NETFUTURE

                    Technology and Human Responsibility

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Issue #88      A Publication of The Nature Institute        April 16, 1999
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            Editor:  Stephen L. Talbott (stevet@netfuture.org)

                     On the Web: http://netfuture.org
     You may redistribute this newsletter for noncommercial purposes.

NETFUTURE is a reader-supported publication.


CONTENTS
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Quotes and Provocations
   How Compelling is Distance Education?
   Couch Potatoes Feeling Oppressed at M.I.T.
   The ATM as Commercial Television

Notes on Health and Medicine (Stephen L. Talbott)
   Midwives, placebos, and healing the whole person

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                         QUOTES AND PROVOCATIONS


How Compelling is Distance Education?
-------------------------------------

The dropout rate for Internet-based, distance education classes is said to
be 32 percent; the conventional classroom rate is 4 percent.  Under the
most obvious interpretation, those are dramatic figures.

Back in the days when I was in school, the most common reason for high
dropout rates in particular classes was, as near as I could tell, lousy
teachers.  The educational experience in those classes simply wasn't
compelling enough to hold students.  The lousy-teacher explanation,
however, can hardly explain the problem with distance education, since
these online teachers will surely be above average in the sense that
they're innovative, energetic, up-to-date, and adaptive.  If they suffer
dropout rates 800 percent of normal, then we ought to look at the
educational limitations of the medium they've chosen.

That figure, it seems to me, may be the best and most direct "hard number"
we now have regarding the educational potentials of distance education.
Of course, as I like to point out, such numbers always require
interpretation; they must be brought into one or another context, which
will in turn determine the significance of the numbers -- a simple truth
that is lost sight of amazingly often.  But the burden in this case is
clearly on the distance education enthusiasts to do some fast
contextualizing footwork if they would find any encouragement in this
statistic.

Actually, I suspect that the real situation is much worse than indicated
above.  Someone should look at how many of the existing 26,000 online
courses are about using computers and the Net, or about cyberculture.  The
percentage is likely to be considerable, and if there is any place
distance education should work, it is in teaching these "wired" subjects.
The online dropout rate stands to be much higher once you separate out the
Net-focused courses and look at the use of the Net in teaching the core
curriculum.

The  figures given here, by the way, come from one of the 300 studies
reviewed by the nonprofit Institute for Higher Education Policy in
Washington, D.C.  In a report released this month, the Institute concluded
from its review that little original or reliable research has been done
regarding the effectiveness of digital technologies in distance education.
IHEP's president, James Meriotis, explains that

   Most of the research is based on anecdotal evidence offered by persons
   and institutions with vested interests in the techniques being
   evaluated or in the very programs they are evaluating.  (quoted in
   Chronicle of Higher Education, Apr. 7, 1999)

Research into the effectiveness of distance education, in other words,
looks to be in much the same state as research into the effectiveness of
K-12 educational technology.

(You'll find a PDF version of the IHEP study at http://www.ihep.com/.
Thanks to Timothy Morriss for alerting me to this study.)


Couch Potatoes Feeling Oppressed at M.I.T.
------------------------------------------

Not to pick on M.I.T. (see article on the Media Lab in NF #87), but....

In yet another high-cost, high-profile attack on the future, the M.I.T.
Laboratory of Computer Science has kicked off a "ubiquitous computing"
project called Project Oxygen.  It's the usual stuff:  networked chips in
walls, doors, cars, refrigerators, and all the rest -- in other words, Bill
Gates' house for the masses.  But what caught my eye in the New York Times
story about this project were two comments by laboratory director Michael
Dertouzos:

** "Our overarching goal is to enable people to do more by doing less."
It is remarkable that someone could make such an empty statement and not
immediately feel compelled to apologize for it.  What are these
multiplying activities we are filling our lives up with by doing "less" of
them?  How satisfying will they be in their own right?  And what are we
sacrificing along with those earlier activities Dertouzos would have us
give up?  You haven't said anything until you at least begin to answer
such questions.

One way or another we will spend our time doing things.  In exchanging
activities we were previously content to do more of for activities we now
prefer to do less of, we ought to inquire about the nature of the bargain
we are striking -- all the more so when we see our lives filling up with
multiplying, decontextualized activities on the "less" side of the ledger.

** Again from Dertouzos:  "We want to liberate ourselves from the tyranny
of `going to the computer'."  The idea is that the computer will be all
around us -- everywhere -- and so we won't be bothered with going to it.

Ah, liberty!  Picture it to yourselves:  this is a man for whom the idea
of tyranny has contracted to the burden of getting to his computer.  We've
come a long way from "No taxation without representation"!

Even if one's tunnel vision must be restricted to the computer, can't one
at least begin to look for the real risks of oppression it poses -- the
risks lying, for example, in the subjection of more and more of our lives
to the fixed patterns of logic embedded in all those networked chips?

Deliverance from "the tyranny of going to the computer" -- and you
imagined that professors at prestigious universities spent their time
helping students to think large thoughts!

(Thanks to Christian Sweningsen for the Times article.)


The ATM as Commercial Television
--------------------------------

Following up "Cluttering Our Lives for Profit" in NF #86, NETFUTURE reader
Richard Smith passes along a brief news item about Wells Fargo.  The bank
is selling ad space on its ATM network.  These days, of course, the
captive audience (why do we seem to find ourselves more and more in that
unhappy assembly?) represents the pot of gold at the end of the digitized
rainbow.  Wells Fargo vice president Barry McCarthy puts the case for ATM
ads succinctly:  "People aren't going to walk away from an ATM in the
middle of a transaction."

True enough.  But some of us, at least, may learn to walk away before the
transaction starts.

SLT

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                       NOTES ON HEALTH AND MEDICINE

                            Stephen L. Talbott
                          (stevet@netfuture.org)

Following are some informal notes I've been collecting over the past year,
mostly relating to medical stories that have appeared in the popular
press.


The Fear of Witches and Midwives
--------------------------------

If you want to explore the anti-human tendencies of the technological
mindset, there is no better place to start than with the modern history of
the mechanization of childbirth.  Some day we will look back at the
barbaric (if antiseptic) practices of the twentieth century much as we now
look back at bloodletting and the application of leeches.  Of course,
under the strengthening influence of women themselves, hospital practices
have been changing for the better in recent years.  But it is well to
remember how difficult the reform has been, and how resistant the high
priesthood of medicine.

Katsi Cook, a traditional midwife from the Mohawk Nation -- and now a
lecturer at the University of Albany School of Public Health and a
visiting Fellow at Cornell University -- tells about one particular front
in the battle for sane practices:

   The Inuit women of Northern Quebec are remarkable women who decided in
   the late '70s that they were tired of the government policy that flew
   them out from their homes when they were 36 weeks pregnant to cities in
   the south, to Montreal, Kingston, and Toronto to have their babies.
   This practice separated them not only from their families but from the
   continuity of the birthing experience, so that when they would get back
   to their homes, having suffered the great stress of being in an urban
   environment where their language was not available, where they were
   lonesome for their families, where they had little kids back at home
   that they were worried about, in some cases they would go back to find
   that their families were no longer intact.  And so they decided
   themselves they wanted to change how health services were being
   delivered to them, and as a result they now have a maternity center
   that lies adjacent to the hospital, where 95% of all the Inuit births
   are done in the Inuit language by Inuit midwives.  They have the best
   statistics in Canada.  (From a talk at a New York Open Center
   conference, reported in Lapis #8.)

But the battle is by no means over.  For example, New York's 1992
Midwifery Act has been used as a weapon to run traditional midwives out of
the state.  In general, one gets the feeling that low-tech midwives suffer
from something like the stigma once attaching to witchcraft.  They deal
with the dark, damp, messy secrets of the genesis of life, and these
secrets, like all mysteries, provoke in us a powerful urge to raise a
veil.  But rather than a veil of modesty, awe, and respect, we prefer a
clean, well-instrumented, precisely controlled illusion.  We cannot relax
until the deformed, mystery-bearing mother has been safely delivered for
exorcism to the fluorescent-lit, stainless-steel sterility of the hospital
operating room.


Does Caring Matter?
-------------------

"Patients", Bernard Lown writes, "will not acquiesce to the ultimate
alienation of being reduced to standardized objects.  No one will accept
for long being merely identified by their illness, or seen as nothing but
an assemblage of broken down biologic parts."

Lown is professor emeritus of cardiology at the Harvard School of Public
health and chairman of the Lown Cardiovascular Research Foundation in
Brookline, Massachusetts.  He is also a co-recipient of the 1985 Nobel
Peace Prize.  He writes that

   Patients crave a partnership with physicians who are as sensitive to
   their aching souls as to their malfunctioning anatomy.  They yearn not
   for a tautly drafted business contract, but for a covenant of trust
   between equals earned by the doctor while exercising the art of
   caring."

Then he concludes by quoting the essayist Anatole Broyard:

   I wouldn't demand a lot of my doctor's time.  I just wish he would
   brood on my situation for perhaps five minutes, that he would give me
   his whole mind just once, be bonded with me for a brief space, survey
   my soul as well as my flesh .... Without some such recognition, I am
   nothing but my illness.  (From an op ed column in the Christian
   Science Monitor, Mar. 4, 1999)

Is this lack of recognition the reason why, in a society widely regarded
as one of the healthiest on earth, we seem to be consumed by an awareness
of our ills.


The Alternative Rebellion
-------------------------

The gains made by alternative medicine during the past decade or so have
been striking, to say the least.  According to American Medical
Association polls, in just two years -- from 1995 to 1997 -- the number of
medical schools offering courses in alternative medicine leapt from 46 to
75 out of 117 schools surveyed.  Now Congress has created a new National
Center for Complementary and Alternative Medicine Research, and insurance
companies are increasingly offering coverage for alternative therapies.

This past November the Journal of the American Medical Association,
at the request of its readers, devoted an entire issue to alternative
medicine.  A Harvard Medical School study cited in that issue shows that
patient visits to alternative practitioners were up 47% since 1990.  Today
Americans visit such practitioners more often than conventional
therapists, and they spend more money out of pocket on alternative
treatments than conventional ones.  As J. P. Harpignies summarizes the
matter:

   Americans from all walks of life have voted decisively with their feet and
   wallets for more personal and cultural autonomy in their health care
   choices.  And they've done it despite decades of, until recently, almost
   universally negative propaganda from the mainstream media and virtually no
   insurance coverage for alternatives.  (Lapis, no. 8.  Harpignies is a
   contributing editor at Lapis and author of Double Helix Hubris: Against
   Designer Genes.)

Harpignies finds in all this a

   profound challenge to the authority of technocratic elites obsessed
   with military metaphors of "wars" on disease, purely reductionist
   science and techno-utopian attempts to subjugate and redesign the
   natural world.  [Alternative medicine] is, in that sense, the most
   culturally and politically successful mass movement embodying holistic
   principles to have emerged in the modern West.

An encouraging thought.  Anyone concerned about the unhealthy role of
digital technologies in the modern world would do well to study the
makings of the popular rebellion against technologized medicine.


When Sugar Pills Heal
---------------------

Any discussion of alternative medicine inevitably comes around to the
placebo effect.  A New York Times article entitled "Placebos Prove
So Powerful Even Experts Are Surprised" began with this narrative:

   Many doctors know the story of "Mr. Wright," who was found to have
   cancer and in 1957 was given only days to live.  Hospitalized in Long
   Beach, Calif., with tumors the size of oranges, he heard that
   scientists had discovered a horse serum, Krebiozen, that appeared to be
   effective against cancer.  He begged to receive it.

   His physician, Dr. Philip West, finally agreed and gave Mr. Wright an
   injection on a Friday afternoon.  The following Monday, the astonished
   doctor found his patient out of his "death bed," joking with the
   nurses.  The tumors, the doctor wrote later, "had melted like snowballs
   on a hot stove."

   Two months later, Mr. Wright read medical reports that the horse serum
   was a quack remedy.  He suffered an immediate relapse.  "Don't believe
   what you read in the papers," the doctor told Mr. Wright.  Then he
   injected him with what he said was "a new super-refined double
   strength" version of the drug.  Actually, it was water, but again, the
   tumor masses melted.

   Mr Wright was "the picture of health" for another two months -- until
   he read a definitive report stating that Krebiozen was worthless.  He
   died two days later.

Sandra Blakeslee, the article's author, notes that "doctors who know this
story dismiss it as one of those strange tales that medicine cannot
explain.  The idea that a patient's belief can make a fatal disease go
away is too bizarre."  And yet, the burden of the article is that the
placebo effect has turned out to be "even more powerful than anyone had
been able to demonstrate", and the "biological mechanisms" underlying the
effect can "achieve results bordering on the miraculous".  Among the
reported findings:

** Patients with knee problems were divided into two groups, one of which
received fake arthroscopic surgery, while the other received the real
thing.  Two years later both groups showed equal relief from pain and
swelling.

** In a Japanese study, thirteen people extremely sensitive to poison ivy
were rubbed on one arm with a harmless leaf and on the other arm with
poison ivy.  They were told that the harmless leaf was poison ivy, and
that the poison ivy was a harmless plant.  All thirteen subjects broke out
in a rash where the harmless leaf contacted their skin; only two reacted
to the ivy.

** "A recent review of placebo-controlled studies of modern antidepressant
drugs found that placebos and genuine drugs worked about as well."

** In another study, a baldness remedy enabled 86% of the male subjects to
maintain or increase the amount of hair on their heads.  The same was true
of 42% of the men taking a placebo.

** "Asthmatic children were given a sniff of vanilla along with a squirt
of medicine from a bronchodilator twice a day.  Later, the vanilla odor
alone increased their lung function 33% as much as did the bronchodilator
alone."

** According to one physician's claim cited in the article, placebos are
"about 55% to 60% as effective as most active medications like aspirin and
codeine for controlling pain."

In general, the author concludes, "studies have shown, time and again,
that placebos can work wonders."


Are Placebos Lies?
------------------

All this is remarkable -- so remarkable that it seems to throw the
opponents of alternative medicine into a state of hopeless mental
confusion.  You'd think they would welcome the data about the placebo
effect as evidence of yet-unexplored dimensions of healing.  But instead
all too many of them still mutter revealingly about "real effects" versus
"quackery".  Oddly, "real" in this context means "attributable to a single
factor artificially isolated from the whole", or "validated within the
inhuman, patient-as-object conditions of a double-blind experiment".  And
"quackery" means "achieved through partly subjective pathways we have long
been taught to ignore and therefore refuse to look at".

But, such attitudes notwithstanding, the placebo effect is indisputable.
One problem with dismissing the results of alternative medicine as
"merely" the placebo effect is that this argument cuts both ways.  When
actual and fake arthroscopic knee surgeries yield roughly the same relief
to patients, what grounds do you have for claiming that the actual surgery
provided "real" relief rather than placebo relief?  More generally, it
appears that a substantial part of the healing effect provided by many or
most "real" treatments is due to their role as placebos.

The standard experimental approach, of course, focuses on the differential
gains provided by a "real" treatment relative to a placebo.  But why
reduce your vision to this often very narrow difference?  Wouldn't it make
more sense, and be more scientific in spirit, to look at the whole
situation, and to evaluate all the factors at work?

One way or another, we will have our faces rubbed in the larger picture.
As Christopher Bamford, a student of the history of medicine, remarked at
a recent conference:  "The placebo effect might be seen as the return of
the excluded whole."

It's been said that placebos are "lies that heal".  There is doubtless
truth to that.  But when a physician, as one human being trying to help
another, doles out a placebo, is that act of caring nothing but a lie?  Or
is the real lie the prevailing message from medical researchers that they
know where healing comes from, that it is merely a matter of mechanisms
and molecules, and that it has little to do with the entire context of
physician-patient interaction?

We come back, then, to that remark by Anatole Broyard:  "Patients crave a
partnership with physicians who are as sensitive to their aching souls as
to their malfunctioning anatomy."  This is not a wish for something above
and beyond medical treatment.  It is a simple wish for medical treatment.
Medicine that doesn't embrace this wish is only a sick fragment of a true
medicine.


Elusive Holism
--------------

You can't open a newspaper these days without reading the complaint of one
medical expert or another that alternative health remedies are not
scientifically proven.  In some cases -- given what is normally meant by
"scientifically proven" -- this is true.  And it's also true that
alternative health publications are littered with advertisements you just
know are scams.

But don't forget:  the same medical establishment that looks at the
alternative remedies and says "not proven" has treated us to a long
history of revelations about conventional treatments, often radical and
invasive, that turn out to have offered no advantage at all over a
complete absence of treatment.  Should we be upset when an herbal remedy
fails to produce a benefit, but cheerfully pass it off as "scientific
progress" when we learn that surgeons have been ripping open people's
chests and screwing around with their hearts for no particular gain?

It's hard to quarrel with Burton Goldberg when he says,

   Listen carefully the next time you hear "medical experts" whining that a
   substance or method has not been "scientifically" evaluated in a
   double-blind study and is therefore not yet "proven" effective.  They're
   just trying to mislead and intimidate you.  Ask them how much "scientific"
   proof underlies using chemotherapy and radiation for cancer or angioplasty
   for heart disease.  The fact is, it's very little.  (Alternative Medicine
   Digest no. 22)

New York Times health columnist, Jane Brody, seconds this point:

   What critics often ignore is that many mainstream techniques, including
   most forms of surgery, also were never subjected to the acid test of
   science:  the double-blind controlled clinical trial.  Also forgotten
   is that many mainstream remedies, including aspirin and penicillin,
   became widely used long before experts knew how they worked.

The real problem here is that only the whole person can be healed in any
profound sense, and our very notions of scientific proof exclude the whole
person from view.  The double-blind study, as Goldberg points out, aims to
assess a single substance or procedure under isolated, controlled
conditions.  The assumption is that we need to look for "magic bullets"
that can reverse the effects of neat, single causes.  No holistic medicine
can take such a view.

"Multiple factors", Goldberg writes, "contribute to the emergence of an
illness and multiple modalities must work together to produce healing."
But simply multiplying the "factors" you are dealing with is not enough,
if you continue to conceive each factor in the old way as an isolatable,
cause-and-effect mechanism.  A whole does not exist as a collection of
interacting mechanisms, however numerous, and however complex their
interactions; a whole can only arise as expression -- as an interior laying
hold of an exterior and raising it to an expressive unity.

The task of the therapist is to grasp that unity, or potential unity, and
to read every particular in its expressive light.  One can bring to such
an understanding no knowledge of a single, unambiguous cause, nor of a
single, unambiguous remedy.  One must allow one's fragmentary knowledge of
causes and remedies to be transformed by the context of the whole person,
in whom both causal and remedial factors are "spoken" in a distinctive
way, as unique gestures of the individual.  The same list of symptoms in
two people of the same age and sex does not necessarily mean that they
suffer from the same "condition".

As we have seen, the placebo effect points us toward the whole person.
The irony is that conventional medicine has spent the past century
documenting this effect and using it as a crude bludgeon against
alternative medicine, instead of recognizing it as a validation, obscurely
understood, of the alternative therapist's call for a medicine of the
whole person.

Part of the idea behind the bludgeon, of course, is that unapproved
remedies are "merely subjective" in their mode of action.  Well, perhaps
it is time to gain a disciplined understanding of all the modes of action,
not just those that come easily to a mindset riveted upon neat mechanisms.

The next time you are accosted by an expert who disdains your alternative
medical choices as "no better than placebos", you might remind him that
measuring up to the best placebos isn't all that shabby a performance.  It
means that many of the elements of an overall healing context have been
achieved -- elements that conventional medicine has willfully ignored with
something like the stubbornness of those who refused to look through
Galileo's telescope.  The only missing element may be the least important:
a substance or procedure possessing fixed, absolute, and objective healing
properties independent of its healing context.  The search for such a
substance is often the biggest illusion of all, not unlike the search for
a way to turn lead into gold.

Or else say this:

   Okay, fine.  So I'm misled by my own wish for healing.  Give me, then,
   your scientific elucidation of this placebo effect that you
   acknowledge to be a massive infection of all your data.  When you've
   got something reasonable to say about it, then maybe I'll listen to
   your warnings about quackery and scientific proof.  Until then, I'll
   keep an open mind about just who the quacks really are.


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                          ABOUT THIS NEWSLETTER

Copyright 1999 by The Nature Institute.  You may redistribute this
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Steve Talbott :: NetFuture #88 :: April 16, 1999

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