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Wednesday, October 12, 2016

Force majeure? Not so fast

North Carolina can be divided geographically into three parts: Appalachian mountains in the west, the "Piedmont" (rolling hills) in the center, and the coastal plain in the east. The Eastern Continental Divide passes along the spine of the mountains, and surface water from the small portion of NC west of the ECD eventually enters the Mississippi River. But east of the ECD, all surface water in NC goes to the Atlantic Ocean via the Piedmont and the coastal plain.

There are peculiarities about the coastal plain in NC. It has no large river going to the Atlantic, unlike the Potomac and the James in Virginia, or the Santee and the Pee Dee in South Carolina, or the Savannah on the SC-Georgia border. The rivers that pass through the NC coastal plain — the Cape Fear, the Neuse, the Tar, the Roanoke, and the Chowan — are small in comparison. They don't have the natural capacity of rivers in adjacent states.

Furthermore there are few large lakes along these rivers in the NC coastal plain, whereas SC has situated numerous large lakes along its corresponding rivers in the coastal plain. Lakes serve an important role in flood control by buffering inflow while increasing outflow by a lesser amount over a longer period of time. North Carolina, in contrast, placed dams such as Falls and Jordan upstream in the Piedmont. That's understandable because the geography in the Piedmont is more amendable to deep lakes that don't require so much surface area and also because the populous Piedmont needed sources of drinking water. But the consequence is that Falls Lake and Jordan Lake are too far upstream to prevent the catastrophe that began Saturday.

The NC coastal plain is naturally vulnerable to broad floods, but this vulnerability has been intensified by the rapid population growth of the Triangle. Growth creates impervious surfaces such as roofs, parking lots, and roads. Although the Piedmont counties have attempted to mitigate this ever-increasing runoff with their own small-scale lakes — I live near one, Lake Lynn in north Raleigh — the attempt was only partly successful, in part because the growth of the Triangle has exceeded all estimates from the 1970s when these lakes were planned, in part because ongoing construction in the Triangle has silted up these lakes and reduced their capacity to hold temporary floodwaters.

And we have the sad story of the Woodlake Dam, built expressly to provide a scenic and recreational environment for a country club and resort development. The weakness of this dam has been known for some time, but there was no sense of urgency to fix it. The odds of a storm anytime soon that could overwhelm the dam seemed very low to officials.

What we saw Saturday was our own highly improbable but very real "perfect storm". The combination of Hurricane Matthew and a cold front moving rapidly from the northwest to the southeast produced far more rain than anyone expected. The National Weather Service has confirmed one reading of 18.38 inches in Elizabethtown (for my European friends, that's almost half a meter of rainfall). At my house I measured 10 inches. There was brief flooding in the Triangle, but the real problem began on Sunday and Monday as the bolus of rainfall departed the Piedmont rapidly and moved into the coastal plain that would have had difficulty expelling the rain it got itself, much less what came from upstream.

The catastrophe is upon us. Many have died. No, not as many as in Haiti, but deaths nevertheless. Property damage and economic disruption will be extensive. After similar floods in 1996 from Hurricane Fran and 1999 from Hurricane Floyd, the coastal plain took 10 years to recover. In some cities such as Rocky Mount, the recovery was never full. The coastal plain, in general, has not enjoyed the economic prosperity of the Piedmont or the beaches. Financial resources of coastal plain counties were already stretched thin before Saturday.

And what people in NC aren't keen to discuss is that the lowest elevations of inhabited land in the coastal plain are disproportionately occupied by African-Americans, Latinos, and Native Americans who cannot afford to live on higher land. Metro New Orleans saw this too in the aftermath of Hurricane Katrina. The poor will suffer not only a loss of life and property, but also a loss of livelihood because many businesses in the affected areas will close indefinitely. Yes, there will be jobs in construction but the poor often have no skills for those projects and the number of openings for unskilled labor will not nearly match the number of people looking for work. Meanwhile, our NC General Assembly has cut employment insurance benefits to the bone.

The perfect storm would have inflicted misery, for sure, but our own choices have multiplied that misery.

Wednesday, October 5, 2016

My brother, Ben Stiller

Ben Stiller has disclosed that he is recovering for treatment of prostate cancer, which afflicted him at age 46. Without PSA screening that detected the cancer before it became symptomatic and (more importantly) before it metastasized, he believes he would have died.

I'm with you, Ben. That's my story, too. I was 51 when my PSA test showed a problem. Like him, my "Gleason score" was 7. Like him, I underwent laparascopic surgery assisted by a robot. Like him, I am alive today with a zero PSA level — which, after one's prostate has been removed, is an unambiguous statement that no prostate cancer remains.

Unfortunately, the U.S. Preventive Services Task Force continues to tell men that they should not have PSA testing in the absence of symptoms. It's absurd. Their position effectively condemns men like Ben and myself to an early, unnecessary death.

The argument from USPTF is that a PSA test is not specific to prostate cancer. Non-cancerous diseases of the prostate can elevate one's PSA. That's true. In order to diagnose prostate cancer, one's prostate must be biopsied. This is a painful procedure that has its own risks and has a high price tag. That's true. There is a chance that the biopsy will give a false negative (in other words, that it will not find cancer even though the cancer is present). That's true. There is a possibility that some men will panic and rush to treatment by surgery or radiation, even though their particular type of prostate cancer is so slow-growing that it would not pose a threat for 10 or 20 years. That's true. There is also a possibility that some doctors practicing defensive medicine or hungry for income will encourage patients to get treated when waiting would be a better decision. That's true.

But in cases like Ben's and mine, the situation simply doesn't play out that way. Ben and I had 35-40 years of projected lifespan ahead of us; we were not octagenarians likely to die of something else soon. Our cancers were asymptomatic; I had "digital exams" (guys, you know what that is) by at least ten physicians before surgery. None of them could feel anything amiss, and of course I hadn't noticed any symptom myself. Our cancers were fast-growing, not slow-growing. His PSA level was rising rapidly, and so was mine. In fact, in the months it took between my initial test and my surgery, I passed from the zone of intermediate risk (PSA=15) to the zone of high risk (PSA=25). Usually a PSA of 6 is considered ominous, if it continues to rise. After my surgery it came to light that my cancer had just begun to spread outside the prostate.

There is zero doubt that without PSA screening, my cancer would have become untreatable within a year and that I would not be alive today. No doctor familiar with my history believes otherwise. And when I wrote an MD at the USPTF to object, he didn't dispute my imminent and certain demise. He simply replied that in the aggregate, too much money is being spent on unnecessary treatments and the complications they cause. In other words, it's ok for men like Ben and myself to die prematurely just because other men and their doctors are making poor decisions.

I think that sucks.

Do we need a more specific test than PSA? Yes. Do we need more conservative treatment — in some cases, engaging in "watchful waiting"? Yes. Are those sufficient reasons to tell men not to get screened in the first place? No.

Someday the brotherhood that Ben and I belong to will be joined by one of physicians who participates in the USPTF. At that point, I expect to see change in the recommendation. Until then, ignore the USPTF and get screened. It could mean your life, too.

Thursday, September 22, 2016

What police can and cannot do

It's always risky to comment on a developing situation whose facts are uncertain, but I wrote the following in response to a family member who opined on Facebook.

"Police officers are not 'the law' [a quote from the post of my family member]. Police officers serve the law. They are under the law like everybody else. The law grants them powers but also imposes limits and holds them accountable if they don't stay within those limits.

"Whether the dead person had, in fact, a gun is one question that ultimately a jury will have to decide. Beyond that, open-carry in North Carolina has been legal for decades and concealed-carry in North Carolina is also legal with a permit. (No one knows whether the dead person had a permit or not.)

"I'm sure the officer believes the dead person had a gun. Whether or not that was, in and of itself, justification for a command to drop the weapon is a debatable point at law and there have been several court cases about that already. It's also a debatable point at law whether a LEO is justified in shooting someone simply because the person is armed and declines to disarm. There have been court cases about this too. The question is really whether the dead person made a threatening gesture or there was some other legitimate reason for the LEO to open fire.

"It's a borderline case based on the facts that have come to light. In short, LEOs do not have unlimited discretion to open fire — even in situations where a firearm is present. This is far from open-and-shut."

Saturday, September 17, 2016

Where art thou, First Union?

When it was clear in 1986 that Gail, Ryan and I would move from Atlanta to Raleigh, I wanted to open a bank account in Raleigh several months before the family would arrive. So, during a business trip I dropped by Crabtree Valley Mall and visited the branches of the "big three" banks in Raleigh at the time. Each heard the same story: I didn't have much time to talk, but I would leave my name and Atlanta home address so that they could send me a packet of available services and a fee list.

  • Nothing ever arrived from NCNB.
  • Wachovia sent something by first-class mail, and I received it five days later.
  • First Union sent me a package overnight.
I went with First Union and became a very happy customer. Ultimately First Union was acquired by Wachovia. I had misgivings about the takeover, but Wachovia turned out to be good, too.

But Wachovia got caught playing mortgage games in 2008-2009, and along came Wells Fargo.

Only two things good have happened since: on the rare occasions when I travel in the western U.S., there are more ATMs to use; and I prefer Wells Fargo's process for accessing a safe deposit box. Otherwise I've found Wells Fargo to be generally uncooperative compared to First Union or Wachovia, and I tired long ago of being upsold everytime I talked to a Wells Fargo person, used their ATM, or used their website. Look, if I want an additional service from Wells Fargo, I'll ask you about it!

But all that upselling was indicative of an underlying management problem, it turns out. I am not surprised by the disaster now revealed. I am surprised, however, that no head has rolled yet within the bank. Let's hope that the Federal Reserve, the Department of Justice, or the Congress plows into this situation. Civil litigation by customers of Wells Fargo is inevitable, but that's insufficient. Heads must roll, and the bank and relevant executives including the CEO and the president of the consumer banking division must be prosecuted, fined, and — in the case of the executives — jailed. That's the only way to prevent this from recurring.

As to whether Gail and I will take our banking business elsewhere, we haven't decided yet.

Monday, September 12, 2016

Looking at the presidential election

When thinking about the upcoming election for President, I put the electorate into six buckets. Each bucket gets a color in my diagram:

People in the yellow bucket cannot or will not vote. The light blue and light red buckets are folks who will vote for Clinton or Trump, respectively, on the basis of party affiliation or general political stance (e.g. liberal vs. conservative) regardless of their views of the candidates personally. There are always some voters in these buckets, but in 2016 there appear to be more than ever.

At this point, no one knows how the green bucket will eventually be dispersed across the other five. No one knows how many people will step out of the yellow into a red or blue bucket — or will decide to sit on the sidelines by moving into the yellow bucket. And even if the election were tomorrow, no one can say with confidence whether Clinton or Trump would win; that is, whether the sum of the light blue and the dark blue buckets will be larger or smaller than the sum of the light red and the dark red buckets. Things to bear in mind at this point:

  • The big TV money hasn't been spent yet.
  • The election is nine weeks away, and a lot can happen in that time. For example, a candidate can make a profound misstatement or can score a knock-out punch. Small impacts can be decisive in close elections.
  • In North Carolina, last-minute changes to the voting process as a consequence of legislation and subsequent litigation make it very difficult to predict voter turnout.
The net unfavorability ratings of both Clinton and Trump also cast doubt on outcomes of down-ballot races.

Turnout is the key. Polls have become notoriously inaccurate in predicting turnout. I call it 50-50.

Wednesday, September 7, 2016

The process of deciding

Life sometimes presents us, confronts us, with finely calibrated decisions where the choice between two alternatives is not easy, but the consequences of choosing rightly or wrongly are significant. I saw an example of this Monday at a baseball game. Let me tell you the story, and you don't have to be an expert on baseball to see the point.

After eight innings, neither team had scored. In fact, no runner had made it to third base and only two had reached second. You could politely call it a thrilling duel by two skilled pitchers, or you could note wryly that both teams had a sorry batting average — not surprising for the minor leagues on the last day of the season, when the better players had been called up for tryouts or injury fill-ins. Anyway, we entered the top of the ninth 0-0.

The home team's pitcher had given up only two hits. Does the manager leave him in, betting on another 3-up, 3-down inning but accepting the risk that the pitcher will tire and give up a sudden run? Or does the manager bring in a reliever with a fresh arm, but who might come to the mound flat? You know that the starting pitcher does not want to be yanked, so even if his arm is getting rubbery, he won't confess it. After all, it's the last game of the season and he wants to leave the organization with a strongly positive memory of a complete game shutout. And the catcher isn't much help to the manager in making the decision because the pitcher showed really good stuff in the eighth.

The manager opted to bring in the reliever, who gave up a hit but eventually got three outs without giving up a run.

Now it's the bottom of the ninth, still 0-0. The visiting team's manager faces exactly the same decision. His pitcher has given up six hits through eight innings, but most of them were weak singles "with eyes". The manager opts to leave his starter in. Things turn sour for the visiting team immediately: the first four pitches are balls, and the next batter hits a walk-off double to deep left that brings in the winning run.

Superficially, one manager looks like a genius and the other manager looks like a dolt. But that's not fair to either. One manager played the statistics strictly, and the other manager followed a hunch or perhaps had another objective in mind. I know that the losing pitcher will always remember the vote of confidence he got from his manager. Point is, both managers had reasonable means by which to reach their decisions. In this circumstance, one approach worked and the other didn't.

Philosophers have said, to paraphrase, that we are the sum of our choices. Maybe they're right, but it's a scary way of looking at life. In my years I have run across a few people who appear to be very adept at making finely calibrated decisions that consistently turned out well — but only a few such people. Are they so skilled or just lucky? I wonder. Meanwhile, the rest of us proceed through life doing the best we can, hoping that we find ourselves on the favorable side of a 1-0 score more often than not.

Monday, August 22, 2016

Medals per million

Athletes from the U.S. won the most medals at the 2016 Summer Olympics, but before Americans think once again that they're better than everyone else, let's calculate medals per million population. It's just logical to expect that the more populous countries win more metals than the less populous countries, right? Here are the numbers.

  • Jamaica 3.67
  • New Zealand 3.60
  • Croatia 2.50
  • Denmark 2.50
  • Slovenia 2.00
  • Azerbaijan 1.80
  • Georgia 1.75
  • Hungary 1.50
  • Armenia 1.33
  • Lithuania 1.33
  • Australia 1.21
  • Serbia 1.14
  • Netherlands 1.12
  • Sweden 1.10
  • U.K. 1.03
  • Belarus 1.00
  • Cuba 1.00
  • Kazakhstan 0.94
  • Czech 0.91
  • Switzerland 0.88
  • Norway 0.80
  • Slovakia 0.80
  • France 0.65
  • Canada 0.59
  • Belgium 0.55
  • Greece 0.55
  • Germany 0.51
  • Italy 0.47
  • South Korea 0.41
  • Uzbekistan 0.41
  • Russia 0.38
  • U.S. 0.37
  • Japan 0.32
  • Spain 0.30
  • Kenya 0.30
  • North Korea 0.29
  • Poland 0.29
  • Ukraine 0.26
  • Romania 0.25
  • South Africa 0.18
  • Colombia 0.16
  • Malaysia 0.16
  • Iran 0.10
  • Turkey 0.10
  • Brazil 0.09
  • Argentina 0.09
  • Thailand 0.09
  • Ethiopia 0.08
  • China 0.05
  • Mexico 0.04
  • Indonesia 0.01
  • For example, in proportion their populations, the Australians won three times as many medals as the Americans.

    The populations in these calculations were rounded to the nearest million, so for the less populous nations, there might be some movement in the rankings if the calculations had been made to three significant digits. But the overall message of the numbers is clear.

    Jamaica, of course, is at the top because of Usain Bolt. An exceptional athlete can skew his or her nation's numbers.But the U.S. had Michael Phelps and Simone Biles, among others.

    Anyway, I think the U.S. Olympic Committee has something to think about — as does their counterpart in China. Host nation Brazil did poorly, perhaps distracted by logistics. Note that some countries like Sweden emphasize winter sports. Their numbers for the summer are particularly impressive.