Bookless Libraries

A friend sent me word of yet another library that is replacing its books with computer work stations. In this case it is the library at Cushing Academy, a New England prep school. The school is spending millions to build a digital learning center filled with computer stations, laptop friendly study carrels, and large flat screen TVs that will project data from the Internet. The headmaster reports he sees books as an “outmoded technology.”

Still more and more books are being printed each year. However, the number of library books in circulation is not growing in tandem as most librarians report that their circulation figures are holding steady or decreasing. In contrast, digital use has increased significantly with a dramatic increase in “hits” to library electronic databases.

Another result of the digital revolution is the allocation of library funds with a major shift away from books to electronic resources. In 1998 the library at the University of Texas in Austin spent roughly 5% percent of its annual materials budget on electronic resources and 30% on monographs. In only three years, those allocations were reversed so that in 2001 20% was spent on electronic materials and only 15% on monographs. Virtually every library in this country reports comparable trends.

New library designs, as well as renovations of older ones, call for storing books in buildings apart from the library computer centers. A major renovation at the University of Minnesota-Twin Cities library eliminated the libraries book stacks and moved them to the basement or elsewhere on the campus to provide space for computer labs and a digital media center.

What will be gained and lost by the digital transformation of libraries? When I used to study in the library, every once in a while I’d take a little “study break” to wander up and down the aisles, checking the titles of the books that caught my eye. This kind of exploration will no longer be possible in the new bookless library. There will no discovery of that unknown book that you subsequently found indispensable. Thomas Benton has recently described the importance of such moments in the process of doing research.

I remember one time I was writing about Edgar Allan Poe and phrenology when I found a box of ephemera—not catalogued in any detail—that included a pamphlet for a book by an early psychologist who analyzed Poe on the basis of daguerreotypes of the poet. I quickly found the book in another area of the same library, and discovered a sequence of pages that purported to show that Poe was suffering from a disorder that affected only one hemisphere of his brain and that revealed itself in the asymmetry of his face…that accidental discovery—the centerpiece of a subsequent article—would never have been made but for the serendipity and convenience of the stacks.

How often I recall a similar experience in my own research in the library. I would go in search of a particular bound volume of a journal. Accidentally I’d pick out the wrong volume and beginning scanning the pages, only to discover another article, perhaps even more important than the one I was searching for and that, in turn, led me on a path of further inquiry that would never had occurred if I was searching for the article online. Who has not had the pleasure of discovering such an article by thumbing through the journals of their discipline?

A few months ago I went back to the library to try to locate the date of an article in The New Yorker that I had copied many years ago. Fortunately, the bound volumes of the magazine that has been published week after week since 1925 were still on the shelves in the stacks. I thought for more than a moment about the remarkable treasures contained within those pages--Capote, Cheever, Flanner, Nabokov, O’Hara, Thurber, Salinger, etc. And then I ploughed into the volume that I thought might have the article I was seeking.

I opened the cover, and began reading the Talk of the Town, the section where I was certain the little piece was located. I started reading and kept reading, page after page that I know I had read before but seemed as timely and as fresh as they first did at first reading. I didn’t find the article. It didn’t matter for I was overtaken by the pleasure of reading once again those few pages in but a single issue in one bound volume on the shelf along with countless other bound volumes of the magazine. I wonder what will become of all those priceless volumes in the new bookless library?

Summer Break

I’ve been blogging for Marks In The Margin for over a year now and it’s time to take a summer break. Thanks for reading and for responding. You can still send me ideas or comments at rkatzev@teleport.com. I would enjoy hearing from you.

Weekend Links

What Happened?
http://www.newyorker.com/humor/2007/11/26/071126sh_shouts_ephron

Book Chat
http://www.npr.org/templates/story/story.php?storyId=106150832&ft=1&f=1008

Racy Novel for Students
http://www.independent.co.uk/news/education/education-news/teachers-racy-novel-to-encourage-pupils-to-read-1735250.html

Stages of E-Mail
http://www.nytimes.com/2007/07/01/opinion/01ephron.html?_r=1

Remaking Civilization
http://www.guardian.co.uk/books/2009/jun/28/search-civilization-john-armstrong-review

50 Best Summer Reads
http://www.guardian.co.uk/books/2009/jul/05/summer-reading-books-recommendations

Truth in Fiction

Fiction is better at “the truth” than a factual record. Why this should be so is a very large subject and one I don’t begin to understand. Doris Lessing

I would be less inclined to read fiction were it not for the truths I find there. These are truths that, as others have said, one rarely finds elsewhere. (Fiction, at least some fiction, can also confront us with truths we might otherwise never have encountered--Elliot Perlman). In trying to unravel Lessing’s puzzlement about the nature of literary truths, I have looked more closely at those truths I found in my Commonplace Book. These truths are for the most part propositions that fall into one of four general categories:

Conceptual Truth: A passage that reinforces a belief, value or moral conviction that I hold, often one that is not widely held and so its literary expression makes it especially noteworthy or is one that I have not thought about but calls for consideration.

Ian McEwan’s Saturday contains a great many passages of this kind. Throughout, McEwan speculates about the origins of human behavior and difficulties of identifying them with any precision. Here is one:

It’s a commonplace of parenting and modern genetics that parents have little or no influence on the characters of their children. You never know who you are going to get. Opportunities, health, prospects, accent, table manners—these might lie within your power to shape. But what really determines the sort of person who’s coming to live with you is which sperm finds which egg, how the cards in the two packs are chosen, then how they are shuffled, halved and spliced at the moment of recombination.

Personal Truth: A passage that reveals something about myself (or one that I had not recognized before), as well as a correspondence between some aspect of my life and a character in a story, most likely one that I identify with in some respect. Colm Toibin writes in The Master.

Everyone he knew carried with them the aura of another life which was half-secret and half-open, to be known about but not mentioned.….He remembered the shock when he first came to know Paris, the culture of easy duplicity, the sense he got of these men and women, watched over by the novelists, casually withholding what mattered to them most.

Hypothetical Truth: The passages in this group pose a question or put forward a hypothesis that seems original or usual in some respect, one that warrants inquiry or confirms a finding that I have read about before. In The Black Violin Maxence Fermine writes,

There is nothing worse than having been truly happy once in your life. From that moment on, everything makes you sad, even the most insignificant things.

Aesthetic Truth: A passage that has captured my attention or moved me deeply or is so well written that it has a certain quality that one can only call beautiful. Its truth consists in being true to real life or, as Seilmann & Larsen have pointed out, has the character of verisimilitude—the semblance of real life. Here is an example by Andre Aciman from Pensione Eolo,

That winter, when it was all over, I would walk or ride a bus past her building. Sometimes I’d think how lucky I’d been to have spent a year with her there and how gladly I would give everything I now had to be back with the same woman, staring out those windows whenever she went sulking into the other room, imagining and envying those strolling outside, never once suspecting that one day soon I might be a stroller, too, looking in envying the man I’d been there once, knowing all along, though that if I had to do it over again, I’d still end where I was, yearning for those days when I was living with a woman I had never loved and would never love but in whose home I had…invented a woman who, like me was neither here nor there.

The truths that I find in these passages, as in most of those in my Commonplace Book, may be uniquely true for me. That is the wonderful thing about literature: it makes no claims of universality, it does not intend to be not true or false in the way an empirical proposition is.

Rather we read ourselves into literature without concern, as we are in science, for whether or not the passage is true for others, and if so, for how many and to what degree. Instead, the truth of any given passage is immediately true for the reader because it corresponds to his or her experience or provides a language for it in a way that had not been available before. “Yes,” we say, “that is true for me. This is my story. That’s exactly the way I felt. Or I had not realized its truth until I saw it on the page.”

Fiction Therapy

Reading great works of literature is not often considered among the foremost sources of personal change. Yet many individuals say it was a book that changed the course of their life. Others put it more generally as Patrick Kurp has. “I’ve read thousands of books since I learned to read 50 years ago and that, certainly, has had a cumulative impact on my life – all that time I could have spent bowling or watching the History Channel …Books have helped populate my interior landscape, overhauled my imagination, buffered me against loneliness and despair, kept me amused, honed my critical faculties…”

Reports like this suggests that both practitioners and investigators of the behavior change process may be neglecting the very considerable influence that works of literature can have for individuals. To be sure, some attempts have been made to examine their clinical implications. One approach, with highly variable results, is known as bibliotherapy--the use of reading material (usually self-help manuals), whether imaginative or informational...to effect changes in alcoholism, obesity, and mild depression, etc.

The application of poetry, also with variable effects, has been employed in clinical situations. Reading a poem to an individual or group and then discussing its personal meaning is the most widely used poetry therapy technique. In addition, individuals are sometimes asked to write a poem on a subject the therapist believes would allow the patient to express more freely the issues to be resolved.

A few years ago, I chanced upon a Web site with a provocative hypothesis by Edward Santoro, a teacher of literature, who wrote, “Many years ago I was thinking seriously about a radical psychology (though I wasn’t calling it that) that would include fiction as therapy, quite similar to prescribing Prozac or Ritalin or whatever is the flavor of the day. If somebody is trying to work through a difficult issue, particular works of fiction could be prescribed, discussed, analyzed. This dialogue and the learning to think critically about a text would put a person into a better position of knowing the self and society and their interrelation. I thought and still do think this would be a successful therapy. The irony is that this is exactly what education is supposed to do. Years ago I was looking for books on just such a topic, and though there were a few, nothing really described what I had in mind."

Joseph Gold in Read for Your Life: Literature as a Life Support System illustrates precisely what Santoro was seeking. According to Gold, the literature can be therapeutic because in reading literary fiction or poetry “…you experience feelings, emotions, as well as thoughts and images. You see pictures in your mind and you have feelings associated with the pictures. …When you learn to do this, you can use your feelings about what you read to explore yourself, your relations, your attitudes to job, home, sex, children and parents, aging, death and religion, for example. There is a direct link between what you feel about stories and what you feel about everything else, especially about yourself.”

In one case study, Gold describes a woman who had been suffering from an extremely poor self-image that he attributed to a childhood characterized by a rejecting mother. Eventually Gold asked her to Daddy’s Girl by Charlotte Vale Allen, a novel that depicts a young girl growing up under somewhat similar conditions. Gold reports that for the first time the woman “felt some real energy and excitement at seeing her feelings described in print.” In turn, this led the woman to begin to redefine her early experience and move on to a more fulfilling life.

In another case study, Gold describes a student who came from a profoundly troubled home. After assigning her Lawrence’s Lady Chatterley’s Lover, the student wrote to Gold: “What I admire about Connie Chatterley is her courage to be free, to do what she wants and to live her own life.” Sometime after Gold learned that this student had indeed taken charge of her own life by entering the Canadian Armed Forces flight-training program.

In Read For Your Life Gold recounts numerous applications of literary therapy in his practice, applications that he believes were directly associated with subsequent improvement in his clients. These apparent successes are largely due to Gold’s very considerable knowledge of literary fiction. Tailoring the reading material to the client’s emotional or cognitive needs is one of the critical requirements for a successful application of bibliotherapy. To be an effective as a bibliotherapist, a practitioner has to be well versed in both literature and clinical technique, a combination that is not often found among professionals in either discipline. It remains to be seen whether further applications of this approach will lead to the establishment of training programs to develop just such expertise.

Becoming Less & Less

Life made more sense in the Middle Ages, when no one lasted past forty.
Brian Morton Starting Out in the Evening

Philip Roth’s Exist Ghost, like his other recent books (The Dying Animal and Everyman) is a meditation on aging. In Exit Ghost, Nathan Zuckerman returns to New York from his solitary home on a mountain in New England, sans television, sans computer, sans telephone, although he does have a typewriter.

“I’d conquered the solitary’s way of life; I knew its tests and satisfactions and over time had shaped the scope of my needs to its limitations, long ago abandoning excitement, intimacy, adventure, and antagonisms in favor of quiet, steady, predictable contact with nature and reading and my work.”

In New York he confronts old age squarely in the person of Amy Bellette, the former mistress of his beloved mentor, also a cloistered writer, and Jamie, the young and beautiful writer, who along with her husband, will swap their West Side apartment for his isolated retreat for a year.

The once beautiful and charming Amy is now an old woman, an invalid who is recovering from brain surgery. Jamie’s allure draws him back to everything he thought he had left behind, an intimacy of the mind and body. “…a man who’d cut himself off from sustained human contact and its possibilities yielding to the illusion of starting again.” To paraphrase Roth, there is the desire still and the temptation aroused and the reality is agony.

Yet Zuckerman is 71 years old now and has recently had prostate surgery, leaving him both impotent and incontinent. “To possess control over one’s bladder—who among the whole and healthy ever considers the freedom that bestows or the anxious vulnerability its loss can impose on even the most confident among us.” Again, to paraphrase Roth, there is no virility, only the arousal and the anticipation.

Earlier in Everyman Roth had written that “Old age isn’t a battle; old age is a massacre.” No once has characterized aging more accurately; no one has described it so cogently.

In a longer passage from Everyman, Roth ruminates further about the experience of growing old, “He neither possessed the productive man’s male allure nor was capable of germinating the masculine joys, and he tried not to long for them too much. On his own he had felt for a while that the missing component would somehow return to make him inviolable once again and reaffirm his mastery, that the entitlement mistakenly severed would be restored and he could resume where he’d left off only a few years before. But now it appeared that like any number of the elderly, he was in the process of becoming less and less and would have to see his aimless days through to the end as no more than what he was—the aimless days and uncertain nights and the impotently putting up with the physical deterioration and the terminal sadness and the waiting and waiting for nothing. This is how it works out.”

Much of what Roth says is consistent with current medical research on aging. Atul Gawande summarizes this work in an article he wrote for the New Yorker in 2007. Gawande says, “The idea that living things shut down and not just wear down has received substantial support in the past decade.” Gawande continues, “…one too many joints are damaged, one too many arties calcify. There are no more backups. We wear down until we can’t wear down anymore. We just fall apart.” Echoing Morton in the passage at the start of this post, Gawande says that human beings are in a way like freaks who are living well beyond their appointed time.

Roth is now 75 and has been through some rough times recently. I am getting close and am not as fit as I once was either. So his tales of growing old, while depressing and grim, do confirm much of what I am either experiencing or surely about to experience. How bleak the prospect, how sad the inevitable.

Nor surprisingly, aging was one of the most frequent themes in the study that I undertook a few years ago of my Commonplace Book. Below are a few of the passages I collected in the books I had been reading up until the time of my review.

From now on, little by little, you must prepare yourself to face death. If you devote all of your future energy to living, you will not be able to dwell. You must begin to shift gears, a little at a time. Living and dying are, in a sense, things of equal value.
Haruki Murakami

For the first time he has a taste of what it will be like to be an old man, tired to the bone, without hopes, without desires, indifferent to the future.
J. M. Coetzee Disgrace

As he eased himself out of bed he reflected that survival was a mixed blessing. It involved surrendering that once young self to time, and time taught harsh lessons.
Anita Brookner Making Things Better

…he didn’t mind death so much as dying.
Joseph Epstein Fabulous Small Jews

She’s probably no older than me. In fact, she’s my future—the wart, the walker, the wheelchair. As she came closer, he heard her mumbling.
Irving Yalom The Schopenhauer Cure

She Always Wears Black

My first job was in a bookstore. The store was called Martindale’s who along with his store and so many others is long gone. It was not your ordinary first job. To this day I can remember the smell of the new books and the distinctive scent they created in that relatively small space.

Even then I knew the books, knew their titles, and authors. I could tell people what they were about and, without much of effort, get them to buy the book, and then one or two others as well. I have utterly no idea how I was able to this, especially at that age, long before I had ever heard of “Literature.”

It was the young girl who worked with me that made that summer so unforgettable. Her name was N, the clever, sprightly N, now well known for her literary and cinematic wit. I had a blazing crush on her that summer at Martindale’s. Those who know N may be aware she is slightly cross-eyed. What young man could resist that?

And N could talk. She was clever, funny and bright. We spent all the time we were there bantering and jesting with one another. It is a mystery how we managed to get anything done or sell any books, or remember to give the proper change to those well-healed customers.

I am sure N has no recollection of me or our “brief encounter” at Martindale’s Bookstore or probably even working there. But every time I hear about her or see one of her films, I remember the summer of my very first job. Books, magazines, paperbacks, and the beautiful cross-eyed girl who talked with me. Her name is Nora Ephron and she is profiled by Ariel Levy in this week’s New Yorker.

Levy confirms everything we know about Nora. She is charming, talented, full of surprises and hilarious remarks. I am certain she is as much fun as she was when I knew her, ever so briefly. She not only writes film scripts (among them When Harry Met Sally, Sleepless in Seattle, You’ve Got Mail, Heartburn, Silkwood, etc), she writes articles and essays, she blogs, cooks terrific meals, and knows everyone. Levy writes, “She can tell you who the doctor is for what you’ve got. She can tell you when to forget something, let it go. Where the best food is. Wheat the greatest new idea for cooking this or that is. She knows.”

I’ve always imaged Nora much like Meg Ryan’s depiction of Sally. And Levy, who knows her well, says much the same, “When Ephron knows that she knows something, or knows that she wants something, she does not hesitate to say so. She is like Meg Ryan’s character in When Harry Met Sally. I just want it the way I want it, Sally tells Harry, about her habit of ordering, say a piece of apple pie a la mode with the ice cream on the side, strawberry instead of vanilla if it’s an option, and, if it’s not, then whipped cream, but only if its real.”

Nora was raised by her screen writing parents in Los Angeles. She says the tone of the household was upbeat and that it felt like growing up in a sitcom. When they became “unglued” as Levy puts it, Nora almost shrugged it off. She told Levy, “I’m very into denial.” And later, “I don’t mean that you can’t have your feelings hurt or that you can’t sit at home and feel sorry for yourself—briefly…But then I think you have to just start typing and do the next thing.”

Levy says and I couldn’t agree more that her essays and articles are “vivid and cunning and crackling with her personality.” In one of her essays in I Feel Bad about My Neck, she says “Sometimes I think that not having to worry about your hair anymore is the secret upside of death.”

Many people seem to be intimated by her. Levy quotes Meryl Streep as saying, “She always wears black and she’s so cool and she always has the perfect bon mot to toss off just effortlessly. I mean, who can be like that?” No doubt Ephron feels much the same about Streep.

I’ve thought about writing Ephron to remind her of our memorable affair at Martindale’s. But I haven’t been able to find her e-mail address or where to write her. In both cases, I first need to contact her agent. That isn’t very promising. So until I do, I will be more than content to remember our times together and enjoy reading her hilarious articles in the New Yorker. As Levy notes early in her profile, “People need sarcasm, Ephron seems to think, but they also need fairy tales.”

The Higher Yearning

If you based your notions on academic life from some of the recent movies (Elegy, The Squid and the Whale, One True Thing, etc.), you’d think that most professors slept with their students. This is especially true of teachers in literature departments; you don’t often see professors in the scientific disciplines following suit. As one not far from the academic fray, I can report the “reality” depicted in the cinema is nothing but a myth.

Nevertheless, there is some truth to this academic stereotype, one that I became aware of gradually over the years, as I developed very close friendships with some of my students. It is one that is intimate, but in this case it is an intimacy of the mind. In his essay, Love on Campus, in the Summer 2007 American Scholar William Deresiewicz writes eloquently about what is often a fairly intense intimacy between a student and professor.

“..the good teacher raises in students a burning desire for his or her approval and attention….The professor ignites these feelings just by standing in front of a classroom talking about Shakespeare or anthropology or physics, but the fruits of the mind are that sweet, and intellect has the power to call forth new forces of the soul. Students will sometimes mistake this earthquake for sexual attraction, and the foolish or inexperienced or cynical instructor will exploit that confusion for his or her own gratification.”

While it didn’t change my relationship with students once I recognized the power of this situation, I realized the time a student is in college is a critical period, one not unlike the critical period in which all forms of animal life form an attachment to a parent or a surrogate parent. Who does not remember their favorite professor, the one who has to this day exerted a powerful influence on their life? No doubt there is more than one.

Deresiewitcz reminds us that all this was known to Plato who, in the Symposium, described the powerful attraction Socrates had on his students. “This is why, for the Greeks, the teacher’s relationship with the child was regarded as more valuable and more intimate than the parents. Your parents bring you into nature but your teacher brings you into culture.”

In my own teaching I eventually came to see that I was at my best when I was helping students realize things they might have already known or, if not known, find a way to discover them in the exchanges we had with one another. And in the process of doing this, I learned that teaching, as Deresiewicz says, is “about relationships. It is mentorship, not instruction.”

Perhaps that’s because I taught at a small liberal arts college, where the classes were small and where teaching often involved tutorial sessions on a weekly basis that, at times, went on for hours. I suspect at the larger universities, where teaching is largely synonymous with lecturing, the kind of intense intimacy this form of instruction develops is far less likely to occur.

In his essay Deresiewicz treats at length the inability of our culture to understand these ideas. “Can there be a culture that is less equipped than our to receive these ideas?” He argues that we simply don’t have the necessary vocabulary to comprehend, let alone accept this kind of intimacy.

This point interests me less, than the reality of the experience itself, the way in which a professor can become a student’s muse. As one of Deresiewicz’s students says, “I wanted to have brain sex with him.” In the vast majority of cases then, the real attraction between students has little to do with their bodies but far more with their minds.

In her essay, The Higher Yearning, published in Harpers a few years ago, Cristina Nehring goes even further claiming, “Teacher-student chemistry is what sparks much of the best work that goes on at universities, today as always. It need not be reckless; it need not be realized. It need not even be articulated, or mutual. In most cases, in fact, it is none of these. In most cases, academic eros works from behind the scenes. It lingers behind the curtain and ensures that the production on state is strong. It ensures that the work in the classroom is charged, ambitious, and vigorous.”

The intimate bond between teacher and student may often last a lifetime. Deresiewicz concludes, “…the feelings we have for the teachers or students who have meant to most to us, like those we have for long-lost friends, never go away, even when the two are no longer together.”

Weekend Links

Is Marriage Passe?
http://scienceblogs.com/cortex/2009/06/is_marriage_passe.php

New Yorker Book Critic Drums
http://www.youtube.com/watch?v=CVhUBMgd9jE

Getting Back to the Classics
http://maudnewton.com/blog/?p=9447

Theory of Time
http://www.guardian.co.uk/books/audioslideshow/2009/jun/24/dan-falk-search-time

Summer Science Reading
http://www.guardian.co.uk/science/blog/2009/jun/25/royal-society-science-book-prize

Out of Town Tales
http://www.guardian.co.uk/books/2009/jul/01/top-10-out-of-town-tales

Month in the Sun

The molten sun beat down mercilessly. The hot, slow afternoon was a furnace. The parks lay green and motionless. Pavements shimmered like burning lakes.

When I arrived in Florence that summer, I was overwhelmed by the incredible warmth in the air and the prospect of days of bright, sunny days in the 90s. I had not experienced such days in months, maybe years. Early in the morning I stepped outside on to the street to find myself engulfed by warm air and bright sunlight.

I had to stop for a moment to take account of what this was. What it was was blissful. I had forgotten it still existed. And then the questioning began. Does it only exist here? Isn’t there a place like this closer to home? I’ve been yearning for this all year and now I was in its midst.

It galvanized me into a frenzy of work that I’ve not known in years. Others wilt or find the heat oppressive; I flourish in it, especially when I’m in Italy. Robert Penn Warren once said that he liked to write in a foreign country “where the language is not your own and you are forced into yourself in a special way.” A Paris Review interviewer asked Tobias Wolff: “You’re just back from seven months in Rome. Why were you there?” Wolff replies in a similar vein:

I had no immediate reason for going. It wasn’t to do research. I speak some Italian, but living in a country where I can’t be completely aware of what people are saying around me puts this sort of bubble around the head, in which, for a time, not indefinitely, I find I’m able to work with more than the usual concentration and joy.

In Philip Roth’s The Ghost Writer Nathan, the aspiring writer asks Lonoff, his literary idol: “How would you live now, if you had your way?” Lonoff replies, “I would live in a villa outside Florence.” Nathan then asks: “Yes with whom?” “A woman of course.” Clearly that is the solution—live with a beautiful Italian woman who can translate the Italian essays and articles I cannot read here

The Parco Delle Cascine is an enormous park on the western edge of Florence that stretches along the Arno for miles. Over the years I have gone there often, first as a runner, then as a walker, and now as a sunbather. I marvel at how few people I usually see in the Cascine. It is surely because the park is so vast and so heavily treed that the people are simply hidden in between the bushes and shrubs and down the long pathways that traverse the park from one end to the other.

A few miles into the park there is a public swimming pool, the Publico Piscina where I have been going of late. It is far from luxurious; I am reluctant to shower there. But it is the sun and surrounded by lovely tall trees and open fields. On day I realize that the sun that shines on the sunbathers at the Publico Piscina is the very same one that shines on the beautiful people by the pool at the Splendido in Portofino.

As I prepare to return home, I am once again reminded that we are what our situations hand us. In Florence it is warm; at home it is cold. In Florence it is quiet; at home it is “noisy.” I am a different person in Florence. I am turned upside down mostly by the warmth that seems in some strange way to be remarkably therapeutic. Each time I go there I realize how much difference the temperature and light can make, how much they seem to matter to me, how noticeable they are. I feel more at home here than anywhere else.

In the final analysis, however, Florence can only be for me much like Andre Aciman said Illiers was for Proust.

Illiers itself was simply a place where the young Proust dreamed of a better life to come. But, because the dream never came true, he had learned to love instead the place where the dream was born.

Catastrophe in the Works?

Last week the US House of Representatives passed a bill requiring mandatory ceilings on the gases linked to global warming. It was the first time either chamber of Congress had approved a bill with clear targets, albeit modest, and crammed with concessions (“something for everyone”) for reducing greenhouse gas emissions.

In his Times column this Monday, the recent Nobel Laureate in Economics, Paul Krugman, called the debate on the bill and its subsequent passage “treason against the planet.” He argues that never before in the history of this planet has it changed faster than even the pessimists expected—“ice caps are shrinking, arid zones spreading, at a tarrying rate.” He notes that researchers who had predicted about a 4 degree temperature increase by the end of this century are now predicting a rise of more than 9 degrees as global greenhouse gas emissions are rising faster than expected.

His views echo those of James Hansen NASA’s leading (and controversial) climate investigator who is profiled by Elizabeth Kolbert in last week’s New Yorker. According to Kolbert, Hansen has concluded on the basis of his own and the observations of other scientists that “the threat of global warming is greater than even he had had suspected. Carbon dioxide isn’t just approaching dangerous levels; it is already there.”

And like Krugman, Hansen asserts that the companies that are pumping greenhouses gases into the atmosphere “should be tried for high crimes against humanity and nature” for spreading false and misleading information about global warming. It is clear, he argues that “carbon dioxide is being pumped into the air some ten thousand times faster than natural weather processes can remove it”

When Hansen began to realize how serious the problem was, he thought, like most everyone else that getting this information out in front of the policy makers and government officials would be so clear and overwhelming that action would be taken to reduce greenhouse gases. This is the usual assumption about social and individual change: get the information out and change will occur. Of course that rarely happens and in this case was, as Hansen and others now recognize, naïve.

Even the visual images of what is happening to the planet don’t work. Who has not seen images of those massive sheets of ice melting in Antarctica? Or pictures of the Arctic ice cap which, according to Kolbert, “have been melting at a shocking rate; the extent of the summer ice is now only a little more than half of what it was just forty years ago.”

What is it going to take to deal what many consider a major emergency? Hansen believes there are three steps than we can begin to take to confront this problem head-on.

First, he argues for a moratorium on any new coal plants and a phase out of existing ones over the next twenty years. (Kolbert writes that coal now provides half of the electricity produced in the United States and in China it is estimated to be eighty percent). Hansen says, “There’s enough carbon in the ground to really cook us. Coal is my worst nightmare.”

Second, he suggests that reforestation if practiced on a massive scale could begin to greatly reduce global CO2 levels.

Third, he argues that the notion of a cap-and-trade system is a sham. (The centerpiece of the recently passed House bill is a cap-and-trade program!) “What is required, he insists, is a direct tax on carbon emissions.”

Taking these steps is technically feasible. But “it requires us to take action promptly.” Easier said than done, of course, as we have been observing for years. Usually it takes a major catastrophe for significant change to take place in this country. Will this scenario be played out once again as the Senate considers the House bill on reducing greenhouse gas emissions? Hansen believes “The science is clear. This is our one chance.”

Workplace Learning

It is generally assumed that intelligence in the broadest sense is closely associated with formal education—the longer you have been in school and the more varied your studies, the more intelligent you will be. In the latest issue of the American Scholar (Summer 2009) Mike Rose, author of The Mind at Work: Valuing the Intelligence of the American Worker, takes a hard look at this assumption.

He begins by describing the multiple tasks that his mother undertook in the many years she worked as a waitress in a restaurant. He spent hours observing what she did and came to appreciate how much her work, as well as the working habits of other blue-collar workers, involves both body and brains.

His mother learned to “work smart and make every move count.” Rose says, “Her tip depended on how well she responded to these needs, and so she became adept at reading social cues and managing feelings, both the customers’ and her own.” And while she quit school in the seventh grade and never returned, Rose gradually began to see that in those mundane and repetitive tasks, she was always learning something new.

He reached the same conclusion in watching one of his mother’s brothers, who also left school early, supervising a factory paint-and-body department. “The floor was loud—in some places deafening—and when I turned a corner or opened a door, the smell of chemicals knocked my head off. The work was repetitive and taxing, and the pace was inhumane.”

Still Rose says the factory work provided his uncle a setting wasn’t a school, but rather a factory where he was constantly learning. It came from a flurry of tasks that demanded his attention and both mental and physical resources, “keeping a number of ongoing events in his mind, returning to whatever task had been interrupted, and maintaining a cool head under the pressure of grueling production schedules.”

As a result, Rose claims his uncle was learning other more general elements of the automobile industry, “the technological and social dynamics of the shop floor, the machinery and production processes, and the basis of paint chemistry and of plating and baking.” And while he was becoming skillful in different ways of thinking and analyzing than one usually acquires in a classroom, the fundamental learning process was much the same.

Rose describes other blue collar and service jobs that require equally varied skills. The use of tools by a plumber, for example, “requires the studied refinement of stance, grip, balance, and fine-motor skills. But manipulating tools is intimately tired to knowledge of what a particular instrument can do in a particular situation and do better than other similar tools.”

They also require knowledge of mathematics (“numbers are rife in most workplaces”), planning, and problem solving. Everyday jobs may look mindless to an observer but they are so for the performer. Rose persuasively argues that we are wrong to think of everyday work as a task carried out without abstract thinking or diverse forms of intelligence.

His fine grain study of the components of so-called routine tasks reveals they are anything but routine. When looked at closely it they are cognitively complex and demand diverse intelligences. Rose concludes that our biases and stereotypes about workplace activities have blinded us to the “remarkable coordination of words, numbers, and drawings required to initiate and direct action.”

Questions in Fiction

Asking questions is one of those mundane, everyday activities that characterize the way we speak and write. Some individuals ask a great many questions, while others ask one or two and more commonly none at all. I sense that questioning as a mode of conversation, indeed, as a way of thinking, may be a central personality dimension.

My hunch is that it is strongly associated with a philosophical turn of mind, a general skepticism about most beliefs and assertions, at least, a continuing effort to look more deeply into the claims of others whether they are expressed in conversation or on the printed page.

Lately, I’ve been thinking about the role of asking questions in fiction. I first began to realize that authors vary widely in their use of questions in reading Night Train to Lisbon by Pascal Mercier. In reading Night Train to Lisbon I was not deliberately looking for passages that posed questions. It was only after finishing the book and began to look closely at those I had recorded that I realized how many were framed this way.

In fact, of the 120 passages I recorded from the book, a number that may be the most in my reading history by a sizable margin, 47 (40%) included at least one question. I began to wonder if questioning also played a similar role in the passages I recorded from other books that meant a lot to me.

I copied 46 passages from Ian McEwan’s Saturday, a book I enjoyed every bit as much as Night Train to Lisbon but of these quotations, only 15% included at least one question. Similarly, I recorded 47 passages in Philip Roth’s Exist Ghost and of these only 15% included a question. And of the 83 passages I recorded in Eliot Perlman’s Seven Types of Ambiguity, just 8% included a question.

It is clear from this small sample that questioning is not a critical feature of the novels I like most. I may enjoy that style of writing and tend to think that way myself, but it probably plays little if any role in my reading preferences. Henry Perowne, the central character in Ian McEwan’s Saturday is depicted as a deeply reflective man who spends a good part of that day at least, wondering about a wide range of topics. But his reflections are rarely formulated as questions.

Many of the questions in Night Train to Lisbon are also posed for rhetorical effect rather than a direct answer. That is, the answer is simply implied by the question. Prado, the Portuguese physician-author, asks:

Why hadn’t there been anybody before in his life who understood him so fast and so easily?

Is it so that everything we do is done out of fear of loneliness?...Why else do we hold on to all these broken marriages, false friendships, boring birthday parties?

We humans: what do we know of one another?

Clearly he implies that we know very little. Still he wants the reader to consider the issue and give some thought to the implications of the implied answer. It is a style of writing that encourages an internal dialogue for any reader who takes the text seriously.

Posing questions of almost any kind, regardless of their function, usually sets me off in another direction as my mind wanders off the page. Above all, I read more actively as I consider the questions or make all those associations it engenders from a lifetime of experience. In a way, I join with the author who, with his questions, invites me to join with him in telling his tale. It is a reading experience at its best

On the Move

This is the season to travel, perhaps not so far this year, but still somewhere if you can afford it. Long ago Blaise Pascal wrote, “The sole cause of man’s unhappiness is that he does not know how to stay quietly in his room.” And yet most of us leave our room at this time of the year to travel hither and yon. But why? The current issue of Lapham’s Quarterly has devoted its current issue to the subject of travel and sometimes to this question.

The issue consists of a series of excerpts from contributors as varied as Herodotus, Basho, Melville, Dorothy Parker, etc. It is a little confusing to skip from one excerpt to another but enough are interesting to make it worthwhile and, even better, on most pages there is a painting, a map, a drawing, a box with historical facts, or a photograph.

In reading the issue, I made note of some of the quotations sprinkled throughout the text and, along with some of my own, I have selected a few to post.

On Going
What an odd thing tourism is. You fly off to a strange land, eager abandoning all the comforts of home, and then expend vast quantities of time and money in a largely futile attempt to recapture the comforts that you wouldn’t have lost if you hadn’t left home in the first place. Bill Bryson

The wise traveler travels only in imagination. W. Somerset Maugham

Traveling is the ruin of all happiness! There’s no looking at a building here after seeing Italy. Francis Burney

Purpose
The soul of a journey is liberty, perfect liberty, to think, feel, do just as one pleases. We go on a journey chiefly to be free of all impediments and of all inconveniences—to leave ourselves behind, much more to get rid of others. William Hazlitt

Out of touch was where I wanted to be. The wish to disappear sends many travelers away. The greatest justification for travel is not self-improvement but rather performing a vanishing act, disappearing without a trace. Paul Theroux

One’s destination is never a place but a new ways of seeing things. Henry Miller

Getting There
Thanks to the interstate highway system, it is now possible to travel from coast to coast without seeing anything. Charles Kuralt

More and more I like to take a train. I understand why the French prefer it to automobiling—it is so much more sociable, and of course these days so much more of an adventure, and the irregularity of its regularity is fascinating. Gertrude Stein

Journeys are the midwives of thought. Few places are more conducive to internal conversations than moving planes, ships, or trains. Alain de Botton

Effects
The farther one goes
The less one knows. Lao Tzu

And see all the sights from pole to pole,
And glance, and nod, and bustle by;
And never once possess our soul
Before we die. Matthew Arnold

Journeys, like artists, are born and not made. A thousand differing circumstances contribute to them, few of them willed or determined by the will—whatever we may think. Lawrence Durrell

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time. T. S. Eliot

Weekend Links

Quiet Time?
http://www.newyorker.com/humor/2009/06/01/090601sh_shouts_borowitz

Imaginative Writer
http://papercuts.blogs.nytimes.com/2009/06/19/stray-questions-for-elina-hirvonen

On Daydreaming
http://online.wsj.com/article/SB124535297048828601.html

Too Complex?
http://www.boston.com/bostonglobe/ideas/articles/2009/06/14/too_complex_to_exist/?page=full

Place Matters in Fiction
http://www.chicagotribune.com/features/lifestyle/chi-0621-lit-life-cj-mainjun21,0,6936712.column?track=rss

Literary Threesomes
http://www.guardian.co.uk/books/2009/jun/23/ewan-morrison-menage-trois

Motorcycles and Heidegger

Idols, a short story by Tim Gautreaux in the current issue of The New Yorker, is about a man who works at repairing and restoring old typewriters. It isn’t the most impressive or busiest of current professions.

A few pages later Kelefa Sanneh reviews Matthew Crawford’s first book, Shop Class as Soulcraft: An Inquiry Into the Value of Work. After reading Sanneh’s review, repairing old typewriters didn’t seem like such a menial activity after all.

Crawford’s book is written in the tradition of Robert Pirsig’s almost classic Zen and the Art of Motorcycle Maintenance that George Steiner, also writing in The New Yorker, compared to Moby Dick. Crawford writes about the “soul destroying consequences of our new work habit—endless hours spent at flexible jobs, performing abstract tasks on computer screens.” If you’ve ever held a job like that, you’ll know full well the experience Crawford describes. I did once and it was sheer misery.

Crawford argues for the return of old fashioned hard work, work where the outcome is clear and where success is evident. When you work at repairing a typewriter, you know with certainty when it is fixed. His book is also an argument that localism can help cure our spiritual and economic woes.

Sanneh says that Crawford believes that fixing motorcycles is a form of philosophical investigation that helps him understand Heidegger’s theory of skillful coping. The logic of this relationship eludes me. Nevertheless, I do understand Sanneh when he says Crawford believes “a cluster of cultural prejudices have steered many potential tradesmen into college, and then toward stultifying office jobs, which provide less satisfactory and less security than skilled manual labor, and sometimes less money.”

Indeed, Crawford believes that those who are trained in skilled labor, such as a mechanic, a plumber, an electrician, a carpenter, offers a person “a place in society” as well as an “economically viable” job that isn’t going to evaporate in the next recession or moved overseas in the next wave of global buyouts. It also guarantees a job just about anywhere you might wish to live.

That was never true of university teaching. If I wanted to move Palo Alto, I needed to know the university there had an opening in my field and that I had a good chance of ranking number one in its highly competitive selection process. Plumbers and electricians can move to Palo Alto and find plenty of work without giving the matter a second thought.

Crawford’s manifesto for skilled manual labor and the return of craft originates in his first hand experience maintaining motorcycles. He claims repairing motorcycles fills him with a “sense of agency and competence.” None of can readily occur in big corporations that Crawford claims do little else but elicit boredom and engage employees in mindless tasks or routine activities that one can hardly take any degree of pride in.

Here I am reminded of the argument Malcolm Gladwell made in Outliers in accounting for the success of the cultures formed in the rice paddies of Asia. Those endless hours in the hot sun, planting and weeding in a rice paddy brought forth a product that gave those in the fields a sense of accomplishment under conditions of considerable uncertainty and poverty.

Sanneh concludes his review of Shopcraft as Soulcraft with this note: “Crawford wants his readers to become better, happier, more productive workers. Who could argue with that?”

Reading In Secret

The extraordinary events occurring in Iran today have taken me back to a remarkable novel I read about an equally turbulent period there during the late 90’s--Azar Nafisi’s Reading Lolita in Tehran: A Memoir in Books.

Every now and then a book nearly takes command of my life, when my day is measured only by the time remaining before I can get back to it. Nafisi’s memoir is one of them. Not long after I began reading it, I went out of town for a few days to work on a project that was as remotely associated with literature as Newtonian physics. When I left, I was halfway through Reading Lolita in Tehran.

The book brought alive for me the meaning of literature for those who could only read and discuss it in hiding. Within an hour after returning home, I took up the book once again. A feeling of relief swept over me, an emotion I often feel in getting back to literature.

I am not entirely sure what gives rise to this feeling. All I know is that when I am reading literature as fine as Nafisi’s work I fall into a mood, one of rumination, sometimes moody, sometimes elated, that makes the experience such an imperative. It is an effect not unlike the one Jonathan Franzen described in reading Alice Munro.

Reading Munro puts me in that state of quiet reflection in which I think about my own life: about the decisions I’ve made, the things I’ve done and haven’t done, the kind of person I am, the prospect of death.

Nafasi’s novel describes the experiences of a group of her students who met to discuss the books they were reading when it was forbidden to read Western literature in Iran. They read the works of Nabokov, James, Jane Austen and Fitzgerald’s Gatsby. They met in secret when “…all the normal acts of life had become small acts of rebellion and political insubordination…”

The book is also about the unexpected parallels they found between the novels they read and the life they were forced to lead under the mullahs—not wearing the veil or wearing it improperly, not speaking out in public against the government, and “for studying decadent Western texts and for embracing the ambiguities and conundrums of fiction” as Michiko Kakutani puts it in her Times review.

The group tended to interpret each of the works they read against this background. So, for example, “The desperate truth of Lolita’s story is not the rape of a twelve year old by a dirty old man but the confiscation of one’s individual life by another.”

The meetings became a refuge for the women. The novels they read began to transform their life, leading them to those truths that one often finds in fiction. Nafisi writes, “If I turned towards books, it was because they were the only sanctuary I knew, one I needed in order to survive, to protect some aspect of myself that was no in constant retreat.”

Through their readings and discussions, Nafisi and her students discovered themselves and the larger world that confronted them. “Fiction was not a panacea, but it did offer us a critical way of appraising and grasping the world—not just our world but that other world that had become the object of our desires.”

And elsewhere, “Not only did the most ordinary activities gain a new luminosity in the light of our secret, but everyday life sometimes took on the quality of make-believe or fiction. We had to reveal aspects of ourselves to one another that we didn’t even know existed.”

In reading Lolita in Tehran, I too came to share the joy of reading fiction that those in the group experienced. And in a way I leaned just as much about each of the novels they read, most of which I was only dimly aware of. “You don’t read Gatsby to learn whether adultery is good or bad but to learn about how complicated issues such as adultery and fidelity and marriage are.”

Nafisi’s novel also reinforced my view that the best fiction always forces us to question our fundamental beliefs. Questioning traditions and ideologies and doing so in secret was for these women also the purest form of insubordination. Given the way events are currently unfolding in Iran, I suspect we are likely to learn about more Iranian groups of underground readers in the near future.

Fifteen Notable Books

An amusing game is currently circulating around the literary blogs. It was initiated by David Meyers at A Commonplace Blog who laid out its rules: “Name the fifteen books that have most influenced your thinking, that you have found yourself referring to most often in reflection, speech, and writing.”

Putting the matter this way is different than asking for your favorite book or one that has transformed your life. Instead you are asked to name a book, fifteen to be exact, that have influenced the way you write, talk and think. In my view, that’s a very powerful effect that, while it may not have turned your life around, has clearly left its mark.

To date there have been only three readers who have contributed a fifteen book list. Obviously you need to have read a great many fine books to put forward such a list, to say nothing of remembering the title and author of each one. The dilemma has been well expressed by Zbigniew Herbert in this excerpt from his poem A Life:

Someone recommended a classic work—as he said
it changed his life and the lives of million of others
I read it—I didn’t change—I’m ashamed to admit
for the life of me I don’t remember the classic’s name.

I will only mention the first five selections of each of the contributors. The rules of the game are to identify those that first came to mind and not spend too much time thinking about it. Meyers, who first proposed the game, named Vladimir Nabokov’s Lolita, Henry James’ The Portrait of a Lady, Saul Bellow’s Mr. Sammler’s Planet and Philip Roth’s American Pastoral. The remaining 10 are listed on his blog.

Patrick Kurp had no trouble coming up with his list, claiming it took him less than 7 minutes to write and then edit the collection. The first five are Guy Davenport’s The Geography of the Imagination, Walt Whitman’s Leaves of Grass, A. J. Liebling’s, Normandy Revisited, and Joseph Mitchell’s The Bottom of the Harbor. The remaining ten on Kurp’s list can be found on his blog, Anecdotal Evidence.

A blog by the name Underbelly was the last participate so far. The first 5 volumes on this list were Thucydides, History of the Peloponnesian War, George Eliot’s Middlemarch, Betram Wolfe’s Three Who Made a Revolution, James Boswell’s Life of Johnson and Tolstoy’s War and Peace. The next ten are shown on Underbelley.

Of the forty-five books mentioned there isn’t a single one common to each of the three lists, although Boswell’s Life of Johnson appeared on two. And with the exception Boswell, no author appeared more than once in the three lists—not Shakespeare, Tolstoy, Proust, or Joyce. Once again this attests to the remarkable subjectivity of the reading experience and the way in which we bring our own perception and emotional history to the books we read.

In the Guardian last week, Molly Flatt offered a current testimonial to the power of literature. She points out that “religious texts are prime examples of how stories have transformed people and societies in a very real way…” She notes that Shakespeare and Petrarch dramatically shaped the evolution of our language.

This reminded me of a remark Ian McEwan wrote in a tribute to Saul Bellow: “Writers we admire and re-read are absorbed into the fine print of our consciousness, into the white noise of our thoughts and in this sense, they can never die.”

And Flatt concludes her article with a personal account: “I'm convinced that novels change me all the time. After reading Jon McGregor's If Nobody Speaks of Remarkable Things I made an effort – which admittedly lapsed after a few days – to live in the present and notice the little stuff. After reading Blood Diamond I joined Amnesty International. After reading Dorothy Dunnett's Lymond Chronicles at the age of 15, I doomed my love life for years by measuring every potential date against a borderline genius, angelic-voiced, blond-haired 16th-century aristocrat. And don't tell me there isn't a whole generation out there campaigning to save the forests because they adored The Faraway Tree.”

She ends with a question that I too would like to pose: “So – be it in a serious or frivolous way, for good or for bad – what was the last story that really changed you?”

The Parks of Paris

In the Guardian last weekend William Boyd wrote about the parks in London and the inspiration they have been for novelists. In Virginia Woolf’s Mrs Dalloway, Peter Walsh goes for a walk in Regent’s Park after visiting Clarissa Dalloway who had earlier that day been there herself on the way to collect the flowers for the party she gave that night. In Graham Greene’s The End of the Affair, several key events take place in Clapham Common, a park not far from where he had lived one year.

Boyd has a strange definition of parks. Namely, there must be tall trees that must give the impression of random planting. An avenue here and there is OK and the ground must be undulating in a significant way and you mustn’t be able to see all the sides of the park at once. And finally you must have a gated entrance. All these “musts.” Consider what this means for Paris: on this definition Les Tuileries isn’t a park, nor is the Parc Monceau or the Luxembourg Gardens for that matter. Isn’t this absurd?

In reading Boyd’s account of the parks in London and the many others he would like to visit, I was reminded what the parks of Paris came to mean to me one summer several years ago. After being there awhile, I thought the romance of Paris had begun to fade. Maybe it had all been an illusion in the first place, one fostered by all those storytellers who have written so beautifully of love in Paris and the beauty of the place

But as I walked about the city that summer, I wondered what had happened. It was crowded. And noisy. In some places dirty. Even a bit shabby. With one exception--the parks. The parks of Paris brought me back to the romance of the city. And they were everywhere, on almost every block and corner.

They never looked lovelier. Many with well-tended flower-beds in full bloom. Lawns that had been freshly mowed. Trees that had been carefully trimmed. Each park appeared perfectly manicured and yet I never saw a gardener at work. I kept wondering who were these people who took such good care of the parks? How were they paid? Where did the funds come from to maintain these jewels? It surely cost a fortune to do that.

So in its parks, I saw a different Paris. Or more exactly, the old Paris. Children playing. Lovers picnicking. Others just out for a stroll. Or a little nap. Then there are the benches and chairs found in every Parisian park. Not just one or two. But many, spread out along the open paths. There are no chains bolting them to the ground in Paris.

And more often than not they were occupied by individuals who were quietly reading, oblivious to the passing scene. Young and old. Each one reading something. It was wonderful. The flowers, the children and people reading.

In City of Books Don Bell writes, “Perhaps no city in the world rivals Paris for its voluptuous literary pleasures.....In warm months parks become outdoor libraries. Walk through delightful Parc Monceau on a fair day, for instance, and on virtually every bench you will likely see some happy-looking citizen, book in hand, mind faraway in an enchanted otherworld.”

I have a feeling Parisians don’t spend much time in their apartments on the hot, sultry days of summer. In most cases, their apartments are probably not very inviting then anyway. Little or no sun. No chirping birds. No children sailing their little boats on the lake. How much nicer to take a book and head for their neighborhood park. Coming off my background in social research, I thought how interesting it would be to interview some Parisians—to ask them what the park meant to them? How often they visited their park? Did they have a favorite?

I wanted capture of the psychological meaning for Parisians of being in the small neighborhood parks, as well as the larger, better known ones. I wanted to know if the parks represent a Third Place in the sense that Ray Oldenburg uses the term in The Great Good Place.

I was reminded of all this by Boyd’s literary tour of these urban oases that he describes as “a refuge for lovers, loners, children and outcasts—parks provide the settings for some of our most innocent and illicit encounters. No wonder they are such an inspiration for novelists.”

A few years ago the New York Times ran a lengthy article on the numerous, no less beautiful hidden gardens of Paris, places I had never heard of or seen that are spread throughout the city. Perhaps one day I will be able to return to Paris to continue my encounters with those who go there to read or admire the lovely flowers.

The Cost Conundrum

As the debate about health care reform moves into its decisive and most contentious phase, Atul Gawande has once again joined the fray in the June 1st issue of The New Yorker. In this article he reports on the costs of medical care in McAllen, Texas, an obscure town on the south-west border of the state that claims to be the Square Dance Capital of the World. Why McAllen?

According to Gawande, McAllen is one of the most expensive health-care markets in the country. He says in 2006 Medicare spent fifteen thousand dollars per enrollee there, almost twice the national average. Gawande wants to know why. Step by step he considers each of the likely reasons.

He notes that the people who live in McAllen are not healthy and with its high poverty rate “has an incidence of heavy drinking, sixty percent higher than the national average. And the Tex-Mex diet has contributed to a thirty-eight percent obesity rate.”

Still he says that the incidence of cardiovascular disease there is actually lower than the national average and that the health statistics in nearby El Paso County are “just as bad as in McAllen, yet Medicare expenditures were half as much as in McAllen, so an unhealthy population couldn’t be the reason that McAllen’s health care costs are so high.”

Further, after visiting most of the hospitals in the area, Gawande concludes there’s no evidence the treatments and technology in McAllen are superior (and therefore more costly) than those found at some of the best medical centers in the country, e.g., Harvard, Stanford and the Mayo Clinic.

So the service is no better, physician malpractice insurance isn’t any higher, and McAllen is no more litigious than anywhere else in the country. A surgeon finally confessed, “We all know…There is overutilization here, pure and simple. Doctors, he said, were racking up charges with extra tests, services and procedures.”

Gawande writes, “Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care…critically ill Medicare patients received almost fifty percent more specialist visits in McAllen than in El Paso…twenty percent more abdominal ultrasounds, thirty percent more bone density studies, sixty per cent more stress tests with echocardiography…The primary cause of McAllen’s extreme was, very simply, the across-the-board overuse of medicine.”

In spite of this, the patients in such high spending areas do “no better than other patients, whether this is measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything they seemed to do worse.” They simply do not get what they need, such as low cost preventive services, flu and pneumonia vaccines, etc.

In addition to over utilization of costly medical technology, the physicians in this area of the country have come to view their practice as primarily a business, as a revenue stream. Gawande writes, “They instruct their secretary to have patients who call with follow-up questions to schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patient’s scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work.”

Taken together with the over-utilization of medical services, the medicine-as-business mindset has led to the extraordinary per person cost of medical care in this community, while at the same time, doing little if anything to improve patient health.

To get a handle on these costs, Gawande urges the expansion of “accountable care organizations in which doctors collaborate to increase prevention and the quality of care while discouraging overtreatment, undertreatment, and sheer profiteering.”

The President has said that the biggest threat to our nation’s economic future is the “skyrocketing” cost of medical services. Gawande makes it abundantly clear that we can avoid this threat by delivering better health care, avoiding unnecessary medical tests, and taking measures to blunt excessive financial incentives. Doing all this is likely to reduce significantly the “skyrocketing” costs of medical services in this country without negatively affecting the quality of patient care.

Weekend Links

Reading Russian Literature
http://www.newyorker.com/online/blogs/books/2009/06/what-are-you-reading-david-denby.html

Social Contagion
http://scienceblogs.com/cortex/2009/06/social_contagions.php

Power of the Pen
http://www.guardian.co.uk/books/booksblog/2009/jun/12/fiction-healthmindandbody

Let Writers Report the News
http://www.newyorker.com/online/blogs/books/2009/06/haaretz-gets-creative.html

Bookalholism
http://www.guardian.co.uk/books/booksblog/2009/jun/10/promoting-bookaholism

Need a Dictionary?
http://www.newyorker.com/online/blogs/books/2009/06/need-a-dictionary-with-that.html

Grab Your Dream

Each year the Times publishes snippets of some of the most interesting commencement speeches of the year. Earlier I wrote about the provocative commencement remarks of David Foster Wallace and Ann Patchett, both later published in their entirety as slim volumes.

It seems that this year most orators spoke about the bleak economic conditions that would greet graduates outside the campus. President Obama told Notre Dame graduates that they needed to “find a path back to prosperity.” Even Bud Selig, the commissioner of Major League Baseball, acknowledged “We are living in the most difficult economic environment since the Great Depression.” None of this was the sort of message one normally expects to hear in a commencement address.

The actress Laura Linney had a more traditional message for the graduates of The Julliard School. “Remember that no matter which art you practice, there is no more valuable skill than the ability to listen carefully. Especially when you listen to the music, or listen to the text, listen!”

So too did Larry Page, the co-founder of Google, who spoke to the graduates of the University of Michigan. “I had one of those dreams when I was 23. I suddenly woke up, I was just thinking, What if we download the whole Web and just keep the links? And I grabbed a pen and started writing. Sometimes it is important to wake up and stop dreaming….When a really great dream shows up, grab it.”

The historian David McCullough spoke about the importance of teachers to the graduates of the University of Oklahoma. “There is no such thing as a self-made man or woman…We are all, as were those in whose footsteps we follow, shaped by the influence and examples of countless others—parents, grandparents, friends, rivals. And by those who wrote the music that moves us to our souls, those whose performance on state or on the playing field took our breaths away, those who wrote the great charters which are the bedrock of our system of self-government. And so many who, to our benefit struggled and suffered through times of trouble and grave uncertainty. And by teachers…I want to stress as emphatically as I can the immeasurable importance of teachers.”

To the graduates of the School of Journalism at UC, Berkeley, Barbara Ehrenreich said, “You are going to be trying to carve out a career in the worst economic downturn since the Great Depression. You are, furthermore, going to be trying to do so within what appears to be a dying industry…Welcome to the American working class.”

I welcomed the timely remarks of Richard Haass, President of the Council on Foreign Relations, to the graduates of Oberlin College: “Dissent will be, and should be, part of your lives. This country was born of dissent (the Revolutionary War), defined by it (the Civil War) and changed profoundly by it. The labor, suffrage and civil rights movements as well as the anti-Vietnam protests all come to mind. Dissent is as America as cherry pie.”

Finally, there was even a speaker who put in a word for literature. It was the playwright John Patrick Shanley who delivered the commencement address at the College of Mount St. Vincent. “…when you leave here today, you may go through a period of unemployment. My suggestion is this: Enjoy the unemployment. Have a second cup of coffee. Go to the park. Read Walt Whitman. Walt Whitman loved being unemployed. I don’t believe he ever did a day’s work in his life. As you may know, he was a poet. If a lot of time goes by and you continue to be unemployed, you may want to consider announcing to all appropriate parties that you have become a poet.”

A Big Mistake?

Roni Rabin has written an important article in the New York Times (June 16, 2009) about the purported relationship between moderate alcohol consumption and a person’s overall health. She wonders if moderate drinking is really good for you. Given the countless studies that have demonstrated its benefits, how can anyone seriously entertain this question anymore?

Well, Rabin does. She says what if it’s all a big mistake? “For some scientists, the question will not go away. No study, these critics say, has ever proved a causal relationship between moderate drinking and lower risk of death—only that the two often go together.”

This is the reason I find her article so important. It gets to the nub of the many studies reported in the media about the association between a behavior, drug, or food product and another physiological or behavioral measure. For example, it is sometimes claimed that daily dose of aspirin decreases the risk of a heart attack. Or that excessive coffee consumption decreases bone mineral density and increases the risk of osteoporosis. And that eating a goodly number of fruits and vegetables decreases the risk of lung disease. The list of such claims seems limitless.

But it is essential to remember the nature of the evidence upon which they are made. Almost all are derived from correlational data in which one variable is found to go together with another with varying degrees of probability. However, it is impossible to claim a causal relationship with such data. We have no idea, for example, if the relationship is due to any number of third variables can account for the relationship.

Consider, for example, the claim that moderate alcohol consumption may promote cardiovascular health and reduce the risk of diabetes and dementia. Could it be that the moderate drinkers differ from those who abstain? Rabin suggests, “It may be that moderate drinking is just something healthy people tend to do, not something that makes people healthy.”

She quotes Kaye Middleton Fillmore, a sociologist from the University of California Medical School in San Francisco: “The moderate drinkers tend to do everything right—they exercise, they don’t smoke, they eat right and they drink moderately. It’s very hard to disentangle all of that, and that’s a real problem.”

The fact that abstainers and moderate drinkers have widely different life styles is crucial in understanding why one must be cautious in claiming a causal relationship in this case or, by extrapolation, to any statistical correlation, regardless of its size.

Rabin adds to the plausibility of this interpretation by citing the data of Dr. Naimi of the C.D.C. who reports that moderate drinkers and abstainers are “so different that they simply cannot be compared. Moderate drinkers are healthier, wealthier and more educated, and they get better health care, even thought they are more likely to smoke. Moderate drinkers tend to be socially advantaged in ways that have nothing to do with their drinking. These two groups are apples and oranges.”

Rabin reminds us that many researchers are haunted by the recently discovered mistakes in studies of hormone replacement therapy, “which was widely prescribed for years on the basis of observation studies similar to the kind done on alcohol.”

The fact remains that researchers have yet to carry out the kind of randomized, controlled experiment in which a group of abstainers are randomly assigned either to get a daily dose of alcohol or not and then closely monitored for several years to determine its effects on indices of health. Comparable designs can be imagined for other subgroups of individuals, such as those who are at risk for cardiovascular disease or diabetes. Such designs are uniformly required before the introduction of any new pharmaceutical agent in this country.

She concludes her article by quoting Dr. Sei Lee, again from the University of California Medical School in San Francisco who recently proposed a large randomized clinical trial on alcohol and health. “But this is a really important question, because here we have a readily available and widely used substance that may actually have a significant health benefit—but we just don’t know enough to make recommendations”