For more than a week, she lay comatose. Then, slowly, she came back to life.
First, her pupils started to react to light. Next, she began to breathe on her own. And, one day, she simply awoke. Two weeks after her accident, she went home. Her right leg and left arm were partially paralyzed. Her speech was thick and slurry. But by age five, after extensive outpatient therapy, she had recovered her faculties completely. She was like any little girl again.
What makes her recovery astounding isn’t just the idea that someone could come back from two hours in a state that would once have been considered death. It’s also the idea that a group of people in an ordinary hospital could do something so enormously complex. To save this one child, scores of people had to carry out thousands of steps correctly: placing the heart-pump tubing into her without letting in air bubbles; maintaining the sterility of her lines, her open chest, the burr hole in her skull; keeping a temperamental battery of machines up and running. The degree of difficulty in any one of these steps is substantial. Then you must add the difficulties of orchestrating them in the right sequence, with nothing dropped, leaving some room for improvisation, but not too much.
For every drowned and pulseless child rescued by intensive care, there are many more who don’t make it—and not just because their bodies are too far gone. Machines break down; a team can’t get moving fast enough; a simple step is forgotten. Such cases don’t get written up in The Annals of Thoracic Surgery, but they are the norm. Intensive-care medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.
On any given day in the United States, some ninety thousand people are in intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an I.C.U. from the inside. Wide swaths of medicine now depend on the lifesupport systems that I.C.U.s provide: care for premature infants; victims of trauma, strokes, and heart attacks; patients who have had surgery on their brain, heart, lungs, or major blood vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, I.C.U.s barely existed. Today, in my hospital, a hundred and fifty-five of our almost seven hundred patients are, as I write this, in intensive care. The average stay of an I.C.U. patient is four days, and the survival rate is eighty-six per cent. Going into an I.C.U., being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.
A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions—but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard. There are dangers simply in lying unconscious in bed for a few days. Muscles atrophy. Bones lose mass. Pressure ulcers form. Veins begin to clot off. You have to stretch and exercise patients’ flaccid limbs daily to avoid contractures, give subcutaneous injections of blood thinners at least twice a day, turn patients in bed every few hours, bathe them and change their sheets without knocking out a tube or a line, brush their teeth twice a day to avoid pneumonia from bacterial buildup in their mouths. Add a ventilator, dialysis, and open wounds to care for, and the difficulties only accumulate.
The story of one of my patients makes the point. Anthony DeFilippo was a forty-eight-year-old limousine driver from Everett, Massachusetts, who started to hemorrhage at a community hospital during surgery for a hernia and gallstones. The bleeding was finally stopped but his liver was severely damaged, and over the next few days he became too sick for the hospital’s facilities. When he arrived in our I.C.U., at 1:30 A.M. on a Sunday, his ragged black hair was plastered to his sweaty forehead, his body was shaking, and his heart was racing at a hundred and fourteen beats a minute. He was delirious from fever, shock, and low oxygen levels.
“I need to get out!” he cried. “I need to get out!” He clawed at his gown, his oxygen mask, the dressings covering his abdominal wound.
“Tony, it’s all right,” a nurse said to him. “We’re going to help you. You’re in a hospital.”
He shoved her—he was a big man—and tried to swing his legs out of the bed. We turned up his oxygen flow, put his wrists in cloth restraints, and tried to reason with him. He eventually let us draw blood from him and give him antibiotics.
The laboratory results came back showing liver failure, and a wildly elevated white-blood-cell count indicating infection. It soon became evident from his empty urine bag that his kidneys had failed, too. In the next few hours, his blood pressure fell, his breathing worsened, and he drifted from agitation to near-unconsciousness. Each of his organ systems, including his brain, was shutting down.
I called his sister, who was his next of kin, and told her of the situation. “Do everything you can,” she said.
So we did. We gave him a syringeful of anesthetic, and a resident slid a breathing tube into his throat. Another resident “lined him up.” She inserted a thin, two-inch-long needle and catheter through his upturned right wrist and into his radial artery, and then sewed the line to his skin with a silk suture. Next, she put in a central line—a twelve-inch catheter pushed into the jugular vein in his left neck. After she sewed that in place, and an X-ray showed its tip floating just where it was supposed to—inside his vena cava at the entrance to his heart—she put a third, slightly thicker line, for dialysis, through his right upper chest and into the subclavian vein, deep under the collarbone.
We hooked a breathing tube up to a hose from a ventilator and set it to give him fourteen forced breaths of a hundred-per-cent oxygen every minute. We dialled the ventilator pressures and gas flow up and down, like engineers at a control panel, until we got the blood levels of oxygen and carbon dioxide where we wanted them. The arterial line gave us continuous arterial blood-pressure measurements, and we tweaked his medications to get the pressures we liked. We regulated his intravenous fluids according to venous-pressure measurements from his jugular line. We plugged his subclavian line into tubing from a dialysis machine, and every few minutes his entire blood volume washed through this artificial kidney and back into his body; a little adjustment here and there, and we could alter the levels of potassium and bicarbonate and salt in his body as well. He was, we liked to imagine, a simple machine in our hands.
But he wasn’t, of course. It was as if we had gained a steering wheel and a few gauges and controls, but on a runaway eighteen-wheeler hurtling down a mountain. Keeping his blood pressure normal was requiring gallons of intravenous fluid and a pharmacy shelf of drugs. He was on near-maximal ventilator support. His temperature climbed to a hundred and four degrees. Less than five per cent of patients with his degree of organ failure make it home. And a single misstep could easily erase those slender chances.
For ten days, though, all went well. His chief problem had been liver damage from the operation he’d had. The main duct from his liver was severed and was leaking bile, which is caustic—it digests the fat in one’s diet and was essentially eating him alive from the inside. He had become too sick to survive an operation to repair the leak. So we tried a temporary solution—we had radiologists place a plastic drain, using X-ray guidance, through his abdominal wall and into the severed duct in order to draw the leaking bile out of him. They found so much that they had to place three drains—one inside the duct and two around it. But, as the bile drained out, his fevers subsided. His requirements for oxygen and fluids diminished. His blood pressure returned to normal. He was on the mend. Then, on the eleventh day, just as we were getting ready to take him off the mechanical ventilator, he developed high, spiking fevers, his blood pressure sank, and his blood-oxygen levels plummeted again. His skin became clammy. He got shaking chills.
We didn’t understand what had happened. He seemed to have developed an infection, but our X-rays and CT scans failed to turn up a source. Even after we put him on four antibiotics, he continued to spike fevers. During one fever, his heart went into fibrillation. A Code Blue was called. A dozen nurses and doctors raced to his bedside, slapped electric paddles onto his chest, and shocked him. His heart responded, fortunately, and went back into rhythm. It took two more days for us to figure out what had gone wrong. We considered the possibility that one of his lines had become infected, so we put in new lines and sent the old ones to the lab for culturing. Forty-eight hours later, the results returned: all of them were infected. The infection had probably started in one line, perhaps contaminated during insertion, and spread through his bloodstream to the others. Then they all began spilling bacteria into him, producing his fevers and steep decline.
This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. I.C.U.s put five million lines into patients each year, and national statistics show that, after ten days, four per cent of those lines become infected. Line infections occur in eighty thousand people a year in the United States, and are fatal between five and twenty-eight per cent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. After ten days with a urinary catheter, four per cent of American I.C.U. patients develop a bladder infection. After ten days on a ventilator, six per cent develop bacterial pneumonia, resulting in death forty to fifty-five per cent of the time. All in all, about half of I.C.U. patients end up experiencing a serious complication, and, once a complication occurs, the chances of survival drop sharply.
It was a week before DeFilippo recovered sufficiently from his infections to come off the ventilator, and it was two months before he left the hospital. Weak and debilitated, he lost his limousine business and his home, and he had to move in with his sister. The tube draining bile still dangled from his abdomen; when he was stronger, I was going to have to do surgery to reconstruct the main bile duct from his liver. But he survived. Most people in his situation do not.
Here, then, is the puzzle of I.C.U. care: you have a desperately sick patient, and in order to have a chance of saving him you have to make sure that a hundred and seventy-eight daily tasks are done right—despite some monitor’s alarm going off for God knows what reason, despite the patient in the next bed crashing, despite a nurse poking his head around the curtain to ask whether someone could help “get this lady’s chest open.” So how do you actually manage all this complexity? The solution that the medical profession has favored is specialization.
I tell DeFilippo’s story, for instance, as if I were the one tending to him hour by hour. But that was actually Max Weinmann, an intensivist (as intensive-care specialists like to be called). I want to think that, as a general surgeon, I can handle most clinical situations. But, as the intricacies involved in intensive care have mounted, responsibility has increasingly shifted to super-specialists like him. In the past decade, training programs focussed on critical care have opened in every major American city, and half of I.C.U.s now rely on super-specialists.
Expertise is the mantra of modern medicine. In the early twentieth century, you needed only a high-school diploma and a one-year medical degree to practice medicine. By the century’s end, all doctors had to have a college degree, a four-year medical degree, and an additional three to seven years of residency training in an individual field of practice—pediatrics, surgery, neurology, or the like. Already, though, this level of preparation has seemed inadequate to the new complexity of medicine. After their residencies, most young doctors today are going on to do fellowships, adding one to three further years of training in, say, laparoscopic surgery, or pediatric metabolic disorders, or breast radiology—or critical care. A young doctor is not so young nowadays; you typically don’t start in independent practice until your mid-thirties.
We now live in the era of the super-specialist—of clinicians who have taken the time to practice at one narrow thing until they can do it better than anyone who hasn’t. Super-specialists have two advantages over ordinary specialists: greater knowledge of the details that matter and an ability to handle the complexities of the job. There are degrees of complexity, though, and intensive-care medicine has grown so far beyond ordinary complexity that avoiding daily mistakes is proving impossible even for our super-specialists. The I.C.U., with its spectacular successes and frequent failures, therefore poses a distinctive challenge: what do you do when expertise is not enough?
On October 30, 1935, at Wright Air Field in Dayton, Ohio, the U.S. Army Air Corps held a flight competition for airplane manufacturers vying to build its next-generation long-range bomber. It wasn’t supposed to be much of a competition. In early evaluations, the Boeing Corporation’s gleaming aluminum-alloy Model 299 had trounced the designs of Martin and Douglas. Boeing’s plane could carry five times as many bombs as the Army had requested; it could fly faster than previous bombers, and almost twice as far. A Seattle newspaperman who had glimpsed the plane called it the “flying fortress,” and the name stuck. The flight “competition,” according to the military historian Phillip Meilinger, was regarded as a mere formality. The Army planned to order at least sixty-five of the aircraft.
A small crowd of Army brass and manufacturing executives watched as the Model 299 test plane taxied onto the runway. It was sleek and impressive, with a hundred-and-three-foot wingspan and four engines jutting out from the wings, rather than the usual two. The plane roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. Hill.
An investigation revealed that nothing mechanical had gone wrong. The crash had been due to “pilot error,” the report said. Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, a retractable landing gear, new wing flaps, electric trim tabs that needed adjustment to maintain control at different airspeeds, and constant-speed propellers whose pitch had to be regulated with hydraulic controls, among other features. While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed, as a newspaper put it, “too much airplane for one man to fly.” The Army Air Corps declared Douglas’s smaller design the winner. Boeing nearly went bankrupt.
Still, the Army purchased a few aircraft from Boeing as test planes, and some insiders remained convinced that the aircraft was flyable. So a group of test pilots got together and considered what to do.
They could have required Model 299 pilots to undergo more training. But it was hard to imagine having more experience and expertise than Major Hill, who had been the U.S. Army Air Corps’ chief of flight testing. Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist, with step-by-step checks for takeoff, flight, landing, and taxiing. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking, but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But this new plane was too complicated to be left to the memory of any pilot, however expert.
With the checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident. The Army ultimately ordered almost thirteen thousand of the aircraft, which it dubbed the B-17. And, because flying the behemoth was now possible, the Army gained a decisive air advantage in the Second World War which enabled its devastating bombing campaign across Nazi Germany.
Medicine today has entered its B-17 phase. Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone. I.C.U. life support has become too much medicine for one person to fly.
Yet it’s far from obvious that something as simple as a checklist could be of much help in medical care. Sick people are phenomenally more various than airplanes. A study of forty-one thousand trauma patients—just trauma patients—found that they had 1,224 different injury-related diagnoses in 32,261 unique combinations for teams to attend to. That’s like having 32,261 kinds of airplane to land. Mapping out the proper steps for each is not possible, and physicians have been skeptical that a piece of paper with a bunch of little boxes would improve matters much.
In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.
The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.
Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.
Pronovost recruited some more colleagues, and they made some more checklists. One aimed to insure that nurses observe patients for pain at least once every four hours and provide timely pain medication. This reduced the likelihood of a patient’s experiencing untreated pain from forty-one per cent to three per cent. They tested a checklist for patients on mechanical ventilation, making sure that, for instance, the head of each patient’s bed was propped up at least thirty degrees so that oral secretions couldn’t go into the windpipe, and antacid medication was given to prevent stomach ulcers. The proportion of patients who didn’t receive the recommended care dropped from seventy per cent to four per cent; the occurrence of pneumonias fell by a quarter; and twenty-one fewer patients died than in the previous year. The researchers found that simply having the doctors and nurses in the I.C.U. make their own checklists for what they thought should be done each day improved the consistency of care to the point that, within a few weeks, the average length of patient stay in intensive care dropped by half.
The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance.
These are, of course, ridiculously primitive insights. Pronovost is routinely described by colleagues as “brilliant,” “inspiring,” a “genius.” He has an M.D. and a Ph.D. in public health from Johns Hopkins, and is trained in emergency medicine, anesthesiology, and critical-care medicine. But, really, does it take all that to figure out what house movers, wedding planners, and tax accountants figured out ages ago?
Pronovost is hardly the first person in medicine to use a checklist. But he is among the first to recognize its power to save lives and take advantage of the breadth of its possibilities. Forty-two years old, with cropped light-brown hair, tenth-grader looks, and a fluttering, finchlike energy, he is an odd mixture of the nerdy and the messianic. He grew up in Waterbury, Connecticut, the son of an elementary-school teacher and a math professor, went to nearby Fairfield University, and, like many good students, decided that he would go into medicine. Unlike many students, though, he found that he actually liked caring for sick people. He hated the laboratory—with all those micropipettes and cell cultures, and no patients around—but he had that scientific “How can I solve this unsolved problem?” turn of mind. So after his residency in anesthesiology and his fellowship in critical care, he studied clinical-research methods.
For his doctoral thesis, he examined intensive-care units in Maryland, and he discovered that putting an intensivist on staff reduced death rates by a third. It was the first time that someone had demonstrated the public-health value of using intensivists. He wasn’t satisfied with having proved his case, though; he wanted hospitals to change accordingly. After his study was published, in 1999, he met with a coalition of large employers known as the Leapfrog Group. It included companies like General Motors and Verizon, which were seeking to improve the standards of hospitals where their employees obtain care. Within weeks, the coalition announced that its members expected the hospitals they contracted with to staff their I.C.U.s with intensivists. These employers pay for health care for thirty-seven million employees, retirees, and dependents nationwide. So although hospitals protested that there weren’t enough intensivists to go around, and that the cost could be prohibitive, Pronovost’s idea effectively became an instant national standard.
The scientist in him has always made room for the campaigner. People say he is the kind of guy who, even as a trainee, could make you feel you’d saved the world every time you washed your hands properly. “I’ve never seen anybody inspire as he does,” Marty Makary, a Johns Hopkins surgeon, told me. “Partly, he has this contagious, excitable nature. He has a smile that’s tough to match. But he also has a way of making people feel heard. People will come to him with the dumbest ideas, and he’ll endorse them anyway. ‘Oh, I like that, I like that, I like that!’ he’ll say. I’ve watched him, and I still have no idea how deliberate this is. Maybe he really does like every idea. But wait, and you realize: he only acts on the ones he truly believes in.”
After the checklist results, the idea Pronovost truly believed in was that checklists could save enormous numbers of lives. He took his findings on the road, showing his checklists to doctors, nurses, insurers, employers—anyone who would listen. He spoke in an average of seven cities a month while continuing to work full time in Johns Hopkins’s I.C.U.s. But this time he found few takers.
There were various reasons. Some physicians were offended by the suggestion that they needed checklists. Others had legitimate doubts about Pronovost’s evidence. So far, he’d shown only that checklists worked in one hospital, Johns Hopkins, where the I.C.U.s have money, plenty of staff, and Peter Pronovost walking the hallways to make sure that the checklists are being used properly. How about in the real world—where I.C.U. nurses and doctors are in short supply, pressed for time, overwhelmed with patients, and hardly receptive to the idea of filling out yet another piece of paper?
In 2003, however, the Michigan Health and Hospital Association asked Pronovost to try out three of his checklists in Michigan’s I.C.U.s. It would be a huge undertaking. Not only would he have to get the state’s hospitals to use the checklists; he would also have to measure whether doing so made a genuine difference. But at last Pronovost had a chance to establish whether his checklist idea really worked.
This past summer, I visited Sinai-Grace Hospital, in inner-city Detroit, and saw what Pronovost was up against. Occupying a campus of red brick buildings amid abandoned houses, check-cashing stores, and wig shops on the city’s West Side, just south of 8 Mile Road, Sinai-Grace is a classic urban hospital. It has eight hundred physicians, seven hundred nurses, and two thousand other medical personnel to care for a population with the lowest median income of any city in the country. More than a quarter of a million residents are uninsured; three hundred thousand are on state assistance. That has meant chronic financial problems. Sinai-Grace is not the most cash-strapped hospital in the city—that would be Detroit Receiving Hospital, where a fifth of the patients have no means of payment. But between 2000 and 2003 Sinai-Grace and eight other Detroit hospitals were forced to cut a third of their staff, and the state had to come forward with a fifty-million-dollar bailout to avert their bankruptcy.
Sinai-Grace has five I.C.U.s for adult patients and one for infants. Hassan Makki, the director of intensive care, told me what it was like there in 2004, when Pronovost and the hospital association started a series of mailings and conference calls with hospitals to introduce checklists for central lines and ventilator patients. “Morale was low,” he said. “We had lost lots of staff, and the nurses who remained weren’t sure if they were staying.” Many doctors were thinking about leaving, too. Meanwhile, the teams faced an even heavier workload because of new rules limiting how long the residents could work at a stretch. Now Pronovost was telling them to find the time to fill out some daily checklists?
Tom Piskorowski, one of the I.C.U. physicians, told me his reaction: “Forget the paperwork. Take care of the patient.”
I accompanied a team on 7 A.M. rounds through one of the surgical I.C.U.s. It had eleven patients. Four had gunshot wounds (one had been shot in the chest; one had been shot through the bowel, kidney, and liver; two had been shot through the neck, and left quadriplegic). Five patients had cerebral hemorrhaging (three were seventy-nine years and older and had been injured falling down stairs; one was a middle-aged man whose skull and left temporal lobe had been damaged by an assault with a blunt weapon; and one was a worker who had become paralyzed from the neck down after falling twenty-five feet off a ladder onto his head). There was a cancer patient recovering from surgery to remove part of his lung, and a patient who had had surgery to repair a cerebral aneurysm.
The doctors and nurses on rounds tried to proceed methodically from one room to the next but were constantly interrupted: a patient they thought they’d stabilized began hemorrhaging again; another who had been taken off the ventilator developed trouble breathing and had to be put back on the machine. It was hard to imagine that they could get their heads far enough above the daily tide of disasters to worry about the minutiae on some checklist.
Yet there they were, I discovered, filling out those pages. Mostly, it was the nurses who kept things in order. Each morning, a senior nurse walked through the unit, clipboard in hand, making sure that every patient on a ventilator had the bed propped at the right angle, and had been given the right medicines and the right tests. Whenever doctors put in a central line, a nurse made sure that the central-line checklist had been filled out and placed in the patient’s chart. Looking back through their files, I found that they had been doing this faithfully for more than three years.
Pronovost had been canny when he started. In his first conversations with hospital administrators, he didn’t order them to use the checklists. Instead, he asked them simply to gather data on their own infection rates. In early 2004, they found, the infection rates for I.C.U. patients in Michigan hospitals were higher than the national average, and in some hospitals dramatically so. Sinai-Grace experienced more line infections than seventy-five per cent of American hospitals. Meanwhile, Blue Cross Blue Shield of Michigan agreed to give hospitals small bonus payments for participating in Pronovost’s program. A checklist suddenly seemed an easy and logical thing to try.
In what became known as the Keystone Initiative, each hospital assigned a project manager to roll out the checklists and participate in a twice-monthly conference call with Pronovost for trouble-shooting. Pronovost also insisted that each participating hospital assign to each unit a senior hospital executive, who would visit the unit at least once a month, hear people’s complaints, and help them solve problems.
The executives were reluctant. They normally lived in meetings worrying about strategy and budgets. They weren’t used to venturing into patient territory and didn’t feel that they belonged there. In some places, they encountered hostility. But their involvement proved crucial. In the first month, according to Christine Goeschel, at the time the Keystone Initiative’s director, the executives discovered that the chlorhexidine soap, shown to reduce line infections, was available in fewer than a third of the I.C.U.s. This was a problem only an executive could solve. Within weeks, every I.C.U. in Michigan had a supply of the soap. Teams also complained to the hospital officials that the checklist required that patients be fully covered with a sterile drape when lines were being put in, but full-size barrier drapes were often unavailable. So the officials made sure that the drapes were stocked. Then they persuaded Arrow International, one of the largest manufacturers of central lines, to produce a new central-line kit that had both the drape and chlorhexidine in it.
In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.
Pronovost’s results have not been ignored. He has since had requests to help Rhode Island, New Jersey, and the country of Spain do what Michigan did. Back in the Wolverine State, he and the Keystone Initiative have begun testing half a dozen additional checklists to improve care for I.C.U. patients. He has also been asked to develop a program for surgery patients. It has all become more than he and his small group of researchers can keep up with.
But consider: there are hundreds, perhaps thousands, of things doctors do that are at least as dangerous and prone to human failure as putting central lines into I.C.U. patients. It’s true of cardiac care, stroke treatment, H.I.V. treatment, and surgery of all kinds. It’s also true of diagnosis, whether one is trying to identify cancer or infection or a heart attack. All have steps that are worth putting on a checklist and testing in routine care. The question—still unanswered—is whether medical culture will embrace the opportunity.
Tom Wolfe’s “The Right Stuff” tells the story of our first astronauts, and charts the demise of the maverick, Chuck Yeager test-pilot culture of the nineteen-fifties. It was a culture defined by how unbelievably dangerous the job was. Test pilots strapped themselves into machines of barely controlled power and complexity, and a quarter of them were killed on the job. The pilots had to have focus, daring, wits, and an ability to improvise—the right stuff. But as knowledge of how to control the risks of flying accumulated—as checklists and flight simulators became more prevalent and sophisticated—the danger diminished, values of safety and conscientiousness prevailed, and the rock-star status of the test pilots was gone.
Something like this is going on in medicine. We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, and I.C.U. medicine—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.
It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation.
The still limited response to Pronovost’s work may be easy to explain, but it is hard to justify. If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly—and hospitals have spent tens of millions of dollars on them. But, with the checklist, what we have is Peter Pronovost trying to see if maybe, in the next year or two, hospitals in Rhode Island and New Jersey will give his idea a try.
Pronovost remains, in a way, an odd bird in medical research. He does not have the multimillion-dollar grants that his colleagues in bench science have. He has no swarm of doctoral students and lab animals. He’s focussed on work that is not normally considered a significant contribution in academic medicine. As a result, few other researchers are venturing to extend his achievements. Yet his work has already saved more lives than that of any laboratory scientist in the past decade.
I called Pronovost recently at Johns Hopkins, where he was on duty in an I.C.U. I asked him how long it would be before the average doctor or nurse is as apt to have a checklist in hand as a stethoscope (which, unlike checklists, has never been proved to make a difference to patient care).
“At the current rate, it will never happen,” he said, as monitors beeped in the background. “The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.” We have a thirty-billion-dollar-a-year National Institutes of Health, he pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.
I asked him how much it would cost for him to do for the whole country what he did for Michigan. About two million dollars, he said, maybe three, mostly for the technical work of signing up hospitals to participate state by state and coördinating a database to track the results. He’s already devised a plan to do it in all of Spain for less.
“We could get I.C.U. checklists in use throughout the United States within two years, if the country wanted it,” he said.
So far, it seems, we don’t. The United States could have been the first to adopt medical checklists nationwide, but, instead, Spain will beat us. “I at least hope we’re not the last,” Pronovost said.
Recently, I spoke to Markus Thalmann, the cardiac surgeon on the team that saved the little Austrian girl who had drowned, and learned that a checklist had been crucial to her survival. Thalmann had worked for six years at the city hospital in Klagenfurt, the small provincial capital in south Austria where the girl was resuscitated. She was not the first person whom he and his colleagues had tried to revive from cardiac arrest after hypothermia and suffocation. They received between three and five such patients a year, he estimated, mostly avalanche victims (Klagenfurt is surrounded by the Alps), some of them drowning victims, and a few of them people attempting suicide by taking a drug overdose and then wandering out into the snowy forests to fall unconscious.
For a long time, he said, no matter how hard the medical team tried, it had no survivors. Most of the victims had gone without a pulse and oxygen for too long by the time they were found. But some, he felt, still had a flicker of viability in them, and each time the team failed to sustain it.
Speed was the chief difficulty. Success required having an array of equipment and people at the ready—helicopter-rescue personnel, trauma surgeons, an experienced cardiac anesthesiologist and surgeon, bioengineering support staff, operating and critical-care nurses, intensivists. Too often, someone or something was missing. So he and a couple of colleagues made and distributed a checklist. In cases like these, the checklist said, rescue teams were to tell the hospital to prepare for possible cardiac bypass and rewarming. They were to call, when possible, even before they arrived on the scene, as the preparation time could be significant. The hospital would then work down a list of people to be notified. They would have an operating room set up and standing by.
The team had its first success with the checklist in place—the rescue of the three-year-old girl. Not long afterward, Thalmann left to take a job at a hospital in Vienna. The team, however, was able to make at least two other such rescues, he said. In one case, a man was found frozen and pulseless after a suicide attempt. In another, a mother and her sixteen-year-old daughter were in an accident that sent them and their car through a guardrail, over a cliff, and into a mountain river. The mother died on impact; the daughter was trapped as the car rapidly filled with icy water. She had been in cardiac and respiratory arrest for a prolonged period of time when the rescue team arrived.
From that point onward, though, the system went like clockwork. By the time the rescue team got to her and began CPR, the hospital had been notified. The transport team got her there in minutes. The surgical team took her straight to the operating room and crashed her onto heart-lung bypass. One step went right after another. And, because of the speed with which they did, she had a chance.
As the girl’s body slowly rewarmed, her heart came back. In the I.C.U., a mechanical ventilator, fluids, and intravenous drugs kept her going while the rest of her body recovered. The next day, the doctors were able to remove her lines and tubes. The day after that, she was sitting up in bed, ready to go home. 
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God’s ongoing struggle against science

The topic of God is deeply tied to our existence in many ways – and continues to influence society both positively and negatively. The fact that politics and religion should be kept separate does not mean that this is easy.

However, this is also a topic on which evidence is sorely missing, and faith has to take its place. To be educated means to be a searcher for the truth through the exercise of reason. But the faith-based concept of God – with its potential implications for our lives and the hereafter (if any) – sits uneasily with the reality of our material world where evidence is king. Nothing that we do in our life is ultimately without reason. But not God. At that stage reason takes a back seat.

Surely this topic cannot be exempt from the application of reason. We must continue to research God rigorously and stretch reason till it reaches an end.  And that is what Victor Stenger's book God: The Failed Hypothesis, does (I wrote a short blog post a few weeks ago on this book).

The book is a fascinating battle against the concept of God. Those who have John Hosper's read  exposition on these issues (i.e. arguments in favour of and against God) in his book, Philosophical Analysis will find further food for thought in Stenger. 

I'm therefore providing below an interesting extract from Stenger's book, noting that there are people out there who dispute Stenger's arguments  (e.g. see here). Personally, I haven't yet finished this book nor will I attempt a rigorous and critical review of the facts of the matter at this stage (That is something I will do in due course when I have the time and inclination for such analysis). But I've learnt a lot of useful scientific information from this book. Definitely a book worth having in every educated person's library.

(Note: a recent issue of The Economist reported on work by Roger Penrose and Vahe Gurzadyan that argues that the world had no beginning and that data from the big bang show traces of a previous universe! This concept has been discussed in Stenger's book but empirical proof has only recently been published. Read this report here. Fascinating! 

To me, though, there remain many gaps in our knowledge about the universe, the most important being that we still don't know how energy is converted into matter – although I suspect there is a purely mechanical explanation for that process . If you are interested in such topics, then join me on Facebook here.)



The anthropic argument for the existence of God can be turned on its head to provide an argument against the existence of God. If God created a universe with at least one major purpose being the development of human life, then it is reasonable to expect that the universe should be congenial to human life. Now, you might say that God may have had other purposes besides humanity. As has been noted several times in this book, apologists can always invent a god who is consistent with the data. One certainly can imagine a god for whom humanity is not very high on the agenda and who put us off in a minuscule, obscure corner of the universe. However, this is not the God of Judaism, Christianity, and Islarn, who places great value on the human being and supposedly created us in his image. Why would God send his only son to die an agonizing death to redeem an insignificant bit of carbon?

If the universe were congenial to human life, then you would expect it to be easy for humanlike life to develop and survive throughout the universe.

As we will discuss in chapter 6, the cosmological universe bears no resemblance to what is described in Genesis. Indeed, the biblical myth is more akin to what one might expect from a perfect creator. But that is not what we see. Earth is not the flat, immovable circle at the center of a firmament or a vault of fixed stars, circled by the sun, moon, and planets pictured in Genesis. Rather, Earth is one planet among ten or so (depending on how you count) revolving around an atypical star, our sun. On the distance scale of human experience, the solar system is immense. Earth is one hundred and fifty million kilometers from the sun. Pluto is some six billion kilometers away. The Oort cloud of comets, which marks the edge of the solar system, extends to thirty trillion kilometers from the sun. Although the space between the planets contains smaller asteroids, comets, and dust, the solar system consists mainly of empty space that seems to serve no purpose.

On this distance scale, the planets are tiny points. Yet they are huge on the human scale. The diameter of Earth is 12,742 kilometers. The largest planet, Jupiter, is 139,822 kilometers in diameter.

Beyond the solar system we find even more space. The next closest star (after the sun), Proxima Centauri, is forty trillion kilometers away. This is part of the triple-star system called Alpha Centauri. On this scale we should start using light-years as the unit of distance, where the light-year is the distance traveled by light in a year (9.45 trillion kilometers). The Alpha Centauri system is 4.22 light-years away. Note that multiple-star systems, which are very common, do not provide the kind of orbital stability we experience on Earth that is very important to our survival. It would seem that only single-star systems are likely to support life, another indication that life is not high on the universe's agenda.

Our sun and its planetary system are well away from the center of a galaxy containing an estimated two hundred to four hundred billion other stars. Called the "Milky Way," after the band of stars we see across the sky on a clear night, our visible galaxy is a flat, spiral disk one hundred thousand light-years across, and about ten thousand light-years thick.

The Milky Way is but one of perhaps a hundred billion galaxies in the visible universe. We have two satellite galaxies, just outside the Milky Way, the Large and Small Magellanic Clouds. The next galaxy nearest to us, Andromeda, is 2.44 million light-years away.

And, you might ask, how big is the universe? The farthest observed galaxy at this writing, Abell 1835 IR1916, is 13.2 billion light-years away. Since it has taken 13.2 billion years for its light to reach us, and the current estimate of the age of the universe is 13.7 billion years, we are seeing this galaxy as it was only five hundred million years after the start of the big bang. Because the universe has been expanding since the light left Abell, this galaxy is now about forty billion light-years away.

The farthest distance we can ever hope to see, what is called our horizon, is 13.7 billion light-years from Earth. Beyond that, light would take longer than the age of the universe to reach us. As vast as is the universe within our horizon, cosmology suggests that a far vaster one lies beyond. If the inflationary big bang model of the early universe is correct, then in a tiny time interval (something like 10-35 second), the universe expanded in size by a factor that is almost impossible to imagine. Here is one estimate of that factor: Write down the number 1 and follow it by a hundred zeros. Then raise the number 10 to that power (10 to 10100). I have not been able to think of any analogy from common experience or science to help visualize that number. The size of the visible universe (1026 meters) is only 1061 times larger than the smallest distance that can be defined, the Planck distance (10-35 meter).

In short, if God created the universe as a special place for humanity, he seems to have wasted an awfully large amount of space where humanity will never make an appearance.

He wasted a lot of time, too. Instead of six days, he took nine billion years to make Earth, another billion years or so to make life, and then another four billion years to make humanity. Humans have walked on Earth for less than one-hundredth of one percent of Earth's history.

In fact, when you think of it, why would an infinitely powerful God even need six days? Wouldn't he have the ability to create everything in an instant? And, why would he have to rest when he was all done?

Let us also ponder the enormous waste of matter. The hundred billion galaxies, each with on the order of a hundred billion stars, are composed of "atomic matter," that is, chemical elements. The portion that is luminous, that is, visible to the eye and optical telescopes, constitutes just one-half of one percent of all the mass in the universe. Another 3.5 percent of the matter in galaxies is of the same atomic nature, only nonluminous. Just 2 percent of atomic matter is composed of elements heavier than helium. One-half of 1 percent of this is composed of carbon, the main element of life. That is, 0.0002 of the mass of the universe is carbon. Yet we are supposed to think that God specially designed the universe so it would have the ability to manufacture, in stars, the carbon needed for life?

Still-unidentified "dark matter" makes up 26 percent of the mass of the universe, while the bulk of the universe, about 70 percent, is "dark energy," which also remains unknown in nature but possesses no known miraculous properties. From this breakdown of mass, we see that 96 percent of the mass of the universe is not even of the type of matter associated with life.

Energy is wasted, too. Of all the energy emitted by the sun, only two photons in a billion are used to warm Earth, the rest radiating uselessly into space.

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Recent books by friends

In this post I'll introduce you to three recent books by friends.


If you recall, a few months ago Harsh Vora introduced me to Dr K C Mahendru's book Baba Ramdev – Resurgence of New India (Freedom Movement-2). I did think at that time that Dr Mahendru's name sounded very familiar but I thought this must be someone else since he was writing not about Dayanand but about Baba Ramdev. It turns out that Professor Mahendru and I know each other very well indeed, a relationship that goes back a long time. He and my father were classmates in Doaba College, Jullundur where they both took their masters degree in political science. My father joined the civil service, Prof. Mahendru became an academic (and prolific writer, I find).

When I was a student living in the DAV College Hostel in 1978-79, Prof. Mahendru was my direct neighbour and chief warden of the hostel. His home was one door away from my room, and periodically he would emerge from that door to inspect the hostel and stop by to have a chat with me. I also wrote an article for the golden jubilee celebration souvenir of DAV college – an issue that Prof. Mahendru edited. It turns out that Prof. Mahendru not only became the Principal of DAV Jullundur (a very important academic position indeed, in Panjab), but also occupied other senior roles in the DAV institutions. 

It will be my privilege to read Dr. Mahendru's books as soon as I can lay my hands on them. If Professor Mahendru supports Baba Ramdev then there must surely be some substance in this young man, Ramdev. 

(In the meanwhile Prof. Mahendru and I have connected on Facebook. Such are the ways of the modern world.) 

I'm providing low-resolution scans from the Diamond Jubilee souvenir of DAV Jullundur – for old time's sake (!) But read on, below. There are two other friends I'm covering in this post.

Rakesh Wadhwa

I've only very recently come across the publication of Rakesh Wadhwa's book, The Deal Maker. Rakesh is a friend who was actively involved in the Swatantra Bharat Party effort of 2004 that I supported through the India Policy Institute. Indeed, he provided a not insignificant financial contribution to SBP, as well – something that was surely pivotal in getting Sharaj Joshi a Rajya Sabha seat.

Rakesh had conceptualised, even in 2004, a novel that would talk about the story of (future) political change in India brought about by a freedom-loving protagonist. His book, that finishes this story, has been recently published and has received positive reviews in the media, I gather. I encourage you to rush out and buy it! Let me know what you think about it.

Rakesh is a brilliant writer, being an editor of the Boss magazine published in Nepal of which his wife Shalini is the boss (CEO). Rakesh has won the Bastiat award in the past for his outstanding writings on liberty.

Pictured Rakesh Wadhwa, Gurcharan Das, Sharad Joshi and I in January 2004 (I had sprained my ankle at the public seminar and was in crutches).

Sharad Joshi

Before I forget I must not forget to mention that Sharad Joshi recently published his book Down to Earth (details here). It is based on the 300 plus “Down to Earth” columns he has written for Business Line since 1998. This must surely be a book of great wisdom – particularly on agricultural policy. I strongly encourage you to buy and read it.

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