A working life

by reestheskin on 17/01/2020

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I don’t like the work-life balance meme. I know what it means, but I never wanted it. Medicine was once talked of as a vocation, and when I was a medical student I can remember many doctors who clearly believed so as well. Neonatologists who appeared to live on the special care baby unit; surgeons whose idea of Christmas day was to do a ward round and bring their children with them; and ‘be a paediatrician and bring up other people’s children’. The job was not just any job. I remember the wife of one professor who appeared on the ward when I was a houseman very late one night. “Had I seem the professor, her husband?” I had: I saw him there most evenings when I was on call. On this night, for whatever reason, she had accompanied him. Sadly for her, he had forgotten, and gone home without her. Thales and the well.

For me being an academic was a ‘calling’. A grand phrase, I know. But it has for most of my career been a way of life beyond the paycheque. I believe in the academic ideal, but increasingly fear the institutions no longer do. For me, home and office were not distinct. I vaguely remember — and it is quite possible I am mistaken here — that my first Professorial contract at the University of Newcastle stated ‘that by the nature of the work no hours of work are stipulated’. As my children would testify, weekend mornings were spent in the (work) office, and the afternoon in the gym and pool with them.

I retire* in the near future, and I face a practical problem. Much of my ‘work’ is at home — books and papers of course, but also the high spec iMac Pro that I have used to produce videos, alongside video cameras and lights. On the other hand, my office is full of things that strictly speaking are personal, in that I bought them with my own money rather than with a univeristy purchase order. But my work space — measured in square metres if not mental capacity, I hope — is diminishing. A domestic negotiation is required.

*From paid employment, not from my work.

Diseases of Deans

Woodrow Wilson once remarked that it is easier to change the location of a cemetery than it is to change a curriculum.

Via Jon Talbot, commenting on an article on the failures of online learning. I would only add the comment made by Henry Miller (in the context of medicine):

Curriculum reform, a disease of Deans.

The itch that rashes

by reestheskin on 15/01/2020

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My earliest conscious memory of disease and doctors was in the management of my atopic dermatitis. Here is Sam Shuster writing poetically about atopic dermatitis in ‘World Medicine’ in 1983.

A dozen years of agony; years of sleeplessness for child and parents, years of weeping, itching, scaling skin, the look and feel of which is detested.

The poverty of our treatments is made all the worse by the unfair raising of expectations: I don’t mean by obvious folk remedies; I mean medical folk remedies like the recent pseudoscientific dietary treatments which eliminate irrelevant allergens. There neither is nor ever was good evidence for a dietary mechanism. And as for cows’ milk, I would willingly drown its proponents in it. We have nothing fundamental for the misery of atopic eczema and that’s why I would like to see a real treatment—not one of those media breakthroughs, and not another of those hope raising nonsenses like breast-feeding: I mean a real and monstrously effective treatment. Not one of your P<.05 drugs the effect of which can only be seen if you keep your eyes firmly double-blind, I mean a straightforward here today and gone tomorrow job, an Aladdin’s salve—put it on and you have a new skin for old.

Nothing would please me more in the practice of clinical dermatology than never again to see a child tearing its skin to shreds and not knowing how long it will be before it all stops, if indeed it does.

Things are indeed better now, but not as much we need: we still don’t understand the itch nor can we easily block the neural pathways involved. Nor has anything replaced the untimely murder of ‘World Medicine’. A glass of milk has never looked the same since, either.

You don’t have to be mad to read this

by reestheskin on 13/01/2020

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There is an interesting review in the Economist of the ‘Great Pretender: The Undercover Mission that Changed out Understanding of Madness,’ written by Susan Cahalan. The book is the story of the American psychologist David Rosenhan who “recruited seven volunteers to join him in feigning mental illness, to expose what he called the ‘undoubtedly counter-therapeutic’ culture of his country’s psychiatry”.

Rosenthal’s studies are well known and were influential, and some might argue that may have had have a beneficial effect on subsequent patient care. The question is whether they were true. The review states:

in the end Rosenham emerges as an unpalatable symptom of a wider academic malaise”.

As for the ‘malaise’, the reviewer goes on:

Many of psychology’s most famous experiments have recently been discredited or devalued, the author notes. Immense significance has been attached to Stanley Milgram’s shock tests and Philip Zimbardo’s Stanford prison experiment, yet later re-runs have failed to reproduce their findings. As Ms Cahalan laments, the feverish reports on the undermining of such theories are a gift to people who would like to discredit science itself.

I have a few disjointed thoughts on this. There are plenty of other considered critiques of the excesses of modern medical psychiatry. Anthony Clare’s ‘Psychiatry in Dissent’ was for me the best introduction to psychiatry. And Stuart Sutherland’s “Breakdown’ was a blistering and highly readable attack on medical (in)competence as much as the subject itself (Sutherland was a leading experimental psychologist, and his account is autobiographical). And might the cross-country diagnostic criteria studies not have happened without Rosenham’s work?

As for undermining science (see the quote above), I think unreliable medical science is widespread, and possibly there is more of it than in many past periods. Simple repetition of experiments is important but not sufficient, and betrays a lack of of understanding of why some science is so powerful.

Science owes its success to its social organisation: conjectures and refutations, to use Popper’s terms, within a community. Just repeating an experiment under identical conditions is not sufficient. Rather you need to use the results of one experiment to inform the next, and with the accumulation of new results, you need to build a larger and larger edifice which whilst having greater explanatory power is more and more intolerant of errors at any level. Building large structures out of Lego only works because of the precision engineering of each of the component bricks. But any errors only become apparent when you add brick-on-brick. When a single investigator or group of investigators have skin in the game during this process — and where experimentation is possible — science is at its strongest (the critiques can of course come from anywhere).

An alternative process is when the results of a series of experiments are so precise and robust that everyday life confirms them: the lights go on when I click the switch. This harks back to the reporting of science as ‘demonstrations’.

By these two standards much medical science may be unreliable. First, because the fragmentation of enquiry discourages the creation of broad explanatory theories or tests of the underlying hypotheses. The ‘testing’ is more whether a publishable unit can be achieved rather than nature understood. Second, in many RCTs or technology assessments there is little theoretical framework on which to challenge nature. Nor can everyday practice act as the necessary feedback loop in the way the tight temporal relationship between flipping the switch and seeing the light turn on can.

Term of the day

Negative egalitarianism (also known as jealousy)

Richard Gombrich

We need more STEM (STEAM etc)

by reestheskin on 08/01/2020

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Perhaps, perhaps not. But when and where is even more important.

Hailed as a maths prodigy at school, Shields accepted a junior position at Merrill Lynch after studying engineering, economics and management at Oxford University because the trading room floor offered him a thrilling, dynamic environment. He was not alone: of 120 engineers in his year group at university, Shields added, only five went into engineering.

I think we should be much more cautious in attempting to direct young people’s choices beyond providing them with an education. We should feel proud of their independence of mind, remembering that supply side factors will likely win out over central planning. It is the supply side that we need to deal with, not least Putts Law. The same applies to medicine.

This personal story is worth a read for other lessons, too.

‘The men who plundered Europe’: bankers on trial for siphoning €60bn | Business | The Guardian

What do you want?

The government has instructed Health Education England to consult patients and the public on what they need from “21st century” medical graduates

Patients to be asked what they need from doctors | The BMJ

It won’t end well.

On (or off) New Year’s Resolutions

by reestheskin on 06/01/2020

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The productivity abyss…and how to escape its gravitational pull. Here is an article extolling time-wasting.

To which she has two responses — first, most people overestimate the amount of time they actually work and second, she proposes accepting that your to-do-list will never get done.

Let’s rebrand a bit of time-wasting as healthy living | Financial Times

The fist I agree with. Awhile back I tried time tracking using the Timery app and Toggl. It’s scary. And that is even when you include meetings as work. But the second point, entailing an amnesty on all the things you thought or think you are going to do, conflicts with my sense of original sin. The sun has to rise, just like guilt.

We need a science of the night

by reestheskin on 03/01/2020

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One-third of everyone employed in London, 1.6 million people, work at night.

In 2018, at least 8,855 people slept rough on the streets of London, a 140% increase over the past decade, with similar trends globally.

We need a science of the night

Finnish lessons

by reestheskin on 19/12/2019

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No, not Pasi Salberg, but cognate.

But idealists now have another international beacon of social mobility: long live the Finnish dream, in which a 34-year-old woman who once worked in a shop can become prime minister.

“I am extremely proud of Finland. Here a poor family’s child can educate themselves and achieve their goals in life. A cashier can become even a prime minister,” tweeted Sanna Marin

Meanwhile back in the UK as the FT rightly comments:

..egregious examples of rigging the game endure: on being rejected by the voters, Zac Goldsmith is to be elevated to the House of Lords, from where he will carry on as a minister in the government of Boris Johnson, also an Etonian from a high-profile family.

Looking in envy at Finland’s social mobility pin-up PM | Financial Times

On not being the Queen of Sciences

by reestheskin on 16/12/2019

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“If biology is difficult, it is because of the bewildering number and variety of things one must hold in one’s head”.
John Maynard Smith (1977).

Leo Szilard recalled, that when he did physics he could lounge in the bath for hours and hours, just thinking. Once he moved into biology things were never the same: he was always having to get out to check some annoying fact. Dermatology is worse, trust me.

Mark Blyth on Goldman

Goldman [Sachs) are smart: they can rip your grandmother’s face off and make her feel good about it.

The Crash of 2008: 10 years on

Check your privilege

by reestheskin on 13/12/2019

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An article fit for this deceitful day by Nick Laird in the NYRB. UK education doesn’t escape from it either, but the context is Ireland or that British problem.

“I thought, if these bastards are voting Remain, I’m voting Leave.”

As for ‘identity’

An old friend of mine, a Catholic and a fellow poet from Belfast, was in New York City last week and described being told once to “check her privilege.” She had replied that the privilege her identity had given her was a mild form of PTSD. The phrase “identity politics” has a darker resonance in Northern Ireland.

Every evil act I’ve ever seen committed was done in the name of identity

Blood and Brexit | by Nick Laird | NYR Daily | The New York Review of Books

 Breakfast reading

The Lancet as breakfast reading. Not a medical meeting, just a nice hotel in the Middle East.

Even the human world is queerer than I can imagine

The world is indeed very strange and common sense not much of a guide. Facts, my dear boy, facts…

link

Fiction, apparently.

“…what he read was clear proof of an Anglo-American covert operation already in the planning stage with the dual aim of undermining the social democratic institutions of the European Union and dismantling our international trading tariffs…In the post-Brexit era Britain will be desperate for increased trade with America. America will accommodate Britain’s needs, but only on terms. One such term will be a joint covert operation to obtain by persuasion — bribery and blackmail not excluded — officials, parliamentarians and opinionmakers of the European Establishment. Also to disseminate fake news on a large scale in order to aggravate existing differences between member states of the Union”

Agent Running in the Field, John le Carré

Knowing more than we can see

by reestheskin on 05/12/2019

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I spent near on ten years thinking about automated skin cancer detection. There are various approaches you might use — cyborg human/machine hybrids were my personal favourite — but we settled on more standard machine learning approaches. Conceptually what you need is straightforward: data to learn from, and ways to lever the historical data to the future examples. The following quote is apposite.

One is that, for all the advances in machine learning, machines are still not very good at learning. Most humans need a few dozen hours to master driving. Waymo’s cars have had over 10m miles of practice, and still fall short. And once humans have learned to drive, even on the easy streets of Phoenix, they can, with a little effort, apply that knowledge anywhere, rapidly learning to adapt their skills to rush-hour Bangkok or a gravel-track in rural Greece.

Driverless cars are stuck in a jam – Autonomous vehicles

You see exactly the same thing with skin cancer. With a relatively small number of examples, you can train (human) novices to be much better than most doctors. By contrast, with the machines you need literally hundreds and thousands of examples. Even when you start with large databases, as you parse the diagnostic groups, you quickly find out that for many ‘types’ you have only a few examples to learn from. The rate limiting factor becomes acquiring mega-databases cheaply. The best way to do this is to change data acquisition from a ‘research task’ to a matter of grabbing data that was collected routinely for other purposes (there is a lot of money in digital waste — ask Google).

Noam Chomsky had a few statements germane to this and much else that gets in the way of such goals (1).

Plato’s problem: How can we know so much when the evidence is do slight.

Orwell’s problem: How do we remain so ignorant when the evidence is so overwhelming.

(1): Noam Chomsky: Ideas and Ideals, Cambridge University Press, (1999). Neil Smith.

Books

We commonly think of books as containers of ideas or wrapping for literature, but they can be understood in other ways—as if they were blood cells carrying oxygen through a body politic or data points as infinite as stars in the sky. Books lead lives of their own, and they intersect with our lives in ways we have only begun to understand.

Best Sellers by the Bargeload | by Robert Darnton | The New York Review of Books

A job for life

In the essay “Telling,” he describes the upsetting case of the director of a hospital who, struck down by Alzheimer’s, is admitted to his own hospital. He behaves as if he were still running it, until one day by chance he picks up his own chart. “That’s me,” he says, recognizing his name on the cover. Inside, he reads “Alzheimer’s disease” and weeps. In the same hospital a former janitor is admitted; he too is convinced that he is still working there. He is given harmless tasks to perform; one day he dies of a sudden heart attack “without perhaps ever realising that he had been anything but a janitor with a lifetime of loyal work behind him.”

Truth, Beauty, and Oliver Sacks | by Simon Callow | The New York Review of Books

My mother, a nurse, took on such imagined roles when she too was demented and in a care home.

Downward mobility for all!

by reestheskin on 02/12/2019

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Obituaries are a source of much joy and enlightenment. None more so than those in the Economist. Last week’s was devoted to the ’60’s photographer Terry O’Neill (you can see some of his iconic images here.

Stars had been his subject since 1962, when he was sent to photograph a new band at the Abbey Road Studios. The older blokes at the Sketch scorned that kind of work, but the young were clearly on the rise, and he was by far the youngest photographer in Fleet Street at the time. At the studios, to get a better light, he took the group outside to snap them holding their guitars a bit defensively: John, Paul, George and Ringo. Next day’s Sketch was sold out, and he suddenly found himself with the run of London and all the coming bands, free to be as creative as he liked. A working-class kid from Romford whose prospects had been either the priesthood or a job in the Dagenham car plant, like his dad, had the world at his feet. He wouldn’t have had a prayer, he thought, in any other era.

And obviously it couldn’t last. In a couple of years he would find a proper job, as both the Beatles and the Stones told him they were going to. For it was hardly serious work to point your Leica at someone and go snap, snap.

Obituary: Terry O’Neill died on November 16th – Catching the moment

The reason I found this particularly interesting is the way social mobility appeared to work and the way it was tied to genuine innovation and social change. I have always loved the trope that when jobs are plentiful, and your committments minimal, you can literally tell the boss to FO on a Friday and start another job on the Monday. Best of all you can experiment and experiment lifts all. This to me is one of the best 1960’s rock n’ roll stories.

If you lift your head above the parapet in universities you come across various conventional wisdoms. One relates to ‘mental wellbeing’ or ‘mental issues’, and another is the value of education in increasing social mobility. My problem is that in both cases there seem (to me at least) many important questions that remain unanswered. For the former, are we talking about mental illness (as in disease) or something else? How robust is the data — aside from self-reporting? The widely reported comments from the former President of the Royal College of Pyschiatrists receive no answer (at last not in my institution). An example: I have sat in a meeting in which one justification for ‘lecture capture’ (recording of live lectures) was to assist students with ‘mental health issues’. But do they help in this context? Do we trust self-reflection in this area? Under what conditions do we think they help or harm?

Enhancing life chances and social mobility is yet another area that I find difficult. I picked up on a comment from Martin Wolf in the FT

We also believe that changing individual characteristics, principally via education, will increase social mobility. But this is largely untrue. We need to be far more honest.

He was referring to the work of John Goldthorpe in Oxford. Digging just a little beneath the surface made me realise that much of what I had believed may not true. Goldthorpe writes:

However, a significant change has occurred in that while earlier, in what has become known as the golden age of mobility, social ascent predominated over social descent, the experience of upward mobility is now becoming less common and that of downward mobility more common. In this sense, young people today face less favourable mobility prospects than did their parents or their grandparents.

This research indicates that the only recent change of note is that the rising rates of upward, absolute mobility of the middle decades of the last century have levelled out. Relative rates have remained more or less constant back to the interwar years. According to this alternative view, what can be achieved through education, whether in regard to absolute or relative mobility, appears limited.

[Jnl Soc. Pol. (2013), 42, 3, 431–450 Cambridge University Press 2013 doi:10.1017/S004727941300024X]

There is a witty exchange in Propect between the journalist (JD) and Goldthorpe (JG).

JD: Would you say that this is something that politicians, in particular, tend not to grasp?

JG: Yes. Tony Blair, for instance, was totally confused about this distinction [between absolute and relative rates of mobility]. He couldnʼt see that the only way you can have more upward mobility in a relative perspective is if you have more downward mobility at the same time. I remember being in a discussion in the Cabinet Office when Geoff Mulgan was one of Blairʼs leading advisors. It took a long time to get across to Mulgan the distinction between absolute and relative rates, but in the end he got it. His response was: “The Prime Minister canʼt go to the country on the promise of downward mobility!”

On both these topics I am conflicted. And on both these topics there are the tools that characterize scholarly inquiry to help guide action: this is what universities should be about. I am however left with a strong suspicion that few are interested in digging deep, rather we choose sound bites over understanding. Working in a university often feels like the university must be somewhere else. That is the optimistic version.

Not only God plays dice

There is an article this week in Nature about how some funders are explicitly funding grant proposals randomly (lotteries). The cynic might say they have been doing this for a longtime.

Pharma: business as usual

by reestheskin on 29/11/2019

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The article is about pharma and the way its interests flit because of perceived commercial rather than clinical value. There are two phrases that should make you sit up.

  1. ‘Scientists were given incentives to meet milestones in the clinical trials,’
  2. ‘One precondition for success is a large salesforce’.

The first phrase, is scary. We already know how dishonest much of pharma is. We can manage well without more perverse incentives. Short term shareholder value wins over morality every time.

The second begs the question: if the evidence is good, why do you need to flog your medicine with advertising? A collection of data sheets — with citations — is all you need. And since most pharma spends more on advertising than research, here is a simple way to reduce drug costs. (The answer is of course, that advertising sells more than research — shame on us all).

Novartis cholesterol deal highlights mass-market opportunity | Financial Times

Writings from the margins

by reestheskin on 28/11/2019

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I was back in Dublin a few weeks ago for a family celebration. Then last night — on C4 I think— I was listening to an interview with Fintan O’Toole. Something stirred and below are two quotes from Brian Friel: the context may be Brexit, the reality is something much more.

As a character in Translations says, describing his own fading Gaelic world, “a civilisation can be imprisoned in a linguistic contour which no longer matches the landscape of fact”.

 

To remember everything is a form of madness,” warns one of Friel’s characters.

(1) Brexit, the UK and Ireland: a dialogue of the deaf | Financial Times

Costs of business

by reestheskin on 26/11/2019

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This is from the Guardian. The background is serious allergic reactions to food components, and allowing accessible information about what purchased food contains. In her phrase, ‘high-profile casualties on the high street’ she is referring to businesses; I am sure others may have read it differently.

But Kate Nicholls, the chief executive of UKHospitality, said a law change could have a serious impact on the viability of some of the 100,000 restaurants her organisation represents. “Hospitality and particularly high street restaurants are under intense cost pressures and are struggling,” she said. We’ve had a number of high-profile casualties on the high street. Those businesses operate on tight net profit margins. And there’s no doubt some would not be able to cope with any significant change in their cost structure.”

(BTW: she thinks ‘training’ is the solution. Training and education are offered as the answer to everything…”education, education, education”. If only.)

Grieving family’s call for allergy law gets cool response | Society | The Guardian

Indulging our future(s)

by reestheskin on 25/11/2019

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Carbon offsetting is shaping up to be the greatest mis-selling scandal since the Dominican friar Johann Tetzel sold pardons to redeem the dead. Martin Luther attacked this practice in 1517, in his 95 theses.

Five hundred years later, those of us who seek planetary redemption should reduce our carbon footprint in ways that we control — rather than relying on middlemen who may or may not plant trees. The road to hell, I seem to remember, was paved with good intentions.

Well, the Catholic church usually got there first.

Carbon offset gold rush is distracting us from climate change | Financial Times

Dark matters.

by reestheskin on 21/11/2019

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Frank Davidoff had a telling phrase about clinical expertise. He likened it to “Dark Matter”. Dark Matter makes up most of the universe, but we know very little about it. In the clinical arena I have spent a lot of time reading and thinking about ‘expertise’,  without developing any grand unifying themes of my own worth sharing. But we live in a world where ‘expertise’ in many domains is under assault, and I have no wise thoughts to pull together what is happening. I do however like (as ever) some nice phrases from Paul Graham. I can’t see any roadmap here just perspectives and shadows.

When experts are wrong, it’s often because they’re experts on an earlier version of the world.

any

Instead of trying to point yourself in the right direction, admit you have no idea what the right direction is, and try instead to be super sensitive to the winds of change.

How to Be an Expert in a Changing World

Dublin

by reestheskin on 18/11/2019

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These bronze statues at Custom House Quay are even more haunting face to face. As they say, the English never remember, and the Irish never forget. At a celebration of an aunt’s 90th last night, those events were still not ghosts. 

Out of time

by reestheskin on 13/11/2019

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The following is from Janan Ganesh of the FT. The title of the article was “The agony of returning to work in September”.

A personal ambition is to reach the end of my career without having managed a single person.

It seems to me a very sensible ambition, one which used to be the lot of many academics — usually the better ones. He goes on:

Friends who have been less lucky, who have whole teams under their watch, report a quirk among their younger charges. It is not laziness or obstreperousness or those other millennial slanders. It is an air of disappointment with the reality of working life. They will be among the people described in Bullshit Jobs by the anthropologist David Graeber….

A generation of in-demand graduates came to expect not just these material incentives but a sort of credal alignment with their employer’s “values”. The next recession will retard this trend but it is unlikely to kill it.

At one time the words ‘manager’, ‘management’, or worst of all, ‘line-manager’ were alien to much of medicine or academia. Things still got done, in many ways more efficiently than now. It is just that our theories of action and praxis have been ransacked by Excel spreadsheet models of human motivation and culture. It is the final line from the quote that those controllers of ‘managers’ should be scared of:

The next recession will retard this trend but it is unlikely to kill it.

Bullshit (of the world-class variety)

by reestheskin on 12/11/2019

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Andrew Wathey its chairman [of the UK Standing Committee for Quality Assessment] and vice-chancellor of Northumbria University, said: “The UK delivers world-class education to students from all nations. It is therefore right that the sector commits to ensuring that the value of these world-class qualifications is maintained over time in line with the expectations of the UK Quality Code for Higher Education.”

Universities agree more openness on degree marking guidelines | Financial Times

The language betrays all you need to know: spoken by somebody who clearly has no idea what UK higher education once stood for, or who has any sympathy or understanding of the academic ideal. Will the last person who leaves please turn off the ….

Thought of the day

by reestheskin on 11/11/2019

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That, across human experience, in all places and at all times, only one or two societies have unwound concentrations of income and wealth as great as [those that] plague the US today without losing in war to a foreign foe or succumbing to a domestic revolution.

Interview with Daniel Markovits

THE, 31-10-2019