I wanted to write about something fun but with the flurry of news about H5N1 yesterday, it is with a heavy heart that I have decided more people would want and might benefit from some notes about the bird flu.

Here's the TL;DR: H5N1 is not spreading human-to-human at this time. This is subject to change, and I really hope it doesn't. If it does change, it will become apparent pretty quickly. (This is an epidemiology thing, you can deduce how something is spreading from its patterns of spread. They make you do endless exercises on this in public health grad school; my takeaway from that is, never eat the mayonnaise-based salad at the cookout. It’s always the mayonnaise-based salad.)

There are outbreaks in many herds of dairy cattle across the US, some of which have caused human infections; these human infections have generally been mild, not the terrifying level of severity we usually associate with bird flu. The strain of H5N1 circulating in cattle herds is clade 2.3.4.4b, genotype B3.13. Another strain of H5N1 (2.3.4.4b genotype D1.1) is circulating in wild bird populations. This strain, not the cattle strain, is the one responsible for two severe human cases (that I am aware of), a teenager in British Columbia who remains in the hospital and an adult in Louisiana whose hospitalization was reported on yesterday.

What do you, as a member of the general public who does not work with potentially infected animals, do to protect yourself against H5N1 at this point? Two things: 1) do not drink raw milk, and 2) avoid contact with wild birds, especially dead ones; avoid contact with birds in general.

I hadn’t planned to write anything but as always, the shower is Where The Thoughts Catch Up With You. This morning I was thinking about a few pieces of media related to the shooting that I have consumed lately. The first is this New York Times interview with three columnists; predictably, Dr. McMillan Cottom’s remarks are the worthwhile ones. She mentions the concept of moral economy, which I have written about here, taking inspiration from Nate’s (apparently) idiosyncratic reading of E.P. Thompson.

Though the term predates Thompson, we’re working with it as developed in Thompson’s 1971 essay, “The Moral Economy of the Crowd in the Eighteenth Century” (which I really ought to read, for how much mileage I get out of it). I’ll keep it short and sweet — Nate and I have been using it as a way of reading the moral valence around the economy, which is similar to but different from how Thompson used it (to describe the feudal economy based on common values of mutual obligation, rather than the capitalist economy based on abstract values of supply and demand and the like). Dr. McMillan Cottom is also using it in a similar sense as Nate and I: “markets have moral economies” and “our moral economy sucks.” Indeed!

I’ve also listened to a few podcasts about this that have been interesting. The most recent TrueAnon episode with Joshua Citarella (I'm sorry for no direct link but linking to SoundCloud is so annoying here, I'll figure it out later) is an interesting deep dive into Mangione’s background, online activity, and trajectory of radicalization. This Canadian critical theory podcast that I quite enjoy had an interesting discussion as well. Both of these, though, are sort of orthogonal to What’s Really Going On. The TrueAnon episode chronicles the particularly rancid and decidedly not left-wing intellectual environment of the techie “digital nomad” world that Mangione was immersed in, and PillPod tried to scan the event as strategic left-wing action (a failure in that read) or terrorism (perhaps a success in the Baudrillardian sense) and talked at length about ideology, mostly vis-a-vis the media.

But here’s the main thing, I think: on their own, each of chronic pain, dealing firsthand with American health care, and the Online of the past four years in particular are more than enough to disarrange anybody’s brain. The Online point bears emphasizing; McMillan Cottom and others (including me!) have written about the syncretic scramble of the privatized internet, where fringe right and spiritual left really do horseshoe together, oscillating in and out of weird phase space. One of those unlikely superpositions and amplifications happens in particular in the ideology of “tech,” whose creepy focus on self-optimization and human biology seems to take equally from the long and storied lineage of scientific racism and from the LSD-soaked countercultural left.

This has been the week where everyone is scrambling to come up with The Take about Luigi Mangione, alleged shooter of Brian Thompson. In the scramble, an interesting bit of trivia has been overlooked except as a joke among certain kinds of terminally online communities: Mangione’s Goodreads review of Industrial Society and its Future by Theodore John Kaczynski, a.k.a. the Unabomber manifesto. As a long time Manifesto-head, this obviously drew my interest in a more-than-extracurricular way. 

The basic overview of the Manifesto is essentially summed up in its opening line: “The Industrial Revolution and its consequences have been a disaster for the human race.” The arguments, which are not really all that outlandish (or all that original), are that the requirements of industrial society – technologically advanced society organized on a large scale such as we’re living in today – tend necessarily and, for Kaczynski, unacceptably, towards restriction of human freedom and autonomy, mostly (though not completely) via disruption of what Kaczynski terms the “power process.” (The power process is not all that important for the rest of this newsletter, so I’m not going to go into it further.) The terse manifesto (though not as terse as Mangione’s own) argues that the good parts of technological advancement are inseparable from the bad parts; that in the final analysis, there’s no way out but revolution (at best) or individual withdrawal and acts of disruptive violence intended to accelerate the painful demise of the system, which is obviously the route Kaczynski himself opted to take.

It’s hard to think of a technological apparatus that subverts human freedom and corrodes human dignity as efficiently as the US health care system. The exuberant, rattling anger that has bubbled over like boiling milk from a pot in all corners of US society, all ends of the ideological spectrum, and all walks of life following the shooting attest to how much this particular way of organizing advanced technical society degrades and dehumanizes people – and pisses them off.  Horror stories abound. So too does reporting on the bottomless evils of the health insurance industry. Everyone knows. In particular, the highly technified aspects of this industry have come under scrutiny in recent years, though as I will ultimately argue, that scrutiny (much like Kaczynski’s manifesto) is more than slightly misguided.

Just last year, United Health Group got in trouble for issuing so-called “algorithmic” denials of care in its Medicare Advantage programs (for last week’s post with more info on Medicare Advantage, see here). Here’s how Stat News summed up the lawsuit:

Just a quick note about something I’ve been thinking about… saving the Big One (my manifesto, if you will) that gets into similar topics in a lot more depth for tomorrow. Or perhaps later in the week — just depends on how productive I can be.

For anybody that doesn’t know (I do have some readers outside the US, weirdly enough), the US does have two “public” insurers, Medicare which primarily covers people over 65 and Medicaid which covers very low-income people. The Medicare Advantage program, which began in 1999 — although it wasn’t named Medicare Advantage until 2003 — essentially amounts to a privatization of Medicare. Medicare Advantage allows private insurers to offer all the same benefits that traditional Medicare offers, as well as some other stuff that isn’t covered by the core components of traditional Medicare. Enrollment in Medicare Advantage plans really started to take off after the passage of the Affordable Care Act in 2010, and has been growing especially quickly in the last few years. By 2018, the share of Medicare beneficiaries enrolled in Medicare Advantage private plans had risen to 37%, to 48% in 2022, and finally to 54% of all Medicare beneficiaries in 2024, some 33 million people.

The Medicare Advantage “space” is dominated by a small number of private insurers, with Humana and United Healthcare insuring nearly half (47%) of all Medicare Advantage enrollees in the country. I am going to write more about the behemoth that is United Health Group (which has an insurer, United Health Care, and another business unit, Optum, which aggregates a number of different businesses under its aegis), but briefly: United Health Group has grown via aggressive acquisitions over the past 10-20 years to make up a huge portion of the health care industry itself, and its profitability depends in large part on paying itself via deals between its different business subunits, a practice euphemistically termed “flywheeling” in the business press. More on this later — again, perhaps tomorrow. For now, I’m going to focus on the insurance side and Medicare Advantage.

The majority of enrollment in United Health Care has come from Medicare Advantage in the last 10 years, and Medicare Advantage is extremely profitable. According to this post, United Health Care “now takes in nearly twice as much revenue from the 7.8 million people enrolled in that program as it does from the 29.6 million enrolled in its commercial insurance plans in the United States.”

On the urging of a close friend I’ve been listening to and really enjoying the TrueAnon podcast. This past weekend I listened to an episode from Back in April (sorry the embedding is so weird here, I can’t just link it):

with Erik Davis, author of High Weirdness: Drugs, Esoterica, and Visionary Experiences in the Seventies and the Blotter: The Untold Story of an Acid Medium. It’s actually a two-parter but I think the second part may be paywalled.

Since Trump’s election and the appointment of his anti-science MAHA cabinet, there’s a Carl Sagan quotation I’ve been seeing floating around the internet in meme format:

One of the saddest lessons of history is this: If we’ve been bamboozled long enough, we tend to reject any evidence of the bamboozle. We’re no longer interested in finding out the truth. The bamboozle has captured us. It’s simply too painful to acknowledge, even to ourselves, that we’ve been taken. Once you give a charlatan power over you, you almost never get it back.

This is from Sagan’s 1995 book The Demon-Haunted World: Science as a Candle in the Dark. Sagan was writing in the middle of a specific New Age moment in the mid-1990s. His book reads like a tart episode-by-episode rebuttal of Art Bell’s Coast to Coast AM from the same year – topics addressed and dispatched as pseudoscientific or “baloney” (to use Sagan’s word) include UFOs, witchcraft, extra-sensory perception, angels, channeling, and so-called “recovered memories” (which featured heavily in that decade’s Satanic Panic). The core of Sagan’s argument is fashioned into what he calls a “baloney-detection kit,” essentially a popularized Scientific Method that readers can use to distinguish real science from pseudoscience and woo, to use logic to defang superstition, and ultimately, to widen the small pool of light, cast by reason, against the oppressive, encroaching darkness of ignorance and delusion.

It sure does seem like we need Sagan’s baloney-detection kit more than ever now. I’ve written extensively about the MAHA cabinet on this newsletter, and about the issues they’re concerned with, like anti-fluoridation and raw milk, from a very debunk-ey perspective that jives with Sagan’s project. I definitely intend to continue – anybody interested in whatever the hell is really up with seed oils? But even as I’m doing this, I’m doubting myself. I’ve been on this tip since the early 2000s, when I was rattling off facts about thimerosal, the preservative in vaccines that the now-retracted cornerstone paper of the anti-vaccine movement spuriously linked to an increase in autism spectrum diagnoses, about the need for preservatives in multi-dose vaccine vials, about how vaccines themselves work, to anyone who would listen. What did all this accomplish? Not shit.

Last week, Trump announced the appointment of Jay Bhattacharya to head the NIH — we all knew it was coming. I didn’t have any kind of plan or destination in mind when I started writing this a few hours ago; it’s not heavily considered, chewed-over, or edited, just some general thoughts about where I’m at today. Read in that spirit.

I don’t know what to say about Bhattacharya that I haven’t already said. Way back on October 11, 2020, Justin Feldman and I published a deep dive into the now-infamous Great Barrington Declaration, of which Bhattacharya was one of the three fringe authors — joke’s on us now, I suppose. I’ve done some smaller-scale investigations into Bhattacharya’s discredited COVID “seroprevalence study” (discredited and also corrupt — remember how a JetBlue executive funded it? to show that COVID was already widespread, mostly asymptomatic, and not very deadly, and thereby undercut the case for nonpharmaceutical interventions?) of Santa Clara County, CA. I could note that the scientific arguments characteristic of Bhattacharya’s COVID career explicitly contradict some of his earlier research, such as this 2010 NBER influenza modeling study that highlights the effectiveness of early adoption of “avoidance measures,” a.k.a. nonpharmaceutical interventions. If anyone reading this would be interested in a deep dive analysis of Bhattacharya’s scientific publications, email me. I’m happy to do it if people would find it useful. I’m not sure I find it useful for myself at this point.

I’ve talked about COVID as a political defeat. This is it. I’m so glad I didn’t become a professor of epidemiology. Don’t get me wrong — what I really want to be doing is teaching and writing. I’m still trying to figure out a way to do that; being a professor of epidemiology would not have helped. While teaching and writing are what professors in most disciplines do, it’s not the case in epidemiology. What professors in epidemiology do is write grant applications to the NIH to fund their own salaries and their universities. (As an aside, I think this contributes to the structural tendency of epidemiology programs to produce astoundingly ignorant graduates and to the structural tendency of the discipline as a whole towards irrationality, ignorance, and myopia. Since grant writing is the only metric of success, no one is trained or hired for their ability to think, write, or teach, only for their “demonstrated track record of securing extramural funding,” to use the tired stock phrase of every academic job description.)

Bhattacharya is about (to try, anyway) to take an axe to the NIH, which means that a lot of people’s careers are about to get a lot more precarious. It’s way more than just long COVID research that will be affected if Bhattacharya and the interests he was appointed to represent get their way — my intuition tells me infectious disease research, particularly of a population/epidemiologic bent, is possibly in big trouble. The experiences of the past several years have made me a bit of a nihilist about the science the institutions produce as well as about the institutions themselves. But this is really pretty bad. My guess is that a lot of academics who maybe signed the John Snow Memorandum out of some vague sense of wounded expert authority are going to suck up to Bhattacharya and reconfigure their research agendas to be more attractive to Bhattacharya’s NIH, once it becomes clear what the funding priorities of the institution will be under him. It’s understandable, but it’s sad.

Trump appointed Marty Makary as head of the FDA. Marty Makary is one of the peripheral D-list conservative baddies of the COVID era, kind of a Trump administration gadfly who came out hard against vaccine mandates especially. Here’s how PBS describes him:

Makary gained prominence on Fox News and other conservative outlets for his contrarian views during the COVID-19 pandemic. He questioned the need for masking and, though not opposed to the COVID-19 vaccine, had concerns about booster vaccinations in young children. He was part of a vocal group of physicians calling for greater emphasis on herd immunity to stop the virus, or the idea that mass infections would quickly lead to population-level protection.

The Centers for Disease Control and Prevention estimated that COVID-19 vaccinations prevented more than 686,000 U.S. deaths in 2020 and 2021 alone. While children faced much lower rates of hospitalization and death from the virus, medical societies including the American Academy of Pediatrics concluded that vaccinations significantly reduced severe disease in the age group.

Before surfing the COVID waves to minor Fox news celebrity, Makary was most famous as the first author of a 2016 “study” purporting to show that medical errors are “the third leading cause of death in the US.”

What is in Makary’s paper? I put “study” in scare quotes above because it is not, in fact, a study. The authors (Makary and someone named Michael Daniel) neither collected nor analyzed any data. They did not systematically review any literature, either quantitatively (pooling the data from each selected paper and analyzing it as in a meta-analysis) or qualitatively (as in a narrative review of the existing literature, its strengths or weaknesses). None of that shit. The paper is a two page — literally, two page — overview of four other papers on medical error.

Pour one out for Raw Farm and CEO Mark McAfee, whose business and livelihood depend on making people wretchedly ill with his company’s raw milk products. Santa Clara, CA county public health officials just detected H5N1 (bird flu) in a retail sample of Raw Farm raw milk taken from a Fresno. It’s nearly 9 PM where I am, so I am going to keep this brief, but: this is very bad. Perhaps I will do a longer post soon explaining in more detail just why this is bad. For now, suffice it to say, this indicates tangibly increased risk of a so-called spillover event. Right now, H5N1 isn’t very good at infecting humans, and the people that have been infected have been (overwhelmingly but not totally) people who work very closely with infected animals. Viruses, as we have seen with COVID, increase their “fitness” to infect humans (and spread human-to-human) with increased transmission; one critical driver of this is the rate at which the virus’s genetic material mutates. (Mutation = variability, and variability is what the process of natural selection works on.) Not awesome news for us, influenza mutates very fast and very often. It’s a probabilistic game: any given individual mutation is unlikely to turn the virus into an airborne superbug, but every transmission — from bird to bird, bird to cattle, cattle to human — is an explosion of roulette spins, new opportunities for the virus to mutate. The risk gets higher and higher, the more the virus circulates, that one (or more) highly unlikely things might happen.

This is a huge reason why factory farming of chickens is the worst idea ever. It basically creates a crucible for breeding ever-more pathogenic strains of bird flu. Mike Davis (Z”L) wrote an entire book about this back in 2003 (it’s called The Monster At Our Door and it is quite good, maybe I’ll review it on here). Factory farming in general creates optimally hellish conditions for sparking off an influenza pandemic by concentrating different species of animals together in abject close quarters — influenza loves to recombine in nasty ways in pigs in particular. Conditions for human laborers on factory farms are nearly as dangerous and atrocious as the conditions for the animals — it’s an educated guess that there’s not a lot of PPE for these workers that would help confine any animal infections to the animals. (And American news has the gall to sniff about “wet markets” in Asia. Get a fucking GRIP.) Then, on top of this, in the dumbest possible timeline, we are getting dragged over the event horizon of another terrifying pandemic by scientifically illiterate kundalini cult Erewhon girlies who want to shit their brains out 24/7, the closer we are to Gwyneth, amen.

Pour one out for Emily Oster, who just last week wrote a New York Times article dismissing concerns about bird flu in commercially available milk. You know what would have killed the bird flu in this sample of Raw Farm milk? Pasteurization. Fucking dipshit. Pour one out for Jennifer Nuzzo, public health mediocrity (even by public health standards) and COVID waffler now at the helm of “The Pandemic Center” at Brown who is quoted in the LA Times article downplaying the risks of drinking raw milk but impelled by… some glimmer of conscience, maybe? (are you there, Gwyneth?) to say that “I personally would avoid drinking it.” Ya don’t say. (Nuzzo: “This isn’t surprising, given how quickly H5N1 seems to be spreading among farms in California and given the fact that these outbreaks on farms are being discovered in large part due to bulk testing of raw milk from farms.” How else would you propose we discover it, Jennifer? Might you put on, I dunno, your “pandemic preparedness” cap to think about this?)

Lmfao. I’ll let Mark McAfee — we NEED a deep dive into this dude and his whole deal, can anyone point me in the right direction? — have the second-to-last word here.

In my youth I was a punk and I especially loved the Dead Kennedys. The Dead Kennedys’ arguably most famous song is California Über Alles, a sendup of Jerry Brown’s (first) hippie-rightwing tenure as California governor from 1975-83 (“your kids will meditate in school,” Jello Biafra, in character as Brown, threatens in his warbly singing voice as the song reaches the chorus, “YOUR KIDS WILL MEDITATE IN SCHOOL!”). After Reagan’s election, the band recorded an updated version of California Über Alles for their 1981 In God We Trust, Inc., inserting some jazzy, louche, lounge-singing interludes between the blasts of power chords (waiting for Bon Appétit to release a recipe for the “Tricky Dicky Screwdriver,” which Biafra entreats the listener to enjoy: one part Jack Daniels, two parts purple Kool-Aid, and “a jigger of formaldehyde from the jar with Hitler’s brain in it”) and revising the lyrics to skewer the Great Communicator himself. The song also gets a new title: We’ve Got A Bigger Problem Now.

Well, folks, here I stand at The Limits of Rhetoric thinking to myself… we’ve got a bigger problem now. For years, I’ve been writing and speaking about what I see and believe in as “leftist” public health, a complicated, difficult story about public health and what it’s doing in the world, historically and in the present. I’ve been complicating the narrative to death, interrogating flashlight-in-face style the faulty assumptions of public health and biomedicine, arguing in an increasingly shrill and angry voice for a collectivist idea of public health that is regulatory, precautionary, organized around something other than the “valorization of value” (aka the profit motive) at the heart of the capitalist logic of everything. And I’ll be brutally honest, I didn’t really see MAHA coming, I didn’t take it seriously enough, I just ascribed it to more of the same in our fucked up economy of health.

Which, it kind of is, but with a sinister new twist. I have another post coming and mostly drafted about what it would mean to actually take this shit seriously rather than dismissing it out of hand as for a) crackpots, b) losers, c) stupid people, d) health economics-brained liberals. There’s a lot in there about science and science communication, but I’ll save that for later. Right now I think I’m going to try to back the fucking truck up and see clearly where we’re actually at now that RFK Jr. is in charge of HHS, Dr. Oz is in charge of CMS, and so on.

I’ve been investigating the Means siblings, Calley and Casey means, brother-sister team of health entrepreneurs that are some of the most visible proponents of the MAHA movement. (That’s Make America Healthy Again, for anybody that doesn’t know.) Apparently Calley is launching a newsletter on 12/19 which I will absolutely be signing up for. In looking at Calley’s webiste, I was really struck by something, though. Even though I know this dude is just an alternative health grifter, here’s how he summarizes what he has learned on his “journey”:

I promised a post about fluoridation. This is it. This may be the first of several; I won’t pretend to be familiar with any of the literature on this, whether on the health effects (detrimental or beneficial) of water fluoridation or on how fluoridation fears are an entry-level conspiracy theory. (Although, I have some anecdotal evidence — long ago I lived in Austin, TX and thought the Alex Jones/Infowars people who camped out in front of city hall protesting fluoridation were kind of campy and funny. Little did I know where we were headed.)

Leana Wen and Emily Oster both wrote about fluoridation last week, Oster in her New York Times piece and Wen for Amazon house rag The Washington Post. Their points are almost identical, which should alert you to the level of effort these brown-nosers are putting into their public intellectual output.

Both mention that European countries stopped recommending fluoridation. Hmm, can we think of anything that is different between European countries and the US of A? Here’s one: nationalized health care. In the US, dental insurance is separate from health insurance, and both are private. (Fun fact, I got two wisdom teeth extracted with nothin’ but shots of Novocain because I had no dental insurance — paid out of pocket for the extraction — and my crappy health insurance didn’t cover nitrous oxide.) Dental care is a crisis in the US, and if the legislative panels convened to worry over it don’t convince you, may I point you in the direction of the huge repository of memes about teeth as “luxury bones”? In this context, where kids go to bed suckling on bottles of Mountain Dew (is RFK gonna do anything about those Big Ag corn subsidies or are we just gonna get some kind of funky MAHA remix of the soda tax?) and many can’t go to the dentist at all, might the value of something like public water fluoridation be evident?

Anyhow, this post isn’t going to focus on that. This post is going to focus on how to read a study. Both Oster and Wen cite the same study, from JAMA Pediatrics (scoffing here because people think JAMA is some kind of prestigious journal when in reality the statistical review is shit-tier and the journal publishes mostly dreck from unqualified clinical personnel under tremendous pressure to churn out research, no matter what it says, in order to move up the rungs of competitive medical training), purporting to show an association between prenatal “fluoride exposure” (this is, I will state up top, not what the study measured) and child IQ.

Sorry! Insomnia brain still whirring. One more thing that I want to note: the elision Oster makes of the distinction between individual-level and population level constructs of “risk.” Here, again, is what she says in the article:

“There is no good evidence of any health benefits associated with raw milk. But the overall picture here is of a slightly elevated risk, and one that is in the range of other risks people take, especially for healthy individuals.”

BZZZZZT! Wrong! The population-level incidence of illness linked to raw milk is not an index of the individual-level likelihood of becoming sick from drinking raw milk. If you drink 100 bottles of raw milk and 99 of them are uncontaminated (or uncontaminated with a sufficient number of pathogens to make you sick), you won’t get sick. You might conclude from this that raw milk is basically safe because 99/100 is pretty good. The risks are low, on par with others we take in normal life!!! (or whatever horseshit she’s serving, it’s always an argument like that). But if the 100th is contaminated with E. coli 0157:H7, you will get very sick and you might get hemolytic uremic syndrome and/or kidney failure. It’s spinning a roulette wheel, but you have even less information than you do about a roulette wheel. A roulette wheel has 37 or 38 numbers. The combinatorial mathematics can get complicated, but you can work them out. You have no idea what is in a given batch of raw milk. There are very good reasons to suspect that it might be something really nasty. There are also very good reasons to suspect that with RFK Jr. in charge of the FDA, regulations on the productions and sale of raw milk are about to get much more lax. More spins of the wheel, more potential for bad bets.

Do not be fooled by the Freakonomics parenting lady scowling in the fugly MM Lafleur. She does not know what the fuck she’s talking about.

A minor personal update, I have been sober for just over a month (it’s less serious than it sounds) and this, my first un-self-medicated menstrual cycle in a long time, is kicking my fucking ass with insomnia. I’m a lifelong insomniac and this is rough even for me. That’s why this is coming to you at 2:20 AM EST. I wrote this earlier today, before it was reported that Trump is appointing RFK Jr. to head HHS after all. Haha. All is well with me, this too shall pass, the way out is through, etc., but the world is pretty completely fucked. Nevertheless, I’ve still gotta work tomorrow, and you probably do too. After I send this I’m gonna make myself a lemon balm and valerian root tea (have you tried this shit? In normal, non-insomniac times it totally knocks me out) and restart my bedtime routine* over again for the third time tonight. Wish me luck, or don’t; whatever the case, I hope you enjoy.

We’re barely a week out from the election and Tweedle-Dee and Tweedle-Dum of the early pandemic, Leana Wen and Emily Oster, are back again. Both are in large national publications this week, doing exactly what they did with COVID: laundering fringe bullshit for respectable liberal audiences through the language of data. They shot their shot with Biden, bit the dust pretty hard, lost credibility, and now they’re trying again with Trump. Best of luck to these ladies!

About a year ago, I was working with a friend and colleague on a vague idea for a piece along the lines of "abortion is health care... and health care sucks!" I gave a guest lecture on some of the themes we were exploring, we both got busy, the piece (God do I hate the word "piece") never developed further. Well, now here we are, sitting with the "puzzling" result that ballot measures protecting abortion at the state level did well while Kamala Harris bit the fucking dust in the presidential race. What could explain this? I don't expect the Democrats to do any reflection on this, but here on Closed Form we can say and do whatever we want.

A few years ago I wrote a profile of Leana Wen (she's baaaaaaaack!). I didn't have much as much space as I would have ideally liked to go into a detailed critique of her tenure as president of Planned Parenthood, but I came to take major issue with her "abortion is health care" campaign. Here's what I wrote then:

In 2018, Wen left Baltimore to accept a new job as the sixth president of Planned Parenthood — the first Asian-American woman and the second doctor to ever hold the role. Less than a year later, Wen was dismissed from the position, with a flurry of news reports describing differences in vision and strategy for the organization. The most insurmountable differences derived, in part, from her center-aisle approach to business; Wen’s vision, in her telling, was to depoliticize abortion by rebranding Planned Parenthood as a general health-care provider. In Lifelines [Wen’s memoir], this is framed as a concession to sensible moderates, based on her previous interactions with some Title X grant recipients who were leery of attending meetings where Planned Parenthood would be present. “If Planned Parenthood was seen as too controversial,” Wen writes, “then reproductive health was at risk of becoming even more cut off from the rest of health care.”

Wen’s goal was to resituate abortion within the spectrum of “regular” health care, but she confused cause and consequence: abortion is siloed off from other health care precisely because it is so politicized, and it is politicized because of fundamental values conflict over reproductive autonomy. Thus, with longstanding political conflicts increasingly placing reproductive rights at jeopardy, the head of the single largest provider of reproductive health services in the nation was busy placating a phantom constituency of moderates.

Good morning to everyone out there in internet-land. I am having some nice strong coffee and listening to jazz, enjoying the golden sunshine of a daylight savings morning. I hope your Saturday is treating you at least as well.

In general, I really want to move away from writing about Covid, because it feels completely purposeless at this point in time – just inviting pain and judgment and hatred, which I already have plenty of. I certainly don’t want to write about the election; I’m no longer enough of a left-wing narcissist to think that my “analysis” is something anyone needs any of. But today I’m going to write about both, because there’s something going on that I think is interesting.

In the days since the election result was announced, I have seen a thread by a familiar Covid grifter circulating all over the internet. The thread is an evidence-less argument that pandemics lead to fascism. The examples in support of this are: the Great Depression, and hyperinflation in Weimar Germany* (only one of those things led to fascism, but whatever?) came after the 1918 influenza pandemic, and Donald Trump’s reelection in 2024 after the pandemic began in 2020 (Trump was already elected once before, pre-Covid, in 2016, but whatever?). The mechanism proposed for how these things happened is that they “brought eugenics into the mainstream” or some such. Obviously, this is not true. Eugenics long predates, and was mainstream long prior to, 1918. The ideology and movement first coalesced in the 1880s; the US state of Indiana passed the world’s first compulsory sterilization law for the “unfit” in 1907. In 1911, the Carnegie Institution – hardly a fringe outfit – released a report proposing several methods for removing the genetically unfit from the general population, including euthanasia by gas chamber. The connection between eugenics and fascist ideology is clear. What I’m saying is that this connection predates, and is only remotely and tenuously connected to, the influenza of 1918 or the Covid-19 of 2020.

I could take a weathered desire path here and argue that these analyses are politically dangerous in addition to being ignorant; that they misidentify the culprits, misunderstand the problems, point people galvanized to “get involved” down dead-end paths. Someone else can make those arguments. I want to talk about something weirder: the funky thread of esotericism running through the beautiful tapestry of the Covid grifter community and through its associated epistemological stance. I read a really fun paper by Susannah Crockford yesterday that reviews the “sociology of secrecy” in an analysis of esotericism, neoliberalism, and the Goop jade vaginal egg (my essay about Goop Lab, which covers some of the same ground, is here). The relationship between esotericism and what we now call science is long, complicated, and fuzzy, but for our purposes, some simple definitions will suffice.

Verso books, man. Why are they like this?

I picked up a copy of Justin Joque's 2022 book Revolutionary Mathematics: Artificial Intelligence, Statistics, and the Logic of Capitalism -- sounds promising, right? Wrong.

I wanted to like it. Obviously! This book is way up my alley, judging from the title alone -- in fact, at first glance I was worried that it had sort of scooped the idea for my own (glacially progressing) book project. But the book is simply, where the thread of argument is briefly intelligible, like a dark street illuminated by a flash of lightning, wrong. At least, this is my take on it about three turgid chapters (of eight) in. I've read three chapters, and I still have absolutely no fucking clue what this book is trying to argue about statistics and its relationship to capitalism. A few of my stray thoughts are below.

Joque describes a "revolution" in statististical inference which seems to refer to... a move to Bayesian inference? This is hardly a revolution. For one thing, the move to Bayesian inference techniques over the more familiar midcentury frequentist techniques is far from total. I guess many so-called AI models (which are really "machine learning," which is to say, statistical learning models) use some kind of Bayesian methodology, but if you look around, frequentist statistics are very much the norm (hah hah) in many other fields. I work as a statistician facilitating (really subpar) clinical research; I reside in, have my mail forwarded to, frequentist-land. I spend my days arguing with pompous surgeons about why a p-value doesn't mean what they think it means (I do not want to be doing this, so please, if you've got any job leads, or are looking for writers or book reviewers for hire, please reach out).

The 2019 version of me would have been shocked and horrified at what I’m about to say: Nancy Krieger is incredibly fucking tedious to read. I’m so over it. I’m particularly tired today (and particularly exhausted lately), but today is not the problem. I’ve been incubating an idea for this essay for months at this point — a take on Krieger’s arid 50-page 2012 paper “Who and what is a ‘population’? Historical debates, current controversies, and implications for understanding ‘population health’ and rectifying health inequities.” I haven’t published anything yet because I simply can’t get through the fucking thing. Even trying to say the title out loud is tiresome to the jaw muscles, like trying to break down a Tootsie pop. Not that I don’t have a high tolerance for boring text. (I’m a Marxist, after all. Ask me how many yards of linen to make a coat.)

I can barely even even bring myself to open the document again, honestly. It’s not even really necessary. Like all Krieger papers, the “argument,” if we can call it that, is an extremely pedestrian non-point buried under a sludge of dictionary definitions. (Literally. And if that’s not annoying enough, she archly close-reads dictionary entries for “population” according to a completely arbitrary and occult set of criteria — Miriam-Webster defines population this way, but they don’t specify exactly what a population is, that kind of grating vibe.) Here’s a quote from the paper: “Consequently, apart from specifying that entities comprising a population individually possess some attribute qualifying them to be a member of that population, none of the conventional definitions offers systematic criteria by which to decide, in theoretical or practical terms, who and what is a population, let alone whether and, if so, why their mean value or rate (or any statistical parameter) might have any substantive meaning.” Okay? What I want to get into here is… what are the epistemic assumptions, or the system of thought, behind the idea that having “systematic criteria” to decide “who and what is a population” is something that we really need.

At issue is the concept of population, “core to epidemiology” (as Krieger says) or some such nonsense, and a rather interesting story.

Have you ever thought much about what an average really is? It’s kind of a funny joke about the “average American” with 2.5 kids, which of course corresponds to no actual person, living or dead. The joke, which makes fractional children possible, is that the average is an abstraction, a reified statistical object, that we nevertheless endow with some kind of meaning or authority as a representation of a group of things. How did we get here?

Numbers have a qualitative dimension. Or, the same number doesn’t always mean the same thing. If we had COVID-19 transmission numbers (we don’t, and beware grifters trying to tell you we do), they would not mean the same thing today as they did this time in 2020. The population of the US has changed, the virus itself has undergone several transformations, we have vaccines and therapeutics now that we didn’t have in 2020. This makes the medical (versus the social) end of a pandemic highly ambiguous.

We saw some outlines of this with the fruitless “epidemic or endemic?” arguments that have circulated in the COVID discourse, less and less frequently in recent years. I’ve done some public-facing work around this and given a couple of interviews, the upshot of which is that epidemic vs. endemic is a qualitative rather than a quantitative distinction. By this I mean that there is no threshold of infection or transmission below which an epidemic disease becomes and endemic one. Diseases are rendered as endemic via a complex socio-ecological process — adaptations are installed or not, pandemic income supports go away, the business of life, for those of us still here, must go on somehow.

Other examples I can think of. COVID cases are certainly much more numerous than cases of locally-acquired dengue in the US, but the dengue is more concerning to me as an epidemiologist. At this point, COVID is the devil everyone knows; one dark cloud on the horizon, for me, is the recrudescence of mosquito-borne illness in the USA. (Another one is pandemic influenza… although the COVID grifters are trying to latch on to it, it’s mercifully not an emergency; not yet, anyway.)

Or, to use a non-infectious-disease example, pregnancy-related mortality. The numbers tell a jarring story: Black and Indigenous people are unnervingly more likely to die in pregnancy or childbirth than their white counterparts. These numbers have a qualitative dimension that is expressed in quantitative terms as “relative” or “absolute” rates of mortality. Relative to white people, Black and Indigenous people have extremely high risk. In absolute terms, though, even the demographic groups with the most social privilege (white people) have alarming rates of pregnancy-related death. Which is to say, Black and Indigenous people bear the brunt, but the picture is not good even for white people. What to make of this?

Good day, freaks — and my apologies for a lack of content over the last few weeks. I have several things I want to publish here in the works and I keep getting mired in perfectionism (which I do have the power to change) and life stress (which I don’t). So, thanks for hanging in there with me.

This is just to alert you all that both parts of the episode of Last Born in the Wilderness I recorded recently are now available. You can find the Soundcloud links to both parts at this page here.

To my chagrin, I didn’t know about this podcast until the host reached out to me to appear on it. It is fantastic — I’ve been catching up on past episodes over the last few weeks, and I highly recommend subscribing to the show on Patreon if you have a couple bucks to spare.

More of substance from me soon, I promise!

Quick note here. I wrote this a few months ago and am still kind of workshopping it. But I was revisiting it today and I think this fragment is sufficiently developed to send out.

A little while ago, I wrote some posts about Goran Therborn and ideology: here and here.

As I was reading Therborn’s book, and writing those posts, I (Carrie Bradshaw voice) couldn’t help but wonder: what is the ideology of public health? (In the interest of limited time, I am not going to rehash Therborn’s analysis in depth here. You can go back and read my posts if you’d like to, but basically, following Althusser, Therborn argues that ideology “interpellates” different kinds of human subjects; ideology is a process that subjectifies you and also qualifies you for certain kinds of social roles and responsibilities.)

Who does public health “subject and qualify”? What kind(s) of subject(s) does it interpellate? Immediately, I think there are already two distinct ways to talk about this: the ideological processes of public health interpellate 1.) public health professionals and also interpellate 2.) “the public” that public health is addressed to. Bringing Therborn back in, he argues that ideology interpellates human subjects according to: ontology (what is), possibility (what could be), and normativity (what is good or desirable).

Good morning, everyone. This is just a quick bulletin to let you know that my new radio show, A COURSE IN MIRACLES, starts today. It will be this evening (and every subsequent Sunday evening) from 5-7 PM, Eastern time. You can stream it at www.wrct.org. If your heart is tender or heavy then I hope you find the show as therapeutic to listen to as I do to put it together.

Till next time!

Though this isn’t its most vernacular meaning, “embodiment” has a second life as a term of art in a marginal subdiscipline of epidemiology, so-called “social” epidemiology. Depending on the day and my mood, I could articulate social epidemiology as the heir to some kind of real public health, before molecular medicine got in the way, or as the part of epidemiology that traffics the most cynically and shamefully in trauma questionnaires and DEI ambulance-chasing. It is supposed to be, I guess, the part of epidemiology that deals with social conditions and gives them primacy over individual factors like genotype or health behaviors. Social conditions are a hugely important aspect of population health and this is (or at least can be) a hugely powerful line of inquiry — look into any public health problem that is formulated as such (to be a public health problem is to be a technical problem amenable to technical manipulation) and there is a sense of vertigo as one realizes how deeply the roots of the technical problem reach into social organization and history. The concept of “embodiment” (in overwrought language about how “bodies tell stories”) is basically The Body Keeps the Score for the population health scientist — we in-corp-orate, quite literally, the social conditions in which we live. I, for example, embody the thick fug of particulate air pollution constantly lying over my neighborhood, which is a historically redlined one… you get the picture.

But, I have soured a little bit on social epidemiology in recent years. One reason is pretty obvious — this shit is not original. It might be compelling, but it’s not original. It might have been original for Rudolf Virchow in 1848, but it’s absolutely no longer in 2024, though people make interminable, monotonously prolific careers out of announcing over and over again that social conditions matter. Yes, I am subtweeting Nancy Krieger, the person who coined the term “embodiment” in its epidemiological application. I used to really love and admire Krieger’s work, but am coming to view it as quite unsatisfying. This is connected to another of my objections to social epidemiology as such right now, that there’s not really much “there” there. True that everything is connected to everything else. True that we are not isolated laboratory subjects. So what? What are we supposed to do with this information? How to actually link the insights derived from thinking about epidemiology through embodiment with actual practice of public health? It’s not clear, and the practice of social epidemiology seems to be little more than an endless iteration and explication of a familiar parade of social ills: capitalism, racism, environmental destruction, and so on. (Wouldn’t you know? All bad for your health!)

The last reason I will mention and the one I want to focus on is: the very existence of social epidemiology effects the same artificial severance of living individuals from social context that social epidemiology is (at least ostensibly) meant to mend. Are history and “social conditions” external to the human beings that constitute them? Is there any place for experience in public health? A very familiar reference point for me is Lewontin’s Gene, Environment, Organism — tl;dr, all three actively constitute and “make” each other, all the time. A very new and unfamiliar reference point for thinking about this stuff (for me) is Maurice Merleau-Ponty’s Phenomenology of Perception.

Merleau-Ponty makes use of embodiment in a different sense and to a different end, but one that I think is generative for thinking about stale public health concepts. His concern was a philosophical treatment of perception, and as far as I understand it, in Phenomenology of Perception he is trying to argue against both “empiricist” notions of perception (perception is a causal process of sense-experience or stimulus-response, for example, light of a certain wavelength striking certain receptors in my eyes and giving my brain the perception of the color red; unidirectional influence of world on mind) and “intellectualist” notions (my mind synthesizes different objects in the world into a perception of the color red; unidirectional influence of mind on world) in favor of a secret third thing, something like gestalt theory. From the Stanford Encyclopedia of Philosophy entry:

A couple of weeks ago, the Pandemic Mitigation Collaborative rolled out some updates to their models, which I’ve posted about before: here and here. Since then, I’ve seen Eric Topol, director of the Scripps Research Translational Institute and member of the National Academy of Medicine, cite the “one million cases per day” pseudo-statistic on PBS Newshour, which sucks. I’ve seen the figures from this model cited all over the news — in the absence of real information, grifters like Hoerger fill the void, and with the sorry state of media today, nobody is any the wiser and his bullshit claims get spun up and amplified into synthetic truths. It’s really awful to watch. I am critiquing these models as a PhD epidemiologist. This is exactly my lane, this is exactly my expertise, and people like me and our insights are being completely marginalized as the pandemic grifters crowd us out with fake data, hyperbole, truly horrendous and stigmatizing claims about “airborne AIDS,” and all other manner of dog shit.

The PMC published a “technical appendix” about the updates to their models. I reviewed the technical appendix and it is one of the most bizarre documents I’ve ever laid eyes on. So, in today’s bonus edition of this newsletter, let’s close-read it — or at least some of it (I will get to anything I don’t cover today, a Friday evening, at a later time). The TL;DR: Dr. Hoerger definitely read my previous posts (LOL) but doesn’t really have a response to any of the critiques in them, and the technical appendix doesn’t go far enough in elucidating exactly what their modeling methodology is or how accurate it is. I am repeating my call for the PMC to publicly share the code they use to run these models (this can be done easily on GitHub and is in fact common practice among working scientists, at least in epidemiology) and will reiterate it at the end.

I’m going to take it by sections as they appear in the appendix, with heading titles italicized and bolded and direct quotes of text from the appendix italicized. My commentary will appear below any text quoted, not italicized.

What’s new?

I often hear “public health has failed us” bandied about in the discourse these days, axiomatically, and usually in response to COVID policy. While I agree in broad strokes, I think the circulation and repetition of this phrase implies a coherence to “public health” that public health simply doesn’t have, and — as I have perhaps mentioned here before — assumes the existence of a golden era of public health at some point in the past where public health was “succeeding.” I don’t think there has ever been such a golden era, and I think it’s really, really worth thinking about what it means for public health to succeed. What does success in public health look like?

For some reason, I still get the Morbidity and Mortality Weekly Report emailed to me. My curiosity was recently piqued by a report of travelers returning to the US from Brazil and Cuba with something called “oropouche virus.” I looked it up. I suspected mosquitos and while mosquitos can transmit oropouche, its main vector is actually biting midges. I don’t know exactly what those are, but sounds bad?

The symptoms of oropouche are reportedly similar to those of mosquito-transmitted viruses like dengue (called “break-bone fever,” to give you a sense of what dengue is like), chikungunya (which was, confusingly, called dengue for a long time; after being absent from the Americas for roughly 200 years it was detected again in 2013 in St. Martin), Zika (which you may remember from the epidemic in 2015-2016), yellow fever, and malaria. These are predominantly transmitted by two Aedes mosquito species, Aedes aegypti and Aedes albopticus, which are both present in the United States and whose geographic ranges (where the conditions are favorable for them to reproduce) are expanding as climate change heats up the country.

Anthony Fauci just had West Nile, another mosquito-transmitted virus. This one is transmitted by Culex pipiens, which are all over southwestern Pennsylvania; every year since 2002, my county (Allegheny) has reported cases of West Nile in humans. Fauci was hospitalized with the virus, and described the experience as like “being hit by a truck.” The symptoms, again, are similar to other arboviruses (viruses that are spread by arthropods, a.k.a. insects, like mosquitos, ticks*, and — ugh — midges): headache, nausea, joint pain, fever, encephalitis or meningitis in severe cases, fatigue that can last for weeks or months after acute infection.

“All models are wrong, but some are useful.”

Are the Pandemic Mitigation Collaborative models — which are wrong — useful?

I wrote a post about this already, about the wastewater-to-cases conversion that the model purports to do; I found this to be extremely unconvincing, to say the least. Here, I want to get a few quick thoughts in about the forecasting model. A new version of the forecasting model launched today. Here is Dr. Hoerger’s X post about it. The only thing that is different is that the underlying data sources have changed; instead of relying exclusively on Biobot wastewater data, they are now relying on Biobot and CDC wastewater data. According to the post: “Essentially, we link all three data sources, which have been active over different points of the pandemic to derive a composite ‘PMC’ indicator of true levels of transmission.”

These three sources are, again, Biobot and CDC wastewater data, and modeled IHME case estimates from prior to April 2023. No matter which way you slice it, this is not good data; converting wastewater to cases remains impossible to do reliably, and the PMC do not have access to any actual “ground truth” data about COVID transmission. They are as in the dark about it as any member of the general public. Claims about the greatness of the data are simply exaggerations. I remain skeptical that reliable modeling of wastewater concentrations to daily new cases is even possible, let alone forecasting based on those new case estimates.

Did you all know I have a radio show? I do. (A show on college radio: the hallmark of someone whose Life Is Going Well.) You can listen to it live on Thursdays at 11 AM EST on www.wrct.org — though a fall semester time change is likely and imminent — and listen back to the most recent two episodes here. Our cursed DJ software only keeps recordings for two weeks; I am one day going to figure out how to record my broadcasts and upload them somewhere for posterity, but for now, you’ve got to catch them while they’re (relatively) fresh.

I jokingly called today’s show the “vagus nerve regulation mix.” I put it together yesterday when, instead of pushing myself through a fug of stress and depression-induced mental chaos to make mediocre edits to my book proposal, I decided to try to just listen to myself and accept how I was feeling. I went for a walk in the park instead of procrastinating work, and composed the mix while I did it. I listened to it on my way home and laughed to myself a little bit because I had clearly made it to chill myself out. (I usually play blistering psychedelia and Steely Dan deep cuts.)

Hence the vagus nerve stuff. Vagus nerve regulation is a deeply silly area of new age healing horseshit and one that is a perennial joke among my friends, many of whom work in mental health and think this shit is a big eyeroll, and I. The “vagus nerve” is actually two big branching nerves that regulate your parasympathetic nervous system (the cooling one; the activating one is your sympathetic nervous system).

Like many obscure psychiatric concepts that are being chopped up, recombined, and disseminated on social media platforms, the vagus nerve bullshit is based on so-called polyvagal theory, proposed in the early 1990s by a psychologist named Stephen Porges. I’m in a hurry, so instead of going over the components of polyvagal theory and why they’re wrong, I’ll just refer interested readers to this article from last year. TL;DR, it’s a mess in there, a real hash of galaxy-brain evolutionary psych bogus and incorrect neuroscience. Everybody knows this is bullshit, except for Bessel van der Kolk, who everybody loves to dickride because of The Body Keeps the Score. Some day I would like to do a really deep dive into this stuff — the trauma-industrial complex and the suite of associated MLM scams you can enter into to receive “therapies” for diffuse “traumas.” But I’m just one lady being nibbled to death by work, family, and social responsibilities right now and this is a free newsletter — you get what you pay for, at least until I find my Engels.

* Many thanks to Nate Holdren for his feedback on this post. He does a companion newsletter to mine which you can read and subscribe to at: https://buttondown.email/nateholdren.

* Also, a disclaimer at the top: I am no longer affiliated with Death Panel and none of my views expressed in this newsletter reflect the views of the show.

“Catastrophe — to have missed the opportunity.” - Walter Benjamin

A short disclaimer about Death Panel up top: I am no longer affiliated with the podcast. The TL;DR is: my views do not reflect the views of the show, don’t harass them if you don’t like this post. Don’t harass them if you do, either. Basically, don’t harass them at all. If you have any feelings about the podcast in relation to this post, I encourage you to go subscribe to the show, or write an entry in your journal about how much you hate my guts, or both.

The aim of this post is to give you, the reader, some tools to understand what you’re looking at when you see figures and estimates from the Pandemic Mitigation Collaborative (PMC). If you are online at all, you have probably seen these figures and estimates, as I have many times (just in the past few days, I have seen this model cited in outlets as diverse as the World Socialist Web Site, Current Affairs, Self Magazine, and People Magazine). Before I launch into my detailed critique of the model, a few general considerations. In my opinion, it is not “COVID minimization” to want to know the truth about COVID, to want other people to know the truth about COVID, even when this truth is less comforting than fabricated certainty. People have a lot of different ideas, some unconscious, about how scientific claims translate into political or social activity, or change in “the real world.” I think exaggeration and outright fabrication of claims about COVID, its impacts, and the level of transmission currently underway in the country right now correspond to a well-meaning but (in my opinion) incorrect theory of change – the idea that if enough people understand how bad it is, some kind of corrective action will be taken (just look at climate change). If the idea is to use scientific data to develop programs for political organizing, it is crucial to subject the truth claims supported by the data to verification.  Organizing that is built around incorrect interpretations of scientific data is self-undermining, sooner or later. You don’t need to agree with my critique or my analysis, because the point is not that I have some kind of correct answer or magic bullet (one weird trick to solve the pandemic!) that other people don’t. I’m making this critique because it is part of my praxis as a leftist and a scientist to subject scientific claims with political import to scrutiny. That’s it. 

Proper identification of the problem is key to strategizing about the problem politically. “I have to wear a mask everywhere and individually take on the burden of COVID precautions because COVID is airborne HIV and it is surging out of control worse than at almost any time previously” is a different articulation of the political pickle we are in now than “I must always assume the worst and individually take on the burden of COVID precautions because we have only very vague and belated indicators of where the virus is spreading thanks to the federal government’s abandonment of COVID monitoring.” If the idea is to make continuing or reinstating COVID precautions seem reasonable, I think a more effective way to do that is to emphasize the uncertainty people are being forced to live with rather than asserting a false certainty that things are secretly much worse than anyone knows. To be extremely, excruciatingly clear, I have no issue with people continuing to take whatever COVID precautions they can. I even think it’s a good thing to take COVID precautions right now and in general (I’m an epidemiologist, after all!). At the same time, a lot of the precautions discourse (much of which hinges on things like estimates from the PMC model) smooths over how burdensome and outright impossible it is to access “the tools” at this point in time. Masks are really expensive, and people are really broke. I was trying to find rapid antigen tests in the grocery store the other day and straight up couldn’t – four grocery stores, two drug stores, and half a tank of gas later, my friend came through in the clutch with some tests he had at home.  

Finally, I am absolutely not saying that COVID infections aren’t up or increasing right now. From where I live, and from my anecdotal experience, it is clear that COVID is on the rise again. Just how much is unclear, and this is the crux of the problem. I look at my local county health department website and see that cases are increasing in recent weeks, but still lower than cases during this past winter; I don’t know if this is because transmission is really lower, or because more people are asymptomatic, or because more people are doing rapid antigen tests or not testing at all. It’s probably some combination of the three, which is all I can really say – and that is a problem. 

I actually started writing this yesterday morning, before someone tried to assassinate DJT at a rally in Butler County, PA (about a 45-minute drive from where I live in Pittsburgh). I have a lot of thoughts about what this means and what is going to happen from here (none of them involve rosy predictions for the future of the US left) that I am not going to elaborate on. Instead, I’m going to present the post below, which I do think is deeply relevant both for how we think about the recent past and how we should strategize about the future.

I’ve been reading (listening to, more accurately) Vince Bevins’s new book If We Burn: The Mass Protest Decade and the Missing Revolution on the recommendation of a friend. There are several interesting things going on in the book, one of the most bracing being its frank confrontation of something that I have wondered through countless grueling political and organizing experiences: what the fuck are we actually doing here? Bevins examines, obliquely but effectively, the deep structuring effect that social media has had on the mechanics of street protest. (McLuhan is right — the medium is the message. More than that, the medium is the tactic, which in a lot of US left-wing formations and movements has completely displaced the idea of strategy. I’m sure I don’t need to tell you this, I’m sure you’re already familiar with “street contention” — Bevin’s great term — optimized for engagement. I can think of dozens of examples of this but one that sticks out in my mind is the response of the politically and ideologically vague, but vaguely left-wing, American Jewish group If Not Now to the Trump administration’s scandalous mass imprisonment of migrant children in 2019. Pick a target — just about any will do — recruit some people, stage a sit-in, make sure to livestream it, try to get arrested, end the livestream after the arrests.) Related to the replacement of strategy with tactics, I think there is something going on ideologically here as well.

[Here, I had written several paragraphs about my experiences in protest movements and various forms of organizing over the decade that Bevins covers. Maybe some other day, or maybe I’ll save these for another post about Hannah Proctor’s Burnout, or The Romance of American Communism. Hah. I will speak in generalities below; these generalities are informed by the particularities of my experiences which, of course, are not universal. I make no claim that they are. Moreover, everything I criticize below, I have done and taken part in myself. This is self-criticism as much as anything else.]

An idea of Lenin’s runs through Bevins’s book like a golden thread. This idea is usually read through the caricature of Lenin as “against spontaneity” and indeed there’s some truth to that (Rosa Luxemburg ably criticized Lenin’s stance in The Mass Strike). But Lenin is, unsurprisingly, correct. He argued in What Is To Be Done? that, as Bevins paraphrases, spontaneous uprisings will take on whatever ideology is “in the air” around them. (Rosa Luxemburg, as I understand her argument, which it has been several years since I’ve read, asserts — also correctly, in my view — that quasi-spontaneous uprisings are the form of motion of the proletarian masses. Interesting!) This, as Bevins’s book documents in contemporary example after contemporary example (mercifully few of them based in the US), is how big uprisings can create power vacuums, how the incredibly abstract and heterogeneous “demands” that issue from such uprisings are susceptible to appropriation, perversion, and to stunning reversals of momentum and fortune.

Hello everybody, just a quick note at first because there are some new people here. Welcome! I hope you like my silly posts. If you are new to me, I am an epidemiologist (by training), a statistician (by profession, reluctantly), and a longtime leftist (by an inborn tendency to masochism, I guess). I am working on this newsletter as part of a long and open-ended collaboration with Nate Holdren developing a theory of social murder in service of a Marxist analysis of COVID-19 and public health more generally. I am also in the proposal phase of writing a critical book about statistics — the idea, at this point, is that it will teach you some statistics as it simultaneously teaches you to hate statistics. Fun! You may send me distance reiki, good vibes, prayers, incantations, and whatever other psychic tokens you’d like in support of this. Whatever.

I mention these two strands of my “work” not only because there are some new readers here, but because the two converged in a project I worked on in my day job recently. The details of the project aren’t important; what is important is that it was a data analysis related to the surgical treatment of carpal tunnel syndrome. You’ve certainly heard of carpal tunnel syndrome — remember Janice’s carpal tunnel from pulling espresso shots in The Sopranos? I was interested to discover, in the course of the project, that there actually is no “gold-standard” diagnosis for carpal tunnel syndrome.

The carpal tunnel is the name given to the little lacuna in the bones and ligaments, located on the palm side of the hand, that the important “median nerve” passes through to connect the hand to the wrist. Carpal tunnel syndrome is one of a number of so-called “repetitive strain injuries” and is most often caused by — you guessed it — repetitive hand motions that can cause the carpal tunnel to narrow, pinching the median nerve, causing a number of symptoms like pain, numbness and tingling, and in many cases resulting in inability to use the affected hand.

A random book I picked up recently from a used bookshop — Allard E. Dembe’s Occupation and Disease: How Social Factors Affect the Conception of Work-Related Disorders — devotes nearly a hundred pages to carpal tunnel and other “cumulative trauma disorders” (another, more vague, term for “repetitive strain injuries”). I have not finished reading this chapter, but two interesting aspects of the book are already apparent. First — I will take this back up shortly — how the politics of scientific evidence come into play in instances of complex causality. Something like the loss of a finger is causally straightforward. Second, repetitive strain injuries have been recognized since, literally, antiquity (not Hippocrates describing the arm paralysis of a worker long engaged in twisting twigs!). Unsurprisingly, repetitive strain injuries of the hand, wrist, and arm exploded with the industrial revolution and corresponding increases in repetitive, mechanized factory work and also the associated clerical work required to do capitalism. “Writers’ cramp”: worse than it sounds.

Good evening, sickos. I hope Pride month has been treating you well and that everybody is staying relatively safe out there. I am (finally!) firmly into the heave-ho portion of trying to get two big writing projects off the ground; it’s going well, but it eats a lot of time even as it gives me a lot of good ideas for shorter newsletter posts and things like that. As part of this reading, I’ve been deep in Foucault on biopower and population for the fifth or sixth time in my public health career. (Nate wrote an excellent post touching on biopolitics here.) I want to get through the minimum about of theory necessary, as quickly as possible, in order to get to my point.

Basically (and this is very hard to summarize because, as a friend of mine recently put it, Foucault’s “archeological” method means that the history is the argument, which makes it almost impossible to extract terse little nuggets of insight from his texts or lectures) Foucault charts a “dual seizure of power over the body” in the seventeenth and eighteenth centuries. The first movement he traces is what he calls disciplinary power, a power of the individual body. Schools, prisons, barracks, hopsitals… all the classic Foucauldian disciplinary institutions have as their goal the inscription of control in the smallest movement, the most minute gesture. In school, you are being disciplined to sit quietly for long periods of time, to look like you’re paying attention (even if you’re not — I know most people can relate to this). Discipline and Punish, his book-length treatment of this phenomenon, spends as much time on the extreme exactitude of the techniques of French military training as it does on enumerating the exquisitely barbaric medieval tortures corresponding to the right of the sovereign (the monarch) to take life. Foucault eventually (in a series of lectures at the Collège de France in the late 1970s) calls this an “anatomo-politics of the body.”

He also charts another kind of power that emerges a bit later, in the second half of the eighteenth century. This type of power is not disciplinary, it is regularizing. It’s not concerned with disciplining the individual body, optimizing the productive discipline (for education, for industrial work, for martial purposes) that can be wrung from an individual body. This type of power doesn’t care much about the individual body at all; its object is, instead, the population, the mass of individual bodies. This type of power sort of lets the chips fall where they may in terms of what happens at the level of this or that individual body; its explicit concern is the management of the population at the population level — birth rates, endemic illness (Foucault has a really interesting digression on epidemic vs. endemic read through these modes of power in one of his lectures that maybe I will write about one day), death rates, and so on. This is biopower.

Biopower doesn’t replace disciplinary power. Foucault stresses that these two are complementary, they exist at different levels (the individual body vs. the “social body” of the population) without nullifying each other. That much seems clear. The way Foucault describes the relation between the two forms of power is interesting: he describes biopower as “infiltrating” and “permeating” disciplinary power.

There was a bit of Discourse today about COVID mortality reporting and what — if anything — it means that we are currently in a trough of COVID deaths, with weekly COVID deaths at their lowest point since the beginning of the pandemic in the USA in March 2020. The Discourse issues from the altogether predictable confusion about what the hell is still being tracked or reported as far as COVID indicators. A lot of people know that huge components of COVID surveillance have just been straight up nuked and discontinued, most notably electronic case reporting (aka “transmission” or “case” data); the changes to data reporting and presentation have been rolled out in the most confusing and befuddling manner possible (this, I think, is half on purpose and half down to typical bureaucratic bullshit); and people aren’t really trusting that official figures capture the true state of the pandemic anymore. That is all valid and true. However, death reporting has basically not changed, even with the end of the public health emergency (PHE) last May.

The federalized system of death reporting in the USA sucks and I’m not here to defend it. (You can read a previous edition of this newsletter where I talk about how much it sucks in detail, with regards to perinatal death or “maternal mortality,” here). Nevertheless, the process for death reporting remains much as it always has been — not great, but almost certainly not hugely and systematically undercounting COVID deaths. I will tell you why.

When someone dies, a death certificate is filled out, typically by a physician, a medical examiner, or a coroner. (There are lots of issues here that I will not get into, just know that this means that there are wildly different processes for completing death certificates at the level of an individual death and they aren’t all equally good or accurate.) Part of the death certification process is listing contributing causes of death on the death certificate — also an imperfect and uneven process that I will touch on briefly in a moment. I won’t pretend to be an expert on the ins and outs of cause of death certification, but there are guidance documents from the National Vital Statistics System (NVSS) on COVID-19 death certification, including an expanded guidance document about accurately certifying deaths related to Long Covid. Once a death certificate has been completed, it is transmitted to the state vital statistics office, which then transmits it to the National Vital Statistics System. This is how we get death data for all deaths, due to COVID or otherwise.

This process has not changed. Although, one would be forgiven for thinking that it has. The CDC itself, always with its finger on the pulse of what would be maximally confusing to the public, really made it sound like reporting had changed. They did this by touting their “new metrics” for COVID mortality data presentation (which is not in fact a new metric, but rather a maneuver in data abstraction — COVID deaths are now presented not as raw numbers but as a percentage of all total deaths in the country, clearly a move to make it harder for someone looking at the CDC website to understand whether COVID deaths are high or low right now) and using a flurry of confusing language to make it sound like they had revamped death reporting to be some cool new process.

[Note: what follows is my Gravity’s Rainbow, a metatextual meditation on the subject of entropy… my fancy way of saying that it starts fairly structured and then degenerates into a lot of notes and questions I’m asking myself. One of my personal purposes for this newsletter is to let go of perfectionism and just put stuff out there even if it’s unfinished, tentative, sketchy, or otherwise imperfect. So, that’s what’s happening with the marked shift in tone and deterioration of the prose structure after the block quote towards the end.]

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For some time now I have been vaguely alluding to the  “discursive power of data” (I think we can all agree that data and numbers do have something like “discursive power”) and trying to locate its origins somewhere in the productive structure of the real economy, i.e., being a good little Marxist. This strategy has been unsatisfying, because it limits the discursive power of data to a ratifying or legitimating role vis-a-vis some kind of ideology that is encoded in and enacted through the productive structure. Now, however, I think I have been focusing on the wrong aspect, and I have (record scratch) Jean Baudrillard to thank for that. In thinking so much about the social construction (production) of data, I have been trying to link the social processes of data construction with the various functions that data perform out in the world, but sort of missing the bridge to be able to do it. Is it because statistics is eugenicist? Not exactly. Is it because of “methodological individualism?” Also not exactly. All to say, in thinking so much about the production of data, I have neglected to think about its consumption. Borrowing some language from semiotics and a lot of conceptual framework from Baudrillard, I want to venture the hypothesis that the discursive authority of data issues from the sign function of data and its operation in the symbolic logic of consumption.

This is not a base/superstructure argument. The symbolic economy and social logic of consumption (which Baudrillard develops extensively, and which I will not recapitulate here) is not some kind of epiphenomenon of the productive economy; rather, production/consumption are two chambers of the same heart, two aspects of an organic whole. To borrow from Ursula Le Guin, consumption is the “left hand” of production. Here, social and psychic logic operate according to the code of signs. (In semiotics language, the sign is the atomic unit of meaning composed of signified – a thing itself – and the signifier – the concept referring to the thing.) The meaning or value of signs depend on their relationships to other signs. Signs perform particular “signifying” functions within the symbolic and psychic logic of consumption – this is one of Baudrillard’s major (early) hypotheses.

As you probably know by now, I do this newsletter as part of a tandem project with Nate Holdren, one of the aims of which is to develop a concept or theory of social murder adequate to explaining, in general, the role of capitalism in shaping population health, and in particular, the COVID-19 response. As part of this, Nate has been encouraging me for awhile now to do a post on what exactly public health is. This post is going to be one approach to this idea, an attempt to explain what public health is, but in a peculiar and hopefully interesting way.

Of course, public health is a lot of things — a public service, a complicated federalized bureaucracy, a private academic discipline, a vibe, an ideology, a loose constellation of methods. I have seen the serviceable analogy that medicine is to the individual body as public health is to the social body. What I want to address, primarily, is this interesting characterization along the lines of “individual vs. collective” orientation. The heuristic dualities here break down into public vs. private, collective vs. individual, social vs. biological, and so on. I want to propose something a little bit different: that the “individual/collective” framework actually flattens out the different levels of structural organization within which complex social phenomena play out.

Capitalism and the population distribution of disease or debility are both emergent properties of human social interaction and organization; they emerge, however, at a level above the individual, in the realm of the social or the collective or whatever you want to call it. This is absolutely different from a mindset orientated towards individual or collective phenomena, which is what people almost always mean when they bellyache about “individualism” getting in the way of public health (not hating, I’ve done my fair share of such bellyaching).

Population health is emergent at a higher level of social organization than the individual or groups of individuals — at the population level. Public health is, supposedly, the technocratic field that “manages” (but in actuality, usually ratifies) the population distributions of health and disease. “Social murder” can then be said to characterize the form of population health under capitalist social organization, what Tony Smith calls “dissociated sociality.”

As part of my recent exposure to continental philosophy, I just read Hegel for the first time ever. I am going to try to sketch through a vague idea that I had reading part of the Phenomenology of Spirit (which, by the way, I loved, because and not in spite of its crabbed incomprehensibility). I’ve read a lot of Marx in my life, which definitely made it easier to grasp Hegel’s method and structure — the Phenomenology of Spirit is an incredible, four-dimensional work, the three-dimensional, spiraling aspect of the dialectical method, plus time. In Marx, and in Hegel, the phenomena under investigation are processes, always in motion, developing in accordance with their essential internal tensions and contradictions. There’s really no wonder biologists love both Hegel and Marx so much; there’s something very organic about investigating the “totality” of a given system this way.

One “moment” in Hegel’s dialectical investigation involves the development of self-consciousness, which he posits not as a property that people have or don’t have but as a process of mutual recognition by and of others. These helices of Aufhebung are all over Marx as well, most strikingly (to me anyway) in the concept of value. In Capital, value is a property of commodities that is realized when privately-undertaken production is socially validated through the process of exchange.* (The dialectic never stops, of course; value the resolves the internal tension between the use-value and exchange-value of commodities but further internalizes a contradiction between concrete and absolute labor, which is further resolved… and so on.)

This makes very clear, on a deep level, von Hayek’s insight that markets are mechanisms of transmitting information. Exchange is how you “know” the value of whatever you’re selling. I have mentioned it in this newsletter before, but von Hayek is actually responsible for the idea of the first neural net, which was supposed to approximate the action of a market, not of a human brain. (The brain is the metaphor for the computer, not vice versa.) Which brings us, of course, to cybernetics yet again. We, as a species, keep inventing (or realizing, or manifesting, as with capitalism itself) variations on the cybernetic idea — distributed nodes, self-organization, feedback, control. There is something super seductive about self-organization and homeostasis as a metaphor across distinct disciplines and domains of human social organization. Consider again Hegel and biologists — entelechy, self-organization, dialectical movement and relation of parts to wholes, all much more intuitive and appealing than linear, mechanistic, reductionist explanations.

People are liking this lately, these metaphors referencing the self-organization of nature, and I don’t think that this is without meaningful content. I was going to write a whole big thing about why Emergent Strategy (a self-help book incorporating many of these cybernetic metaphors from nature) is WRONG. But I actually think it’s much more fruitful to explore why these metaphors are so widely appealing. Why do we keep inventing and iterating on this idea, again and again? What if we understood capitalism as the deeply weird psychic thing that it is — yet another manifestation of this cybernetic impulse, arising (emerging) from human social relations at a higher level or organization (planetary, trans-national), this almost God-like (or Geist-like) thing we all participate in making without wanting to. Marx’s mystical language doesn’t seem so silly from this vantage.

I’m reading a lot more continental philosophy lately than I ever have before (I know — I know. I know!) and been having an interesting thought about epidemiology and the practice of science that I want to share — mostly because I’m genuinely not sure what I think yet, and on top of that, I don’t really know enough yet to begin to determine what I think. The basic idea is this: epidemiology as it is taught and learned is basically a deconstructive project. This is distinct from how epidemiology functions in the social and political spheres. I will try to illustrate with an example that I am actually capable of handling — Derrida is like Beetlejuice, I’m afraid to invoke him directly too many times for fear he’ll jump-scare materialize behind me in a striped suit.

The best part of science education is the venerable institution of journal club. In my opinion, we don’t do journal clubs nearly enough, which is to say, we don’t do nearly enough close-reading of scientific texts. My original home discipline is biology; journal clubs in biology are a lot of fun. Journal clubs in epidemiology are much more rare (not surprisingly — very boring managerial discipline lurching hard into Vox-style smug irrelevance post-2020) but when they’re good, they can be really good, for a really specific reason.

The way I usually like to think about things in my field is: “data are compatible with multiple states of reality.” Developing the intuition necessary to imagine what these states of reality might be and how they might have converged to produce the data collected and analyzed in a given article is the real work of journal club — epidemiologic critique as tacit acknowledgment that there is no interpretation of a given piece of data analysis that closes the interpretive act for good, or brings the process of interpretation to a definitive end. Iterative and open-ended critique of a given journal article is supposed to excavate, like dusty buried artifacts, not only the investigator decisions (implicit or explicit) and values structuring the analysis, but also the stuff lurking out there in the “real world” that may explain a given set of findings better than the authors’ interpretation or cut against the interpretation supplied. (From the Wikipedia page on deconstruction: “Derrida refers to the — in his view, mistaken — belief that there is a self-sufficient, non-deferred meaning as metaphysics of presence. Rather… a concept must be understood in the context of its opposite.”)

There’s a lot to deconstruction and I am simply not pretending I know. I don’t know shit. Just want to be very clear about that, because a lot of what follows is over my head and maybe sounding even more addled than the rest of this post. But considering deconstruction in the technical sense, we have to consider also what the binary opposition at stake in journal club is. To my mind, it’s something like “real/not real” or “true/not true,” pertaining to the findings or overall declarative statement about what a particular paper “shows.” This opposition can never be definitively resolved or synthesized, and in fact the two sides of the binary are sort of mutually haunted by their opposites, as illustrated by the sheer number of epidemiologic findings that seem to be both true and not true simultaneously — for example, are coffee or wine supposed to be good or bad for you? What’s the consensus this week?

One of the purposes of this newsletter is to work through some theoretical materials to excavate whatever in them might be useful to developing a more sophisticated structural account of the failures of the COVID pandemic and response in the United States. To this end, I finally started reading Tony Smith's Beyond Liberal Egalitarianism, a favorite recommendation of Nate's.

I don't think anybody is on the edge of their seat waiting for it at this point, but J*stin's and my planned book about COVID is not happening anymore. One of the rocks we dashed ourselves on is: what is the appropriate level of analysis of the general social structure as concerns COVID and the COVID response? He wanted to focus much more on a retelling of the Merchants of Doubt story, adapted to the pandemic, chronicling the corruption of various governments and scientific advisory bodies, the distortions of the scientific process and its outputs imposed by well-funded private interests, and how these things, combined with a lack of organizing among scientists and the susceptibility of the scientific community to reasonable-sounding bad ideas (like those advanced in the Great Barrington Declaration), ultimately undermined the pandemic response.

I, on the other hand and controversially (?), wanted to focus on the structural overdetermination of the failures of the pandemic response. By which I mean: by digging into the history of public health, its roots in the industrial revolution and its inseparability from the "abstract social logic of capital," its individualizing and managerial ethos, and how the structures and imperatives of capitalism shape knowledge production as well as the politics of social coordination and emergency response, I wanted to show how little there was (by way of some kind of robust, democratic organization of science at the societal level) to undermine. I wanted to show how the pandemic response was rotted from the inside out rather than subverted by a handful of malevolent actors -- in my view, this more than anything else explains how the Republican and Democratic presidents of two different administrations overseeing the pandemic response converged on essentially the same set of policy actions, just glossed with different rhetorics (but not that different, at the end of the day), although both stories are obviously true and complementary at different levels of analysis and different levels of social organization.

In any case, an interesting and not altogether encouraging thought struck me reading through Chapter 3 of Smith's book. This chapter is devoted to placing liberal egalitarianism and Marxian theory in some kind of dialogue or juxtaposition with each other to illuminate the mutual misunderstandings in each approach's view of the other. As Smith writes (p. 64):

Good evening, sickos. I am preparing to record an episode of Death Panel duck-hunting Sandro's new-ish book, Within Reason: A Liberal Public Health for an Illiberal Time. It's a doozy, not in the sense of being packed with ideas but in the sense of being one of the worst books I have ever read in my life. It fails on every level as a book (at the level of idea, the level of argument, the level of prose). Big ups to the University of Chicago press for binding a bunch of this man's toilet paper scribbles (blog posts) into a book and selling it to rubes and bitter bitches like me. Anyway, I wrote some rambling notes on the first parts of the book as a way to get back into it and jog my memory for recording. These are just notes, please don't hate me because they're sketchy and full of block quotes. I'm trying to synthesize the common threads that make this so shitty and so of a piece with what passes for thinking about the pandemic in my cursed field... but this is not that. Proceed with the knowledge that this is raw process!

Big thoughts

• He managed to write an entire book about “liberalism” and “public health” without once advancing a serious definition (let alone a serious thought) about either

• … Because UChicago Press paid him to print out and bind some of his ice cream brain blog posts. I guess this is the level of COVID analysis that publishers (the public??) are looking for. 

• The unifying theme is how hackneyed and fucking irritating he is while saying absolutely nothing at all. 

• He loves to talk about “marginalizing forces” and “disparities” and “structural determinants” but doesn’t ever complicate the narrative – that liberalism itself is one of these marginalizing forces and structural determinants. (I’ve skipped several grade levels over Sandro here)

• He doesn’t even aspire to internal consistency. 

  • “Narratives” – are they good or bad?

• Overidentifies public health with “Enlightenment science” which is just wrong. The techniques of public health were not developed in the enlightenment. Public health itself developed during the industrial revolution. Was this a time of flourishing liberalism? No. This was a time when the contradictions and weaknesses of liberalism were exposed. 

• Does liberalism transcend time and place? According to Sandro, both yes and no. (Because he’s too fucking dense to be bothered sorting it out.) He takes pains to let us know that racial justice and other forms of social justice are important to liberalism – which is decidedly not true of many, many episodes in the history of liberalism. The liberalism of the Enlightenment is not the same thing in any way as the liberalism of today. But public health is failing because we’ve forgotten our “liberal roots” and Enlightenment values (reason?? Whose reason and who decides?). 

• It’s crazy this book got published because the basic thesis of it is so fucking confused. 

• He wants the nice parts of liberalism but none of the nasty parts. He doesn’t even know there are nasty parts. He’s allowed to do this because he’s a Spreadsheets Doctor, nobody expects him to know anything.

• Phenomenology of reading this book: despair. This is what passes for serious scholarly discourse in my field. It makes me want to KMS. 

I'm currently preparing to record an episode of Death Panel about my most important niche interest: counting deaths in pregnancy and postpartum. This is in the news recently due to a new study in the American Journal of Obstetrics and Gynecology (hereafter AJOG) entitled "Maternal mortality in the United States: are high and rising rates due to changes in obstetrical factors, maternal medical conditions, or maternal mortality surveillance?" This study made the news because it purports to show, contrary to the popular narrative, that the rising rates of perinatal death we've been hearing so much about are not real increases, but rather artifacts of inaccurate perinatal death surveillance. It has been known since at least 2018 that the current method used to count these deaths is inaccurate and likely inflates death counts. The CDC pushed back on the study in a characteristically confusing way, taking issue with the alternative methodology the study's authors used to count perinatal deaths (known to result in substantial undercounting), even as it acknowledged that its own current method of counting results in overcounting.

So what's going on here? Indulge me as I pull back the veil on the social construction and social life of mortality data before getting into some more general (and more interesting) theoretical considerations. It all starts with the system of death reporting in the US. Death reporting is done at the state level; local officials or health authorities typically fill out death certificates then transmit those death certificates to the state vital statistics office, which then forwards them along to the National Vital Statistics System (NVSS), which tabulates mortality data from the whole country.

Accurately reporting pregnancy-related and pregnancy-associated deaths (more on the difference between these two presently) has been a huge challenge for the United States, even though it ain't rocket science to count deaths in pregnancy. The UK, for example, has a prospective obstetric surveillance system (called UKOSS for, straightforwardly enough, the UK Obstetric Surveillance System) that works very well. Not so in the US, which had problems harmonizing state-level mortality rates due to state-level differences in death reporting practices, especially around pregnancy. It was known through the 1980s and 1990s, furthermore, that the NVSS was severely undercounting pregnancy-related deaths. To remedy this problem, a so-called "pregnancy checkbox" was added to the 2003 Revised Standard Death Certificate. The purpose of the checkbox was to indicate whether the decedent was pregnant at the time of death or within 42 days of death (42 days post-delivery is the arbitrary cutoff we use to bracket the "postpartum period," although very good arguments can be made -- using so-called "late" pregnancy-associated deaths -- that this restriction leads to undercounting).

States didn't all adopt the revised death certificate at the same time, however. The US was unable to report a national maternal mortality rate (embarrassing, tbh) between 2003 and 2017 due to staggered adoption of the new death certificate across states. It is well-known that the checkbox estimates overcount perinatal deaths (this was highly publicized in Texas in 2018). Despite these issues, every state is now using the death certificate with the checkbox, so NVSS is once again able to tabulate national perinatal mortality rates. The results have been grim. NVSS documents a near-doubling of the already-high perinatal mortality rate from 17.4 deaths per 100,000 live births in 2018 to 32.9 deaths per 100,000 live births in 2021, with these overall rates masking emergency-level rates among Black and Indigenous women -- for example, 70 deaths per 100,000 live births among Black women that same year. For comparison, national perinatal mortality rates in the UK (not even one of the countries with the lowest rates) are on the order of 7-8 deaths per 100,000 live births annually. (COVID was definitely related to this increase, with 2021 appearing to be a high-water mark; provisional data seem to indicate these rates coming down, ever so slightly, in 2022.)

Hey everyone. I really am sorry. I am doing a really shitty job keeping up with this newsletter, and it hasn't really been because I'm busy, but more because I'm struggling to have thoughts that feel interesting. It has been a year of a lot of inner turmoil (and growth!), I guess I am busy, but busy with non-remunerable life stuff that doesn't scan as real to anyone in our capitalist hellscape. (Sidebar: I saw a pastel-colored pop psych infographic about "internalized capitalism" and its symptoms today.)

Maybe internalized capitalism isn't as silly as it sounds... maybe it's just alienation, in the psychological sense or the phenomenological sense (the feeling of being alienated) rather than the strictly Marxist sense of the products of my labor being alien-able from me. The container for all my tedious crises and upsets, the big nesting doll that holds them all, is my journey through and out of academia, which is to say my journey of identity dissolution, formation, and dissolution again. This is why I don't have any good ideas right now. Since I am no longer an academic, I'm no longer subjectified as an ideas-haver. There's no nice sticky matrix of connective tissue holding me in relation to other people who are thinking, or writing. I've only been spiraling one way, inward, away from people and the kind of intellectual exchange that keeps the little flame burning. I feel like I have a gray heap of cold, spent embers right where my diaphragm is.

I was so fucking good, as an academic. I was also killing myself in a million ways, and the killing myself was what made me so good. I was bright, original, overflowing with great ideas, and diligent enough to execute a fair number of them. What happened to me? I got disenchanted. I was always pretty disenchanted with the system of academia. I got disenchanted with the work itself, the only kind of work I have ever really loved and wanted to do. It was starting to happen pre-2020. You allow yourself to question what one psychometric scale or Census-derived social inequality index is really measuring, or what regression models really are, and heretical thoughts start creeping in. What really did me in, though, was obviously COVID, the spectacle of all of it, how eager I was to be a dog in everyone else's fight (I think this was a good quality for some very worthwhile COVID fights, but is a trait I would like to get better at recognizing in myself so I can counter it as far as day to day operations of living are concerned).

One of the minor tragedies of this journey for me is that COVID intensified the heretical thoughts, and for a time, it seemed like -- for the first time ever -- somebody was listening. Original thinking of any kind in epidemiology is flatly unwelcome; we are to memorize the Healthy People 20XX objectives, complete the modules, perform the rote statistical operations, compose the awkward papers, try to get some money, and repeat. Suddenly, everyone's eyes were on my field, and it turned out I had a valuable perspective to share that people wanted to hear. For a moment. This is where the Marxist sense of alienation comes in. I'm a big dumbass, tweeting all my good thoughts, because good thoughts are free and should be shared. Or so I thought. Good thoughts are also alienable, and time and time again, it has been demonstrated to me that my ideas are desirable and productive -- and even more so when they aren't attached to me but rather free-floating, Vogelfrei, appropriable by anyone with some institutional credentials to just plug-and-play in their templates for doing equity-focused research or whatever the fuck.

Before 2020, nobody knew what epidemiologists did -- I can track the normalization of COVID-19 by the number of people who, upon meeting me, ask if that's like, some kind of skin doctor or something. The beginning of the pandemic was a weird, sudden intrusion of everyone in the world into my cozy little academic space. A similar thing happened last year around this time in a very different corner of my life. The reality show I had religiously followed since its 2013 debut suddenly became national, even international, news following the spectacle of a cheating scandal among the cast members. The Scandoval, while pretty run of the mill drama for Vanderpump Rules, took over the actual news cycle for awhile and catapulted the cast members into realms of fame they weren't ready for. Tom Sandoval, the titular cheater, became (as a days-old New York Times magazine cover story put it) the most hated man in America. Rachel Leviss, his affair partner, was skinned alive in the media, by her fellow cast members, and in every possible public venue and wisely checked herself into a trauma treatment facility in Arizona. And Ariana Madix, who Tom Sandoval cheated on, has been rather puzzlingly lionized and showered with lucrative career opportunities, doing sponcon for real brands now (like Glad and Lay's and Uber Eats) and playing Roxy Hart on Broadway.

Just to get things out of the way, I am Team Rachel to the core. Yes, she did a bad thing. But it's a bad thing that has to be understood in its proper context. It really is Tom Sandoval's MO to scoop women up right out of deeply abusive relationships and kind of love bomb them (Rachel had been engaged to a very volatile cast member, an alcoholic DJ named James, for a long time). In fact, this is what he (Tom) did with Ariana, the woman he would later cheat on: it was a major plot point for several early seasons that Tom Sandoval cheated on his previous girlfriend Kristen with Ariana; he and Ariana both, as a united front, spent years (literally years, on national television) calling Kristen crazy and dragging her name through the mud. This is just scratching the surface of the reality TV drama in the background here, but these swirling questions of guilt, responsibility, and atonement are what make Ariana's utterly imperious attitude towards everyone so hard to take. Everyone who has ever been on Vanderpump Rules is guilty of the exact same behavior (and worse -- remember when Jax tried to dump Laura-Leigh moments after her Narcotics Anonymous meeting?). What has made the show work for all these years -- some years better than others -- is that there are no lines in the sand, no untransgressable boundaries, and really no consequences for any of these folks' incredibly fucked up and harmful behavior towards each other. (Keep it coming, I do not care about these people or their lives except insofar as they want to debase themselves for my entertainment!)

It might seem like kind of a curveball to bring in 19th century Russian literature at this point -- but hear me out. I've been working my way through The Brothers Karamazov for the last few months. I suppose it's my One Big Book for this winter (I always have exactly one every year). I've read it before but it was a long time ago; now, as a grownup, I'm really struck by how hilarious and real it is, and how funny and idiosyncratic Dostoevsky's sensibility is. He has an incredibly sympathetic knack for seeing the absolute transcendence at the heart of even the most degraded and ridiculous human drama. I think he would have absolutely loved Vanderpump Rules. I also think he would have loved really miserable airport travel -- the more delays and the bigger the crowds, the better -- for the same reason. The depths of human wretchedness and the heights of human transcendence are one and the same. A phrase that recurs throughout the book is "for all and on behalf of all," from the Russian Orthodox liturgy, meaning that we are all guilty of all the world's sins, in front of God and everyone. What this really means is that we are all really connected, we are all responsible for each other. This idea recurs again and again, in the words and actions of different characters, from the monk Father Zosima to his disciple, young Alexei Karamazov, to the group of schoolboys that look up to Alexei, to Grushenka, the "fallen woman" common to Dostoevsky's works, to Dmitri Karamazov, accused of patricide.

I have been trying and struggling to write an essay about Emergent Strategy and what rubs me the wrong way about it. Writing this just now has clarified one thing. We are all connected, we do all share in each other's guilt and responsibility. In Emergent Strategy, this idea hinges on a worn-out appropriation of the concept of a fractal. Because fractal objects are self-similar at different scales, the author argues, this is also how reality actually is, and small actions are the same as big actions -- e.g., being in an annoying workbook polycule and intentionally trying to form "Liberated Relationships" is exactly the same thing as political work and urgent struggles for justice on the macro scale because "micro is macro."

Let's see... can I write about the second chapter of this book in a fun and engaging way?

Nobody wants to look at the hole COVID blew in our collective psyche anymore. Boo hoo for me. You could analogize it to Walter Benjamin's angel of history; I would analogize it more to trying to outswim the sinking Titanic (like COVID itself, another smashing success for capitalist society).

Here's a general summary of the first chapter of this book, at least up to the part that I find really interesting (there's more, a four-part typology of different types of ideologies, that I will cover later).

• Subjectivity refers to acting as a subject in a given context; it is not the same thing as personality.

• Ideology interpellates human beings as subjects. This is Althusser again, who describes ideology as a "quadruple system" of 1. interpellating individuals as subjects; 2. subjecting them to the big-S Subject (like God, or the king, that kind of thing); 3. facilitating mutual recognition between Subject and subject, subject and subject, subject and self; and 4. "the absolute guarantee that everything is really so" (Therborn's words). Althusser's system can be summarized, tersely, as interpellation-recognition and subjection-guarantee.

• Keeping Althusser's concept of interpellation-recognition (following from above), Therborn modifies the description from Althusser's original subjection-guarantee to subjection-qualification. Subjection to some kind of ideological discourse process in turn qualifies the subject for various kinds of roles.

Happy New Year, everybody. I'm looking forward to getting back into some heavy theory posting and navel gazing in 2024. To ease us all back in, I'm sharing the short essay I wrote about the Netflix series Goop Lab back in February 2020. It's interesting to revisit my perspective on this after... the events that transpired in the rest of 2020 and subsequently. Hope you enjoy!

What condition my condition is in (02/10/2020)

A few weekends ago, I gave into peer pressure and morbid curiosity and queued up Goop Lab: the Netflix series by Goop, Gwyneth Paltrow’s “lifestyle and e-commerce” company. I knew very little about Goop, except that they sell really expensive stuff, that they were sanctioned for making unsubstantiated medical claims about their infamous jade vaginal eggs, and that the promotional image for the show was hilarious. The show consists of six short episodes, each featuring a wellness trend, treatment, or subject. Every episode is hosted by Gwyneth Paltrow and Goop “chief content officer” Elise Loehnen, who has the screen presence of a stunned hostage. And in each episode, a trim, young collection of fresh-faced Goop staffers try out the featured treatment, exercise, or experience. If that doesn’t already seem like a potential HR nightmare, the show adopts a “monster of the week” format where the monster in each episode is the personal trauma or health struggle of someone that Gwyneth and Elise directly employ.

Just a quick introductory note -- this is an essay that is no longer going to appear in the publication it was scheduled to. Everything is fine, but since it's now sort of Vogelfrei (winking emoji) I'm just posting it here for all of your enjoyment. The idea is for this to be one essay of a series of length n summarizing a Marxist theoretical intervention that isn't explicitly related to the pandemic, and trying to use it to "think with" the concept of social murder we are developing. I hope you like it.

Thanks to the catastrophic experience of the COVID pandemic, Friedrich Engels’s obscure concept of “social murder” has enjoyed a small renaissance in some corners of the academic literature and discourse since 2020.  Ironically, as COVID has made the concept of social murder – which my colleague Nate Holdren describes as the “depoliticized mass killing of working people” and which Engels described as the death produced by placing working people in the position where they can neither survive the conditions of work, nor survive on the wages paid, nor survive without wages altogether – more popular, its inner mechanisms have become more and more depoliticized, mystified, and naturalized. Currently, provisional weekly death counts associated with COVID-19 – if you know where to find them – suggest lower levels of death relative to previous years. We are still, however, almost totally in the dark about transmission of the virus, and therefore of the general level of risk, following dismantling of testing infrastructure and associated reporting systems. 

The highly unequal distribution of COVID mortality drew a bright, highlighter-yellow line under other health inequalities in the United States, and further suggests some kind of structural explanation rather than the individualist-lifestyle attitudes many of us hold about health. But leftists and leftist formations in the US have largely not investigated this from a structural perspective, nor made any concerted attempt to develop a coherent analysis of the biggest mass death event in living memory. A recent book by Søren Mau, Mute Compulsion: A Marxist Theory of the Economic Power of Capital while not intended to address or make sense of either social murder generally or COVID specifically, is promising in terms of developing an actionable critical analysis of public health, the pandemic, and the catastrophically failed pandemic response. Specifically, Mau’s concept of economic power can help us make sense of several episodes in the pandemic in ways that mainstream explanations, focused on the cultural and ideological correlates of individuals, simply can’t. 

Recently on Death Panel we did a loose episode on AI in healthcare, inspired by the class action lawsuit against UnitedHealth over the use of its algorithmic tool "nH Predict" to deny coverage for post-acute care. What follows are my notes for that episode -- so if you listen to it, some of the points will be familiar. These really are just scratchy notes, not organized or edited at all, but perhaps interesting as I/we continue to develop critiques of so-called "artificial intelligence."

Distinct strands:

1. The Life and Death Committee

2. Overdose risk scoring/prescription drug monitoring programs (PDMPs)

3. UnitedHealth scandal and lawsuit

4. Other developments in health care

5. "The Gospel," the IDF's AI-enabled target-production system

What unites all of these?

I've been listening to too much Ram Dass, because every time I think about sitting down to actually finish writing this, I immediately think "yeah, but who am I?" And then I don't do it. Everybody thinks they're somebody doing something. What the hell does it matter?

My birthday just happened, late in October. (I am now 35, apparently my "karmic year.") This makes me a Scorpio; according to the system of astrological correspondences in the tarot, my birth card is Death. Death can signify literal, biological death, as it seems to in the opening sequence of Cléo from 5 to 7.

As I have been working on a draft of something else, I have been thinking a lot about the explanations available to us for sense- and meaning-making around the pandemic. I have also been preoccupied with the uses of different kinds of explanation, and the difference between explanation and analysis (or in Jungian parlance -- apparently -- explaining vs. explaining away). Most of the explanations and narratives coming from the right about COVID are obviously bogus, and I won't spend time on them here. The explanations coming from the center, the great American ideological mainstream, are also obviously bogus; interesting in the social function they are supposed to serve, to exculpate and even celebrate the Biden administration, but little else.

What I'm most interested is leftist accounts of why the COVID response was such a disaster. These can be explanations, intended to make meaning by fitting the events of COVID into some narrative structure, or analyses, intended to illuminate the what and why of the pandemic and see what can be excavated in practical terms to inform organizing strategy. For our purposes (as... a left), I think the analytic approach is the right one. I have spent too much of my own life on dissipative tactical campaigns that are completely misinformed and misguided as to the nature of the problem. For example, I was once directed to canvass every house, without a plan, in a given municipality to get signatures in support of Medicare for All to take to the mayor of the municipality to try to get a resolution in support of Medicare for All passed. Needless to say, this is bad strategy and I did not comply.

The stakes are similar with COVID. Insofar as the left overall even seems interested in learning what can be learned from the most cataclysmic event in recent memory, the thinking seems to always redound to vagueness and hand-waving about "capitalism," or if the speaker wants to show their sophistication, "racial capitalism," "interconnectedness," "organizing." (Something I've just realized, we use "redound" on the podcast all the time but we're using it in a very archaic sense). One explanation that is superficially convincing and not altogether wrong -- and one that I myself have devoted substantial time to developing -- is that what happened with COVID is essentially a replay of the events covered in the book Merchants of Doubt. For anyone who isn't familiar, this is about how scientists allied with industry groups to distort the process of knowledge production in order to create false debate and the illusion of uncertainty on matters of public import, principally the dangers of tobacco smoking and climate change.

This was, undoubtedly, part of it. A very interesting part at that, specifically for what analysis of something like the Great Barrington Declaration can teach us about science under capitalism, how knowledge is made and disseminated. As a global explanation for the disaster of the pandemic response, though, I'm not sure it's comprehensive enough.

Greetings! Happy Halloween! And apologies for the long interval between newsletters. Further apologies that this one isn't a very heavy hitter. The reason for all of it is that I was out of town for a week recently -- ever since the pandemic started, traveling is even more vexing and exhausting than it was before, and I'm fighting for my fucking life here trying to get back on some kind of track. So it goes. I went to Austin, TX, because I used to live there and haven't been back since pre-pandemic.

It's wild. Austin is a really interesting place. Here's what I noticed on this trip:

• The volume and color contrast on everything are just sort of turned up. More people, more stuff, more kinetic energy...

• More franchises. Austin is blessed with an incredible "food scene," and many, many, many of the restaurants that were new and just opening up when I lived there have mushroomed into gigantic franchise operations. We went to a Ramen Tatsu-Ya at South Congress and Slaughter (this is very far south and remote from the original location in north Austin), one of several franchises. There are a couple of Easy Tigers too. Just a few things I noticed.

• Ugly box condos everywhere. Even more of them. Austin is, if not the ugly apartment complex capital of the world, a close second or third to Dallas or Houston. Previously quiet and "undeveloped" areas are now covered with big, hideous condo developments.

• Everyone and everything I care about/am involved in has spun out to farther and farther reaches of the city -- the center is too molten, nobody can afford to even get close to it anymore. So that when I was there I was renting in Travis Heights and on the east side, but now most people are far south or far north. (North/South is the most important Austin axis, because the city has not invested at all in adapting infrastructure to the feverishly growing population, and traffic on the two major north-south arteries, Mopac and I-35, gets even more unmanageable and disruptive every year).

• In spite of this and all the other horrible, intractable problems with the city that I haven't even mentioned... it's still fucking great. The vibes are still good. The food is still amazing. Time moves differently. The "porch culture" is still welcoming and fun. (The downside: it's VERY easy to be an alcoholic, to drink constantly... everyone's always socializing, the weather's always beautiful. Catch me in the morning.)

• There are a lot more burners at Barking Springs. (Barton Springs is a huge pool, fed by a spring and unchlorinated, ice cold all the time, a very classic Austin institution... Barking Springs is the portion of the pool that isn't "included" in Barton Springs, separated by just some concrete and a fence, so called because you can do everything you're not allowed to do at Barton Springs -- drink, smoke, sit in an innertube with your dogs and your burner husband all day long, whatever).

• Everyone, and I mean everyone, in Austin is a VVITCH these days. But only a brave minority (of which I am proudly a part) are witchy enough to go out and about in a city full of incredibly hot people with unshaven, unsightly stubbly legs.

The sociology stuff is all well and good. I'm no urban studies person. What's important to me is I stayed with my best friend from when I lived there, a woman I haven't spoken much to since I moved. A classic millenial tale, our lives simply knocked us spinning in different directions for awhile. Hard to describe the special feeling of being "back" in an older episode of life, but as a different person -- that's kind of what these long friendships are, at the end of the day, I guess. This friend is blessed with a big, echt-Austin constellation of girlfriends, one of whom was staying at the house with us a mere 12 hours or so after breaking through on DMT. Time moves differently, more leisurely, in Austin ("where adults go to retire," as my dad, an erstwhile but longtime Austin resident, puts it), and she and I had a lot of 1:1 time to talk ("integrate" as they say) and our conversations kept coming back to the same idea. The real thing, the important thing, is connection. Is it ever anything else?

Remember Co-Star? The algorithmic astrology app? (My Co-Star horoscope today: "You don't need to catalog everything you think." Well, you're not the boss of me.) A typical headline from late 2019, from Vogue: "Meet the astrology app that's intriguing millenials everywhere." From the article,

The app’s proprietary AI technology takes data from the publicly accessible Jet Propulsion Laboratory to map out the position of the planets. The team, which consists of 10 people, has writers who translate the astrological data into thoughtful daily horoscopes and push notifications.

Public data, proprietary algorithm. It's a common enough scenario, and an interesting one. What does it really mean to encode the esoteric knowledge of astrology practice -- in this case, the knowledge of the relative positions of planets -- in a mathematical algorithm that a tech company owns?

This is basically the question addressed in the first half of The Eye of the Master, a "social history of artificial intelligence" by Matteo Pasquinelli. (I got a galley copy of this book from a Verso pal I met at the conference in September, but Google informs me it actually came out yesterday!) It's definitely "a choice" to begin a social history of AI from the industrial revolution in England, and to start with a close reading of Marx's writings on machinery in the Grundrisse and Capital. I think it's a choice that makes sense. As Pasquinelli argues, pace Marx and Charles Babbage, science isn't the inventor of technology -- labor, or rather the division of labor, is. This did not make sense to me for the first few chapters of the book, to be quite honest, but I think it's a valuable insight and I'm going to try to explain why.

Today is a bit of a failure to launch for me so I'm using this newsletter to construct a short playlist out of things that aren't available on streaming (to my knowledge). I really feel that music has a seasonal dimension. Springsteen for example: Darkness on the Edge of Town is a summer record, The River is for the dead of winter. Don't ask me to explain this. This morning was the first day that really felt autumnal; misty, a little rainy, cool, the leaves starting to go yellow and red.

The Bob Seger System - Lucifer

Bob Seger is our dad rock. Springsteen is for the east coast, Neil Young for the west, but Bob Seger is from Detroit. Pittsburgh isn't the Midwest, but Detroit is probably spiritually the most similar city. (Some autumn trivia, Pittsburgh and Detroit are the only cities in the USA where the night before Halloween is routinely called "devil's night.") If you only know Bob Seger from the Chevy commercials (WHOOOAA-OHH, LIKE A ROCK!) then you should be aware that Bob Seger fucking slaps. His earlier output with the Bob Seger System is particularly good -- a little more punk, a little more heavy psych, a little less classic rock.