The Planetary Patient: A China Update

Posted on | April 23, 2014 | No Comments

Eight  years ago, I wrote about a range of ecological issues impacting water policy in China. It seemed as if unintended consequences were coming about at every turn. Two examples I mentioned at that time had to do with the Three Gorges Dam and the diversion of the Shiyang River.

Most are still aware of China’s gigantic Three Gorges Dam project, based at the upper margins of the Yangtze River, which feeds 186 cities. The Yangtze historically has actually been pretty clean, not because it isn’t regularly polluted, but rather because its massive flow has provided cleansing wash-out into the sea of Shanghai. But new dams have reduced  flow, and Beijing has been suffering its worst drought in 50 years. It sits in the northern provinces, within reach of the Yangtze’s life-preserving flow.

Ecological management is all about choices. In China, the size and scale of their economic expansion has forced a trade-off that severely limits options. Dams produce much needed hydro-electricity. But they also impact much required fresh water supply and the survival of fish and wildlife species that support a good portion of China’s human population.

In 2013, The Guardian reported that, “Between now and 10 June the dam will release 5 billion cubic metres of water – equivalent to the volume of Lake Windermere in Britain every day – as engineers sacrifice hydroelectric generation for irrigation, drinking supplies and ecosystem support.”

The article continues:

“The dam’s role in the drought has been the subject of a fierce debate. Downstream communities have accused the Three Gorges of holding back too much water to generate power. Environmentalists say this has contributed to the demise of lakes and wetlands, which are already under pressure from urban development and the demands ofagriculture. The operators, however, say the reservoir is helping to ease shortages through a timely release of water…Last week the state council – China’s cabinet – acknowledging that Three Gorges faces “urgent problems” of geological disaster prevention, relocation and ecological protection. It noted the negative impact on downstream water supplies and river transport…The dam is not the only hydro-engineering project that has come under scrutiny as a result of the drought. The state’s massive south-north water diversion project, which aims to tap the normally moist Yangtze basin to supply arid northern cities like Beijing, is also being called into question because one of its source reservoirs at Danjiangkou has fallen 4 meters below the minimum requirement for its operation.”

The diversion of the Shiyang River, dating back to Mao’s time in the 1950s, was intended  to support the agricultural expansion of Minqin, a desert oasis. Today, not only is Minqin having trouble surviving, but wide swaths of formerly viable land are being gobbled up by an ever-enlarging, north central China desert that is now even threatening Beijing. As a result, China’s large population, which has been migrating for the past 200 years from south to north for opportunity, is now reversing that migration.

Now Mongolia has come into the picture with problems. Dust from the Gobi Desert, some 300,000 tons worth, covered Beijing in one storm in 2007. In the 50s, you’d have one or two of these bad sand storms every seven years, and in the 70s, every two to three years. On  April 26, 2012, NASA satellite’s recorded images of the dust storms from outer space. Spring is dust storm season in Mongolia, and 20 to 30 days of storms are expected this year. The Gobi Desert borders Mongolia on its southern border and China on its northern border. Gobi dust travels around the globe, with traces found in places like Kansas. But in Mongolia, it’s more than a trace. About 50,000 square miles have now given way to desert. 683 rivers have dried up in recent years. Average temperatures have risen 3.6 degrees since the 1940s with a 10% drop in rainfall during the same time span. In winter it can drop to -40 degrees Fahrenheit and in summer hit 110 degrees with ease.

My point? When it comes to water and the support of life, everything is integrated. Global warming, river damming and diversion, political collapse of a sponsor nation, the culture of herding and fishing, all now are part of the desertification of a large part of Asia.

I focus on China (the world’s largest growth engine at the moment) because it illustrates how important it is for the human race to act wisely as we make local, regional, national and planetary decisions. Our planet is increasingly fragile — that we know. What we need now to grasp is that our health, and our lives, over this next century are tied to our management of this planet. And in many areas around the world, citizens’ lives already hang in the balance.

For Health Commentary, I’m Mike Magee.

The Economic Determinants of Homeland Security: Why The U.S. Is A Better Bet Than China or Russia.

Posted on | April 17, 2014 | 1 Comment

Mike Magee

Homeland security is all about economics. And the two levers most critical to the U.S. economy are energy independence and health care. On these two measures, I like America’s odds when compared to China and Russia.

Growing up through the 50’s and 60’s, I’d listen to my parents discuss politics with their friends.  My father carried the bias that foreign policy trumped domestic issues. Some of his friends would argue otherwise. As circumstances at home and abroad shifted, their opinions would harden or soften depending on the country’s situation, the economy, and America’s appetite for engagement versus isolation.

Now fifty years later, the clear demarcation between foreign and domestic affairs has largely disappeared. And while we still have waves of enthusiastic zeal for foreign interventions versus cautious retrenchment, the country seems to have absorbed a general truism – economic power equals homeland security.

In this regard, the United States has accomplished much in the past six years. We have addressed an historic financial crisis – albeit it one that resulted from our own deficient financial regulatory systems allowing banks “too big to fail” to fail us all. We have gradually extricated ourselves from Iraq and Afghanistan after taking bin Laden’s bait, an action that has stemmed the outflow of national treasure – both human and financial. We have positioned ourselves to be energy independent – and even more to be an energy exporter, which as we have seen with the Ukraine experience may prove to be strategically critical. And finally, we have broken through the status-quo on health care, and are beginning to see proof that prevention may yield enormous positive economic results.

When we look at our traditional adversaries, we see a very different trend line. The Wall Street Journal this week had a feature on the Chinese building bubble and the risks of foreign investment in this region.(1) Yes, an incredibly large market, but a long list of liabilities and vulnerabilities including: 1. Widespread fraud in local and regional governments. 2. “Build it and they will come” speculation 3. Environmental degradation with serious growing water scarcity and air quality issues. 5. Huge and exponentially growing chronic burden of disease thanks to cigarette consumption, unhealthy environments, and variable and constrained health resources. Add to these, Americans increasing desire to “build it at home” and avoid the cost of shipping product of variable quality from overseas producers.

And then there is Russia, which, thanks to Putin fresh off the $50 billion dollar Sochi Olympics, is now stuck with absorbing an economically troubled Crimea into its already stagflated $2 trillion economy. Low birth rates have created an inadequate work force in both quantity and quality. Russian banks have adjusted growth rate projections as the World Bank predicts near 2% deflation of their economy this year. This is in the wake of a $70 billion capital outflow as Putin rattles his saber. And just this week, a 3% drop in one day of the Russian stock market which is down 10% from March.(2)

And then there is America, where the whine, whine, whine and pick, pick, pick of a vocal minority about the performance of our President, at home and abroad, is relentless. What is the news from home? Well, it’s pretty good actually, especially in health. When President Obama managed to push through the Accountable Care Act a few years back he did more than reform our insurance system. More importantly, he unlocked the status-quo prison gates of a century old, heavily compromised and expensive system, and invited innovation. Make it better. Make it more efficient. Make it faster. Make it smarter. Make it more convenient. Make it more preventive. Make us healthier.

If a report this week on diabetes is any indication, we’re on the right track, and the economic rewards of enhanced productivity could be enormous. Our new competitive and inclusive approach, outcome driven and evidence based, has seen a 31% decline in heart disease since 1990. Even more striking, in patients with diabetes, heart attacks are down 68%.(3) Behind those numbers are an intensive team based focus on vulnerable populations and an evolutionary plan to manage risk factors with a combination of behavioral and pharmacologic solutions. This is what happens when you engage and put patients interests and the nation’s interests ahead of your own.

If we continue to move deliberately and cautiously as we have for the past six years, avoid being drawn into offshore financial sink holes, focus deliberately on environmental and population health, and concentrate on more equitably expanding quality of life to all Americans, the future looks bright. And regardless of your political persuasion, you can thank our current leadership for that.

For Health Commentary, I’m Mike Magee

References:

1. Davis B, Fung E Housing Trouble Grows in China. WSJ. April 14, 2014.

2. Herszenhorn DM. Russia Economy worsens even before sanctions hit. NYT. April 16, 2014.

3. Gregg EW et al. Changes in Diabetes-Related Complications in The United States, 1990 – 2010. NEJM. April 17, 2014. 370: 1514-1523.http://www.nejm.org/doi/full/10.1056/NEJMoa1310799

Turning Over A Rock: Salamanders and Medicare Fees To Physicians

Posted on | April 10, 2014 | No Comments

Mike Magee

I always felt there was something important and mystical about salamanders. So it’s not surprising that I opened Richard Conniff’s New York Times article this week titled, “Salamander’s Hefty Role In The Forest”. In the Science section article, Conniff opens with this statement, “If someone asked you to name the top predator in North American forests, you might think of bears, or maybe great horned owls. But here’s another answer to think about: woodland salamanders.”

Drawing from a recently published study in Ecosphere by Hartwell H. Welsh Jr., of the United States Forest Service’s research station in Arcata, CA, and Michael L. Best, at the College of the Redwoods in Eureka, CA, the article lays out a few eye catching facts including:

These innocent looking and beautiful creatures lurking in wet leaves and under rocks consume an average 20 ants and 3 to 5 other small leaf shredding invertebrates a day.

The deciduous leaves that these insects favor are 47.5% carbon. Their munching releases this carbon into the atmosphere, contributing to global warming.

Left undisturbed, the leaves house the carbon, in layers of leaves on the forest floor, long enough for it to be reabsorbed into the soil.

In the absence of salamanders, insect leaf shredders shred 13% more leaves than when  these little wiggly creatures are present. Insert them into the ecosystem, and nearly two hundred pounds of extra carbon per acre make it into the soil.

The salamander is an extremely efficient life form, breathing through its skin rather than relying on lungs. As a result, the meager calories provided by these tiny leaf shredders is enough to supply their needs. Not so for birds and mammals.

So here we have another example of the exquisite beauty and complexity, efficiency and necessity of lifeforms that on first glance may seem a luxury, an add on.

In the world of science, humans get the lion size portion of our attention. Discoveries here often lead to products, and products to blockbuster performance. As outlined in part this week with the Medicare physician data release, just how and to what extent and in what manner these discoveries are advantaged by the doctors and their patients is highly variable – and controversial.

But the salamanders labor on unheralded except by young children struggling to turn a rock by a stream in the hopes of possibly catching a brief glimpse of this mystical creature. Without knowing the facts, these children are able to see and sense the linkages and the value of all living things.

That is reassuring.

For Health Commentary, I’m Mike Magee

Fort Hood: Abnormal Minds in Normal Times, or Normal Minds in Abnormal Times

Posted on | April 4, 2014 | 2 Comments

Mike Magee

When Spc. Ivan Lopez, a soldier at Fort Hood, Texas opened fire on his fellow soldiers, killing three this week, he once again focused a light on the chronic, lasting and largely hidden burden of war – mental illness in soldiers who serve our country. But what escaped notice in the broad coverage of the event was our limited understanding of the root causes and  the long term potential impact on those professionals charged with caring for these mentally wounded veterans over the many years ahead.

More on that in a moment. But here are a few facts. The VA estimates that nearly 1000 veterans a week are receiving a diagnosis of post-traumatic stress disorder. Add to that an additional 800 who are tagged for depression. That adds up to about 100,000 a year for just those two diagnoses. And that only includes soldiers who actually come forward.

Of the 155,000 that the Pentagon currently agrees have PTSD, about 3/4 were in combat. That means 1/4 were not. This is not a new revelation. We learned from our experience in World War II that a fairly large percentage of soldiers who received discharges for “battle fatigue” were not actually in battle. Rather a combination of loneliness, deprivation, change and occasional hostility in an environment not fully under the individual’s control was enough to trip mental illness.

Currently, veterans age 18 to 24 are committing suicide at a rate 4 times that of non-veterans of the same age. That amounts to 80 deaths in every 100,000 veterans  per year. The VA has attempted to respond. Over the past 4 years they have increased the number of therapists by nearly 50% to just under 10,000. These therapists and the IOM have taken a critical look at a wide range of instigators including behavioral modifiers in the field or in training, drug and alcohol abuse, and a range of injuries including traumatic brain injury.

The problem has been building. Since the beginning of the wars in Iraq and Afganistan, nearly a million soldiers have reported in with mental health issues. And in spite of the attention and resources thrown at the issue, our understandings of the various complex factors that cause an active soldier or veteran to descend into despair remains remarkably obscure.

This combination of high disease burden in those who have honorably chosen to put themselves at risk for our security combined with a rather remarkable inability to make them all reliably well again has created an auxiliary disease burden that doesn’t receive much publicity.

Back in 2007, I wrote about the toll on health professionals with direct responsibility for veterans with mental illness. In the week of March 19th, seven years ago, both Newsweek and the Wall Street Journal had drawn attention to some disturbing facts -that high or very high degrees of burnout were found in 45% of doctors and nurses, 33% of psychiatrists and counselors, and 27% of chaplains caring for these patients. The message was clear even then – our military caregivers were struggling.

Matt Friedman of the VA’s National Center for PTSD acknowledged as much at the time when he said, “If the therapist finds they cannot listen to another awful war story or that they can’t shut down once they’re at home with their kids, that should be a warning sign.” Chad Peterson of the San Francisco VA Medical Center added,  “I’ll hear about the things they’ve seen or done, the close calls, and my pulse quickens. I’ll get agitated or feel hopeless, because I can’t take this person’s pain away.”

During World War II, William Menninger and his colleagues attempted to better understand what was really happening. During the war, one study commented that, “it would seem to be a more rational question to ask why the soldier does not succumb to anxiety, rather than why he does.”(1)  This observation was reinforced in an article in the American Journal of Psychiatry in 1944 which reflected on the need “to shift attention from problems of the abnormal mind in normal times to problems of the normal mind in abnormal times”.(2)

That last comment deserves some modern reflection.

For Health Commentary, I’m Mike Magee

References:

1. Grinker Roy R. and John P. Spiegel, War Neurosis in North Africa: The Tunisian Campaign, January–May 1943 (Washington, DC: Josiah Macy Foundation, 1943). This manual was later printed, with a number of changes, as Grinker and Spiegel, War Neurosis.

2. Farrell Malcolm J and John W. Appel, “Current Trends in Military Neuropsychiatry,” American Journal of Psychiatry 101, no. 1 (1944): 19.

Rev. Martin Luther King’s Position on Family Planning.

Posted on | March 26, 2014 | No Comments

In response to this week’s story on contraceptive use and the positions of the U.S. Conference of Catholic Bishops, a subscriber commented, “To write anti-Catholic bigotry like this, do you still have to formally join the Ku Klux Klan, or do you just get an automatic honorary membership once the column is published?” You can read my response in the comment section.

On May 5, 1966, Rev. Martin Luther King had this to say about Family Planning on receiving the Margaret Sanger Award from Planned Parenthood:

“There is no human circumstance more tragic than the persisting existence of a harmful condition for which a remedy is readily available. Family planning, to relate population to world resources, is possible, practical and necessary. Unlike plagues of the dark ages or contemporary diseases we do not yet understand, the modern plague of overpopulation is soluble by means we have discovered and with resources we possess.”

Dr. King’s full speech on Family Planning is available HERE.

Is It Time To Close The Bedroom Door On Catholic Bishops?

Posted on | March 26, 2014 | 3 Comments

Mike Magee

If you are interested in the intersection of religion and medical science, March 26, 2014, is a fascinating day indeed.

Today, the Supreme Court Justices (including six Catholics, three Jews and no Protestants or Muslims) are considering a case brought by two business corporations. They state that they are running their businesses based on “religious principles”, and challenge an element of the Accountable Care Act that requires many employers provide coverage for a range of contraceptives.(1)

Today is also the day President Obama visits Pope Francis in Rome. Discussion points to be determined.(2)

For the vast majority of Catholics in America, contraception is a controversy they long ago put to bed. Surveys dating back to the 1960’s have repeatedly demonstrated that U.S. Catholics of child bearing age in large majorities support and utilize contraceptives to manage family planning.(3) In so doing, they have consistently rejected the opinions and directives of the United States Conference of Catholic Bishops who historically direct rather than dialogue.(4)

In large numbers, the Catholic lay public’s response has been to turn a deaf ear to their religious leaders. The disconnect has been reinforced and in many cases made permanent by widespread sexual abuse of minors with institutional cover-up and obstruction of justice well documented.(5)

In both the case of opposition to birth control and sexual abuse of minors, issues of power and sexuality are critical levers. Church hierarchy by design is decidedly male dominated, non-representative and non-transparent with power derived from infallible leaders and divine sources. The people in their flocks, challenged with the up’s and down’s of everyday life – including the possible financial and psychological challenges of unintended children or the protection of their children from possible sex abuse by Church leaders – have been forced to fend for themselves.(6) Keep in mind as well that the U.S. Conference of Catholic Bishops ultimately controls the restrictive policies that govern distribution of contraceptives and prohibition on procedures like tubal ligation and vasectomy in the 600+ Catholic hospitals that control 15% of the nation’s hospital beds and the health care of 1 of every 6 American patients, many of whom are not Catholic.

This disconnect with an elderly male, largely white, ruling elite is long standing in America Catholicism. It gained steam in the years following World War II. Between 1940 and 1960, the ranks in the American Catholic Church doubled, with new records in weekly church attendance. But at the same time, on the back end of the war, with soldiers aggressively exposed to contraception overseas, and many of their wives experienced independence and empowered decision making for the first time as part of the war mobilization effort at home, Church leaders witnessed a growing revolt in the ranks. The issue: family planning.(6)

As a first baby step in the late 1940’s, some Catholic health care workers designed the “rhythm method”, an imperfect system of predicting the fertile moments during the menstrual cycle. Declining intercourse during those periods would “naturally” avoid (sometimes) pregnancy. But for many in the Church leadership, even this was a step too far.

Consider the words of Rev. Hugh Calkins, O.S.M., who broadcast the “Faith In Our Times” program in 1948:  ““Catholic couples have gone hog-wild in the abusive employment of rhythm…A method meant to be a temporary solution of a critical problem has become a way of life, a very selfish, luxury-loving, materialistic way of life.   But heaven, not security, is the goal set for the babies God sends…Every couple  should have the children God wants them to have.”(6)

As for how God would view those using contraception, consider the company they would be joining as described by the popular preacher of the time, Father Flannon Gannon, who listed those on God’s wrong side on Judgement Day as “…birth controllers, adulterers, fornicators, prostitutes, drunkards, Mass Skippers…”(6)

As these words suggest, religious leaders opposed to contraception defined the debate not in the context of public health or medical science or gender equality, but rather in absolutist terms within the highly orthodox context of spiritual versus material dominance. The fact that it leaves women especially powerless, increases the number of abortions, and complicates our nations attempts to address poverty and income inequality have been irrelevant over the ensuing years.

The reality that vocations in the priesthood are in steep decline (7) and that the ranks of practicing Catholics in America have significantly shrunk (8) has done nothing to shake the certitude of the Catholic Bishops on this issue. Neither has the historic bipartisan support for coverage of contraception dating back to 1998.(9)

At that time, on the tail winds of widespread insurance coverage for Viagra, some states and employers for the first time began to mandate that insurers provide coverage for contraception. The insurance companies were agnostic. All they knew was that it cut into their profits. They justified unequal coverage by labeling contraception as not a “medical necessity”.

At the time, in August, 1998, Republican Rep. Nancy Johnson (CT) and Democrat Rep. Nita Lowey (NY) led a move to provide Federal workers with coverage for contraception, and described their progress as ”very good news. It demonstrates that across the ideological spectrum, we recognize that women — and men — have to have the right to plan their families.”(9)  Rep. Johnson’s support was especially relevant, not only because she was considered the resident expert on the Republican side in all things “health care”, but also because her state was the site of the Supreme Court landmark case, “Griswold v. Connecticut”, which in 1965 declared unconstitutional an 1879 Connecticut law which prohibited the use of contraceptives in the state.(10)

Despite an all out campaign by the United States Conference of Catholic Bishops, prior to the passage of the Accountable Care Act 26 states had already mandated that insurers who cover prescription drugs under their plans must pay for contraceptives as well. (11)

So will today be the day we embrace the 19th century or the 21st century? If the Catholic bishops have their way, and our Supreme Court Justices wilt under the pressure, bet on the former.

For Health Commentary, I’m Mike Magee.

References:

1. Barnes R. High Court With Vocally Devout Justices Hear Religous Objectoions To Health Care Law. Washington Post. March 23, 2014.

2. Faris S. President Obama Prepares To Meet The People’s Pope. TIME. March 26, 2014.http://time.com/37361/obama-pope-francis-vatican/

3. Americans, Including Catholics, Say Birth Control Is Morally OK. Gallup Poll. May 22, 2012. http://www.gallup.com/poll/154799/americans-including-catholics-say-birth-control-morally.aspx

4. Contraception. United States Conference of Catholic Bishops. 2014.

5. Clergy Sex Abuse Crisis. Boston Globe. 2014.http://www.bostonglobe.com/metro/specials/clergy

6. Tentler LW. An American History: Catholics and Contraception. Cornell University Press. 2004. http://bit.ly/1j3BhEN

7. Frequently Requested Church Statistics: US Data Over Time. Cara/Georgetown. 2014. http://cara.georgetown.edu/caraservices/requestedchurchstats.html

8. Briggs D. Counting U.S. Catholics: Signs of Growth and Decline. 12/27/12. Huff Post.

9. Kilborn P.T. Pressure Growing To Cover The Cost Of Birth Control. NYT, August 2, 1998.

10. Griswold v. Connecticut. 381 U.S. 479 (1965) http://www.ucs.louisiana.edu/~ras2777/judpol/griswold.html

11. National Conference of State Legislatures. Insurance Coverage For Contraceptive Laws. 2012. http://www.ncsl.org/research/health/insurance-coverage-for-contraception-state-laws.aspx

Health Manpower Planning In “A Zero Marginal Cost” Economy.

Posted on | March 20, 2014 | No Comments

Mike Magee

This week an economist with rose colored glasses suggested that there were two reasons for extreme optimism toward the United States economy, even as Putin goes out on an economic limb to assume the liability of his old Soviet partners. The first positive is our well publicized movement toward energy independence, with the beginnings of natural gas surpluses already visible and available for export.

The second is the emerging signals that the American health care cost curve is not only flattening, but actually indicating some possibility of reversing itself. This was  reinforced  on March 19th by  Citigroup executive and former CBO head Peter Orzag when he said that “The news on the cost trends in Medicare – unbelievably good…The first five months of this fiscal year, the increase in Medicare compared to the previous year – 0.0, despite the baby boomers retiring…Health care is an exciting sector right now because there is a ton going on, and there is a ton that should be going on, not only in coverage, but on changing the way doctors and hospitals are paid….There is much better news on the cost curve in the past 4 or 5 years than people realize…Basically everything you think you know about our fiscal future, if this slowdown in health care costs were to continue, would be wrong. Our fiscal future would be much, much better.”

Say what? OK, what is going on here? Jeremy Rifkin, president of the Foundation on Economic Trends calls it the “zero marginal cost society”. He says that, “We are beginning to witness a paradox at the heart of capitalism, one that has propelled it to greatness but is now threatening its future: The inherent dynamism of competitive markets is bringing costs so far down that many goods and services are becoming nearly free, abundant, and no longer subject to market forces.”

Rifkin calls our rapidly expanding technology infrastructure the “Internet of Things”, a zero margin data assessment and onsite delivery system all in one. He notes that we already have 11 billion independent data sensors at work, with growth projected to 50 billion by 2020. Attached to what? To “natural resources, production lines, the electricity grid, logistics networks and recycling flows, and implanted in homes, offices, stores and vehicles, feeding big data.” Already major disruptions in energy, manufacturing, education and entertainment are obvious.

Rifkin sees “ 3-D printers, open-source software and recycled plastic as feedstock” in our near future, with “ households and businesses that are generating and storing green electricity on-site from their solar and wind installations”. Crazy you say. Well, 37 million buildings in the U.S. are already fully sensored and tied in electronically to the nation’s energy grids. Cisco is projecting private sector productivity gains of 14 trillion by 2022, and G.E. says productivity gains will fundamentally impact the business plans of over half of all global economies and businesses by 2025.

You don’t have to be a genius to know that productivity gains usually mean job losses. In a capitalist society, this has traditionally meant a decrease in for-profit and occasionally government jobs. What about non-profits. Well here is where it gets interesting. In the past decade (2000 – 2010), nonprofit revenues increased 41% compared to for-profit increases of 16%. 50% of the non-profit revenue came in the form of service fees, 36% in government grants, and only 14% from private philanthropy. Numbers of organizations grew 25% during those years from 1.3 million organizations to 1.6 million. By 2012, non-profits accounted for over 5% of our Gross Domestic Profit, and the shift in that direction continues.

Where can we expect sector growth. Rifkin believes “opportunities lie in the collaborative commons in fields that tend to be nonprofit and strengthen social infrastructure — education, health care, aiding the poor, environmental restoration, child care and care for the elderly, the promotion of the arts and recreation.”

From a sociologic standpoint, says he, we are already moving from a capitalist neighborhood based society to a virtual collaborative commons where everything is shared, and usually at a zero margin cost or completely free. It’s not only the 1.7 million cars that were shared last year, “ but also homes, clothes, tools, toys and other items “. As for the job market, consider the head winds like “workerless factories and offices, virtual retailing and automated logistics and transport networks”.

So let’s sum up:

1. National security in the future will depend more on economic strength than on military strength.

2. The U.S. reluctance to getting drawn into expensive areas of conflict, and Putin’s apparent willingness to do just the opposite, will strengthen the U.S. position.

3. In addition to energy independence and investment in high technology, and education based solutions, the U.S. should reinvigorate our aging infrastructure while fully building out the collaborative commons.

4. The linchpin of the collaborative commons, because it contains the largest bank of financial, social and human capital, is health care. Manage this sector efficiently, and everything above will swing in our favor.

5. But remember, efficiency and productivity go hand in hand. And “workerless factories and offices, virtual retailing, automated logistics and transport networks” mean more self-management and patient responsibility, less over use of diagnostics and pharmaceuticals, better and different nutrition and fewer doctors and hospitals.

Are you ready for that?

For Health Commentary, I’m Mike Magee.

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