Sunday, November 25, 2012

Thoughts on Public Health Care (II)

Last week I discussed my personal thoughts about the question of publicly providing for health care. That discourse examined three issues: (1) the parallel situation with public education in America, (2) the lack of choice available in all publicly provided systems, and (3) the unsuitability of insurance as a business model in an environment of rapidly improving medical knowledge and practice. Insurance is an inappropriate way to pay for routine health maintenance and a really bad way to take care inevitable processes, like dying.

4. Health Care Will Become More Effective—and More Complex

Of course, “inevitable” is just a state of mind. If you think medicine has advanced since the 19th century, you ain’t seen nothing yet!

The sequencing of the human genome in 2000 was originally intended to find “genes,” the A-C-G-T combinations that code for proteins, the building blocks of cells. This effort assumed that all three billion base-pairs in the genome were just the parts list. What we learned in the process was that protein-coding occupies only about 10% of the genome. The far larger and more complex story is that the other 90%—rather than being the leftover “junk” of evolution, as we first thought—is actually the internal mechanism for timing the expression of those proteins, controlling the differentiation of cells in the body, directing its development from a fertilized egg to an adult human being, and coordinating the daily operation and maintenance in all the different cell types. The larger part of the genome is an assembly and instruction manual riding along with the parts list.

Life scientists at universities all over the world are now working eagerly and productively on two fronts. First, they are linking proteins and their coding to various cellular functions and diseases. Second, they are figuring out the assembly manual so that we can understand how humans develop and grow. When we know the latter, we will be able to program the body’s repair kit—the various stem cells associated with each tissue type—to grow new tissues and replacement organs.1 And then we will quickly advance from simply growing replacement parts, to fixing any genetic defects that may have damaged the original organ, to adding genetic enhancements so that the new organ functions better than before.2

People who worry about medical privacy and the possibility that insurance companies will deny a person coverage because of his or her inherent genetic propensities are simply not seeing the bigger picture. Genetic defects will be eradicated or compensated as a matter of routine practice, probably in the womb if not before conception. Accidents and diseases that now cause disfigurement and disability will no longer be life-changing events but mere temporary inconveniences. Aging will become optional, and its debilitating effects will be corrected as they occur. Medicine might not be able to repair a case of sudden accidental death—or not right away—or eliminate death’s ultimate arrival, but we’ll all go into old age as healthier, happier, and stronger individuals.

What do I mean by “all”? Surely, this new medicine will just be a perk for the super-rich, won’t it? In the meantime, the rest of us proles will struggle along with perfunctory care and shoddy medicine, won’t we?

Well, no. Once we have perfected the techniques for chemically manipulating stem cells and growing them on armatures that are mass-produced from proteins or other inert materials—and true, these techniques will first be tried out on the rich—the rest is just a matter of grunt work. Medical technicians will sample your tissues, isolate the stem cells, apply the appropriate reagents, take a prefabricated armature off the shelf, and put the whole works into an incubator. The most complex part of the medicine, requiring real hands-on expertise, judgment, and timing, will be the surgery that cuts out your old heart, kidney, spleen, or whatever and installs the new one. Getting a new heart will be about as complicated as getting a new titanium hip or knee replacement today.

In this environment, medicine becomes less expensive. It’s only “personalized” because it starts with a person’s own copy of the genome as coded in his or her stem cells. But as we know more about the body and its processes, about how each person’s genome guides his or her susceptibilities and propensities according to universally recognized patterns, medicine becomes less an art of diagnosis and discovery and more a science of observation and application.3 The mystery and the chance—and the heartbreak—go away, because we understand human bodies the way a mechanic these days understands your car. The processes become routine, simple, and inexpensive.4

What will we do with all these superannuated citizens? Since they’re stronger and healthier—we’ll put them to work. The problem in developed societies today is not over-population but under-reproduction. Smart, educated, busy people have less time for children and, with the Pill and other means of contraception, children become a decision for the future rather than an unexpected consequence of conjugal relations. In this environment, life becomes more precious, not less. We will cherish each new child and work to make its health and education complete. We will value the knowledge and experience of older people at the peak of their productivity and try to prolong their best years. Quality, not quantity, will become the human mantra.

In this environment, medical care advances far beyond being a response to an insurable catastrophe. Health maintenance, physical repair, and improvement of the body become a necessity of living, like education to improve and prepare the mind.

5. The Affordable Care Act Pushes Insurance Over the Cliff

If insurance is the wrong business model to pay for the new medicine, the Affordable Care Act is the perfect antidote. When it was first proposed, the insurance companies supported the legislation because it mandated that all citizens buy health insurance, whether they expected to need it or not. That way, healthy young people would pay premiums that covered the costs of caring for sick and old people. The insurance companies saw a bonanza of new premiums and came aboard.

But the act also does two things that insurance companies don’t like and wouldn’t support under the normal business model. The first poison pill is treatment of pre-existing conditions. Even if you’re sick or have a bad prognosis through a history of obesity, smoking, or lousy genetics, the insurance company has to take you on and then pay out for your treatments—which are now a matter of certainty rather than actuarial chance. The second pill is community rating. No matter how sick you become or how high the costs of your care, the insurance company can only charge you the same premium as everyone else. These are gifts to the patient at the expense of the insurance business model.

Add to these pills the fact that the legislation lets the government define the menu of benefits that an insurance policy must offer. As we’ve seen in implementation, these mandates now include routine maintenance practices like contraception and chemical abortion. Pretty soon, at the whim of government regulation, the business model becomes broken no matter how many healthy young people are paying premiums for catastrophic services they don’t expect to need for years.

No one can force the insurance companies to stay in business if they are losing money. So, for the uninsured, unemployed, or self-employed people whose insurance company happens to leave the industry, the legislation offers a state insurance pool, similar to Medicare and Medicaid, with funding shared between the federal government and the states. The bet, in the view of those who desire an end-result of single-payer medicine, is that insurance companies will eventually give up or go broke, and then the federal government and the states will have to step up and fund the entire system of providing medical care.5

It would probably not be legal, or even workable, for the government simply to close down the insurance companies one night and start funding health care through taxes the next morning. But the Patient Protection and Affordable Care Act sets up circumstances that accomplish this slowly, over time, with a maximum of apparent personal and corporate choice and a minimum of fuss. You’d call that pretty sneaky, if it wasn’t all out there in plain sight.

There are probably other potential systems for funding health care that would work better at a state, county, or community level—which is the way we handle education in this country. However, with the results of the national election, those won’t be proposed or tried now. And that probably makes no difference in the long run.

One way or another, health care as a societal obligation is no longer a matter of personal luck and a strong constitution. Advances in the life sciences are already taking medicine out of the realm of insurance and into the sphere of everyday expectations and necessities. Staying healthy and growing old while maintaining your strength and abilities will be like obtaining an education and ongoing training through state-funded schools, colleges, and training programs. Claiming the bonanza of scientifically boosted medicine will be like tapping into any of the other national infrastructures that are dominated by science and technology: the energy grid, transportation systems, food supply chains, the internet, and communications systems.

All of these complex networks are designed to provide good service and a rich lifestyle at low cost. They’re what’s keeping this continent-wide whirligig we call the United States functioning smoothly. Health care as a right of citizenship will be no different.

1. The concept of organ “transplants”—which involve taking a fully grown organ from one person and donating it to another, with the requirement of suppressing the recipient’s natural immune system so that he or she will not reject the foreign tissue—becomes a rapidly passing phase of our current medicine, rather like leech craft. Instead, it will become so much easier to grow a new organ from a person’s own cells, which already have all the right chemical signatures. These “implants” will become a huge part of medical practice. And the whole business of matching donors with recipients, fraught with issues of desperate need, fairness, and compensation, will wither away.

2. And I won’t even speculate on the issue of “designer” genes, so that new organs and tissues confer particular preferences beyond the normal human range—like the desirability of orange- or silver-colored eyes, or the ability to see in the dark by detecting ultraviolet or infrared radiation.

3. Consider that, today, prescribing a medication to treat a condition is a matter of the doctor’s experience and judgment—and luck. The active ingredient in any medicine is selected and developed according to a drug researcher’s particular theory of the disease. The medication is then tested in clinical trials against a limited number of people—usually about 3,000 at the third-stage trial. The medication remains under prescription, with strict requirements for reporting adverse effects, until about a million patients have used it. But not every medicine works for every patient. Genetic differences control how an individual responds to the disease, or to the medicine’s operative chemistry, or to its recommended dosing. In the future, we’ll know how those genetic differences interact with the disease process and the therapeutic process. Prescriptions will then be targeted not only to the disease but also to the patient’s genetic inheritance. The practice of medicine will become much more effective.

4. Of course, it will help if the patient is already mindful and careful about lifestyle and health. Yes, we’ll be able to replace lungs damaged by years of smoking, but complete replacement of smoke-damaged arteries will be a little trickier. And it’s easier to replace a liver if you don’t have to cut through cubic centimeters of belly fat to find it.

5. Under the Affordable Care Act, health insurance does remain the primary responsibility of employers. But the legislation offers them the alternative of paying a fine for every employee they fail to cover—usually at a much lower rate than the cost of insuring the employee in the first place. This fine becomes a tax to defray the expenses in the state insurance pools to which the newly uninsured citizens will have to apply.

Sunday, November 18, 2012

Thoughts on Public Health Care (I)

My conservative friends are not going to like this posting. Come to think of it, neither will my progressive friends. But here are my thoughts, from what I conceive to be the political center, on the issue of public health care.

With the Supreme Court decision in June and results of the national election this month, the Patient Protection and Affordable Care Act of 2010 will stand as the law of the land. Whatever the details of this legislation, some of which are still being worked out, its import and I believe its intention are to move the country to a single-payer system of publicly provided medicine. (More next week on how a bill requiring universal insurance coverage achieves this.) This will align the United States with the health care systems used in most of the rest of the world—if those governments address the issue at all. But is this really such a huge departure for our country?

1. We Publicly Pay for Education

Health care and education are two of the personal-, family-, and society-level necessities that cannot be supplied on an ad hoc basis—not in the way that you can build houses one at a time, or provide dry clothes and hot meals adequately from any number of possible supply channels. Unless you’re a parent providing home schooling, or a tribe wandering in the wilderness and teaching its young to hunt and fish, you need a complex infrastructure to educate a generation of people: locally situated classrooms, a plethora of introductory books on different subjects, teachers trained to present those subjects, and a supporting network that extends beyond the purely local level to decide on and shape the curriculum, approve the books, train the teachers, and accredit the institutions.

From our earliest days, Americans have agreed that providing basic schooling is a community function, because raising a generation of literate adults with a common base of knowledge is essential to democratic government. Grammar schools and high schools have always been public. Yes, certain communities also host parochial schools and elite “preparatory” schools, which are privately funded, but these have functioned in addition to the local public school for families who felt the need of something different or better. And those families still pay the taxes that support the public school. Higher education—at the college level and above—started out as a collection of privately or religiously backed institutions. In the middle of the 19th century, however, states began funding land-grant colleges and “normal schools” (i.e., for educating teachers) as public institutions.1 Today, public colleges and universities are a big part of the education mix.

Health care is not that different from education, in that it requires a complex infrastructure of hospitals, clinics, testing laboratories and services, primary care physicians, treatment specialists, researchers, medical technicians, nurses and orderlies, and administrators, as well as pharmaceuticals and medical supplies, and a supporting network of teaching hospitals, training programs, accreditation, and drug and equipment manufacturing. Even if personal health is not properly a community concern—as we agree that educating the young should be—providing for people’s various health requirements and caring for them when they are sick and injured is a hugely complex business. And we can all agree, I think, that any society functions better when people are healthy and strong.

At current reckoning, health care in the U.S. represents at least 14% of the national economy. That’s why many people hesitate to turn our patchwork of private providers (doctors’ practice groups, for-profit and religiously funded hospital organizations, insurance companies, and drug and equipment companies) and public providers (Medicare and Medicaid funding, community hospitals, county clinics, and various national institutes managing health issues) over to a single government system operated at the federal level. When all the eggs are in one basket—who’s watching that basket?

2. You Get What You Pay For

Right now, the average American experiences health care in a world of choice—well, some choice. Most people get health care through their employer, and most employers offer a variety of insurance plans with varying options about coverage, copays, premium costs, provider lists, and other pieces of the puzzle. If you don’t have coverage, then you take whatever you can get from an emergency room visit or the charity of a public hospital. No one, except the truly rich, gets everything he or she wants.

When you buy something for yourself, you get to make choices. You weigh what you’ll pay against what you ideally want, what you actually need, and what makes the most sense to you. When you get insurance through an employer, the company is paying part of the insurance premium, so the options are more limited. You can buy the gold-plated health plan with all the bells and whistles, but you’ll pay more out of your own pocket for it.

Advocates of a single-payer system—universal health care provided at government expense—tend to forget about the choice side of the equation. When a third party pays the piper, you dance to his tune. When you eat at public expense, you don’t get to choose between steak and chicken. Under a single-payer system, you may have a strong, bonded relationship with a certain doctor, but he or she might be assigned elsewhere. You may be in pain and need a new hip now, but resources are limited and so you might have to wait. You may be a vigorous, healthy 78-year-old with a lot still to contribute, but if you get cancer after the mandated cutoff age for aggressive treatment, then you will get only palliatives and hospice care.

If health care in America follows the British model, where private insurance and religious-based or for-profit medical providers are permitted to function, then you will be able to exercise choice by paying more outside the system—in the same way that parents can choose to put their children in a parochial or private school. If the system limits competition from private resources, as in the Canadian model, then you will accept the choices made for you by bureaucrats in the state capital or in Washington, DC.

3. Insurance Isn’t the Right Business Model

In the early days, certainly at the beginning of the 19th century, only two kinds of people went to doctors: the rich and royalty. With their theories about the four humors, bleeding, and black bile, the most that doctors were really good for was setting broken bones or stitching up wounds. For the rest of human ailments, their practice involved administering placebos, watching, and waiting. Oh, surgeons could cut out a large tumor or amputate a mangled limb in extremis. And hospitals were filthy places where you went to recuperate or die—and usually the latter.

Not until the melding of science and medicine—which began with the germ theory of disease in the late 19th century and progressed to antibiotics with the discovery of penicillin in 1929—did medicine gain a solid and respectable footing. But still, for most people, health was a matter of good luck and a strong constitution. Serious illness and injuries were considered natural catastrophes, and death usually followed quickly.

It made sense, in this medical environment, to insure yourself against the catastrophes. You took out hospital insurance, also called “major medical,” against surgery or an acute condition like cancer involving a long hospital stay. But for routine aches and pains, fevers, and the occasional broken bone, a family would pay out of pocket to visit their neighborhood doctor.2

In the 1930s, while building what became Hoover Dam, the Henry Kaiser organization set up the first comprehensive health care system—Kaiser Permanente—which tended to their workers’ complete medical needs through a network of dedicated facilities and physicians that was paid for through insurance-style premiums. Providing complete medical services through insurance at the workplace became an employment perk during World War II, because health insurance was not subject to federally imposed wage caps. Gradually, with the rise of Health Maintenance Organizations in the 1970s, the emphasis moved from catastrophic coverage to complete medical coverage. This was generally a good thing, because regular checkups and preventive care were now encouraged and paid for, but the transition had some bad consequences, too.

Insurance is a means of alleviating the potentially crippling costs of an unexpected catastrophe, such as your house burning down, crashing the car, or a family member becoming badly hurt and needing surgery and months of therapy. Insurance is not meant to pay for routine and expected expenses like replacing the roof, painting the porch, or changing the oil and tires. To be sure, medical checkups, routine diagnostics, booster shots, and birth control all have to do with a person’s health, but they are not unexpected expenses and therefore not properly paid for by insurance. If you insist on paying for these services through insurance premiums, then you are no longer making an actuarial bet—like betting that the house won’t burn or that you’ll stay healthy—but instead you are simply structuring your monthly expenses through an exotically complex and costly method of payment.

And even if you are perfectly healthy, eventually you will die. In the early days, this was a fairly uncomplicated process. Some part of the organism was damaged by disease or injury, began to break down, the patient failed to thrive, and—on a time scale dictated by the nature of the disease or damage—further living became impossible and you said good-bye. Now, through the miracles of modern medicine, we can hold off that final act for an unnaturally long time and can even keep a brain-dead shell breathing and pumping blood in perpetuity. If you had to pay for such “heroic measures” out of pocket, you would eventually call it quits and succumb to the inevitable. But so long as someone else is footing the bill out of premiums you’ve been paying all along—why spare the expense?

It’s commonly understood that about 50% of the medical costs a person consumes are incurred in the last six months of life. From a personal point of view, the natural feeling is “Why not stick it to the insurance company? We’ve been paying the bloodsuckers all these years!” But from a societal point of view, “Why spend these resources on the dying, who ultimately can’t be helped? There are more important medical needs to be served!”

Insurance is a bad business model for paying out monthly expenses. It’s a really lousy model for trying to delay or override the inevitable.

So that’s the background to my thoughts on public health care. Next week I’ll explore where I think medicine is going in the future and why a better system of paying for it will become inevitable.

1. I went to a former land-grant university, Penn State.

2. This was back in the days when a doctor, lawyer, or other trained professional expected to earn a solidly middle-class living. Doctors still made house calls and charged for their services according to the wealth of the community in which they lived. Training as a physician was not considered a sure route to a six-figure income, high society, and a vacation home in the Hamptons. Hospital stays cost a lot back then—more than a local hotel room, certainly—but they were not like moving into the Waldorf Astoria with concierge and room service.

Sunday, November 11, 2012

Not With a Whimper

… But with a sprained ankle. That’s the way life ends—or at least how it starts the final and irrevocable slide.1

As I grow older, the one thing I’ve learned that the young have still to discover is how adaptable and accommodating the human body, the human mind, and many other aspects of human life can be. If you maintain your body and brain, keeping both flexible and strong through daily exercise, challenging reading, animated conversation, complex music and puzzles, and occasional stress tests that require you to move outside your comfort zone both physically and mentally, then you can find health, a measure of happiness, and peace of mind. If you live within your means, save some money, buy insurance, and prepare for the unexpected, then your household can survive any number of economic shocks.

But that’s not actually my point in this posting. “Adaptable and accommodating” can also mean just the opposite: the body gradually shapes itself and its potential to whatever becomes your everyday way of life. I’ve been to that comfortable place, seen others go there before me—and now I’m trying to come back.

The young are, for the most part, gifted with healthy bodies, supercharged metabolisms, clarity of mind, and a future full of possibilities. Life is a golden promise. But what they don’t yet know is that life is also a succession of idle minutes, passing days, repetitive stresses and choices, accumulating habits, and suddenly passing years. The cigarettes, the drugs, rich foods, and other treats we once consumed only at parties and on special occasions eventually find their way into our fingers and our mouths every day. The book we put aside to watch a really stupid television show, because we were just too tired, becomes a dusty stack on the bedside table. The workout that we skipped on Monday is soon skipped on Tuesdays and Wednesdays, then for a week at a time, and eventually forgotten. The unpaid balance that we once tolerated on our credit cards “just for this month,” because payday fell a week after the “due by” date, slowly becomes the balance we carry from month to month and expect to pay off someday. Life has a way of catching up with us and becoming real, the norm, the expected.

And we adapt to and accommodate our changed reality. We carry the physical and mental debits because our resources are, of course, still boundless. We schedule our day around that little hangover which lingers in the morning. We carry the extra pounds because they really don’t slow us down that much.2 We pay the finance charges on our cards from month to month because we’re making more money now and we need more things to match our lifestyle.

Life has a way of creeping up, however. Soon we’re taking a glass of wine or whisky at lunch to chase the hangover that will otherwise fog up the afternoon. We have trouble bending over to tie our shoes and instead buy a pair of loafers we can slip into standing up. We take the elevator, even if we’re only going up a floor or two, because the stairs would leave us out of breath. We’re paying finance charges on the credit cards that have gradually become a noticeable fraction of the monthly rent.

My point is that we adapt to these stresses, we become comfortable with them. They are part of the life we lead. And meanwhile, silently, invisibly, without even a whimper, the boundless resources we once enjoyed in youth—and thought we could rely on in a crisis—are eaten up with the need to support these daily deficits. We go from being able to climb the steps of a picturesque lighthouse or the medieval towers of Bologna,3 to being winded by the stairs in a friend’s home. We go from running marathons to being unable to walk five miles if the car breaks down. We can still carry the weight, the strain of drinking and smoking, the cost of the debts—but we have arrived on a knife edge.

And then the unexpected happens, the jolt that takes us out of our daily path: we sprain an ankle, get stranded with a broken fuel pump, lose the roof to a freak windstorm. And what would have been an inconvenience in our youth becomes a life-and-death situation. We can no longer move our bulk from the chair to the table to the bathroom, no longer walk to find a payphone, no longer absorb the added cost to keep our house.

It’s certainly not the case that shedding our vices, losing the weight, and paying off the cards guarantee we’ll live forever. Everybody dies of something. But you don’t have to die of something silly like turning your ankle or running out of gas.

What applies on a personal scale also applies on a national scale. Like a person who’s become careless about credit card debt, our country has relied on deficit spending because we’ve always been able to cover the finance charges. The current mountain of national debt—$16 trillion and counting—won’t sift down like snow and smother us softly, so that we go out with a whimper. Instead, we will face a crisis—one more war we cannot avoid, an earthquake that shatters the infrastructure of an entire region,4 or some other unexpected national crisis—and the debt will suddenly become unsustainable. Our resources will have been eaten out from the inside, and the collapse will be fast and unavoidable.

We don’t necessarily want to live forever. But we also don’t want to die of something stupid. That would just be embarrassing.

1. The reference, of course, is to T. S. Eliot’s poem The Hollow Men and its last line about the way the world ends: “Not with a bang but a whimper.”

2. If you think about it, an extra fifty pounds is like packing two suitcases and carrying them strapped around your middle and across your buttocks. Most of us resist the effort to carry those two suitcases for a mile through the airport, yet we carry that much weight around with us every day.

3. It’s 498 steps to the top of the Asinelli Tower. I could climb them twenty years ago. Oh, what a view!

4. As I’m writing this, the East Coast is still recovering from the super storm called “Sandy,” with billions of dollars in damage repairs ahead of us. I woke up wondering if this is the sprained ankle that our economy has been shuffling towards for a couple of years now.

Sunday, November 4, 2012

Mass Effects and Magical Thinking

We live in an age of wonders. Humanity’s new way of thinking, based on observation, hypothesis, and testing—the scientific method—supplies us with new machines and tools to support our advanced and rapidly evolving lifestyle, things like electric motors, microprocessors, satellite communications, and sophisticated data mining. This way of thinking also enables us to understand the principles behind many natural processes which humans have observed, wondered about, and created religions to explain since the first primate became self-aware, things like storms, earthquakes, solar eclipses, and the nature of life itself.

Some of the tools and their underlying principles are easy to understand and observe, like the actions of spark plug, piston, connecting rod, and crankshaft that drive an internal combustion engine. Some are difficult to understand and almost impossible to observe, like the electrons chasing around circuits inside a microprocessor, or the complex statistical algorithms that let researchers sift huge amounts of data to answer specific questions. For processes and principles that a person can’t study on a human scale and trace out with a fingertip, one is usually forced to accept—on faith, as it were—the explanations of trusted experts and the empirical fact that, whatever’s going on, the machine or process does work and provides reliable, usable results. Even if you don’t understand transistors and binary logic, you can still use a cell phone or computer.

But some processes are so vast, played out on inhuman scales of distance and time, or involving so many interactions and moving parts—for which I’ll use the shorthand term “mass effects”—that most people have a hard time seeing the chains of cause and effect. And so they may tend to disbelieve that the process is actually working at all. Two examples come to mind. First, the process of evolution, which plays out in millions of individual organisms over thousands of generations. Second, the price-setting mechanism of a marketplace, which plays out in thousands or millions of individual buy-sell decisions over a like number of transactions.

You can’t observe the process of evolution in any one individual or any one generation. Instead, you have to understand—or believe in—the cumulative power of thousands or millions of small changes to create a big effect over time. Similarly, you can’t observe the dynamics of a marketplace in any single interaction where A sells and B buys—which is the classic haggle of the bazaar. Instead, to understand a market, you have to multiply that interaction over hundreds or thousands of instances that establish a relationship among desire, availability, and price.

Curiously, if you divide the world into political parties—right and left, conservative and progressive—you find no appreciable difference in the power of these mass effects to confuse rational thinking. Each party has its adherents who face the challenge of understanding these far-flung and abstruse principles and then reject them as a kind of “magical thinking.” On the right, there is a tendency to doubt the power of evolution; on the left, a distrust of markets. These tendencies are not universal, of course. You can find traditionalists who are confirmed evolutionists (I’m one myself). And you can find progressives who are market-based economic theorists. But the tendency to doubt in either realm is well enough established to have become almost a trademark.

The traditionalist has a reason, of course, for dismissing evolution: it flies in the face of established teaching about the nature and intention of God. Evolution is messy. It has no foresight and cannot “intend” to produce any specific result. It builds on a series of tiny changes to simple structures that eventually, over time, creates more complex structures. And those tiny steps can as easily go backwards as forwards.1 Darwin understood this process and theorized about random changes that could be inherited long before anyone had defined the DNA molecule or worked out complementary base pairs, triplet reading frames, amino acid coding, and the mutations that might change one base in that genetic code into another.

Evolution works because it applies a filter, a process of selection, to the random changes that mutation produces in our genes and so affects the structures they build. The filter, the selection, is fitness of purpose. It doesn’t matter what the purpose might be or how it’s achieved.2 If the change abets the purpose, it creates advantage, and the next generation fares better. If the change defeats the purpose, it creates liability, and the next generation suffers. If the change is neither beneficial nor harmful, it might carry forward unnoticed for many generations—a genetic time bomb, as it were—until the environment and its demands change around the individual.

Religious believers hate this for a variety of reasons. Evolution makes no promises. It might have easily conferred the gift of awareness, thought, and personal purpose on sharks or dinosaurs or field mice as on a particular branch of the primates. What does that say about the God who made us in his own image? And evolution is cruel. It ignores the individual, his or her personal welfare, and any sense of destiny in this cascade of random improvements and disfigurements. A loving and benevolent God simply wouldn’t work that way.

The progressive has a reason, of course, for distrusting markets: they are inherently unfair to some portion of the people involved. Markets are based on discretionary transactions. A thousand or a million individual buyers look at the offering of a product at a certain price, weigh their need for the product, and decide, “Yes, I’ll pay that” or “No, too expensive.” A thousand or a million individual sellers look at the cost they’ve incurred to offer the product and the price they can get for it, based on the hunger in a buyer’s eyes, and decide, “Yes, now is the time to sell” or “No, I’ll wait for a better price.” For the average person of average means who can choose to buy or not, this might work equitably and fairly.

But the progressive sees and responds to the inherent disparities in the population. No matter what the market price may be, the rich man can always afford to buy—and take as much as he desires. No matter the market price, in times of scarcity it will usually rise out of reach of the very poorest. This disparity at the two extremes doesn’t matter much if the product in question is caviar or diamonds. But when the product is a necessity of life like food, housing, energy, or education, it becomes intolerable that the rich should gorge themselves while the poor go hungry. Market-based pricing makes no promises about what the “fair” price will be. And markets are cruel, because in times of scarcity some segment of the population will suffer. The market ignores individual wants and needs.

I find it curious that in these two areas, where mass effects play such a decided role, rational people deride belief in and reliance on these natural processes as some kind of “magical thinking.” Traditional believers deny that evolution can be the author of so much beauty and complexity to be seen all around us.3 Progressive economists deride the “dead hand” of the market as a means of distributing goods and services.4 In each case, the natural, human desire is for some kind of “intelligent design”—meaning an intelligence that an average human being can observe and accept. The religious believer wants a kind and loving God to design the living world along lines which he can understand and in which he can believe. The progressive theorist wants a kind and benevolent state to identify the population’s needs and fill them from available resources according to principles of fairness and equity of which he can approve.

Unfortunately, in each of these strivings for some human-quality intelligence to drive the natural system, the result does violence to the underlying principle.

A market can be made fair and benevolent for the disparately advantaged only by doing violence to the opposing party in the transaction. When products are naturally in short supply, holding prices artificially low for buyers robs the producers and distributors of their choice not to sell. When products are abundant, enacting price supports in favor of producers and distributors robs the consumers of their chance to stock up and save. When the benevolent state decides to take control of the entire economy and tries to direct production and sales according to “rational” principles, it always ignores niche markets, the needs and preferences of contrary-minded individuals, and the voluntary nature of an equitable exchange.

A planet’s flora and fauna that were created according to some “rational” or “intelligible” design would fix each creature in its niche within the environment. Even with godlike understanding and foreknowledge guiding the creation, the environment itself would have to remain fixed and unchanging forever: no climatic drift, no asteroid impacts, no solar life cycle, no perturbations among the stars. The slightest change, with its effects allowed to accumulate over millions of years, would oust each creature from its appointed place in the great scheme. Ultimately, life would die out entirely—a greater violence than the small daily and annual dyings out that set the stage for new life that is better adapted to current conditions.

What these systems of “mass effects” both address is the underlying dynamism in everyday affairs. In economics, that dynamism responds to the wide ranging differences in human needs, desires, ambitions, and preferences—the innate individualism of our species. In ecology, that dynamism responds to the unstable nature of reality—in which nothing is fixed, nothing permanent, nothing undying and unchanging.

People who live in modern apartment blocks tend to believe they inhabit a comprehensible, three-dimensional, clockwork, Euclidean-Newtonian world, because the walls, floors, and ceilings all come together in straight lines and neat corners, and the train schedules, banking hours, and television programming of their daily lives all run on the same time structure. They haven’t yet absorbed the underlying nature of reality, which is fluid, relativistic, stochastic, quantum-Einsteinian, and responds to statistical probability rather than to human constructs. In the same way, people who crave “rational” and “intelligent” solutions think they live in a static and unchanging world, where all humans want the same things, all fish swim in the sea, and horses run forever across fields of green grass under a warm and benevolent sun.

We live in an age of wonders. Not least of them is the amount of catching up required for human thought and emotion to match our accelerated scientific understanding.

1. The classic example of evolution is the bird’s wing, and you can duplicate the process in a metal shop—if you have enough time and patience, not to mention enough metal. Take a thousand or a million strips of sheet metal. Give each one a random whack with a hammer, then put it in a wind tunnel and see if the bent metal generates any kind of lift. If it does, set it aside; if not, discard it. For those pieces that generated some lift, give each one another random whack and test it. If it lifts, keep it; if not, discard. Repeat this process over and over, adding new pieces of metal as necessary. Eventually, over time, one piece will survive that has the perfect airfoil curve of a bird’s or an airplane’s wing. But a dozen times in the process, heartbreakingly, you will be one step away from the perfect wing and destroy it with the next random whack. Evolution cares more about results than progress and decrees that life is cheap.

2. A bunch of single-celled protozoans swim in a puddle. One undergoes a mutation that gives it the ability to manufacture a chemical sensitive to visible light. After that, and in every generation of single-cell division, the little animalcule makes that chemical without particular effect. Then, eventually, a second change lets the protozoan react to this newfound photosensitivity. If the creature also happens to acquire its daily energy through photosynthesis, suddenly it can move toward the light and thrive. Or, if the puddle happens to be gradually drying up—and drying faster in areas exposed to sunlight—the protozoan can move toward the shade and perhaps survive the drying out. Purpose and benefit are not directed. But still, in the land of the blind, the light-sensing protozoan is king. From that single chemical and the ability to sense it, to a full-grown eye—with an iris to regulate the amount of light that enters it, a lens to focus that light into an image, and a retina to retain and interpret the image—is just a matter of so many more baby steps.

3. But stop and think. Were not our eyes evolved to see and cherish, to take comfort in and seek pleasure from, the world in which we find ourselves?

4. Even though that “dead hand” merely represents the sum of individual choices freely made. What could be more fair and democratic than that?