Gumption

Locked-in Syndrome: Diving Bells, Butterflies, Freedoms and Families

Amy and I recently saw The Diving Bell and the Butterfly (or, more properly, Le Scaphandre et le Papillon), during an unexpected extended layover in San Francisco. The movie is about the late Jean-Dominique Bauby, former editor of the fashion magazine Elle, who at age 43 suffered a stroke that left him paralyzed except for his left eye, after which he continued to suffer for the next 12 years from locked-in syndrome - aware and awake, but unable to communicate. Fortunately (at least for viewers and readers), a dedicated speech therapist (Henriette) was able to open up a new communication channel for him - through repeatedly reciting a frequency-sorted version of the alphabet and watching for him to blink his eye when she reached the desired letter - and a dedicated transcriber (Claude) was able to navigate this channel with him to help him get his story out. And that story is a powerful one, touching on the challenges he faced in dealing with his highly constrained condition, and its effects on his opportunities - past, present and future.

The diving bell in the title is an allusion to the restrictions imposed by his physical condition, while the butterfly refers to the relative freedom of his mental and imaginative capacities that he appreciated - and indulged - all the more after the stroke. What struck me most about the film was that we all suffer some degree of locked-in syndrome - unable (or, perhaps more often, unwilling) to communicate effectively with the people around us. I do not mean to imply for a moment that most of us suffer anything close to the incredible challenges Bauby faced, but the movie did offer me an opportunity to reflect on how often I underutilize communication channels in my own life (this blog notwithstanding).

I remember one time, at the beginning of a surgical procedure, I had been given anesthesia, but it had not yet taken [full] effect before someone started inserting a tube down my throat. I tried to alert the medical staff to the pain I was feeling during this part of the procedure, but was unable to move or talk, and the fear I felt about being so incapable of communicating my predicament was at least as painful as the insertion itself. This was a far more dramatic example of feeling locked-in than most of my experiences, in which I am able to communicate, but unable to effectively convey something I am thinking or feeling to another person ... or situations in which I consciously or unconsciously choose not to communicate at all.

Bauby, of course, could have also chosen not to communicate. It required far more effort for him - and for the people with whom he was communicating - than it typically does for me (and presumably, however ponderous my writing and speaking may be, for the people with whom I communicate), and his willingness to make that effort to not only communicate with the people around him in his activities of daily living but to dictate a book about his experience is inspiring. I was reminded of a Richard Bach quote,

Argue for your limitations and sure enough, they're yours

as well as the lyrics to the Eagles song, Already Gone [video],

So oftentimes it happens that we live our lives in chains
and we never even know we have the key.

Another aspect of the film that moved me was Bauby's relationship with his children ... and their mother (Celine, to whom he was not married). After his stroke, his ability to interact with them was extremely limited, illustrated by a picnic on the beach, during which they play the word game hangman. Amy and I were watching the film on the eve of my "homecoming" - after having commuted nearly every week from Seattle to Palo Alto (or other business-related destinations) for 16 months - and so the lost opportunities for enjoying time with his children was especially poignant ... as was his continued underappreciation for Celine.

Bauby's relationship with his father was also very poignant (for me). Early in the movie, while Bauby is shaving his father (Papinou), his father expresses how proud he is of his son, which brought back memories of my own father expressing pride and approval - as best he could - for his son ... as well as more painful memories of him not expressing pride or approval ... for his son or himself. [In writing this, I'm struck by how my father suffered from a form of locked-in syndrome, tightly bottling up his emotions, which eventually started leaking out in various ways, shapes and forms.]  In my last conversation with him before he died - in 1996 - I was talking with him about the three job offers I had as I was nearing the completion of my Ph.D. One would have enabled me to continue working text-based information extraction; a second would have enabled me to work in the related area of speech interfaces; the third, which seemed both the most promising and the most challenging - what he called "the big job" - would have enabled me to work on something completely different. His last words to me were "Take the big job. You can do it!" I did take that big job - I felt the fear and did it anyway - but I never saw him [alive] again. Although I have many memories of episodes in which I did not receive much-desired approval (from him ... and other authority figures in my life), I'm glad to have the most recent - and lasting - memory be an example of explicit and enthusiastic approval.

During the shaving scene in the film, Bauby expands on this theme, noting "We all are children. We all need approval." Andrea Gronvall expands this theme even further, in her Chicago Reader review:

The Diving Bell and the Butterfly inter-twines the need for validation—which is tied to the impulse to create—and the inevitability of isolation and death. Locked in, Jean-Dominique Bauby wrote a luminous treatise on life and love, leaving behind a work of art that says “I was here and I mattered.” [Director Julian] Schnabel honors that impulse with this mature, resonant portrait of an artist.

This need for approval ... for validation ... for appreciation ... for mattering ... is something I continually struggle with. As I noted in an earlier post on living without a goal, and mattering without being useful:

I can't honestly say I'm entirely willing to release my attachment to others' [expressions of] appreciation at this moment -- despite the opportunities for practicing such detachment currently being offered me -- but I'm at least willing to re-open the question of whether and how I matter ... and if it is possible to matter without being [acknowledged as] useful to others.

And so I guess I'm still in the question ... perhaps locked-in to the question ... and in the current context, I'm wondering whether the answer - or the key - lies along the path of the butterflies.

Six month update on my elbow Platelet Rich Plasma (PRP) treatment

Amid the broad range of emotions and activities in which I'm engaging this week - a sad last week at Nokia before an exciting new start at MyStrands - I was able to schedule an appointment for my 6-month followup visit with Dr. Mishra regarding progress on the platelet-rich plasma (PRP) treatment for my right elbow. [I am very grateful for Kevin's recent comment on an earlier PRP-related post, and an email from Mark, who had commented on my first elbow PRP post - and who has since also undergone the PRP treatment - which reminded me that I needed to schedule this appointment before I leave town.]

I was not looking forward to the visit, in part because I have not been diligent in my theratube exercises (probably averaging once every three days rather than three times per day since my three-month PRP checkup), and in part because I thought that if I wasn't 100% back to normal by now, I would have to choose between surgery and living with my elbow's current status, which is probably around 90% of pre-tendonitis strength (and absence of pain).

However, my fears, as is so often the case, were unfounded - at least with respect to the latter one (I should [still] resume more diligent theraband exercising). I found out that it can take up to 12 months for the full effects of PRP to manifest themselves, so the fact I'm not completely "cured" is not surprising, and in fact, my current status, in which I rarely feel pain greater than 3 (on a scale of 10) - even after moving a humongous solid oak entertainment center from our bonus room to the garage last weekend - is a significant improvement over the last checkup.

During this visit, I was able to exert 135 pounds of grip strength with my right hand with a subjective pain level of 1 (vs. 120 pounds of grip strength with a pain level of 4 at the 3-month mark), and was able to resist attempts to pull down my upturned or downturned hand with a pain level of 1 or 0. As I noted earlier, during my first visit, I was only able to exert 65 pounds before I hit the wall (of pain) at level 9, and my resistance was lower and pain higher for the upturned hand exercise. It is relatively rare for my elbow to be sore - except after I move heavy furniture or engage in repetitive motions for extended periods.

Among the differences I've noticed in the past 3 months were:

• being able to carry around and drink from my 20-oz coffee mug with no pain
• being able to carry heavy furniture with some pain (I would not have even attempted to move the entertainment center 3 months ago)
• being able to do pushups with little pain (again, I would not have attempted pushups 3 months ago)

Dr. Mishra was actually quite encouraged - and encouraging - about my prospects for eventually regaining full use of the elbow with little or no pain! And, even better (to me), he suggested that if I have not reached that status by the 12-month mark, given the progress I've shown thus far, he would now recommend a second PRP treatment rather than PRP + surgery (which is what I thought would be the next step).

So, once again, my optimism is restored. I just did a round of theratube exercises (that makes 3x today), and will gradually start experimenting with exercising more regularly - pushups and perhaps even full-scale elliptical training (now that I'll be home - where we have a Precor FX - more regularly) - though ramping up on an [uncharacteristically] gradual slope. I will also restart my yoga practice.

I noted in my response to Kevin's comment that Dr. Mishra's PRP web page had a link to the Total Tendon Network, and that while I was excited about encountering my first Ning network "in the wild", it appeared to be a site targeting [only] tendon care providers:

This is a group of providers dedicated to improving the diagnosis, treatment and prevention of tendon related disorders.

Dr. Mishra told me that the site was, in fact, intended for both providers of treatment and patients who are receiving, or considering receiving, treatment (he said he will change the text on the login page - and said he requires login to ensure some level of quality control on this social network). I've signed up, but am still waiting for "approval", and so will report further on the Total Tendon Network during my next update ... probably around six months from now.

Three month update on my elbow Platelet Rich Plasma (PRP) treatment

On Monday, I had a followup visit with Dr. Mishra to evaluate and discuss progress and prospects for the restored health of my right elbow, three months after my treatment with Platelet Rich Plasma (PRP). One week after treatment, things had gotten worse (though, as Dr. Mishra had warned, this is often the case shortly after treatment). At the one-month mark, my elbow was feeling pretty much like it had just before the treatment. At this point, I'm happy to report that my elbow feels better than it did before the treatment, though still not as well as it felt before the initial injury.

Among the daily activities that I have resumed doing with reduced pain are

• drinking my 22-ounce mug of coffee with my right hand
• doing full-form yoga sun salutations (including the elbow-loading cobra pose and downward-facing dog pose, which I'd been omitting from my routine until recently)
• flossing my teeth with regular dental floss (vs. floss picks)
• scrubbing pots & pans

On Sunday, I was moving our four 20-pound Lafuma recliner chairs from the deck to the garage (one at a time), requiring a relatively significant amount of elbow strength and agility (given the rather cramped state of our garage). Although my elbow was sore afterward for a few days, I was surprised I was able to pick the chairs up at all - and, as with some of the activities I mentioned in my last update, I probably should not have pushed (or pulled) that hard.

During the visit on Monday, I was able to exert 120 pounds of grip strength with my right hand with a subjective pain level - at the limit - of about 4, and was able to resist Dr. Mishra's attempt to pull down my upturned hand with a pain level of 3. During my first visit, I was only able to exert 65 pounds before I hit the wall (of pain) at level 9, and my resistance was lower and pain higher for the upturned hand exercise.

I was feeling pretty awful at the one-week mark, and was [still] rather disheartened at the one-month mark (though the email and comments on that post helped cheer me considerably). I have to say that I'm feeling much better at this stage - physically and emotionally - about my present condition and my future prospects for continued healing. I think Dr. Mishra is also encouraged at the progress in the last two months.

So, the current plan is to continue doing the stretching and theratube resistance exercises, hold off on resumption of more comprehensive strength training (for the right arm at least) and repetitive exercises (e.g., elliptical trainer with moving arms) and very gradually [continue to] extend my activities to accommodate more loading of the elbow.

I'll be going back for another followup at the six-month mark (second week in January), by which point I should have achieved about as much progress as I can expect from the treatment. I'm a little more optimistic about full - or nearly full - recovery, but there is still a chance I'll ultimately need surgery.

I've been in communication with a number of people who are considering or undergoing PRP treatments for their ailments. I wish you all the very best progress in your consideration and/or healing processes, and will do my best to honestly share my experience, strength and hope through exchanges of comments on this blog or via email.

[Note: I prefer communicating via blog comments, as many of the emails also contain gems of wisdom - and inspiring experience, strength and hope - that I'd like to share more broadly, i.e., through this blog, but I understand that some (many?) people are not comfortable posting public comments on blogs - er, perhaps particularly on this blog, given my recent tirades on spampliments - and so anyone who prefers email can also use the "Email me" link below my "thinking spot" photo at the top left.]

[Additional note (2007-10-11): NPR ran a story on Morning Edition today on how and why Patients Turn to the Internet for Health Information, based primarily on the recent Pew Internet study on E-patients With a Disability or Chronic Disease and a University of Wisconsin 17-year study called Comprehensive Health Enhancement Support System (CHESS) ... one of the programs in the similarly acronymed Center for Health Enhancement Systems Studies.

Here's an abstract from the Pew study:

About a fifth of American adults say that a disability, handicap, or chronic disease keeps them from participating fully in work, school, housework, or other activities. Half of those living with a disability or chronic disease go online, compared to 74% of those who report no chronic conditions. Fully 86% of internet users living with disability or chronic illness have looked online for information about at least one of 17 health topics, compared with 79% of internet users with no chronic conditions.

Those with chronic conditions are more likely than other e-patients to report that their online searches affected treatment decisions, their interactions with their doctors, their ability to cope with their condition, and their dieting and fitness regimen.

My decision to seek PRP treatment for my elbow was due to chronic tendonitis / tendinosis. I didn't do all that much research on the Internet (compared to other things I research), but since Dr. Mishra offers an alternative treatment (to surgery), is located very close to where I work, and is a blogger himself (!), I decided to visit him. I did get second (and third) opinions, from the doctor I'd seen for earlier episodes of elbow "flare ups", and from one of my cousins, who is an orthopod, and both agreed that non-surgical intervention was generally preferable over surgical intervention, and PRP seems to offer a reasonable cost/benefit ratio (based on how little we know yet on its long-term efficacy from larger-scale trials).

The people who have contacted me through email and comments on my blog posts have clearly done far more online research - and in many cases, suffered more and longer from chronic conditions - than I have ... and, of course, I'm not quite sure how much online research has been conducted by other readers of my PRP-related posts. In any case, I think we offer, collectively, a number of data points to corroborate the Pew findings.

I can't find the CHESS study referenced in the NPR story, but I did find another one that is interesting and somewhat relevant (and also related to my recent rant on fundamentalism in a post on Blessed Unrest), Effects of prayer and religious expression within computer support groups on women with breast cancer (press release), where they found:

As hypothesized, writing a higher percentage of religion words was associated with lower levels of negative emotions and higher levels of health self-efficacy and functional well-being, after controlling for patients' levels of religious beliefs. Given the proposed mechanisms for how these benefits occurred and a review of the support group transcripts, it appeared that several different religious coping methods were used such as putting trust in God about the course of their illness, believing in an afterlife and therefore being less afraid of death, finding blessings in their lives and appraising their cancer experience in a more constructive religious light.

I do not know the religious beliefs of the scientists who conducted the study (or other studies purporting to find a link between prayer and health), but as scientists, we have to be extra careful to not fall into the very human trap of seeing what we want to see (particularly when trying to study others' behavior that I believe amounts to seeing what they want to see). The New York Times ran an article on "Long-Awaited Medical Study Questions the Power of Prayer" last March reporting an American Heart Journal study - "Study of the Therapeutic Effects of Intercessory Prayer (STEP) in cardiac bypass patients: A multicenter randomized trial of uncertainty and certainty of receiving intercessory prayer" - that reports intercessionary prayer - praying for someone else's health (without their knowing about it) - has no measurable impact on the recipient of that prayer. What's interesting in the CHESS study (to me) is that it looks at the impact of prayer on the sender vs. receiver (or subject vs. object) of prayer - the person who is praying ... and although I don't know of any scientific justification for this, I do believe in  the power of positive thinking (and speaking (and writing)) ... which is why I so often find myself preaching what I want to practice, if not praying about it.]

[Yet another update (2007-10-12): Another study verifies the power of positive thinking:

Research is showing the power of expectations, that they have physical -- not just psychological -- effects on your health. Scientists can measure the resulting changes in the brain, from the release of natural painkilling chemicals to alterations in how neurons fire.

Among the most provocative findings: New research suggests that once Alzheimer's disease robs someone of the ability to expect that a proven painkiller will help them, it doesn't work nearly as well.

It's a new spin on the so-called placebo effect -- and it begs the question of how to harness this power and thus enhance treatment benefits for patients.

"Your expectations can have profound impacts on your brain and your health,'' says Columbia University neuroscientist Tor Wager.

The report referenced above contains yet another link to a study reporting that optimists live longer, but I think I've done [more than?] enough lateral drifting for one post.]

An update on my elbow, one month after Platelet Rich Plasma (PRP) treatment

I had my one-month followup visit with Dr. Mishra today, to review progress since undergoing a platelet rich plasma (PRP) treatment for chronic elbow tendonitis (or, based on an earlier comment, tendonosis) on July 12. I'd posted an update at the 1-week mark, and given all the comments I've received on the blog and via email, I wanted to post an update at the 1-month mark (well, the 5 1/2 week mark, technically speaking).

At this point, my right elbow feels pretty much like it did before the treatment - normally very little pain, a dull ache that starts after even light exercise (e.g., just standing / walking around for 20 minutes with the elbow unsupported ... or typing / mousing for that long), and occasional very sharp pain when I pick up something too heavy or otherwise overextend the elbow. I've regained most if not all of the flexibility in my elbow, e.g., I can now touch fingers from both hands with arms crossed diagonally behind my back, and can use my right hand for eating, drinking (though not my 20 ounce coffee mug) and brushing my teeth - though I'm still using the floss sticks. I can also wash and [towel] dry my hair with relatively little discomfort.

I confessed to Dr. Mishra that I had not followed some of the recommendations he and/or his assistant, Amy, had made on both specific activities and general actvities. They had recommended against taking both the dune buggy tour and the jet boat tour on our recent family vacation down the Oregon coast, as well as prolonged driving; I did all of the above. They had also recommended that I slow down on my typing speed (and duration), which I did, but only for the first two weeks - I suspect I'm back up to my normal speed, which is probably somewhere in the range of 80-100 wpm. I also did some vacuuming around the house yesterday, which, although they did not specifically recommend against it, I knew would not be good for my elbow - and Dr. Mishra confirmed that vibration, in general, is bad, and recommended that I not do more vacuuming for a while. I have, however, been diligent about avoiding anti-inflammatory medications and have been pretty good about doing the gentle stretching exercises.

Dr. Mishra said it is not at all uncommon for the condition of a PRP-treated elbow to be at the same level - or even slightly worse - at the one-month mark after treatment as it was prior to treatment. He re-iterated earlier recommendations (especially about the typing - so I'm going to try to keep this short), and I have started some theratube strengthening exercises. I'll have another followup visit on September 24, after which I'll post another update.

I'm glad that what I was interpreting as a lack of progress is not necessarily indicative of failure of the procedure. I have to say that during the vacation, I was feeling sad about not being able to so much ... though in writing this, I'm a bit embarrassed, as I know many other people have far more extensive disabilities (or, I suppose I should say, challenges). I still feel a bit disheartened, but writing this has been therapeutic - as has been the support offered through comments and emails - and so I will do my best to practice acceptance.

Update, 2007-08-23:

Pete sent me a note with a link to a Runner's World forum topic on My Platelet Rich Plasma Prolotherapy Journey (so far), started 24 May 2007, detailing a series of ups and downs with a PRP injection for knee tendonitis - including the ability to run 5 miles 3 days after the injection (!) - and ending with a report of 100% recovery on 15 August 2007. I'm glad to read of both the eventual success, and the ups and downs that were part of the journey, but I am a bit confused about the conflation of PRP and Prolotherapy, which I'd thought were different procedures. Clearly I have much to learn (and experience). [In a followup note, Pete sent me a link to the Prolotherapy Nashville page, along with some commentary that suggests that Prolotherapy is the more general term for injecting a specific substance - which may be saline, glucose or PRP - into the region around an injured ligament or tendon in order to stimulate healing. (Thanks^2, Pete!)]

Mark sent me a note detailing extensive experiences with various treatments that included an overuse of Cortisone; he now urges people to avoid the use of Cortisone. Fortunately, the doctor's I've seen about my elbow problems over the years have all been averse to using Cortisone, but I did have two Cortisone injections, and one of them was effective (for a while). I wanted to pass along Mark's (and my doctors') recommendations to avoid using Cortisone, as it is a complicating factor in the potential efficacy of PRP.

While I'm on the topic of avoidance, I'd meant to include a few recommendations for things I would have liked to avoid more (well, things I might have avoided more ... clearly, these are things I like), in the course of the healing process, if I were a bit more disciplined. I already mentioned [not] avoiding prolonged or fast typing [... he types, quickly]. Another strategy is to not buy a new 10-megapixel digital SLR camera during the recovery period. Holding the camera for shooting photos during our recent family vacation along the Oregon coast, resulted in significant pain, but I kept repeating the procedure many, many times, reveling in my renewed appreciation for [digital] photography. Another thing I wish I was more disciplined about is avoiding handshakes, at least with the right hand. I was pretty good about this during the first week, but the social discomfort I feel in reaching out with my left hand - or giving a less than firm handshake with my right hand - often overcomes my good sense about protecting my elbow. I still feel sharp pain during - and lingering pain after - firm handshakes. Another area in which I've not been able - or willing - to be more disciplined is [elbow] safe sex. I realize there are many, er, variations available, but [for me], it just is not a "hands off" (or "hand off") activity. My wife, of course, is far more disciplined than I am - fortunately, she doesn't read my blog, or I might get some extra, unwanted help, in practicing greater discipline in this dimension. In general, It seems that any activity that involves the use of the right arm in which I typically enter a flow state (typing, photography, sex) is a candidate for avoidance ... or perhaps more mindful attention.

Progress Report on Platelet Rich Plasma (PRP): Week 1

It's been a little over a week since my platelet rich plasma (PRP) injection for chronic tendonitis; as with my [blog posts about] my wife's anal cancer treatment (which was successful, as far as we can tell, having recently passed the two year milestone of being cancer-free), I've received email and other inquiries about the treatment and how my post-treatment experience is going, from people suffering from other types of tendinopathy (Dr. Mishra's web site suggests PRP can also be used for the treatment of Rotator Cuff, Patellar and Achilles tendinopathy, and his blog chronicles the use of PRP for a variety of disoreders). In case my experience may be of interest / use to others, I've decided to report on a few of my observations, insights and experiences at the end of my first week.

First of all, I neglected to mention that the doctor and his assistant initially neglected to mention that the treatment is not effective if it is administered within two weeks of the use of Ibuprofen (and I think aspirin, which I never use, and possibly other medications I never use), due to its adverse impact on blood thickness. Since this information was not provided at the outset, we had to abort our first scheduled date of treatment. And since patients are advised against flying for 7 days after the treatment, due to the increased risk of blood clotting (which they did initially mention), my travel schedule resulted in having to postpone treatment for 2 months.

The treatment itself was relatively painless - I felt a little burning when the local anaesthetic (Lidocaine) was injected, and a little pressure when the PRP was injected, but that was all. The main problem I had was that I often get lightheaded whenever a needle pierces my skin - I'm not conscious of any fear, but it happens every time - so I had to lie down for the procedure.

The rest of the day (afternoon) and the next day, I refrained from any activity. I felt no pain the first day, but did feel some pain the second day. I took some Vicodin that day, but have since felt relatively little pain - except when I forget to be careful with my elbow - and have taken very little pain medication (acetaminophen).

The primary ongoing challenges are stiffness and reduced range of motion, but these are diminishing over time. I've been doing some gentle stretching exercises throughout each day, and was able to start using my right hand for brief, non weight-bearing tasks after a few days. I was able to bend my arm 90 degrees by Thursday, and can now touch my nose. I started using my right hand for typing again on Thursday, but my arm feels fatigued quickly, and so I've cut back considerably on typing (in general) ... er, and I did not actually catch up on much reading, but that was for other reasons having to with preparations for a big internal launch of next generation proactive displays on Thursday ... about which I'll write separately (though a preview of our proactive display plans can be found on SlideShare.net).

Among the tricks, tools and [other] behavior modifications I found helpful - bearing in mind that I'm right-handed and the PRP injection was in my right elbow - were

• Switching from briefs to boxers (for the first week) ... reminding me of a Seinfeld episode


• Wearing sandals (socks and shoe ties would be difficult), polo shirts (buttons, especially near the top, would be difficult) and cargo pants (with extra pockets on each side that are easily reachable) ... of course, this is my typical "business casual" attire, anyway


• Extra pillows to prop my arm up while sleeping


• An electric toothbrush and dental floss picks


• Using a pump dispenser for soap and shampoo (actually, I didn't do this, but wish I had)


• Eating more sandwiches, wraps, pizza and other foods that do not require the [coordinated] use of silverware


• Making greater use of the Bluetooth earbud for my phone (my most painful moment so far has been to reach up to scratch my nose with my right hand while holding my phone to my ear with my left hand)


• Renting a car with a pushbutton [keyless] starter for the week; in my case, this was a Nissan Altima from my favorite rental car service, Enterprise Rent-A-Car

I'll post another update when there is more significant progress to report. Meanwhile, if others have questions or other observations, insights and experiences to share, please feel free to comment.

Mending Tendonitis via Platelet Rich Plasma (I hope)

I have been suffering for the past several months with the 3rd episode of tendonitis in my right elbow in 3 years. The first episode occured in November 2004 after excessive raking - I spent every waking moment for 2 consecutive dry days raking the wet leaves that had fallen over several rainy weeks from the Bigleaf Maple trees in our yard. After waiting several weeks for the pain to go away, I started several weeks of physical therapy, eventually coupled with several weeks of acupuncture - neither of which had significant effect (I was told that 30% of people have neuroreceptors that are not receptive to accupuncuture treatment, and I was likely a member of that minority); a cortisone shot finally resolved the problem in the summer of 2005.

The next episode occured in February 2006, when I joined some other fathers in running an informal baseball training clinic for our boys, who would be soon trying out for Minors in Woodinville Little League. I threw pitches in a batting cage for over an hour, after which my right arm felt like rubber ... after which my right elbow felt a great deal of familiar pain. This time, I thought I'd cut to the chase, and started with the cortisone shot. Unfortunately, this has no effect, so I tried physical therapy, but that had little effect, either. Finally, I went to see Becky Beveridge, of Feel the Knead Massage Therapy in Duvall, WA, who practices a rather unique style of massage she somewhat uneuphemistically calls "search and destroy" (as contrasted with the school of "fluff and buff" massage) - and in one session, the pain was gone.

The latest episode started in October 2006, shortly after joining Nokia Research Center Palo Alto. I suspect that the trigger was some combination of a new computer (IBM Thinkpad with a TrackPoint), a new physical workplace environment (Steelcase furniture with Herman Miller Aeron chair), and the inevitable stress that accompanies any significant life event, even one that is positive and welcome - actually, all of these were welcome developments, as I'd missed the ThinkPad + TrackPoint, Steelcase furniture and Aeron chairs I'd enjoyed at Accenture Technology Labs, as well as the opportunity to actually earn money while doing work that I love. Perhaps the stress of the long commute was a factor.

In any case, this time, I started with Becky, but despite three treatments, there was little change. I've been so engaged in my work during the weekdays, that it took me a long while to find - or make - the time to find a new doctor (now that I was spending weekdays in Palo Alto). I wasn't sure how to find a good doctor, but I'd walked by the Agile Physical Therapy office many a time on my way to / from lunch on California Avenue, and figured they would probably be able to recommend good doctors.

As it turns out, one of the doctors they recommended was Allan Mishra, an orthopedic surgeon at the Menlo Clinic who specializes in tendon disorders, and who is pioneering a new, relatively non-invasive, treatment for chronic tendonitis, using Platement Rich Plasma (PRP). The treatment involves withdrawing blood, separating the platelet rich plasma from the platelet poor plasma, and injecting the PRP into the injured area, which stimulates growth factors in the blood to help regenerate and repair the tissue in that area. More details can be seen in a 5-minute video that Dr. Mishra has posted on YouTube (!):

[He also has a blog (!!)]

The new treatment is not [yet?] FDA-approved, and I'll be paying for it out-of-pocket (and, unfortunately, we've never played the HSA game). However, the level of expected disability is lower than surgery, and the expected recovery time is shorter, and so I'll be able to type two-handed again sooner ... and avoid some of the other risks inherent in surgery (not that the PRP treatment is without attendant risks).

I'll be undergoing the procedure at noon today, and there will still be a period of at least a few weeks where I'll be avoiding or significantly reducing the use of my right arm, and so I'll likely be reducing the frequency and length of blog posts (and other forms of written or typed communication) for a while. Perhaps this will give me a chance to catch up on some reading...

On Virginity, Vulnerability and Vaccines

Last night, I discovered of The Virginity Project (via Shel Israel's blog), a book project in which Kate Monroe is compiling a list of stories about how, when and why people lost their virginity. On the drive in this morning, I heard a segment on NPR's Morning Edition entitled "Young People and Sex: Parents, Can We Talk?" by Johanna Greenberg of Blunt Youth Radio. It turns out -- surprise, surprise -- that the parents of most of teens [that Johanna interviewed] have never said anything about sex to their kids, and of the few that had, it was mostly focused on the mechanics of sexual intercourse, or the risks of [unintended] pregnancy and sexually transmitted diseases. The preceding NPR segment was on one such STD, human papillomavirus ("Detecting High-Risk HPV in Older Women"), and an earlier segment on local NPR affiliate KQED, in the locally produced series, Perspectives (I think), was an opinion piece by another young woman, Alana Germany, about The HPV Vaccine (Gardasil), focusing on the social and economic issues surrounding its availability, and the political issues surrounding the proposed school attendance requirement for the vaccine in California middle schools. Reading Kate Monroe's most recent post, "The truth, the whole truth, and nothing but ...", she writes about her motivation behind pursuing this project, and in so doing, exhibits great openness and vulnerability (reminiscent of Shel and Robert Scoble's openness in Naked Conversations):

I, like most human beings, am innately insecure. There are questions that I need to ask - but I don’t think I am the only one who wants to know the answers. I want to know what other people really felt about having sex for the first time. Not the version that we tell our friends around the pub table but the no holds barred version. The reality, the joy, the pain, the sheer physical sensation of allowing somebody so close for the very first time. And if we take a step further toward truth, how does this one-off experience compare to our present arrangement? How good have we got? ... We all want to know that we are improving and we all want to know that we are normal.

Upon further reflection, I see vulnerability and sexual intimacy as deeply intertwined, and one's first sexual experience -- the loss of virginity -- as among the most vulnerable. [It's interesting that virginity is always lost ... what is gained?] I feel very fortunate that my first sexual experience (er, with someone else) was very positive, but I've often wondered about others' first experiences. I suspect it is generally, and perhaps drastically, different for men and women, but the only person I've ever spoken with about first experiences is Amy (and we did have different experiences of our first sexual encounters). I felt very vulnerable that first time, not really knowing quite how to proceed (although I was later told that my lack of experience was not apparent at the time), and feeling great fear and joy simultaneously. I'm somewhat embarrassed to admit that I still often feel fear before, during and after a sexual encounter, and for similar reasons -- does she want to? am I being too selfish? am I doing it right? was it good for her? Fortunately, I also still [often] feel great joy, too. Johanna Greenberg's recommendation was that parents should talk more openly with their kids about their feelings and values regarding sex (wow, talk about vulnerability!). Amy has been more forthright with our kids in talking about sexual matters, which is ironic, as I generally like to think of myself as so open and communicative. Given that my 15 year-old daughter sometimes reads (and comments on) my blog, I suppose this post may represent some kind of potential opening. My feelings about sex in my own experience are often conflicted, and they become all the more so when I project them onto anyone else ... especially if that someone else is, in a significant respect, the outcome of a sexual encounter (i.e., my daughter (or son)). I already mentioned my experience of the fear and joy of sex. As for values, I value honesty and trust in all my relationships, and I believe these qualities are all the more important the more intimate the relationship ... and the more intimate the exchange. Over the weekend, I watched the movie Munich; in one scene, one of the Mossad agents is found in naked and dead in his hotel bed, after having last been seen heading in the direction of an attractive and flirtatious woman in the hotel bar. I was thinking "What was he thinking?" (he was part of a team had been involved in several assassinations, and must have known that they, in turn, were likely targets). How can such a person -- or at least a person in that role -- trust anyone, much less leave himself as vulnerable as one becomes during sexually intimate encounters (or, at least, as vulnerable as I become ... but I probably wouldn't cut it as an assassin, anyhow). Turning to the third "V", the HPV vaccine (Gardasil), I am glad that the vaccine is available, but I'm not convinced that requiring it to be administered to all students is the best policy. It seems to me that other vaccines required for school attendance are for diseases that can be transmitted through casual contact, or simple proximity. While I hear and read that casual relationships (or "friends with benefits") is on the rise, reports of any kind of sexual activities -- especially among youth -- are often greatly exaggerated, on an individual and/or aggregated basis. Taking measures to prevent the transmission of disease to others who are simply in the same room on a daily basis seems like a reasonable precaution. Mandating such measures to prevent transmission that requires a great deal more, er, engagement, seems overreaching. So I don't support mandatory vaccinations, but I am totally in favor of making [other] more casual or incidental prophylactics more widely available ... especially among youth ... who are, after all, especially vulnerable.

Mobile Persuasion 2007: Triggering Changes in Attitudes and Behavior

BJ Fogg and his colleagues brought together an interesting and diverse collection of researchers, developers, designers, entrepreneurs and [other] activists at the Mobile Persuasion conference at Stanford University recently to discuss and debate the use of mobile technology to change people's beliefs and behaviors. The twelve pages of notes I took are evidence that I am persuaded that mobile technology will play an increasingly influential role in culture and society ... I'll try my best to condense those down to a more managable size.

BJ led things off -- and often provided filler in between other speakers -- by sharing his views on what mobile persuasion is, and why we should care. One of the bold claims he started out with is that within 7 to 10 years, mobile phones will be the #1 platform for changing people's attitudes and behavior. [I saw Howard Rheingold, the author of Smart Mobs, in the audience during the morning session, and wonder if he would agree with that time frame ... or if the unevenly distributed future may arrive (here) sooner than that.] BJ defined [mobile] persuasive technology as technology that motivates, facilitates and triggers  changes in behavior and attitudes, and invited us to consider how can we use mobile [persuasive] technology to bring greater harmony to this planet.

Sean White (Columbia University) shared some field notes from the Electronic Field Guide he and his colleagues have created -- a tangible augmented reality application that uses a tablet PC equipped with GPS, a camera, and computer vision software to enable field researchers to identify the leaves they encounter in real time and place (vs. recording samples for identification later). [Sean offered the following clarification via email: "We actually have two separate interfaces to the electronic field guide, one that uses a head worn display for augmented reality interaction and one that uses a tablet PC for 2D interaction."]

Justin Oberman (Mopocket / Stanford University) conducted a live experiment in which he invited everyone to exchange their mobile phone with the person next to them, and then figure out how to send themselves an SMS from their neighbor's phone ... very few people succeeded in the 1 minute allotted. He proceeded to offer a short history of how mobile technology has affected political change (in the Phillipines, South Korea, Ukraine, Canada, Ethipia, Spain and Kuwait). He also clarified the notion of persuadability, invoking [in my judgment] a variation on a famous Eleanor Roosevelt quote, noting that mobile technology cannot persuade anyone who doesn't already want to be want to be persuaded.

Marcus Yoder (Veeker) talked about veeks (video peeks), noted efforts by a youth-oriented citizern journalism site (YouthNoise), to engage voters ("veek the vote") through a collection of 750 mobile videocamera-recorded messages posted on the site on election night in 2006, and claimed that 2 minutes of video is more powerful than 10,000 signatures.

Alex Kass (Accenture Technology Labs) presented the motivations behind -- and futuristic video depiction of -- a Mobile Personal Performance Coach that utilizes a mobile phone connected to a network of simple, inexpensive sensors to help one gain greater awareness of [bad] habits in communication, exercise and diet.

Mike Liebhold (Institute For The Future) talked about how the advent of the geospatial web, with layered geodata, is making the invisible visible, enabling mobile augmented reality applications, and approaching the "tricorder dream" of Star Trek. Mike offered a historical perspective on the waves of computing, communicating and sensing, and claimed that we are now in the era of contextual sensemaking.

Mirjana Spasojevic (Nokia Research Center, Palo Alto) and Rachel Hinman (Adaptive Path) presented Stuck in the Roundabout, collaborative ethnographic research on people's use of mobile cameraphones and the mobile Internet they did while they were at Yahoo. They offered the following design principles:

• Think uniquely mobile, not mini-PC
• Think always with you, not just on-the-go
• Think building and reinforcing common ground and identity
• Think access to what's essential, not just browsing

Mor Naaman (Yahoo! Research Berkeley, "Understanding User Motivations in Online and Mobile Photo Sharing") shared some experiments with and insights into users' motivations regarding online / mobile photo sharing (which include elicitation, organization, communication, identity and self-disclosure), noting how the suggestion of tags for users to consider when submitting photos through ZoneTag represented a form of mobile persuasion ... or (to my thinking, at least), mutual inspiration.

Josh Ulm (Adobe Systems) presented some abstract and informative art designs for the nature-oriented backgrounds of mobile phone screens that could indicate time of day (sky lightness / darkness) and signal strength (number of clouds), emphasizing the importance of delighting, perhaps even exciting, the users.

Jordy Mont-Renaud (Digital Chocolate, motto: "Seize the Minute") presented AvaPeeps FlirtNation, a combination avatar toy + flirting / dating game + social networking service, released on Boost Mobile in November 2006, ending off with a personal story of a full-cycle relationship he experienced in one day. The goal of the game is to improve people's social lives through enabling them to experiment with and explore relationships in the context of a game, but as I've wondered before, [how] does this translate into real life (is it an enhancement or a substitute for real relationships)?

Steffen P. Walz (ETH Zurich) introduced the notion of persuasive playcemaking (play + place), and described the REXplorer project, in which visitors to the Regensburg Experience Museum will be able to play history onsite with a spellcasting Wii (starting on June 16).

Ian Bogost (Georgia Tech), author of Persuasive Games, introduced the concept of anamorphosis, invoked the genre of alternate reality in gaming articulated by Jane McGonigal (and others), and persuaded me that videogames can be effective channels for procedural rhetoric, with Exhibit A being Airport Insecurity, an arcade-style mobile videogame to promote critical reflection on the effectiveness of the Transportation Security Administration ... and have fun.

Sunny Consolvo (Intel Research Seattle & University of Washington) and Ian Smith (Intel Research Seattle) gave a tag team presentation, combining past, present and future research. Ian prosposed a new project using mobile technology to encourage environmental awareness through participatory mobile sensing combined with collaborative authoring, sharing and remixing, using the example of music playlist widgets for blogs -- Ian's blog has one -- to suggest what this might look like. Sunny presented earlier work on encouraging increased step count through mobile social support, and the more recently developed Ubifit ambient display for mobile phones.

Peter Boland (Be Well Mobile) offered a patient engagement software plaform to refill, remind, record, report, redirect and reward, in a mobile asthma solution that  has reduced the average number of hospital visits per year for asthma patients from 6 to zero in a recent San Mateo County pilot study.

Paul Hedtke (Qualcomm), noted that majority of our US$2T annual healthcare expenditures are for the chronic conditions that one third of Americans live with, and introduced the LifeCOMM initiative, whose goal is to enable consumers to self-manage chronic conditions and / or avoid / delay onset, using a broad array of technologies delivered on the mobile platform in the form of a Virtual Assistant.

Eric Holmen (Smart Reply, "Mobile Marketing: By Permission Only") championed permission marketing, shared some "reality from the field" (which I thought was not so different from the realities shared by some of the other presenters), including the Meijer Gas Alert service, which sends out SMS alerts to subscribers whenever gas prices are going to increase. Eric claimed that "mobile marketing" doesn't exist, and that the 4 C's of Content, Community, Customization and Commerce will lead to a great mobile customer experience (reminiscent of the 3 C's of our research project at Nokia Research Center: Context, Content and Community ... perhaps we have some silent C's).

Mike Mettler (AdMob, a company I saw and wrote about at the UTR Mobility Conference) presented in lieu of Jason Morse, who was allegedly engaged in an activity elsewhere relating to raising money for their startup (talk about realities (!)). Admob seeks to address the problem of closed systems and scalability, enabling more players to participate in the mobile advertising space through an interface that facilitates running a mobile ad campaign. Mike offered his (or AdMob's) own version of 3 C's -- Content, Community and Commerce.

Mark Brooks (Mobile Dating Watch) noted that for many [single] people, "my cell is my social life", and predicted that for the hyper-connected Generation Y, mobile dating will be a more popular -- and lucrative -- service than [non-mobile] online dating within 5-7 years. He also predicted a steady increase in the use of videos rather than photos, as part of prospective partners' representations of selves, because "videos don't lie".

Deb Levine (Internet Sexuality Information Services, Inc.) shared elements of the history, motivations and use of SexINFO, a sexual health text messaging service for San Francisco youth. Contrasting the goals of SexINFO with, say, mobile online dating, she noted that sex is like nutrition, but due to societal, parental and relationship pressures, the relative ephemerality of SMS turns out to be a better delivery mechanism than email or web pages. After noting that one of the topics that users can query via SMS was chlamydia, she ironically observed -- as she explained that this is a sexually transmitted disease (to an audience [mostly] filled with technology professionals) -- that she usually has to explain what SMS is to [U.S.] audiences filled with public health professionals.

Erik Damen (Pam) was the speaker who traveled the farthest, perhaps fittingly, given that his company sells a device, Pam, intended to encourage mobility (though on foot, vs. by plane). The small wearable device measures footsteps, computes a "Pam score" -- a ratio of the activity-induced energy expenditure (AEE) over the body mass index (BMI) of the wearer --  and displays the wearer's activity level in one of four zones (sitting, living, healthy and sports). An evaluation indicated that 63% of the subjects were more active, and 19% were significantly more active (I did not note the size or length of the study ... not sure that was mentioned).

Sebastien Tanguay (My Food Phone,  "The Start of a Mobile Health Revolution") observed that 40% of doctor's visits could be handled by someone else, and offered a glimpse of a future mobile triage application that includes an initial questionnaire interface for the [prospective] patient, a real-time scheduling and mobile video conferencing capabilities for doctors -- or perhaps other medical professionals -- to conduct remote assessments.

Marion Zabinsk (Sensei) invoked the notion of a sensei, someone who has lived before, and is [now] a master / teacher, in describing a mobile application for behavioral informatics, wherein a user can take a self-inventory, and using [unspecified] context-sensitive AI techniques, gain increased awareness (the most critical component in facilitating behavioral change).

Gabriel White (Frog Design) raised the issue of how we design for the last 1 billion people (who do not [yet] have mobile phones), many of whom are illiterate, and find menu hierarchies and soft keys unintelligible. Instead, he proposed -- and demonstrated (via Motorola's MotoPhone) -- the use of shallow spatialized designs with real-world analogues.

Suzanne Thomas (Intel Emerging Markets Platforms Group) presented some results of her ethnographic study of love, play and digital literacy among migrant youth within the People's Republic of China, who are willing to spend large proportions of their income on mobile technology for the goal of social inclusion and participation in their new urban environments. Many of the specific examples were interesting (including Ms. Wu, who sends 100 SMS messages / day), but many of the general observations seem as applicable in the "developed" world as in the developing world.

Ame Elliot (PARC) shared some of the insights she and her colleagues had gleaned from "Tokyo Youth at Leisure: Towards the Design of New Media to Support Leisure Planning and Practice". Among the surprises (for me) were the primacy of relaxation as a leisure time pursuit among young adults (age 18-25), the relatively low priority of finding new romance (perhaps the study looked at a narrow time slice?), and the dependence upon personal recommendations from friends and relative aversion to personalized recommendations from non-friends (e.g., through computer-based collaborative filtering).

Liz Goodman (UC Berkeley Information School) revealed some interesting uses of mobile photography in the construction of social identities -- and relationships -- among young single adults in the United Arab Emirates. In what I considered to be the most engaging presentation of the day (although I would rate most as "above average" and many as "excellent" in the category of engagement ... not to mention persuasiveness), she showed examples of how searching Flickr for "interesting" photos with the tag "Nokia N70" a few months ago yielded a surprising number of photos of young men and pairs of young women from UAE -- where [a photo of] an unmarried man and woman being together is forbidden -- and the associated comments, create, in effect, a massively mobile mixed gender online social space. Liz ended with a quote from the Emirate (regarding restrictions imposed by UAE on Flickr): "When photos talk, who cares about language?" Liz then posed the question "Who's listening, and what are they listening for?" ... and I couldn't help but wonder whether her research may result in greater restrictions on Flickr use within UAE ... especially given that when I searched for interesting Nokia N70 photos just now, it did not turn up many from UAE.

The conference concluded with a lightning round panel on the present and future of mobile persuasion, where each panelist had 30 seconds to articulate one or more themes. Among the articulated themes that resonated with me were the connection to David Allen's Getting Things Done (where one small step can change your life), the prevalence of health problems resulting from Balkanization (reflecting views I recently read in my gradual digestion of The Wealth of Networks), and the challenges of measuring persuasion (people rarely like to admit they've been persuaded).

Among my takeaways were

• [Mobile Persuasion] research is not so distant from new businesses (especially in health care)
  
• Many people love to hate the cellular carriers (and their closed, proprietary systems)
  
• Shameless self-promotion is less shameful when everyone is doing it (BJ led the way, promoting his views on the principles of persuasion (or captology) during speaker transitions ... and [thereby] practicing what he preaches, while preaching what he practices ... and in a case of "you spot it, you got it", I acknowledge that, I, too, am practicing self-promotion in this blog, however much I may write about self-reflection and self-expression.)
  

The conference was remarkably well-run, with great content and community. My only quibble was that there was surprisingly little participation from the audience, in large part due to the small times allocated for questions, and the fact that questions were always posed to groups of speakers rather than individuals (and thus many responses were often offered to a single question). The standout [audience] question for me was actually a comment -- by Karl Long -- at the end, where he drew an analogy between the cellular carriers and AOL, and said that in both cases, power is leaking through their fingers. I hope that Mobile Persuasion 2008, if it is convened, will incorporate mobile persuasion technologies to engage the audience in [mutual] persuasion. I'll be there (if / when there is a there there) ... and maybe I can help (in that regard).

[Update: Other blogs that contain nice [shorter] distillations of the conference include

• Ian Smith's sleepless
• Craig Lefebvre's On Social Marketing and Social Change
• Ayman's comments on the Yahoo! Research Berkeley blog

and I'm sure there are others ...

BJ Fogg and Dean Eckles have published Mobile Persuasion, a book of 20 of the presentations]

ABSolutely Obsessed: Men's and Women's "Health"?

In the checkout line at Whole Foods last week, I looked over and noticed a couple of magazine covers:

I was struck by a couple of thoughts: obsession over ab[domen]s does not appear to be gender specific ... and neither does sex.

Browsing around a bit for online images of the magazine covers, I was surprised to learn that [subscriptions to] Men's Health is considerably more expensive than Women's Health ($24.94 vs. $14.97, at Magazines.com). I don't know whether that says more about the relative value of men's health vs. women's health, the circulation or ad rates of the magazines, or the appeal of the target demographic for each publication (all these are, of course, related).

In perusing a number of magazine covers for each, and the topics suggested by the headlines, I am a bit surprised that either of these magazines is popular at Whole Foods (whose racks also include Yoga Journal and What Is Enlightenment?) ... but this is probably due to my naivete with respect to the Whole Foods clientele. Eating and being healthy need not preclude looking healthy, and I may well have friends who subscribe to Men's Health or Women's Health (just as I may have friends who subscribe to Playboy or Cosmopolitan), but I'm feeling disillusioned about what seems to constitute "health" in these publications, and that Whole Foods would include these in their media mix.

[Update, 2006-01-05: An AdAge article today, "'Cosmo' Girl Seeks 'Men's Health' Guy" (subscription req'd), reports that

Cosmopolitan and Men's Health are plotting to swap editors for their May issues, giving Dave Zinczenko his way with a special section of Cosmo and Kate White a section of her own in Men's Health.

The article goes on to ask

But is the happy couple forgetting their friends? Cosmo has an automatic guy buddy in Esquire, as they're both published by Hearst Magazines. And Rodale's Women's Health and Men's Health obviously keep seeing each other at the gym.

So I now realize that Esquire would have been a more appropriate foil than Playboy in my original comment. Oh well, rant and learn...]

The Health of Nations: Inequality, Stress and Dissatisfaction

Stephen Bezruchka wrote an article in Sunday's Seattle Post-Intelligencer noting the higher average health found in nations with more egalitarian distributions of wealth.  The article, "Economic equality is best medicine" bore the subtitle "Health of societies mostly relies on political and economic policies, not the individual treatment of disease."  Bezruchka notes that Japan has the highest rate of male smokers of any wealthy country, and yet also has the highest average health, based on statistics collected in the Human Development Report from the United Nations Development Programme.  The United States, despite being the world's wealthiest country, is not even close to being the world's healthiest country, on any of the metrics in the report (e.g., it ranks 29th in life expectancy, just ahead of Cuba). 

The distribution of wealth in a country is a challenging thing to measure.  A recent Guardian article, Wake Up: The American Dream is Over (found via Bridging the Income Gap), reports that the richest quintile (top fifth) of Americans have incomes 9.3 times higher than the poorest quintile, up from a multiple of 6.8 25 years ago, and that a higher proportion of Americans (12.7%, or 37 million) are living in poverty than the citizens of any other developed country.  A Wikipedia entry with a List of Countries by Income Equality shows that Japan ranks second in income equality (after Denmark), with a richest to poorest quintile multiple of only 3.4, whereas the United States ranks 92nd (out of 122).

Of course, a correlation between two factors does not necessarily entail a causal connection.  Bezurchka speculates on how and why large disparities in income may diminish the average health of a population:

Intuitively, we can see that not everyone shares the same stress in a bigger-gap society and those lower down suffer more of the slings and arrows of misfortune rained down from above. There is less caring and sharing in society when the gap is in our face.

Another study, "Economic inequality, working-class power, social capital, and cause-specific mortality in wealthy countries" corroborates this correlation ... and much to my surprise, finds a weaker correlation between another difficult to measure concept, social capital, and population health.

Bezruchka suggests that in our quest for better health in this country, we have been asking the wrong people the wrong question.  Invoking the wisdom of Mark Twain -- "It is very difficult to get people to understand something when their salary depends on their not understanding it" (an observation also made by Al Gore in An Inconvenient Truth, in analyzing why we're not making [more] progress on recognizing and reversing global warming trends) -- he recommends that if we want to address the question of "What makes a healthy society?", we focus our attention on politics and economics: "Economic justice is the medicine we need".  Of course, in a country where recent polls show that 68% of the people support a repeal of the estate tax, which only affects the wealthiest 2% of Americans, this may be very tough medicine to swallow.

I find this poll result counterintuitive -- why would so many people be against a policy that would benefit them?  I wonder if many people (66%) are consciously or unconsciously thinking that someday they may be in the wealthiest top 2%, and thus wouldn't want their future estates to be subject to additional taxes.  This reminds me of some of the observations made by Daniel Gilbert in Stumbling on Happiness, regarding our generally poor ability to project into the future.  It may also illuminate one of the sources of stress that Bezruchka intuits: dissatisfaction, i.e., many of us are stressed out because where we are (financially) so far short of where we want to be.  This, in turn, reminds me of one of the questions raised by Oriah Mountain Dreamer in the prelude to her book, The Dance:

What if the question is not why am I so infrequently the person I really want to be, but why do I so infrequently want to be the person I really am?

Interestingly, although much of the analysis and recommendations for addressing income inequality may seem rather socialistic, Chapter 4 of the UN report is about "International Trade: Unlocking the Potential for Human Development", which brings to [my] mind Adam Smith's Wealth of Nations:

Adam Smith railed against [the] restrictive, regulated, 'mercantilist' system, and showed convincingly how the principles of free trade, competition, and choice would spur economic development, reduce poverty, and precipitate the social and moral improvement of humankind. To illustrate his concepts, he scoured the world for examples that remain just as vivid today: from the diamond mines of Golconda to the price of Chinese silver in Peru; from the fisheries of Holland to the plight of Irish prostitutes in London. And so persuasive were his arguments that they not only provided the world with a new understanding of the wealth-creating process; they laid the intellectual foundation for the great era of free trade and economic expansion that dominated the Nineteenth Century.

So perhaps what we need is an intellectual foundation, perhaps a manifesto, that would promote free trade, competition, and choice for both the creation and distribution of wealth, one that would take into account the modern, technologically-enhanced means of production and [thus] focus more on networks than hierarchies.

Speaking of which, I just picked up The Wealth of Networks: How Social Production Transforms Markets and Freedom, by Yochai Benkler ... which I believe may represent just such a manifesto, laying down a new intellectual foundation for a new era of free trade among small parts loosely joined.  I haven't read the book yet, but was inspired and intrigued by an earlier, shorter, paper on the topic, Coase's Penguin, or Linux and the Nature of the Firm, which lays out a framework for "commons-based peer-production".  I'm sure I'll have more to say about this in the future.

Circling back to the topic that got me started, the health of nations: on Dr. Bezruchka's Population Health Forum page, he lists six actions people can take to support better health through better political and economic equality:

1. Fight for JUSTICE to reduce the gap between rich and poor. Being active as a public citizen is good for your health.
2. Advocate for CHILD-SUPPORTIVE ENVIRONMENTS where children get love, care, and opportunities to develop. Ways of becoming involved center around acting to promote true family values.
3. Promote SPIRITUAL AND SOCIAL CONNECTIONS in your community. Know and share with your neighbors. Communities where people trust and help one another are healthier than places with less cooperation.
4. Work to increase