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                        Technology and Human Responsibility
    Issue #88      A Publication of The Nature Institute        April 16, 1999
                Editor:  Stephen L. Talbott (stevet@netfuture.org)
                         On the Web: http://netfuture.org
         You may redistribute this newsletter for noncommercial purposes.
    NETFUTURE is a reader-supported publication.
    Quotes and Provocations
       How Compelling is Distance Education?
       Couch Potatoes Feeling Oppressed at M.I.T.
       The ATM as Commercial Television
    Notes on Health and Medicine (Stephen L. Talbott)
       Midwives, placebos, and healing the whole person
    About this newsletter
                             QUOTES AND PROVOCATIONS
    How Compelling is Distance Education?
    The dropout rate for Internet-based, distance education classes is said to
    be 32 percent; the conventional classroom rate is 4 percent.  Under the
    most obvious interpretation, those are dramatic figures.
    Back in the days when I was in school, the most common reason for high
    dropout rates in particular classes was, as near as I could tell, lousy
    teachers.  The educational experience in those classes simply wasn't
    compelling enough to hold students.  The lousy-teacher explanation,
    however, can hardly explain the problem with distance education, since
    these online teachers will surely be above average in the sense that
    they're innovative, energetic, up-to-date, and adaptive.  If they suffer
    dropout rates 800 percent of normal, then we ought to look at the
    educational limitations of the medium they've chosen.
    That figure, it seems to me, may be the best and most direct "hard number"
    we now have regarding the educational potentials of distance education.
    Of course, as I like to point out, such numbers always require
    interpretation; they must be brought into one or another context, which
    will in turn determine the significance of the numbers -- a simple truth
    that is lost sight of amazingly often.  But the burden in this case is
    clearly on the distance education enthusiasts to do some fast
    contextualizing footwork if they would find any encouragement in this
    Actually, I suspect that the real situation is much worse than indicated
    above.  Someone should look at how many of the existing 26,000 online
    courses are about using computers and the Net, or about cyberculture.  The
    percentage is likely to be considerable, and if there is any place
    distance education should work, it is in teaching these "wired" subjects.
    The online dropout rate stands to be much higher once you separate out the
    Net-focused courses and look at the use of the Net in teaching the core
    The  figures given here, by the way, come from one of the 300 studies
    reviewed by the nonprofit Institute for Higher Education Policy in
    Washington, D.C.  In a report released this month, the Institute concluded
    from its review that little original or reliable research has been done
    regarding the effectiveness of digital technologies in distance education.
    IHEP's president, James Meriotis, explains that
       Most of the research is based on anecdotal evidence offered by persons
       and institutions with vested interests in the techniques being
       evaluated or in the very programs they are evaluating.  (quoted in
       Chronicle of Higher Education, Apr. 7, 1999)
    Research into the effectiveness of distance education, in other words,
    looks to be in much the same state as research into the effectiveness of
    K-12 educational technology.
    (You'll find a PDF version of the IHEP study at http://www.ihep.com/.
    Thanks to Timothy Morriss for alerting me to this study.)
    Couch Potatoes Feeling Oppressed at M.I.T.
    Not to pick on M.I.T. (see article on the Media Lab in NF #87), but....
    In yet another high-cost, high-profile attack on the future, the M.I.T.
    Laboratory of Computer Science has kicked off a "ubiquitous computing"
    project called Project Oxygen.  It's the usual stuff:  networked chips in
    walls, doors, cars, refrigerators, and all the rest -- in other words, Bill
    Gates' house for the masses.  But what caught my eye in the New York Times
    story about this project were two comments by laboratory director Michael
    ** "Our overarching goal is to enable people to do more by doing less."
    It is remarkable that someone could make such an empty statement and not
    immediately feel compelled to apologize for it.  What are these
    multiplying activities we are filling our lives up with by doing "less" of
    them?  How satisfying will they be in their own right?  And what are we
    sacrificing along with those earlier activities Dertouzos would have us
    give up?  You haven't said anything until you at least begin to answer
    such questions.
    One way or another we will spend our time doing things.  In exchanging
    activities we were previously content to do more of for activities we now
    prefer to do less of, we ought to inquire about the nature of the bargain
    we are striking -- all the more so when we see our lives filling up with
    multiplying, decontextualized activities on the "less" side of the ledger.
    ** Again from Dertouzos:  "We want to liberate ourselves from the tyranny
    of `going to the computer'."  The idea is that the computer will be all
    around us -- everywhere -- and so we won't be bothered with going to it.
    Ah, liberty!  Picture it to yourselves:  this is a man for whom the idea
    of tyranny has contracted to the burden of getting to his computer.  We've
    come a long way from "No taxation without representation"!
    Even if one's tunnel vision must be restricted to the computer, can't one
    at least begin to look for the real risks of oppression it poses -- the
    risks lying, for example, in the subjection of more and more of our lives
    to the fixed patterns of logic embedded in all those networked chips?
    Deliverance from "the tyranny of going to the computer" -- and you
    imagined that professors at prestigious universities spent their time
    helping students to think large thoughts!
    (Thanks to Christian Sweningsen for the Times article.)
    The ATM as Commercial Television
    Following up "Cluttering Our Lives for Profit" in NF #86, NETFUTURE reader
    Richard Smith passes along a brief news item about Wells Fargo.  The bank
    is selling ad space on its ATM network.  These days, of course, the
    captive audience (why do we seem to find ourselves more and more in that
    unhappy assembly?) represents the pot of gold at the end of the digitized
    rainbow.  Wells Fargo vice president Barry McCarthy puts the case for ATM
    ads succinctly:  "People aren't going to walk away from an ATM in the
    middle of a transaction."
    True enough.  But some of us, at least, may learn to walk away before the
    transaction starts.
    Goto table of contents
                           NOTES ON HEALTH AND MEDICINE
                                Stephen L. Talbott
    Following are some informal notes I've been collecting over the past year,
    mostly relating to medical stories that have appeared in the popular
    The Fear of Witches and Midwives
    If you want to explore the anti-human tendencies of the technological
    mindset, there is no better place to start than with the modern history of
    the mechanization of childbirth.  Some day we will look back at the
    barbaric (if antiseptic) practices of the twentieth century much as we now
    look back at bloodletting and the application of leeches.  Of course,
    under the strengthening influence of women themselves, hospital practices
    have been changing for the better in recent years.  But it is well to
    remember how difficult the reform has been, and how resistant the high
    priesthood of medicine.
    Katsi Cook, a traditional midwife from the Mohawk Nation -- and now a
    lecturer at the University of Albany School of Public Health and a
    visiting Fellow at Cornell University -- tells about one particular front
    in the battle for sane practices:
       The Inuit women of Northern Quebec are remarkable women who decided in
       the late '70s that they were tired of the government policy that flew
       them out from their homes when they were 36 weeks pregnant to cities in
       the south, to Montreal, Kingston, and Toronto to have their babies.
       This practice separated them not only from their families but from the
       continuity of the birthing experience, so that when they would get back
       to their homes, having suffered the great stress of being in an urban
       environment where their language was not available, where they were
       lonesome for their families, where they had little kids back at home
       that they were worried about, in some cases they would go back to find
       that their families were no longer intact.  And so they decided
       themselves they wanted to change how health services were being
       delivered to them, and as a result they now have a maternity center
       that lies adjacent to the hospital, where 95% of all the Inuit births
       are done in the Inuit language by Inuit midwives.  They have the best
       statistics in Canada.  (From a talk at a New York Open Center
       conference, reported in Lapis #8.)
    But the battle is by no means over.  For example, New York's 1992
    Midwifery Act has been used as a weapon to run traditional midwives out of
    the state.  In general, one gets the feeling that low-tech midwives suffer
    from something like the stigma once attaching to witchcraft.  They deal
    with the dark, damp, messy secrets of the genesis of life, and these
    secrets, like all mysteries, provoke in us a powerful urge to raise a
    veil.  But rather than a veil of modesty, awe, and respect, we prefer a
    clean, well-instrumented, precisely controlled illusion.  We cannot relax
    until the deformed, mystery-bearing mother has been safely delivered for
    exorcism to the fluorescent-lit, stainless-steel sterility of the hospital
    operating room.
    Does Caring Matter?
    "Patients", Bernard Lown writes, "will not acquiesce to the ultimate
    alienation of being reduced to standardized objects.  No one will accept
    for long being merely identified by their illness, or seen as nothing but
    an assemblage of broken down biologic parts."
    Lown is professor emeritus of cardiology at the Harvard School of Public
    health and chairman of the Lown Cardiovascular Research Foundation in
    Brookline, Massachusetts.  He is also a co-recipient of the 1985 Nobel
    Peace Prize.  He writes that
       Patients crave a partnership with physicians who are as sensitive to
       their aching souls as to their malfunctioning anatomy.  They yearn not
       for a tautly drafted business contract, but for a covenant of trust
       between equals earned by the doctor while exercising the art of
    Then he concludes by quoting the essayist Anatole Broyard:
       I wouldn't demand a lot of my doctor's time.  I just wish he would
       brood on my situation for perhaps five minutes, that he would give me
       his whole mind just once, be bonded with me for a brief space, survey
       my soul as well as my flesh .... Without some such recognition, I am
       nothing but my illness.  (From an op ed column in the Christian
       Science Monitor, Mar. 4, 1999)
    Is this lack of recognition the reason why, in a society widely regarded
    as one of the healthiest on earth, we seem to be consumed by an awareness
    of our ills.
    The Alternative Rebellion
    The gains made by alternative medicine during the past decade or so have
    been striking, to say the least.  According to American Medical
    Association polls, in just two years -- from 1995 to 1997 -- the number of
    medical schools offering courses in alternative medicine leapt from 46 to
    75 out of 117 schools surveyed.  Now Congress has created a new National
    Center for Complementary and Alternative Medicine Research, and insurance
    companies are increasingly offering coverage for alternative therapies.
    This past November the Journal of the American Medical Association,
    at the request of its readers, devoted an entire issue to alternative
    medicine.  A Harvard Medical School study cited in that issue shows that
    patient visits to alternative practitioners were up 47% since 1990.  Today
    Americans visit such practitioners more often than conventional
    therapists, and they spend more money out of pocket on alternative
    treatments than conventional ones.  As J. P. Harpignies summarizes the
       Americans from all walks of life have voted decisively with their feet and
       wallets for more personal and cultural autonomy in their health care
       choices.  And they've done it despite decades of, until recently, almost
       universally negative propaganda from the mainstream media and virtually no
       insurance coverage for alternatives.  (Lapis, no. 8.  Harpignies is a
       contributing editor at Lapis and author of Double Helix Hubris: Against
       Designer Genes.)
    Harpignies finds in all this a
       profound challenge to the authority of technocratic elites obsessed
       with military metaphors of "wars" on disease, purely reductionist
       science and techno-utopian attempts to subjugate and redesign the
       natural world.  [Alternative medicine] is, in that sense, the most
       culturally and politically successful mass movement embodying holistic
       principles to have emerged in the modern West.
    An encouraging thought.  Anyone concerned about the unhealthy role of
    digital technologies in the modern world would do well to study the
    makings of the popular rebellion against technologized medicine.
    When Sugar Pills Heal
    Any discussion of alternative medicine inevitably comes around to the
    placebo effect.  A New York Times article entitled "Placebos Prove
    So Powerful Even Experts Are Surprised" began with this narrative:
       Many doctors know the story of "Mr. Wright," who was found to have
       cancer and in 1957 was given only days to live.  Hospitalized in Long
       Beach, Calif., with tumors the size of oranges, he heard that
       scientists had discovered a horse serum, Krebiozen, that appeared to be
       effective against cancer.  He begged to receive it.
       His physician, Dr. Philip West, finally agreed and gave Mr. Wright an
       injection on a Friday afternoon.  The following Monday, the astonished
       doctor found his patient out of his "death bed," joking with the
       nurses.  The tumors, the doctor wrote later, "had melted like snowballs
       on a hot stove."
       Two months later, Mr. Wright read medical reports that the horse serum
       was a quack remedy.  He suffered an immediate relapse.  "Don't believe
       what you read in the papers," the doctor told Mr. Wright.  Then he
       injected him with what he said was "a new super-refined double
       strength" version of the drug.  Actually, it was water, but again, the
       tumor masses melted.
       Mr Wright was "the picture of health" for another two months -- until
       he read a definitive report stating that Krebiozen was worthless.  He
       died two days later.
    Sandra Blakeslee, the article's author, notes that "doctors who know this
    story dismiss it as one of those strange tales that medicine cannot
    explain.  The idea that a patient's belief can make a fatal disease go
    away is too bizarre."  And yet, the burden of the article is that the
    placebo effect has turned out to be "even more powerful than anyone had
    been able to demonstrate", and the "biological mechanisms" underlying the
    effect can "achieve results bordering on the miraculous".  Among the
    reported findings:
    ** Patients with knee problems were divided into two groups, one of which
    received fake arthroscopic surgery, while the other received the real
    thing.  Two years later both groups showed equal relief from pain and
    ** In a Japanese study, thirteen people extremely sensitive to poison ivy
    were rubbed on one arm with a harmless leaf and on the other arm with
    poison ivy.  They were told that the harmless leaf was poison ivy, and
    that the poison ivy was a harmless plant.  All thirteen subjects broke out
    in a rash where the harmless leaf contacted their skin; only two reacted
    to the ivy.
    ** "A recent review of placebo-controlled studies of modern antidepressant
    drugs found that placebos and genuine drugs worked about as well."
    ** In another study, a baldness remedy enabled 86% of the male subjects to
    maintain or increase the amount of hair on their heads.  The same was true
    of 42% of the men taking a placebo.
    ** "Asthmatic children were given a sniff of vanilla along with a squirt
    of medicine from a bronchodilator twice a day.  Later, the vanilla odor
    alone increased their lung function 33% as much as did the bronchodilator
    ** According to one physician's claim cited in the article, placebos are
    "about 55% to 60% as effective as most active medications like aspirin and
    codeine for controlling pain."
    In general, the author concludes, "studies have shown, time and again,
    that placebos can work wonders."
    Are Placebos Lies?
    All this is remarkable -- so remarkable that it seems to throw the
    opponents of alternative medicine into a state of hopeless mental
    confusion.  You'd think they would welcome the data about the placebo
    effect as evidence of yet-unexplored dimensions of healing.  But instead
    all too many of them still mutter revealingly about "real effects" versus
    "quackery".  Oddly, "real" in this context means "attributable to a single
    factor artificially isolated from the whole", or "validated within the
    inhuman, patient-as-object conditions of a double-blind experiment".  And
    "quackery" means "achieved through partly subjective pathways we have long
    been taught to ignore and therefore refuse to look at".
    But, such attitudes notwithstanding, the placebo effect is indisputable.
    One problem with dismissing the results of alternative medicine as
    "merely" the placebo effect is that this argument cuts both ways.  When
    actual and fake arthroscopic knee surgeries yield roughly the same relief
    to patients, what grounds do you have for claiming that the actual surgery
    provided "real" relief rather than placebo relief?  More generally, it
    appears that a substantial part of the healing effect provided by many or
    most "real" treatments is due to their role as placebos.
    The standard experimental approach, of course, focuses on the differential
    gains provided by a "real" treatment relative to a placebo.  But why
    reduce your vision to this often very narrow difference?  Wouldn't it make
    more sense, and be more scientific in spirit, to look at the whole
    situation, and to evaluate all the factors at work?
    One way or another, we will have our faces rubbed in the larger picture.
    As Christopher Bamford, a student of the history of medicine, remarked at
    a recent conference:  "The placebo effect might be seen as the return of
    the excluded whole."
    It's been said that placebos are "lies that heal".  There is doubtless
    truth to that.  But when a physician, as one human being trying to help
    another, doles out a placebo, is that act of caring nothing but a lie?  Or
    is the real lie the prevailing message from medical researchers that they
    know where healing comes from, that it is merely a matter of mechanisms
    and molecules, and that it has little to do with the entire context of
    physician-patient interaction?
    We come back, then, to that remark by Anatole Broyard:  "Patients crave a
    partnership with physicians who are as sensitive to their aching souls as
    to their malfunctioning anatomy."  This is not a wish for something above
    and beyond medical treatment.  It is a simple wish for medical treatment.
    Medicine that doesn't embrace this wish is only a sick fragment of a true
    Elusive Holism
    You can't open a newspaper these days without reading the complaint of one
    medical expert or another that alternative health remedies are not
    scientifically proven.  In some cases -- given what is normally meant by
    "scientifically proven" -- this is true.  And it's also true that
    alternative health publications are littered with advertisements you just
    know are scams.
    But don't forget:  the same medical establishment that looks at the
    alternative remedies and says "not proven" has treated us to a long
    history of revelations about conventional treatments, often radical and
    invasive, that turn out to have offered no advantage at all over a
    complete absence of treatment.  Should we be upset when an herbal remedy
    fails to produce a benefit, but cheerfully pass it off as "scientific
    progress" when we learn that surgeons have been ripping open people's
    chests and screwing around with their hearts for no particular gain?
    It's hard to quarrel with Burton Goldberg when he says,
       Listen carefully the next time you hear "medical experts" whining that a
       substance or method has not been "scientifically" evaluated in a
       double-blind study and is therefore not yet "proven" effective.  They're
       just trying to mislead and intimidate you.  Ask them how much "scientific"
       proof underlies using chemotherapy and radiation for cancer or angioplasty
       for heart disease.  The fact is, it's very little.  (Alternative Medicine
       Digest no. 22)
    New York Times health columnist, Jane Brody, seconds this point:
       What critics often ignore is that many mainstream techniques, including
       most forms of surgery, also were never subjected to the acid test of
       science:  the double-blind controlled clinical trial.  Also forgotten
       is that many mainstream remedies, including aspirin and penicillin,
       became widely used long before experts knew how they worked.
    The real problem here is that only the whole person can be healed in any
    profound sense, and our very notions of scientific proof exclude the whole
    person from view.  The double-blind study, as Goldberg points out, aims to
    assess a single substance or procedure under isolated, controlled
    conditions.  The assumption is that we need to look for "magic bullets"
    that can reverse the effects of neat, single causes.  No holistic medicine
    can take such a view.
    "Multiple factors", Goldberg writes, "contribute to the emergence of an
    illness and multiple modalities must work together to produce healing."
    But simply multiplying the "factors" you are dealing with is not enough,
    if you continue to conceive each factor in the old way as an isolatable,
    cause-and-effect mechanism.  A whole does not exist as a collection of
    interacting mechanisms, however numerous, and however complex their
    interactions; a whole can only arise as expression -- as an interior laying
    hold of an exterior and raising it to an expressive unity.
    The task of the therapist is to grasp that unity, or potential unity, and
    to read every particular in its expressive light.  One can bring to such
    an understanding no knowledge of a single, unambiguous cause, nor of a
    single, unambiguous remedy.  One must allow one's fragmentary knowledge of
    causes and remedies to be transformed by the context of the whole person,
    in whom both causal and remedial factors are "spoken" in a distinctive
    way, as unique gestures of the individual.  The same list of symptoms in
    two people of the same age and sex does not necessarily mean that they
    suffer from the same "condition".
    As we have seen, the placebo effect points us toward the whole person.
    The irony is that conventional medicine has spent the past century
    documenting this effect and using it as a crude bludgeon against
    alternative medicine, instead of recognizing it as a validation, obscurely
    understood, of the alternative therapist's call for a medicine of the
    whole person.
    Part of the idea behind the bludgeon, of course, is that unapproved
    remedies are "merely subjective" in their mode of action.  Well, perhaps
    it is time to gain a disciplined understanding of all the modes of action,
    not just those that come easily to a mindset riveted upon neat mechanisms.
    The next time you are accosted by an expert who disdains your alternative
    medical choices as "no better than placebos", you might remind him that
    measuring up to the best placebos isn't all that shabby a performance.  It
    means that many of the elements of an overall healing context have been
    achieved -- elements that conventional medicine has willfully ignored with
    something like the stubbornness of those who refused to look through
    Galileo's telescope.  The only missing element may be the least important:
    a substance or procedure possessing fixed, absolute, and objective healing
    properties independent of its healing context.  The search for such a
    substance is often the biggest illusion of all, not unlike the search for
    a way to turn lead into gold.
    Or else say this:
       Okay, fine.  So I'm misled by my own wish for healing.  Give me, then,
       your scientific elucidation of this placebo effect that you
       acknowledge to be a massive infection of all your data.  When you've
       got something reasonable to say about it, then maybe I'll listen to
       your warnings about quackery and scientific proof.  Until then, I'll
       keep an open mind about just who the quacks really are.
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