Steamboats Are Ruining Everything

Venice in April

A few weeks ago, after a visit to friends in Garrison, New York, I spotted a sign for a bookstore and made Peter get off the highway. We ended up in a shop called Antipodean Books, where I stayed so long that our plans for that evening were ruined, but where the proprietor, in an act of generosity, offered me thirteen out of the seventeen volumes (what dealers poetically call a "broken set") of the Heinemann edition of Turgenev's complete works (Constance Garnett's translation) for just twenty-five dollars. They are still in their original dust jackets, a fetching, hazardous-materials shade of orange! Since I'd already read a few of Turgenev's better-known titles in other translations, the broken set suited me perfectly. Also, aesthetically speaking, I am weak-willed about duodecimo hardcovers, and each of these is just 4.5 by 6 inches—genuinely pocket-sized. And did I mention the highway-worker's-raincoat orange?

This is by way of bloggy-autobiographical prelude to my point, which is just to present a couple of quotes that I like. The two novels I've read in the set so far are about revolutionaries, but for some reason the passages that have most pleased me in them were about spring. In Virgin Soil, when the hero Nezhdanov wanders in the garden of his employer one May afternoon, Turgenev writes:

Nezhdanov sat with his back to a thick hedge of young birches, in the dense, soft shade. He thought of nothing; he gave himself up utterly to that peculiar sensation of the spring in which, for young and old alike, there is always an element of pain . . . the restless pain of expectation in the young . . . the settled pain of regret in the old. . . .

I don't have anything to say about the quote, other than that I like the precision and the poignancy of it. (The ellipses are Turgenev's, by the way, not mine.)

The other passage that particularly struck me comes toward the end of On the Eve, a novella about a Bulgarian revolutionary and the Russian woman who falls in love with him, when the hero and heroine find themselves staying in Venice much longer than they intended to and somewhat against their wishes. The Venice chapters come as something as a surprise, a surge of sentiment in a book that has seemed up to that point to be concerned mostly with conflict, and if the book offered no more, they would make it worth the price of admission. The passage seems uncannily to prefigure Thomas Mann, but the bittersweetness is Turgenev's own. Reading it, I discover that my few visits to Italian cities have all taken place in the wrong months, but that's the least of the regrets evoked.

No one who has not seen Venice in April knows all the unutterable fascinations of that magic town. The softness and mildness of spring harmonise with Venice, just as the glaring sun of summer suits the magnificence of Genoa, and as the gold and purple of autumn suits the grand antiquity of Rome. The beauty of Venice, like the spring, touches the soul and moves it to desire; it frets and tortures the inexperienced heart like the promise of a coming bliss, mysterious but not elusive. Everything in it is bright, and everything is wrapt in a drowsy, tangible mist, as it were, of the hush of love; everything in it is so silent and everything in it is kindly; everything in it is feminine, from its name upwards. It has well been given the name of 'the fair city.' Its masses of palaces and churches stand out light and wonderful like the graceful dream of a young god; there is something magical, something strange and bewitching in the greenish-grey light and silken shimmer of the silent water of the canals, in the noiseless gliding of the gondolas, in the absence of the coarse din of a town, the coarse rattling, and crashing, and uproar. 'Venice is dead, Venice is deserted,' her citizens will tell you, but perhaps this last charm—the charm of decay—was not vouchsafed her in the very heyday of the flower and majesty of her beauty. He who has not seen her, knows her not; neither Canaletto nor Guardi (to say nothing of later painters) has been able to convey the silvery tenderness of the atmosphere, the horizon so close, yet so elusive, the divine harmony of exquisite lines and melting colours. One who has outlived his life, who has been crushed by it, should not visit Venice; she will be cruel to him as the memory of unfulfilled dreams of early days; but sweet to one whose strength is at its full, who is conscious of happiness; let him bring his bliss under her enchanted skies; and however bright it may be, Venice will make it more golden with her unfading splendour.

The President of the American Medical Association Is Disingenuous

On the Tuesday, July 21, episode of All Things Considered, NPR’s Robert Siegel interviewed James Rohack, president of the American Medical Association (AMA), about the AMA’s recently declared support for a health care reform bill, H.R. 3200, which is currently before Congress. Because the AMA has sabotaged health care reform in the past, its support is somewhat unexpected, and some have worried that the Obama administration has won the allegiance of the AMA and groups like it at too high a cost. Indeed, to judge by an FAQ on the association’s website, what the AMA most enthusiastically appreciates about H.R. 3200 is that it may remove a legal ceiling on the growth of Medicare reimbursements to doctors: H.R. 3200, the AMA writes, "represents medicine’s best hope for eliminating the current sustainable growth rate (SGR) formula for updating Medicare physician payments." The tone is pretty rich. "Medicine's best hope"—you'd think they were talking about a cure for cancer.

But what made me prick up my ears on Tuesday night was that NPR's Siegel challenged the AMA's Rohack to respond to an insight into the causes of runaway health care expenses that Atul Gawande described in "The Cost Conundrum," a June article for the New Yorker. As is becoming clear in the Congressional negotiations, health care reform will fail unless costs can be contained, and there aren't a lot of solid ideas (as opposed to wishful thinking) for how to do this without compromising standards of care. Gawande, however, has found a plausible and promising one.

In McAllen, Texas, more is spent on health care per person than almost anywhere else in the United States. Medicare spends $14,946 per enrollee there, "almost twice the national average," Gawande writes. Why? Gawande visited to find out. For comparison's sake, he also looked at nearby El Paso, Texas, where the population has the same ethnic makeup, the same socioeconomic profile, and similar health issues, but where Medicare pays only $7,504 per enrollee—roughly half as much. Empirically, and with mind-blowing lucidity, Gawande in the course of his article considers and rejects a number of possible explanations for the disparity, and concludes that McAllen is not getting better health care, just more of it, because its doctors are focusing not on their patients' health but on making money. You could call it an entrepreneurial culture, or you could cut to the chase and call it a corrupt one. Doctors in McAllen are paid according to how many treatments and consultations they order for their patients. Not surprisingly, they order more of them. Many have also invested in private diagnostic and treatment centers, where they make money twice over when they refer patients—first for having recommended the procedure, and then a second time in their capacity as owners of the facility that administers it. Even doctors without centers of their own can get in on the take; Gawande discovers that in McAllen the private centers are expected to pay kickbacks to doctors who refer patients to them.

In El Paso, by contrast, doctors for the most part make money only once—for the practice of medicine. Indeed, Gawande discovers, some of the nation's lowest health care costs—and best health care performance—are delivered by organizations like the Mayo Clinic, headquartered in Rochester, Minnesota, which pays its physicians a set salary, along with incentives correlated to measurements of patient health. Doctors are rewarded for long-living, robust patients, not for the number of interventions they make into their lives. In many cases, it turns out, doing no harm not only saves money but is also good medicine. Gawande's article is exhilarating to read, because it suggests that it may be possible to cut health care costs significantly—in a city like McAllen, by up to 50 percent—without any sacrifice to anyone's health. There are vested interests who don't want to hear this, of course, and in a follow-up blog post on the New Yorker website, dated June 23, Gawande entertains and refutes a number of attempts to spin or dismiss his conclusions.

If you search the AMA's website for the terms "Gawande" or "McAllen," you will find only a couple of hits, none of them regarding his article. But one of the lovely things about a live interview is that it can force someone powerful to address a question he would be able to slip away from in other circumstances. On Tuesday night, NPR's Siegel asked Rohack, the AMA's president, what he thought about the case of McAllen, where, Siegel explained, Gawande had found that health care costs were exorbitant "essentially because the doctors there are collecting as much money as they possibly can." Siegel continued: "Why hasn't the AMA stood up for best practices?"

Here's Rohack's response:

What McAllen, Texas, is, is not only a unique area but it's also one of the poorest counties in the United States, and so there's cost-shifting that's going on there, because of the uninsured burden. So we're committed as the AMA to try and create a solution so we can reduce unnecessary variation in care, but also have that liability protection so that if we don't order that extra test or do that extra procedure, we don't have to worry about being sued because we didn't do that test that wasn't necessary.

Note that Rohack doesn't pretend not to have read Gawande's article. He merely pretends to have found two explanations that, he implies, eluded Gawande: McAllen is poor, and malpractice lawsuits have raised costs there. It is true that McAllen is poor. Gawande says in his article's third sentence that it's located in the nation's poorest county. But poverty is not why McAllen's costs are higher, because El Paso, Gawande's point of comparison, is almost exactly as poor. In his blog follow-up, Gawande notes that McAllen's poverty rate is 27.4 percent, but El Paso's is 27.3 percent, and El Paso's median household income is actually $4,000 lower than McAllen's. Rohack is not quite lying: because McAllen is poor,  there no doubt is cost-shifting. But there must be cost-shifting in El Paso, too, and if he read Gawande's original article, he must know that this can't explain the cost discrepancy between the two places. Rohack's answer is not technically a lie but it is less than candid.

On the second claim—namely, that malpractice has raised costs in McAllen—NPR's interviewer catches Rohack out, by noting that malpractice liability is capped in Texas (Gawande notes in his blog post that premiums for malpractice insurance have actually dropped lately) and is irrelevant to any comparison of the two Texas towns. Siegel: "It's not malpractice, it's a commercial culture, and doctors trying to make as much as the system permits them."

Rohack:

The reality is that there is variation in care, and part of the reason is we don't have the science to help guide patients and physicians. Is a device or a drug better for that patient? The FDA approves new drugs, approves new devices, but there's no matching, and that's why we were very supportive of legislation to create comparative-effectiveness research, so we can have information to be able to provide the doctor and the patient at the time care is delivered, what's really best for them.

In other words, Rohack changes the subject. No one was talking about comparative-effectiveness research. It's sweet that the AMA supports it. At issue, however, was whether doctors should be paid per procedure or paid a salary, and Rohack's answer sounded to me like weaseling. It's possible that Rohack read Gawande's article inattentively, and failed to see his blog-post follow-up. But that's the most charitable interpretation I can make of his comments, and I'm inclined to believe that he read both very carefully, and is hoping that America will get confused and forget about the idea of reining in the profiteering of rogue doctors.

The Mayo Clinic—whose leaders come across as heroes in Gawande's article—has criticized the healthcare reform proposals pending in Washington, writing on July 16 that "the proposals under discussion are not patient focused or results oriented." Indeed, on July 21, David Leonhardt regretfully observed in the New York Times that no one very powerful in Washington is fighting for the ideas in Gawande's article: "So far, no one has grabbed the mantle as the defender of the typical household—the opponent of spending that creates profits for drug companies and hospitals at no benefit to people’s health and at significant cost to their finances." A pilot program to reform doctor pay is in the current bill, Leonhardt notes, but it's no more than that: a pilot program. Is an opportunity being squandered? In "Salaries for Doctors, Not Fees," published in the New York Times on July 25, Gardiner Harris recapitulates Gawande's thesis, writing:

Doctors in the United States are usually paid fees for each service they provide. The more procedures and tests they order, the more money they pocket. There is widespread agreement among health policy analysts that many of these procedures are unnecessary, raising costs in ways that often do nothing to improve patient health.

But, Harris writes, "almost nothing in proposed legislation that has so far emerged in Congress would encourage the creation of . . . hospitals" that pay doctors salaries instead of fees per treatment. He, too, takes note of the pilot program to reform pay, remarking glumly that "the history of Medicare is full of pilot programs" and observing that the AMA has long opposed such reforms.

Heavy Rotation, the later reviews

This weekend, my boyfriend's music-memoir anthology Heavy Rotation was reviewed by the Los Angeles Times, which calls it "a collection of informed essays that offer personal insight and literary merit." 

Meanwhile, over at the website for Powells bookstore, Peter is blogging all week, and has already written about trying as a child to return albums whose sexuality embarrassed him and about the clash between his curating and his collecting impulses.

Update, July 28: At More Intelligent Life, a blog associated with the magazine The Economist, Corbin Hiar writes that "Like a discerning vinyl collector in a cluttered record shop, Peter Terzian has assembled an impressive and eclectic group of essayists to reflect on “the albums that changed their lives” in his new book Heavy Rotation."

Further update, July 31: The Second Pass features Heavy Rotation on its blog, noting that the women in the anthology tend to relate music to "external experiences," while the men focus on "what the music says about them."

Still more, August 3: Mark Medley of Canada's National Post interviews Peter in-depth about the inspiration for and assembling of Heavy Rotation, the future of the album, and what he's listening to now.

Bike salmon: omen or harbinger?

Last summer, I got a new bike, much easier to ride and much zippier than the hand-me-down I’d been using. A little high on my new confidence, I was for about twenty-four hours a somewhat aggressive, even reckless biker. I don't remember my sins very clearly, but I probably sailed through red lights, rode on and off the sidewalk, and cruised down one-way streets the wrong way.

It didn't last, because I discovered that I didn't like the experience of seeing my life flash before my eyes. I reformed abruptly and rigorously. My principle became, roughly speaking, bike in such a way that even relatively inattentive drivers can be expected to see you and know what you’re going to do next. Also: don't be annoying to pedestrians. I began halting at red lights and stop signs. (Later I relaxed this somewhat, almost to Idaho rules.) I made sure to bike in the bike lane, if there was one (or on the outer edge of it, if biking inside it was going to put me within swinging distance of the opening doors of parked cars). I stayed off sidewalks. And I never, ever biked the wrong way down a one-way street.

Gradually I became hoity-toity about my righteous biking. I glared at cyclists who came at me the wrong way down a one-way street and began to refer to such transgressors by a moniker that blogger Bike Snob NYC invented for them: "bike salmon." I shook my head at cyclists who insisted on riding on the side of the street opposite the bike lane. I clucked my tongue at cyclists who didn't even bother to slow down at busy intersections.

I was therefore interested, and a little chastened, to read in Jeff Mapes's Pedaling Revolution: How Cyclists Are Changing American Cities, that moral indignation about the adherence of bicyclists to traffic laws is absent from the Netherlands, the utopia of cycling, which has, Mapes reports, "the lowest per-capita vehicle death rate in Europe," about a third that of the United States. Except for the requirement that bicycles on the road at night have lights, Dutch police do not enforce traffic laws on cyclists. Explains Mapes:

The Dutch don't see much sense in going after cyclists and walkers when the only people they are putting at risk are themselves. "It's their choice," shrugged [Amsterdam top traffic-safety official Jack] Wolters. . . . The statistics seem to bear him out. . . . One influential 2003 study, by researchers John Pucher and Lewis Dijkstra, found American cyclists were at least three times as likely to get killed as Dutch cyclists, while American pedestrians faced at least six times the danger of dying.

Such laissez-faire will probably not arrive in America. For one thing, there’s no question that it’s dangerous to ride a bike lawlessly. According to Mapes, a 1996 study by the University of North Carolina Highway Safety Research Center found that "as many as a third of all bike accidents involved simply riding against the flow of traffic," and a 2003–2004 Orlando, Florida, study found that "nearly two-thirds [of bike accidents] involved riding on the sidewalk or another unsafe choice by the cyclist." But the Dutch attitude has nonetheless thrown a monkey wrench in my moralism.

To look at the problem through the most rose-colored glasses possible, might bike salmon merely be a sign that biking is on the rise? What if most bike salmon are like me on my first day with my spiffy new bike? If so, and if they survive, they'll eventually settle into abiding by the law. Moreover, when you first start biking in a city as byzantine as New York, the street patterns are novel to you (streets good to bike on do not often coincide with streets good to drive on) and highly confusing, and a newbie sometimes finds himself following a series of well-marked bike lanes into a virtual dead end, the only exit from which is by the bad choice of bike-salmoning (Bergen Street ending at Court Street, when the cyclist wants to reach one of the bridges over the East River—I'm looking at you here). As a cyclist learns the map, he becomes less likely to repeat such errors. If bike salmon are by and large newbies, they will in all likelihood reform with time, the way I did.

But to try out the Dutch way of regarding it, why should I care if they don't? I might care, magnanimously, because I don't want them to die, and I might care, a little more abstractly, because, as a commenter to my previous post noted, lawless bikers could spoil the good name of bicyclists generally, and contribute to a political backlash. But am I responsible for the anger that motorists might feel? It seems unfair for me, as a cyclist, to have to adopt motorists' displeasure as my own, simply because I fear it as a political force, especially when the motorists might be mistaken in their anger. The Dutch facts suggest that irregular cyclists, by making the streets less predictable, force motorists to pay more attention, and when motorists habitually pay more attention, the streets become safer—for motorists, as well as everybody else. Of course lawless bikers offer this (perhaps hypothetical) public benefit at enormous cost to themselves—at the potential cost of death, in fact, which I can't recommend.

At the end of the day, then, I still do wish that all cyclists went the right way down one-way streets, but maybe I won’t tsk-tsk the bike salmon any more. (Can I ask something, though? If you’re a bike salmon, and you and I are headed for a collision, would you mind being the one to swerve into the car lane? Because I didn’t sign up for that.) It would, after all, be swell if motorists paid more attention to the road. The trouble is that motorists hate to have to pay more attention. Their disgust has to do, I think, with the asymmetrical nature of the warfare between cyclists and motorists. As I vaguely recall from high-school physics, the damage that a moving object can do is proportional to its momentum—its mass times its speed. A 5000-pound SUV going 35 miles an hour is therefore about 81 times as dangerous as a 150-pound cyclist on a 30-pound bike going 12 miles per hour.* The worst thing a motorist can do to a cyclist is kill him, and the worst thing a cyclist is likely to be able to do to a motorist is saddle him with the guilt of having killed. But guilt enrages in a way that fear doesn't, maybe because people are softies underneath, and would rather run the risk of being killed than of killing. (Between the certainty of one or the other, the choice might be different, naturally.) The only way a motorist could level the playing field would be to drive 81* times more prudently than the average bicyclist, and that may not be humanly possible.

* Correction, July 27: My memory of high-school physics is even hazier than I knew. As several commenters below have pointed out, the damage that a moving object is capable of is proportional not to its momentum but to its kinetic energy—its mass times the square of its velocity. So the SUV in my example is not 81 times but 236 times more dangerous than the bicycle.

Pole position

A couple of weeks ago, while I was waiting in the bike lane at a red light in Williamsburg, a fellow cyclist passed me and ran through the light just as it turned green. The driver of an SUV, who had been waiting at the same light, edged up to me. “I saw what that guy did to you,” he said. “Do you want me to hit him?” He didn’t seem to be joking. Terrified, I assured him that I didn’t want revenge.

The SUV driver probably was joking, of course, and as is often the case, I was slow on the uptake. But I suspect that beneath his joke, the rage he felt on my behalf may have been in earnest, because I’ve sometimes felt a similar rage when I’ve been passed while driving. Which set me wondering: Why don’t I feel the same rage when I’m passed on a bike?

A moralist might answer that bicyclists, as people, are more humane and ethical than car drivers, but I don’t think that’s true. In general, bicycling may be more ethical than driving, because the carbon dioxide in car exhaust raises the world’s average temperature, but bicyclists aren’t more ethical than drivers, in their essences—or so I believe, mostly because I myself happen to switch between the two kinds of vehicles. The rage must have something to do with the nature of cars.

A more plausible answer is that cars are bulky. If you’re driving, and another car passes you, there may not be an opportunity to pass it in return, even if it slows down, for several blocks. In a narrow street, if a car in front of you suddenly decides to double-park—to pick up a passenger or make a delivery—you’re stuck behind it for the interval of the errand. To be passed by another car aggravates your chances of delay; something has in fact been taken from you. I understand that in bicycle races, bicycles can obstruct one another, but this almost never happens when cycling merely for transportation. If a fellow bicyclist passes you and then slows down or stops, you simply pass him again, no hard feelings. On a bicycle, passing doesn’t usually involve the possibility of blocking.

A somewhat subtler explanation, however, may lie in the different forces that power the two kinds of vehicle. If a fellow bicyclist passes me, he’s going faster than I am, either because he wants to or can. If he wants to go faster, then it’s probably because I don’t feel safe going as fast. Since speeding bicycles don’t kill nearly as many people as speeding cars do, I’m not likely to resent his speed. I just prefer a lower level of risk for myself. In such a case, the most hostile sentiment I could summon up would be something like, “Hope you don’t wipe out, guy.”

More likely, though, he’s going faster because he’s able to go faster. In other words, he passes me because he’s in better shape than I am, because he has more energy at the moment, or because his bike is more efficient. And these are factors that, even if I’m not happy to have to acknowledge them, I have to respect, because they’re more or less the same limits to motion that I, as a human animal, have had to be at peace with since around the time I learned how to walk. I can’t simply will my bicycle to go as fast as any bicycle that passes me. Or rather, I can will it to, but I then have to work to make it happen—work that I’ll feel in the ache of my muscles and the flow of my sweat. If that sounds a little sexy, that’s because it is: I’m not likely to rise to the challenge unless the exertion it will require strikes me as pleasant. If I don’t have the energy or the appetite for it, I won’t mind letting the challenge go, because I’ll understand myself to be reserving my energies and appetites for something else. It’s all about my pleasure.

The case is very different behind the wheel of a car. As a matter of physics, cars are fueled by the controlled explosion of hydrocarbons, but as a matter of psychology, they are fueled by mere will. To make a car go, you don’t have to work up a sweat, tire out your muscles, or burn off calories. On a racetrack, one driver passes another to show off the superiority of his car, but off the racetrack, most cars are capable of driving faster than the legal speed limit, and are therefore practically identical, give or take negligible differences in acceleration time. In daily life, therefore, the decisive force behind the passing of one car by another is mere cussedness. As is well known, the supply of cussedness, in general and in any single individual, is limitless. Compounding the problem, cussedness does not dispel itself, when exercised, in happy-making endorphins. It breeds more cussedness, in oneself and in the person it is directed against. The reason that it is so infuriating to be passed and cut off by a fellow driver is that nothing finite is at stake. The action of passing costs a driver no energy and proves nothing about his strength. It expresses no more than a wish to get in front of you; all he did was dip his right toe a little faster and a little harder than you. It isn’t easy for the cut-off driver to find within himself the greatness of spirit needed to say, “Yes, behold, you are a little more cussed than I.” For one thing, such a statement isn’t likely to be true. One is almost always as full of cussedness as the next guy. In such circumstances, fresh supplies of cussedness well up from deep within one, unbidden. Or rather, bidden—by the next guy’s cussedness.

The cycle of resentment doesn’t even occur to a cyclist, unless it spills out of one the automobiles on the road beside him. So I was startled by the SUV driver’s rage, and he was nonplussed to discover I didn’t think myself aggrieved. The difference is part of what makes cycling so lovely, though I wonder if it’s harder for cyclists and motorists to communicate with each other from such distinct states of mind.

"Heavy Rotation" on WNYC radio

Shortly after 1:20pm EDT today (Monday), editor Peter Terzian and contributors Joshua Ferris and Martha Southgate will be talking about Heavy Rotation on WNYC's Leonard Lopate show, airing in New York City on 93.9 FM and AM 820 and streamable anywhere from the show's webpage. (Free download through I-Tunes available here, at least for a while.)

In other Heavy Rotation news, Liz Brown has blogged about the book at Kill Fee, and Peter has written a guest post at Large-hearted Boy about the role music has played in helping him mourn the loss of his mother.

Update, July 13: Newsday published a full-page preview of the book on July 11, and Publishers Weekly gave the book a starred review (scroll down) on July 6, writing that "these essays exhibit a perfect blend of respect and irreverence, with an intoxicating intimacy; readers who love music will devour this collection, and beg for a second volume."

My review of Matthew B. Crawford's "Shop Class as Soulcraft"

"Nice Work If You Can Get It," my review of Matthew B. Crawford's Shop Class as Soulcraft: An Inquiry Into the Value of Work , appears in this weekend's edition of The National (Abu Dhabi). For the record, I wrote this review well before the controversies of the past week.

Heavy Rotation in Bryant Park

Some photos from New York's Bryant Park today, featuring John Jeremiah Sullivan on the guitar, Nick Laudadio on the drums, James Wood on the bongos, and readings by Peter Terzian, Asali Solomon, Cliff Chase, Stacey D'Erasmo, and Joshua Ferris—all in honor of the release of the music-memoir anthology Heavy Rotation.