The authors of the study divided their samples into the “conservative” and “liberal” parts of the blogosphere, depending on the positions they took on certain litmus-test issues, like gun-control, abortion and the like.  Having found a way to assign colors to each dot, the researchers then examined how these blogs linked to other sites. They found curious differences in the way the conservative and liberal blogosphere were topologically organized.  They resembled each other in that the respective “camps” tended to draw their links from like minded sites, but there were differences too. The liberal blogosphere was somewhat more insular than the conservative blog universe.

a great majority of the links remaining internal to either liberal or conservative communities. Even more interestingly, we found differences in the behavior of the two communities, with conservative blogs linking to a greater number of blogs and with greater frequency.   … In our study we witnessed a divided blogosphere: liberals and conservatives linking primarily within their separate communities, with far fewer cross-links exchanged between them. This division extended into their discussions, with liberal and conservative blogs focusing on different news, topics, and political figures. An interesting pattern that emerged was that conservative bloggers were more likely to link to other blogs: primarily other conservative blogs, but also some liberal ones. But while the conservative blogosphere was more densely linked, we did not detect a greater uniformity in the news and topics discussed by conservatives.

One of the interesting questions is why this division persists in the face of a clear commercial incentive to be “moderate”. Common sense suggests that sites which bridge disconnected parts of the Internet (at the collision point of these two memetic clouds) may get more traffic than those which remain in their own little corner. It is almost always better to be at the “crossroads” than in the cul-de-sacs. A glance at the graphic above shows that if you are far enough left or far enough right then nobody much will link to you. And indeed,  the bigger purple or red grapes (presumably representing the bigger sites) seem visually concentrated near the center. It’s been said that newspapers in the past attempted to adopt a magisterial tone in order to attract a mixed readership of liberals and conservatives, thereby broadening their audience, and consequently their ad revenues.  Why have the blogs divided into two camps instead of merging into a single blob? One possible explanation is that many smaller bloggers do not operate their sites for profit and therefore political preference and ideology are far more powerful drivers and low levels of ad revenue than any benefits added traffic might bring. In other words, since most bloggers don’t blog for a living, they will write what they please instead of trying to optimize their web ad revenue.

It would be interesting to see how much things have changed in four years. Jason Lee Miller of Webpronews argues that despite assertions to the contrary, the “conservative blogosphere” is bigger than its liberal counterpart, though I suspect that depends on how you measure things. However, is apparently some agreement that the role of the political blogosphere is bigger than the 9% number given in the 2005 study.

To say the Internet skews left, as many believe, might be a little deceptive. True, The Huffington Post is the most popular of standalone sites, grabbing 4.5 million visitors in September, up a whopping 472 percent from last year.

But combining the second and third place in the top three, the audience is nearly even with HuffPo with over 4.4 million visitors split between Politico.com, up 344 percent from last year and attracting nearly 2.4 million visitors, and The Drudge Report, which was up 70 percent to almost 2.1 million visitors in September.

If you combine the top 15, it’s conservative blogs bringing in the largest overall audience. Left-leaning sites grabbed an audience of about 6.6 million in September, while right leaning sites attracted a combined audience of 8.4 million. It may be because political blog readers tend to be more affluent.

I’m not so sure affluence has anything to do with being conservative or liberal. And those numbers, it seems to me, are way too low and I think they are wildly inaccurate. But Miller, in mentioning affluence, touches on something that has not yet been closely studied: the effect the progressive enlargement of the blogosphere will have on the left-right divide itself. I think the early days of the blogosphere were perceived to be dominated by the conservatives because they were early adopters. They were early adopters because, unlike most of the liberals active in the culture wars, conservatives did not have platforms in the traditional mediums: print, TV, video, etc, with the exception of radio. So they turned to the blogs. But as the blogosphere matured and the traditional mediums declined, liberal media people migrated in ever large numbers to the Internet. What followed was a transfer of resources from traditional mediums to the blogosphere. Newspaper columnists got blogs; people in broadcast made videos or start video blogs, etc. Eventually the liberal transfereees began to catch up with the conservative early adopters. Moreover, many of them were professionally trained in the media skills and this added to the perception of liberal predominance.

In fact maybe the liberals did predominate for a brief window of time. But maybe that time is now already past. As even newer entrants who were never in the “culture wars” before come online via Twitter, Facebook — and the blogs — the topology is bound to change. The blogospheric significance of events in Iran and China is that people we don’t even know about are going to make an impact on news and opinion in ways that Dan Rather could not have conceived. I think the phenomenon of Internet publishing is migrating away from the traditional culture warriors downward and outward. Downward to nonculture warriors (like the Tea Party amateurs) and outward to international locales. The reporter and pundit of tomorrow is someone who doesn’t even know he is a reporter or is unaware he is a pundit. It’s interesting to consider what this means to people who aim to politically mobilize the average Joe in the near future. The major drivers of the democratization of the Internet have not been content providing sites like the Huffington Post, nor extensions of traditional PR activities like “accrediting” bloggers, but architecture; architecture which enables content provision. In this year of the Iranian demonstrations the Nobel Peace prize should be awarded to Twitter, Facebook and Blogger. Time magazine should consider them candidates for the Virtual Men of the Year, and put Time Magazine itself on its obituary pages. Perhaps the long term political equilibrium of the blogosphere will converge to the underlying distribution of political allegiance in society as a whole. It will certainly be interesting to see what kind of map of the blogosphere researchers will draw in 2010.

The US military recently released five Iranian Qods Force agents who had posed as diplomats and were detained in northern Iraq in late 2006. The Iranian agents were released to the Iraqi government, which is expected to promptly turn them back over to Iran. … “The five detainees are connected to the Iranian Revolutionary Guard – Qods Force (IRGC-QF), an organization known for providing funds, weapons, improvised explosive device technology and training to extremist groups attempting to destabilize the Government of Iraq and attack Coalition forces,” noted Multinational Forces Iraq in press release announcing the arrest in mid-January 2007. …

US intelligence officials who directly deal with the Iranian threat in Iraq are dismayed by the release of the Qods Force agents, and say the release of more is in the pipeline.

“If you didn’t like the release of Laith and the Irbil Five, you’d better get used to it,” one official told The Long War Journal in disgust.

“We worked hard to catch these bastards, now we’re cutting them loose with little thought to the consequences of doing this.”

McClatchy says that the US military didn’t want to release the Qods operatives to Iran and suggested that the Iraqi government, for reasons of its own, decided to release the operatives once it became legally possible for them to do so.

State Department spokesman Ian Kelly said the U.S. military turned over the five Iranians after Iraq issued arrest warrants for all third-country nationals in U.S. custody. … Kelly acknowledged misgivings about the release, and its impact on U.S. military personnel in Iraq. “That is a big concern of ours, is the safety of American forces. And we . . . have of course made our concerns known to the Iraqi government,” he said. Kelly and other U.S. officials said the release did not involve a quid pro quo with Iran and was not a part of the Obama administration’s attempts to engage that country’s leaders.

Rather than re-arrest the five, the Iraqi government granted them a meeting with Maliki and then reportedly turned them over to Iran’s embassy in Baghdad … Thursday’s developments were further evidence of the shifting relationship between Iraq and the United States, which just over a week ago withdrew its remaining combat troops from Iraqi cities. In carrying out the forces agreement — and in negotiating it last year — Maliki has acted with increasing assertiveness, and sometimes in ways not in line with U.S. interests.

The release of the Qods operatives came even as US intelligence reported more Iranian-backed terrorists coming into Iraq. Roggio writes:

The US and Iraqi military believe the Special Groups are preparing to re-initiate fighting as their leaders and operatives are beginning to filter back into Iraq from Iran. On Feb. 4, Lieutenant General Lloyd Austin, the deputy commander of Multinational Forces Iraq, said that Iran continues to arm, fund, and train the Special Groups, and that munitions traced back to Iran continue to be uncovered in Iraq. Recent intelligence and the finds of new Iranian caches “lead us to believe that Iranian support activity is still ongoing,” Austin warned.

Britain is ready to cut its nuclear capability if rogue states are prepared to cooperate, Gordon Brown signalled last night. The Prime Minister and other G8 leaders agreed to U.S. President Barack Obama’s proposal for a major summit next spring designed to pave the way to a revised global nuclear treaty. …

The U.S., France and Russia have also made some significant-reductions. This week President-Obama and Russian president-Dmitry Medvedev signed a preliminary agreement to reduce the world’s two biggest nuclear stockpiles by as much as a third. Mr Obama’s proposal brings to an end eight years of U.S. resistance to new arms treaties. …

‘North Korea is attempting to build a nuclear weapon. We have got to show we can deal with this by collective action. What we need is collective action by the nuclear weapons powers to say that we are prepared to reduce our nuclear weapons, but we need assurances also that other countries will not proliferate them.’

What sort of assurances might be sufficient? The problem is that if the West promises to reduce their nuclear arsenals they are actually going to do it. But if Kim Jong Il promises not to sell nuclear technology to certain unsavory persons, what do we have? His word as a North Korean gentleman? Gordon Brown’s offer brings to mind the famous dialogue between the bandido Gold Hat and Dobbs in the Treasure of the Sierra Madre:

Gold Hat: Hola, senor. We are Federales. You know, the mounted police.
Dobbs: If you’re the police, where are your badges?
Gold Hat: Badges? We ain’t got no badges! We don’t need no badges. I don’t have to show you any stinkin’ badges!
Dobbs: You’d better not come any closer.
Gold Hat: We aren’t trying to do you any harm. Why don’t you try to be a little more polite? Give us your gun and we’ll leave you in peace.
Dobbs: I need my gun myself.
Gold Hat: Oh, throw that ol’ iron over here. We’ll pick it up and go on our way.
Dobbs: You go on your way without my gun and go quick!
[Dobbs fires a warning shot with his rifle at Gold Hat, piercing a big hole in the top of the bandit's hat]
Gold Hat: Look here, amigo. You got the wrong idea. We don’t wanna get your gun fer nothin’. We wanna buy it. Look. I have a gold watch with a gold chain, made in your own country. The watch and the chain - they worth at least two hundred pesos - I ‘change it fer yer gun. Y’better take it, thatsa good bizness for you!!
Dobbs: You keep your watch. I’ll keep my gun!

Who would be stupid enough to fall for the “throw that ol’ iron over here” trick? Oh wait …

Everything I said in Minus Five applies, only more so.

Let us be frank. We must look at the situation and ask, “How far can we nudge this place by the year 2100 … if Afghanistan is to reach even the level of Nepal — maybe we could do that in 25 years. Meanwhile, Germans and Canadians seem to be growing weary … Yet we and our many allies must realize that this cake will not be baked in 10 years. … a key Japanese official … told me they are committed to 10, 20, maybe 30 years. It will take 100, but at least the Japanese are thinking straight, while most of us are not.

The current plan for Afghanistan campaign has implicitly assumed that the goal of creating a society able to resist al-Qaeda like groups can be reached with the time and resources available. There’s no reason to believe why this must be true beyond the assertion that it is. If Michael Yon’s insight is correct, then the assertion is not proved; and we may be trying to solve an problem of exponential complexity with a polynomial time algorithm; that is to say trying to attain a strategic goal unreachable by the tactical means at our disposal. The way forward in these cases is to solve a smaller problem that will have most of the benefits of solving the big intractable one. Good strategists find these smaller but still useful solutions when they can’t fix everything. Bad strategists simply hire spin doctors to declare things fixed before the cracks show.

There’s a saying among the Taliban that the Americans have all the watches but the Jihadis have all the time. Good strategists find ways to make time work for them. Bad strategists and spin doctors know only one kind of time: the “decent interval”. Michael Yon’s dispatches raise questions to which there may be no good answers. But getting the right questions is half the battle won.

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It’s probably too early to tell, but if it does represent a long term fall in President Obama’s popularity numbers, where will it lead?

Sometimes a President responds to growing unpopularity by becoming more cautious about his initiatives. At other times it hurries him on. In this case, I think it will hurry him on. The size of his initiatives means that if he doesn’t succeed in putting them across, then they will round on him and bite. He’s staked too much to turn around now. So if his popularity continues to drop his attempts at Hope and Change may, paradoxically intensify.

• “I think there’s a great opportunity right now for a Sunni-Jewish convergence. The Sunni Arab states and Israel have, for the first time, a common adversary.”
• “The question of Israel is the question of what happens to all minorities in the Middle East. The Arab Muslim Middle East has 300 million people. It has a very hard time treating Coptic Christians with equality, treating Maronites in Lebanon with equality, treating Southern Sudanese in an equal way, treating Kurds in an equal way, and dealing with Jews – not only in their national expression, but even as minorities within their own countries.”
• “Just because a belief sounds ridiculous to you doesn’t mean it’s not sincerely held.”
• “Palestinians, over the years, have proven that they’re willing to sacrifice generations of people to achieve their goal of a Jewish-free Palestine. “
• “there are two Israeli strategic doctrines in confrontation right now. The first is: never do anything that harms the strategic relationship with the United States of America. The second is: prevent, at all costs, the possibility of a Second Holocaust. What if these two things come into conflict?”
• “Arabs are misreading history if they believe Israel is a temporary phenomenon. Nothing like this has ever happened in history. A dead tribe came back and seized the land it had, and did so after a devastating tragedy.”

It’s fascinating reading.

Meanwhile, Michael Yon visits the Maranaos of Mindanao in company with Filipino and American soldiers. Some excerpts:

• “Since going to British tracking school in Borneo, I pay closer attention to feet. The Taliban normally wear running shoes that often are not available in local Afghan markets. One British soldier wrote that he took inventory of all the shoes sold in his Area of Operations (AO) in Afghanistan, and subtly photographed all the men’s shoes so that he could build a library of footprints in his AO. His men avoided at least one bomb due to his tracking skills.”
• “The AFP troops held themselves like experienced soldiers. The were respectful and professional, but watchful. Made sense because I had a camera, but I also had plenty of time alone with the villagers and they could have dropped a hint if this were just a dog and pony show, but none did.”

Perhaps the greatest driver of military outcomes in history is demography, and its handmaiden, culture. Goldberg’s view of the problems of the Middle East appear to be partly rooted in the unresolved question of minorities under the Ottoman Empire. That vanished entity was based on the idea of civil peace in exchange for subordination. For so long as minorities acknowledged the theoretical superiority of the Sublime Porte and Islam then the principle of subordination was observed. When the Ottoman Empire collapsed under the impact of rising nationalism that principle was challenged. Huge upheavals followed beside which the foundation of Israel was small potatoes. Who can now remember that Smyrna was once the largest Greek city in the world. It’s now Izmir. Vast populations moved into their historic “homelands” from the wrack of the Ottoman empire. Some succeeded, some failed. In the case of the Maronites and the Jews the issue is still in doubt. Now, with nationalism and the West apparently on the wane, the old idea of subordination may be asserting itself again.

In Mindanao the story is similar but on a much smaller scale.  What defeated the Moros were roads and ports and public school teachers. Together they brought the Christian Filipinos in vast numbers to Mindanao under the security of the US Army.  So many that “Muslim Mindanao” as such died, probably forever. And while the Filipino Christians were often the early adopters of Western technology and education, many of the Muslims clung to their warrior ways. The Mindanao State University, which is located in the area Michael Yon visited, was lavished with an extraordinary amount of funding not only from the Philippine government but from the Middle East. But it remained a hulk, its funds looted by Muslim warlord politicians and its culture of Western-style learning fundamentally despised.  The divide between the two cultures remained, though they lived in close proximity. What holds the ring in Mindanao isn’t tactics but demography.

Michael Yon is absolutely correct is emphasizing the importance of “professionalism” and relative honesty as important factors in the long term victory in Mindanao. The biggest contribution American troops make in a Philippine setting is that they often provide the role models which Filipino politicians do not. Strange though it may sound to some, many Filipino soldiers want to be good, professional and disciplined soldiers. But like everyone else, they must have leadership. And while there are some Filipino officers and politicians who provide that, many alas, fall somewhat short of the mark. And while some Americans by contrast can be rascals, by and large, when you consider the average values of professionalism in their respective cultures, the US military is much more likely to provide a good role model than the Manila politician. I know it is an oversimplification to say it, but if informal American influence can simply keep the Armed Forces of the Philippines from descending into chaotic gangsterism, then numbers will do the rest. Many of the problems of the AFP are rooted in Philippine politics. On paper its numbers are impressive. On the ground, except for the few units which are combat effective, much of the Philippine Armed Forces is fit only for garrison. Available ammo, fuel and money limit the actual sustained combat capacity of that force to a small fraction of its numbers.

Maybe history suggests that “democracy agendas” and “grand bargains” are misleading terms.  Perhaps when we say “democracy” we really mean decent behavior more than mere formal elections. I doubt that the Muslims of Mindanao can ever learn to love the Christian Filipinos, but they can learn to grudgingly respect them; to live and let live. And in the Middle East, what “grand bargain” is possible when the demand on the one side is the destruction of the other? Goldberg notes that for the first time in decades, Israel’s choice may be between its strongest alliance and its self preservation.  When were the roots of this contradiction planted? When Britain defeated the Ottomans? When the US toppled Mossadegh? When Carter dropped the ball on Iran? When Bush invaded Iraq? Or when Barack Obama, in pursuit of his Grand Bargain, drove the Sunnis and the Jews into temporary alliance? Political dreams often give rise actual nightmares.

There is in Michael Yon’s article a series of pictures showing the everyone eating rice and fried fish off a mat on a table, washing it down with Pepsi. The kids are giggling, the Americans are pawing at the rice with as much gusto as anyone else and even the scowling Muslim warrior is grinning, in spite of himself. It’s a snapshot of a non-political moment; an instant in time when everybody forgets he’s from Duluth, or Marawi, or Fort Bonifacio and one mumbles to the other, “please pass the ginamos“.  History is our curse. We cannot transcend it. But we can glide through it with as much goodwill as we can muster.

A spokesman for NHS East Riding of Yorkshire said Mr Boynton’s case gave an ‘inaccurate scare-mongering picture of dental service provision in East Yorkshire based solely on the claims of one man’… NHS East Riding of Yorkshire has invested around £1 million in helping dentists target new patients. At many of our dental practices appointments are being offered to new patients within two weeks. ‘Our local out-of-hours and Accident and Emergency Services would have both been able to give Mr Boynton details of how to access emergency/urgent dental services if he had approached them.’

Appointments to the dentist within two weeks. If you know where to call. And conditions apply. The Father of the British welfare state, David Lloyd George, described his goal as one of creating “a land fit for heroes”. But that has not worked out too well in some respects.  It’s not as if the British were discriminating against ex-servicemen.  One enterprising civilian, similarly unable to find an NHS dentist, has resorted to the expedient of supergluing the fragments of his teeth together.

Gordon Cook, 55, has used the bizarre “DIY dentistry” technique on a loose crown for the last three years - with each fresh application of glue lasting around two months. The father of seven, who was erased from his original dentist’s register after moving to a new home in Tranmere, Merseyside, said he turned to glue after losing hope of finding a dentist. He said: “I tried to find a new dentist but they had all gone private.

“A lot of them said they would take me on as an NHS patient, but only if I agreed to have the loose crown fixed as a private patient, which would cost around £100.

“In the end, I just decided to take matters into my own hands. I had read somewhere that super glue was invented for medical use, to bond skin, so I gave it a go.

“I tried a few different brands but the one I use now, which is just called Industrial Super Glue, is the best.

Time Magazine wrote that while the Britons on average have fewer cavities than many other European nations, about 6% of the population engages in some for of do-it-yourself dentistry.

In a survey of thousands of English dental patients and hundreds of dentists published this month by the government-backed Commission for Patient and Public Involvement in Health, 6% of English patients fessed up to administering their own treatments. One admitted to yanking out 14 of his teeth with pliers; another had used Super Glue to repair a crown. Paul Rowland, a warehouse worker from Derby, in central England, was at least smart enough to take “a good swig of whisky for the pain,” before using pliers and thread to pull out his own troublesome back tooth last month, he says. “It hurt like hell for a couple of seconds,” 52-year-old Rowland recalls. His post-op pain relief? “Another swig of whisky.” …

Rowland insists he’s suffered no ill effects. And it’s only the second tooth he’s ever lost as an adult. But why take fangs into your own hands? Like most of those surveyed who owned up to self-treatment, Rowland has found it difficult getting professional treatment, because of a shortage of dentists offering services through Britain’s decades-old, taxpayer-funded National Health Service (NHS). There were 21,000 dentists available to NHS patients in England in March this year, almost a quarter more than the number drilling and filling a decade ago — although around 500 less than a year ago. Hundreds of dentists quit the NHS for more lucrative private work before revamped NHS working arrangements came into force in April last year.

Among those said to be using a private dentist is Prime Minister Gordon Brown, who reportedly had his teeth whitened to improve his appearance on camera. According to the Guardian ,Dr. Mervyn Druian’s promises to turn your teeth up to 14 shades whiter — for a fee. But it costs.

Framed on Dr Mervyn Druian’s waiting room wall is a two-page puff piece from Vogue. This is a dental surgery with a press kit. ‘If you’re splashing out for Prada,’ it reads, ‘why not splash out on your smile!’ The number of people buying porcelain veneers - at around £600 per tooth - has risen 144 per cent in the last year, while demand for tooth-whitening, at around £500 a pop, has also rocketed. Teeth, ladies, are the new handbags. They’re sparklier and stronger, and about 80 per cent less likely to be nicked. Bargain.

Besides obvious contenders for a glow-in-the-dark smile (Hollywood A-Listers), less glamorous types are choosing to bleach out their imperfections. See Gordon Brown. The new Prime Minister visited Dr Druian in his London Centre for Cosmetic Dentistry last year, though they insist, repeatedly, that he was there for non-aesthetic surgery. He emerged hours later to run the country with a dazzling smile.

For those without the funds, Wite-Out, together with the channel-lock pliers and superglue remain an option.

The most exciting and underreported news of the past few weeks in Iran has been that the emerging challenger to the increasingly frantic and isolated “Supreme Leader” Ayatollah Ali Khamenei is former President Ali Akbar Hashemi Rafsanjani. And Rafsanjani has recently made a visit to the city of Najaf in Iraq to confer with Ayatollah Ali Husaini Sistani, a long-standing opponent of the Khamenei doctrines …

It is this dialectic between Iraqi and Iranian Shiites that underlies the flabbergasting statement issued from Qum last weekend to the effect that the Ahmadinejad government has no claim to be the representative of the Iranian people. One of the apparent paradoxes involved in visiting Iran is this: If you want to find deep-rooted opposition to the clerical autocracy, you must make a trip to the holy cities of Mashad and Qum.

Among the more surprising members of the anti-Khomeini opposition is the late ayatollah’s grandson Sayeed Khomeini, a relatively junior cleric in Qum about whom I have also written before. … Which brings me to a question that I think deserves to be asked: Did the overthrow of the Saddam Hussein regime, and the subsequent holding of competitive elections in which many rival Iraqi Shiite parties took part, have any germinal influence on the astonishing events in Iran? Certainly when I interviewed Sayeed Khomeini in Qum some years ago, where he spoke openly about “the liberation of Iraq,” he seemed to hope and believe that the example would spread. One swallow does not make a summer. But consider this: Many Iranians go as religious pilgrims to the holy sites of Najaf and Kerbala in southern Iraq.

An Australian general officer who recently served in Iraq remarked at a dinner address I attended that all he expected OIF to achieve was to ‘restart the clock of history which had been stopped by Saddam Hussein’.  He did not imagine that Iraq would automatically be pro-Western, but he did expect that it would find its own destiny. Certainly this implies, as Christopher Hitchen’s article suggested, that opposition to the current regime in Iran would not necessarily resemble an American political party. But to the question of whether OIF helped restart the clock of history in Iran, I think the probable answer is yes. The connections between the Iraq’s Shi’ite South and Iran run too strong and deep for there to have been no effect.

But there is an implicit tragedy in Hitchen’s analysis. His article does not follow the argument far enough. If he is right, the overriding goal of Iranian diplomacy must of necessity be the strangulation of a rival power center south of the border. If Hitchens is right about Iraq precipitating much of the unrest against Teheran, then it follows that Teheran will want to clamp down in Iraq. And it also follows that if Barack Obama is truly attempting a “grand bargain” with Iran in exchange for an “exit” from Iraq, then Teheran will surely want him to neuter Shi’ite dissidents in Iraq. Unless Iraq is dampened, then Teheran will fear regime change from that quarter and Obama has already forsworn that. Whether Obama will accede to the pressure remains to be seen. The clock of history may have restarted, but Iran will try to persuade Washington to let it wind down. It may however be the case that the Shi’ite resurgence in Iraq is already irreversible; in which case, as Michael Ledeen says, the storm is still ahead.

Emanuel and the White House are attempting to reorganize the delivery and reimbursement systems of health care, changing what the types of procedures doctors rely on, making people more aware of disease prevention, encouraging insurance companies to expand coverage, and so on. It is a process rife with sensitivities, trickeries and, of course, the potential for failure. It is not, he insists, impossible.

“It is a complicated process and we have to try and make the choices clear and give people good reasons for making them,” Emanuel explains. “I don’t think that’s an impossible task and thankfully we have one of the great communicators, Barack Obama, at the helm of this ship of state.”

Emmanuel recently authored an article in the Lancet describing the various models of non-market health care rationing. Titled “Principles for allocation of scarce medical interventions”, its is co-authored with Govind Persad and Alan Wertheimer. In it the authors simply review the pros and cons of the various ways of deciding who gets treated and who doesn’t. The allocation mechanisms they discuss are divided into strategies and substrategies. The pros and cons of each are laid out.

Treating People Equally

1. Lottery
2. First-come, first served

Prioritarianism

1. Sickest first
2. Youngest first

Utilitarianism

1. Saving the most lives
2. Saving the most life-years
3. Saving the most socially useful
4. Reciprocity (paying back people who have ‘contributed’, such as organ donors)

The authors are not very satisfied with the current metrics used for making medical decisions based on saving the most life-years. Both the “Quality-adjusted life-years” model and the “Disability-adjusted life-years” have shortcomings which they believe can be addressed by another model of their own: “The complete lives system”, which takes all the factors into account. They write:

Because none of the currently used systems satisfy all ethical requirements for just allocation, we propose an alternative: the complete lives system. This system incorporates five principles: youngest-first, prognosis, save the most lives, lottery, and instrumental value. … When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated … the complete lives system is least vulnerable to corruption. Age can be established quickly and accurately from identity documents. Prognosis allocation encourages physicians to improve patients’ health, unlike the perverse incentives to sicken patients or misrepresent health that the sickest-first allocation creates.

Under this system, patients would receive scarce care according to the graph shown below.

The paper concludes: “the complete lives system combines four morally relevant principles: youngest-first, prognosis, lottery, and saving the most lives. In pandemic situations, it also allocates scarce interventions to people instrumental in realising these four principles. Importantly, it is not an algorithm, but a framework that expresses widely affirmed values: priority to the worst-off, maximising benefits, and treating people equally. To achieve a just allocation of scarce medical interventions, society must embrace the challenge of implementing a coherent multiprinciple framework rather than relying on simple principles or retreating to the status quo.”

What’s not mentioned anywhere in the discussion, except by implication is the identity of the narrator. Who is the “we” in “Principles for allocation of scarce medical interventions” that decides who gets scarce medical care? The answer is tangentially provided in the paper itself, which writes that “the complete lives system is least vulnerable to corruption”.The “we” is  a system; a system that can possibly be corrupted; hence Dr. Emmanuel’s efforts to design one in which such distortions will be held to a minimum.

Ultimately health care reform is as much about politics as it is about medicine. The discussion in Dr. Emmanuel’s paper is incomplete if limited to pure public health considerations. Politics is central to the whole issue. Whatever “guidelines” are chosen, however rational, however humane, can never implement themselves. Human beings in positions of power are required to do that. And while it is important to note that even under the current system these decisions are being made by someone or by some consensus, it is also vital to realize that in any “health care reform” effort, one of the principal outcomes is to shift the power to make those decisions to someone else. That may not be a fit subject for the Lancet, but it is the elephant in the operating room in the national health care debate.