Silicon Valley Under the Dome (Again)

I have been living away from the so-called Silicon Valley for almost a decade now; I live in Paris, and thus I don't miss life back there terribly, but do try to keep up with the scuttlebutt.  Over the years, I've written several posts about the Bay Area, where I spent most of my adult life.  For a blogger, the Bay Area provides a steady fodder for discussions about innovation (or lack of it), demographics and the impact they have, the evolution of the word "entrepreneur", and social issues like privilege and gentrification.  

One of the hot topics right now in the Valley - aside from how 'hot' (and difficult) the housing and jobs markets are (really, issues with nearly predictable cycles - you could cut and paste San Jose Mercury News articles from 1997, 2005, and now 2014 almost verbatim) are issues of what "makes" a startup/tech company successful, and why the rewards seem to be going to a statistcally skewed group.

Further militating for the maxim that to err is human, but to really muck up an analysis requires a human from Harvard.  One from the Harvard Business School is a daily double,

To wit, this article in the recent Harvard Business Review (motto: "Mis-measuring the social sciences since 1922").  The click-bait title of the article "The Myth of the Tech Whiz Who Quits College to Start a Company" poses itself as a sort of myth-busting piece in the vein of Malcolm Gladwell.  The article sets up as its pins that there are three 'common myths' about tech founders: that they are young, that they are technically trained, and that they were graduated from a prestigious, local university.

One is confronted immediately with the inherent contradiction that the title (that tech founders are drop-outs) contrasts with popular myth three.  But let's set that to the side.

Unsurprisingly, HBR notes that "the data tell a different story." Unsurprising, because if the data from the analysis supported the story, I reckon that the article would not have been published.

The mythos is summarised un-succinctly in the following narrative form:

The verdict follows a familiar line: for better or worse, successful tech sectors are products of young entrepreneurs, who disrupt whole industries without ever having worked in them. 

These founders, in turn, are invariably portrayed technical experts. Science, technology, engineering, and math (STEM) education is now at the center of entrepreneurship policy, and cultivating technical talent has become an important goal of the White House’s Office of Science and Technology Policy (OSTP).

Where better to get that technical education than at a great local university? Stanford is the classic example, with hundreds of future Silicon Valley entrepreneurs passing through its Palo Alto campus. A university of this caliber not only creates great talent, the theory goes, but also helps a region to retain it. It makes sense, then, to assume that without a world-class university nearby, a city’s tech sector cannot thrive.

The authors of the story, who work for a consulting company called Endeavor Insight, turn to data in the New York tech sector that are available on public data sites such as LinkedIn, AngelList, and Crunchbase in an attempt to analyse the veracity of the myths. A sample of 1600 "tech founders" in New York city forms the analysis cohort.

The first item to fall, it turns out, is the straw-man about being a college drop-out - noting that dropout founders are "the exception, not the rule."  No numbers are given, but any sort of reasonable analysis would have to look at the numbers in comparison to some sort of control.  Of course, it's unlikely that the majority of founders would be college dropouts (despite the fantasies of, e.g., Peter Thiel), but how does the distribution of dropouts vs degreed founders of tech compare to the tech workforce in general?  To the population of founders of non-tech companies?  Any sort of reference?
This conclusion is an example of the sound of one hand clapping.

The next item under the microscope is the question of whether are particularly young.  The conclusion: yes; they are young, but 'seldom fresh out of school' (whether dropping out or not - whoops).  The data are presented as a histogram below:

There is a handful of problems with this analysis.

First, the authors offer no objective definition of what "young" means.  Myth Number Two is states as "they are young."  In fact, they are young, so HBR have failed to knock over their own straw-man.  But what defines "young?"  A post hoc definition of "fresh out of school" is offered.

Second, from a statistical point of view, the authors use average, when plainly, the distribution is pretty skewed.  That average (31 years) is being pulled to the right by a group of people clearly at least a standard deviation and a half over the mode of the distribution.  When talking about the myth of the "typical" tech founder, does it make sense to you to look at the average age of a skewed distribution, or to where the bulk of the data are?

Put another way, the average colour of a rainbow is white.  It's an inappropriate measure here.

The median of this distribution is around 27 or so.  That's about the age of median player in professional baseball (28.8)  It's a bit older than the median age, which is 25.5.  The 'typical' founder of a tech company is younger than the 'typical' professional baseball player, and a bit older than the 'typical' NFL athlete.

And third, there is no comparator.  How, for example, do the tech founders stack up against similar, non-tech company leaders?

The whole "analysis" is incredibly sloppy, and fails even to support the claims made by the authors.

The next "myth" attacked is that tech founders are heavily STEM (science, technology, engineering, and mathematics).  Surprisingly, only 36% majored in one of the STEM fields;

Tech founders are also much less technical than conventional wisdom leads us to believe. We divided New York City tech founders’ college majors into two categories: STEM (science, technology, engineering, and mathematics) and non-STEM, and found that just 35% studied STEM fields, while 65% majored in something else. In fact, these founders were more likely to study political science than electrical engineering or math.

Is this a reasonable analysis?

According to the data published recently by NPR, about 2.5% of US graduates in 2010 took their major in CS.  1% were maths majors.  Engineering was 5%.

By comparison, business and economics degrees were held by 25% of college graduates  History and humanities were 5%.

It's obvious that the founders of successful tech companies are far, far more likely to derive from scientific disciplines, when one controls for the sample pool, than from business or psychology,

Worse, the examples given to illustrate the point call into serious doubt the definition of "tech" used by HBR.  In making their case, the authors cite Alexandra Wilson (MBA founder of Gilte Group, an "e-commerce business") and Neil Blumenthal, founder of on-line eyeglass retailer Warby Parker.

It's worth pointing out that neither Gilte Group nor Warby Parker is a "tech" company.  They are essentially marketing companies.  Gilte provides an on-line platform for consumers to purchase luxury brands; Wilson (in fact, not the founder, but rather, one of four co-founders) brought to the company her experience with brands like Bulgari.  One of the other co-founders is a man named Dwight Merriman, who provided the code and oversaw the actual TECH.

Both Warby Parker and Gilte Group may be highly successful companies, but calling them 'tech' is a stretch at best.  Fed Ex deliver eye glasses and clothes; I would not call them an ophthalmologist nor a design house.

As an aside, as I have written many times before, including most recently here, Silicon Valley has changed from a place where real new ideas and technology were created, into a place that is largely slick marketing masquerading as innovation.  It used to be made of companies like HP or Intel; it's now Yo dot Com and Twitter.  I asked then, and still ask, is the Valley out of big ideas?

As Peter Their famously said, on the way that actual innovation is slowing, "We wanted flying cars, instead we got 140 characters."

One place where HBR get it 'right' is that they are moving the discussion of what an "entrepreneur" is away from the false idea one gets in reading the self-congratulatory press releases out of Palo Alto and back to what a real entrepreneur really is.  Living in France and speaking French, it's clear that an actual entrepreneur is a person who is in the middle of bringing together ideas, marketing, funding, and the operations to produce the product.  It's not, despite what Stanford undergraduates think, a guy with a brilliant idea with the technical chops to realise it.

And ultimately, what the failed "analysis" that HBR offers reveals is not that the founders of tech companies are not young, not technical, and not tied to a university, but rather, that today - perhaps as yesterday - there is an enormous gulf between an idea and a successful business.  And this is where the MBA comes in.  That is the actual role of the entrepreneur.

Tech companies - even Gilte and Warby Parker - need to have a tech head to survive (in both cases, at least one of the co-founders was, in fact, a young STEM graduate).  There is also always going to be a guy with an MBA talking about synergies, share of voice, and channels.

Daddy, How Come there Are SO Many People Named "Charlie?"

"Daddy, see that man over there?  And that one?  And that woman?  They all aren't really named Charlie, are they?  And why are they all wearing name-tags that say "Je suis Charlie?  Are these people all going to a first day of school or something?"

No, son.  In fact, I doubt any of them is actually named "Charlie."  And they aren't going to a 'Welcome Back to School' day at all.  They are going to a march. A march in support of Charlie Hebdo, and to show support for freedom.

"Huh?  Who is Charlie Hebdo?

Charlie Hebdo is the name of a satirical magazine; last week, some men went to their office with guns and attacked them because they didn't like what the magazine had printed.

"Oh; my teacher was talking about that this week in class.  Our school had a moment of silence.  I guess that this is what they were talking about.  What did Charlie Hebdo print that made these guys so angry, and why did they shoot the cartoonists?  And what is 'satire' anyways?"

Well, son; satire is a kind of political way of talking, where you try to show how silly ideas that some people are really serious about are.  Remember Gulliver's Travels?  Where Gulliver, a giant, is tied-down by hundreds of tiny people?  It doesn't look like a serious book, but it was, and it was in this case not laughing about little people, but instead, it was pointing out how lots of people with small minds use hundreds of tiny rules to stop great people from doing things.  That was a kind of satire of rigid society in England in those days.  

Here, the cartoonists of Charlie Hebdo were using satire to make fun of a group of people who try to use their own religious beliefs to control others.  The people whose beliefs were mocked got angry, and they decided to kill the cartoonists, partly to punish them, and also to make other cartoonists afraid so that they would not make similar cartoons in the future.

"I see.  Do you think that it will work?  Will cartoonists stop drawing cartoons because it may make these guys mad again?"

No.  I don't think it will work.

THAT is why these people are marching.  They want to show to those who think it is OK to control what other people think by threatening them that they will fail.  Here, the French people are saying: "No.  I am not going to let your threats scare me into being quiet.  I have a right to think and to say and to draw cartoons as I like.  You think that you hurting these people is going to control how I think, and I say to you that it won't.

"OK.  So it's important then for all these people to stand together.  But why do they say "Je suis Charlie?"

They say "je suis Charlie" not because they agree with Charlie Hebdo, or even like what Charlie Hebdo had to say.  What they are saying is that, like Charlie Hebdo, we all stand up together for the freedom of thought.  Though our ideas are different, our values are not.  If you want to attack the cartoonists at Charlie Hebdo because you don't like what they say, then you have to attack me, too.

"Hmmmm... OK.  But you know, I've heard you complain when newspapers or other people make fun of your beliefs.  My teacher even said that Charlie Hebdo in the past has made fun of our religon.  They shouldn't make fun of people, should they?  You don't think it's OK to say things that hurt your feelings, do you?  You don't even like their cartoons, after all.

Son, this is the point.  I don't like it when people say things that hurt me.  I don't think it's good when they say things that insult other people.  It's generally not a good idea going around trying to offend people, and the world generally is a better place if people try to be nice to each other instead of trying to be mean.

But this is important for you to understand.  Because I don't like something, it doesn't mean I am going to tell someone else that they can't say it.  I can ask them not to say mean things.  I can control what I say and try to be nice - though I know at times, I am certainly going to say things other people do not like.  But if Charlie Hebdo or anyone else writes something that someone is hurt or offended by, then that person should respond explaining why they think that Charlie Hebdo's comments are wrong.

If there are bad ideas, and you think your ideas are better, then let the other guy have his say, tell people why you think he is wrong, and then let people decide who is right. That is how "the market place of ideas" works.

If you do not like an idea, you pick up a pencil, you do not pick up a gun.

And here, this is why it's so important as it is for everyone to be at this march.  Freedom of thought and freedom of speech means defending ideas that you don't like.  It's easy to stand up for viewpoints you agree with - the cartoonists were not attacked because they drew nice cartoons about puppies.  That sort of speaking does not need anyone to defend it.

No.  Freedom of thought and freedom of speech exist to protect ideas that are not popular.

And never, never, forget this: what is popular now may not be tomorrow.  If someone tries to ban speech or to attack a cartoonist that they disagree with today - even one you don't like or agree with - well, they might be coming after you some day.

So, it's really good then, that so many people are going to go out and stand up for Charlie. 

Even if they aren't named Charlie.  

Another Shooting: Where Do We Go From Here

Warning: Drawing Kills

As just about everyone knows by now, the city of Paris was struck yesterday by its most serious terrorist attack in 50 years, measured by the loss of life.  In the end, 12 people were executed by at least two and possibly three well-armed, disciplined, and obviously well-trained assassins.  There were eight cartoonists, a couple of editors, and two policemen killed.

Because, apparently, the magazine had dared to print cartoons that radical Islamists in France and undoubtedly abroad as well found offensive.

The weekly journal Charlie Hebdo, which takes its name partially because it was an outlet for Peanuts cartoons (hence, Charlie) and partially due to its frequency of publication ("hebdo" in French is short for Hebdomadaire, or weekly) has long been an instrument of satire, some plainly in questionable taste.  Its targets were somewhat indiscrimant; one week it would be President Hollande.  The next, Pope Francis.  Frequently, it poked fun at Islamists.

The blow is like a crash of thunder in a country whose motto is "liberté, égalité, fraternité" ("libery, equality, and brotherhood").  The killing of satirists is a chilling attack at free speech and free thought in a very real way, unlike the sorts that are often held out as examples elsewhere.

I am struck by the reaction for a couple of points. First, the hypocrisy to a point of the US government, who seem now ready to stand, maudlin shoulder to maudlin shoulder with a magazine that just three years ago it attacked publicly; in the words of then spokesman Jay Carney:

We are aware that a French magazine published cartoons featuring a figure resembling the prophet Muhammad, and obviously we have questions about the judgment of publishing something like this,

Another truly bizarre, through-the looking glass reaction can be had from Nicholas Kristof, columnist for the New York Times.  Like the famous "#IllRideWithYou" forelash against imagined anti-Moslem violence in Australia following another terrorist attack in Sydney last month (it's not even accurate to call it a backlash, as it turns out the story that provoked the incident was made up almost of whole cloth), Krisrof talks about Islamophobia and how people jumped to conclusions that the perpetrators were Islamist when others (Christians, Jews, right wingers) had grievances as well.

Kristoff has become almost a caricature of himself. The comment about why people concluded it was Islamist radicals ("(w)e don't know exactly who is responsible") stands in direct conflict with the facts. It was *immediately* known that the killers shouted Islamists slogans (Allahu akbar, "On a vengé le prophète Mohammed") and they were described by eyewitnesses immediately.

I live in Paris and this was documented on social and other media within minutes.  In fact, it turns out that the perpetrators were exactly who we thought that they were, and also in fact, at least one was known to the police for radical activity.

Kristof is making excuses and projecting in a naseauting and clueless way. Why would anyone conclude that the killers were Jewish or Christian?  This column would not have been written by a sane, informed, non-tendentious writer. The information was available. He works for a newspaper for Christ’s sake.

People are asking what it all means to France, and there is right now a lot of bravado about standing together in solidarity and the importance of freedom.

As a foreigner living in France, I am going to take a contrarian view and say that in the long run, it will likely mean little more than a continued erosion of freedom of speech here.

Politicians like François Hollande will issue mawkish statements about solidarity with the writers, the confreres of Charlie Hebdo will replace their banners with black-ink as an hommage, but in the end, the key players are not going to do more than STOP printing cartoons and other material they think is scandalous.

Recall that France, unlike some other nations, does not have a real freedom of press.  Writers and actors are prosecuted for making statements that "incite hatred" (witness the fracas last year with the "comedian" Dieudonne Mbala Mbala).  Even today, one of the two leading papers here in Paris (Le Figaro) has re-tweeted several times how people can report racist or offensive tweets or posts on social media.

I expect that we will see more - not less - of this.

One thing further to keep in mind is this - a few years back when Jyllandsposten in Denmark printed a cartoon deemed "offensive" to some Muslims, newspapers in France - Le Monde and Le Figaro included - refused to show the cartoon even in stories about the controversey.  Charlie Hebdo was one of a very small number who ran the cartoon.

Sadly, I think that that is likely to be what this event will mean ultimately here.

And I am less concerned right now about the rise of xenophobia or votes for Marine Le Pen and more concerned about self-censorship.  And surely more concerned that 12 people, including two policemen, lost their lives.

Does "Economics" go with "Health?"

The Doctor Won't See You Now

I was reading a story today that was recently broadcast on the US NPR network.  Reprinted was an interview from the show "Fresh Air" with Steven Brill, a lawyer and writer who has recently focused on the impact of health care costs in the US.  

Brill in 2013 wrote a 24,000 word cover article for Time magazine entitled "Bitter Pill: Why Medical Bills Are Killing Us," in which he outlined the ways be which (he sees) hospitals and others in the health care business rig the US health care market to enrich themselves whilst at the same time drive up the costs and reduce the access to medical care.  Brill has recently extended his earlier essay into a full-length book, broadening its targets to include the political battles around the Affordable Care Act ("Obamacare"), including pharmaceutical company lobbyists, 

The interview with Brill is fascinating, and I highly recommend reading it.  It puts the work into a more personal context by framing the book around a recent incident where Brill had been diagnosed with a heart condition that required surgery - expensive surgery - to fix. 

The piece really frames well the essence of the situation - and one that, as a health economist, takes up the lion's share of my waking day.

That issue is, people in general, and Americans in particular, pay an enormous amount of money for "health care" without really understanding what they are paying, what the risks and outcomes are, and how to evaluate them.  Brill, a lawyer and not a doctor, or health economist, or medical ethicist, doesn't really frame it this way, but that's what more or less comes across. 

The quote that took my interest most directly was near the top:

At that moment I wasn't worried about costs; I wasn't worried about a cost benefit analysis of this drug or this medical device; I wasn't worried about health care policy," Brill says. "It drove home to me the reality that in addition to being a tough political issue because of all the money involved, health care is a toxic political issue because of all the fear and the emotion involved."

"A patient in the American health care system has very little leverage, has very little knowledge, has very little power," Brill says. [emphasis mine]

This is really an insoluble issue from my vantage point. 

In my reading, his first point is either vacuously true or vacuously false, depending on how you look at it.  ANY consumer of any product, in deciding whether to purchase the product, empirically, if sub-consciously, is making a cost-benefit analysis.  It doesn't matter whether it's an iPad, a candy bar, "the clapper," or open-heart surgery.  If you decide to buy the iPad, you are implicitly deciding that the value of having the device is more beneficial than the money you are handing over to get it, and thus by extension, the other items you will not be able to afford by making this purchase.  By electing for heart surgery - itself carrying risks of death on the operating table, as well as some costs you will have to bear, even if only in the deductible, co-pay, and other costs you will incur.

In this sense, there is nothing fundamentally different about choices for consuming a "health care service" versus other choices.

On the other hand, there are fundamental flaws as well - if you are insured, then the overwhelming majority of the actual, economic costs of your choice are obscured from view, and most of the health risks of the procedure are poorly (at best) understood, and thus your choice is made in an environment of unequal information.  

Doctors (the providers) will, in almost every case, have an enormously larger reservoir of information than patients (the consumers) on the true risks, benefits, and costs.  This information asymmetry means that, while you surely are making a cost-benefit analysis, that analysis is sufficiently ignorant that typical "market" analytics do not really apply.

Does it Even Make Sense To Talk about the "Health Care Market?"

What comes out in reading Brill's piece to me is multifaceted.

First, his basic argument is freighted with opinions that he would masquerade as fact.  He makes an incredible statement that "(t)he insurance companies are not really the bad actors in this movie."  This is contrary to the back-story that, when he got his bills from United Health Care (his insurer), they were 36 different letters in 36 different envelopes, filled with conflicting, confusing, and contradictory information.  The climax of this thread is reached when Brill, in the course of working on his book, confronts the CEO of UHC with a bill that states that there is $0 billed, $0 paid (by the insurer), and yet $154 owed by the patient.  The CEO has no way to explain - or even understand - this situation.

The insurers, he says, are incompetent and terribly managed, and create and send out bills that they cannot understand, and yet they are "victims" just like everyone else.

I really don't know what more to say about this than the fact that the insurers are, in essence, the real customers of health care in the US.  THEY are what in health economics are called the payers.  They negotiate the prices; they decide what medicines and treatments you as the end consumer will be able to have access to.

It is close to axiomatically true that, in an economic system, where the negotiator is incompetent, terribly managed, disorganised, and ignorant of the costs and benefits, then the price structure is going to be distorted.  Perhaps, terribly distorted.

Brill goes on to make some observations that are, to be kind, wrong.

He makes the following claim that simply isn't so:

But they're (the insurance companies) sort of stuck in the same ditch we're in, which is being forced — unlike the payers for health care in any other developed country on the planet — being forced to pay uncontrolled, exorbitant prices and high profits that are generated by nonprofit hospitals and by drug companies and medical device makers.

It's wrong on two counts.  The first is that foreign payers - in this sense, he is talking about single payer systems like the UK or France, "control" prices in a way that American ones cannot.  In fact, prices are negotiated in most single payer systems in ways that are not fundamentally different from the way that they are in the US with large payers like UHC.  France, which is often cited as offering a model for high-quality care at lower cost, goes through a quite complex system of cost-benefit analysis wherein the medical value and innovation are evaluated, and then price negotiations, based on the level of need, benefit, and innovation established - occurs.   

The drug companies are not forced to accept the prices negotiated; if they do not, they simply do not make the products available in France.  Similar systems exists in the other markets. Different countries assess value differently, and hence, prices are not uniform across Europe, nor is access to treatments.  For example, I would far prefer to get a highly aggressive form of cancer in Germany than in the UK.

In the US, large payers have a similar tool available - UHC can easily decide that the value offered by a treatment is not sufficient for the price at which it is offered, and thus decide not to re-imburse it.

The difference is, in France, there is a single payer, so it has larger influence on the price.  In the US, if UHC does not choose to re-imburse a product, one of its rivals - perhaps Aetna or Kaiser - will. One presumes that an insurer that provided access to more and more expensive treatments would likely have higher premiums and higher deductibles. Consumers could then, hypothetically make a choice on whether the additional cost is worth the additional coverage.

In short, US healthcare payers have precisely the same tools to control costs at their disposal as their European peers.  They choose not to deploy them precisely because they know their customers - people who are ready to demand Cadillac service at a Chevy price.

This is where the problem of information asymmetry comes in, and where something like comparative effectiveness could be a big help.  Other countries with 'health care technology assessment" systems (HTA) in place - like France, Canada, or the UK - make data-driven analyses of the costs and benefits of competing treatments.  The process is not perfect, and it is not entirely "transparent," but it provides a somewhat information-based way to assess what to re-imburse and what not to.  

When such a system was discussed as part of the ACA in the US, it was quickly shot down under a fusillade of remarks about "death panels."

Worse still, Brill talks about "exorbitant" prices and "exorbitant" profits.  Indeed, the prices of some treatments are eye-popping.  The current enfant terrible is Gilead Sciences, which recently launched a treatment called "Harvoni" that provides a near 100 per cent cure rate for chronic hepatitis type C (hep-c).  The price tag is close to $100,000.

Is that, however, "exorbitant?"  Are Gilead's profits "humongous?" 

These are intrinsically subjective questions.  $100,000 is a lot of money.  I would bet that the house Brill lives in (he made $45 million selling one of his companies), if offered at $100,000 would not be called an "exorbitant" price.  

In a sentence, "price" and "value" are not the same thing.  They're related, but the relationship is not necessarily a strong one.

This is the sort of question that economics is set up to answer, and why health economics exists.  But given Brill's thought exercise, the price of health care and if it's "reasonable:"

The first way to look at it, which is certainly the way I was looking at it the morning after my surgery and ... eight days later when I walked out of that place a healthy person, is that those people saved my life. So in that sense, would I beg, borrow and steal or insist that my insurance company beg, borrow and steal to pay for all that? Yes. Were the people there highly professional, highly skilled? Did they care a lot about me? Yes. So in that sense, it's reasonable.

your ability to live - the most basic urge of any living thing - is directly related to the care you get when you are sick.  And given that Brill would "beg, borrow, and steal" to be able to access care that he admits "saved (his) life," is economics really an appropriate tool?  Is it a useful one?

In classical economic theory, you have costs that are either partially or completely elastic (the more cost there is a for a product, the lower the deman) or partially or completely inelastic (demand is constant irrespective or price).  Health care price/demand are highly inelastic.  If you *need* something to live, you are not going to reduce your demand for it unless price distortions become extreme.

In this sense then, the most basic law of economics does not apply to medical care.  Precisely because the products have value, their prices cannot follow a free market scheme.  

This turns the price/value relationship on its head.  Unlike say, an iPod or a CD or a type of automobile, value is decoupled from the argument of cost.  THIS has distortive effects on policy and on the language of the discussion.

If one steps back from the heat of the argument, this is obvious - Harvoni costs $100,000, an "exorbitant" price.  Recently, a cel from an earlier Tintin cartoon sold for many times that price.  The first has the power to save lives, while the second (as much as I like Tintin comics) has absolutely no intrinsic value.

The standard argument companies make for their high prices is that these are needed to finance R&D (itself a not completely honest answer); seldom does a company like Gilead respond that the price is high because the value of what they offer is high, which is the more honest answer.

But it is an unpalatable one because we claim that we cannot place a value on life.  This itself is plainly false (cf: arguments by Princeton bio-ethicist Peter Singer), but it is instructive.  However, since the absolute value of medical interventions is so high, price must be decoupled from the price means that economic analyses of an economic question are inappropriate.

Unfortunately, we live in a world where we measure what we value, and we act on what we measure.  And thus, healthcare systems - even in European social democracies - have no alternative but to turn to cost-benefit analyses when assessing how to allocate their resources.

Vive La Fete

One of the (many) excellent things about living in a foreign land is the chance to learn about and embrace new traditions.

Today is the 6th of January; on the Christian calendar, that means the Feast of the Epiphany.  Tradition holds that it was this 12th day of Christmas on which the three magi (wise men) from the East appeared in Bethlehem to render homage to Jesus.

In France, and indeed other Latin, Catholic nations like Spain and its former terriroties, the day is celebrated with the famous galette des rois - the kings' cake.

This delicious, sweet, almond-infused cake is served at a family gathering on the Epihpany.  Beyond the sweetness of the cake, a hidden surprise is baked into the cake's centre - a small fève.  Dating back approximately to the fourth century, the fève was initially a fava bean (the French word is literally a fava bean), which was taken from the Roman winter custom of Saturnalia and melded with Christian tradition.

The cake is divided into n+1 pieces, where n is the number of celebrants.  The extra piece, symbolic of almsgiving, was called "God's share," and held out for the first poor or hungry person to visit the home, in recognition of the gift of God's Son to the world.

Whoever locates the fève is entitled to be king for the day.  A paper crown is provided to mark just that purpose.  In order to ensure fairness, the youngest child in the room typically sits under the table and indicates to whom each slice above is alotted.

The bean of course has long gone, and is now replaced by a small, porcelain figurine.

Our household celebrated its first galette last Christmas, and has of course jumped in again this year with both feet.  We have only one child, so it's relatively easy to rig the game so that he gets the fève and hence, the crown.

Though there is only one Epiphany per year, we are sure to celebrate with many galettes des rois this year, as we did last.  We've even selected our favourite baker who produces the best galette as well as the shop who supplies the best fèves.

Bonne année à tous.

2014..--->...2015 Of Monsters and men

We've turned the page from 2014 to 2015.  An old year is over, and a new one is now five days old.  

Right now, it's not at all clear what it will bring.  What new experiences.  The end of what old ones.  Of course, there are some things certain to come.  I will write the wrong year (2014) on at least one contract, cheque, or other public document.  All of us will be a year older at some point - well; some of us won't of course make our next birthday.  No one knows who just yet.  There will be a cartoon version of Le Petit Prince.  That is, unless Kim Jong Un reckons that the title is an insult, in which case Paramount Pictures will perhaps be the next target of cyber-attacks.

My little boy will turn 10 in August - a fact that I find hard to accept.

Ten years old.  My, how time flies.

I remember turning 10 pretty clearly, though it's now (almost) three and a half decades passed.  A double-digit number.  I felt pretty grown-up then, though obviously, not really.  

Was talking about it over dinner one night during the Christmas holidays with him - once you acquire a two-digit age, there is no going back.  Of course, in life, there is no going back no matter the age - only relentless progression.  

One goes once from one to two digits, and then (for a very lucky few) from two to three.

Our little boy was a bit apprehensive at the prospect - he seems in no hurry to grow up, something he does not share with a much younger me.  Of course, we encourage him to stay small as long as he can, ultimately, a hopeless hope.

Over Christmas, my kid brother (himself now 41 years old) celebrated the first Christmas in the life of his baby son, born in June of 2014.  We live on the far-side of the Atlantic Ocean, and must rely on on-line photos these days, but he posted several.  James's son's birthday is separated from ours on the calendar by almost exactly two months (10th June versus 11th August), so the pictures of his little boy's first Christmas are not dis-similar to those of our own.

By the Christmas tree in a onesie.  Ringing in the new year.  

When your kids are really young, their world is pretty small.  Many experiences are new, and the world is full of potential.  Almost limitless potential.  But much like the turn of the calendar from one year to the next, much of life is predictable.  Some of it is even deterministic.  A baby reminds us of the possibilities; re-inforces the illusion that something exciting and un-known could be just around the next corner or in the next page of the calendar.

As an aside, there was last year a fantastic movie called "Boyhood," which tracked (in real time) twelve years in the life of a little boy, from beginning in school at age six until he is off to college at 18.  It was a tour de force that allows you to watch a life evolve over the course of two hours.

One of the gifts we gave our son Alastair was a Lego toy - in fact, a Star Wars ship.  The thing must have between two and five-thousand tiny plastic pieces.  He and I have been putting it together, little by little.  It's not his first Lego, so we've been down this road before.  

This year, he is doing most of the work, and I am doing most of the watching.  This is different from the past.

Another reminder of the inscrutable passage of time.

When he was six months old, six years old, his mother and I were nearly omniscient, omnipotent beings in his little world.  When asking me questions, at that point, I almost always knew the answer, and he seemed quite disappointed - upset in some cases - when I had to confess that I did not know the explanation, or a challenge arose that I could not 'fix.'  When you're six, most such situations revolve around being able to lift something a child cannot, or reach high onto a shelf to get something impossibly out of reach.

At 9 going on 10, there are now many, many questions he asks that I haven't the answer for, and challenges that I haven't the solution to.  And, perhaps as a sign of growing maturity, he now shrugs it off when I cannot fix or answer.  The illusion that daddy really knows everything and can do anything is gone.

For James and his son, that world still exists.  It won't last forever, and I miss it.

The Lego ship will take some more time to put together, but the ability to fix all of the problems of my son's world is something that cannot be found in a little, pictorial instruction booklet printed in Denmark.