#the double capitalist maneuver

[starcanwreckedpulp-doyoushipit]

do you ship it?

[ecto42]

I think in D&D terms the typical assumption would be that a character with a chronic illness and/or chronic pain would have a low constitution score. The reality is a lot of people like myself would probably have constitution as our biggest stat because not only are we constantly staying up while fighting our bodies, we’re generally expected to ignore our own physical needs and wellbeing in exchange for being able to get things done. For example, I have been fully in the middle of a POTS episode and had to cook myself dinner, carry multiple loads of laundry up and down the stairs, etc. Like there’s such a real thing to Ashton Greymoore having chronic pain and yet their highest stat being Constitution.

I think something people are really good at acknowledging for Ashton as well as being apparent with Taliesin is that chronic illness generally means you’re stronger than people would assume, but you also blow through your resources faster and they can be just as counterproductive as they are helpful. It’s important to note that Taliesin struggles with chronic issues like hand tremors and has other chronically disabled friends like Dani Carr.

Like personally as an AMAB person with a condition that primarily hits AFAB people particularly hard, I’ve had cardiologists tell me “If anything your heart is overly muscular.” Which like, thanks dude yeah that’s decades of anxiety and years of POTS hitting and me having to stay standing up. Like I was in marching band in high school and I was the kid basically double-time marching in giant steps every show because I was the easiest to place since I’m so tall. Then when I worked fast food I had to either maneuver through hoardes of people to get back to my station or just push through them completely. In 90+ degree weather in the summer in Alabama with an anxiety disorder and a “heart condition” that’s actually just another neurological condition. Like I spent years doing manual labor and unloading trucks and pallets while exhausted on like 3 hours of sleep. You have to develop that kind of resilience when the capitalist system reinforces a world where no matter what if you want to survive as a person straddling the poverty line you have to work your ass off.

This doesn’t even get into the kind of resiliency you have to develop as an undiagnosed neurodivergent person who’s being told by absolutely everyone for most of your life that you’re doing everything wrong. Like Adaine from Dimension 20 is such a good example of that. This is also why I love the portrayal of Ayda Aguefort so much, because she really is like me having to learn everything from books because no one else in her life can explain things the same way that a book can. That is one of those things that as a late diagnosed autistic & ADHDer it’s really hard to explain personally without getting really like tragic or depressing in conversation because it sometimes is just a matter of “I’ve effectively been abused my entire life purely because the system wasn’t built for me and I had a lot of expectations I failed to live up to.”

All of this as a way to say that neurodiversity and disability are much more interesting and heroic feeling when they are portrayed by actually neurodiverse and disabled people, as well as those who love those people enough to tell stories that include them. I think TRRPGs and RPGs in general are a great way to explore this. Often times when we see disabled people in shows or movies that revolve around their disability there is a lack of agency, whereas often times with TTRPGs you have to create your own agency in the first place.

[thevividgreenmoss]

...The sense that postmodernist appropriation of non-European histories and texts would be the inevitable result of postmodernist dominance within the Euro-American academe - had been there much earlier, virtually inscribed in the very making of that dominance, and one of the earliest to read the signs was the Indian feminist scholar, Kumkum Sangari, in her essay 'Politics of the Possible,' published in 1987 but first drafted, judging from the footnotes, three years earlier. Toward the end of that essay, she speaks first of what she calls

the academised procedures of a peculiarly Western, historically singular, postmodern epistemology that universalizes the self-conscious dissolution of the bourgeois subject, with its now famous characteristic stance of self-irony, across both space and time.

She then goes on:

postmodernism does have a tendency to universalize its epistemological preoccupations - a tendency that appears even in the work of critics of radical political persuasion. On the one hand, the world contracts into the West; a Eurocentric perspective (for example, the post-Stalinist, anti-teleological, anti-master narrative dismay of Euro-American Marxism) is brought to bear upon 'Third World' cultural products; a 'specialized' scepticism is carried everywhere as cultural paraphernalia and epistemological apparatus, as a way of seeing; and the postmodern problematic becomes the frame through which the cultural products of the rest of the world are seen. On the other hand, the West expands into the World; late capitalism muffles the globe and homogenizes (or threatens to homogenize) all cultural production - this, for some reason, is one 'master narrative' that is seldom dismantled as it needs to be if the differential economic, class, and cultural formation of 'Third World' countries is to be taken into account. The writing that emerges from this position, however critical it may be of colonial discourses, gloomily disempowers the 'nation' as an enabling idea and relocates the impulses of change as everywhere and nowhere...

Further, the crisis of legitimation (of meaning and knowledge systems) becomes a strangely vigorous 'master narrative' in its own right, since it sets out to rework or 'process' the knowledge systems of the world in its own image; the postmodern 'crisis' becomes authoritative because...it is deeply implicated in the structure of institutions. Indeed, it threatens to become just as imperious as bourgeois humanism, which was an ideological maneuver based on a series of affirmations, whereas postmodernism appears to be a maneuver based on a series of negations and self-negations through which the West reconstructs its identity...Significantly, the disavowal of the objective and instrumental modalities of the social sciences occurs in the academies at a time when usable knowledge is gathered with growing certainty and control by Euro-America through advanced technologies of information retrieval from the rest of the world.

I have quoted at some length because a number of quite powerful ideas are summarised here, even though some phraseology (e.g., 'the West reconstructs its identity') indicates the Saidian moment of their composition. Kumkum Sangari was in any case possibly the first, certainly one of the first, to see how a late capitalist hermeneutic, developed in the metropolitan zones, would necessarily claim to be a universal hermeneutic, treating the whole world as its raw material. This goes, I think, to the very heart of the point I made earlier about the aggrandizements of postcolonial theory as it takes more and more historical epochs, more and more countries and continents, under its provenance, while it restricts the possibility of producing a knowledge of this all-encompassing terrain to a prior acceptance of postmodernist hermeneutic.

The work of Homi Bhabha is a particularly telling example of the way this kind of hermeneutic tends to appropriate the whole world as its raw material and yet effaces the issue of historically sedimented differences. Indeed, the very structure of historical time is effaced in the empty play of infinite heterogeneities on the one hand, and, on the other hand, the relentless impulse to present historical conflicts in the terms of a psychodrama. In the process, a series of slippages take place. The categories of Freudian psychoanalysis which Lacan reworked on the linguistic model were in any case intended to grapple with typologies of psychic disorder on the individual and familial plane; it is doubtful that they can be so easily transported to the plane of history without concepts becoming mere metaphors. This problem Bhabha evaporates by offering a large number of generalizations about two opposing singularities, virtually manichean in their repetition as abstractions in conflict: the coloniser and the colonised, each of which appears remarkably free of class, gender, historical time, geographical location, indeed any historicisation or individuation whatever. Both of these abstract universals appear as bearers of identifiable psychic pressures and needs which remain remarkably the same, everywhere. The colonizer, for example, is said to always be unnerved by any of the colonised who has in any degree succeeded in adopting the colonizer's culture. Translated into concrete language, it would mean that colonizers were not afraid of mass movements resting on the social basis of a populace very unlike themselves but by the upper class, well educated intellectual elite that had imbibed European culture.

What historical evidence is there to show any of that? Bhabha is sublimely indifferent to such questions of factity and historical proof presumably because history in that mode is an invention of linear time invented by rationalism, but more immediately because one allegedly knows from psychoanalysis that the Self is not nearly as unnerved by absolute Otherness as from that Otherness that has too much of oneself in it. What is truly unnerving, in other words, is seeing oneself in mimicry and caricature. That the hybridized colonial intellectual mimics the coloniser and thereby produces in the coloniser a sense of paranoia is, according to Bhabha, the central contradiction in the colonial encounter, which he construes to be basically discursive and psychic in character. The mimicry that Naipaul represents as a sign of a sense of inferiority on the part of the colonised, becomes, in Bhabha's words, 'signs of spectacular resistance.' The possibility that revolutionary anti-colonialism might have unnerved the colonial power somewhat more than the colonial gentlemen who had learned to mimic the Europeans, Bhabha shrugs off with remarkable nonchalance: 'I do not consider the practices and discourses of revolutionary struggle as the other side of "colonial discourse."'

...The figure of the migrant, especially the migrant (postcolonial) intellectual residing in the metropolis, comes to signify a universal condition of hybridity and is said to be the Subject of a Truth that individuals living within their national cultures do not possess. Edward Said's term for such Truth-Subjects of postcoloniality is 'cultural amphibians'; Salman Rushdie's treatment of migrancy ('floating upward from history, from memory, from time', as he characterizes it) is likewise invested in this idea of the migrant having a superior understanding of both cultures than what more sedentary individuals might understand of their own culture...Telling us that 'the truest eye may now belong to the migrant's double vision', we are given also the ideological location from which this 'truest eye' operates: 'I want to take my stand on the shifting margins of cultural displacement - that confounds any profound or 'authentic' sense of a 'national' culture or 'organic' intellectual . . .' Having thus dispensed with Antonio Gramsci - and more generally with the idea that a sense of place, of belonging, of some stable commitment to one's class or gender or nation may be useful for defining one's politics Bhabha then spells out his own sense of politics:

The language of critique is effective not because it keeps for ever separate the terms of the master and the slave, the mercantilist and the Marxist, but the extent to which it overcomes the given grounds of opposition and opens up a space of 'translation': a place of hybridity ... This is a sign that history is happening, in the pages of theory ..."

Cultural hybridity ('truest eye') of the migrant intellectual, which is posited as the negation of the 'organic intellectual' as Gramsci conceived of it, is thus conjoined with a philosophical hybridity (Bhabha's own 'language of critique') which likewise confounds the distinction between 'the mercantilist and the Marxist' so that 'history' does indeed become a mere 'happening' - 'in the pages of theory' for the most part.

...'Imperialism,' Spivak says, 'establishes the universality of the mode of production narrative.' Here we encounter, of course, the astonishing literary-critical habit of seeing all history as a contest between different kinds of narrative, so that imperialism itself gets described not in relation to the universalisation of the capitalist mode as such but in terms of the narrative of this mode. Implicit in the formulation, however, is the idea that to speak in terms of modes of production is to speak from within terms set by imperialism and what it considers normative. In the next step, then, Spivak would continue to insist on calling herself an 'old-fashioned Marxist' while also dismissing materialist and rationalist accounts of history, in the most contemptuous terms, as 'modes of production narratives'. This habit would also then become a regular feature of the 'subaltern perspective' as Spivak's gesture gets repeated in the writings of Gyan Parkash, Dipesh Chakrabarty and others. This distancing from the so-called 'modes of production narrative' then means that even when capitalism or imperialism are recognised in the form of an international division of labour, any analysis of this division passes 'more or less casually over the fully differentiated classes of workers and peasants, and identifies as the truly subaltern only those whom Spivak calls 'the paradigmatic victims of that division, the women of the urban subproletariat and of unorganised peasant labour.'" It is worth saying, I think, that this resembles no variety of Marxism that one has known, Spivak's claims notwithstanding. For, there is surely no gainsaying the fact that such women of the sub-proletariat and the unorganised peasantry indeed bear much of the burden of the immiseration caused by capitalism and imperialism, but one would want to argue that 'the paradigmatic victims' are far more numerous and would also include, at least, the households of the proletariat and the organised peasantry. Aside from this definitional problem, at least three other moves that Spivak makes are equally significant. First, having defined essential subalternity in this way, she answers her own famous question - Can the Subaltern Speak? - with the proposition that there is no space from where the subaltern (sexed) subject can speak." What it means of course is that women among the urban sub-proletariat and the unorganised peasantry do not assemble their own representations in the official archives and have no control over how they appear in such archives, if they do at all. It is in this sense that the sati, the immolated woman, becomes the emblematic figure of subaltern silence and of a self-destruction mandated by patriarchy and imperialism alike. As Spivak puts it: 'The case of suttee [suti] as exemplum of the woman-in-imperialism would...mark the place of 'disappearance' with something other than silence and nonexistence, a violent aporia between subject and object status.'"

Now, it is not at all clear to me why the self-immolating woman needs to be regarded as the 'exernplum of the woman-in-imperialism' today any more than such self-immolating women should have been treated in the past by a great many colonialists - and not only colonialists - as representing the very essence of Indian womanhood. Why should the proletarianization of large numbers of poorer women, or the all-India productions of the bhadramahila, or the middle class nationalist woman, not be treated as perhaps being at least equally typical of what Spivak calls 'woman-in-imperialism?' Even so, the argument that the essence of female subalternity is that she cannot speak is itself very striking since in this formulation of the situation of the subaltern woman, the question of her subjectivity or her ability to determine her own history hinges crucially not on her ability to resist, or on her ability to make common cause with others in her situation and thus appear in history as collective subject, but on her representation, the terms of her appearance in archives, her inability to communicate authoritatively, on one-to-one basis with the research scholar, perhaps in the confines of a library. This is problematic enough. But, then, the implication is that anyone who can represent herself, anyone who can speak, individually or collectively, is by definition not a subaltern - is, within the binary schema of subalternist historiography, inevitably a part of the elite, or, if not already a part of the elite, on her way to getting there." This is of course remarkably similar to the circular logic we find in Foucault, where there is nothing outside Power because whatever assembles a resistance to it is already constituting itself as a form of Power. But it also leaves the whole question of subaltern history very much in the lurch. If the hallmark of the true, the paradigmatic subaltern is that she cannot speak - that she must always remain an unspoken trace that simply cannot be retrieved in a counter-history -and if it is also true that to speak about her or on her behalf when she cannot speak for herself amounts to practising an 'epistemic violence', then how does one write the history of this permanently disappeared?

Spivak seems to offer four answers that run concurrently. First, there seems to be a rejection of narrative history in general, often expressed in the form of much contempt for what gets called empirical and positivist history, even though it remains unclear as to how one could write history without empirical verification; nor is it at all clear just how much of what we know as history is being rejected as 'positivist'; at times, certainly, all that is not deconstructionist seems to be categorised as positivist or some such. Second, in the same vein of emphasizing the impossibility of writing the history of the real subalterns, Spivak criticises those earlier projects of subalternism, including implicitly such writings of Ranajit Guha as his works on peasant insurgency", which sought to recapture or document patterns of subaltern consciousness even in their non-rationalist structures. She criticises such projects on the grounds, precisely, that any claim to have access to subaltern consciousness and to identify its structures is prima facie a rationalist claim that is inherently hegemonizing and imperialist. As she puts it, 'the subaltern is necessarily the absolute limit of the place where history is narrativised into logic' and 'there is no doubt that poststructuralism can really radicalize the old Marxist fetishisation of consciousness.' That scornful phrase, 'old Marxist fetishisation,' on the part of someone who often calls herself an 'old-fashioned Marxist' and whom Robert Young unjustly rebukes for taking too much from 'classical Marxism,' of course takes us back to the Derridean claim that deconstruction is a 'radicalisation' of Marxism and Bourdieu's retort to this Heideggerian 'second-degree strategy.'

Be that as it may. In terms of method, the previous formulation is of course the more arresting, so let me repeat it: 'the subaltern is necessarily the absolute limit of the place where history is narrativised into logic.' The programmatic move of theoretical anti-rationalism is stated here in methodic terms: while the statement appears to be merely anti-Hegelian, what it in effect rejects, in relation to subalternity, is the very possibility of narrative history, with its reliance on some sense of sequence and structure, some sense of cause and effect, some belief that the task of the historian is not simply to presume or speculate but to actually find and document the patterns of existing consciousness among the victims as they actually were, and a dogged belief, also, that no complete narrative shall ever be possible but the archive that the dominant social classes and groups in society have assembled for their own reasons can be prised open to assemble a counterhistory, 'people's history', a 'history from below'. E. P. Thompson's great historical narratives on the Making of the English Working Class, on patterns of 18th Century English Culture, on the social consequence of industrial clock time for those who were subjected to it, come readily to mind in this context. I don't think it would serve Professor Spivak's purposes to dissociate herself from that tradition altogether, but the actual effect of her deconstructionist intervention in matters of writing the history of the wretched of this earth is to make radically impossible the writing of that kind of social history, whether with reference to the social classes of modern capitalism or in the field of literary analysis.

Such, then, are the burdens of the Post Condition, even for those who may recoil at the Fukuyamaist variant.

Aijaz Ahmad, Post Colonial Theory and the 'Post-' Condition

[allthecanadianpolitics]

Chuka Ejeckam studies political science and public policy at the University of British Columbia. His work focuses on drug policy and inequality, the latter both political and economic.

The Canadian cannabis industry is booming. From giant industrial operations such as Canopy Growth to smaller “luxury” cannabis retailers, to an array of cannabis “lifestyle” brands and “cannabis brand consultancy” firms, the industry is a lucrative frontier for those seeking wealth in a rapidly growing market.

And oh, is there wealth to be had. Canadians spent $1.6-billion on legal weed in 2018 – double the total spent on medical cannabis the year before – despite the fact that non-medical cannabis was legally available only after Oct. 17. Statistics Canada’s National Cannabis Survey from the first quarter of 2019 found that use of non-medical cannabis has increased among men and people aged 45 to 64. The survey reported that 646,000 people tried cannabis for the first time in the prior three months, half of whom were aged 45 or older.

The non-medical cannabis market in Canada, too, is increasingly treated like any other for-profit industry. The Globe and Mail’s reporting on CannTrust Holdings��� unlicensed production scandal reads like any other kind of corporate controversy, with the language of alleged executive misbehaviour, market shares, and intra-industry maneuvering. Cannabis is quickly becoming mainstream, and – as is the norm for our capitalist society – firmly corporate.

This is a failure. As non-medical cannabis shifts from a criminal offence to a legal commercial product, revenue from legal weed should be used to fund meaningful reparations for communities targeted for decades by racist drug laws and enforcement. However, even a surface-level analysis of the rapidly growing cannabis industry in Canada reveals a troubling trend: The profits and wealth being generated are overwhelmingly landing in the pockets of white Canadians.

Continue Reading.

Tagging: @ontarionewsnow @abpoli @politicsofcanada

[artyrogue]

Blind Date Gaming: Tiny Toon Adventures: Montana Max’s Movie Madness

The name of my next blind date filled me with a bit of trepidation. I know you shouldn't judge by a name alone, but my instincts were kicking in as well as a flood of bad memories.

PRANG served me up Tiny Toon Adventures: Montana's Movie Madness. While I have no beef with Tiny Toons in the least, licensed games are typically pretty crappy. Usually they're cobbled together by folks with little programming skill and little knowledge on the source material to shove out a title quickly that will sell by the license name alone. I buckled in and steeled myself for another horrid chapter in the book of bad games. But lo! Behold the logo that arose and saved me from my misfortune!

My inner neat freak was triggered by that 'O' being two pixels taller than the other letters

Konami! An actual gaming company! Also the folks who have made plenty of great games like Contra and Castlevania! This might be a good date yet!

The game starts with a small cutscene. Apparently Montana Max made a new movie theater since he's more loaded than Elon Musk and Bill Gates as a power couple in a creepy fanfic. He apparently also owns all the sets and movies shown at the theater too. Being the only cinema in town, I guess everyone was forced to go? I mean, I'm pretty sure the Tiny Toons lived in a capitalist society, so I don't see why they didn't just force Max to net a loss by not attending, but who am I to question the economical landscapes of fictional 90's children's cartoon worlds?

So what you get is a platformer with different stages being different movie themes. There are 4 in all: Western, Kabuki, Future, and Horror. I like how Kabuki somehow made it in; it keeps that flavor of Japan-themed levels that many video games have for whatever reason. Regardless, there are different elements for each world that gives them a unique feel. For example, there's an electrical maze in the future set, slippery sloped roofs in the kabuki set, and a race against rising water in the horror set. It's rather fun and keeps you on your toes.

I like the presence of fire-breathing fish in this completely wooden pagoda

Between the stages, you get some mini-games to earn some extra lives. The games change between each set, so it's a nice new challenge each time. The difficulty ramps up with the progression, too, so good luck with some of the later ones! There's a basketball game, a tug of war with some jacked jack russel, and essentially the Fire Game and Watch. You're going to want to grab these lives, as things get really rough later on.

I will never be as cool as this friggin' dog

The enemies are pretty tame -- mostly quite boring, actually -- though there are a few that stand out. Sometimes the enemy placement borderline griefs the player, as an enemy may chuck a box right when you see it or dive at you with little room to maneuver around it. You mainly defeat foes by jumping on them, but the hitboxes can be wonky at times. You have a kick attack, too, but it mostly just stuns things. You can use stunned enemies as platforms, but they hurt you if you’re standing on them when they exit their comatose state, so you really don't use that often unless you want to grab some carrots (the coins of this game). But like carrots are only used for points, and who really cares about that...?

Oh yeah, gotta get that high score and post it to Game Boy Live for bragging rights

The bosses are actually fair and fun, so that's a plus. Each one is some iteration of Montana Max. Surprise! They each have patterns that are easy to pick up. 3 hits will take each down, as is customary for adhering to the Video Game Boss Pact of 1986 stating that golden number as a requirement for all interactive electronic media end-of-level bestiary.

Someone turned Max into one of those Goombas from the live action Mario Bros. movie

So if the enemies and bosses are more or less tame, where's the challenge? Well, friend, just wait until you get to the rocket part of the future set. You. Will. Die. Over and over. Just like the Battletoads level, you'll need to know what's coming, as reacting blindly will kill you. Luckily it's not nearly as bad as Battletoads, but there's still a long stretch with no continuation points that requires you to both fit your rocket in a tiny hole in the center of the screen and do this weird jump where you have to go as far left as you can and move right as fast as you can when you hit a very specific part of the track to fully make a jump. This part alone claimed so many of my lives that it can probably fill several dozen cats. (Yes, we are using cats as decanters for lives now since they can hold up to nine.)

When not on a rocket, the controls are usually fair. There's an essential move that's required to progress in the game, though, and the controls for it are absolutely frustrating. By pressing down, you start a dash chargeup. From there, you press left or right to dash in that direction, giving you more speed and a higher jump. However, you have a short slowdown animation at the end of the move and sometimes the dash just kind of...not happens? It's readily apparent in some of the later stages where you have to make jumps quickly before water or a moving platform kill or hurt you. You also have to use it to harm some bosses too (as you need the jump height), but good luck finding the space to execute the dash well without colliding into the boss.

The artists had a clear vision of brilliance when making Max's pain face. They probably just used the beta testers’ faces as models after they tested the rocket part

I should also mention the music briefly. The tracks are all geared around the Tiny Toon theme song, but each has a unique flavor and sounds overall fairly pleasing. I actually liked the future set's theme so much I found a version online to grab as an mp3. you can listen to it here (as long as the video is still up):

Despite some of the slowdowns and difficulty spikes, I did quite enjoy the game and managed to beat it in my allotted date time. However, apparently I was just playing on easy mode? What is this witchery?!

So you can play through the game a second time with less max HP. I looked up some more details and apparently the bosses have double HP as well. So less max HP and more Max HP. Right. It wouldn't be that hard really, as the most challenging parts of the game were insta-kill segments like the rocket and the rising water. Still, my time was out and I kind of wasn't feeling a replay. I did have fun with it, though, so I'm on the fence about going back for a second date. Maybe later after I get that rocket part out of my mind...Gah, sorry to keep bringing that up, but it seriously dragged the whole experience down. Like all the notches. So many notches that I think I'll skip a second date after all. Boo! At least I grabbed a pretty stellar Sprite of Passage, though. Focus your mind on miniature cartoons and you, too, will likely see this as your spirit animal.

I think that cocktail umbrella hit a nerve in his head

[omniversalobservations]

Empire Games (2017)

The Merchant Princes is a science fantasy and alternate history series by British writer Charles Stross. There are currently eight novels in the series, with another forthcoming. In the series, there exists a number of parallel worlds all of which are on the same geographical Earth, but with different societies at different points of development. Members of a certain bloodline can travel between these worlds along with their immediate possessions. The series largely follows Miriam Beckstein, a technology journalist raised in a familiar "normal" Earth, who discovers she was born in a parallel world and is a member of this bloodline. She quickly becomes entangled in political maneuvering and assassination plots with her estranged family. Miriam uses modern technology and investigative journalism to attempt to stay a step ahead.

The implications of this world-traveling ability are thoroughly explored by the series. The ability to take clothing and held items across allows a phenomenally lucrative import/export trade between worlds; wielders of this power have used it to become wealthy. Invaluable modern technology and medicine can be shipped to the feudal world; illegal drugs can be shipped in a world where the DEA has no power; and packages or messages that would take months to deliver by horseback can simply be mailed via FedEx in the modern world. This power has implications for security and crime as well, since it is now possible to commit a crime then disappear into thin air, and difficult to lock someone up in any effective manner. It also means there is immense social pressure on members of the genetic bloodline to breed with other compatible members to increase the likelihood of the ability manifesting.

The first six novels in the series were released from 2004 to 2010, and take place in 2002–2004 of an alternate present. The books were later re-released in 2014 as A Merchant Princes Omnibus, a trilogy of three books with each book a combination of two of the original novels: The Bloodline Feud (books 1 and 2), The Traders' War (books 3 and 4), and The Revolution Trade (books 5 and 6). The re-release also included a considerable amount of editing and rewriting by Stross, although no major plot changes. A new trilogy began in 2017 with the release of Empire Games featuring new characters and updating the year in-setting to 2020.

Source: Wikipedia

Charlie Stross's longrunning Merchant Princes series are a sneaky, brilliant techno-economic thought experiment disguised as heroic fantasy, and with Empire Games, the first book of the second phase of the series, Stross throws in a heavy dose of the noirest spycraft, an experiment in dieselpunk Leninism and War on Terror paranoia.

Empire Games is a fresh start in the series, quickly establishing the backstory that spans the previous seven volumes: a clan of worldwalking transdimensional mercantalists have quietly taken over their medieval, parallel world by establishing a triangle trade in ours: they bring messages from their world's kingdoms into our dimension and use telephones and computers to get them across the planet in a hot second; then they take heroin from our world and transport it by mule train across their world, creating an unstoppable -- and unbelievably profitable -- courier service that catapults them to power.

When the clan is fractured by factionalism and discovered by the US Department of Homeland Security, the catastrophic war drives the remainder of the clan into Timeline 3, a dieselpunk version of North Korea where an exiled English tyrant rules over all of the Americas, brooding at the French imperial usurpers who hold all of Europe. With the clan's help, the King is overthrown and a kind of worker's paradise is established in Timeline 3, with the top priority task of leapfrogging American technological prowess before the DHS shows up and nukes them all into oblivion.

That's where Empire Games starts: the US has become a surveillance state that exceeds even our own paranoid moment, where privacy is shredded by adversarial genomics, internet-of-surveilling-things, and a paranoid deep state pierced through with conspiracy theorists, Dominionists, even highly placed Scientologists.

What's more, they've just figured out that the clan's worldwalkers are still dropping by to pick up technological resources to export to World 3, where the revolutionaries are on an accelerated course of technological development, like the post-Sputnik space race, but for every imaginable technology.

Lucky for the DHS, they've figured out how to make non-worldwalking clan members into worldwalkers by tweaking their biochemistry, and even luckier, they've got a few candidates to work as double-agents for them and set up a forward base in whatever timeline their adversaries are using as their new home. Chief among these is Rita, the adopted-out daughter of Miriam, the hero of books 1-t, who was raised by paranoid refugees from East Germany who have taught her a suspiciously large amount of spycraft on the way.

What follows is a brilliant spy novel, intricately plotted and beautifully told -- but posed against a backdrop of economic speculation that uses science fiction to play out some of the longrunning arguments that kicked off with Leninism and its insistence that peasants could use capitalist technology to leapfrog the industrial revolution and go straight to socialist abundance, with dashes of Deng's "Communism with Chinese characteristics" and the post-Soviet doctrine of "emerging markets" that would use technology and markets to supercharge their economy.

Source: Boing Boing

[nicholas-martin]

Scooters Gaining in Popularity

Electric scooters are becoming increasingly popular in cities and towns around the world. They are overtaking station-based bicycles as the most popular form of shared transportation outside transit and cars in the U.S. Riders took 38.5 million trips on shared electric scooters in 2018, eclipsing the 36.5 million trips on shared, docked bicycles, according to a report released Wednesday by the National Association of City Transportation Officials. This as scooter companies face challenges from every direction, including vandalism, theft, rider injuries, intense competition and aggressive regulations in cities across the country. Yet the scooter industry persists, and venture capitalists, ride-hailing companies and traditional auto manufacturers continue to pour millions into the fledgling companies.

Companies are jockeying for strategic position in the so-called micromobility revolution, where consumers are embracing shared scooters and bikes for short trips and exploring alternatives to car ownership buoyed by the ubiquity of smartphones. Riders took 84 million trips on micromobility services such as shared scooters and bikes in 2018, more than double the number from the year before. Scooter and bike riders typically use an app to find one nearby and pay a few dollars to ride for a set period of time, paying within the smartphone app using a credit card. Some shared mobility services, such as Lyft-owned Citi Bike in New York City, offer monthly or annual memberships for riders.

There were more than 85,000 electric scooters available for public use in the U.S. in 2018 compared with 57,000 station-based bikes. Shared bikes are considered "station-based" or "docked" if a rider takes out the bike and returns it to one of many docking stations — basically parking lots for bikes — which are spread throughout a city. Dockless bikes, which represent a smaller portion of shared bikes, can be left anywhere, and can be found and unlocked through a smartphone app. Shared docked bike usage among monthly pass holders peaks during rush hours, suggesting use by commuters, but shared scooter usage does not, indicating scooters may be more likely to be used for recreational use, according to the report.

The popularity of electric scooters is riding so high that, in some towns, leaders don’t want the e-scooter rental business to invade their streets and have decided to ban this means of transport. For example, in Colorado, Breckenridge wants to stay “scooter free.” In this popular mountain destination where bicycles are the preferred mode of alternate transportation, scooters are far from welcome. “I think we’ve seen across the country we’re just trying to be proactive,” said Haley Littleton with Breckenridge. “We have a lot of pedestrians up and down our streets and we have pretty narrow sidewalks because we’re historic. We think it does probably a public safety hazard.” The ban applies to e-scooter businesses like Bird, Lime and Lyft scooters. “We’re always increasing walk-ability, even though we are banning the rental business of the scooters we are trying to get people out of their cars,” said Littleton.

So why are Electric Scooters Popular? The obvious answer is that they’re a practical, ecological and economical alternative to city traffic. Every day, more and more people are changing their way of commuting to work, school, and university in order to save time and money. Electric scooters are perfect for a short city ride, and they are perfect as a “last-mile” vehicle. Electric vehicles have many advantages, but the electric scooter specifically adds some more to that list as it is lightweight, foldable and small. For instance, speed. While the speed is not that high compared to cars or motorcycles, the ability to avoid traffic jams is great with the ability to maneuver around others. You can reach your destination in a similar time without having to worry or deal about traffic.

Other advantages include the fact that you ride without effort, so you don’t need to worry about sweat stains or being tired after the ride. Finally, it’s fun! That’s why electric scooters are especially popular among teens. Kids also love them, and there are some small models for kids. Kids use them for having fun, as opposed to commuting, so they are unlikely going to kindergarten/elementary school on them.

In conclusion, electric scooters are popular now and will become even more popular in the years to come. They are a fast, efficient, and eco-friendly alternative to the traditional car and motorcycle. Due to their advantages (portability, good speed, ability to avoid traffic jams, size) they are probably the best vehicles for a city ride.

[parigrin]

He winced as he scrapped his knee against the side of the wall, his heavy drenched clothing squishing wetly against his white feathers. He smelled, he hurt, and he hadn’t eaten since that morning. If he’d eaten at all. He couldn’t quite remember, and it didn’t seem as important when compared to the sheer enormity of everything else that had happened that day. He got up and threw himself back into the task, scrambling to find enough space to press himself through the opening to the sewer drain. He’d seen a raccoon go down one of these before while waiting for a gig that had been canceled without notice and while he was no pesky procyonid, he was certain that If! He! Just! Through! Enough! Back! Into! It! He would somehow manage to get himself out. That or he’d be stuck down in the gutters for an eternity and he’d either go mad and start feeding on rodents to survive or meet some subterranean adolescent abomination with a thirst for pizza and a curious knowledge of ninjutsu. Whichever came first. He fell again, this time on his back and he gasped in pain, suddenly winded. He gave himself a minute to catch his bearings. Still hurt. Still Alive. Still needed to get out. He got up again, this time giving himself running space and hurtled himself up into the air. The pain of impact was immediate, fire breaking across his beak, he tasted blood where his all too sharp teeth had bitten into his tongue and a nearly overpowering crescendo timed with the beating of his own heart crashed over him, but above all that was a feeling of steely determination, because this time, unlike his other tries, he had managed to hook his hands out the opening. If he could just pull himself through, he’d finally be free of the dark and dreary tunnels. He pushed his arms out, wriggling and wreathing like a worm on a hook, scrapping his body this way and that, ripping feathers loose from their roots, breaking the exposed skin underneath those feathers in more places than he could count. He needed to get out. He couldn’t stay down here. The mantra repeated ad nauseum in his head. If there was a word that could accurately encompass exactly what was going through his mind, it escaped him. He felt the racing thrumming burning energy of his emotions coursing through his body, shocking him with the striking intensity of it, whatever “it” even was. He wanted it to stop. But a bigger part of it needed it to continue. He felt something creak dangerously around him and he pushed his face flat against the grown and tasting cloying dirt and gritty asphalt on his tongue, as he twisted his body up, kicking his legs against the walls below to give him some sort of leverage to help him maneuver himself out of his current predicament. It concerned him to know that despite the pain, despite everything else that was going on that he really should take more time to process, he was having more fun than he had in years. It was almost like he was on set again, and by the Late great Adam West did he miss the old show. He grunted as he carelessly scraped a foot against the unforgiving sewer walls. He’d kept in shape and was remarkably spry by most people’s estimation, but at his…mature… age perhaps climbing around in sewers was beneath him. He sighed, breathing deeply and went back to it. Jim knew he’d been in a rut for years; his feelings had been limited to boredom and anger and a desperate desire to free himself from one or the other. What he felt now, as he pushed himself agonizingly forward and rocked his hips to and fro until half of his waist was now successfully protruding from the mouth of the sewer, was none of the above. But though he might be enjoying himself, as much as he wanted to play the role of Darkwing, it just wouldn’t come to him as easily as he felt it should. Whatever emotion, whatever drive he now felt coursing through him was so unconnected with what he typically associated with his “Darkwing Persona” that it might as well have been from an alternate universe for all they had in common. It was angry and buzzing and he wasn’t entirely sure he liked it. Really wasn’t sure at all. But he reasoned, continuing to thrash about like hooked trout, it had still managed to galvanize him into action and that was more than could be said of anything he’d felt for more years than he cared to admit. The exasperation he felt as he tried to free his behind from the great gaping maw it was currently trapped in made him feel more aware, more present, more like the “old” him than he could honestly remember himself being since the realization had finally sunk in that no matter how many petitions his old fans  threw together, there would be no miraculous resurrection from the grave of cancellation for his old show. He flailed against the cement holding him in place before he finally felt himself push forward, and the momentum of his thrusts carried him nearly all the way out. He’d caught his feet on the sides of the opening, but, by pressing his hands against the edges, he managed to finally remove one, then the other entirely. He let out some steadying deep breaths and hoisted himself on top of the curb to catch his breath. After gaining control of his bearings he scanned his surroundings and tried to piece together where he was. It was somewhere alarmingly close to the Beagle’s junkyard, he knew that much from having passed by the place before, but with the night shrouding everything in shadow, the specifics eluded him. He looked up at the cloudy sky above and pondered his new path for a moment, speculations on how often he’d be forced to pull himself out of sewers in the future were first and foremost in his mind, then shook his head. He wouldn’t go back to the way he was living before. He couldn’t, not really, thanks to the doppelganger. He had never really put much stock in the supernatural. His knowledge in its presence had come from the daily updated stream of Scrooge McDuck’s reign of capitalist tyranny as reported by one Roxanne Featherly. With so much evidence piled up. only an absolute fool would doubt its existence, of course. But the familiarity had been merely abstract, like knowing the Moon revolved around the Earth, it was a distant sort of knowledge that everyone knew but also never expected the information to be especially useful in one’s daily life. Now he knew better. It was said in old myths that finding one’s evil twin would lead to the original’s destruction, and after spending a mere day living with the knowledge of that hack’s existence he was inclined to believe the stories were true. How else could the knowledge of the movie’s existence fly under the radar of both his agent and himself for so long? He wondered for a moment if his agent had decided to throw in his luck with a newer model, then shrugged and picked himself off the ground. Thinking about his agent only brought up more negative thoughts, and if he was honest with himself, he wondered if any more negativity would make him explode. He glanced around the empty street and pushed himself off the curb, walking slouched with his hands in his pockets. He felt unnecessarily exposed, even with his face covered in the mask.  Anyone could come by and see him, and, with his luck recognize him and then where would he be? He would like to say he could smooth talk his way out of any trouble but remembering his earlier embarrassment at the hands of the security guard, forced him to admit that acting did not, as much as he might vocally protest otherwise, come as easily to him as he wanted to believe. That was a blunt nail he’d had directors try to hammer into him for years, but it was not something he wanted to be embedded into the wood of his mental image of himself, and he had resisted as long as he was able. He’d tried to swallow his pride and find a new career, of course. He was Jim Starling, he did all his own stunts for his show. Surely talent agents would take note of that and he’d land a job as a stunt double at the very least? The years of bitter memories that told a different story than the one he’d wanted to believe said otherwise. He paused when he heard the telltale swish of a car moving through puddles and felt his heart race. It stopped at a stoplight two lampposts ahead of him and he began rapidly debating with himself over the desire to hide behind something to keep himself from being noticed or to keep walking and pretend there was absolutely nothing notable about the solitary figure of a man wearing a mask under his trademark wide-brimmed tando and sporting a fetching cape knitted into the collar of his double-breasted business suit. Honestly, the fact that he was by himself and strutting about at too dang late in the night not to be up to funny business at this hour o’clock for his evening jogs had made some of his more cautious neighbors tattle on him to the police call attendant more times than he could count. Harriette had once been a fan and had been inspired by Darkwing to join the local law enforcement. Meeting him had been a dream come true apparently, and then after the third time of meeting him at One in the morning when found he’d it difficult to sleep (though he had always insisted he was just doing his part to keep in shape), she had asked him to join a gym so they wouldn’t have to keep meeting as they had. By the fifth time, she had requested a transfer, all previous childhood nostalgia seemingly wiped clean by mere association with him. He’d met enough “biggest fans” who could no longer stand him that he had been desensitized to the phrase long ago. The car continued on its path when the light turned green and he absently hoped the fact that he was near Beagle territory made his appearance similar enough to the local canine crime family that the driver had been conditioned not to call the police at the first sign of a disguised prowler.  He’d always been too optimistic. Whenever he’d shown his face for the part of a stuntman the same words had seemed to follow him. “Too clumsy.” They said. “Not enough finesse.” Others commented. There had been others still who had been less polite in their eternally helpful observations, and he felt their poisoned words flitting around his mind like horseflies biting into sensitive flesh whenever the opportunity prevailed itself. He shook his head like a wet dog attempting to dispel the water from its fur. He was injured and walking alone in the middle of the night with no backup with only vaguest inkling of his whereabouts. Now was not the time to have a midlife crisis, and it would him no good to reflect on the past. He’d wasted enough of his years feeling sorry for himself. Now was a time for action! He felt the urge to pose heroically and, had to temper it with a more realistic edge. He posed broodingly instead. Very dark. So very drama. His stance wilted a little when he remembered the itty bitty little problem with that was that he wasn’t entirely sure what action he should be taking. He was a little new to this “grim and gritty hero on the edge” scene. Obviously, he was going to experience some brain freeze while slurping down the slushy of frozen vengeance. The shows he’d watched before he could no longer follow the tales of capes and cowls without being weighed down by resentment had glossed over some immensely irritating hang-ups to the whole “pretending to be dead so he could catch the evildoer with his metaphorical pants down” ploy. The most obvious, of course, was that he needed to find himself some new threads until he could get his suit dry cleaned. He liked to think he had himself a strong stomach, but he doubted the common citizen of Duckberg could cope with parfum d'eaux usées évaporées with the same determination. A bath to rid himself of the aforementioned scent of sewage wouldn’t be remiss, either. This did, unfortunately, lead to the second most obvious problem: he was, temporarily at least, effectively broke. He sighed as he passed the first light post. With the news of his apparent passing, his bank account and assets would be frozen and without any family, friends, or hastily cobbled together fake identities to inherit his estate his effects would likely be seized in their entirety by the state. Some small part of him said that deliberately making the choice to go both penniless and homeless at the same time was taking this hero schtick a too far, but the thought was silenced by headbutting the second light post hard enough to dent the metal. He was not going to quit this thing until he had successfully ousted his duplicitous doppelganger and earned back the respect of his badly neglected fan. His thoughts turned to the young man he’d known for years without actually having met him truly as he stood considering whether to continue forward or cross the empty street, and he felt his stomach flare with the ache of very real guilt.  Jim had not treated the younger man with the respect he should have meted out towards a true loyalist. Yes, he had been something of an irritation, he’d become very familiar with the weight of the man’s body crushing down on him after the fan had been struck with yet another fainting spell. But the fact dawned on him as he stood there under the green glow of the traffic light that this one fan had continued to come to his signings regardless of his own physical and psychological inhibitions. And that one detail should have told him more about the man than he’d thought to attribute to the pelican in all his years of knowing him.  He decided to cross the street and waited impatiently for the light to turn red. Many fans had claimed to be his biggest fan but most had had only proven willing to come to his signing maybe one or twice before their interest in meeting him had ostensibly dried up into dust. But that singular fan, one Launchpad McQuack, had, for all intents and purposes, kept coming, even if it was just to faint on him yet again. He glanced around. There was no one out and about, not a single car to be seen anywhere, but he���d felt inclined to wait lest some cop trying to fill a quota tried to pull over a dead guy for jaywalking. He had nearly decided to walk across anyway when a single car sped by quick enough to almost clip him. ‘Seriously?’ He huffed in annoyance. ‘Was the universe itself out to get him? He hoped not. He was aware that, with the help of his double’s trickery, he had managed to badly damage his greatest fan’s regard of him, but he hoped with a wildness that worried him, that that sort of devotion his fan had possessed  wasn’t the sort that burned away after a very awkward and embarrassing set of missteps he’d manage to make over the course of a single(how could it be only one?) very bad day. The light overhead turned from green to red and the white pedestrian signal flared into life. A car pulled up, and he laughed at the look of consternation on the driver’s face. He loved it when his misfortunes happened to others, it made him feel less singled out by fate. He began walking across at his own pace, and he’d nearly passed over when the light unexpectedly turned green without warning. The driver, a young canine whose path he now blocked blared his horn, startling Jim from his thoughts. He’d glared at the driver who had then proceeded to quite eloquently flip him the single-fingered salute. Now most days, he would have ignored it and gone about his business. He would have grumbled about the lack of respect he was given, but ultimately he would have done nothing. Today, with the strange sensitivity coursing through his veins, a mood he still had yet to name, he decided that today was not a day for inaction. Once that thought crossed his mind his body had stopped dead, practically of its own accord, and when the driver chose to slam his fist on the horn one more time, he sprang into action, moving forward and propelling himself up, up, and over the hood of the driver’s car and ramming himself through the open window of the vehicle and landing on top of the young man with enough force that his heckler was briefly pushed under the steering wheel. The driver, a young canine with a dark mane of greasy black locks that parted on both sides of his face, had a thing for the punk scene(or was it goth? Maybe Elmo? He found it difficult to differentiate between the fashion trends of the poetically minded, it had something to do with music, and poetry, and public safety ads, but really, they all looked like they shopped at the same stores, it wasn’t his thing, but he could respect the work they put into the aesthetics)and was well tailored if the clothing he wore was any indication. The skull clasp on his purple cloak fit nicely in his hand when his hands shot down to get a better grip on him. The two began a dangerous game of whack-a-mole, with Jim’s fists as the mallet and the dog’s face as a terribly tenacious talpid. He removed the keys from the car to prevent the vehicle from crashing into the light posts. The younger man then proved he possessed a rather strong set of jaws when he’d chosen to latch an impressive set of fangs onto the duck’s knee. The disgraced actor had sworn out a string of obscenities that would have immediately landed him in hot water with the censors and had bopped him in the nose, trying to get the pooch to remove the teeth from their agonizing hold on his sensitive joint. This only succeeded in causing him to sink his teeth deeper into the flesh of his leg. He was seized with the urge to use his own teeth on the tyke to show him what it truly meant to bite someone but managed to resist the temptation. As the older of the two, he would be a more civilized party and biting a young man to assert dominance was pressing the envelope a little too hard, even for him. His mind rapidly tried to think of a solution to his problem but kept coming up blank. What he really needed was a vial of pepper spray. Finding himself fresh out of pepper spray, he attempted to spit in the whelp’s eyes, figuring it could at least provide a decent distraction that would allow him to free himself from the kid’s muzzle. Unfortunately, the operating phrase in that sentence was ‘attempt’ because instead of a neat expel of saliva, his throat began hacking up mucus that bubbled from his mouth and clung to his chin. He tried a couple more times but was met with failure each time. Still, the move eventually did its job because when enough of the gathered spittle had begun dripping from his chin the dog’s eyes widened in horrified disgust and he released his leg with an alarmed “Oh my Go-” he was silenced by the duck’s vindictive kick, and the younger man’s body crumpled before it slid limply under the steering wheel and moved no more. Jim hastily scooted into the passenger’s seat and watched the dark form warily in the off chance that the canine roused from the place his body now lay and began taking deep breaths. He began to shake and shiver, all earlier bravado draining from his features as trepidation began to set in and his heart began to beat faster in what he recognized as the early stages of hysteria. While he could claim that he’d been provoked, it didn’t change the reality that the person he had just attacked was obviously a member of the Beagle Crime Family. He’d seen the boy in the news once or twice. Usually accompanied by similarly dressed littermates. He doubted the Beagles would give a tinker’s curse about at his motivations for attacking one of their own. All they would do was see what he’d done and rightly call a spade a shovel and he’d have the entire lot of them on his tail feathers the moment his actions were discovered. And, to toss an already burnt marshmallow on a stick and thrust it into the fire, he hadn’t even intended to attack the dog in the first place. He was used to intrusive thoughts(he was currently holding out against the impulse to lay all his cards on the table and enact various methods of ridding himself of his predicament terminally in ways both disturbing and physically improbable), but to the best of his knowledge, he had never acted on them. His thoughts had often disturbed him, especially when he’d been in the springtime of his life when his feelings had been more varied, and he hadn’t felt like his brain had been enveloped by an endless fog. The years of anguished apathy had deadened how very unsettling he’d once found them, but he hadn’t thought he’d start to treat them as if they were an innate part of his decision making. The truth that he hadn’t even notice before he was already in motion cast further shadow over the course of events. Now he had to decide what to do next. He groaned and eyed the dog again. The younger man was still lying face down, head twisted at an odd angle, from his placement on the passenger’s side of the car, he couldn’t make out whether the boy was breathing or not, and when he leaned closer he couldn’t tell whether to be relieved or not with the knowledge that the dog still lived. He glanced around suspiciously, searching his peripheral vision for any onlookers. Finding none he sighed and straightened, hand going to the door to open it. The specifics of what he’d done would scarcely matter if he was caught out in the open with the…victim (?) of his latest lapse judgment laying in plain sight for any kibitzer to take notice of his actions. He’d be placed behind bars just as quickly as if the dog’s own crimes had ceased to exist, and Jim had instead put the wraps on the near-mythical upstanding citizen who volunteered at homeless shelters in their spare time and would never have ever considered hurting a fly. When he reached the driver’s side, he made another surreptitious check of his surroundings. Finding them unchanged and just as empty as they’d been when this mess started, he opened the driver’s door and hauled the limp Beagle out by his arm sockets. Part of him felt he should be more concerned that he could brush off his earlier alarm just by focusing on what he needed to do next, while a second argued he was merely compartmentalizing his tasks to better organize his activity to avoid further indiscretion, while a third voice wondered if he was just pretending to give himself the third degree just to feel better about himself as a person. He decided he’d rather not ask himself any further questions after that, choosing to focus instead on the task at hand.

[96thdayofrage]

10 Examples of How US imperialism Continues to Kill the People and Planet

The capitalist narrative, aggressively fronted by the Democratic Party in 2016, holds that “conditions in the U.S. were never better.” But all the objective facts say otherwise. “Imperialism's contradictions have been pushed to their natural limit.” By every social, economic and moral measure, conditions of life are deteriorating for the masses of people, while the rich suck up the wealth of the world.

“What has been called a "race to the bottom" by some scholars is really a permanent crisis in the system as a whole.”

The US state apparatus is no longer able to rule in the old way. Trump's rise to power has placed the two-party duopoly in a crisis of legitimacy that cannot be reconciled with the tools at the system's disposal. The system as a whole cannot offer reforms to appease the masses, nor can it conceal the long-standing unity between the two parties on the questions of war, state repression, and austerity. This system, US imperialism, is on a steep decline that has necessitated an intense focus on ideological narratives to move forward with its objectives.

One of the most pervasive narratives of the day is the idea that US imperialism's capitalist infrastructure is on the mend. For the last two years, corporate economists and media outlets have embraced a relative optimism about the state of the economy. Reports have asserted that unemployment has been dropping and median income rising. The Democratic Party campaigned in 2016 on the premise that conditions in the US were never better. Reality didn’t agree, and neither did the electorate. Here are ten examples of how US imperialism continues to kill the people and planet with no regard for the political and economic crisis being paved along the way.

1. US unemployment remains high. 

The measure of unemployment in the US is highly deceiving. It leaves out discouraged workers and those who have temporary, part-time jobs. This means that unemployment is actually a lot higher than the 4.3 percent being officially reported by Washington. In fact, the number of workers in their prime working years (25-54) who are employed is 1.7 percentage points lower than in 2008. According to the Economic Policy Institute, Black unemployment continues to be double that of Whites in 2017.

2. US wages remain low. 

In 2016, Oxfam reported that nearly half of the US population makes less than $15 per hour at their place of work. Twenty-five percent of these workers are without sick-time. To make matters worse, a recent Economic Policy Institute report found that capitalist employers reap an extra 15 billion USD per year in stolen wages. The precarious condition of workers in the US is little talked about in the corporate media. Yet for the majority of US workers, the so-called rise in median income alongside a lower unemployment rate has provided little relief from imperialism's race to the bottom.

3. US life expectancy has decreased. 

The US spends 18 percent of all GDP on healthcare but has some of the worst outcomes in the capitalist world. Healthcare in the United States is under the complete control of monopolies and corporations in the insurance and pharmaceutical industries. Not only are workers in the US working longer hours for less pay, but many of them cannot afford to go to the doctor when ill. In 2015, life expectancy decreased bygone-tenth of a year. Preventable illnesses such as heart disease, diabetes, and drug overdoses were cited as primary causes for the change.

4. The rich continue to plunder the planet. 

Oxfam reports annually on the global wealth divide. And each year, the report reveals the extent to which the wealthy have consolidated most of the planet's wealth into fewer and fewer hands. In 2014, Michael Parenti criticized the conclusion that 85 billionaires had as much wealth as half of the world's population. He argued correctly that 85 billionaires have far more wealth than the rest of us, with concentrated wealth being the result of the private accumulation of surplus value from the world's working masses. The situation is far worse in 2017 than it was just three years prior. Now just six individuals possess more wealth than half of the global population.

5. The US is still the leading prison nation. 

More attention has been placed on the question of mass incarceration of late, especially since 2014. Yet despite all of Obama's PR gestures, such as the commutation of a few hundred sentences, the US remains a gulag state. The Prison Policy Initiative totals the US prison population at 2.3 million. Over half of all inmates identify as Black or Latino. Five hundred thousand prison inmates languish in prison for non-violent drug offenses. While just 5 percent of the world's population, the US possesses 25 percent of the world's prisoners.

6. The US continues to spend more on war than anyone else.

The US spends over 600 billion USD per year on "defense," more than the next seven biggest defense budgets combined. This large sum of taxpayer dollars is distributed among 1,000 military bases and their weapons systems. Huge sums also go to lucrative contracts with weapons manufacturers. Saudi Arabia just struck a deal with the Trump administration that will total over 350 billion USD over ten years. Staunch US allies such as Israel and Saudi Arabia provide guaranteed markets for weapons contractors as they pursue wars of aggression in Palestine, Yemen, and Syria, to name a few.

7. The US continues to threaten Nuclear War.

US military provocations both in the Korean Peninsula and along the Russian border have placed the planet on the precipice of nuclear war. NATO's exercises along the Russian border have yet to cease despite Trump's initial promise to scale back the Cold War institution during his campaign. Furthermore, one of the first military maneuvers made during Trump's Presidency was to threaten the Democratic People's Republic of Korea with a naval fleet armed with tomahawk missiles. The double edged sword of anti-Russia hysteria and military action in South East Asia points in the direction of a possible nuclear war between the US and the powers of the East; the consequences of which would be devastating.

8. Ecological Disaster

Nuclear war threatens the planet's ability to sustain human life. The US military is the world’s largest polluter. US military bases and facilities all over the world have been cited by the EPA for dumping waste materials into the ocean and spreading the dangerous effects of toxic weaponry far and wide. Of course, the system of imperialism that the military diligently serves has no interest in preserving the environment. US imperialism has one goal and one goal only, and that is to maximize private profit at the expense of the planet's habitability.

9. Privatization of Education 

Donald Trump's proposed federal budget includes massive cuts to public education and anti-poverty programs generally. The GOP-led administration has set its sights on the "old-school" privatization model of funneling federal dollars into private school vouchers. Vouchers have been proven to enforce a segregation regime on school districts in a much more overt manner than the de facto segregation encouraged by charter schools. But charter school operators won't have to worry, either. Trump has vowed to continue the Obama and Bush II's assault on public education with similar incentive schemes that will close more schools, fire more teachers, and erect more charter schools into the near future.

10. Political instability

The conditions of US imperialism will no doubt continue to generate political instability both on the US mainland and abroad. What has been called a "race to the bottom" by some scholars is really a permanent crisis in the system as a whole. Imperialism's contradictions have been pushed to their natural limit. Tech and finance capital continue to speed up production and profit without regard for the future of the people or the planet. In response, a resurgence in right and left-wing political movements can be seen in nations such as France and the UK. Sanders and Trump represented the US manifestation of the political instability that currently plagues the imperial apparatus.

The trends outlined in this article reveal the intensity of imperialism's assault on the working class and oppressed masses in all corners of the globe. Those in the US working to organize a movement strong enough to pave the way toward imperialism's demise must pay close attention to the interconnected character of all aspects of the system. Such an analysis is exactly what the US corporate media and the political class are trying to prevent from forming. The anti-Russia hysteria surrounding Trump's administration distracts the masses from the legitimate problems of the oppressed classes and lays the basis for war. And if the elite gets their way, it will be a war that the lot of humanity can ill afford.

[spicynbachili1]

The future of the American left | USA

Two weeks earlier than the November 6 midterm elections, the White Home launched a particular report by the Council of Financial Advisers (CEA) on the chance prices of socialism in response to what they name its “comeback” in American political discourse. 

The timing of the report was no coincidence. Left-wing concepts comparable to common healthcare, absolutely funded public schooling and the abolishment of ICE have been on the forefront of midterm debates. And certainly, on November 6, American voters elected two socialist girls of color, Rashida Tlaib and Alexandria Ocasio-Cortez, to Congress. Their historic wins are a real signal of shifting political terrains in the US. On a regular basis folks at the moment are embracing actual left-wing politics, and this has the capitalist class shaking of their boots.

The CEA report is without doubt one of the many examples of the far-right red-baiting aimed to scare folks away from socialist politics. Assets are scant, they argue, so fascism, not equality, is the way in which out of poverty. In the meantime, Wall Avenue Democrats are clinging to a average agenda rooted in company pursuits. Giving hundreds of thousands to large enterprise house owners, they are saying, is the easiest way to get on a regular basis People again on their ft.

Nonetheless, within the face of those highly effective forces of opposition, the American folks elected a few of the most progressive politicians we have seen in a long time. With Tlaib and Ocasio-Cortez set to enter the Home of Representatives, alongside Bernie Sanders in Senate, we now have three brazenly socialist politicians in Congress – essentially the most in US historical past – and much more socialist politicians in native places of work throughout the nation.

However the skill of those elected officers to grasp the progressive platforms on which they ran will in the end come all the way down to what we, bizarre residents, do. It’s on us to proceed to organise – to march, knock on doorways and struggle for a political agenda that places the wants of working-class folks over large companies.

It is extremely clear that People throughout the political spectrum are prepared for one thing completely different. In actual fact, neoliberal insurance policies are much less widespread than ever earlier than. Seventy % of People help a single-payer healthcare system. Extra People disapprove of the controversial GOP tax-reduction bundle than approve of it. Amongst younger folks, socialism is now extra widespread than capitalism. The precise’s concepts are unpopular. So unpopular that, in lots of locations this election cycle (and around the globe), far proper candidates did not even marketing campaign on them. Totally conscious that the help for his or her political calls for is waning, they as a substitute selected to lie, incite racism and rig the election to imagine or keep energy.

Right here in Florida, GOP gubernatorial candidate, Ron Desantis, adopted this playbook to a T. As a substitute of presenting coverage proposals to win over voters, he turned his marketing campaign right into a race struggle, utilizing racist canine whistles in opposition to black folks, Jews, Muslims and immigrants with a view to lure white voters to his aspect, and away from the progressive agenda of Mayor Andrew Gillum. 

Desantis referred to as Gillum “too radical” for associating with teams like ours, the Dream Defenders. Our political platform, the Freedom Papers, which outlines a plan for high quality healthcare, shelter, meals, schooling and security for all, turned the centre of his assaults. 

However Desantis did not debate the substance of the agenda itself – maybe as a result of he could not discover a strategy to argue in opposition to a proposal to fulfill folks’s most simple wants, particularly when so many are struggling to get by. So as a substitute, he used lies and scare ways, stirring up a racist frenzy selling white nationalist violence, to steer folks away from what’s greatest for everybody, in favour of a right-wing, pro-corporate and anti-people agenda.

Along with utilizing worry and racism, the political proper additionally makes use of strategies like gerrymandering, purging voter rolls, shutting down polling websites and complicated voters to suppress progressive votes and keep their energy globally as political minorities.

Following such right-wing makes an attempt to suppress votes, Florida and Georgia skilled razor-thin margins between the GOP and progressive candidates for governor. In consequence, each states at the moment are in the course of recounts. In Florida, incumbent Republican Governor Rick Scott has equated calls to rely each vote with voter fraud and an try by Democrats to steal the elections.

Whereas many progressive candidates scored landmark victories within the election, many others, primarily on account of the aforementioned voter suppression strategies, both narrowly misplaced to their right-wing opponents or are nonetheless dealing with an actual chance of a loss. Nevertheless, moderately than doubling down on a left-wing agenda that already proved its reputation amongst voters, and preventing in opposition to the GOP’s voter suppression strategies, many throughout the Democratic institution are already arguing that, maybe, some candidates have been simply too progressive to win. The trail to defeating Trumpism and the far proper in 2020, they are saying, is to maneuver additional to the centre.

We’re already seeing the Democratic institution’s makes an attempt to take down the left-wing flank that Tlaib and Ocasio-Cortez have the potential to construct throughout the celebration. Proper after Democrats took again the Home of Representatives, Nancy Pelosi introduced that she believes “Democrats have a duty to hunt frequent floor” with Republicans in Congress, implying that she’s going to concentrate on making compromises moderately than impeaching Trump. That is unacceptable and irresponsible. Our lives are on the road. And clearly, Nancy Pelosi’s pursuits do not align with ours. It’s due to political stances like hers and the Democratic institution’s total neglect of the pursuits of working-class those who we have ended up with Trump within the first place.

We can’t defeat fascism by transferring in the direction of the centre. Sadly, all too usually, politicians who run on left-wing platforms opportunistically transfer in the direction of the centre for the sake of their “profession” as soon as they’re elected. However in the end, whether or not or not the progressives we fought to elect will have the ability to realise the platforms they ran on is just not a lot a matter of what they do as soon as in workplace, however a matter of what we do. For progressive politics to succeed, we – because the folks – want to vary our perspective in the direction of electoral politics. We have to perceive that electing a candidate is just not a matter of selecting a champion or a supreme chief. It is a matter of selecting our greatest opponent. At instances, we are going to organise with these elected officers to result in actual change, however at different instances, we are going to organise in opposition to them to attain the identical. It’s our duty to construct the mandatory energy to carry them accountable to the wants of working folks and never company pursuits.

What issues is to not elect a sure variety of progressive candidates, however to construct the mandatory energy to carry all elected officers accountable to the wants of working folks and never company pursuits.

Midterm voter turnout hit a 50-year excessive in 2018, with greater than 47 % of the voting-eligible inhabitants casting a poll. Nevertheless, greater than half of People nonetheless didn’t go to the polls, probably due to how disillusioned they’re by all the political system. Grassroots actions ought to seize this chance and work tirelessly to persuade these disillusioned People that they, and nobody else, have the facility to vary our world.

We can’t struggle fascism with neoliberalism or by entrusting our destiny within the arms of some politicians. Our solely preventing probability is to construct energy. 

Within the face of rising violence and efforts to make on a regular basis folks flip their again on each other, so we don’t stand up in opposition to the one %, we should deliver folks collectively throughout race, faith and borders to battle in the direction of long-term political unity. Within the spirit of Fred Hampton and the Black Panther Social gathering, we should reignite the Rainbow Coalition, a 1960s Chicago-based alliance between younger folks in Black, poor white and Puerto Rican communities. The Rainbow Coalition was an actual menace to the established powers in Chicago and throughout the nation as a result of it helped folks discover frequent destiny and transfer a shared agenda throughout distinction.

Solidarity amongst working folks within the US and around the globe is our solely manner out.

Collectively, we have to organise our neighbours, plan marches and use boycotts and direct actions to advance a shared, progressive agenda that will profit us all. We should be clear and unapologetic in what it means to be leftist – common healthcare, absolutely funded public schooling, an finish to struggle and a redistribution of wealth. In the end, an important takeaway from the midterm election is that we won’t look forward to politicians to steer. Our energy lies in realising that the progressive agenda is ours to set.

The views expressed on this article are the creator’s personal and don’t essentially mirror Al Jazeera’s editorial stance.

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fbq('init', '968100353246427'); fbq('track', 'PageView');

from SpicyNBAChili.com http://spicymoviechili.spicynbachili.com/the-future-of-the-american-left-usa/

[if-you-fan-a-fire]

“It is at the same time that the State apparatus appropriates the war machine, subordinates it to its "political" aims, and gives it war as its direct object.  And  it is one and  the same historical tendency that causes State to evolve from a triple point of view: going from figures of encastment to forms of appropriation proper, going from limited war to so-called total war, and transforming the relation between aim and object. The factors that make State war total war are closely connected to capitalism: it has to do with the investment of constant capital in equipment, industry, and the war economy, and the investment of variable capital in the population in its physical and mental aspects (both as warmaker and as victim of war). Total war is not only a war of annihilation but arises when annihilation takes as its "center" not only the enemy army, or the enemy State, but the entire population and its economy. The fact  that this double investment can be made only under prior conditions of limited war  illustrates the irresistible  character of the capitalist tendency to develop total war. ... We could say that the appropriation has changed direction, or rather that States tend to unleash, reconstitute, an immense war machine of which they are no longer anything more than the opposable or apposed parts. This worldwide war machine, which in away "reissues" from the States, displays two successive figures: first, that of fascism, which makes war an unlimited movement with no other aim than itself; but fascism is only a rough sketch, and the second, post-fascist, figure is that of a war machine that takes peace as its object directly, as the peace of Terror or Survival. The war machine reforms a smooth space that now claims to control, to surround the entire earth. Total war itself is surpassed, toward a form of peace more terrifying still. The war machine has taken charge of the aim, worldwide order, and the States are now no more than objects or means adapted to that  machine. This is the point at which Clausewitz's formula is effectively reversed; to be entitled to say that politics is the continuation of war by other means, it is not enough to invert the order of the words as if they could be spoken in either direction; it is necessary to follow the real movement at the conclusion of which the States, having appropriated a war machine, and having adapted it to their aims, reimpart a war machine that  takes charge  of the aim, appropriates the States, and assumes increasingly wider political functions.

Doubtless, the present situation is highly discouraging. We have watched the war machine grow stronger and stronger, as in a science fiction story; we have seen it assign as its objective a peace still more terrifying than fascist death; we have seen it maintain or instigate the most terrible of local wars as parts of itself; we have seen it set its  sights on a new type of enemy, no longer another State, or even another regime, but the  "unspecified enemy"; we have seen it put its counterguerrilla elements into place, so that it can be caught by surprise once, but not twice. Yet the very conditions that make the State or World war machine possible,  in other words, constant capital (resources and equipment) and human variable capital, continually recreate unexpected possibilities for counterattack, unforeseen initiatives determining revolutionary, popular, minority, mutant machines. The definition of the Unspecified Enemy testifies to this: "multiform, maneuvering and omnipresent... of the moral, political, subversive or economic  order, etc.," the unassignable material Saboteur or human Deserter assuming the most diverse forms.”

- Gilles Deleuze & Felix Guattari, “1227: TREATISE ON NOMADOLOGY—THE WAR MACHINE” in A Thousand Plateaus: Capitalism & Schizophrenia. Translated by Brian Massumi. Minneapolis: University of Minnesota Press, 1987. pp. 420-422

[newstfionline]

That Popular Hostel in Berlin? It’s North Korean, and It’s Closing

By Alison Smale, Washington Post, May 10, 2017

BERLIN--The City Hostel Berlin operates out of a large, anonymous building in what was Communist East Berlin, but it’s a short walk from Checkpoint Charlie and other attractions and has become a popular place to stay, with good ratings on TripAdvisor and Yelp.

The only tip-off that this hostel differs from others in a city long a magnet for the world’s youth is the dreary embassy next door, where North Korea’s flag flaps from a pole near a poorly tended garden and that country’s ruling family, the Kims, is enshrined in a photo display on a gray metal fence.

The hostel, a former diplomatic quarters, has been earning the Kim government tens of thousands of euros a month over the past decade, but it will soon be closed to comply with the latest United Nations sanctions imposed over North Korea’s nuclear tests.

The German government confirmed Wednesday that it was acting “as swiftly as possible” to cut off the currency flow after German news outlets reported that North Korea was charging an unnamed German businessman €38,000 a month (about $41,000) to operate the hostel.

Some years after the fall of the Iron Curtain, North Korea, in a classic capitalist maneuver, leased the building, which had been the home of dozens of its diplomats. Its prime location in the center of Berlin made it popular with backpackers and students on field trips.

Martin Schäfer, a spokesman for Germany’s Foreign Ministry, said the hostel would be closed in compliance with stiffer sanctions passed in November by the United Nations that specifically ban any commercial dealings with North Korean embassies or on their property. The German authorities are acting as fast as they can within German law, Mr. Schäfer added.

Philipp Lengsfeld, a Berlin deputy for the center-right Christian Democrats in Parliament, said the North Korean connection “was an open secret--every cabdriver knew that.”

The government plans to close the hostel were first reported by the investigative reporting unit of the daily Süddeutsche Zeitung and the public broadcasters WDR and NDR.

The unusual rental arrangement began in the 2000s, according to various German news outlets. Mr. Lengsfeld, who visited North and South Korea with a German parliamentary delegation in 2015, declined in a brief telephone interview to say whether the government of Chancellor Angela Merkel should have acted sooner to end it.

North Korea has relatively few embassies in Europe, and many of them are holdovers from Communist times. Its Berlin mission stands on Glinkastrasse, once a central thoroughfare in the government district of East Berlin. A middle-aged woman emerged after a reporter rang the bell during office hours. In halting English, she said diplomats in authority were not around.

In the hostel, the young German employees were also reticent, referring reporters to the hostel’s website, which promises “cheap accommodation in the city center,” and even covering their name badges.

The rooms range from singles and doubles to bunks for four or eight guests in a room, according to the hostel’s website. Prices are listed as low as €17 a bed (about $18.50), rising to €59 (about $64) for a single room. A man answering the telephone at the hostel said it was booked on Wednesday and most coming days.

Guests came and went at lunchtime on Wednesday. Three teenagers on a school trip from Pforzheim in southwestern Germany were smoking in the courtyard, unaware of the North Korean connection. They, like other guests, did not seem perturbed when told about it.

The lively reception area boasts a terrace with a beer garden, an electronic baby grand piano and vivid signs, all of which enlivens the distinctive uniformity of East German architecture.

But a mural on the back wall might upset the landlords back in Pyongyang, where rigid Marxism still reigns. In cartoon style, it depicts a slice of Berlin’s Cold War history. Jagged fragments of a structure litter the picture while a quiet sign off to the left announces: “Construction of the Wall, 1961. Wall falls, 1989.”

[socialismwithasmile]

Just another ISO presentation

This is in the context of a multi-org anti-semitism/islamophobia solidarity event.

Hello,

I am here on behalf of the ISO. We decided to put this event together in response to the skyrocketing number of cases of both anti-Semitic and islamophobic violence that are sweeping the country. This has included A Sikh man shot in Kent Washington, a Muslim boy hung outside Seattle, four mosques burned and more than 140 bomb threats against Jewish Community Centers… 

With all of that horrific shit going on it seems reasonable to ask: where is this coming from?

An easy answer seems to be the Trump Administration. Among them are those known for their islamophobic and anti-Semitic and even fascistic beliefs. Advisor to the President, Steve Bannon for example is alleged to have said that he “doesn’t like Jews and that he doesn’t like the way they raise their kids to be ‘whiney brats’ and that he didn’t want [his] girls going to school with Jews” and then there is Senior Advisor Steven Miller who in university was not only personal friends with Richard Spencer but worked with notorious islamophobe David Horowitz’s Organization to design a so-called “Islamofascism Awareness Week” to be used at campuses nationwide.

With these openly racist faces in the White House the white-nationalist and neo-Nazi scum that inhabits American far right has taken note of this change in tone by prominent members of the US government and they have been crawling out of the gutters, emboldened to commit a new wave of violence.

As a recent article in Jacobin Magazine put it:

“Although the alt-right remains on the fringes in the United States, it has come within proximity to real power and is trying to position itself as court philosopher. Figures like [the neo-Nazi] Richard Spencer see themselves as the Trump movement’s organic intellectuals, guiding the president’s followers, whom they characterize as a directionless ‘body without a head’”.

It would be easy to say that these are simply new and bad actors in American politics but the roots of these problems go back a long way and are deeply embedded in the US political system.

Islamophobia has long played a dual role in the US political machine, especially since 9/11, on the one hand it functions as a tool to dehumanize Muslims abroad and justify their slaughter by US troops in Iraq, Libya , Yemen, Afghanistan, Pakistan and further abroad while on the other hand it divides working class Americans against each other here at home allowing for a particularly perverse kind of nationalism to take root.  Take for example George Bush’s comments from 2006 when he remarked:

“Since the horror of 9/11, we’ve learned a great deal about the enemy. And we have learned that their goal is to build a radical Islamic empire where women are prisoners in their homes, men are beaten for missing prayer meetings, and terrorists have a safe haven to plan and launch attacks on America and other civilized nations…. This struggle has been called a clash of civilizations. In truth, it is a struggle for civilization.”

This kind of rhetoric calls to memory the words of Marxist writer and psychologist Frantz Fanon who described how in order to justify their oppression colonial overlords depict their subjects as “impervious to ethics, representing not only the absence of values but also the negation of values”

This dual form of racism is no stranger to American Jews either. In the 20s and 30s according to the Congress of Secular Jewish Organizations: “A typical Jewish worker… could easily belong to a Jewish labor union and/or a mutual aid organization… send their child to a socialist… after-school program and summer camp, live in cooperative housing, attend lectures by Yiddish and socialist speakers and vote for the Socialist Party.” However, decades of anti-Semitism and McCarthyism teamed up to paint these liberatory ideas, so popular among the Jewish community, as somehow “foreign” and “un-american” and those spreading them as merely “agents of a global judeo-bolshevik conspiracy”

On top of that this idea of conspiracy doubles as a foil against critques of the capitalist system as a whole. Any systemic problems with capitalism can be easily scapegoated against Jews leaving the American ruling class off the hook for their crimes while Jews get shafted and attacked by fellow members of the working class.

While the Jewish Labor movement might no longer be a target of the mainstream political establishment, racist islamophobic ideas have since 9/11 enjoyed broad cross-the-aisle political consensus in our government. Democratic Party nominee Hillary Clinton for example, when asked in a presidential debate about national security went on a long rant about how American Muslims need to be on the “front lines” of the fight against “terror” and after the Pulse nightclub shooting she called for a return to the spirit of 9/12. Ironically, we might have achieved just the tenor of racist paranoia that reigned supreme after 9/11 under the Trump government.

        On the policy substance while republicans might have been behind the more heinous acts of islamophobic legislation it was the democrats who organized a congressional sit-in with the goal of forcing Republicans into voting on a so called “no-fly, no-buy” gun control measure. A ban that just like Trump’s immigration order would have overwhelmingly been targeted at Muslims, many of them innocent and unrelated to terrorist groups. On top of this, while he was president Obama continued to attack and imprison innocent Muslim civilians.

Along with this consensus against so called “Political Islam” has been a consensus on neo-liberal policies that have overwhelmingly enriched the 1% at the expense of ordinary working class people. These economic policies and the fallout of the global economic recession from 2008 have caused a sustained downturn in standards of living which has led to the very political polarization that has contributed to the rise of Trump and his brand of racist populism. The thing we of course realize as Socialists, is that the problem isn’t caused by Jews running the Banks or by Evil ‘Jihadis’ swarming our shores in the guise of refugees to kill our children, but in the way that these concerns have very strategically been used to turn us against each other and our own self interests. Take for example the story of Peter a former member of the Southern Poverty Law center recognized hate group: the III% organization.

Peter might have continued to share the racist views of his compatriots if it wasn’t for an encounter with a Muslim neighbor of his, through which they became close friends. This rocked Peter’s world and he shortly afterwards dropped out of the III% militia. In the statement, he drafted after leaving he said that:

        “I came to understand that … the III% Movement … had been subtly maneuvered into shifting our attention and efforts towards ensuring that… Muslims were kept in check, and that groups like Black Lives Matter were resisted. It didn’t make any sense anymore. Those people want the same things we do. Better quality of life. Less government intrusion. More justice and accountability. The only difference is the way we were going about getting those things. We should be uniting the working class and poor people across the country, not dividing along racial and religious lines. That is precisely what the rich want. They want more division. More strife in the working class.”

        The general sentiment of his comments ring shockingly true. Islamophobia, more than just a tool of imperialist aggression has, just like anti-Semitism been used to turn people who benefit from unity against each other. Ultimately the same people that have inflicted the economic damage that drove Peter to stand up against the US government in the first place are the ones now carrying out imperial invasions of Muslim countries and perpetuating Islamophobic stereotypes while neo-Nazis and anti-Semites blame the whole thing on a “Jewish conspiracy”. Only through unity and solidarity with each other’s struggles can we possibly hope to overcome this dark time. We must follow in the footsteps of people like Muslim activist Tarek El-Messidi who, when he saw that a local Jewish Burial ground had been attacked raised 80,000 dollars of donations from his local Muslim community to help repair the damage.  Or in the footsteps of the president of Temple Bnai Israel in Victoria Texas who gave the keys of their synagogue to the local Muslim community so that they would have a place to pray after their mosque was set on fire. Whether you are Jewish, Muslim, or none of the above, we must all hold to the truth of the classic slogan, an injury to one is an injury to all.

[phgq]

‘Flawed’ CASER wants surrender of PH sovereignty: OPAPP

#PHnews: ‘Flawed’ CASER wants surrender of PH sovereignty: OPAPP

'NO TO CASER'. Presidential Peace Adviser Carlito Galvez Jr. said the Philippines’ sovereignty would be put at a disadvantage if the government gives its nod to communist movement’s “flawed” CASER. He said the proposed deal was an “irrelevant” proposition and simply a “copycat of the programs” of the communist insurgents. (File photo)

MANILA — The Philippines’ sovereignty would be put at a disadvantage if the government gives its nod to the communist movement’s “flawed” Comprehensive Agreement on Social Economic Reforms (CASER), Presidential Peace Adviser Carlito Galvez Jr. said on Friday. Galvez said there is no need for CASER, as it would only benefit the Communist Party of the Philippines (CPP) since the proposed deal is “irrelevant” and simply a “copycat of the programs” of the communist insurgents. “CASER is based on an obsolete framework and is no longer relevant since it is largely based on the pre-industrialization and pre-globalization era. It is a formula for the surrender of the national government’s integrity, as well as the state’s sovereignty,” he said in a press statement. “The CASER insists that the Philippine government surrenders its sovereignty and tramples on its own integrity by forcing upon the state outmoded and erroneous concepts that were conceived more than half a century ago,” Galvez added. Galvez made the remarks, as Communist Party of the Philippines founder Jose Maria Sison sought the passage of the proposed CASER as a precondition for the possible revival of talks between the national government and the CPP’s political wing, the National Democratic Front (NDF). The two parties’ peace negotiations were officially shelved through Proclamation 360 signed by Duterte on Nov. 23, 2017 following the series of attacks waged by the CPP’s armed wing, the New People’s Army (NPA), against the government troops and civilians. The CPP-NPA has also been branded as a terror group by the Philippines, the United States, the European Union, the United Kingdom, Australia, Canada, and New Zealand. Questionable provisions A former military chief, Galvez raised concern that the CASER contained a "worrisome" provision that demands the demobilization of the Armed Forces of the Philippines nationwide, a clear infringement of the armed force's duty to protect the Filipino from both external and internal threats. "Clearly, the military shall lose its capability to carry out this crucial function once it is demobilized," Galvez said. "If the CPP-NPA-NDF does not have any hidden agenda, then why does it want the AFP to demobilize its troops and yet, the rebel will not do the same with its armed wing? Since 1992, the CPP-NPA-NDF has not given any indication that they accept the conditions of disarmament, demobilization, and reintegration of their members," he added. Galvez also said the draft CASER is advocating for the establishment of a coalition government with the communist group that will unwittingly set the stage for power-sharing. He also took note of the "Financing National Industrialization" provision included in the proposed CASER, which allows funds to be sourced from "confiscated and expropriated assets of foreign monopoly capitalists, big compradors, and bureaucrat capitalists." He also bared another "objectionable" provision of the CASER that pushes for the involvement of NPA guerillas in the "national democratic and people's organizations" that will take part in the implementation of the land reform and other rural development programs. "CASER is a product of a secret backchannel maneuver by the communist insurgents. There was zero consultation with the government's economic team, security forces, local agencies, and local government units, and most importantly, the Filipino people who have suffered the most during this decade-long armed conflict," Galvez said. 'Perfect formula' to sabotage PH economy Galvez claimed that the proposed CASER is a "perfect formula" for sabotaging the country's economic gains. He said CASER will only send the country "backwards" because it contradicts the existing Philippine laws. He issued the statement, as he noted that the Duterte government is implementing major policy reforms covering the areas of agrarian reform, anti-poverty social programs, education, universal healthcare, labor and employment, and indigenous people’s rights. Galvez said the country could have enjoyed a "double-digit" gross domestic product, had the insurgency problem not existed. "It has been crafted in such a way that we expect it to cast a dark cloud over the nation’s economy,” Galvez said. “And second, such a measure will surely put the country at loggerheads with the international financial community, and consequently, could lead to the weakening and eventual decline of the country’s economic standing in global markets,” he added. Equivalent to treason Galvez said allowing the implementation of CASER was tantamount to committing treason because the government would yield the country’s laws, norms, and other institutional democratic foundations. "In hindsight, most of the CPP-NPA-NDF's demands are almost impossible to implement mainly because they are totally skewed in favor of the interest of the communist insurgents," he said. He said for years, the talks were anchored on the Hague Declaration of 1992, the Joint Agreement for Safety and Immunity Guarantees of 1995, and Comprehensive Agreement on Human Rights and International Humanitarian Law but these have been "blatantly abused and violated" by the communists. “However way we look at it, CASER is a flawed document. And even if the government signs the agreement, it cannot be implemented due to legal issues. We can therefore expect the Red to use the government’s non-compliance of the CASER as a justification for committing acts of violence in the future,” he said. 'Impossible' preconditions Galvez said the current administration is still walking the extra mile for the sake of peace. However, the communist group failed to match that same level of sincerity of the government, as it continues to "attack our soldiers, burn public and private installations, and worse, kidnap, rape and kill innocent civilians whom they profess to serve," he said. Galvez said the communist group must show sincerity by demonstrating a "greater level of reciprocity" and avoiding setting "impossible preconditions." “If Jose Maria Sison cannot command his forces to stop carrying out such unlawful acts and to stand down, how then can he effectively lead an organization whose main goal is to help uplift the lives of the masses? As I have previously said, we must walk our talk,” he said. “Sison and his organization must not demand for the passage of CASER because the communist terrorist group has no territorial jurisdiction over any part of the country in the first place,” Galvez said. Meanwhile, the Duterte government will continue to implement initiatives that will bring peace and development to remote, conflict-affected areas in the country, Galvez said. (PNA)

***

References:

* Philippine News Agency. "‘Flawed’ CASER wants surrender of PH sovereignty: OPAPP." Philippine News Agency. https://www.pna.gov.ph/articles/1090521 (accessed January 10, 2020 at 10:38PM UTC+14).

* Philippine News Agency. "‘Flawed’ CASER wants surrender of PH sovereignty: OPAPP." Archive Today. https://archive.ph/?run=1&url=https://www.pna.gov.ph/articles/1090521 (archived).

[kristinsimmons]

Expensive Hospitals: The Enemy Within

By ANISH KOKA MD

Everyone agrees that health care is bankrupting the nation. The prevailing winds have carried the argument that a system that pays per unit of health care delivered and thus favors volume over value is responsible. The problem, you see, was the doctors. They were just incentivized to do too much. This incontrovertible fact was the basis for changes in the healthcare system that favored hospital employment and have made the salaried physician the new normal. Yet, health care costs remain ascendant.

Why?

It turns out overutilization in the US healthcare system isn’t what its cracked up to be.

Figure 1. Utilization rates in different health care systems

A recent analysis (Figure 1) by Papanicolas et al., in JAMA demonstrates that while the United States is no slouch with regards to volume of imaging and procedures in a variety of different categories, it does not explain a health care system twice as expensive as its nearest competitor. The problem turns out not to be volume, rather its the unit price of healthcare in the United States.

Health Care Costs and Glass Houses

There are many stones cast by all the various players in healthcare when it comes to cost, and of course, everyone bears some degree of responsibility, but it’s also clear that some folks live in larger glass houses than others. The most beautiful of all the glass houses are those built by hospitals. From 1996 to 2013, it was not population growth, health status, doctors visits, or prescription drugs that drove spending increases. Sixty-three percent of the increase in cost over an almost 20-year time span can be attributed to hospital stays and testing during doctor visits. Consider that the average hospital stay in the US costs $18,142, and lasts 4.9 days compared to other industrialized countries where average hospital stays last 7.7 days, and cost $6,222. But despite these exorbitant prices hospital systems in the United States complain they barely stay afloat.

Physicians blame administrators, administrators blame physicians, woke liberal venture capitalists blame the Koch Brothers, and economists blame everyone. Ambling through hospitals for the better part of the last two decades suggests real culpability strikes disturbingly close to home. Physicians work in a hospital climate where they are utterly oblivious to the cost of the health care they deliver. No one has any idea what an X-ray, a bag of saline, or an antibiotic costs. Insulation from cost isn’t all bad – it’s nice to know physician decisions are being made irrespective of the ability to pay, but the flip side of this is that there is precious little incentive to be efficient about health care delivery. Physicians ask for the moon and usually get it. Hospital administrators poorly versed in clinical matters respond to high costs by doing what they do best: pushing doctors to see as many patients as possible, and rewarding physician rainmakers that bring in the most clinical revenue. So, hospital administrators don’t choose to run inefficient enterprises, they just happen to be constrained by clinical partners with no incentive to be remotely efficient.

Consider the change over time in how hospitals are staffed. It used to be that hospitals were staging grounds for physicians who owned and operated their practices, managing busy outpatient clinics, and managing patients in the hospital when the need arose. In this setup, the hospital had no role in paying physicians directly, rather physicians paid themselves out of the clinical revenue generated from seeing the patient in the hospital. Driven by a system that moved to pay hospitals per diagnosis rather than by a number of days, and thus put a premium on shortening the length of stay, the inpatient hospitalist was born. Hospitalists are physicians who specialize in the care of hospitalized patients and are almost always employed by hospitals. It soon became standard for outpatient physicians to stay in clinics, and have hospitalists take care of inpatients. In theory, this would allow for better care of inpatients, and allow primary care physicians to see more outpatients. In the real world, as the outpatient practice of medicine was made more onerous and less lucrative, doctors flocked to do hospital shift work upon graduating.

The results in hospitals were wondrous to behold. The same small hospital I frequented that a decade prior operated with a skeleton full-time physician crew now employs over 20 full-time hospitalists. Length of stays are certainly shorter, documentation of inpatient stays is robust, but of course, there is no evidence that real outcomes for patients are any better. Hospitalists initially were focused within general internal medicine, but have now quickly metastasized to specialty care as well. Innovation in hospitals seems to consist of creating a fresh class of hospitalists for every organ system. Soon there will be hospitalists that specialize only in the big toe. The documentation promises to be fantastic. Factoring in medical malpractice and benefits, the average hospitalist in a big city market costs a quarter million dollars yearly today, and there are 50,000 hospitalists now working in the United States. All of this contributes to hospital salt water that is the most expensive in human history. To be absolutely clear, I am not suggesting there is no value to hospitalists. Some of the best physicians I know belong to this group. I am suggesting that this is an utterly inefficient, fragmented way to deliver care supported by health care prices outside the bounds of reality.

Using the Evidence to Compound Health Care Costs And this is only the tip of the iceberg. Hospitals are masterful in their ability to expend vast resources to achieve illusory goals. In all fairness, this is driven by a research industrial complex constantly publishing the next great therapies that may happen to reach statistical significance, but in reality, have at most Lilliputian effect sizes. Consider a recent multidisciplinary ‘teaching’ conference I happened to attend that was focused on the management of pulmonary embolism (clots in the lung). The most important thing to know about pulmonary embolisms is what was not mentioned during the conference – the case fatality rate for the diagnosis has not changed in a quarter century. The chart below does demonstrate a doubling of the incidence of PE, but this would be because of ever more sensitive ways to image the pulmonary arteries that reveal clinically irrelevant pathology since there has been no change in deaths from PE over the same time span!

Nonetheless, this particular academic conference has interventional radiologists, cardiologists, pulmonary critical care doctors, vascular medicine physicians, and yes even hospitalists impressively arrayed to focus on improving the management of Pulmonary Embolism. The propose of this conference is to make a rare problem even rarer by creating a hospital Avengers team know as PERT (Pulmonary Embolism Response Team). The goal of the meeting is to convince the wider medical community to activate the PERT team to evaluate pulmonary embolisms for new therapies for PE. Traditionally PE’s are treated with blood thinners (Heparin/low molecular weight heparin/Factor Xa inhibitors) that prevent propagation of clot or clot-busting drugs that actually break down the clot. A very small number of patients don’t respond to these therapies because the burden of the clot in the lungs is too great, and the thrombus needs to be surgically removed in a gory, but life-saving maneuver called a pulmonary thrombectomy.

More recently, interventional radiologists have developed techniques to thread catheters directly into the pulmonary arteries to dissolve clots – a technique known as catheter-directed thrombolysis (CDT). The clear message at the conference was that your next patient with a pulmonary embolism should be evaluated by the PE response team for advanced therapies such as these. The basis for all of this is sold as evidence-based commandments, but the reality is far from it. (Readers are advised to skip the next two paragraphs if they would like to just take my word for it)

The Evidence-Based House of Cards

The results of this approach are somewhat predictable and are encapsulated in an interesting paper described a single institutions experience with PERT. The study looked at a 20 month time window after PERT came to a New York Hospital. There were a total of 124 PERT activations – 43 in the first ten months, 81 in the last ten months. 21/25 patients taken for CDT were taken because of something called submassive PE. Submassive PE refers to strain seen on the right side of the heart as it attempts to pump blood around the clot. It used to be that right-sided strain was diagnosed based on a heart ultrasound, but recently a more sensitive, but less specific technique measuring proteins released by the straining right heart was included as part of the diagnostic criteria. The problem is that this biomarker elevation without sonographic evidence of right ventricular dysfunction isn’t a high-risk marker in isolation because any stretch of the ventricular chambers will cause some leakage of biomarkers. Only 13-14% who had an abnormal test in a case series ended up dying. While this is not a small number, it does argue against this test in isolation being able to discriminate a population that would significantly benefit from an intervention. Even if you add in the presence of sonographic right ventricular dysfunction, it is unclear that using clot-busting medications up front is beneficial. A 2003 study that compared a clot-busting drug to blood thinning was ‘positive’ only because more people in the blood-thinning arm eventually ended up getting a clot-busting drug. The PEITHO trial in 2014 showed similar results. More patients clinically decompensated in the blood-thinning only group (5.6% vs 2.6%) but overall survival was no different between the two groups, though there were more bleeds into the brain (2% vs 0.2%) with a clot-busting drug. So, in general, a strategy of blood thinning first with the addition of a clot buster in the case of clinical decompensation is a safe yet effective option.

CDT sought to capture the small benefit of systemic thrombolysis while reducing the risk of bleeding into the brain by infusing clot-busting drug directly into the artery where the clot resides. The SEATTLE II trial examine this strategy by taking 150 patients with central PE and performing CDT. Statistically, significant differences were seen before and after CDT with regards to pulmonary artery pressures and left to right chamber size ratio. I don’t mind relevant surrogate endpoints, but the problem here is that the clinical meaningfulness of these surrogate endpoints is questionable. Pulmonary artery pressures, as well as right ventricular chamber size, are notoriously dynamic in nature. Transient elevations in pulmonary artery pressures cause the thin-walled, compliant right ventricle to dilate frequently. Both parameters may quickly return to normal once the underlying cause of high pulmonary pressures has been treated. There was also no control arm to see how CDT performed relative to conventional blood thinning. The trial certainly did demonstrate safety but was far from convincing in demonstrating efficacy.

To be clear, I’m a fan of procedures with a large upside and little downside in patients in extremis. I don’t care that much about negative randomized control trials in this space because I don’t really care about average yardage gained when throwing a hail mary. But we all should care when protocols are put in place to trigger algorithms in patients that aren’t in extremis. This is usually what happens when a panel comes together to design protocols. In order for them to be practical, they are usually simple flow diagrams based on some easy to measure variable. You can’t have a protocol that says “if the patient looks sick” because that would be subjective and introduce that horror of all horrors: variability. Judgment is deferred to the PERT team that is more likely than not to be comprised of someone making a decision based on reading some other disconnected from the case physician report of an echocardiogram. That this is state-of-the-art medical care in 2018 would make Osler weep.

The change in practice pattern after PERT institution are remarkably predictable. If you set up a protocol to call a barber, you get a lot of haircuts. In the 20 months prior to PERT, there was 1 CDT. In the 20 months after PERT inception, there were 25. Recall the problem we are attempting to solve (Death related to PE) has a rare case fatality rate that has not changed in two decades. The majority of these PERT activations were due solely to the presence of a biomarker elevation, which almost surely means most of these interventions took place in patients that would likely have been fine with conventional anticoagulant therapy.

My bias and unwillingness to trust the surrogate endpoint improvement relates to a large number of patients who develop transient RV dysfunction during an acute event that normalizes after conventional therapy. There are a small minority of individuals who develop a chronic clot and elevated pressures, but it is impossible with what we know now to predict who that is, and we don’t have a good sense either mechanistically or in a trial setting if CDT would prevent this. So while it is wonderful to know there is another option for the decompensating patient with a PE, the PERT program appears designed to funnel more patients to a lab to get a procedure with questionable benefit.

The resources to marshall all of this are not cheap. A separate layer of PERT consult physicians are added to the mix, catheters to do the procedure need to be stocked, and staffing to accommodate 24/7 interventional radiology coverage for this procedure are marshaled. Outside community hospitals in the network even start to send patients to the hub just to have this procedure.  Costs spiral, physicians pat themselves on the back, patients thank the heavens their lives were saved, and hospital executives earnestly proclaim to politicians and those who pay for healthcare that providing state of the art healthcare in the United States is an expensive endeavor they can do nothing about.

Physicians are wont to point everywhere but themselves whenever high prices in health care are raised. I know all the arguments well, but the hard truth lurking beneath the covers is that physicians lie at the heart of all of this. Fixing this mess from the bottom up will require physicians to take ownership of a situation we have created lest we wish the solution be dictated to us by people without a clue.

The cartoonist Walt Kelley may have said it best: “We have met the enemy and he is us”.

Anish Koka is a cardiologist in private practice in Philadelphia.  He is fond of living in glass houses and can be followed on twitter @anish_koka

Expensive Hospitals: The Enemy Within published first on https://wittooth.tumblr.com/

[isaacscrawford]

Expensive Hospitals: The Enemy Within

By ANISH KOKA MD

Everyone agrees that health care is bankrupting the nation. The prevailing winds have carried the argument that a system that pays per unit of health care delivered and thus favors volume over value is responsible. The problem, you see, was the doctors. They were just incentivized to do too much. This incontrovertible fact was the basis for changes in the healthcare system that favored hospital employment and have made the salaried physician the new normal. Yet, health care costs remain ascendant.

Why?

It turns out overutilization in the US healthcare system isn’t what its cracked up to be.

Figure 1. Utilization rates in different health care systems

A recent analysis (Figure 1) by Papanicolas et al., in JAMA demonstrates that while the United States is no slouch with regards to volume of imaging and procedures in a variety of different categories, it does not explain a health care system twice as expensive as its nearest competitor. The problem turns out not to be volume, rather its the unit price of healthcare in the United States.

Health Care Costs and Glass Houses

There are many stones cast by all the various players in healthcare when it comes to cost, and of course, everyone bears some degree of responsibility, but it’s also clear that some folks live in larger glass houses than others. The most beautiful of all the glass houses are those built by hospitals. From 1996 to 2013, it was not population growth, health status, doctors visits, or prescription drugs that drove spending increases. Sixty-three percent of the increase in cost over an almost 20-year time span can be attributed to hospital stays and testing during doctor visits. Consider that the average hospital stay in the US costs $18,142, and lasts 4.9 days compared to other industrialized countries where average hospital stays last 7.7 days, and cost $6,222. But despite these exorbitant prices hospital systems in the United States complain they barely stay afloat.

Physicians blame administrators, administrators blame physicians, woke liberal venture capitalists blame the Koch Brothers, and economists blame everyone. Ambling through hospitals for the better part of the last two decades suggests real culpability strikes disturbingly close to home. Physicians work in a hospital climate where they are utterly oblivious to the cost of the health care they deliver. No one has any idea what an X-ray, a bag of saline, or an antibiotic costs. Insulation from cost isn’t all bad – it’s nice to know physician decisions are being made irrespective of the ability to pay, but the flip side of this is that there is precious little incentive to be efficient about health care delivery. Physicians ask for the moon and usually get it. Hospital administrators poorly versed in clinical matters respond to high costs by doing what they do best: pushing doctors to see as many patients as possible, and rewarding physician rainmakers that bring in the most clinical revenue. So, hospital administrators don’t choose to run inefficient enterprises, they just happen to be constrained by clinical partners with no incentive to be remotely efficient.

Consider the change over time in how hospitals are staffed. It used to be that hospitals were staging grounds for physicians who owned and operated their practices, managing busy outpatient clinics, and managing patients in the hospital when the need arose. In this setup, the hospital had no role in paying physicians directly, rather physicians paid themselves out of the clinical revenue generated from seeing the patient in the hospital. Driven by a system that moved to pay hospitals per diagnosis rather than by a number of days, and thus put a premium on shortening the length of stay, the inpatient hospitalist was born. Hospitalists are physicians who specialize in the care of hospitalized patients and are almost always employed by hospitals. It soon became standard for outpatient physicians to stay in clinics, and have hospitalists take care of inpatients. In theory, this would allow for better care of inpatients, and allow primary care physicians to see more outpatients. In the real world, as the outpatient practice of medicine was made more onerous and less lucrative, doctors flocked to do hospital shift work upon graduating.

The results in hospitals were wondrous to behold. The same small hospital I frequented that a decade prior operated with a skeleton full-time physician crew now employs over 20 full-time hospitalists. Length of stays are certainly shorter, documentation of inpatient stays is robust, but of course, there is no evidence that real outcomes for patients are any better. Hospitalists initially were focused within general internal medicine, but have now quickly metastasized to specialty care as well. Innovation in hospitals seems to consist of creating a fresh class of hospitalists for every organ system. Soon there will be hospitalists that specialize only in the big toe. The documentation promises to be fantastic. Factoring in medical malpractice and benefits, the average hospitalist in a big city market costs a quarter million dollars yearly today, and there are 50,000 hospitalists now working in the United States. All of this contributes to hospital salt water that is the most expensive in human history. To be absolutely clear, I am not suggesting there is no value to hospitalists. Some of the best physicians I know belong to this group. I am suggesting that this is an utterly inefficient, fragmented way to deliver care supported by health care prices outside the bounds of reality.

Using the Evidence to Compound Health Care Costs And this is only the tip of the iceberg. Hospitals are masterful in their ability to expend vast resources to achieve illusory goals. In all fairness, this is driven by a research industrial complex constantly publishing the next great therapies that may happen to reach statistical significance, but in reality, have at most Lilliputian effect sizes. Consider a recent multidisciplinary ‘teaching’ conference I happened to attend that was focused on the management of pulmonary embolism (clots in the lung). The most important thing to know about pulmonary embolisms is what was not mentioned during the conference – the case fatality rate for the diagnosis has not changed in a quarter century. The chart below does demonstrate a doubling of the incidence of PE, but this would be because of ever more sensitive ways to image the pulmonary arteries that reveal clinically irrelevant pathology since there has been no change in deaths from PE over the same time span!

Nonetheless, this particular academic conference has interventional radiologists, cardiologists, pulmonary critical care doctors, vascular medicine physicians, and yes even hospitalists impressively arrayed to focus on improving the management of Pulmonary Embolism. The propose of this conference is to make a rare problem even rarer by creating a hospital Avengers team know as PERT (Pulmonary Embolism Response Team). The goal of the meeting is to convince the wider medical community to activate the PERT team to evaluate pulmonary embolisms for new therapies for PE. Traditionally PE’s are treated with blood thinners (Heparin/low molecular weight heparin/Factor Xa inhibitors) that prevent propagation of clot or clot-busting drugs that actually break down the clot. A very small number of patients don’t respond to these therapies because the burden of the clot in the lungs is too great, and the thrombus needs to be surgically removed in a gory, but life-saving maneuver called a pulmonary thrombectomy.

More recently, interventional radiologists have developed techniques to thread catheters directly into the pulmonary arteries to dissolve clots – a technique known as catheter-directed thrombolysis (CDT). The clear message at the conference was that your next patient with a pulmonary embolism should be evaluated by the PE response team for advanced therapies such as these. The basis for all of this is sold as evidence-based commandments, but the reality is far from it. (Readers are advised to skip the next two paragraphs if they would like to just take my word for it)

The Evidence-Based House of Cards

The results of this approach are somewhat predictable and are encapsulated in an interesting paper described a single institutions experience with PERT. The study looked at a 20 month time window after PERT came to a New York Hospital. There were a total of 124 PERT activations – 43 in the first ten months, 81 in the last ten months. 21/25 patients taken for CDT were taken because of something called submassive PE. Submassive PE refers to strain seen on the right side of the heart as it attempts to pump blood around the clot. It used to be that right-sided strain was diagnosed based on a heart ultrasound, but recently a more sensitive, but less specific technique measuring proteins released by the straining right heart was included as part of the diagnostic criteria. The problem is that this biomarker elevation without sonographic evidence of right ventricular dysfunction isn’t a high-risk marker in isolation because any stretch of the ventricular chambers will cause some leakage of biomarkers. Only 13-14% who had an abnormal test in a case series ended up dying. While this is not a small number, it does argue against this test in isolation being able to discriminate a population that would significantly benefit from an intervention. Even if you add in the presence of sonographic right ventricular dysfunction, it is unclear that using clot-busting medications up front is beneficial. A 2003 study that compared a clot-busting drug to blood thinning was ‘positive’ only because more people in the blood-thinning arm eventually ended up getting a clot-busting drug. The PEITHO trial in 2014 showed similar results. More patients clinically decompensated in the blood-thinning only group (5.6% vs 2.6%) but overall survival was no different between the two groups, though there were more bleeds into the brain (2% vs 0.2%) with a clot-busting drug. So, in general, a strategy of blood thinning first with the addition of a clot buster in the case of clinical decompensation is a safe yet effective option.

CDT sought to capture the small benefit of systemic thrombolysis while reducing the risk of bleeding into the brain by infusing clot-busting drug directly into the artery where the clot resides. The SEATTLE II trial examine this strategy by taking 150 patients with central PE and performing CDT. Statistically, significant differences were seen before and after CDT with regards to pulmonary artery pressures and left to right chamber size ratio. I don’t mind relevant surrogate endpoints, but the problem here is that the clinical meaningfulness of these surrogate endpoints is questionable. Pulmonary artery pressures, as well as right ventricular chamber size, are notoriously dynamic in nature. Transient elevations in pulmonary artery pressures cause the thin-walled, compliant right ventricle to dilate frequently. Both parameters may quickly return to normal once the underlying cause of high pulmonary pressures has been treated. There was also no control arm to see how CDT performed relative to conventional blood thinning. The trial certainly did demonstrate safety but was far from convincing in demonstrating efficacy.

To be clear, I’m a fan of procedures with a large upside and little downside in patients in extremis. I don’t care that much about negative randomized control trials in this space because I don’t really care about average yardage gained when throwing a hail mary. But we all should care when protocols are put in place to trigger algorithms in patients that aren’t in extremis. This is usually what happens when a panel comes together to design protocols. In order for them to be practical, they are usually simple flow diagrams based on some easy to measure variable. You can’t have a protocol that says “if the patient looks sick” because that would be subjective and introduce that horror of all horrors: variability. Judgment is deferred to the PERT team that is more likely than not to be comprised of someone making a decision based on reading some other disconnected from the case physician report of an echocardiogram. That this is state-of-the-art medical care in 2018 would make Osler weep.

The change in practice pattern after PERT institution are remarkably predictable. If you set up a protocol to call a barber, you get a lot of haircuts. In the 20 months prior to PERT, there was 1 CDT. In the 20 months after PERT inception, there were 25. Recall the problem we are attempting to solve (Death related to PE) has a rare case fatality rate that has not changed in two decades. The majority of these PERT activations were due solely to the presence of a biomarker elevation, which almost surely means most of these interventions took place in patients that would likely have been fine with conventional anticoagulant therapy.

My bias and unwillingness to trust the surrogate endpoint improvement relates to a large number of patients who develop transient RV dysfunction during an acute event that normalizes after conventional therapy. There are a small minority of individuals who develop a chronic clot and elevated pressures, but it is impossible with what we know now to predict who that is, and we don’t have a good sense either mechanistically or in a trial setting if CDT would prevent this. So while it is wonderful to know there is another option for the decompensating patient with a PE, the PERT program appears designed to funnel more patients to a lab to get a procedure with questionable benefit.

The resources to marshall all of this are not cheap. A separate layer of PERT consult physicians are added to the mix, catheters to do the procedure need to be stocked, and staffing to accommodate 24/7 interventional radiology coverage for this procedure are marshaled. Outside community hospitals in the network even start to send patients to the hub just to have this procedure.  Costs spiral, physicians pat themselves on the back, patients thank the heavens their lives were saved, and hospital executives earnestly proclaim to politicians and those who pay for healthcare that providing state of the art healthcare in the United States is an expensive endeavor they can do nothing about.

Physicians are wont to point everywhere but themselves whenever high prices in health care are raised. I know all the arguments well, but the hard truth lurking beneath the covers is that physicians lie at the heart of all of this. Fixing this mess from the bottom up will require physicians to take ownership of a situation we have created lest we wish the solution be dictated to us by people without a clue.

The cartoonist Walt Kelley may have said it best: “We have met the enemy and he is us”.

Anish Koka is a cardiologist in private practice in Philadelphia.  He is fond of living in glass houses and can be followed on twitter @anish_koka

Article source:The Health Care Blog