Back to: In the pulp | Forward to: "Fuck every cause that ends in murder and children crying" — Iain Banks, 1954-2013

Crib Sheet: The Jennifer Morgue

(As with "The Atrocity Archives" I need to refer you first to the essay I wrote, by way of an afterword, which is included in the book. This crib sheet is about all the other stuff—think of it as metadata about the inception and writing of the novel, rather than the James Bond oriented contents. For the most part.)

All stories have several seeds. In the case of "The Jennifer Morgue", the first seed was the surprising success of "The Atrocity Archives". The novel my agent initially thought was unsaleable sold to Golden Gryphon, a small but respectable Lovecraftian publisher in the United States. It went gold, going into reprint and becoming their second-best selling title at the time. Then, to everyone's surprise, the additional novella I wrote for the book ("The Concrete Jungle") made the shortlist for the Hugo award in 2005. This was a stunning surprise. GG had only sold around 3000 copies of the book; the other novellas on the shortlist had all appeared in magazines or anthologies with four to ten times the number of copies sold! After some hurried email consultation, Gary and Marty at GG agreed to let me put the whole novella on the web, to make it more readily available to the Hugo voters. I don't know if that's what did the trick, or if there were additional home-mover effects from the Worldcon in 2005 being held in Glasgow (thus bringing more British voters in than normal) but at the end of August that year I became the dazed and surprised owner of a very shiny trophy.

(And the performance anxiety that had been haunting me for years—"I'm not a real writer, I'm just winging this"—went away for a while.)

But anyway. This success coincided with a French publisher making an offer for translation rights to "The Atrocity Archives", which in turn got my agent's attention. She proposed a sequel, and James Bond was so obvious that I don't think I even considered any alternatives. It would have to be the Movie Bond franchise, for most people these days don't grow up on the original Ian Fleming novels (the way I did); the humour would come from the incongruity of Bob Howard in James Bond's shoes. We decided to auction the new book, along with paperback rights to "The Atrocity Archives", and ended up cutting a deal whereby Golden Gryphon would publish "The Jennifer Morgue" in hardcover while Ace rolled "The Atrocity Archives" in trade paperback, and eventually in mass market. Which then left me pondering what to write ... because every Bond movie (or novel) needs a Bond-sized plot device, doesn't it?

By this time we were into late October 2005. One evening, we were eating a Chinese take-away in front of the TV, watching a documentary on the Discovery Channel about one of the most bizarre CIA projects to happen during the Cold War—Project Azorian (better, but mistakenly, known to the public as "Operation Jennifer"). Seriously, if you don't know about it, go follow that link right now; it's about how the CIA enlisted Howard Hughes to help them build a 63,000 ton fake deep-see mining ship, the Glomar Challenger, as cover for a deep-sea grapple that would descend 4,900 metres and raise the hull of a shipwrecked Soviet nuclear missile submarine, the K-129. (Project Azorian was so James Bond that the engineering crew working on the ship were cracking jokes about the bald guy stroking the white cat in his seat on the bridge. How post-modern can you go?)

Well, this documentary was livened up by some CGI depictions of the Clementine grab latching onto the hull of the sub and lifting. And one of these animations in particular showed the view from underneath the hull, as the claws on the gigantic mechanical grab locked on and then began to take the weight of the sub ...

At which point my wife made an up-reaching gesture and said, "tentacles".

(And now you know where the first chapter and the whole plot revolving around the Deep Ones come from, right?)

That's when I got serious about studying the Bond movie canon.

Obviously I read all the books. I also ploughed through one and a half biographies of Ian Fleming. But I also realized I had gaps in my movie experience. So I ordered the deluxe 20-DVD boxed set of Bond movies, and with the help of a local film producer and an inordinate quantity of beer, we ran through most of the movies over the next two months. First the Sean Connery classics, then the early Roger Moore—I didn't have the stomach to re-watch "Octopussy" or the subsequent decline—then the Timothy Dalton movies (excellent actor handicapped by poor scripts) and the Pierce Brosnan reboot. This was, of course, pre-Daniel Craig. And I didn't bother with the non-canon movies: "Never Say Never Again", or the Basil Rathbone Bond of "Casino Royale". By the time I got through over a dozen Bond movies my head hurt, but I was up to speed again: I was even at the point of drawing flow charts of the generic Bond movie opening sequence. Here they are:

* Bond movie opening scene flow chart
* Bond movie plot flow chart

By December 2005 I was ready, and I began to write. And when you've got the Bond flow charts in front of you, it pretty much writes itself, from the opening scene to the moment our Hero runs into a femme fatale in a hotel bar, to the Perilous Mission and the Briefing Scene and the bald guy in the Nehru suit with the cat ("Fluffy has very expensive tastes ...") and the explosive finale and then the final villain's-attempted-revenge scene at the end (see also "Diamonds are Forever", "On Her Majesty's Secret Service", etcetera etcetera).

Now, the Laundry novels have a strong horror tone. And while I was writing "The Jennifer Morgue" something very strange was happening to me. I had a peculiar sense of dread, a numb, tingling fear that kept creeping up on me, an unreasoning conviction that something was very wrong in my world: a premonition that I was going to die.

This kept growing over a couple of months, and it was most disturbing. I didn't talk about it to anyone, but it kept eating at me, trying to sneak into the book at odd moments. And then, one Saturday evening, the dam burst at a regular monthly writer's workshop session in Edinburgh (the same workshop that various Edinburgh SF writers have come out of—people like Andrew J. Wilson and Hannu Rajaniemi). I began to feel a fluttery sensation in my chest, my heart skipping beats. That wasn't a premonition: it was an actual physical symptom of something. The parasympathetic nervous system is a wonderful thing, and if you should feel numinous dread creeping up on you for no obvious reason you should consider the possibility that your body is trying to tell you something. In my case, I went home, did some hasty revision, concluded that palpitations weren't immediately life-threatening, and scheduled a visit with my GP the following Monday (rather than clogging up an emergency room on a Saturday night).

My GP back then was very old-school, so when he took my blood pressure, frowned, checked his sphygmomanometer, and took it again, I got a little worried. But not as worried as I got when he picked up the phone, dialed a number, and said, "cardiology ward? Do you have a free bed?"

The reason for the sense of dread was that I was slowly drifting into hypertensive crisis, with blood pressure of 250/150. The palpitations emerged when my blood pressure was so high that the back-pressure was impeding the flow of blood through my heart (which showed signs of enlargement on ultrasound—a common symptom of prolonged hypertension). Seriously. Bizarre sense of dread and palpitations? Go see a doctor. I did—which is why I'm still alive, seven years later, and my blood pressure is much closer to normal, thank you very much (and thanks to my cardiologist).

((Lest you think this medical ramble is irrelevant to the writing of fiction, I'm going to bring it—and its long term consequences—up again in future Crib Sheets. Because going on blood pressure medication for life can have weird cognitive effects, and as most authors are in their 30s to 60s, I'm hoping someone reading these essays finds them helpful—or even life-saving.))

Anyway: this is by way of saying that while "The Jennifer Morgue" isn't as obviously scary a read as "The Atrocity Archives", it was very scary while I was writing it.

(Penultimate note: the incident in the first chapter about Bob, in which he's driving a Smart car up the Autobahn while being strafed with BMWs and Audis from behind, is based on an anecdote the CTO of Datacash told me. Dave had flown out to visit a possible customer in Dortmund, but ended up at Dusseldorf airport's car hire desk, only to discover he'd been given the keys to a Smart car. He survived, but was a bit shaken by the experience.)

The Golden Gryphon cover: Gary Turner commissioned Steve Montiglio to design the cover for hardback of "The Atrocity Archives". So it was a natural choice for him to get Steve to do the cover for the sequel. Now, my input on covers from my major publishers is mostly restricted to being expected to respond enthusiastically when I receive an email with an 8Mb attachment and the text, "Charlie, here's you're new book cover—all of us here at the office love it, what do you think?" (For more on this subject, I have an in-depth explanation.) But with Golden Gryphon, the author is (shockingly!) given some choice in the matter. Steve came up with a couple of rough sketches ... and neither Marty Halpern (my editor) or I were terribly keen on them. So then Steve did a couple more, and a joke design, riffing off the dubious, sexist cheesecake of the Bond movie title sequences (traditionally full of silhouetted naked women), only with a fish-headed chimera in place of the model. And both of us went, "yes!" ... which is where "The Jennifer Morgue" got its cover.

The Jennifer Morgue - original cover

85 Comments

1:

Because going on blood pressure medication for life can have weird cognitive effects [....]

Ummm -- could you expand on that? Or link to a relevant article or two? My paranoid Google searches aren't turning up anything useful, and it would be much appreciated.

2:

I'm going to, but not right now. Papers and articles don't really give a good subjective insight into what it feels like -- they tend to list frequency of notified side-effects, which is generally lower than their actual frequency (not all instances of side-effects are reported) and don't give much attention to what they actually mean in terms of real-world impairment. So it needs a bit more of a discursive approach.

For now, let's just say that I believe antihypertensives have ruined more than one literary career (and coming off antihypertensives "just until the novel's finished" has killed at least one author I knew).

3:

Those Golden Gryphon versions are beautiful to look at, yeah. Though I understand the busi ness reasons behind why the later ones are from a different publisher, I am still sad about it.

4:

GG printed 6000 copies of "The Jennifer Morgue". (I believe they're nearly sold out now.) Previously, with 4000 copies in print (3000 initial run, 1000 second printing), "The Atrocity Archives" was their second best-selling title ever. So TJM was pushing the boat out 50% above their high water mark.

6000 copies is quite a lot less than my normal hardcover run these days ...

Hardcovers are sold on sale-or-return after 90 or 120 days. Some bookstores choose to pay and keep a handful in stock until they eventually sell, but many run on revolving credit, "churning" stock.

My understanding is that the unsold 90 or 120 day returns on a subsequent Laundry hardcover would quite possibly exceed a normal Golden Gryphon hardcover print run. And someone has to store/recirculate those books. I didn't want to be responsible for GG locking up a chunk of their capital in unsold stock; and book #3 coincided with GG down-sizing, cutting back from 3-4 books a year to 1-2 books, and from 2 editors to 1 editor. So moving to Ace was an easy-ish decision.

(I'm not going to discuss the other participants in the auction for paperback rights to the Laundry books until all the editors concerned have retired.)

NB: it is possible that there will be a limited edition hardcover release of a forthcoming Laundry novella with a cover by Steve Montiglio, matching the GG novels, within the next 12-18 months. Watch the blog for a more detailed announcement in the next few months.

5:

I love the Bond flow charts. It occurs to me that thye can be reused for many many action advendture quest kinds of book/movie

6:

Add me to the list of people eager for an explanation of that statement about anti- hypertension medication. I've been on them for more than 15 years, changing dosage and particular meds every few years as the pressure creeps up. I've had EKGs, ballistic EKGs, echocardiograms, renal ultrasounds, and Ghu knows what all, trying to diagnose the cause, and everything is clean.

And while I haven't been specifically aware of any cognitive side effects of the medication, during approximately the same period I've been permanently on meds for ADD and intermittently, but for periods of a year or more, on zolpidem and pain relievers up to and including gabapentin, and had 3 multi-hour surgeries under general anesthesia with codeine chaser, so it's hard to isolate those effects.

Increasing my concern is that during that time I've suffered one major (>2 years) and several minor bouts of clinical depression. At no time has any of my medical professionals mentioned cognitive side effects of the blood pressure drugs.

7:

Minor quibble: Glomar Explorer, not Glomar Challenger.

8:

I remember seeing you wandering around the con a few hours later, still clutching your rocketship and still grinning from ear to ear. :-)

I love the Golden Gryphon covers, and really wish I'd grabbed copies while I was still living in the US and regularly went to Marty Halpern's panels at BayCon.

9:

I lack the words to express how much I loved this book.
It's my favorite Laundry, and I enjoyed the other books A LOT.

10:

Me to I am on some fairly aggressive bp meds 100 MG Lostartin ( i am on the kidney transplant waiting list for a few years hence)

Only had a couple of odd occasions on them and haven't noticed any cognative efects.

Though a few years I was on Prednisalone now that has some interesting side efects.

11:

Can you give a hint about the sales-dynamics inside a series of books ?

My naïve zero-order model would be that the first volume sells most copies and the rest sells about the same number of copies ?

But what happens when you get lucky and get high-level exposure down the series ?

To take a purely hypothetical example: A Nobel Laureate blogs about your book. Does that sell one copy of all books in the series, or do people start, volume for volume, wherever the smart guy with the blog points them ?

I could imagine that freight cost would skew that towards "Hey, it's only three books, I'll buy them all right away" ?

Which exposure have sold most copies of the Laundry stories ?

12:

Your naive model is mostly correct; however, some readers tend to drop a series after book 2 if it doesn't live up to expectations generated by book 1, so there's usually a downward trend. A series that can merely sustain sales on a plateau is doing well.

Well-designed series therefore come with "entrypoint" volumes designed to pick up new readers. The new Merchant Princes series will be three books, beginning with an entrypoint to make it accessible. "The Rhesus Chart" (Laundry Files book 5) is also intended to provide an entrypoint -- you might have noticed the plot of "The Apocalypse Codex" would be a little impenetrable to someone who hadn't read "The Fuller Memorandum" before it.

Gearing sales to individual exposures ... simply doesn't work, unless it's something like being featured on a high-audience TV show like Oprah (back in the way). If that happens, suddenly the publisher's marketing team get a rocket up their collective arse, reprint orders are hastily placed, and there may even be a follow-on signing tour. But chances of that happening to a genre title are minimal.

13:

Add me to the list of those *very* interested in the effects of anti-hypertensives on writing, given that my first novel is coming out this year and that I've just been diagnosed with the kind of low-grade hypertension where they're an option, but not the *only* option.

(Although I must say that the poor cognitive effects of hypertension itself are pretty bad).

Whatever the effects, though, I'm glad they've worked in your case, that you're still alive, and that your writing hasn't suffered.

14:

I'm another with an interest in the anti-hypertensive thing. I can't say that I was aware of the pharma impacting my cognitive state - but when the causes of the potassium deficiency which drives my BP issues was addressed that certainly had a positive effect. The specialist I see is at a unit in an Edinburgh Hospital. To drag this closer to topic, I have shared a waiting room there with our host a couple of times but thought it was an inappropriate time to say hello.

15:

If you are interested in the Azorian inside story, check out http://www.gwu.edu/~nsarchiv/nukevault/ebb305/index.htm

16:

Since I'm one of the many people who have negative responses to statins, I've got an alternative to pitch to those who (like me) are in the "Syndrome X" stage of developing full-blown hypertension/diabetes/etc. from eating a little too much and not exercising enough. In my case, the problem with statin use was persistent muscle pain, especially in the small peripheral muscles. This may sound benign, but when it interferes with the minor muscles associated with swallowing (as in my case), it's big trouble.

Anyway, my partner and I have so far been doing a partial fast: two days per week, we try to eat no more than 500 (or in a pinch, no more than 1000) calories. Just for fun, we're following the basic Greek Orthodox pattern: fasting every Wednesday and Friday, except holidays. On those days, in addition to calorie restriction, we eat no olive oil, no alcohol, and no products of anything with a backbone. Veggies and shellfish are fine (presumably insects are too, but they're expensive and my partner is squeamish).

So far, I've lost about ten pounds, at a bit over a pound per week. My partner's blood chemistry is getting better (she had her physical), and when I go for my physical, I'm hoping my blood chemistry will be better too.

The advantage of a partial fast is that it costs very little. Certainly, it's not incredibly fun to be hungry, and it does hurt productivity on the two fasting days. However, if it can take the place of lifetime statin use, I'm more than willing to do it. It's better than suffering 24/7.

17:

Another minor quibble: David Niven, not Basil Rathbone. (Rathbone died in '67 and was in at least one movie that year, so he could have played Bond; but he didn't.)

18:

I took that as OGH saying that Casino Royale was "Bond" in the same way that the Rathbone films were "Holmes" -- which is to say, not very.

(And after all, Niven wasn't the only Bond in that film...)

19:

So, was there a definite favourite Bond book or film?

20:


In addition to losing weight by the partial fast, try avoiding all grains all the time. My mother saw some improvement in hbp from significant weight loss, but not enough - the NHS doc wanted her to move up to the next most drastic medication; she already felt the cognitive side effects of what she was taking, so she was willing to give 'no grain' a try. Within 8 weeks she and the medics could see enough improvement that she's persisted with it. She's been off all medication for more than two years now, with great improvements in her general level of energy and outlook on the world.

21:

It doesn't exist -- but I'd love to see a true-to-the-book movie of "Octopussy" starring Timothy Dalton circa 1990. (Note: "Octopussy" the book bears no resemblance whatsoever to the shitty Roger Moore movie of the same name. Other than rockets. And Bond, James Bond.)

22:

I've recently started taking meds for my blood pressure, and they do seem to make me a bit less energetic. Less blood pressure means slower blood flow carrying oxygen to my cells, I guess.

Of course, this sort of story leaves the Americans in your audience with a serious case of NHS envy. In similar circumstances over here, you'd probably have gotten a bill in the mid five figures for that stint in the cardiology ward. That sort of thing is the leading cause of bankruptcy over here.

23:

The meds which have had the largest psychological effects on me were decongestants.

1) Once-common nonprescription decongestant; for the first week, mild marijuana-like effects. Diminished and faded away. (I'm told that at the time -- 1960's -- it contained a belladonna derivative.)

2) Prescription decongestant I was trying out made me depressed. Took me a while to realize it, because it felt so natural.

24:

Yes and to put a sf spin on it the case of George Alec Effinger is a salutary tale.

25:

And just to take this back on topic, I just want to say how much I'm enjoying this series of posts.

26:

Of course, this sort of story leaves the Americans in your audience with a serious case of NHS envy.

The sad thing is that the US government is already spending more than enough on health to afford the NHS. In fact the US government is spending more on health on its own than the total health spending in the UK (per capita).

Even sadder, all this money doesn't result in better health. The gross health outcomes (life expectancy, child mortality) are slightly worse in the US compared with the UK.

Somebody somewhere is pocketing $1T/year out of the US health budget.

27:

"Of course, this sort of story leaves the Americans in your audience with a serious case of NHS envy. In similar circumstances over here, you'd probably have gotten a bill in the mid five figures for that stint in the cardiology ward. "

Yes. I had a low five figure bill for just a 5 hour stay in an emergency room. They wanted to transfer me to a cardiology ward for overnight observation, which I had to positively insist on denying despite threats from the attending physician. (When you have insurance, they latch onto you like leeches).

The US hospital system would have made an admirable foe foe Bob, Persephone and Co. Any suitable wards available to fend them off?

28:

Unfortunately the party of crypto-kleptocrats currently running the coalition government are set on introducing "competition" into the NHS, using "efficiency" as a stalking horse for marketization, which in turn will let their crony private healthcare providers in through the back door. Thus turning the NHS into a single-payer insurance system rather than an integrated healthcare system, and permitting profits to be skimmed from it by the private contractors.

This means that the running costs of the (previously non-profit) NHS will have to rise (to provide the profit margin -- because you can't really run a private system cheaper than a non-profit agency with monopsony buying muscle and minimal overheads) so they can point to the failure of "socialist" healthcare and bring in a full-scale American-style private insurance system.

I wish I was making this up. Luckily healthcare is a fully devolved issue for Scotland, meaning it won't happen up here ... unless devolved powers are clawed back to Westminster by a future government, e.g. one influenced by UKIP or the Tory right wing. So we're safe for the time being, but this probably tells you why I'm considering voting for full independence next year: not so much optimism about an independent Scotland's prospects as pure blind terror of what will happen if the Tories win the next UK-wide election.

29:

Sorry, didn't mean to get distracted into a sermon on domestic UK politics. Let's just say that as a 48 year old with two major "pre-existing medical conditions" of the kind that would get me denied health insurance in the USA, my reaction to any shift away from the socialised funding model of the NHS is do not want.

30:

OGH wrote in various places:

Because going on blood pressure medication for life can have weird cognitive effects

Papers and articles don't really give a good subjective insight into what it feels like -- they tend to list frequency of notified side-effects, which is generally lower than their actual frequency (not all instances of side-effects are reported) and don't give much attention to what they actually mean in terms of real-world impairment

and

For now, let's just say that I believe antihypertensives have ruined more than one literary career (and coming off antihypertensives "just until the novel's finished" has killed at least one author I knew).

Judging by my personal experience with hypertension medication, I'm guessing you're talking about beta blockers. As you intend to do a public service post on medication side effects, I'll save my personal horror story until that thread. For now I'll simply say that although they do work without problems for some people, for me they were an absolute evil that damn near wrecked my life.

31:

Umberto Eco did a similar analysis of the Bond novels in 1966. I can't find a link to a version in English, but this blog post sums it up fairly well:

According to Umberto Eco, Ian Fleming used nine plot elements to structure every one of his James Bond novels. The only real difference between any two of the books was the order in which their author presented these elements: “The scheme is invariable in the sense that all the elements are always present in every novel. . . . That the moves always be in the same sequence is not imperative”

Bond, James Bond: A Lesson Concerning the "Inversions and Variations" of a Plot Formula

Eco also makes the observation that we therefore always know that Bond will win in the end, but not how, and that it's partly due to this familiarity that the novels became so popular.

32:

Judging by my personal experience with hypertension medication, I'm guessing you're talking about beta blockers

Not just beta blockers. Bog-standard thiazide diuretics, for example: the NHS loves bendroflumethiazide because it's been around for about 50 years and costs 0.1p/day. Trouble is, it causes impotence in around 25% of male users. In others ... it was like walking around in a fog bank for 8 hours. I stuck that one out for a week before seeing my GP and getting my prescription shifted onto a second line drug (45 years old, cost 0.2p/day) that didn't fog my mind or make me impotent.

The brain-fogging thing seems to be especially common with thiazide diuretics and beta blockers, and it's no fun at all: you just can't think clearly.

Human beings metabolize medicines differently (this goes some way to explaining why) so some of us respond differently. Another bog-standard and well-trusted diuretic, Chlortalidone, works fine for most people ... and nearly put me in hospital: I had a really bad reaction to it (blood pressure spiking and crashing between 80/50 and 190/110 in the space of half an hour). All you can do is iterate through them and hope to find a combination that works well and doesn't have nasty side-effects.

(I've had no problems with nifedipine -- a calcium channel blocker -- and my only problem with ACE antagonists was severe dyspepsia, controlled by omeprazole (risk of suppressing stomach problems is less than risk of a stroke/heart attack in my case). But it takes about 4 drugs in combination to keep my blood pressure within spitting distance of "normal", so just picking one drug and sticking to it isn't a solution.)

33:

Charlie
Do you really think that's what the tory right are up to?
If correct, it's horrible.
Trouble is the NHS is appallingly inefficient at some things - like bulk purchases, for instance - which gives them an excuse.
OTOH, an "Independant" Scotland will be a flat-broke & total-surveillance Calvinist society.
Equally horribly unpleasant.

34:

Actually, a lot of us are pocketing that extra $1 trillion. Since my partner's in the health care industry, even though I'm not happy about prices, I benefit from them.

Here's the deal: a vast majority of the cost in any sector of the US medical industry is salaries. This goes everywhere from drug discovery to patient care and insurance. When I worked at a hospital decades ago, I was told that 90% of the hospital budget was salaries, and I have no reason to think that's changed.

There are some structural problems with competition, including unnecessary reduplication of services among competing hospitals, but probably biggest is the need for medical services to maintain large billing departments to deal with all the different insurance companies.

Rather worse, the insurance model means that the patient (unless she's paying out of pocket) is the product, not the customer. Prices for services don't get set until the health care provider negotiates with the insurance company over what the insurance company is willing to pay for the customer's treatment. It's impossible to keep prices down under such circumstances, both because the insurance company can't entirely back out of paying for crappy service, and because everyone has to have a lot of people haggling over the price.

(As an aside, hospitals in many states are required by law to provide care, whether or not the patient can pay. A lot of those mark-ups like the $5 aspirin are paying for things like the long-term treatment of the homeless, drug-addicted, mental patient who's in for the fifth time this year. The hospital would have to close down its ER otherwise).

But, again, one person's inefficiency is another person's career. For example, we could, by fiat, create a national health insurance that would be much more efficient than the mess we have now. Unfortunately, all those people in hospital billing and insurance companies would then lose their jobs. Did I point out that these tend to be minorities, women, and people in northern Ohio (a big center for the insurance industry) and that they all tend to vote democrat? Yeah, that's a problem.

Anyway, that's where your $1 trillion is going.

This is the ultimate problem in the US: we have a few big industries (oil, military, finance, and medical) that directly employ a lot of people of all educational levels, that indirectly keep the US economy going through how all that money circulates through the rest of the economy. Every single one of them has (and causes) horrendous problems, but dismantling any one of them would cause a recession if not a depression. I don't think any of them is going away soon, unfortunately.

35:

Well it isn't a stated policy for obvious reasons, but it seems a likely out come of their current changes and previous history, abetted of course by the market dogma madness new labour put in place. Also of course bulk purchases could be properly legislated for, to permit the proper exertion of NHS strength in the market place.

I am not so blase about the chances of continued privatisation of healthcare in Scotland, after all we're still stuck with PFI nonsense and that's going to cost us more over time.


36:

"Luckily healthcare is a fully devolved issue for Scotland, meaning it won't happen up here ... unless devolved powers are clawed back to Westminster by a future government, e.g. one influenced by UKIP or the Tory right wing. So we're safe for the time being, but this probably tells you why I'm considering voting for full independence next year..."

This is why (while I couldn't blame the Scots for wanting to bail out if that's the way things turn out) I'm kind of hoping for a No vote....

Without Scotland as a counter-weight to the South I fear things will get very ugly politically for those of us left behind and if it wasn't for the fact that Mrs JayGee has family she's very close to here in Essex I think I might think very seriously about emigrating North to an independent Scotland from an England facing an unpleasant lurch (further) to the right...

37:

>A lot of those mark-ups like the $5 aspirin are paying for things like the long-term treatment of the homeless, drug-addicted, mental patient who's in for the fifth time this year

Every other country in the world has homeless drug addicted mental patients, and they seem to manage without bankrupting people over an ER visit.

In unrelated but thematically similar news, it seems Iain Banks has passed today (My source is Neil Gaiman's blog)

38:

I think it is worse than that.
The US healthcare system has become a mechanism to extract extra profits. Physicians routinely set up facilities to do extra "services" that can be billed. In addition, as the NYTimes & Time Magazine showed, prices for drugs and procedures are multiples of the prices in other countries. Studies have shown that if physicians have an incentive (through facility ownership) to over provide a service, they will. It wouldn't surprise me to learn that hospitals are encouraging physicians to keep their facilities fully utilized with paying patients.

I'm all for medical innovation, but the purpose should be to improve health outcomes, preferably by reducing costs as well.

39:
hospitals in many states are required by law to provide care

No, they're required to provide emergency care.

A lot of those mark-ups like the $5 aspirin are paying for things like the long-term treatment of the homeless, drug-addicted, mental patient who's in for the fifth time this year

No bias there. Here, let me fix it for you:

A lot of those mark-ups like the $5 aspirin are paying for uninsured patients, who have no way to pay for treatments at any price

And even that is not really correct: the US medical industry functions in multiple ways:

  • Inefficiently, primarily.
  • Negotiated rates with insurance companies: "We normally charge $5 for an aspirin, but since we know you'll pay, we'll only charge $0.25."
  • Negotiating lower payments through threats of lawsuits. E.g., a $300,000 bill may be negotiated down to $200k, paid back over time. Interest may result in this being higher than the original amount, but I think generally it works out closer to the original amount.
  • Selling debt to collection agencies, and getting between 10 and 50 per cent of the amount. So that $5 aspirin works out closer to 10 aspirins charged at a total of $12.50.
  • Overblown by politicians, but malpractice suits also factor into this. More importantly, the insurance and lawyer fees factor into it.
  • 40:

    "in a fog bank" .. and people who aren't aware that the medication could do this to them can't always tell that their decision making capacity is impaired, and may not have anyone they trust to tell them so. The brain fogging extends to choices about food, so the downward spiral gets driven faster and tighter.

    Have seen this happen to several people.

    41:

    Yes, it's biased. Since I know a lot of people who are in the hospital on both sides (patient and provider), it's anecdotally true. The homeless ill require a lot of care. The common combination of untreated mental illness, substance addiction, and untreated physical diseases like diabetes and heart disease makes for a complex medical problem that often requires long-term care, not just care in the ER.

    Personally, I'm in favor of housing and treating the homeless ill at public expense. This may be due to my wimpy liberal compassion, but it's primarily because it would be cheaper and better for EVERYONE than leaving them on the streets until they are in such bad shape that they have to be brought into the ER, and given massive care just to get them in minimum shape to survive on the streets again.

    Even the notably conservative city I live in has realized this, because last year they decided that paying ca. $140,000/person to house and treat the sickest homeless was preferable to paying the ca. $300,000/person required for their hospital care as homeless (I haven't fact-checked these numbers, they are what I remember).

    That said, if anyone finds this offensive, I apologize. I'll try to be more neutral in the future with regard to this issue.

    42:

    SHIT

    BBC News 18.00 hrs...
    we were talking about "health" ??

    Ian Banks just died.
    See HERE

    Like I said, SHIT!

    43:

    'it seems Iain Banks has passed today (My source is Neil Gaiman's blog)'

    Ah, Christ. Confirmed elsewhere, also Greg's post.

    Ah, Christ.

    44:
    This may be due to my wimpy liberal compassion

    I prefer to call it "enlightened self-interest" -- it's why I am so in favour of public education (an educated person may defraud me out of all my money, but they are generally less likely to kill me for the change in my wallet). Health care is similar: a restaurant worker who has sick days guaranteed is less likely to come in when sick and pass it on to me; a society that ensures nobody has to go bankrupt dealing with medical issues means my hated relatives and I don't ever have to ponder living together, etc.

    45:

    What Greg said.
    Far too soon.

    What the article says about how his last novel came about almost goes along with what Charle said in the post:
    The parasympathetic nervous system is a wonderful thing, and if you should feel numinous dread creeping up on you for no obvious reason you should consider the possibility that your body is trying to tell you something.

    46:

    Unfortunately abdominal organs such as pancreas, liver, and gall bladder have really crap sensory innervation -- for most of our evolutionary history, if anything went wrong with them we were simply dead meat, so there was no survival advantage in selecting for precise feedback. So with cancers in those organs, by the time you can feel it you're probably as good as dead (at least with the current state of the art).

    It's not appropriate for me to discuss Iain's medical condition here, but I very much doubt it was survivable with currently-existing treatments; it was asymptomatic until it was already terminal.

    (I lost a cousin the same way. Brain tumour, inoperable, chemo not practical, six months from diagnosis to death.)

    47:

    I do know that, too well. My mother had liver surgery a few years ago--thankfully not cancer, and we lost a friend (more of an adopted grandmother) to pancreatic cancer several years ago, she fought hard for a couple years, but we knew how it would end. Knowing what's coming doesn't make it easier when it does.

    Appropriately, or not, reading the article made me think of what you had written.

    48:

    As a newly-minted member of the blood pressure medication for life club (Lisinopril 20mg seems to be working for now), I am also agog to hear your experiences.
    I haven't noticed any effects like you describe (well, if I am honest maybe a lower sex drive but given my current situation that's not a bad thing) but it's hard to establish a baseline for cognitive effects on your own.

    49:

    Actually, a lot of us are pocketing that extra $1 trillion.

    Well... maybe. My best guess would be that whoever is pocketing $1T/year, individual or group, has the means and the motive to misdirect attention somewhere else.

    Obviously things like requiring the poor and the homeless to wait for their condition to reach ER levels wouldn't help either costs or outcomes; compare the Milwaukee protocol with the standard rabies post-exposure vaccination. I don't know whether that would be enough to explain the cost differential, although it probably does explain the differential in outcomes (people on the Milwaukee protocol mostly die).

    How to fix it, I don't know. Obviously, "we'll cut health care in half" is not a winning policy platform.

    50:

    Personally, I'm in favor of housing and treating the homeless ill at public expense. This may be due to my wimpy liberal compassion, but it's primarily because it would be cheaper and better for EVERYONE than leaving them on the streets until they are in such bad shape that they have to be brought into the ER, and given massive care just to get them in minimum shape to survive on the streets again.

    This, and what was said above about "enlightened self interest."

    I was not nearly so strongly opinionated on this subject until I spent six years in a small neighborhood stores. These people are out there: mentally ill, addicted to something, or just plain stupid - and many of them are all three. These folks are never going to be SQL programmers or SF writers; most of them can't even hold down a burger-flipping job. But they're also pretty unmotivated, so when they have food and their drug of choice they don't make much trouble. That's your best answer, to put them on a food program, have at least minimal shelter and health care, and thereby avoid some theft and vandalism problems (you probably don't appreciate how much stealing and property damage is done by even one person with no money or fear of legal consequences). Unfortunately for all of us, the enlightened self-interest answer is contrary to some ideology, and anathema to the principle of Conservation of Human Misery that some politicians press upon us.

    And in the US, Congress is considering $4.1 billion from the food stamp program. *grump*

    51:

    I'll respectfully disagree. This is the Bill Gates problem. Suppose we liquidate Bill Gates' fortune, currently valued at $136 billion, and give it equally to all 7.09 billion people out there.

    The result would be that everybody in the world would get US$19.18.

    This would be a big deal for much of the globe, but even for the poorest $1/day people, it's less than a month's wages, and it certainly wouldn't raise anyone out of poverty. It's a really fascinating argument about whether all that money does more good for the world in Bill Gates' investment portfolio, as opposed to spread evenly out. I don't know, and I'm not a huge fan of Gates.

    While I agree that some people are making out like bandits from health care spending, I'm pretty sure most of it is going into the pockets of ordinary joes like you and me. This in turn means that cutting health care spending in half will put a lot of people out of work.

    Incidentally (and this is where it really bites), cutting insurance costs in half will put a lot of people out of work, too. As noted above, one person's waste is another person's career.

    The nasty part here isn't that some sleazionaire (to coin a word) is making out like a bandit, it's that the oh-so-clever industrialists and their bureaucratic friends have made hundreds of thousands of families hostage to that industry's continued good health by giving them careers and a place in a community near you, if you live in the US. This is true for medicine, the military, finance, and petrochemicals. It's much more effective than pocket-and-misdirect, because you look at the societal harm you'd inflict to ruin the fortunes of a few billionaires, and it scarcely seems worth the cost, does it?

    52:

    hetromeles @ 51
    You have just described how & why people support repressive regimes, even if they privately think that regime stinks.
    It provides them with the only living that they can get ....
    Neat trick if you are crooked enough to pull it.
    And very, very difficult to dismantle, afterwards - ask Nikita Kruschev.

    53:

    Since people are "registering an interest", add me to the list of people who'd be interested in a discussion on antihypertensives and their side-effects (particularly when taken as cocktails).

    54:

    (Note with respect to the following: I am not a pharmacist or licensed medical practitioner and you should not read this as medical advice. Take it purely as informed opinion from someone who used to be a practicing pharmacist 24 years ago; if in doubt, seek advice from a doctor or pharmacist who is up to date with current practice and licensed by the appropriate professional body.)

    If you are put on blood pressure meds, though, here are some things you may want to do (until you're stable on a non-changing repeat prescription that works for you):

    1. There are several families of antihypertensive medication: diuretics (water pills) fall broadly into thiazide diuretics, potassium-sparing diuretics, and "other", then there are beta blockers (out of favour in the UK this decade), ACE antagonists, Calcium channel blockers.

    1a. Each family works in a different manner. So unless your blood pressure is borderline, you can expect your doctor to prescribe two or more antihypertensives, from different families.

    1b. Within each family of antihypertensive, there are multiple different drugs.

    1c. So your doctor will usually start you on the cheapest/oldest drug in a particular family, at a low dose. If it doesn't cause obvious side-effects, they'll then increase the dose until it stops having any additional effect or until side-effects show up. Then they'll add a drug from another family, and repeat, monitoring your BP all the time until it's down to a safe level.

    1d. If side-effects show up, they can quite easily swap drug A in a particular family for drug B, or drug C, and so on.

    So it's up to you to self-monitor for unacceptable side-effects and discuss them with your doctor. Let me emphasize: no doctor wants to harm a patient, or for a patient to stop taking their medicine because it makes their stomach hurt or fogs their mind. So if you say "I really don't like this one," they'll just cross it off their list and prescribe you something slightly more expensive.

    2. Self-monitoring

    2a. If you start on a new medicine, read the patient information sheet and keep an eye open for the side-effects it mentions. Be particularly alert for the first 2-7 days, as the amount circulating in your bloodstream builds up.

    2b. Pay attention to foods and medicines you're supposed to avoid. For example, grapefruit (and grapefruit juice) is a huge no-no with most antihypertensives. Other things you should probably avoid: cocaine, amphetamines, Sudafed (pseudoephedrine) and other decongestants. This isn't about legality: these drugs all drive your blood pressure through the roof, and if you have hypertension there is a risk that they can trigger a heart attack or stroke.

    2c. Allergic reactions: numbness, tingling and swelling in the lips, or breathlessness, when taking a new medicine -- stop taking it and go and see your doctor immediately. This is an emergency. If you're too ill to visit your doctor, you need a hospital emergency room. (Luckily this is quite rare, but it applies to just about all medicines.)

    2d. Blood pressure: the medicine is supposed to lower your blood pressure, and should do so consistently. Get a home blood pressure monitor (armband type, not one of the "wrist watch" models -- they're horribly inaccurate) and start taking readings. You should establish a routine and take two readings in the morning and two in the evening. If possible, put them in a spreadsheet and graph them over time. (There are smartphone apps for this, too.)

    If you start a new antihypertensive you should see a slow but steady drop in your blood pressure. If it falls off a cliff after you start a new drug, or starts to jump all over the place, go see your doctor. (You may be having a bad reaction.)

    2e. Cognitive functioning. If you can do a ten minute crossword every morning, or Sudoku, or a similar puzzle, do so. Do it about an hour after you take your morning medication. Time yourself, and log the time to completion. If your time-to-complete suddenly shoots up after introducing a new medicine, then it's probably doing something bad to your head. Even if you can't regularly take the time to do a puzzle, try and keep a handle on your baseline ability to solve problems. If your head feels as if it's stuffed with cotton wool for a few hours after you take your pills, it's time to go talk to your doctor about swapping them for a less disagreeable medicine.

    2f. Other symptoms. Some thiazide diuretics can have other disagreeable side-effects -- for example, bendroflumethiazide causes erectile dysfunction in about 25% of men who take it. You do not need to suffer through this in silence. Go and talk to your doctor: they'll substitute a different thiazide diuretic, until you find one that is tolerable or they decide to switch to a different family of drugs.

    55:

    and keep an eye open for the side-effects it mentions

    Do you know whether there's a danger of a nocebo response, of the patient getting the side effects because they know of them and sort of expect them?

    56:

    Many many thanks, and please take note of my 1 comment in "Fvck every...2913".

    57:

    Yes, but we've got a technical term for that: "hypochondria". Leave it to the doctor to sort out whether it's real or not.

    58:

    There is another aspect of your Laundry novels somewhat unaddresed in detail on your blog: RPG by Cubicle 7.

    Have you read adventures written by Gareth Hanrahan and others? Are they canon? Are they purely product of C7 or had you helped them somehow?

    Any chance to see a crib sheet about it?

    59:

    I guess $1T/year would be a bit too big to just disappear, so you may be right, maybe it is just inefficiency.

    The rest of your argument sounds like a cousin of the "broken window fallacy", though; surely the extra $1T/year could be spent in a better way that would also employ those people?

    I'm sure we can all think of all sorts of projects that the US could do with even a fraction of $1T/year, from space to humanitarian aid and development, from research to building cathedrals. If you have to give people make-work, make it at least count for something!

    The Apollo project cost $0.2T, total, as did the shuttle program.

    60:

    @41:
    and people who aren't aware that the medication could do this to them can't always tell that their decision making capacity is impaired
    ---
    Also, the link between antihistamines and depression, which seems to be a forbidden subject. I'm allergic to almost everything, so I was on antihistamines of some sort for a large chunk of my life... spent mostly in a haze of apathy and depression. Not to mention the addictive nature of some of those drugs; start getting close to pill time, and feel the itch and twitch ramp up.

    I've remade my life in exchange for the odd sneeze here and there... but all those years I've lost, I'll never get back.

    61:

    @41:
    Personally, I'm in favor of housing and treating the homeless ill at public expense.
    ---
    That was one of Richard Nixon's "Federal I" proposals early in his first term. According to him, they ran the numbers and it was cheaper to just give people the services outright than it was to fund the vast bureaucracy that HEW was in the process of becoming.

    Oddly enough, that and other social proposals all got shouted down by the "Great Society" Democrats, even though it was an extension of their own policies. But of course neither side really had public interest in mind; it was all about funds and political power.

    62:

    The number of hard problems that would be seriously helped by everyone giving up on the fear of someone somewhere getting something they don't "deserve" and moving to universal provision of $good (universal healthcare, guaranteed basic income, the Finnish baby box...) has to be smaller than it seems. Because if it isn't, we're either cruel or insane leaving so many other humans to suffer.

    63:

    Because if it isn't, we're either cruel or insane leaving so many other humans to suffer.

    Have a cigar. This is why I vote for socialist parties, despite knowing that to pay for them I'll end up with a larger tax bill.

    I'd rather be averagely wealthy and live in a society where nobody has to suffer, than be rich in hell.

    And I am extremely bummed over the fact that all the main parties in my country buy into the same neoliberal consensus that denies that an equitable and egalitarian society is possible.

    64:

    Case in point - There's a girl in Stornaway who wants to work, but can't get enough in wages and benefits to pay her bills!

    65:

    I live in a country where the best organized left wing party a) was involved in armed conflict in the last 20 years, and b) is in government in a different jurisdiction, and is most definitely not left wing there. While dubious about the former, the latter is a definite dealbreaker. So I feel your pain.

    My point was rather that - at least here - while providing for those worse off is more or less uncontroversial (depending on varying definitions of "worse off"), everyone with a hope of power seems to have a desperate allergy to universality. Means testing is always the answer, no matter what the question.

    66:

    You know, despite Niven being a terribad writer, I like one of his eponymous laws:

    Ethics change with technology.

    In other words, society will get more 'egalitarian'. Not because people will vote for left wing parties, but because productivity will rise and there will be more resources to dole out.

    67:

    "I refute it thus!"

    (Yes, wildly simplistic, but you don't pass up a chance to pull one of those. :-P)

    68:

    You refute the correlation between technology and the quality of life with a graph on income distribution in 2011 in USA?

    69:

    I suspect that what you meant to say and what you actually said don't quite match.

    You stated In other words, society will get more 'egalitarian'. Which anonemouse addressed with a graph showing just how far from egalitarian the distribution of income in the US is.

    You then seem to accuse him of failing to refute the correlation between technology and the quality of life.

    I don't see where in your initial comment you'd actually got round to mentioning that. It's really quite difficult for other people to argue with what's going on inside your head if you don't say it.

    Either that, or your definition of 'egalitarian' doesn't match ours.

    70:

    Actually, if you want an egalitarian society, you can't do much better than your basic hunter-gatherer set up, preferably in a place that's resource poor enough that there's no way for an elite to grab the best resources and lord it over you.

    This may be why many of us value egalitarianism: it's in our DNA, because it's a great way to survive when you have to depend on your band of people.

    Sadly, with the invention of agriculture, it's gotten much harder to go back to such an egalitarian setup. It's still possible, but it requires a fairly harsh environment (say, inner city minority, or Hopi farmer in an unpredictable desert). The key here seems to be that life has to be fragile for egalitarianism to dominate. When there's a predictable "game" (either a river for irrigation, or salmon runs for food, or similar) that some people can dominate, you tend to get inequality.

    So no, I don't think that rising productivity will lead to an egalitarian society. People will still want to own the means to production, and some of those people will become the super-rich, for all the good and bad that entails.

    On the flip side, given our propensity for climate change, and climate change's propensity to make the world a lot less predictable than it used to be, I suspect we may have many more egalitarian societies in the future.

    This necessarily be bad. As the Hopis reportedly say, people tend to make songs about the things they need the most. Many of the Hopis songs are about rain and water. They think it's kind of sad that most of our songs are about love.

    71:

    Yeah, I'm using your _implied_ definition of an egalitarian society. Which is to say, you don't want a _real_ egalitarian society, because then you should favor a 100% tax and total income redistribution. See also: Communism, USSR and "Handicapper General". I'll choose Somalia over North Korea - easier to escape from the former.

    What you actually want is for modern USA to be more like modern Norway. And I'm fine with that. But both lie very very close to each other on the spectrum which also includes the USA and Norway of 300 years ago. And we didn't get from there to here because people voted for left-wing parties. Rather, it is only due to the progress of technology that left-wing parties even exist.

    72:

    I have a heavy suspicion that this idea of egalitarian hunter-gatherers is somewhere between real matriarchies and the bicameral mind of the ancients. Bullshit, in other words.

    73:

    Not really. I suggest you do some more reading. I'd check out the !Kung anthropology, to start with. You can also get quite a lot by reading about eskimos.

    The point here has to do with the general idea of Dunbar Numbers. If you're living with a small band of people (certainly less than 160, and possibly as few as a dozen or two), you don't need a hierarchy. The group is small enough that everyone knows each other, everyone can talk stuff out, and everybody who wants to be heard can be heard. Yes, there will be people who are smarter and/or more charismatic and/or more bossy than others, and they will organize things when things need organizing, but they don't inherit their jobs, and typically, they get no more say in what the group should do about a collective problem than anyone else does.

    The point here is not about utopia, though, it's about egalitarianism. There's no evidence that having an large amount of material goods leads to equality. The US is certainly proof of that: we've arguably got the greatest consumer society in all of human history, but in terms of equality, we're close to being a banana republic, with our Gini coefficient of income inequality in 95th place, behind the Philippines (and that's from the CIA!).

    I agree that primitive egalitarian societies are not utopias, nor is our own society. The point here is that wealth does not make us equal, and there's no reason to believe that increasing wealth will decrease the inequalities we see in our own society. A civilization-killing disaster, on the other hand, might better achieve your goal of equality for all. But that will be, as the book has it a paradise built in hell.

    74:

    That "sense of dread" thing is something I had a few months ago, and I assumed it was some kind of existential depression. However, it did coincide with a BP scare. I had been spending 12 hours a day getting fat and lazy on the computer. I had a cold coming on and decided to take my BP - something I had not done for months.
    It was something like 210/120, which is excessive (but not as bad as yours). I assumed it might have been connected with a nootropic I was taking, but stopping did nothing to lower it. In the end, what did pull it down was regular exercise again and 4 potassium rich bananas a day. Now it's around 135/85. I don't know whether that massive effect is typical, but it sounds like nature's way of telling me to start running for my life.

    75:

    OTOH, an "Independant" Scotland will be a flat-broke & total-surveillance Calvinist society.

    Look at Glasgow and Edinburgh by way of comparison. Glasgow: allegedly pragmatic; attempts the hard line on alcohol and prostitution. Still has problems with both. Edinburgh: allegedly Calvinist, turns out to actually be pragmatic. Liberalises opening hours, turns a blind eye to "massage parlours". Seems not to have quite the same level of problem.

    Glasgow: vocal religious support and devotion from both sides of the transubstantiation debate. Highly tribalised education system, tribal support for football teams, related violence. Edinburgh: takes religion less seriously (and football, for that matter). Football is more about locale than religion; you're less likely to die in Edinburgh because you're wearing the wrong colour shirt. Outside the Central Belt, fewer care about either (south, it's rugby; north-west, it's shinty)

    I'd say "it depends on the power struggle within the winning party". I suspect that the first sign of a credible yes vote in 2014 will be a spike in house prices in Berwick-upon-Tweed and Carlisle; only an hour or so from Edinburgh and Glasgow respectively. The second sign will be an independence movement forming in the Shetlands... On current figures, though, the result will be "No".

    76:

    "Have a cigar. This is why I vote for socialist parties, despite knowing that to pay for them I'll end up with a larger tax bill.

    I'd rather be averagely wealthy and live in a society where nobody has to suffer, than be rich in hell.

    And I am extremely bummed over the fact that all the main parties in my country buy into the same neoliberal consensus that denies that an equitable and egalitarian society is possible."

    In addition, the way it actually plays out, unless you are in the top few percent (at most!) you'll get a very token tax cut. It'll be waved in your face like a cap before a bull. Meanwhile, back door taxes and 'user fees' are pulled out of your wallet, the infrastructure rots and your customers no longer have enough money to buy luxuries like books.

    77:

    "You know, despite Niven being a terribad writer, I like one of his eponymous laws:

    Ethics change with technology.

    In other words, society will get more 'egalitarian'. Not because people will vote for left wing parties, but because productivity will rise and there will be more resources to dole out."

    I don't know where you live, but here in the good ol' USA, we're around 30 years of productivity and salaries being disconnected, for ~90% of the work force.

    If the rich have far more wealth, then they'll enjoy it while b*tching about how poor they are.

    78:

    gravelbelly 22 @ 75
    The second sign will be an independence movement forming in the Shetlands... Already happening.
    Neither Orkney nor Zetland want much (any?) part of Salmond's nannying & centralist control - London is so far away, they're left much-alone (ish)

    79:

    Romanticized in traditional Nat. Geo. style, but this article on the Hadza is interesting, and a pretty quick read.

    80:

    The hunter-gatherer version of a rich man is a physically strong man with a lot of brothers and male cousins. I don't doubt that they take advantage of their position quite a bit.

    81:

    Also, chimpanzees are not egalitarian, and you don't get more hunter-gatherer then this.

    82:

    30 years in one country is pretty much a fluctuation on the graph. Even assuming that salaries represent the quality of life (they don't - 30 years ago a lot of stuff just couldn't be bought because it didn't exist yet. Now it does, again thanks to progress of technology).

    83:

    Para 2 - No generaliation is true, not even that one.

    This is primarily a Wendyball area despite your comment about it being a Shinty one. From here the next 3 landfalls West are called St Kilda, Rockall, and Canada!

    84:

    This article is well timed:

    http://www.charlotteobserver.com/2013/06/10/4097735/single-payer-is-needed-cure.html

    "He further pointed out that the administrative cost of health care insurance is one of the major drivers of escalating health care costs from 1980 to 2005. According to Friedman, the administrative cost of private insurance will be $200 billion in 2013. In the U.S. billing costs run $83,975 per doctor per year versus only $22,205 in Ontario."

    85:

    Well, add me to the club of the antihypertensive junkies. For my personal cocktail, take some calcium channel blocker, add hydrochlorothiazide, the poison of choice for German thiazide afficionados, and, last but not least, throw in some glorified snake poison, AKA ACE inhibitor.

    http://en.wikipedia.org/wiki/Discovery_and_development_of_ACE_inhibitors

    This is still somewhat better than my mother, whose medicinal cabinet usually gets a "evidence for the excessive consumption of every antihypertensive drugs known to civilized men since 1957", the latter one being the date of the introduction of thiazides.

    http://profiles.nlm.nih.gov/ps/access/XFBBGL.pdf

    I guess she never used Reserpine, but then, nobody is that keen on seeing if the incidence of certain side effects cited by the proponents of the monoamine depletion theory of depression were really that overblown.

    Err, back to the cognitive side-effects, while my first guess'd have been the adrenergic drugs, like beta blockers, alpha blockers, alpha agonists (I'm still not that much convinced about imidazoline receptor involvement) or, well, reserpine, I agree thiazides can be a problem, too, though in my case, the brain fog subsisted after a few days. I put it down to electrolyte imbalence and altered excretion of methylphenidate, and as mentioned, whatever went wrong luckily readjusted itself through some feedback loop.

    Though if you look at it, the thiazides are not that far removed from some anticonvulsants of the carbonic anhydrase inhibitor family

    http://en.wikipedia.org/wiki/Sultiame

    which brings us to the interesting field of off-target -or on-target, some of these effects might be related to antihypertensive actions, e.g. AMPA receptors seem to be involved in blood pressure regulation- pharmacology.

    Though HCT itself is not that big an inhibitor of carbonic anhydrase, and bendroflumethiazide is even less. But then, some thiazides interact with potassium channels

    http://en.wikipedia.org/wiki/Diazoxide

    and last but not least, they bind to AMPA and GABA receptors

    http://en.wikipedia.org/wiki/Cyclothiazide

    Funny thing with the AMPAs, though this action is AFAIK somewhat weak with HCT, it seems to be an allosteric activator, similar to the racetam family of nootropics, and one HCT analog is active as a nootropic

    http://en.wikipedia.org/wiki/IDRA-21

    Now many nootropics seem to have something of an inverse U-shape for effects, with too much often being detrimental, so the brain fog might be due to AMPA overstimulation. Or decreased neuronal excitability thanks to carbonic anhydrase or potassium channel inhibition. Or disturbed electrolytes. Whatever. Just shows how little we know about some of the oldest drugs.

    Some calcium channel blockers have been used in cocaine dependency, in a manner similar to anticonvulsants, though I don't know if this was successful, and as for ACE inhibitors, ACE converts quite some peptides beside angiotensin and is expressed in neurons, so who knows.

    As for the abstaining from cocaine and amphetamine derivatives, there might be problems with other sympathicomimetics, e.g. some of the more noradrenaline reuptake inhibiting antidepressants. Actually, these might be worse than amphetamines in some, which might be of interest for people with ADHD and hypertension

    http://www.ncbi.nlm.nih.gov/pubmed/15705013

    Incidentally, the two might be causally linked in some, alpha2 agonists like clonidine are effective on some symptoms of ADHD and against hypertension, though I guess few people are alpha(2a) knockouts...

    http://www.ncbi.nlm.nih.gov/pubmed/12127086

    But then, I'm just a biologist with a somewhat pop pharmacology fetish...

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