Reflecting Again on American Health Care

A familiar story I like to tell about the fundamental character of health care in the U.S. concerns orthodontics.  Braces are a life experience for millions of American adolescents every year, and yet most dental insurance plans fail to cover orthodontic care on the principle that it is effectively cosmetic.  With this in mind, I was born without one of my lower permanent incisors, causing all of my teeth on this side of my mouth to shift.  Numerous dental professionals have advised me to consider braces, but I have resisted the move both for cost considerations and for the larger inconvenience.  As a result, I have a somewhat unsightly gap between some of my teeth where the gums are somewhat more vulnerable to gingivitis, but, on the whole, I haven't suffered any significant health issues from my decision not to correct my teeth. 
         My brother Norm's children, by contrast, have each gone through orthodontic work.  I cannot blame my brother and sister-in-law for choosing to invest in the straightening of their kids' teeth, especially when dental professionals, no doubt, advised them to do so.  Just the same, I can remember several years back that my mom and dad would take their grandchildren along for the ride up to the Mondiale des cultures festival in Drummondville in Québec, my mom's hometown.  It seemed like every time they would go, they would invariably meet up with the grandchildren of one of my mom's friends about the same age, and not one of these Québécois youngsters had braces, however straight or crooked their teeth were.  The interpretation seemed pretty clear to me.  Orthodontics is an investment that the single-payer health care system in Québec has largely chosen not to invest in, and, given the income levels of these youngsters' family, there simply was not going to be a private investment made in this direction.  Perhaps they would have wanted to, but the cost precluded the possibility.  More over, it seemed like this was a regular outcome in Québec with regard to orthodontics, which did not appear, on its face, to be as prevalent a subset of the medical establishment, at least in Drummondville.
           This conclusion is pertinent to a larger evaluation of medical expenditures in the U.S., and, in particular, of our propensities to accept the diagnoses of medical professionals advising expensive treatments for conditions that are neither life threatening nor particularly debilitating to the everyday lifestyle of the patient.  Emphatically, our health care system is so expensive, in large part, because patients undergo a variety of procedures that may be unnecessary to the general maintenance of their health on the advice of medical professionals who prescribe treatments and/or diagnostic tests for diverse reasons but, pointedly, in the hopes of skirting medical liability from the experience of an unhappy patient who might conclude that their physician was negligent in identifying treatment options and thoroughly diagnosing their condition.  We can, in this manner, conclude that this is another side effect of our relatively litigious culture, but it also tells us something important about our conceptions regarding the integrity of our bodies in relation to medical science's capacity to repair every malady and physical shortcoming, conferring on medicine a more profound stature of objectivity as a science and a more expansive capacity to achieve improvements on the human condition than it might otherwise deserve. 
          That is not say that medical science does not deserve credit for its vast accumulation of knowledge on the human body (and, for that matter, the human mind if we include mental health) and for its striving to research the causes and cures for numerous deadly maladies.  On the other hand, all of the research conducted by medical professionals carries a substantial bill for services rendered that invariably filters down to every patient receiving medical care, partly reimbursed from patients themselves and partly covered by the financial sector through health insurance.   Every penny of capital sunk into medical research or specialized facilities for cutting edge diagnostic technologies or treatment regimens demands a rate of return, frequently recovered by cross subsidization, charging higher rates for more conventional procedures to patients and/or third party payers.  Again, this is not to say that we should not make such investments, but we need to recognize how the normative practices of finance pervert the aims of erstwhile humanists, researching cures to cancers, Parkinson's disease, Alzheimer's, and other chronic maladies impacting humanity (at least among those quarters most able to cough up the cash required to start a research agenda). 
       Beyond the pure economics of health care, the rigorous ethos of professionalism exuded by physicians and other highly trained front line care givers conveys an impression of infallibility that, to some degree, shapes the expectations of patients in ways that may be unrealistic.  This sense of total expertise is the thing that most concerns me in this post.  Again, this is not to say that patients should not listen to the advice of their physicians or entrust them with an expectation that their accumulated training and experience will lend credibility to their diagnoses.  However, no science can ever claim absolute objectivity.  The best that medicine can claim is to possess extremely reliable experiential and research-driven points of reference in regard to particular physical conditions and the infliction of such conditions on individual bodies.  Conceding as much, every human body is different and constituted as much by micro-level interactions with microbial species as with macro-level social/ecological effects on the body.
         Particular strains of the influenza virus, for example, may have a relatively predictable infection pattern on the human body, in the abstract, but when the same strain of influenza infects a particular individual, its progression must, necessarily, depend on the mix of microbial species already coexistent with the individual, with the individual's broader health habits (e.g. diet, sleep, work routines, etc.), and with weather, ecological factors (e.g. exposure to higher levels of air pollution), and social interaction with other infected individuals.  No matter how educated a medical professional might be, it is extremely difficult to isolate and control all of the determinants of an individual's health in order to effectively, precisely diagnose such an infection and prescribe the precise recovery plan, including use of antibiotic and/or anti-viral medications, best suited to that individual without generalizing across unrelated patients in ways that may be unhelpful to the patient's treatment.  In the end, medical diagnostics may reduce itself to a practice of trial-and-error, where multiple diagnoses accompanied by multiple unsuccessful treatment regimens precede a successful resolution of a particular malady, not because the medical professionals treating the malady are incompetent but because the physical constitution of an individual is a complex interrelation between myriad factors that are difficult to analyze.
         Part of the problem here is that the inherent complexities of medicine are difficult to disentangle from claims of incompetence and/or negligence as a matter of civil liability, especially when, as an especially litigious culture, we place so much faith in the capabilities of medical professionals to cure every ill and fix every physical and/or mental impairment.  For medical practices, testing our faith that the powers of medicine are effectively limitless can get expensive and, collectively, drive up rates for malpractice liability insurance.  So, if you cannot achieve an iron clad diagnoses of some patient's condition, it makes sense that you would exhaust every avenue in diagnostic testing, however expensive for the patient and his/her insurer, to make sure that the diagnoses was correct.
         This brings me to another example in medical care involving myself and multiple coworkers.  I noted on this blog that, about a year and a half ago, I broke my wrist (a distal fracture of the radius at the wrist joint).  Coincidentally, no sooner did I return to work than one of my coworkers take a tumble over the handle bars of her bike while trying to avoid a dog along a bike path, in turn, achieving a small radial fracture for which she did not require a cast.  Finally, again by strange coincidence, this coworker's son (with whom I also work) had had an accident while snowboarding that, apparently, resulted in a fracture of some sort to his radius for which he went untreated for almost an entire year, until, after a prolonged history of soreness in that wrist, his physician determined that the radial bone had been fractured, had healed incorrectly, and would require surgery to repair the damage to his wrist joint.  The three wrist fractures in question are pertinent to my larger argument here if only because they show different approaches to the resolution of a common medical problem and different negotiations of health care costs, all under a shared, employer sponsored health insurance plan.

        When I broke my wrist, I required a cast and my treatment precluded me from working at my job for six weeks.  Moreover, I encountered substantial out of pocket expenses in addition to my copays, especially for diagnostic tests (x-rays to determine the progress of healing).  After my cast was removed, I experienced some soreness in the wrist joint attributable to immobilization of my tendons.  The orthopedic surgeon who treated me had prescribed occupational therapy to ensure that I would regain my full range of motion, but, after the expenses I had already incurred, I concluded that it was simply cost prohibitive to undergo such treatment.  I downloaded a video off YouTube showing therapeutic exercises for recovery from radial fractures, committed to doing such exercises for a couple of weeks, and went straight back to work.  I have not encountered any wrist pain since, even when doing push ups.

          By contrast, Cathy, who broke her wrist just after I returned, apparently had such a minor break that she returned to work immediately wearing a brace.  In hindsight, it might have been the case that her treatment was inadequate to the injury, but, again, she got the full account from me on how expensive my treatment had been, and, maybe as a result, she was trying to avoid significant expenses for an injury that just was not very severe to begin with.  On the other hand (figurative, not literally), she apparently still has some discomfort in her wrist, especially when she exercises.

          Finally, Cathy's son, David, apparently had such a minor break that it went completely undetected for almost an entire year, during which time he worked for a moving company!  After he had left the aforementioned job, he apparently had a stretch of real discomfort in his wrist, which prompted his mother to suggest that he should have that checked out.  There was apparent evidence of a fracture that had healed improperly, suggesting that David would experience lifelong problems with his range of motion if it was not surgically reset.  So, he underwent surgery, has been in a cast/brace for the last four months, and has been undergoing repeated (expensive) diagnostic testing to ensure that the joint is indeed healing properly this time.

         A principal motivation for writing this post has been the repeated conversations that I've had with Cathy about the medical expenses from David's surgery and from all of the follow on therapy and examination, including the orthopedic surgeon's decision to send David a bone stimulator machine, apparently all on our insurance company's tab(!).  Noting that they had no idea what the device was for or how it was supposed to assist in David's therapy, Cathy further offered, in exasperation, the question of who is supposed to pay for all of this.  Honestly, that tends to be a question that repeatedly gets aired when Cathy and I talk about David's wrist!
           To be fair, Cathy has bent over backwards to ensure that her son could get the treatment that he needed for his wrist and to follow through, making sure that David goes to all of his orthopedic appointments, only to hear all over again that the joint is healing just fine.  Moreover, as she has pointed out, given that David remains on his parents' health insurance policy and they have invested their money into David's treatment to cover out of pocket expenses, the proper healing of David's wrist has become a real investment for her and David's father.  At the end of all our conversations, however, I always seem to end up coming to the same conclusion, and it is one that ultimately sums up the point that I have been trying to make about American health care over the entire course of this post.  First, every penny of capital that is invested in medical research or the provision of medical services to patients in the U.S. demands a rate of return, and, collectively, as an incompletely but substantially integrated market structure, every patient and every third party payer is on the hook to reimburse every penny of capital invested when patients utilize the health care system, if only by virtue of the accumulation of claims to reimbursement along the long course of a medical industrial supply chain.  As long as medicine continues to attract such heady quantities of capital looking for a decent rate of return, American health care consumers will continue to pay higher and higher health insurance premiums, higher and higher copays, and higher and higher deductibles on annual health insurance benefits, as well as restrictions on certain categories of care.
             The point here is that, at some point, someone on the demand side of the health care market place has to put their foot down and say "no."  "No, I am not going to pay for a bone stimulator when I have no idea what it's supposed to do or how it is supposed to help."  "No, I am not going to pay for braces or clinical teeth whitening."  "No, I am not going for another CT scan, after I have already had two negative scans."  "No, I am not going to pay for the most high tech, new circulatory anti-coagulant medication when older medications work just fine and are available as lower cost generics."  In other health care systems, like the Canadian and Québécois single-payer systems, the problem of saying "no" is easily resolved.  A government bureaucracy is always available to be an ever present gatekeeper to health care services in order to control the expansion of costs.  Likewise, in other health care systems with third party payment by private insurers like, say, Germany, the health insurance industry seems to be readily able to exercise its capacity to say "no" when medical professionals prescribe treatments regimens of questionable merit that will extraneously tax the ability of the health insurance establishment to cover the full range of its expenditures.
            To a certain degree, health insurers in the U.S. are also willing to exercise their authority as the gatekeepers to medical treatment.  The health maintenance organization (HMO), pioneered by Kaiser Permanente in California, for example, was predicated on the principle of controlling expansion of health care expenditures by controlling the terms of health care provision within organizations of salaried medical professional employees.  However, the HMO lost favor quickly because it did not conform to the preferences of American consumers for more choice in selecting medical professionals across the larger span of the market place.  Greater market freedom in American health care means that opportunities always potentially exist to profit from investments of fresh capital.  When health insurers cannot control this process because they cannot control the provision options demanded by policy holders, the only choice they have is pass on an ever increasing share of costs to patients.  In this manner, the ultimate gatekeeper in the American health care is the patient, and the problem is that American health care consumers are inadequately invested, as a whole, with knowledge on medical conditions and treatment options to make informed decisions that will mutually respect their own needs and the imperatives of the larger system to maintain good cost control.  This is a tall order when the American health care consumer/patient demands both the objective truth with regard to any particular physical condition that ails them, expects that their medical professionals can provide that truth, and then uses the recourse of civil litigation when they fail to meet their promises!
             Concluding, it is the peculiar structure of incentives in American health care that is really dooming us to a system where costs rise out of anyone's control because, at the end of the day, too few people are willing or adequately informed enough to say "no."  With this in mind, there is something to be said for reform of medical torts if only because tort reform would place much greater responsibility in the hands of patients to account for the treatment options they've selected.  On the other hand, it would also have to be accompanied by a much greater effort by medical professionals to educate their patients, in particular, on why they are prescribing certain options in treatment of medical conditions, both when such conditions are life threatening and when they are merely cosmetic resolutions to common physical deficiencies.     

Brexit and the Sovereignty of Québec

Briefly, Canadian Prime Minister Justin Trudeau is quite correct in asserting that the Brexit vote by British voters on separation of the UK from the EU cannot be exported to the Canadian/Québécois context to evaluate the threshold by which a sovereignty vote in Québec could be legitimated by Ottawa. It is one thing for a sovereign nation-state to determine democratically that it seeks to leave a free-trading zone, which, notwithstanding the expansive regulatory powers assumed within Brussels, was all the EU ever really constituted to Britain. It is quite another thing for a sovereign nation-state to democratically break apart into new sovereign national entities. To the detriment of Mr. Trudeau, Britain will, in all likelihood, witness the appropriate comparison to a Québécois sovereignty referendum when the Scottish National Party and the government of First Minister Nicola Sturgeon place the question of separation from the United Kingdom before the Scottish electorate, an outcome that I am guessing will be answered overwhelmingly in the affirmative! The United Kingdom is going to break up, as a result of Brexit. The future of Canada and Québec might be slightly murkier, if only because, to my knowledge, Parti Québécois has been utterly incapable of mustering support from marginalized constiuencies, especially among foreign-born newcomers in metropolitan Montréal. As yet, the Péquists do not seem to have constructed an appropriate set of arguments to make a persuasive case for inclusive Québécois nationalism. As a descendant of Québécois lineage on both sides of my family, I anxiously await a good answer from the Péquists that will sway the immigrant folks in Maisonneuve, Côte des Neiges, and Cartierville with something more compelling than old-timey nostalgia about la révolution tranquille. Until the defenders of Québec sovereignty actually make a winning case, no example from abroad will ever turn the tide. However, Mr. Trudeau would be wise to remember that history is something more than a set of idle remembrances contained in school textbooks - it is a continuously lived experience! As the UK breaks off from the EU and Scotland breaks apart the UK, so, one day, may Québec formally define its distinction from Canada by constitutional declaration.

Against "Matching Funds"

This post is inspired by my local NPR affiliate's "summer fun" fund drive.  I typically wake up every morning to NPR's Morning Edition on New England Public Radio (NEPR), to which I have been a sustaining member for the last two years.  I do not give a lot, but I consider it my fair share for content that contributes something meaningful to my life.  Moreover, I do not mind the on air fund drives.  I understand that under the model for public radio and television in the U.S., a regular iteration of on air requests for support are absolutely imperative to ensure that the larger business model for public media can operate without recourse to substantial government funding and without commercialization.  To the extent that this is the case, furthermore, public media is a local cooperative investment, a true community asset.  That said, I had to endure a significant share of fund raising this morning, accompanied by the recurring efforts of NEPR staff to chide listeners who may never have contributed into coughing up a donation to keep the lights on and the NPR network shows coming.  What I found surprisingly irritating, however, was the fact that this morning's collection was a "matching fund" drive.  That is, a handful of otherwise wealthy contributors, remaining anonymous, had agreed to match donations made between certain hours of the day.  The point that irritates me about this tactic to bring in larger quantities of donations is that the matching fund somehow implies that there is some wealthy set of contributors out in the local community who might be giving more to support this community asset except that they want to make their contributions contingent on roping in free riders or otherwise extracting larger contributions from people like me who are already making a good faith effort to keep our station on the air!  In the end, such individuals probably end up coughing up the funds to enable NEPR to balance the books, but they evidently can't bring themselves to increase a donation that is well within their means without shaming their neighbors into picking up more of the slack.  In reply, I can attest to the importance of having accessible and relatively unbiased public media, and, as argued, I am more than willing to donate a share that is reasonable in view of my income, but I find it somewhat disgusting to have a set of wealthy donors dangling their spare funds in front of me as an inducement to get me to raise my contribution when, evidently, they could stand to make up the rest of the shortfall all by themselves.  If being a philanthropist is good for the soul and having an educated and well informed community is important to the functioning of a democracy (especially at a time when the well-informed voters of England have just voted to stab themselves in the back and many, many Americans think it would be safe to put the keys to the nuclear arsenal in Donald Trump's hands), then, next time, spare us all the guilt and just open up your wallets!

London Should Secede

This post qualifies both as a commentary on the future of the UK post-Brexit but also as a statement on the urban, globalized future of a transnationally networked world from a committed Marxian urbanist.  My basic premise is that the world in which we live, and especially the processes comprising our economic lives, do not occur solely in the fixed, ossified spaces of nation-states, but also in the fluid, distanciated, discontinuous spatialities of networks, a premise advanced elsewhere by theorists like Manuel Castells and by the world-city network theorists (e.g. P.J.Taylor and his colleagues at the University of Loughborough, UK).  Most emphatically, to recall a relevant prediction advanced by P.J.Taylor in his World City Network: A Global Urban Analysis (2004, New York: Routledge Books.  Particularly chapter 9: "From Present to Future: Reasserting Cities?"), the future of the world economy, characterized by a dichotomization between knowledge-driven and manually-centered economic processes, may evolve to realize a transformation of political relations between networks of dominant, advanced urban centers, manufacturing semi-peripheral economies, and rural, agrarian and extractive peripheries.  

             There are numerous aspects of this prediction that I am willing to criticize, especially its explicit connections to Immanuel Wallerstein's "world systems" structure, but Taylor's analysis succinctly comes to mind in assessing the potential effects of Brexit on the City of London.  The London financial district will be severely and irreparably harmed by the political after effects of British departure from the EU, if only because the City will no longer have a voice in financial regulatory deliberations in the European Commission.  The City will lack any explicit voice in deliberations over the relative openness of continental economies to financial sector firms headquartered in London.  This situation may eventually prompt firms like HSBC (bankers owe no loyalty to their imperial progenitors; they exist to make profit and situate themselves in order to best effectuate these ends) and J.P. Morgan Chase to pick up roots and move their European subsidiary headquarters to Frankfurt, Amsterdam, or the Défense district of Paris.

The larger question/prediction here must concern the likelihood of any future departures from the EU (i.e. how soon the Netherlands or France might schedule a suicidal vote on EU separation, because, at this moment, such votes would undoubtedly pass!). Returning, however, to the larger theme of this post, London faces the likely departure of some share of its dominant financial district, both because of impending restrictions on free moment of capital and labor between the UK and EU and from the negation of long standing intra-sectoral spillovers/positive economic externalities in the financial district. Its dominant position in foreign exchange markets and in commodities trading may be challenged. At the least, European governments will challenge the centrality of London banks in the marketing of European public sector securities, and the European Commission will likely succeed in locking out London brokerage houses. Assuming the transformation of the European and British financial sectors follows this path, it would be worthwhile to question what would be left of the City when the dust settles. The sensible predictions of economic experts regarding the economic consequences of Brexit are quite likely to bear fruit, if only through the relative decline of the City in relation to other financial centers in Europe, again, assuming that the contagion of separation imparted by Brexit does not rapidly spread. Paris, for example, stands to gain substantially from the UK's exit and the absence of the City as the dominant financial district of Western Europe, if only the government of Manuel Valls and the Presidency of François Hollande can forestall the demands of le Front National to have a referendum on EU membership. For my part, I am neither an advocate of London, nor of Paris, nor of Amsterdam, nor of Frankfurt - I will happily stand as an advocate of peace and unbridled economic development. In these terms, my principled concerns reside in the conditions most favorable to economic development both in the UK (as it currently stands) and the other EU states (as currently arrayed). I remain an enemy of the Euro currency and of the principle of monetary union, per se, but this is not an issue for the Brexit - the UK retained the pound sterling. My point in this post, however, is that we need to look a lot harder at the current set of geographical connections constituting the economies of Europe and ask ourselves why these particular alignments of relatively strong with relatively weak regional economies, both on a national level and internationally, makes absolutely no sense!
For the UK, and England in particular, the political connections between London and the economically dynamic South East, on the one hand, and the Midland, South West, and Northern counties, on the other hand, make very little sense. The Brexit vote has simply reinforced this fact to London's detriment. The City needs, and ultimately demands, the sort of free capital market that can effectuate its dominance over other Western European financial districts. Such a dominant pattern can only exist to the extent that London can claim national membership in the EU, a privilege it will soon lose. The other English regions have suffered free trade in a world economy in which their preexisting comparative advantages have garnered few benefits for several decades. In response, the government of the UK since Thatcher has offered little except the promise that higher levels of education might promote social mobility, a quintessentially American promise in a society still constrained by the limitations of entrenched class boundaries! Emphatically, the government of the UK since Thatcher's administrations bears a substantial responsibility for creating both the conditions of a rapid accumulation of the stature of London's financial sector and for the inconspicuous decline of manufacturing industries outside of London, especially in the Midlands and, in this manner, in Birmingham, the preeminent urban center of the Midlands and, it would seem, a primary target for the "leave" campaign. That is to say, the policies of free-trading liberals, among both the Tories and Labour, created the economic conditions under which the City of London prospered and exit from the EU became the best answer for working people in the London East End, Birmingham, and rural areas throughout England to address their persistent and unaddressed marginalization in the larger European economy! We could make the argument that Westminster and the City had mutually made their own beds when it came to allowing the economic backwardness of the regional English economies to persist without any meaningful remedies. At this moment, however, it is too late to come up with legitimate economic development agendas to address lagging per capita incomes in the regions - Britain is in the process of losing its financial sector cash cow (assuming large numbers of financial sector firms reduce their presence in the City), and, assuming Scotland abandons the UK for the EU, it may likewise lose a significant share of its North Sea oil and natural gas industry. Westminster's fiscal capacity is bound to take a severe and painful hit, though not nearly the hit that the City will take to its foundational liberal, free-market economic ideals as its access to continental financial markets becomes constrained.
The larger conclusion to this post must be that, the mismanagement of regional economic development in England notwithstanding, the City of London cannot maintain its current place in the global financial community if English voters have effectively separated it from the EU. If the idea of London seceding from England sounds, on its face, ridiculously radical, then we have to account for the fact that English voters outside of the metropolitan region have placed London's economy and, especially, the City in a ridiculous and and radically unsustainable place. They have, moreover, extracted a preeminent global city from a context of governance, transnational commerce, and free flow of people and culture to put up xenophobic barriers against anything that might be conceived as foreign to the cultural groundings of the average Englishman in, say, Worcester or rural Lincolnshire.

Globalization is a two-edged sword. Much of the English economy outside of London and the South East has suffered significantly from deindustrialization and vulnerabilities from fluctuations in the prices of goods and services as global commodity chains have evolved geographically away from the higher cost advanced industrial economies. No doubt, patterns of labor demand have reflected such changes, leaving millions of English working people in the regions uncertain about their futures, if not impoverished outright. Under such circumstances, the influx of immigrants, whether from other EU states or from former corners of the British empire, has spurred an imagery of parasitism in the imaginations of millions of alienated and dis-empowered working people, small business owners, and other patriotic stakeholders to the aspiration for a strong and independent Britain, spared the tumultuous shifts and turns of the global economy and the politics of mutual defense and security in a time of serious political instability on Europe's boundaries. This sort of thinking was fodder for Brexit advocates. Unfortunately, it is incompatible with the open, culturally cosmopolitan, information-driven, politically and economically liberal ethos of the global city. London is fundamentally mismatched to its hinterlands. If it is true that British policymakers could have taken a more proactive approach to economic development in the English regional economies, redistributing some of the overabundant gains to economic integration enjoyed by the City back to the losers from globalization, then, thanks to the short sightednness of British liberals of all parties, such an opportunity was squandered in order to pander to the profit maximizing aspirations of the financial sector. The time for a conciliation between the City and its hinterlands is over. This may, however, be the opportunity for London to inaugurate an era of free, cosmopolitan and interconnected cities, freed from the anachronism of territorial states.

Where will the Ulster Unionists Go?

As a very brief reflection on the post-Brexit UK, a country certain on the verge of breaking up into pieces over the realized insanity of separating from a unified Europe, it should be quite certain from Nicola Sturgeon's statements that the Scottish National Party (SNP) will be aiming, as quickly as possible, to put forward another independence referendum in the interest of separating from London to rejoin the EU as an independent sovereign state.  It would, thus, seem that Brexit has sealed the fate of London's connection to Scotland and that the union of England and Scotland, formalized beyond the unity of the crowns through the merging of the English and Scottish parliaments in 1707, will soon be torn asunder.  With this in mind, the status of the remaining pieces of the UK remains an open question.
          Oddly, when it came to the question of EU membership, the Welsh seem to have voted with their neighbors in the English Midlands.  Apparently, outside of Cardiff (which voted 60/40 to stay) and certain areas on the Irish Sea coast, presumably beneficiaries of more active economic connections to the EU Irish Republic, the majority of Welsh voters (53/47) voted to leave the EU.  Again, as with voters in the English Midlands and in certain rural and deindustrialized urban constituencies in the Northern English counties (Lancashire, Yorkshire), there was little perception within the older, Whiter, and predominantly rural electorate of Wales that the UK had anything to gain from a robust connection to the continent and much to lose, especially relative to the perceived negative effects of immigration.  Moreover, Plaid Cymru/the Party of Wales, the left-wing, pro-EU Welsh sovereigntist party, is simply too weak a contingent within the National Assembly of Wales to drive to the conversation among the Welsh electorate in the same direction currently advocated by the SNP in Edinburgh.  For better or for worse, English and the Welsh remain unified, and, at the behest of mostly older White, rural voters, both will be leaving the EU.
            Then there is the question of Ulster/Northern Ireland.  Since the Good Friday Agreement of 1998, ending a generation of armed confrontation between Irish Republicans and Ulster Unionists over the status of Northern Ireland's six counties, the country has enjoyed a more robust aggregate economic growth rate, on average, than the other national components of the UK.  Part of this rate of growth was related to its proximity to the Irish Republic during a period of rapid economic growth in the latter and, secondarily, to the connection of both the UK and the Irish Republic to the continent.  Continental firms apparently invested significantly into the creation of an export base within the Northern Ireland counties, especially in close proximity to metropolitan Belfast, areas that endured substantial rates of unemployment throughout the period of conflict between Irish Republicans and the Ulster Unionists.  Moreover, areas of Northern Ireland directly abutting the border with the Irish Republic enjoyed a degree of economic growth bolstered significantly by the demilitarization of the border with the Good Friday Agreement.  As such, greater Belfast and the outlying border areas of Northern Ireland profited substantially from economic development due, to a substantial degree, to European economic integration and, more directly, to the deepening of economic relations between the Irish Republic and Northern Ireland.  The current economic status of Northern Ireland, thus, remains significantly tied to the continued vitality of the Irish Peace process and to the robust connection of Ireland, as a whole, to both the UK and the continent.  It seems certain that the shifting of any of these pieces could jeopardize the economies of both Northern Ireland and the Irish Republic.  In this regard, Brexit represents a substantial and daunting problem for Northern Ireland, even more so than for Scotland.  At stake is the political and economic trajectory of country that is teetering along edges defined by the peace process and continental economic integration.
                To be brief on how Northern Ireland voted and the impending consequences of the larger vote to leave, the Northern Ireland counties collectively voted 56/44 to stay within the EU.  This stands to reason.  The principal beneficiaries of economic development in metropolitan Belfast and in the outlying border regions to the Irish Republic had no justifiable basis to vote against continued EU membership - they would have been voting to slit the throats of their economy.  By contrast, in largely rural internal areas of Northern Ireland, neither benefiting from significant integration with neighboring regions in the Irish Republic nor located within the privileged economic developmental hot spots of metropolitan Belfast, voters substantially backed leaving the EU.  Emphatically, voters in these constituencies were older, Whiter, and overwhelming Protestant Unionists.  There is not much question that the critical dividing line in Ulster politics, between (Catholic) Irish Republicans and (Protestant) Scot-Irish Unionists, remains, but, on the contrary, it has become at least partially blurred by the same generational dynamic characterizing the larger electorate of the UK for the Brexit vote (i.e. younger voters favoring "stay," older voters favoring "leave") and by the conflict between the countryside and urban areas.  Along these lines, County Antrim, a stronghold for Protestant Ulster Unionists largely separate from the Belfast metropolitan area, voted overwhelmingly to leave the EU, as did northern constituencies of County Armagh and County Down.  Central areas of metropolitan Belfast, along the dividing lines between Counties Antrim and Down, voted overwhelmingly to stay within the EU, as did Londonderry County, especially the urban constituencies in and around Derry, and County Tyrone and County Fermanagh.  We might be able to assert that the Brexit vote in Northern Ireland followed the urban-rural fault line, except that it also traced the Catholic-Protestant fault line and the distribution of positive economic externalities from EU membership and increased commerce with the Irish Republic.
            In the aftermath of the Brexit vote, Northern Ireland seems to face not one, but multiple choices regarding its economic and political future, potentially complicated, in part, by the impending departure of Scotland from the UK to rejoin the EU.  Arlene Foster, the leader of the Democratic Unionist Party and First Minister of the government of Northern Ireland, and a supporter of Brexit, seems to believe that the formality of a UK departure from the EU will not profoundly impact either the Irish peace process, the economic integration of Northern Ireland and the Irish Republic, or the larger economic destiny of her country relative to the larger nexus of European commerce(!).  In this regard, it seems that, at least at the top echelons of the Ulster unionist political establishment, among politicians with power bases in rural areas among decisively conservative Protestant constituencies, a particular species of myopia is rampantly spreading!  It is one thing for Nigel Farage of UKIP to cavalierly promote the virtues of abandoning the EU to constituencies in places like Birmingham that never really felt any economic benefit (and probably experienced some degree of pain from freer trade) from greater commercial linkages with the continent.  It is another for unionist politicians in Northern Ireland to push Brexit to constituencies who have benefited palpably from EU membership, if only because a borderless connection to the Irish Republic has profoundly benefited economic development in Northern Ireland, lowering unemployment substantially since the Good Friday Agreement.  Foster and her party appear oblivious to a potential for political crisis that should be as clear as their noses.  Emphatically, Foster's Deputy First Minister, Martin McGuinness, the leader of republican Sinn Fein, is now calling for a referendum to determine the willingness of the electorate of Northern Ireland to unify itself with the Irish Republic, citing the potential for reinsertion of a border between Northern Ireland and the Irish Republic as the former departs from the EU as a basis for the need to undertake a fundamental reconsideration of the political future of Northern Ireland.  In these terms, by seizing Brexit as an opportunity to flirt with the abolition of Northern Ireland's independence from the Irish Republic, Sinn Fein is moving relevant parties on the Catholic-Protestant fault line back to the breach and inviting a new round of political violence to swallow up the peace process.  It may be worth asking, at this point, whether the Good Friday Agreement is going to survive Brexit!
              To conclude the larger point of this post, I think it is worth noting the obvious observation that the majority of Protestant unionist Northern Irelanders are, at least to my knowledge, descended not from Englishmen but from Scottish Presbyterians.  Notwithstanding the fatal idiocy of unionist leaders like Foster on the idea that Northern Ireland can leave the EU without any consequences, maybe Northern Ireland's future could hinge more on the impending moves Nicola Sturgeon's SNP than on the extraordinarily divisive republican suggestion that Ulster should have a vote on joining the Irish Republic.  That is to say, if sensible, pragmatic Protestant leaders in Ulster, possessed with a wherewithal to comprehend a potential opportunity to steer their country in a direction that would both respect the will of their national electorate to remain in the EU and protect their cultural and political uniqueness in relation to republican Ireland, could steer a secular (Protestant, Catholic, and other) majority toward the idea of departure from the UK and a closer political connection with Edinburgh, rather than Dublin, then, maybe, the effective will of the majority of the electorate relative to EU membership might be preserved, the border with the Irish Republic might remain relatively open, and Northern Ireland might maintain a relevant post-UK partner, committed to the notion that the importance of European economic integration, both to economic development and the maintenance of peace, transcends any appeal to parochial, nationalistic prejudices.  In these respects, I think I may be displaying a substantial degree of idealism, but the alternative looks exceeding grim!            

On Orlando: The Confusing World of Mass Violent Incidents, Supposed Salafist Terrorism, and Presidential Electoral Politics

After a post (in continuous development) that I expect will continue on for many, many more lines, I hope to constrain the growth of this post to some degree.  There are just a few points that I want to make about the mass shooting incident at the GLBT nightclub/community locus, the Pulse, in Orlando, Florida, apparently the deadliest mass shooting in U.S. history.
1.  Mass shootings are a horrible reality in American life that we sadly have to endure, in part, because the weapons of mass murder are so widely available in the U.S. thanks to current juridical readings of the Second Amendment to the U.S. Constitution of 1787.  In making this point, I do not want to overemphasize the significance of radically liberal availability of firearms in the U.S.  There are other countries, Canada for example, where access to firearms is relatively unrestricted.  As I have previously attempted to argue on this blog, we have bigger problems than relatively open availability of firearms relative to the recurrence of mass shooting incidents in the U.S. - the disintegration of a broader sense of community, embracing individuals otherwise stricken by a sense of isolation, social disconnection, and psychological alienation from their own capacities to conceptualize futures of meaning for themselves in connection with broader American society.  Critically, millions of Americans exist in unaddressed and unrecognized states of emotional/mental distress and such individuals are fodder for the growth of murderous violence with firearms.  In this regard, as someone who spent a prolonged stint under medicinal psychiatric treatment for anxiety and depression, I do not think the answer is to medicate millions more than are already under some sort of psychiatric treatment.  Rather, beyond the potential impact of legislative action on either a federal state level, we need to really reinvigorate the sorts of voluntary local practices that might encourage a generalized sense of inclusive community, even and especially in an American society that it becoming increasingly heterogeneous on racial, linguistic, and ethnic grounds.  As such, the key response to mass shooting incidents in the U.S. remains, in my mind, the creation of local institutions that can bring diverse people together to identify their diversities as a source of strength to the larger community rather than as a source of division.  Regarding the Orlando mass shooting incident as, essentially, an incident of prejudice against LGBT individuals, between Americans, that erupted into murderous violence, I would be confident that I could leave my comments here, with the addendum that we need to grieve the dead and work harder to ensure that LGBT individuals achieve recognition as full human beings outside of the limited confines of the federal judiciary, where their rights have been ceaselessly codified despite the lingering reality of widespread prejudice against non-traditional conceptions of love by a significant proportion of the U.S. population.  Sadly, the massacre in Orlando cannot simply be regarded as an incident of domestic militant homophobic prejudice, linked intrinsically, perhaps, to the recent progress of gay rights and the struggle to expand the rights of transgender individuals in the U.S., because Omar Mateen, the murderer at the Pulse nightclub, was a Muslim-American and had the nerve to pledge allegiance to the Islamic State (IS) online two hours into the attack(!).  
2.  We need to differentiate between the religiously grounded motivations of a murderous, militant  Sunni Muslim Salafist against the broader institutions of Western liberal culture, including but certainly not limited to LGBT rights, and the motivations of a homegrown, American, psychological disturbed, sexually confused, and violent, homophobic bigot.  I cannot claim to be an expert on Omar Mateen and his like within the framework of American racial, ethnic, and religious demography.  Nor am I an expert on Islam, in the U.S. or elsewhere, the theological postulates of Salafism, the circumstances that might draw a Sunni Muslim toward Salafist ideas, and the conditions under which Salafists ethical transcend the boundaries of traditional religious discourse to accept, as a matter of principle, the use of violence against apostates and non-believers of Islam.  Emphatically, I do not know that Mr. Mateen was a faithfully practicing Sunni Muslim or that he had any conception of the theological precepts of Salafism.