When medical care didn’t contribute as much to improved health outcomes

An interesting piece on the efficacy of medicine and medical procedures (TLDR: they aren’t always effective but doctors and patients feel compelled to try something) ends with this suggestion about the power medicine has over the public:

Historians of public health know that most of the life-expectancy improvements in the last two centuries stem from innovations in sanitation, food storage, quarantines, and so on. The so-called “First Public Health Revolution”—from 1880 to 1920—saw the biggest lifespan increase, predating antibiotics or modern surgery.

In the 1990s, the American Cancer Society’s board of directors put out a national challenge to cut cancer rates from a peak in 1990. Encouragingly, deaths in the United States from all types of cancer since then have been falling. Still, American men have a ways to go to return to 1930s levels. Medical innovation has certainly helped; it’s just that public health has more often been the society-wide game changer. Most people just don’t believe it.

In 2014, two researchers at Brigham Young University surveyed Americans and found that typical adults attributed about 80 percent of the increase in life expectancy since the mid-1800s to modern medicine. “The public grossly overestimates how much of our increased life expectancy should be attributed to medical care,” they wrote, “and is largely unaware of the critical role played by public health and improved social conditions determinants.” This perception, they continued, might hinder funding for public health, and it “may also contribute to overfunding the medical sector of the economy and impede efforts to contain health care costs.”

It is a loaded claim. But consider the $6.3 billion 21st Century Cures Act, which recently passed Congress to widespread acclaim. Who can argue with a law created in part to bolster cancer research? Among others, the heads of the American Academy of Family Physicians and the American Public Health Association. They argue against the new law because it will take $3.5 billion away from public-health efforts in order to fund research on new medical technology and drugs, including former Vice President Joe Biden’s “cancer moonshot.” The new law takes money from programs—like vaccination and smoking-cessation efforts—that are known to prevent disease and moves it to work that might, eventually, treat disease. The bill will also allow the FDA to approve new uses for drugs based on observational studies or even “summary-level reviews” of data submitted by pharmaceutical companies. Prasad has been a particularly trenchant and public critic, tweeting that “the only people who don’t like the bill are people who study drug approval, safety, and who aren’t paid by Pharma.”

We might attribute this overconfidence in medical care among Americans to two cultural traits: (1) a belief that science can and should solve problems and lead to better lives and (2) an interest in efficient solutions to complex problems. Yet, one takeaway from this is that a healthier lifestyle may be boring and be hard work to implement (on both an individual and community level) but could be more effective in the long-term than medical intervention.

Explaining why Americans desire larger homes

Here are several possible explanations for why Americans want bigger houses:

But there’s no real “normal’’ when it comes to desired home size — except the persistent perception that size equates to prestige, said Dak Kopec, director of Design for Human Health at Boston Architectural College. “Throughout all cultures, bigger is better and associated with wealth and power.’’…

“It’s clear that the American dream of living in a big house on a large lot has not gone away,’’ said Ralph McLaughlin, Trulia’s chief economist…

One reason American homes are so big, Powell argued, is that we have more disposable income. “You’re not just buying a 2,000-square-foot house, you’re also going to fill it with a whole bunch of stuff,’’ she said. The larger house and its contents soon become your new baseline, she said, as the furniture, paintings, and lamps you buy blend into the background to become part of your environment. “And then you can only upsize from there if you choose to keep your possessions.’’…

Dunn speculates that a larger home could boost happiness if it reduces conflict. “If you have a house that enables you to get along well with your spouse, if each person has a little of their own space, that might reduce conflict,’’ she said, “but I suspect there are seriously diminishing returns on that.’’

With these four factors – the status of a larger house, the American Dream, more disposable income and more stuff, and finding more happiness – perhaps we could argue that it requires some effort for Americans to live in a smaller place. It is not impossible to do so and certain factors, such as living in an expensive metropolitan area like New York City or San Francisco, can override the cultural conditioning to have a larger house. But, the American inertia may just be to have a larger dwelling.

We could also add some additional factors leading to larger homes in the United States:

  1. Suburban sprawl leads to more room for larger homes.
  2. Americans privilege private spaces over public spaces.
  3. Over the decades, the government and other actors helped make it easier for more people to own homes.
  4. Americans don’t necessarily need the space but they like the flexibility that more room provides such as having a hobby room or having children, parents, and/or relatives live with them.

Claim: Millennials can’t buy a house so they are serfs

Joel Kotkin makes a bold claim regarding the inability of millennials to purchase a home:

Like medieval serfs in pre-industrial Europe, America’s new generation, particularly in its alpha cities, seems increasingly destined to spend their lives paying off their overlords, and having little to show for it.

No wonder that rather than strike out on their own, many millennials are simply failing to launch, with record numbers hunkering down in their parents’ homes. Since 2000, the numbers of people aged 18 to 34 living at home has shot up by over 5 million…

It’s time for millennials to demand politicians abandon the policies that have enriched the wealthy and stolen their future. That means removing barriers to lots of new housing in cities and, crucially, embracing Frank Lloyd Wright’s notion of Broadacre Cities, with expansive development along the periphery.

These new suburbs, like the Levittowns of the past, could improve people’s lives, while using new technology and home-based work  to make them more environmentally sustainable. They could, as some suggest, develop the kind of urban amenities, notably town centers, that may be more important to millennials than earlier generations. One thing that hasn’t changed is the demand for affordable single-family homes and townhomes. But the supply is diminishing—those under $200,000 make up barely one out of five new homes.

This is a familiar argument for Kotkin: millennials really do want to own homes in the suburbs – like many other Americans since the early 1900s – and economic policies limit their opportunities.

But, this argument is still overstated in its claim that millennials are serfs. Kotkin gets at a deeper question: is homeownership essential to the American way of life? More specifically, a suburban home in a nice community? There is much in American history to suggest that owning land and a home is key, even if it isn’t a right. Yet, does it necessarily have to always be part of American life? Could Americans decide that they value other things (and not be forced away from homeownership by forces outside of their control)?

The cultural bubbles of popular TV shows tell us what exactly?

This is a cool set of maps of the popularity of 50 different TV shows across zip codes in the United States. But, what is the data and what exactly can it tell us? Here is the brief explanation:

When we looked at how many active Facebook users in a given ZIP code “liked” certain TV shows, we found that the 50 most-liked shows clustered into three groups with distinct geographic distributions. Together they reveal a national culture split among three regions: cities and their suburbs; rural areas; and what we’re calling the extended Black Belt — a swath that extends from the Mississippi River along the Eastern Seaboard up to Washington, but also including city centers and other places with large nonwhite populations.

Some quick thoughts:

  1. Can we assume that Facebook likes are an accurate measure? How many people are represented per zip code? Who tends to report their TV show preferences on Facebook? Why not use Nielsen data which likely has a much smaller sample but could be considered more reliable and valid?
  2. How exactly does television watching influence everyday beliefs and actions? Or, does it work the other way: people have certain beliefs and behaviors and they watch what confirms what they already like? Sociologists and others that study the effects of television don’t always have data on the direct connections between viewing and other parts of life. (I’m not suggesting television has no influence. Given that the average American still watches several hours a day, it is still a powerful medium even with the rise of
  3. The opening to the article both suggests TV viewing and the related cultures fall along an urban/rural divide but then also split across three groups. The maps display three main groups – metro areas, rural areas, and areas with higher concentrations of African Americans. I would want to know more about two areas. First, political data – and this article wants to make the link between TV watching and the 2016 election – suggests the final divide is really in the suburbs between areas further out from the big city and those closer. Can we get finer grained data between exurbs and inner-ring suburbs? Second, does this mean that Latinos and Asian Americans aren’t differentiated enough to be their own TV watching cultures?
  4. The introduction to this article also repeats a common line among those that study television:

In the 1960s and ’70s, even if you didn’t watch a show, you at least probably would have heard of it. Now television, once the great unifier, amplifies our divisions.

We certainly are way into the cable era of television (and probably beyond with all of the options now available through the Internet and streaming) but could we argue instead that the earlier era of fewer channels and viewing options simply papered over differences? As numerous historians and other scholars have argued, the 1950s might have appeared to be a golden era but most of the benefits went to white, middle class, suburban families.

In other words, I would be hesitant to state that these TV patterns are strong evidence of three clearly different cultures in the United States. Could these television viewing patterns fit in with other cultural tastes differentiating various groups based on class and race and ethnicity? Yes, though I’d much rather see serious academic work on this developing Bourdieu’s ideas and encompassing all sorts of consumption items treasured by Americans (homes, vehicles, sports fandom, making those hard choices like Coke and Pepsi or McDonald’s and Burger King or Walmart and Target). Also, limiting ourselves to geography may not work as well – this approach has been tried by many including in books like The Big Sort or Our Patchwork Nation – as it did in the past.

What if the best single display of America is Walmart?

In making several trips to Walmart in advance of Christmas, I found myself marveling several times at the store. Here are some reasons why this retail giant may be the best single illustration of America today:

  1. Consumerism rules. Each Walmart has so much stuff, from groceries to auto parts to Christmas trees to dinnerware. And Americans like this stuff even more if it is reasonably priced.
  2. On the flip side of consumerism, how can one company coordinate all that manufacturing and shipping to get items to each store? Walmart’s rise is due in part to their logistical abilities.
  3. Walmart is a great place to find stuff with which to go overboard for whatever holiday is coming up. Americans love Christmas, Halloween, Fourth of July, Easter…
  4. Walmarts generally require customers to drive there, often due to their locations in suburban or rural areas, the need for a good chunk of land, and helping shoppers to transport all the stuff they buy.
  5. Because of the prices and locations, Walmarts tend to attract a diverse set of shoppers.
  6. The company does not let workers unionize.
  7. The Sam Walton story is not exactly rags to riches but it does suggest that a hard worker with some new ideas can make something big of himself.
  8. Everyone has to eat and Walmart is the largest grocery chain in the United States.
  9. It is an iconic American brand though it hasn’t exactly caught on around the world like others (such as Coca Cola, McDonald’s, Nike).
  10. Everyone seems to have an opinion about its merits or flaws. Still, according to the company, “Every week more than 60 percent of Americans shop at Walmart.”
  11. It is convenient and ubiquitous for many: “About 90 percent of Americans live within 15 minutes of a Walmart store.
  12. The company’s size is hard to fathom:

    “And Wal-Mart’s heft is not just financial, it’s physical too. Its 4,600+ U.S. stores occupied almost 700 million square feet. That’s roughly enough space for 11,800 football fields. That means the entire population of Buffalo, New York, could suit up, split into teams and play football against each other simultaneously in Wal-Marts across the country.

    The company’s total revenue for fiscal 2016 was $482.1 billion. That’s enough to buy a gallon of milk every day for every person in Brazil for two years, based on the $2.89 price per gallon at the North Bergen, New Jersey, Wal-Mart.

    Wal-Mart’s costs and expenses hit $458 billion for the year, which is bigger than the budgets of all but four U.S. government departments. Here’s what the rankings would be:

    1) Health and Human Services
    2) Social Security
    3) Treasury
    4) Defense
    5) Wal-Mart.”

For better or worse, is Walmart America?

Why don’t American subways feature open gangway cars?

American subway cars differ in design in one crucial way that would help solve overcrowding issues:

Open gangways, as it happens, may be one of the more widely used elements of subway design. You will find trains like these on every subway system in China, India, Spain, and Germany, as well as in Dubai, Singapore, Tokyo, Rio de Janeiro, Paris, and Toronto. According to research by planner Yonah Freemark, open gangway trains run on 3 out of every 4 subway systems in the world. Mexico City hasn’t bought separate-car trains in two decades.

Yet open gangway trains are nowhere to be found in the United States. They will debut in Honolulu in 2018. New York City might request 10 of them—in an order of 950…

That American transportation authority leaders are reluctant to embrace the concept reflects a couple of facts about how they do business. First, they clearly don’t spend enough time using the systems they run. Second (and relatedly), they are conservative about change. They are willing to let culture, or their perceptions of it, dictate design—rather than the other way around.

The most convincing explanation for the absence of open gangways in the United States is that planners feel “amenity-conscious” (or “choice”) riders would find them unpleasant. The enhanced mobility open gangways grant to beggars, merchants, and buskers has been cited as a potential problem with the model. That shouldn’t be sufficient reason to keep riders stuffed in like sardines. New Yorkers don’t take the subway because it’s pleasant, but because it gets them to work on time. The MTA could aid that cause by ordering a hundred—or a thousand!—open gangway train cars.

Americans have different ideas about personal space as well as who they are willing to mingle with. This isn’t only about subways; planners have tried to figure out how to get more well-off Americans to ride the bus even as Americans seem pretty happy to drive solo in their cars unless it is quite difficult.

Here is a question: what would happen if an entire mass transit system did this without consulting riders? Would people in New York City really stop taking the subway and find other ways to get around? In some places, subways are the most efficient and I’m guessing that riders would adjust over time. When riders have more options, particularly in more sprawling cities, this might not be a good solution as people might actually stop using the subway.

Mass transit use down in the Los Angeles area

It can be tough to get Americans to use mass transit. See the case of Los Angeles: billions have been spent in recent years and use is down.

The Los Angeles County Metropolitan Transportation Authority, the region’s largest carrier, lost more than 10% of its boardings from 2006 to 2015, a decline that appears to be accelerating. Despite a $9-billion investment in new light rail and subway lines, Metro now has fewer boardings than it did three decades ago, when buses were the county’s only transit option.

Most other agencies fare no better. In Orange County, bus ridership plummeted 30% in the last seven years, while some smaller bus operators across the region have experienced declines approaching 25%. In the last two years alone, a Metro study found that 16 transit providers in Los Angeles County saw average quarterly declines of 4% to 5%…

The decline suggests that Southern California policymakers are falling short of one of their longtime goals: drawing drivers out of their cars and onto public transportation to reduce traffic congestion, greenhouse gases and the region’s reliance on fossil fuels…

Southern California certainly isn’t alone. Public transportation use in many U.S. cities, including Chicago and Washington, D.C., has slumped in the last few years. But the question takes on new significance in Los Angeles County, where politicians and transportation officials are considering whether to seek another half-cent sales tax increase in November that could raise $120 billion for major transportation projects, including several new rail lines.

Cheap gas is not helping. I’ve been thinking in recent days that if there was any time to increase gas taxes to provide needed money for roads and other transportation projects, now is the time.

More broadly, most Americans seem to want to drive themselves when they can. Even though the total costs of owning a car add up, driving offers status and freedom. In a society where those are two key values, mass transit may not be able to compete when there isn’t the kind of density found in New York City or San Francisco.