We Freeze People, Don't We?

Perhaps you’ve heard about the controversial Alabama Supreme Court ruling about in-vitro fertilization (IVF), in which the court declared that frozen embryos were people. The court stated that it has long held that “unborn children are ‘children,’” with Chief Justice Tom Parker – more on him later – opining in a concurring opinion:

Human life cannot be wrongfully destroyed without incurring the wrath of a holy God, who views the destruction of His image as an affront to Himself. Even before birth, all human beings bear the image of God, and their lives cannot be destroyed without effacing his glory.

Seriously.

Be careful with those "people" / Credit: Bing Image Creator

Many people have already weighed in on this decision and its implications, but I couldn’t resist taking some pleasure in seeing “pro-life” advocates tying themselves in knots trying to explain why, when they legislated that life begins at conception, they didn’t mean this kind of conception and that kind of life.

John Oliver was typically on point, noting that the Alabama ruling was “wrong for a whole bunch of reasons. Mainly, if you freeze an embryo it's fine. If you freeze a person, you have some explaining to do."

The case in question wasn’t specifically about IVF, nor did the ruling explicitly outlaw it. It was a case about a patient who removed stored embryos and accidentally dropped them, and the couples whose embryos were destroyed wanted to hold that patient liable under the Wrongful Death of a Minor Act. The court said they could. Note, though, that neither the patient nor the clinic was being charged with murder or manslaughter…yet.

Although the Alabama Attorney General has already indicated he won’t prosecute IVF patients or clinicians, the ruling has had a chilling effect on fertility clinics in the states, with The University of Alabama at Birmingham health system and others indicating they were putting a pause on IVF treatments.

Justice Parker has long been known as something of a theocrat; as The New York Times wrote:

Since he was first elected to the nine-member court in 2004, and in his legal career before it, he has shown no reticence about expressing how his Christian beliefs have profoundly shaped his understanding of the law and his approach to it as a lawyer and judge.

His concurring opinion claimed: the state constitution had adopted a "theologically-based view of the sanctity of life." Alabama is not alone. Kelly Baden, the vice president for public policy at the Guttmacher Institute, told BBC: "We do see that many elected officials and judges alike are often coming at this debate from a highly religious lens."

Speaker Johnson has said:

The separation of church and state is a misnomer. People misunderstand it. Of course, it comes from a phrase that was in a letter that Jefferson wrote. It’s not in the Constitution. And what he was explaining is they did not want the government to encroach upon the church — not that they didn’t want principles of faith to have influence on our public life. It’s exactly the opposite.

And here we are.

Umm, a misnomer? Credit: Bing Image Creator

Many Republicans are backtracking on the ruling. Alabama Republican Governor Kay Ivey said she was “working on a solution.” Alabama legislators are already working on bills to protect IVF, clarifying that in vitro fertilization doesn’t count, with life only beginning when implanted in a uterus. Oh, OK, then.

Presumed Republican presidential nominee Donald Trump says he “strongly” supports IVF, and Republican Speaker of the House Mike Johnson said: “I believe the life of every single child has inestimable dignity and value. That is why I support IVF treatment, which has been a blessing for many moms and dads who have struggled with fertility,” Alabama Senator Tommy Tuberville somewhat hilariously managed to somehow both support the ruling and the need for IVF.

Eric Johnston, president of the Alabama Pro-Life Coalition, admitted:

It's a win philosophically for the pro-life movement because it carries on the pro-life recognition of unborn life. But you get into a very difficult situation, where you have this medical procedure that's accepted by most people, and then how do you deal with it? That's the dilemma… But I think the pro-life community in general supports IVF, and I've known and worked with many people who have had children via IVF. And at the same time, they think abortion is wrong. This issue is so different from abortion, but it has to do with life."

The trouble is, red states are scrambling all over themselves passing ever-more restrictive abortion laws, with the “life begins at conception” mantra, and, despite what Speaker Johnson and other House Republicans say now, 125 of them have cosponsored the Life at Conception Act that makes no exception for IVF.

Gosh, who could have guessed IVF would be impacted by all this?  Well, anyone who thought about it for a half second.

Although IVF only accounts for about 2% of births, it has been around for decades. An untold number of embryos are routinely stored (frozen) and, in some cases, destroyed. Now people like Republican Governor Greg Abbott would have us believe IVF is taking us all by surprise:

These are very complex issues where I’m not sure everybody has really thought about what all the potential problems are and as a result, no one really knows what the potential answers are. And I think you’re going to see states across the country come together grappling with these issues and coming up with solutions.

Once a fetus or an embryo is a person, what rights do they have, when do they qualify for tax credits/welfare/child support, and how do their rights compare to other people? As Jacob Holmes suggested in the Alabama Political Reporter: “Imagine you are in an in vitro fertilization clinic that is on fire, and you have time to save only 100 frozen embryos or a single 2-year-old child.” Do you save the most “lives,” or the only one actually breathing?

I would be remiss if I didn’t note that Alabama has the third highest infant mortality rate in the U.S. (thank you, Arkansas and Mississippi!), and that it was one of 15 (red) states that is rejecting federal funds to help feed hungry children doing the summer (Alabama has some 500,000 such children).  

Evidently, unborn or frozen “people” matter more than live ones.

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These are, I admit, complex ethical issues, but trying to legislate them, especially from the standpoint of one particular religious point-of-view, is only going to lead to more outcomes like we're seeing in Alabama. Democracy demands that we do better to listen than to tell.

Chips Off the AI Block

I’ve been thinking a lot about chips lately, and not only because, according to The New York Times, chocolate chip ice cream has fallen out of favor.  As dismayed as I was about that, I was even more surprised to learn that, as of last Wednesday, computer chip maker Nvidia now is the 3^rd largest U.S. company – and 4^th largest worldwide – by market capitalization. Bigger than Amazon, Alphabet, or Meta, not to mention Tesla.

Credit: Bing Image Creator

If you’re a stock maven, or are deeply interested in A.I., you might have been following Nvidia. The company specializes in designing chips that powers A.I. applications. It has also has long been a presence in advanced chips for, among other things, gaming, cloud computing, and image computing. But Nvidia is hardly a top-of-mind company for consumers, unlike Microsoft or Apple (both of whom it trails in market cap) or the other Big Tech companies.

You may want to start paying more attention to it.

The A.I. revolution of the last two years has been very good for Nvidia; its stock is up over 200% in the last 12 months alone. Charlie Blaine of The Street noted: “Let's say you bought 100 Nvidia shares at the end of 2018. Adjusting for the split later on, the price would be $33. Today, your stake would be worth $726,700, up 2,100%.”

Nvidia first hit $1 trillion in market capitalization last May, some 24 years after going public. It is now worth around $1.8 trillion, and analysts are eagerly awaiting Wednesday’s earnings call. "It could be the most important earnings in all tech year to date, and possibly the entire stock market," Jordan Klein, managing director for tech, media and telecom sector trading at Mizuho Securities, said in a client note. "Nvidia is not up 47% year to date to $1.8 trillion market cap because nobody cares, right?"

By contrast, Intel – which many consumers might be able to name – has a market cap about one tenth of Nvidia’s, although Nvidia trailed Intel as recently as 2020.

To call Nvidia a chip maker or chip manufacturer is somewhat misleading, though. What it does uniquely well is chip design. TMSC (Taiwan Semiconductor Manufacturing Company) does most of its actual production, as it does for many chip companies. Oh, sure, there are other chip manufacturers, including AMD, Intel and Samsung, but TMSC produces about 90% of the world’s high performance chips. You want AI? You want quantum computing? You want the future?  Then you need Nvidia.

Given the decades-long tensions between China and Taiwan, not to mention increasing tensions between China and America, including US restrictions on advanced technology to China, it should give pause to think that a Chinese invasion of, or a missile strike on, Taiwan could severely hamper development of AI and other advanced technologies.

That’s one reason TMSC is diversifying the locations of its fabrication plants, with two planned in the US, two in Japan, and “possibly” one in Germany.  Its first planned Arizona plant was scheduled to start production by the end of 2024, but that has slipped into the first half of 2025, a delay attributed in part to lack of skilled employees. Its second Arizona plant now won’t be in production until 2027 or 2028, instead of 2026. The progress is somewhat dependent on “how much incentives that the U.S. government can provide,” Mark Liu, TSMC’s chairman, said in an investor call. The Wall Street Journal reports: “negotiations between the Biden administration and TSMC over subsidies have proven challenging, say people on both sides.”

Those incentives were supposed to come from the 2022 Chips and Science Act, which was to invest some $50b to boost US chip manufacturing. But progress has been slower than expected. Similar to TMSC’s issues in Arizona, Intel’s much publicized Ohio expansion now isn’t expected to even be completed until late 2026, instead of beginning production in 2025 as originally planned.

Just last week the Biden administration released its first major award, some $1.5b to New York-based GlobalFoundaries, with another $1.6b in loans. That’s a long way from $50b and not much visible progress for 18 months since passage. “Nothing has failed yet,” Emily Kilcrease, a senior fellow and the director of the energy, economics and security program at the Center for a New American Security, told NYT. “But we’re going to have to see some progress and those factories actually coming online in the next few years for the program to be considered a success.”

And, in any event, TSMC may be planning to keep its most advanced processes at home, not in its overseas plants. So much for reducing dependency.

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If you think the world’s dependence on a single manufacturing company for our most advanced chips is scary, it’s worse than that. TSMC and other chip manufacturers rely on EUV lithography, which is used to engrave the chips. And there’s only one company -- Advanced Semiconductor Materials Lithography – that produces the machines to do that.

If you hadn’t heard of Nvidia, and perhaps even if you had, you almost certainly hadn’t heard of ASML, or understood its importance. “ASML has a monopoly on the fabrication of EUV lithography machines, the most advanced type of lithography equipment that’s needed to make every single advanced processor chip that we use today,” Chris Miller, assistant professor at the Fletcher School at Tufts University, explained to CNBC. “The machines that they produce, each one of them is among the most complicated devices ever made.” TMSC, Intel, and Samsung – all of whom are major investors -- account for over 80% of its sales.

ASML is located in the Netherlands, so is just one hypersonic missile away from Russia destroying the chip market.

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I’ll be watching Nvidia’s earning report with some interest. Its stock might be in a bubble, but AI is only going to get bigger, which is good for Nvidia. It’d be cool to see if it can top $2 trillion in market cap, especially if it vaults Saudi Aramco into 3^rd overall spot. Its success is a classic capitalism success story; it built a better mousetrap, and the world beat a path to it.

But reliance on two companies – TMSC and ASML – for some of our most advanced technologies is the opposite of capitalism, especially when they are so geographically constrained. If we want to play hardball with our geopolitical rivals about advanced technologies, just remember that they can do some brush back of their own.

The Chips Act was a widely supported effort at industrial policy, but, so far, it has been too little, too slow.

Why Not, Indeed

Recently in The Washington Post, author Daniel Pink initiated a series of columns he and WaPo are calling “Why Not?” He believes “American imagination needs an imagination shot.” As he describes the plan for the columns: “In each installment, I’ll offer a single idea — bold, surprising, maybe a bit jarring — for improving our country, our organizations or our lives.”

Sometimes you just have to ask "why not?" Credit: Bing Image Creator

I love it. I’m all in. I’m a “why not?” guy from way back, particularly when it comes to health care.

Mr. Pink describes three core values (in the interest of space, I’m excerpting his descriptions):

• Curiosity over certainty. The world is uncertain. Curiosity and intellectual humility are the most effective solvents for unsticking society’s gears.
• Openness over cynicism: Cynicism is easy but hollow; openness is difficult but rich.
• Conversation over conversion: The ultimate dream? That you’ll read what I’ve written and say, “Wait, I’ve got an even better idea,” and then share it.

Again, kudos. One might even say “move fast and break things,” but the bloom has come off that particular rose, so one might just say “take chances” or “think different.” Maybe even “dream big.”

Around the same time I saw Mr. Pink’s column I happened to be reading Adam Nagourney’s The Times: How the Newspaper of Record Survived Scandal, Scorn, and the Transformation of Journalism. In the early 1990’s The Times (and the rest of the world) was struggling to figure out if and how the Internet was going to change things. Mr., Nagourney reports how publisher Arthur Sulzberger (Jr) realized the impact would be profound:

One doesn’t have to be a rocket scientist to recognize that ink on wood delivered by trucks is a time consuming and expensive process.

I.e., contrary to what many people at The Times, and many of its readers, thought at the time, the newspaper wasn’t the physical object they were used to; it was the information it delivers. That may seem obvious now but was not at all then.  

Which brings me to health care. Contrary to what many people working in healthcare, and many people getting care from it, might think, healthcare is not doctors, hospitals, prescriptions, and insurance companies. Those are simply the ink on wood delivered by trucks that we’re used to, to use the metaphor.

And it doesn’t take a rocket science to recognize that what we call health care today is a time consuming and expensive process – not to mention often frustrating and ineffective.

Why not do better?

I also thought about health care when reading Mr. Nagourney’s book when he described the conflict between the journalism side of the company versus the business side: was the newspaper about the articles it published, with the advertising just there to support them, or was it really an advertising platform that needed the content the journalists created to bring eyeballs to it? In healthcare, is it about helping patients with their health, or is it a way to provide income to the people and organizations involved in their care?

I.e., is it about the mission or the margins?

That's the dilemma. Credit: Bing Image Creator

If you think that’s too cynical, I’ll point to Matthew Holt’s great article in The Health Care Blog arguing that many hospitals systems are now essentially hedge funds that happen to provide some care, while also creating scads of rich executives. Or to how an actual hedge fund is buying a hospital. Or to how, indeed, private equity firms are buying up health care organizations of all types, even though many experts warn the main impact is to raise costs and adversely impact care. Or to how Medicare Advantage plans may be better at delivering insurer profits than quality care.

I could go on and on, but it seems clear to me that healthcare has lost its way, mistaking how it does things from what it is supposed to be for. If healthcare has become more about making a small number of people rich than about making a lot of people healthier, then I say let’s blow it up and start from first principles.

There’s a “Why Not?”

Mr. Holt’s “Why Not?” is to take a measly $38b from the $300b he estimates those hospitals are sitting on, and invest it in primary care, such as the Federally Qualified Health Centers (FQHCs). Primary care needs the money; the hospitals/hedge funds, not so much. Amen to that.

A couple years ago I proposed an even wilder idea: let’s give every physician $2 million – maybe even $2.5 million – annually. We say we value them, so let’s reward them accordingly. The caveat: from that they’d have to pay for all of their patients’ health care needs – referrals, prescriptions, hospital stays, etc. I posited that they’d negotiate much better deals with their compatriots than we seem to be able to do. Lots of details to be worked out, but it falls into the “Why Not?” category.

Here's another audacious Why Not: it’s fairly well known that CEO to worker pay ratios have skyrocketed from a modest 20-1 in the 1960’s to something like 344-1 now. There’s no evidence I’ve seen that the ratios are any better in healthcare. Since no profession in healthcare is more respected and relied on than nurses, I propose – maybe making it a condition for receiving any federal funds -- that no healthcare organization should have an executive compensation  to nurse compensation ratio that exceeds 20 (and I do mean compensation rather than salary, to avoid the bonus/stock shenanigans that executives have relied on). 

If that sounds low, I’d pity the executive who wants to argue with straight face that he/she is more than twenty times more important than nurses. I bet they couldn’t find many patients who’d agree, or any nurses.

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If you work in healthcare, you should ask yourself: is what I do the ink, the wood, or the delivery truck, or is it truly integral to what healthcare should be in 2024?  If you think your job should be more about health and less about the business of health, why not make it so?

And the rest of us should be asking ourselves: is the healthcare we get still the equivalent of a print newspaper? We don’t have to be rocket scientists to recognize that, in 2024, we should be expecting something better – cheaper, faster, more interactive, more personal, and much more impactful.

Why not, indeed?

Check This Out

As an avid reader, a month ago I was depressed to read that apparently 46% of Americans did not read any books in 2023. If you manage to read just one book a month – just one book per month! -- that puts you in the top 20%. Combine that with the recent wave of book bans and, increasingly, librarians being under siege, it sure seems like grim times for a literate society.  

No, the library isn't dead. Credit: Bing Image Creator

But, it turns out, things might not be quite as bad as I’d feared, and the hope comes from Gen Z and millennials.

A pair of Portland State University professors, Kathi Inman Berens and Rachel Noorda, summarize the results of their new research in an article in The Conversation: Gen Z and millennials have an unlikely love affair with their local libraries.  In a world of TikTok, gaming, and streaming, who’d have thought?

According to their survey, 54% of Gen Z/millennials have visited a library in the past year – versus 45% of Gen X and 43% of baby boomers. Even over half of the 43% Gen Z/millennials who don’t claim to be readers say they’ve visited a library in the past year. The researchers found: “Browsing public libraries is Gen Z’s #3 preferred place to discover books. Libraries are the #5 preferred place for millennials to discover books.”

Credit: Berens and Noorda

The authors note:

The library provides a number of things beyond books: a safe, free place to hang out, important resources and advice during big life changes such as career transition, parenthood, new language acquisition, or learning to read; Wi-fi enabled work spaces; and creativity resources like maker spaces and media production equipment.

The authors argue that, whether the patrons are checking books out or not, libraries serve as a low cost marketing venue for publishers, allowing readers to find books risk-free. They further see print books as fitting better into a social media age than one might think:

When fans are also creators, printed books make good props in visual media like TikTok short videos and Instagram Reels. There are no TikTok videos of ebooks! Printed books can be imaginatively used as conversation pieces or expressive objects.

Every library should prominently post “There are no TikTok videos of ebooks!”

Gen Z/millennials are also going to bookstores, with 58% buying a book there in the past year. Indeed, the research found: “Gen Z and millennials slightly prefer bookstores to libraries for printed book discovery.”

Given all this, it’s shocking how we’re treating libraries and the people who staff them. “We’re no longer seeing a parent have a conversation with a teacher or librarian about a book their child is reading,” Deborah Caldwell-Stone, the director of the American Library Association’s Office for Intellectual Freedom, told The New York Times. “We’re seeing partisan groups demand the removal of books that they’re told are bad books, that they are not even reading, because they don’t meet the political or moral agenda.”

The Times further reported: “People who normally preside over hushed sanctuaries are now battling groups that demand the mass removal of books and seek to control library governance. Last year, more than 150 bills in 35 states aimed to restrict access to library materials, and to punish library workers who do not comply.”

Despite all this, libraries remain a special place, at least for Gen Z/millennials. Professors Berens and Noorda speculate: “Gen Zers and millennials still see libraries as a kind of oasis – a place where doomscrolling and information overload can be quieted, if temporarily…Perhaps Gen Zers’ and millennials’ library visits, like their embrace of flip phones and board games, are another life hack for slowing down.”

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Contrary to the gloomy reading statistics I started with, Professors Berens and Noorda found that young people claim to read 2 print books, 1 ebook, and 1 audiobook a month, with Gen Z slightly outpacing millennials. When asked generally about reading habits, reading print books are, not surprisingly, less common than reading text messages, email, social media, and websites, but is solidly in 5^th place (50%).

Credit: Berens and Noorda

Despite what you might believe about the prevalence of gaming and the creator/influencer economy, when asked about their “media identity,” 57% of Gen Z/millennial identity as readers, versus 53% as gamers and 52% as fans. Reading is not dead.

Despite the encouraging research, we need to keep in mind that U.S. reading scores are at their lowest point in decades (along with math scores). There is now a movement called “the science of reading” that many educators (and legislators) are advocating, but a new study suggests a different culprit: students read better, learn better, when they read text on paper instead of on a screen. As the authors (Froud, et. alia) report: “Reading both expository and complex texts from paper seems to be consistently associated with deeper comprehension and learning.”

The authors say: “We do think that these study outcomes warrant adding our voices … in suggesting that we should not yet throw away printed books, since we were able to observe in our participant sample an advantage for depth of processing when reading from print.”

John R MacArthur, publisher of Harper’s Magazine, wrote about the study in The Guardian, and cited a speech MIT neuroscientist John Gabrielli gave last fall about the use of technology to improve reading:

I am impressed how educational technology has had no effect on scale, on reading outcomes, on reading difficulties, on equity issues.

How is it that none of it has lifted, on any scale, reading? … It’s like people just say, ‘Here is a product. If you can get it into a thousand classrooms, we’ll make a bunch of money.’ And that’s OK; that’s our system. We just have to evaluate which technology is helping people, and then promote that technology over the marketing of technology that has made no difference on behalf of students … It’s all been product and not purpose.

We have a “product” that works; it’s called a book. We have a place that nurtures and encourages young people to read them; it’s called a library. We scream and yell about the pernicious influences of social media while dragging libraries and “controversial” books into the cultural wars, and then wonder why reading scores plummet.

Let’s keep libraries an oasis. If Gen Z/millennials get it, why don’t the rest of us?