Agent death
This page describes the organizational forces that limit change.  It explains how to overcome them when necessary. 

Power& tradition holding back progress
This page uses an example to illustrate how:
  • A business can gain focus from targeting key customers,
  • Business planning activities performed by the whole organization can build awareness, empowerment and coherence. 
  • A program approach can ensure strategic alignment. 
Be responsive to market dynamics
This page uses the example of HP's printer organization freeing itself from its organizational constraints to sell a printer targeted at the IBM pc user. 
The constraints are described. 
The techniques to overcome them are implied. 
Overcome reactionaries
We are products of complexity, but our evolution has focused our understanding on the situation of hunter gatherers on the African savanna.  As humanity has become more powerful we can significantly impact the systems we depend on.  But we struggle to comprehend them.  So this web frame explores significant real world complex adaptive systems (CAS):
  • Assumptions of randomness & equilibrium allowed the wealthy & powerful to expand the size and leverage of stock markets, by placing at risk the insurance and retirement savings of the working class.  The assumptions are wrong but remain entrenched. 
  • The US nation was built from two divergent political views of: Jefferson and Hamilton.  It also reflects the development of competing ancient ideas of Epicurus and Cyril.  But the collapse of Bretton Woods forced Wall Street into a position of power, while the middle and working class were abandoned by the elites.  Housing financed with cash from oil and derivative transactions helped hide the shift. 
  • Most US health care is still operating the way cars built in the 1940s did.  Geisinger is an example of better solution.  But transforming the whole network is a challenge.  And public health investment has proved far more beneficial.  
  • Helping our children learn to be effective adults is part of our humanity, but we have created a robust but deeply flawed education system.  Better alternatives have emerged.  
  • Spoken language, reading and writing emerged allowing our good ideas to become a second genetic material. 
  • The emergence of the global economy in the 1600s and its subsequent development; 
It explains how the examples relate to each other, why we all have trouble effectively comprehending these systems and explains how our inexperience with CAS can lead to catastrophe.  It outlines the items we see as key to the system and why. 

Example systems frame
Dietrich Dorner argues complex adaptive systems (CAS) are hard to understand and manage.  He provides examples of how this feature of these systems can have disastrous consequences for their human managers.  Dorner suggests this is due to CAS properties psychological impact on our otherwise successful mental strategic toolkit.  To prepare to more effectively manage CAS, Dorner recommends use of:
  • Effective iterative planning and
  • Practice with complex scenario simulations; tools which he reviews.   
Complexity catastrophes
E. O. Wilson reviews the effect of man on the natural world to date and explains how the two systems can coexist most effectively. 
Adaptive ecology
Barton Gellman details the strategies used by Vice President Cheney to align the global system with his economics, defense, and energy goals. 
US vds alignment
Kevin Kruse argues that from 1930 onwards the corporate elite and the Republican party have developed and relentlessly executed strategies to undermine Franklin Roosevelt and the New Deal.  Their successful strategy used the credibility of conservative religious leaders to:
  • Demonstrate religious issues with the New Deal. 
  • Integrate the corporate elite and evangelicals. 
  • Use the power of corporate advertising and Hollywood to reeducate the American people to view the US as historically religious and the New Deal and liberalism as anti-religious socialism. 
  • Focus the message through evangelicals including Vereide and Graham. 
  • Centralize the strategy through President Eisenhower. 
  • Add religious elements to mainstream American symbols: money, pledge;
  • Push for prayer in public school
  • Push Congress to promote prayer
  • Make elections more about religious positions. 

Following our summary of his arguments RSS frames them from the perspective of complex adaptive system (CAS) theory.  Strategy is the art of the possible.  But it also depends on persistence. 

Inventing Christian America
Charles Ferguson argues that the US power structure has become highly corrupt. 

Ferguson identifies key events which contributed to the transformation:
  • Junk bonds, 
  • Derivative deregulation, 
  • CMOs, ABS and analyst fraud,
  • Financial network deregulation,
  • Financial network consolidation, 
  • Short term incentives
Subsequently the George W. Bush administration used the situation to build a global bubble, which Wall Street leveraged.  The bursting of the bubble: managed by the Bush Administration and Bernanke Federal Reserve; was advantageous to some. 

Ferguson concludes that the restructured and deregulated financial services industry is damaging to the American economy.  And it is supported by powerful, incentive aligned academics.   He sees the result being a rigged system. 

Ferguson offers his proposals for change and offers hope that a charismatic young FDR will appear. 

Following our summary of his arguments, RSS comments on them framed by complex adaptive system (CAS) theory.  Once the constraints are removed from CAS amplifiers, it becomes advantageous to leverage the increased flows.  And it is often relatively damaging not to participate.  Corruption and parasitism can become entrenched. 

Financial WMD
Matt Taibbi describes the phenotypic alignment of the American justice system.  The result he explains relentlessly grinds the poor and undocumented into resources to be constrained, consumed and ejected.  Even as it supports and aligns the financial infrastructure into a potent weapon capable of targeting any company or nation to extract profits and leave the victim deflated. 

Taibbi uses five scenarios to provide a broad picture of the: activities, crimes, policing, prosecutions, court processes, prisons and deportation network.  The scenarios are: Undocumented people's neighborhoods, Poor neighborhoods, Welfare recipients, Credit card debtors and Financial institutions.

Following our summary of his arguments, RSS comments on them framed by complex adaptive system (CAS) theory.  The alignment of the justice system reflects a set of long term strategies and responses to a powerful global arms race that the US leadership intends to win. 

Aligned justice
Jonathan Powell describes how the government of, the former UK Prime Minister, Tony Blair, actually operated.  Powell was Blair's only chief of staff. 
Mechanics of power
H. A. Hayek compares and contrasts collectivism and libertarianism. 
Libertarianism
John Doerr argues that company leaders and their organizations, hugely benefit from Andy Grove's OKRs. 

He promotes strategies that help OKR success: Focus, Align, Track, Stretch; replaces yearly performance reviews, and provides illustrative success stories. 

Doerr stresses Dov Seidman's view that employees are adaptive and will respond to what they see being measured.  He asserts culturally supported OKRs/CFR processes will be transformative. 

Following our summary of his arguments, RSS comments on them framed by complex adaptive system (CAS) theory.  Doerr's architecture is tailored for the startups KPCB invests in.  It is a subset of the general case of schematic plans, genetic operators and Shewhart cycles that drive all CAS.  Doerr's approach limits support of learning and deemphasizes the association to planning. 

Startup PDCA
David Bodanis illustrates how disruptive effects can take hold.  While the French revolution had many driving forces including famine and oppression the emergence of a new philosophical vision ensured that thoughtful leaders were constrained and conflicted in their responses to the crisis. 
Voltaire's disruptive network
An epistatic meme suppressed for a thousand years reemerges during the enlightenment. 
It was a poem encapsulating the ideas of Epicurus rediscovered by a humanist book hunter. 
Greenblatt describes the process of suppression and reemergence.  He argues that the rediscovery was the foundation of the modern world. 
Complex adaptive system (CAS) models of the memetic mechanisms are discussed. 

Constraining happiness
Isaacson uses the historic development of the global cloud of web services to explore Ada Lovelace's ideas about thinking machines and poetic science.  He highlights the value of computer augmented human creativity and the need for liberal arts to fulfill the process. 
Complex adaptive system (CAS) models of agent networks and collaboration are discussed. 

Arts technology & intelligence
Haikonen juxtaposes the philosophy and psychology of consciousness with engineering practice to refine the debate on the hard problem of consciousness.  During the journey he describes the architecture of a robot that highlights the potential and challenges of associative neural networks. 

Complex adaptive system (CAS) theory is then used to illustrate the additional requirements and constraints of self-assembling evolved conscious animals.  It will be seen that Haikonen's neural architecture, Smiley's Copycat architecture and molecular biology's intracellular architecture leverage the same associative properties. 

Associatively integrated robots
Good ideas are successful because they build upon prior developments that have been successfully implemented.  Johnson demonstrates that they are phenotypic expressions of memetic plans subject to the laws of complex adaptive systems (CAS). 
Developing ideas
A government sanctioned monopoly supported the construction of a superorganism American Telephone and Telegraph (AT&T).  Within this Bell Labs was at the center of three networks:
  1. The evolving global scientific network. 
  2. The Bell telephone network.  And
  3. The military industrial network deploying 'fire and missile control' systems. 
Bell Labs strategically leveraged each network to create an innovation engine. 
They monitored the opportunities to leverage the developing ideas, reorganizing to replace incumbent opposition and enable the creation and growth of new ideas. 
Once the monopoly was dismantled, AT&T disrupted. 
Complex adaptive system (CAS) models of the innovation mechanisms are discussed. 

Strategic innovation
Roger Cohen's New York Times opinion about the implications of BREXIT is summarized.  His ideas are then framed by complex adaptive system (CAS) theory and reviewed. 


BREXIT
Scott Galloway argues that Apple, Amazon, Facebook and Google are monopolists that trade workers for technology.  Monopolies that he argues should be broken up to ensure the return of a middle class. 

Following our summary of his arguments, RSS comments on these arguments assuming they relate to a complex adaptive system (CAS).  While Scott's issue is highly significant his analysis conflicts with relevant CAS history and theory. 

Monopoly job killers
The IPO of Netscape is defined as the key emergent event of the New Economy by Michael Mandel.  Following the summary of Mandel's key points the complex adaptive system (CAS) aspects are highlighted. 
New economy
Ed Conway argues that Bretton Woods produced a unique set of rules and infrastructure for supporting the global economy.  It was enabled by the experience of Keynes and White during and after the First World War, their dislike of the Gold Standard, the necessity of improving the situation between the wars and the opportunity created by the catastrophe of the Second World War. 

He describes how it was planned and developed.  How it emerged from the summit.  And he shows how the opportunity inevitably allowed the US to replace the UK at the center of the global economy. 

Like all plans there are mistakes and Conway takes us through them and how the US recovered the situation as best it could. 

And then Conway describes the period after Bretton Woods collapsed.  He explains what followed and also compares the relative performance of the various periods before during and after Bretton Woods. 

Following our summary of his arguments RSS comments from the perspective of Complex Adaptive System (CAS) theory.  Conway's book illustrates the rule making and infrastructure that together build an evolved amplifier.  He shows the strategies at play of agents that were for and against the development and deployment of the system.  And The Summit provides a key piece of the history of our global economic CAS. 

Bretton woods
A key agent in the 1990 - 2008 housing expansion Countrywide is linked into the residential mortgage value delivery system (VDS) by Paul Muolo and Mathew Padilla.  But they show the VDS was full of amplifiers and control points.  With no one incented to apply the brakes the bubble grew and burst.  Following the summary of Muolo and Padilla's key points the complex adaptive system (CAS) aspects are highlighted. 
Housing amplifiers
Satyajit Das uses an Indonesian company's derivative trades to introduce us to the workings of the international derivatives system.  Das describes the components of the value delivery system and the key transactions.  He demonstrates how the system interacted with emerging economies expanding them, extracting profits and then moving on as the induced bubbles burst.  Following Das's key points the complex adaptive system (CAS) aspects are highlighted. 
Derivative systems
Johnson & Kwak argue that expanding the national debt provides a hedge against unforeseen future problems, as long as creditors are willing to continue lending.  They illustrate different approaches to managing the debt within the US over its history and of the eighteenth century administrations of England and France. 

The US embodies two different political and economic systems which approach the national debt differently:
  • Taxes to support a sinking fund to ensure credit to leverage fiscal power in: Wars, Pandemics, Trade disputes, Hurricanes, Social programs; Starting with Hamilton, Lincoln & Chase, Wilson, FDR;
  • Low taxes, limited infrastructure, with risk assumed by individuals: Advocated by President's Jefferson & Madison, Reagan, George W. Bush (Gingrich);
Johnson & Kwak develop a model of what the US government does.  They argue that the conflicting sinking fund and low tax approaches leaves the nation 'stuck in the middle' with a future problem.  And they offer their list of 'first principles' to help assess the best approach for moving from 2012 into the future.  

They conclude the question is still political.  They hope it can be resolved with an awareness of their detailed explanations.  They ask who is willing to push all the coming risk onto individuals. 

Following our summary of their arguments RSS frames them from the perspective of complex adaptive system (CAS) theory.  Historically developing within the global cotton value delivery system, key CAS features are highlighted. 

National debt
Robert Gordon argues that the inventions of the second industrial revolution were the foundation for American economic growth.  Gordon shows how flows of people into difficult rural America built a population base which then took the opportunity to move on to urban settings: Houses, Food in supermarkets, Clothes in department stores; that supported increasing productivity and standard of living.  The deployment of nationwide networks: Rail, Road, Utilities; terminating in the urban housing and work places allowing the workers to leverage time saving goods and services, which helped grow the economy. 

Gordon describes the concomitant transformation of:
  • Communications and advertising
  • Credit and finance
  • Public health and the health care network 
  • Health insurance
  • Education
  • Social and welfare services

Counter intuitively the constraints introduced before and in the Great Depression and the demands of World War 2 provide the amplifiers that drive the inventions deeply and fully into every aspect of the economy between 1940 and 1970 creating the exceptional growth and standard of living of post war America. 

Subsequently the rate of growth was limited until the shift of women into the workplace and the full networking of voice and data supported the Internet and World Wide Web completed the third industrial revolution, but the effects were muted by the narrow reach of the technologies. 

The development of Big Data, Robots, and Artificial Intelligence may support additional growth, but Gordon is unconvinced because of the collapse of the middle class. 

Following our summary of Gordon's book RSS frames his arguments from the perspective of complex adaptive system (CAS) theory. 

American growth
Carl Menger argues that the market induced the emergence of money based on the attractive features of precious metals.  He compares the potential for government edicts to create money but sees them as lacking. 

Following our summary of his arguments RSS frames his arguments from the perspective of complex adaptive system (CAS) theory.  With two hundred years of additional knowledge we conclude that precious metals are not as attractive as Menger asserts.  Government backed promissory notes are analogous to:
  • Other evolved CAS forms of ubiquitous high energy transaction intermediates and
  • Schematic strategies that are proving optimal in supporting survival and replication in the currently accessible niches. 

Emergence of money
Eric Beinhocker sets out to answer a question Adam Smith developed in the Wealth of Nations: what is wealth?  To do this he replaces traditional economic theory, which is based on the assumption that an economy is a system in equilibrium, with complexity economics in which the economy is modeled as a complex adaptive system (CAS). 

He introduces Sugerscape to illustrate an economic CAS model in action.  And then he explains the major features of a CAS economy: Dynamics, Agents, Networks, Emergence, and Evolution. 

Building on complexity economics Beinhocker reviews how evolution applies to the economy to build wealth.  He explains how design spaces map strategies to instances of physical and social technologies.  And he identifies the interactors and selection mechanism of economic evolution. 

This allows Beinhocker to develop a new definition of wealth. 

In the rest of the book Beinhocker looks at the consequences of adopting complexity economics for business and society: Strategy, Organization, Finance, & Politics & Policy. 

Following our summary of his arguments, RSS explores his conclusions and aligns Beinhocker's model of CAS with the CAS theory and evidence we leverage. 

Economic complexity
Sven Beckert describes the historic transformation of the growing, spinning, weaving, manufacture of cotton goods and their trade over time.  He describes the rise of a first global commodity, its dependence on increasing: military power, returns for the control points in the value delivery system(VDS), availability of land and labor to work it including slaves. 

He explains how cotton offered the opportunity for industrialization further amplifying the productive capacity of the VDS and the power of the control points.  This VDS was quickly copied.  The increased capacity of the industrialized cotton complex adaptive system (CAS) required more labor to operate the machines.  Beckert describes the innovative introduction of wages and the ways found to mobilize industrial labor. 

Beckert describes the characteristics of the industrial cotton CAS which made it flexible enough to become globally interconnected.  Slavery made the production system so cost effective that all prior structures collapsed as they interconnected.  So when the US civil war blocked access to the major production nodes in the American Deep South the CAS began adapting. 

Beckert describes the global reconstruction that occurred and the resulting destruction of the traditional ways of life in the global countryside.  This colonial expansion further enriched and empowered the 'western' nation states.  Beckert explains how other countries responded by copying the colonial strategies and creating the opportunities for future armed conflict among the original colonialists and the new upstarts. 

Completing the adaptive shifts Beckert describes the advocates for industrialization in the colonized global south and how over time they joined the global cotton CAS disrupting the early western manufacturing nodes and creating the current global CAS dominated by merchants like Wal-Mart pulling goods through a network of clothing manufacturers, spinning and weaving factories, and growers competing with each other on cost. 

Following our summary of Beckert's book, RSS comments from the perspective of CAS theory.  The transformation of disconnected peasant farmers, pastoral warriors and their lands into a supply chain for a highly profitable industrial CAS required the development over time: of military force, global transportation and communication networks, perception and representation control networks, capital stores and flows, models, rules, standards and markets; along with the support at key points of: barriers, disruption, and infrastructure and evolved amplifiers.  The emergent system demonstrates the powerful constraining influence of extended phenotypic alignment. 

Globalization from cotton
The structure and problems of the US health care network is described in terms of complex adaptive system (CAS) theory. 

The network:
  • Is deeply embedded in the US nation state. It reflects the conflict between two opposing visions for the US: high tax with safety net or low tax without.  The emergence of a parasitic elite supported by tax policy, further constrains the choices available to improve the efficiency and effectiveness of the network.  
    • The US is optimized to sell its citizens dangerous levels of: salt, sugar, cigarettes, guns, light, cell phones, opioids, costly education, global travel, antibacterials, formula, foods including endocrine disrupters;
    • Accepting the US controlled global supply chain's offered goods & services results in: debt, chronic stress, amplified consumption and toxic excess, leading to obesity, addiction, driving instead of walking, microbiome collapse;
  • Is incented to focus on localized competition generating massive & costly duplication of services within physician based health care operations instead of proven public health strategies.  This process drives increasing research & treatment complexity and promotes hope for each new technological breakthrough. 
  • Is amplified by the legislatively structured separation and indirection of service development, provision, reimbursement and payment. 
  • Is impacted by the different political strategies for managing the increasing cost of health care for the demographic bulge of retirees.  
  • Is presented with acute and chronic problems to respond to.  As currently setup the network is tuned to handle acute problems.  The interactions with patients tend to be transactional. 
  • Includes a legislated health insurance infrastructure which is:
    • Costly and inefficient
    • Structured around yearly contracts which undermine long-term health goals and strategies.  
  • Is supported by increasingly regulated HCIT which offers to improve data sharing and quality but has entrenched commercial EHR products deep within the hospital systems.  
  • Is maintained, and kept in alignment, by massive network effects across the:
    • Hospital platform based sub-networks connecting to
    • Physician networks
    • Health insurance networks - amplified by ACA narrow network legislation
    • Hospital clinical supply and food production networks
    • Medical school and academic research network and NIH
    • Global transportation network 
    • Public health networks 
    • Health care IT supply network
Health care
Deaton describes the wellbeing of people around the world today.  He explains the powerful benefit of public health strategies and the effect of growth in material wellbeing but also the corrosive effects of aid. 

Following our summary of Deaton's arguments RSS comments from the perspective of complex adaptive system (CAS) theory.  The situation he describes is complex including powerful amplifiers, alignment and incentives that overlap broadly with other RSS summaries of adaptations of: The biosphere, Politics, Economics, Philosophy and Health care. 

Improving wellbeing
Donald Barlett and James Steele write about their investigations of the major problems afflicting US health care as of 2006. 
Problems of US health care
Glenn Steele & David Feinberg review the development of the modern Geisinger healthcare business after its near collapse following the abandoned merger with Penn State AMC.  After an overview of the business, they describe how a calamity unfolding around them supported building a vision of a better US health care network.  And they explain:
  • How they planned out the transformation,
  • Leveraging an effective governance structure,
  • Using a strategy to gain buy in,
  • Enabling reengineering at the clinician patient interface. 
  • Implementing the reengineering for acute, chronic & hot spot care; to help the patients and help the physicians.  
  • Geisinger's leverage of biologics.  
  • Reengineering healing with ProvenExperience.  
  • Where Geisinger is headed next. 

Following our summary of their arguments RSS comments on them.  We frame their ideas with complex adaptive system (CAS) theory. 

E2E insured quality care
Robert Pearl explains the perspectives of a health care leader and son who know that the current health care network interacts with human behavior to induce a poorly performing system that caused his father's death.  But he is confident that these problem perceptions can be changed.  Once that occurs he asserts the network will become more integrated, coordinated, collaborative, better led, and empathetic to their patients.  The supporting technology infrastructure will be made highly interoperable.  All that will reduce medical errors and make care more cost effective. 

Following our summary of his arguments RSS comments on them.  We frame his ideas with complex adaptive system (CAS) theory including synergistic examples of these systems in operation.  The health care network is built out of emergent human agents.  All agents must model the signals they perceive to represent and respond to them.  Pinker explains how this occurs.  Sapolsky explains why fear and hierarchy are so significant.  He includes details of Josh Green's research on morality and death.  Charles Ferguson highlights the pernicious nature of financial incentives. 

Bad medical models
US healthcare is ripe for disruption.  Christensen, Grossman and Hwang argue that technologies are emerging which will support low cost business models that will undermine the current network.  Applying complex adaptive system (CAS) theory to these arguments suggests that the current power hierarchy can effectively resist these progressive forces. 
Disrupting health care
Atul Gawande writes about the opportunity for a thirty per cent improvement in quality in medicine by organizing to deploy as agent based teams using shared schematic plans and distributed signalling or as he puts it the use of checklists. 

With vivid examples from a variety of situations including construction, air crew support and global health care Gawande illustrates the effects of complexity and how to organize to cope with it. 

Following the short review RSS additionally relates Gawande's arguments to its models of complex adaptive systems (CAS) positioning his discussion within the network of US health care, contrasting our view of complexity, comparing the forces shaping his various examples and reviewing facets of complex failures. 
Complexity checklists
Friedman and Martin leverage the lifelong data collected on 1,528 bright individuals selected by Dr. Lewis Terman starting in 1921, to understand what aspects of the subjects' lives significantly affected their longevity.  Looking broadly across each subject's: Personality, Education, Parental impacts, Energy levels, Partnering, Careers, Religion, Social networks, Gender, Impact from war and trauma; Friedman and Martin are able to develop a set of model pathways, which each individual could be seen to select and travel along.  Some paths led to the traveler having a long life.  Others were problematic.  The models imply that the US approach to health and wellness should focus more on supporting the development and selection of beneficial pathways. 

Following our summary of their arguments RSS comments from the perspective of CAS theory.  The pathways are most applicable to bright individuals with the resources and support necessary to make and leverage choices they make.  Striving to enter and follow a beneficial pathway seems sensible but may be impossible for individuals trapped in a collapsing network, starved of resources. 

Promoting longevity
Agent death
Sonia Shah reviews the millennia old (500,000 years) malarial arms race between Humanity, Anopheles mosquitoes and Plasmodium.  250 - 500 million people are infected each year with malaria and one million die. 
Malaria
Peter Medawar writes about key historic events in the evolution of medical science. 
Medical science events
Using John Holland's theory of adaptation in complex systems Baldwin and Clark propose an evolutionary theory of design.  They show how this can limit the interdependencies that generate complexity within systems.  They do this through a focus on modularity. 
Modular designed systems
Lou Gerstner describes the challenges he faced and the strategies he used to successfully restructure the computer company IBM. 
Compartmented systems
Grady Booch advocates an object oriented approach to computer software design. 
Object based systems
Bertrand Meyer develops arguments, principles and strategies for creating modular software.  He concludes that abstract data types and inheritence make object orientation a superior methodology for software construction.  Complex adaptive system (CAS) theory suggests agents provide an alternative strategy to the use of objects. 
Software construction
Tools and the businesses that produce them have evolved dramatically.  W Brian Arthur shows how this occurred.
Tools
Matt Ridley demonstrates the creative effect of man on the World. He highlights:
  • A list of preconditions resulting in
  • Additional niche capture & more free time 
  • Building a network to interconnect memes processes & tools which
  • Enabling inter-generational transfers
  • Innovations that help reduce environmental stress even as they leverage fossil fuels

Memetic trading networks
E O. Wilson argues that campfire gatherings on the savanna supported the emergence of human creativity.  This resulted in man building cultures and later exploring them, and their creator, through the humanities.  Wilson identifies the transformative events, but he notes many of these are presently ignored by the humanities.  So he calls for a change of approach. 

He:
  • Explores creativity: how it emerged from the benefits of becoming an omnivore hunter gatherer, enabled by language & its catalysis of invention, through stories told in the evening around the campfire. He notes the power of fine art, but suggests music provides the most revealing signature of aesthetic surprise. 
  • Looks at the current limitations of the humanities, as they have suffered through years of neglect.  
  • Reviews the evolutionary processes of heredity and culture:
    • Ultimate causes viewed through art, & music
    • The bedrock of:
      • Ape senses and emotions,
      • Creative arts, language, dance, song typically studied by humanities, & 
      • Exponential change in science and technology.  
    • How the breakthrough from our primate past occurred, powered by eating meat, supporting: a bigger brain, expanded memory & language. 
    • Accelerating changes now driven by genetic cultural coevolution.  
    • The impact on human nature.  
  • Considers our emotional attachment to the natural world: hunting, gardens; we are destroying. 
  • Reviews our love of metaphor, archetypes, exploration, irony, and considers the potential for a third enlightenment, supported by cooperative action of humanities and science

Following our summary of his arguments RSS frames these from the perspective of complex adaptive system (CAS) theory:
  • The humanities are seen to be a functionalist framework for representing the cultural CAS while 
  • Wilson's desire to integrate the humanities and science gains support from viewing the endeavor as a network of layered CAS. 

Evening campfire rituals
Brynjolfsson and McAfee explore the effects of Moore's law on the economy.  They argue it has generated exponential growth.  This has been due to innovation.  It has created a huge bounty of additional wealth.  But the wealth is spread unevenly across society.  They look at the short and long term implications of the innovation bounty and spread and the possible future of technology. 

Following our summary of their arguments RSS comments from the perspective of CAS theory. 

Brilliant technologies
Salman Khan argues that the evolved global education system is inefficient and organized around constraining and corralling students into accepting dubious ratings that lead to mundane roles.  He highlights a radical and already proven alternative which offers effective self-paced deep learning processes supported by technology and freed up attention of teams of teachers.  Building on his personal experience of helping overcome the unjustified failing grade of a relative Khan:
  • Iteratively learns how to teach: Starting with Nadia, Leveraging short videos focused on content, Converging on mastery, With the help of neuroscience, and filling in dependent gaps; resulting in a different approach to the mainstream method. 
  • Assesses the broken US education system: Set in its ways, Designed for the 1800s, Inducing holes that are hidden by tests, Tests which ignore creativity.  The resulting teaching process is so inefficient it needs to be supplemented with homework.  Instead teachers were encouraging their pupils to use his tools at home so they could mentor them while they attended school, an inversion that significantly improves the economics. 
  • Enters the real world: Builds a scalable service, Working with a real classroom, Trying stealth learning, At Khan Academy full time,  In the curriculum at Los Altos, Supporting life-long learning. 
  • Develops The One World Schoolhouse: Back to the future with a one room school, a robust teaching team, and creativity enabled; so with some catalysis even the poorest can become educated and earn credentials for current jobs. 
  • Wishes he could also correct: Summer holidays, Transcript based assessments, College education;
  • Concludes it is now possible to provide the infrastructure for creativity to emerge and to support risk taking. 

Following our summary of his arguments RSS frames them from the perspective of complex adaptive system (CAS) theory.  Disruption is a powerful force for change but if its force is used to support the current teachers to adopt new processes can it overcome the extended phenotypic alignment and evolutionary amplifiers sustaining the current educational network? 

Education versus guilds
Amy Chua and Jed Rubenfeld's New York Times opinion based on The Triple Package is summarized.  Their ideas are then framed by CAS theory and reviewed. 


What drives success
Peter Turchin describes how major pre-industrial empires developed due to effects of geographic boundaries constraining the empires and their neighbors' interactions.  Turchin shows how the asymmetries of breeding rates and resource growth rates results in dynamic cycles within cycles.  After the summary of Turchin's book complex adaptive system (CAS) theory is used to augment Turchins findings. 
Warrior groups
Through the operation of three different food chains Michael Pollan explores their relative merits.  The application of complex adaptive system (CAS) theory highlights the value of evolutionary testing of the food chain. 
Natural systems
E. O. Wilson & Bert Holldobler illustrate how bundled cooperative strategies can take hold.  Various social insects have developed strategies which have allowed them to capture the most valuable available niches.  Like humans they invest in specialization and cooperate to subdue larger, well equipped competitors. 
Insect superorganisms
Computational theory of the mind and evolutionary psychology provide Steven Pinker with a framework on which to develop his psychological arguments about the mind and its relationship to the brain.  Humans captured a cognitive niche by natural selection 'building out' specialized aspects of their bodies and brains resulting in a system of mental organs we call the mind. 

He garnishes and defends the framework with findings from psychology regarding: The visual system - an example of natural selections solutions to the sensory challenges of inverse modeling of our environment; Intensions - where he highlights the challenges of hunter gatherers - making sense of the objects they perceive and predicting what they imply and natural selections powerful solutions; Emotions - which Pinker argues are essential to human prioritizing and decision making; Relationships - natural selection's strategies for coping with the most dangerous competitors, other people.  He helps us understand marriage, friendships and war. 

These conclusions allow him to understand the development and maintenance of higher callings: Art, Music, Literature, Humor, Religion, & Philosophy; and develop a position on the meaning of life. 

Complex adaptive system (CAS) modeling allows RSS to frame Pinker's arguments within humanity's current situation, induced by powerful evolved amplifiers: Globalization, Cliodynamics, The green revolution and resource bottlenecks; melding his powerful predictions of the drivers of human behavior with system wide constraints.  The implications are discussed. 

Computationally adapted mind
The stages of development of the human female, including how her brain changes and the impacts of this on her 'reality' across a full life span: conception, infantile puberty, girlhood, juvenile pause, adolescence, dating years, motherhood, post-menopause; are described.  Brizendine notes the significant difference in how emotions are processed by women compared to men. 

Complex adaptive system (CAS) theory associates the stages with the evolutionary under-pinning, psychological implications and behavioral CAS. 

Evolved female brain
The complexity of behavior is explored through Sapolsky developing scenarios of our best and worst behaviors across time spans, and scientific subjects including: anthropology, psychology, neuroscience, sociology.  The rich network of adaptive flows he outlines provides insights and highlight challenges for scientific research on behavior. 

Complex adaptive system (CAS) theory builds on Sapolsky's details highlighting the strategies that evolution has captured to successfully enter niches we now occupy. 

CAS behavior
Carlo Rovelli resolves the paradox of time. 
Rovelli initially explains that low level physics does not include time:
  • A present that is common throughout the universe does not exist
  • Events are only partially ordered.  The present is localized
  • The difference between past and future is not foundational.  It occurs because of state that through our blurring appears particular to us
  • Time passes at different speeds dependent on where we are and how fast we travel
  • Time's rhythms are due to the gravitational field
  • Our quantized physics shows neither space nor time, just processes transforming physical variables. 
  • Fundamentally there is no time.  The basic equations evolve together with events, not things 
Then he explains how in a physical world without time its perception can emerge:
  • Our familiar time emerges
    • Our interaction with the world is partial, blurred, quantum indeterminate
    • The ignorance determines the existence of thermal time and entropy that quantifies our uncertainty
    • Directionality of time is real but perspectival.  The entropy of the world in relation to us increases with our thermal time.  The growth of entropy distinguishes past from future: resulting in traces and memories
    • Each human is a unified being because: we reflect the world, we formed an image of a unified entity by interacting with our kind, and because of the perspective of memory
    • The variable time: is one of the variables of the gravitational field.  With our scale we don't register quantum fluctuations, making space-time appear determined.  At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions

Emergence of time
Consciousness has confounded philosophers and scientists for centuries.  Now it is finally being characterized scientifically.  That required a transformation of approach. 
Realizing that consciousness was ill-defined neuroscientist Stanislas Dehaene and others characterized and focused on conscious access. 
In the book he outlines the limitations of previous psychological dogma.  Instead his use of subjective assessments opened the window to contrast totally unconscious brain activity with those including consciousness. 
He describes the research methods.  He explains the contribution of new sensors and probes that allowed the psychological findings to be correlated, and causally related to specific neural activity. 
He describes the theory of the brain he uses, the 'global neuronal workspace' to position all the experimental details into a whole. 
He reviews how both theory and practice support diagnosis and treatment of real world mental illnesses. 
The implications of Dehaene's findings for subsequent consciousness research are outlined. 
Complex adaptive system (CAS) models of the brain's development and operation introduce constraints which are discussed. 

Conscious access
Reading and writing present a conundrum.  The reader's brain contains neural networks tuned to reading.  With imaging a written word can be followed as it progresses from the retina through a functional chain that asks: Are these letters? What do they look like? Are they a word? What does it sound like? How is it pronounced? What does it mean?  Dehaene explains the importance of education in tuning the brain's networks for reading as well as good strategies for teaching reading and countering dyslexia.  But he notes the reading networks developed far too recently to have directly evolved.  And Dehaene asks why humans are unique in developing reading and culture. 

He explains the cultural engineering that shaped writing to human vision and the exaptations and neuronal structures that enable and constrain reading and culture. 

Dehaene's arguments show how cellular, whole animal and cultural complex adaptive system (CAS) are related.  We review his explanations in CAS terms and use his insights to link cultural CAS that emerged based on reading and writing with other levels of CAS from which they emerge. 

Evolved reading
Read Montague explores how brains make decisions.  In particular he explains how:
  • Evolution can create indirect abstract models, such as the dopamine system, that allow
  • Life changing real-time decisions to be made, and how
  • Schematic structures provide encodings of computable control structures which operate through and on incomputable, schematically encoded, physically active structures and operationally associated production functions. 
Receptor indirection
Antonio Damasio argues that ancient & fundamental homeostatic processes, built into behaviors and updated by evolution have resulted in the emergence of  nervous systems and feelings.  These feelings, representing the state of the viscera, and represented with general systems supporting enteric operation, are later ubiquitously integrated into the 'images' built by the minds of higher animals including humans. 

Damasio highlights the separate development of the body frame in the building of minds. 

Damasio explains that this integration of feelings by minds supports the development of subjectivity and consciousness.  His chain of emergence suggests the 'order of things.'  He stresses the end-to-end integration of the organism which undermines dualism.  And he reviews Chalmers hard problem of consciousness. 

Damasio reviews the emergence of cultures and sees feelings, integrated with reason, as the judges of the cultural creative process, linking culture to homeostasis.  He sees cultures as supporting the development of tools to improve our lives.  But the results of the creative process have added stresses to our lives. 

Following our summary of his arguments RSS frames his arguments from the perspective of complex adaptive system (CAS) theory.  Each of the [super]organisms discussed is a CAS reflecting the theory of such systems:
  • Damasio's proposals about homeostasis routed signalling, aligns well with CAS theory. 
  • Damasio's ideas on cultural stresses are elaborated by CAS examples. 

Emergence of feelings
Alfred Nemeczek reveals the chaotic, stressful life of Vincent van Gogh in Arles. 

Nemeczek shows that Vincent was driven to create, and successfully invented new methods of representing feeling in paintings, and especially portraits.  Vincent worked hard to allow artists like him-self to innovate.  But Vincent failed in this goal, collapsing into psychosis. 

Nemeczek also provides a brief history of Vincent's life. 

Following our summary of his main points, RSS frames the details from the perspective of complex adaptive system (CAS) theory. 
 
Vincent creates
Richard Dawkin's explores how nature has created implementations of designs, without any need for planning or design, through the accumulation of small advantageous changes. 
Accumulating small changes
Russ Abbott explores the impact on science of epiphenomena and the emergence of agents. 
Autonomous emergence
Terrence Deacon explores how constraints on dynamic flows can induce emergent phenomena which can do real work.  He shows how these phenomena are sustained.  The mechanism enables the development of Darwinian competition. 
Constraint based phenomena
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Agent death



Summary
Gawande uses his personal experience, analytic skills and lots of stories of innovators to demonstrate better ways of coping with aging and death.  He introduces the lack of focus on aging and death in traditional medicine.  And goes on to show how technology has amplified this stress point.  He illustrates the traditional possibility of the independent self, living fully while aging with the support of the extended family.  Central planning responded to the technological and societal changes with poorly designed infrastructure and funding.  But Gawande then contrasts the power of bottom up innovations created by experts responding to their own family situations and belief systems. 

Gawande then explores in depth the challenges that unfold currently as we age and become infirm.  He notes that the world is following the US is the United States of America.   path.  As such it will have to understand the dilemma of integrating medical treatment and hospice strategies.  He notes that all parties involved need courage to cope. 

He proposes medicine must aim to assure well being.  At that point all doctors will practice palliative care. 

Complex adaptive system (CAS) models of agency, death, evolution, cooperation and adaptations in evolutionary biology is a trait that increased the number of surviving offspring in an organism's ancestral lineage.  In Deacon's conception of evolution an adaptation is the realization of a set of constraints on candidate mechanisms, and so long as these constraints are maintained, other features are arbitrary. 
to new technologies are discussed. 

Being Mortal
In Atul Gawande's book 'Being Mortal' he uses true stories to illustrate the various ways in which the old, frail and dying are cared for by the evolving societies in which they live.  As a practicing surgeon he notes that his medical training ignored: how death unfolds, how people experience the end of their lives, how it affects them; the subject seemed beside the point when the goal was to save lives. 

It has been typical to treat a dying person as if they just need the right treatment and they will become fully functional again. 

Gawande's initial simplistic view was that he should treat all his patients with honesty and kindness which would result in his providing compassionate indicates an emotional state where resonance with someone else's distress leads one to help them. 
care.  But some of his surgical patients were forced to confront the realities of decline and mortality.  It struck Gawande that he was unprepared to help them.  Patients with incurable, terminal disease given the choice of either comfort care or treatments often selected the treatments which were inherently dangerous with difficult or improbable recovery paths.  Its hard for anyone involved to discuss the reality of such situations.  It is far easier to hide in the details rather than focus on the limits of treatments and true implications of the terminal condition. 

Gawande explains that modern scientific capabilities have turned the process of aging and dying into medical experiences.  But health care is not designed to cope with old age and in trying it removes the responsibility and experience from the rest of society.  Death is normal but its concrete reality is divergent from medicine as curing.  Doctors strive to be competent.  They aim to be knowledgeable and technically skilled.  Those goals are misaligned with accepting death.   For the dying such system problems are experienced as callousness and inhumanity and can result in extraordinary suffering. 

The independent self
Indian tradition supports the old as the center of the extended family.  The family ensure their [grand]parents can be as independent as possible.  Gawande notes that this system scaled in the past because very few people previously lived into old age.  In the west a number of changes undermined this framework of support:
  • The development of the nuclear family required that one child remained at home to care for their parents. 
  • Living into old age has become more common.  
  • Increased longevity means that parents compete for resources, such as the family home, with their offspring resulting in tensions between the generations. 
The global system now encourages individual agency tearing down the extended family strategy. 

Increasing wealth is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker.  It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche.    and property rights has enabled 'retirement'.  Parents were able to collateralize their resources and live off of some of the capital is the sum total nonhuman assets that can be owned and exchanged on some market according to Piketty.  Capital includes: real property, financial capital and professional capital.  It is not immutable instead depending on the state of the society within which it exists.  It can be owned by governments (public capital) and private individuals (private capital).  .  And women now have fewer children so their offspring become adults sooner increasing the possibility of retiring.  Separation provided both parents and offspring with increased individual freedom. 

This western trend of individual agency is now happening in China, Japan and Korea. 

The US is the United States of America.  
Robert Gordon argues that the inventions of the second industrial revolution were the foundation for American economic growth.  Gordon shows how flows of people into difficult rural America built a population base which then took the opportunity to move on to urban settings: Houses, Food in supermarkets, Clothes in department stores; that supported increasing productivity and standard of living.  The deployment of nationwide networks: Rail, Road, Utilities; terminating in the urban housing and work places allowing the workers to leverage time saving goods and services, which helped grow the economy. 

Gordon describes the concomitant transformation of:
  • Communications and advertising
  • Credit and finance
  • Public health and the health care network 
  • Health insurance
  • Education
  • Social and welfare services

Counter intuitively the constraints introduced before and in the Great Depression and the demands of World War 2 provide the amplifiers that drive the inventions deeply and fully into every aspect of the economy between 1940 and 1970 creating the exceptional growth and standard of living of post war America. 

Subsequently the rate of growth was limited until the shift of women into the workplace and the full networking of voice and data supported the Internet and World Wide Web completed the third industrial revolution, but the effects were muted by the narrow reach of the technologies. 

The development of Big Data, Robots, and Artificial Intelligence may support additional growth, but Gordon is unconvinced because of the collapse of the middle class. 

Following our summary of Gordon's book RSS frames his arguments from the perspective of complex adaptive system (CAS) theory. 

market economy developed retirement communities designed to venerate the independent self. 

But Gawande notes the ideal of independence ignores the reality of aging, serious illness and infirmity. 

Things fall apart
Gawande discusses how modern medicine has altered the impact of aging.  For all but recent history death was ever present.  But now medical and public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public.  Its global situation is discussed in The Great Escape by Deaton.  Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels.  Public health includes:
  • Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons: lead; Joint damage from over-exercise;
  • Research, monitoring and control of disease agents, processes and vectors by agencies including the CDC. 
  • Monitoring of the public's health by institutes including the NIH.  This includes screening for cancer & heart disease. 
  • Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.  
  • Development, deployment and maintenance of vaccination strategies.  
  • Development, deployment and maintenance of fluoridation. 
  • Development, deployment and maintenance of family planning services. 
  • Regulation and constraint of foods, drugs and devices by agencies including the FDA.  
 improvements have pushed out the likelihood of immediate death.  Today medicine has cut the mortality of heart attack is an AMI. It can induce cardiac arrest.  Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI.  Risk factors include: taking NSAID pain killers (May 2017).  There is uncertainty about why AMI occur.  Alternative hypotheses include:
  • Plaques started to gather in the coronary arteries and grew until no blood flow was possible.  If this is true it makes sense to preventatively treat the buildup with angioplasty. 
  • Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot.  If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors. 
s, respiratory illness, stroke is when brain cells are deprived of oxygen and begin to die.  750,000 patients a year suffer strokes in the US.  85% of those strokes are caused by clots.  There are two structural types: Ischemic and hemorrhagic.  Thrombectomy has been found to be a highly effective treatment for some stroke situations (Jan 2018). 
etc.  And even incurable diseases such as cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure.  It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA.  In 2010 one third of Americans are likely to die of cancer.  Cell division rates did not predict likelihood of cancer.  Viral infections are associated.  Radiation and carcinogen exposure are associated.  Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). 
can be treated to extend life, until a major organ is undermined.  So old age now reflects the accumulated crumbling of one's bodies systems.  And medicine is often disinterested in this unless there is something for it to cure. 

Aging encourages damage of the body parts:
Gawande outlines some alternative theories about why we age:
  1. Genetically organized shutdown. 
  2. Gawande notes that until recently we died on average before 30 so he doubts that aging is normal.  So he sees wear and tear as likely culprits.  He cites Leonid Gavrilov who claims that all complex systems fail randomly and gradually because they leverage redundancy.  But over
    Carlo Rovelli resolves the paradox of time. 
    Rovelli initially explains that low level physics does not include time:
    • A present that is common throughout the universe does not exist
    • Events are only partially ordered.  The present is localized
    • The difference between past and future is not foundational.  It occurs because of state that through our blurring appears particular to us
    • Time passes at different speeds dependent on where we are and how fast we travel
    • Time's rhythms are due to the gravitational field
    • Our quantized physics shows neither space nor time, just processes transforming physical variables. 
    • Fundamentally there is no time.  The basic equations evolve together with events, not things 
    Then he explains how in a physical world without time its perception can emerge:
    • Our familiar time emerges
      • Our interaction with the world is partial, blurred, quantum indeterminate
      • The ignorance determines the existence of thermal time and entropy that quantifies our uncertainty
      • Directionality of time is real but perspectival.  The entropy of the world in relation to us increases with our thermal time.  The growth of entropy distinguishes past from future: resulting in traces and memories
      • Each human is a unified being because: we reflect the world, we formed an image of a unified entity by interacting with our kind, and because of the perspective of memory
      • The variable time: is one of the variables of the gravitational field.  With our scale we don't register quantum fluctuations, making space-time appear determined.  At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions

    time     the backup systems fail too resulting in frailty and eventual collapse.  Felix Silverstone a senior geriatrician at Parker Jewish Institute NY agrees.  He does not see a single common cellular mechanism.  Instead we just fall apart.  
Increased life expectancy is a measure of the average life time of a new born baby.  Without public health assistance many children die in the first five years of life significantly lowering the life expectancy of the whole group.  There are representational and data capture problems with the model:
  • Not knowing the risk of dying in the newborn's future, demographers use the risks present at that time to predict impacts in the future of the person.  No adjustment can be made for increased wellbeing. 
  • Saving the lives of children has a far larger effect on increasing life expectancy than extending the lives of the elderly
  • Impacts that occur in a particular year, such as a epidemic or pandemic, are treated as permanent effects for that years life expectancy even though they may be handled by public health strategies and hence be transients.  For life expectancy calculations in subsequent years the impact is ignored.  
  • Programs that reduced the impacts of infectious diseases, such as antibiotics and vaccine deployment, have reduced the variability of life expectancy following their introduction.  
  • Vital registration systems gather accurate data for life expectancy.  But most countries do not have the infrastructure and instead estimates are generated from demographic and health surveys. 
has altered society's demographics.  But societies have not responded: 
Gawande took the
Carlo Rovelli resolves the paradox of time. 
Rovelli initially explains that low level physics does not include time:
  • A present that is common throughout the universe does not exist
  • Events are only partially ordered.  The present is localized
  • The difference between past and future is not foundational.  It occurs because of state that through our blurring appears particular to us
  • Time passes at different speeds dependent on where we are and how fast we travel
  • Time's rhythms are due to the gravitational field
  • Our quantized physics shows neither space nor time, just processes transforming physical variables. 
  • Fundamentally there is no time.  The basic equations evolve together with events, not things 
Then he explains how in a physical world without time its perception can emerge:
  • Our familiar time emerges
    • Our interaction with the world is partial, blurred, quantum indeterminate
    • The ignorance determines the existence of thermal time and entropy that quantifies our uncertainty
    • Directionality of time is real but perspectival.  The entropy of the world in relation to us increases with our thermal time.  The growth of entropy distinguishes past from future: resulting in traces and memories
    • Each human is a unified being because: we reflect the world, we formed an image of a unified entity by interacting with our kind, and because of the perspective of memory
    • The variable time: is one of the variables of the gravitational field.  With our scale we don't register quantum fluctuations, making space-time appear determined.  At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions

time to observe a geriatrician at work.  They use specialized skills:
  • Check feet since if they are in poor condition it signals that the person is not able to care for them. 
  • Check agility of the patient in getting onto the exam table.  Loss of agility typically correlates with increased falling.  Falling is the key danger:
    • 40% of falls drive the person into a nursing home. 
    • 20% never walk again. 
    • The risk factors are poor balance, muscle weakness and more than four medicines.  There is a 10% chance of falling without one of these factors.  With all three its 100%.  
      • Medicines may include a diuretic.  As people age these become problematic causing dehydration leading to dizziness.  Geriatricians can hugely reduce the risks by thoughtfully adjusting the medicines to be age appropriate.  
      • Old people tend to eat too few calories.  This contributes to muscle weakness. 
  • They aim to help their patients to:
    • Gain as much freedom from the ravages of disease as possible.  
    • Retain enough function for active engagement in the world.  This is an unusual goal for most doctors.  
Gawande noted that deterioration has complex implications.  For example lordosis of the spine which occurs commonly with age tips the head forward.  This means that when sufferers eat they are more likely to choke on food particles and cough them into the lungs where the aspirated particles can result in pneumonia is an inflamed lung.  It can be caused by infection with viruses or bacteria, drugs and autoimmune diseases.  HAP, including VAP can be very troubling. ! 

Dependence
The care experienced by the elderly can be exasperating.  All too often the elderly are treated like patients not persons.  And their care worker does not have enough
Carlo Rovelli resolves the paradox of time. 
Rovelli initially explains that low level physics does not include time:
  • A present that is common throughout the universe does not exist
  • Events are only partially ordered.  The present is localized
  • The difference between past and future is not foundational.  It occurs because of state that through our blurring appears particular to us
  • Time passes at different speeds dependent on where we are and how fast we travel
  • Time's rhythms are due to the gravitational field
  • Our quantized physics shows neither space nor time, just processes transforming physical variables. 
  • Fundamentally there is no time.  The basic equations evolve together with events, not things 
Then he explains how in a physical world without time its perception can emerge:
  • Our familiar time emerges
    • Our interaction with the world is partial, blurred, quantum indeterminate
    • The ignorance determines the existence of thermal time and entropy that quantifies our uncertainty
    • Directionality of time is real but perspectival.  The entropy of the world in relation to us increases with our thermal time.  The growth of entropy distinguishes past from future: resulting in traces and memories
    • Each human is a unified being because: we reflect the world, we formed an image of a unified entity by interacting with our kind, and because of the perspective of memory
    • The variable time: is one of the variables of the gravitational field.  With our scale we don't register quantum fluctuations, making space-time appear determined.  At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions

time to understand the needs of the person in their care.  Self-help and partner based care leave more control over life.  They have to give up their homes.  The institutions focus is on safety and require their residents give up:
  • Household possessions
  • Transport independence
  • Personalized and interesting meals
  • Own control of activities.  Many institutions organize group activities which are not valued by the residents.  
Gawande reviewed the historic development of hospitals and nursing homes.  Western Europe and the US is the United States of America.   replaced poor houses with care homes.  It was assumed that the old needed medical care within a nursing home to ensure they were safe.  Post 1945 the emergence of modern drugs encouraged the US congress to sponsor the building of hospitals.  The Hill-Burton Free and Reduced-Cost Health Care act of 1946 gave health facilities including: Hospitals: General, Long-term care, Mental; Nursing homes, Outpatient facilities, Public health centers; grants and loans for construction and modernization.  It specified administration through the HRSA.  It was amended by Congress in 1954 to cover development of nursing homes. 
act (1946) allocated huge government funds to building hospitals.  That resulted in the construction of 9000 new hospitals.  There emerged a new option: 'cure me'. 

It was hoped that the poor house system would be made redundant with the advent of Social Security in 1935 is the social securities act of 1935 was part of the second New Deal.  It attempted to limit risks of old age, poverty and unemployment.  It is funded through payroll taxes via FICA and SECA into the social security trust funds.  Title IV of the original SSA created what became the AFDC.  The Social Security Administration controls the OASI and DI trust funds.  The funds are administered by the trustees.  The SSA was amended in 1965 to include:
  • Title V is Maternal and child health services. 
  • Title XVIII is Medicare.  
.  But it became obvious that there were many people who were too weak, frail, senile, and broken to care for themselves.  In the 1950s hospitals were used to house these people.  Congress allocated Hill-Burton funds in 1954 for extended recovery facilities -- the modern nursing homes.  With many states having substandard facilities funded with federal money it was felt necessary to allow the substandard nursing homes to remain funded with the 1965 inclusion of 'substantial compliance'.  Access to this flow of funds encouraged an explosion in the number of nursing homes.  There were 13,000 by 1970. 

Assistance
Nuclear families caring for parents introduce huge stresses is a multi-faceted condition reflecting high cortisol levels.  Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight.  As these actions occur the levels of cortisol return to the baseline rate.  A stressor is anything that disrupts the regular homeostatic balance.  The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis. 
  • The short term response to the stressor
    • activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response.  The brain's acuity and cognition are stimulated.  The immune system is stimulated with beta-endorphin and repair activities curtail.  But when the stressor is
  • long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues.  Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in.  Sustained stress provides an evolved amplifier of a position of dominance and status.  It is a strategy in female aggression used to limit reproductive competition.  Sustained stress:
    • Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment! 
    • Activates the integration between the thalamus and amygdala. 
      • Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful. 
      • BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning. 
    • Makes it easier to learn a fear association and to consolidate it into long-term memory.  Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala.  And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces.  Accuracy of assessing emotions from faces suffers.  A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand.  The activation of the amygdala seems to determine how the hippocampus responds. 
    • Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression. 
    • Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive.  It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.  
    • Increases the risk of autoimmune disease (Jan 2017) 
  • During depression, stress inhibits dopamine signalling.  
  • Strategies for stress reduction include: Mindfulness. 
:
  • Parent and child trade roles
  • Parent no longer master of his house
  • Parent moves away from old friends and communities
In this situation:
  • Parents often adapt to the situation by befriending visitors
  • Caregiver (daughter) has little help but a demanding role and becomes more constrained:
    • Coping with falls
    • Woken by parents nightmares
    • Having to upgrade infrastructure
    • Handling prostrate issues
    • Having to provide different menus for parent and family
    • Managing the trips to specialists
    • Finds job impacted
With nursing homes typically rejected by the parent, assisted living is an alternative to parents joining their children's nuclear family or entering a SNF, or Greenhouse Nursinghome.  Atul Gawande's Being Mortal describes the situation.  Federal Medicaid does not directly cover assisted living.  State Medicaid adds coverage through a federal waiver.  Congressional legislation covering assisted living is limited.  Assisted living providers are represented by the National Center for Assisted Living. 
facilities offered an attractive way out.  The concept originated by Karen Brown Wilson in Oregon in the 1980s as an alternative to nursing homes.  They had the goal of providing a life of freedom and autonomy, no matter what physical limits, for their residents. 

Karen's mother was a stroke is when brain cells are deprived of oxygen and begin to die.  750,000 patients a year suffer strokes in the US.  85% of those strokes are caused by clots.  There are two structural types: Ischemic and hemorrhagic.  Thrombectomy has been found to be a highly effective treatment for some stroke situations (Jan 2018). 
victim who hated traditional nursing homes.  The problem is they were designed to control. 
The vision was of an alternative small place with a little kitchen and bathroom.  A place where she could keep her cat, and her unfinished projects, coffee pot, cigarettes;  Where she could lock the door, control her heat and have her furniture.  It was a vision of a person in control again rather than a patient. 

Karen designed and built such a facility with her husband.  Retirement community developers disliked her proposal.  Once built Oregon would not license the facility she named Park Place.  But explains Gawande by 1983 she had overcome all the hurdles.  And Park Place was a sellout.  It offered a life of freedom but added help with food, personal care, medications, and provided an onsite nurse and urgent care button.  Called 'assisted living' it was attacked for failing to protect the elderly.  But in 1988 results showed satisfaction with lives was higher and health had been sustained while the costs were 20% lower. 

Gawande explains that while fit young people are keen to attain aspirational goals as life is threatened goals and priorities adapt.  They narrow in from achievement and building networks.  Any assisted living facility must provide everyday comforts and companionship.  By doing this Park Place was very successful. 

By 1990 Karen's company Assisted Living Concepts was a Wall Street success.  But by 2003 Nursing homes had used marketing to relabel themselves as assisted living.  By this time only 11% of "assisted living" facilities provided the capabilities that Karen had designed.  Wilson comments that it is not surprising: 
  • It is difficult to do. 
  • Caregivers have to think and act differently.  They have to be less efficient and more attentive. 
  • Children of the elderly are interested in their parents' safety. 
  • Parents allow their children to make the choices. 

A better life
Gawande similarly describes  how a driven visionary Bill Thomas transformed a nursing home.  He became the medical director of Chase Memorial nursing home which was looking after 80 severely disabled residents.  Half were physically disabled.  Four out of five had Alzheimer's is a dementia which correlates with deposition of amyloid plaques in the neurons.  As of 2015 there are 5 million Alzheimer's patients in the USA.  It was originally defined as starting in middle age which is rare, so it was a rare dementia.  But in 1980s it was redefined as any dementia without another known cause. Early indications include mood and behavioral changes (MBI) and declarative memory and thinking problems (MCI).  Specific cells within the hippocampal circuitry and its gateway, the entorhinal cortex, are damaged.  The amygdala, cerebelum and other areas supporting implicit memory are not impacted during the early stages of the disease.  Grid cell destruction results in a sense of being lost.  The default mode network is disrupted.  Variants include: late-onset sporadic; with risk factors - ApoE4 for late onset Alzheimer's, presenilin, androgen deprivation therapy (Dec 2015), type 2 diabetes.  There are multiple theories of the mechanism of Alzheimer's during aging: Allen Roses argues that it is due to gene alleles that limit the capacity of mitochondria to support neuron operation, Neurons of sporadic Alzheimer's sufferers show greater APP gene diversity due to somatic recombination; It may be initiated by: stress induced HHV-6a, HHV7 herpes activation (Jun 2018) and or an increasingly leaky blood-brain barrier; and a subsequent innate immune response to the infections (May 2016).  The Alzheimer's pathway follows:
  • Plaques form.  These are seen in fMRIs 10 to 15 years prior to detecting memory and thinking changes.  APP deployed in the cell membrane is cut into three parts.  The external part becomes amyloid-beta peptide which aggregates into Amyloid plaques, external to the neurons, if too much is generated or it is not removed fast enough. 
    • Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016). 
    • Encouraging the garbage collection of amyloid and tau with gamma rhythms stimulation retards Alzheimer's in mice studies (Mar 2019)
    • BACE inhibitors block an enzyme needed to form amyloid. 
  • Mutation driven misfolded Tau proteins can form tangles within the cytoplasm of neurons.  The Tau tangles kill nerve cells.  LMTX is a drug treatment targeted at these tangles. 
  • The brain becomes inflamed resulting in the killing of many more nerve cells.  The hippocampus disintegrates and the brain loses critical functions and memory loss becomes noticeable. 
.  He was immediately concerned about the despair evident in all the residents.  Eventually he concluded it was caused by 'lack of life'.  He noted boredom, loneliness is an aversive signal like thirst, hunger or pain.  It has been associated with the dorsal raphe nucleus (Sep 2016).  Loneliness affects several important bodily functions through overstimulation of the stress response.  Chronic loneliness is associated with increased cortisol levels, hypertension and impaired production of white blood cells undermining the immune system.   and helplessness.  He proposed adding:
  • Plants - vegetable garden and plants. 
  • Animals - Dogs, cats and 100 birds. 
  • Children.  
Again it was against all the government regulations.  But the results undermined the constraints:
  • Residents began to wake up and come to life
  • People who were considered incapable of speech started speaking. 
  • People who had been completely withdrawn and non-ambulatory started walking the dogs. 
  • Residents named the birds. 
  • The number of prescriptions per resident halved.  Psychotropic drug need fell more.  Deaths fell by 15% 
Thomas formed the Eden Alternative.  This is a not-for-profit to teach Eden principles.  He founded Pioneer network which developed the Green House Greenhouse nursing homes offer personal service and private rooms.  This reduces the opportunities for cross infections reducing cost of errors. 
  • Most nursing homes are designed like hospitals.  They are designed around the nursing station.  They are institutions and aim to limit risk and serve the patient's childrens' interest in the safety of their parents.  But they actually undermine will to live. 
  • Greenhouses are smaller and designed around the kitchen.  They allow knives.  Patients keep their own shoes - even though they may increase the likelihood of falling.  Patients bring in their own furniture.  Greenhouse nursing home developers had to educate the regulators and health officials about the goal of improved purpose of life rather than patients being destroyed by 'safety' (really boredom, loneliness and helplessness).  
.  It is funded by the Robert Wood Johnson foundation.  The Green House looks like a nursing home to the government but feels like a home to residents.  150 Green Houses have been developed in 25 states. 

Gawande describes one The Leonard Florence Center for Living:
  • It has all single rooms - a typical issue for residents of regular nursing homes. 
  • Caregivers are given control of their schedule.  They are encouraged to be focused on just a few residents and to do the cooking, cleaning, helping and friending.  

Gawande concludes that typical medicine is mismatched to owning the care of the aged.  Medicine's focus is narrow -- on repair of health.  Death is related to greater things by transcendence.  The probability of death induces a need to feel meaningful and worthwhile.  This is often achieved by seeking a cause beyond you.  Gawande explains how Peter Sanborn Place's determined and informed manager had used trained staff and smart goals to support the infirm, without it ever becoming a nursing home or assisted living is an alternative to parents joining their children's nuclear family or entering a SNF, or Greenhouse Nursinghome.  Atul Gawande's Being Mortal describes the situation.  Federal Medicaid does not directly cover assisted living.  State Medicaid adds coverage through a federal waiver.  Congressional legislation covering assisted living is limited.  Assisted living providers are represented by the National Center for Assisted Living. 
facility.  Again Peter Sanborn Place had to battle the medical system:
Gawande describes a further success story:  Newbridge on the Charles which he introduces as a new model of nursing home architecture.  It supports the full continuum of care is a Post-Acute Care provider.  A three-day hospital admission and discharge are prerequisite requirements to receiving Medicare PAC services.  Acute care hospitals become portals to the PAC business.  Referrals are key.  PAC includes different types of facility focused on different severity of illness (high to low):
  • Long term care Hospital (LTCH),
  • Inpatient rehabilitation facility (IRF),
  • Skilled nursing facility (SNF),
  • Home health agency (HHA) - most acute care hospitals and EMR providers have strategies for integration with home based care,
  • Outpatient rehabilitation.  SNF and HHA represent 80% of discharges and expenditures.  Assisted living is not part of federal Medicaid, but states often include it through a waiver. 
offering independent living, assisted living and skilled nursing.  Its building is constructed as pods -- Rooms around a central dining room, kitchen and activity room.  The pods are family size inducing a sense of safety, increasing socialization and friendship and reducing anxiety is manifested in the amygdala mediating inhibition of dopamine rewards.  Anxiety disorders are now seen as a related cluster, including PTSD, panic attacks, and phobias.  Major anxiety, is typically episodic, correlated with increased activity in the amygdala, results in elevated glucocorticoids and reduces hippocampal dendrite & spine density.  Some estrogen receptor variants are associated with anxiety in women.  Michael Pollan concludes anxiety is fear of the future.  Sufferers of mild autism often develop anxiety disorders.  Treatments for anxiety differ.  50 to 70% of people with generalized anxiety respond to drugs increasing serotonin concentrations, where there is relief from symptoms: worry, guilt; linked to depression, which are treated with SSRIs (Prozac).  But many fear-related disorders respond better to psychotherapy: psychoanalysis, and intensive CBT. 
and depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events.  There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide.  Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time.  There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015).  The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure.  Michael Pollan concludes depression is fear of the past.  It affects 12% of men and 20% of women.  It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016).  Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression.  Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease.   It has been associated with an aging related B12 deficiency (Sep 2016).  During depression, stress mediates inhibition of dopamine signalling.  Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC.  There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC.  Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression.  Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable.  Sufferers of mild autism often develop depression.  Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25.  Drug treatments are required for cases with above average activity of the right anterior insula.  As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony.  By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress.   Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;.  Newbridge leverages children's participation to inspire life. 


Letting go
Gawande comments that reviewing the needs of the elderly introduces a question for medicine.  When should doctors try to fix and when should they not? 

25% of all medicine spending is for the 5% of patients who are in their final year of life, and most of it is spent on care that is of apparently little benefit. 

Gawande illustrates the issue with a typical cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure.  It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA.  In 2010 one third of Americans are likely to die of cancer.  Cell division rates did not predict likelihood of cancer.  Viral infections are associated.  Radiation and carcinogen exposure are associated.  Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). 
cost curve. 
He explains that the cost curve does not have to look this way.  A 2008 study by the National Coping with Cancer project compared terminally ill cancer patients put on a mechanical ventilator, given defibrillation, or admitted when near death to an ICU is intensive care unit.  It is now being realized that the procedures and environment of the ICU is highly stressful for the patients.  In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD.  Intubation and catheterization are also traumatic.  Sometimes seperated into MICU and SICU.  eICU skill centralization may bring down costs. 
have a worse quality of life for their final week than those who do not get intervention.  The intervention fails to achieve the patients typical goals:
  • Avoid suffering
  • Strengthening relationships with family and friends
  • Being mentally aware
  • Not being a burden on others
  • Achieving a sense that their life is complete

Gawande notes that swift catastrophic illness is now the exception.  Instead one can expect a long struggle with:
He continues that death is certain but the timing isn't.  We all struggle with how and when to accept that the battle is lost.  And technology can now sustain the body past the point of awareness and coherence. 

In comparison hospice has the key goal of helping people with a fatal illness to have the fullest possible life right now.  There are major hospice chains focused on providing palliative care. 
has the key goal of helping people with a fatal illness to have the fullest possible life right now.  But it too has to fight against the momentum of medical treatment. 

A visiting hospice nurse has a set of key questions:

75% of people enter hospice with a terminal illness but not accepting that they are dying.  Typically feel that doctors have abandoned them.  A hospice nurse has about 5 seconds to get a new patient to like is an emotion which initiates and maintains an altruistic partnership.  It is a willingness to offer someone a favor.  It is directed to those who appear likely to return the favor.   and trust and distrust are evolved responses to sham emotions.  During a friendship where no sham emotions have been detected trust will build up. 
them.  They have a powerful offer: "I am a hospice nurse and here's what I have to offer to make your life better and I know we don't have a lot of
Carlo Rovelli resolves the paradox of time. 
Rovelli initially explains that low level physics does not include time:
  • A present that is common throughout the universe does not exist
  • Events are only partially ordered.  The present is localized
  • The difference between past and future is not foundational.  It occurs because of state that through our blurring appears particular to us
  • Time passes at different speeds dependent on where we are and how fast we travel
  • Time's rhythms are due to the gravitational field
  • Our quantized physics shows neither space nor time, just processes transforming physical variables. 
  • Fundamentally there is no time.  The basic equations evolve together with events, not things 
Then he explains how in a physical world without time its perception can emerge:
  • Our familiar time emerges
    • Our interaction with the world is partial, blurred, quantum indeterminate
    • The ignorance determines the existence of thermal time and entropy that quantifies our uncertainty
    • Directionality of time is real but perspectival.  The entropy of the world in relation to us increases with our thermal time.  The growth of entropy distinguishes past from future: resulting in traces and memories
    • Each human is a unified being because: we reflect the world, we formed an image of a unified entity by interacting with our kind, and because of the perspective of memory
    • The variable time: is one of the variables of the gravitational field.  With our scale we don't register quantum fluctuations, making space-time appear determined.  At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions

time to waste." 
The nurse must evaluate the patient's family for its ability to support the care.  They will provide a comfort pack and a help line for how to use it.  The pack includes:
  • Morphine for pain
  • Ativan for anxiety
  • Compazine for nausea
  • Haldol for delirium
  • Tylenol for fever
  • Atropine for death rattle

But it is not easy for the elderly, their care givers or doctors to decide on the right approach.  There are new experimental therapies.  S. J. Gould was told he had a terminal cancer but he lived due to the long tail of possibility.  These possibilities offer hope in treatment.  

And the strategy of withholding treatment because it is costly and has no statistical validity was undermined when Healthnet took this approach in 1991 and their patient died.  The family was awarded $89 million by a jury. 

Aetna in 2004 found that offering hospice in addition to, rather than as an alternative to treatment, resulted in less visits to the ER is emergency department.  Pain is the main reason (75%) patients go to an E.D.  It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital.  The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals.  Unreimbursed care is supported from federal government funds.  E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing.  The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics.  Commercial nature of care requires walk-ins to register to gain access to care.  With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016). 
, ICU is intensive care unit.  It is now being realized that the procedures and environment of the ICU is highly stressful for the patients.  In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD.  Intubation and catheterization are also traumatic.  Sometimes seperated into MICU and SICU.  eICU skill centralization may bring down costs. 
and costs fell 25%. 

The key need in either strategy is to help people negotiate overwhelming anxiety.  Gawande notes it has to be a process.  You must sit down and take time and the doctor must mostly listen.  The aim is to find out what is important to them in the circumstances.  Then can provide information and advice on the best chance of achieving their desires. 

Their circumstances will depend on what they understand their prognosis to be.  As such they will have concerns about what lies ahead.  It is important to understand what tradeoffs they are willing to make.  How do they want to spend their time?  Who do they want to make decisions for them if they become incapacitated? 

Hard conversations
The world is now following the US is the United States of America.   trend of deploying hospitals.  The US is adopting hospice has the key goal of helping people with a fatal illness to have the fullest possible life right now.  There are major hospice chains focused on providing palliative care. 
: 45% of deaths by 2010 will be hospice supported.  But Gawande warns there is no process to link the hospital and hospice approaches.  With his father developing a terminal cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure.  It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA.  In 2010 one third of Americans are likely to die of cancer.  Cell division rates did not predict likelihood of cancer.  Viral infections are associated.  Radiation and carcinogen exposure are associated.  Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). 
Gawande experienced the problem at first hand. 

He describes three approaches taken by the hospital doctors:
  1. 'Dr. knows best' enforces a treatment plan that moves the patient to the ICU is intensive care unit.  It is now being realized that the procedures and environment of the ICU is highly stressful for the patients.  In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD.  Intubation and catheterization are also traumatic.  Sometimes seperated into MICU and SICU.  eICU skill centralization may bring down costs. 
    .  
  2. 'Dr. informative' who presents details of treatments and their statistical effects.  This approach leaves the patient anxious and bewildered but also heading towards the ICU. 
  3. 'Dr. complexity' who:
Still Gawande concedes there is a difficult decision that must be faced.  Should we focus on our vision and legacy or making our present the best experience possible.  We are not built to make this decision effectively.  Gawande describes the remembering self and the experiencing self from Daniel Kahneman's research and book Thinking Fast and Slow.  This is what evolution has provided us with to make decisions over a long life of repeating experiences.  But these patients probably only have the here and now!  When time is limited they both seem important. 

Courage
Gawande identifies two kinds of courage required to cope with aging and sickness:
  1. To confront reality of our mortality -- the courage to seek out the truth of what is to be feared and what is to be hoped
  2. To act on the truth we find
But the wise choice is frequently unclear.  Should one care most about hopes or fears?  The perspective of
Carlo Rovelli resolves the paradox of time. 
Rovelli initially explains that low level physics does not include time:
  • A present that is common throughout the universe does not exist
  • Events are only partially ordered.  The present is localized
  • The difference between past and future is not foundational.  It occurs because of state that through our blurring appears particular to us
  • Time passes at different speeds dependent on where we are and how fast we travel
  • Time's rhythms are due to the gravitational field
  • Our quantized physics shows neither space nor time, just processes transforming physical variables. 
  • Fundamentally there is no time.  The basic equations evolve together with events, not things 
Then he explains how in a physical world without time its perception can emerge:
  • Our familiar time emerges
    • Our interaction with the world is partial, blurred, quantum indeterminate
    • The ignorance determines the existence of thermal time and entropy that quantifies our uncertainty
    • Directionality of time is real but perspectival.  The entropy of the world in relation to us increases with our thermal time.  The growth of entropy distinguishes past from future: resulting in traces and memories
    • Each human is a unified being because: we reflect the world, we formed an image of a unified entity by interacting with our kind, and because of the perspective of memory
    • The variable time: is one of the variables of the gravitational field.  With our scale we don't register quantum fluctuations, making space-time appear determined.  At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions

time also affects how our goals and fears are evaluated. 

Gawande reflects that assisted suicide has multiple problems seen in this light.  It:
  1. Should not be allowed for healthy people who are likely to reevaluate their situation in the future. 
  2. Presents a valuable option for the terminally ill who are suffering.  But Gawande notes in societies where it has been deployed it tends to undermine the development of hospice has the key goal of helping people with a fatal illness to have the fullest possible life right now.  There are major hospice chains focused on providing palliative care. 
    type strategies that could reduce the suffering and allow the patient to achieve more of their immediate goals.  
When palliative care aims to relieve and prevent the suffering (symptoms, pain and stress of serious illness) of patients what ever their prognosis.  works the patient's goals extend.  This extension enables the development of a rewarding 'dying role'. 


Epilogue
Gawande argues being mortal is about the struggle of coping with the constraints of our biology.  Medical science can push against the limits.  But there is harm induced when we fail to acknowledge the limits. 

Gawande suggests the job of medicine has been misunderstood.  It is easy to assume that it is to ensure health and survival.  Really it is to assure wellbeing indicates the state of an organism is within homeostatic balance.  It is described by Angus Deaton as all the things that are good for a person:
  • Material wellbeing includes income and wealth and its measures: GDP, personal income and consumption.  It can be traded for goods and services which recapture time.  Material wellbeing depends on investments in:
    • Infrastructure
      • Physical
      • Property rights, contracts and dispute resolution
    • People and their education
    • Capturing of basic knowledge via science.  
    • Engineering to turn science into goods and services and then continuously improve them. 
  • Physical and psychological wellbeing are represented by health and happiness; and education and the ability to participate in civil society through democracy and the rule of law.  Life expectancy as a measure of population health, highly weights reductions in child mortality. 
.  Then all doctors will practice palliative care aims to relieve and prevent the suffering (symptoms, pain and stress of serious illness) of patients what ever their prognosis.  . 




Complex adaptive system
This page introduces the complex adaptive system (CAS) theory frame.  The theory is positioned relative to the natural sciences.  It catalogs the laws and strategies which underpin the operation of systems that are based on the interaction of emergent agents. 
John Holland's framework for representing complexity is outlined.  Links to other key aspects of CAS theory discussed at the site are presented. 
(CAS) theory supports reasoning about agency, death, evolution, cooperation and adaptations in evolutionary biology is a trait that increased the number of surviving offspring in an organism's ancestral lineage.  In Deacon's conception of evolution an adaptation is the realization of a set of constraints on candidate mechanisms, and so long as these constraints are maintained, other features are arbitrary. 
to new technologies. 

Death is typically an architected aspect of a CAS
Plans are interpreted and implemented by agents.  This page discusses the properties of agents in a complex adaptive system (CAS). 
It then presents examples of agents in different CAS.  The examples include a computer program where modeling and actions are performed by software agents.  These software agents are aggregates. 
The participation of agents in flows is introduced and some implications of this are outlined. 
agent.  Indeed when such aspects fail as in many metastatic cancers is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure.  It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA.  In 2010 one third of Americans are likely to die of cancer.  Cell division rates did not predict likelihood of cancer.  Viral infections are associated.  Radiation and carcinogen exposure are associated.  Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). 
the planning and cooperation typical of CAS as well as the system itself collapses.  For multi-cellular agents and superorganisms is a wealthy autonomous entity needing and controlling the richest niches in the proximate environment, that emerges from the bundled cooperation of schematically aligned agents.   The term is based on the social insect model, used by: ants, termites, and bees; and identified by Holldobler & E.O. Wilson.  For humans it is an evolved cultural strategy used when the environment is supportive.  It depends on inter-agent signalling.  In both insects and humans it allows specialization, and encourages operations and flows that are tightly controlled, limiting waste, leveraging parallel activity, supporting coherence.  Superorganisms reflect cliodynamic flows.  A superorganism has a development and operational phase.  As additional agents are coopted into the superorganism they align, participate in supply and demand activities and so contribute to the evolutionary amplification.  Damasio notes that prokaryotes, in rich environments, can similarly operate in a symbiotic fashion expressing cultural behaviors. 
death also provides a key support for
In this page we summarize the arms race between hosts and their parasites.  The deadly nature and adaptive pressure of the relationship is introduced.  How the slowly reproducing hosts cope is described.  Cultural hosts and parasites are discussed. 

sexual reproduction's competitive response to parasites.  And it appears important in moving the parents out of the way and thus allowing the offspring access to the resources they will need to survive and reproduce. 

From the perspective of the system once the agent has replicated, its
Plans emerge in complex adaptive systems (CAS) to provide the instructions that agents use to perform actions.  The component architecture and structure of the plans is reviewed. 
schematic plan is perpetuated.  The agent need only persist while it is providing material support to the developing offspring.  But as Gawande notes the structure of the family has been transformed from the large extended to the small nuclear.  There are significant unintended consequences.  One appears to be the limited opportunity for cross infection from one familial infant to another.  Key participants of the human microbiome, the trillions of bacteria and viruses that live inside higher animals' guts, on their skin etc.  These bacteria and viruses seem to play a role in: immune responses, digesting food, making nutrients, controlling mental health and maintaining a healthy weight.  The signals from the gut microbiota are relayed by major nerve fibers: vagus; to the central nervous system.  The symbiotic relationship must be actively managed.  Human armpits include glands which provide food favoring certain symbionts who build a defensive shield above the skin.  In the human gut: Barriers are setup: Mucus secretions form a physical constraint and provide sites for bacteriophages to anchor and attack pathogenic bacteria; Symbiont tailored nourishment: Plant-heavy food creates opportunities for fibre specialists like Bacteroides thetaiotaomicron; is provided, Selective binding sites are provided, Poisons are deployed against the unwelcome, and Temperature, acidity and oxygenation are managed.    High throughput sequencing allows the characterization of bacterial populations inside guts.  Beginning at birth, as they pass down the birth canal infants are supplied with a microbiome from their mothers.  If they are borne via cesarean they never receive some of the key bacteria: Bifidobaterium infantis which is also dependent on oligosaccharides in breast milk; from their mothers.  A variety of diseases may be caused by changes in the microbiome:
  • Eczema can be related to changes in the skin microbiome. 
  • Obesity can be induced by changes to the gut microbiome.  
  • Chronic inflammation
  • Allergies
  • Type 1 diabetes
: Bifidobacterium infantis is a key symbiont in the human infant microbiome.  It is selected for by breast milk's array of oligosaccharides.  This structures the microbiome and helps bootstrap the immune system.  Its growth limits the opportunities for pathogenic bacteria to occupy the infant lower intestine.  But its transmission to further generations may depend on large families where the children typically cross infect.  It appears to be collapsing in western societies with small nuclear families and a focus on cleanliness. 
, Helicobacter pylori is a gram-negative bacteria, found in the stomach microbiome.  Having been identified as the causative agent of stomach ulcers and stomach cancer it has been a focus of eradication campaigns.  However, it has been subsequently realized that it limits acid reflux and esophageal cancer, and may be a necessary component of the infant microbiome. 
; are collapsing as their transmission chains have failed. 

Gawande suggests that aging is an unusual event for humans and that complex systems are redundant and fail randomly and gradually in fragile ways.  The high death rates of infants and old people distort average death rates.  Most adults in previous ages did not die at 30.  A lot of infants died lowering the average.  For CAS agents tailored and customized through the execution of genetic plans which specified their emergence by aggregation of cooperating lower level agents' randomness can only be part of the picture.  Whenever agent death is valuable from the systems perspective it can surely be invoked.  Such mechanisms exist.  Janet Mann describes in The Adapted Mind when economically is the study of trade between humans.  Traditional Economics is based on an equilibrium model of the economic system.  Traditional Economics includes: microeconomics, and macroeconomics.  Marx developed an alternative static approach.  Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics.  Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics. 
stressed is a multi-faceted condition reflecting high cortisol levels.  Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight.  As these actions occur the levels of cortisol return to the baseline rate.  A stressor is anything that disrupts the regular homeostatic balance.  The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis. 
  • The short term response to the stressor
    • activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response.  The brain's acuity and cognition are stimulated.  The immune system is stimulated with beta-endorphin and repair activities curtail.  But when the stressor is
  • long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues.  Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in.  Sustained stress provides an evolved amplifier of a position of dominance and status.  It is a strategy in female aggression used to limit reproductive competition.  Sustained stress:
    • Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment! 
    • Activates the integration between the thalamus and amygdala. 
      • Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful. 
      • BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning. 
    • Makes it easier to learn a fear association and to consolidate it into long-term memory.  Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala.  And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces.  Accuracy of assessing emotions from faces suffers.  A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand.  The activation of the amygdala seems to determine how the hippocampus responds. 
    • Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression. 
    • Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive.  It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.  
    • Increases the risk of autoimmune disease (Jan 2017) 
  • During depression, stress inhibits dopamine signalling.  
  • Strategies for stress reduction include: Mindfulness. 
mothers find they have too little food to feed their whole family they may opt for 'infanticide' of one or more of the children.  And Medawar and Williams's mutations potentially set an upper limit on life span in the scenario Gawande outlines for humans (Dec 2016)

At each
This page discusses the mechanisms and effects of emergence underpinning any complex adaptive system (CAS).  Physical forces and constraints follow the rules of complexity.  They generate phenomena and support the indirect emergence of epiphenomena.  Flows of epiphenomena interact in events which support the emergence of equilibrium and autonomous entities.  Autonomous entities enable evolution to operate broadening the adjacent possible.  Key research is reviewed. 
emergent level the agents must be able to
The agents in complex adaptive systems (CAS) must model their environment to respond effectively to it.  Samuel modeling is described as an approach. 
model their proximate environment.  For multi-cellular animals this requires the
Consciousness has confounded philosophers and scientists for centuries.  Now it is finally being characterized scientifically.  That required a transformation of approach. 
Realizing that consciousness was ill-defined neuroscientist Stanislas Dehaene and others characterized and focused on conscious access. 
In the book he outlines the limitations of previous psychological dogma.  Instead his use of subjective assessments opened the window to contrast totally unconscious brain activity with those including consciousness. 
He describes the research methods.  He explains the contribution of new sensors and probes that allowed the psychological findings to be correlated, and causally related to specific neural activity. 
He describes the theory of the brain he uses, the 'global neuronal workspace' to position all the experimental details into a whole. 
He reviews how both theory and practice support diagnosis and treatment of real world mental illnesses. 
The implications of Dehaene's findings for subsequent consciousness research are outlined. 
Complex adaptive system (CAS) models of the brain's development and operation introduce constraints which are discussed. 

development of neuronal infrastructure and adaptive learning.  With these constraints it is not surprising that our ability to represent our historic experiences uses short cuts.  Our remembering self maintains just the notable event and the end event.  Given the previous comments on death the remembering self seems satisfactory from
This page reviews the implications of selection, variation and heredity in a complex adaptive system (CAS).  The mechanism and its emergence are discussed. 
evolution's perspective. 

Gawande provides powerful demonstrations of the issues of
H. A. Hayek compares and contrasts collectivism and libertarianism. 
central planning.  His contrasting illustrations of local agents (Karen Brown Wilson, Bill Thomas) developing adaptive strategies which proved valuable and grew by replication are clearly superior approaches. 

The crumbling of one's bodily systems is Aubrey de Grey's focus as discussed in our
In his talk 'The Science of Ending Aging' Aubrey de Grey argues we should invest more in maintenance of our bodies.  In this page we summarize his video comments and then use complex adaptive system (CAS) theory to review his arguments.  Focusing the lens of CAS theory and mechanisms of emergence on the system we highlight the pros and cons of ending aging. 
summary of the science of ending aging. 





Being Mortal provides a sophisticated and visionary description of the challenge of aging in our high technology society and how we should organize to cope with it.  I hope my health care providers have read and thought about Atul Gawande's important points. 

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Market Centric Workshops
The Physics - Politics, Economics & Evolutionary Psychology
Politics, Economics & Evolutionary Psychology

Business Physics
Nature and nurture drive the business eco-system
Human nature
Emerging structure and dynamic forces of adaptation
integrating quality appropriate for each market
 
This page looks at schematic structures and their uses.  It discusses a number of examples:
  • Schematic ideas are recombined in creativity. 
  • Similarly designers take ideas and rules about materials and components and combine them. 
  • Schematic Recipes help to standardize operations. 
  • Modular components are combined into strategies for use in business plans and business models. 

As a working example it presents part of the contents and schematic details from the Adaptive Web Framework (AWF)'s operational plan. 

Finally it includes a section presenting our formal representation of schematic goals. 
Each goal has a series of associated complex adaptive system (CAS) strategy strings. 
These goals plus strings are detailed for various chess and business examples. 
Strategy | Design |
This page uses an example to illustrate how:
  • A business can gain focus from targeting key customers,
  • Business planning activities performed by the whole organization can build awareness, empowerment and coherence. 
  • A program approach can ensure strategic alignment. 
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