Wednesday, December 04, 2013

“Magical Thinking:The Decline of Intellectualism in America” Supper Club Presentation by Paul Rider, November 19, 2013

Magical Thinking:The Decline of Intellectualism in America”
Supper Club Presentation by Paul Rider, November 19, 2013
General definitions: of Magical Thinking
The identification of causal relationships between actions and events where scientific consensus says there is none.
The belief that one event happens as the result of another without a plausible link of causation between them.
Believing in things more strongly than either evidence or experience would justify.

Clinical definition: (from the field of Psychology)
A belief that merely thinking about an event in the external world can cause it to happen.
Thinking that can lead to delusional behavior when done by someone who continues to hold a belief that is clearly contrary to any evidence available.

All of us resort to thinking associated with the general category on a regular basis in our lives, and hope that we do not resort to what is described in the clinical category. It is probably accurate say that humans have relied on the general notions of magical thinking since our species evolved rudimentary intellect.
Although we were probably analytical in the early stages of human development, owing to the advantage this provided for our survival, we were not prone to develop what has become known as the kind of “critical thinking” associated with modern science and its reliance on the scientific method of inquiry that has resulted in the kind of culture in which we found ourselves today.
I have described in my previous talks how the phenomenon of critical thinking first emerged through the Ionian approach in ancient Greece and re-emerged in the Western World during and after the Renaissance and The Age of Enlightenment in the 18th Century.
This style of analysis and thinking relies on acceptance of an external reality from which an observant mind can extract information and evidence to form predictive models about how things occur in that reality. The Ionians were content to use observation to provide information while modern science has developed a rigorous and stringent set of rules that apply to not only observing but to actually tweaking the reality to make it behave in ways that can be studied, analyzed and ultimately described by theories and models that are predictive and useful.
So, when we contrast “magical thinking” with “critical thinking,” we begin to appreciate some of the controversies and conflicts that exist in our modern culture, especially as they relate to the major areas of human concern such as politics, economics, social responsibility and religious beliefs and practices.
While it is an oversimplification to suggest that people can be placed into one of these two ways of thinking in some categorical sense, for the sake of discussion I will suggest that each of us tends to rely more on one of these approaches than the other in regard to how we view our existence as it relates to our upbringing and life experiences.
The scientific approach and its reliance on critical thinking have had a strong appeal for me throughout most of my life. Thus, I analyze such things as the meaning of life, particularly my own, in terms of what we can learn about the Universe in which we live, and the planet on which we find ourselves. How they relate to one another is a crucial matter in unveiling the mystery of life in any meaningful way for people like me.
Someone prone to magical thinking may reach a level of satisfaction in accepting ideas about the meaning of life from how they were raised as well as from what they have seen and read in the religious and philosophical writings of others. This may be done without the willingness or need to subject such material to critical analysis. He or she has been conditioned to accept ideas, with little concern about how they me be at odds with scientific knowledge.
If there is a contention in one’s religious views that runs contrary to scientific fact, a decision about how to resolve this type of conflict becomes problematic. Not being a critical thinker may make it easier for such people to ignore such facts. In this way, they can be described as “ignorant.”
Biological evolution is an obvious example. President George W, Bush, when asked about his views, stated that the “jury is still out on the validity of the theory of biological evolution.” This level of ignorance for someone in such a position is quite disturbing. The evidence for genetic variation and change in species through time, driven by the prevailing natural environment in which those species exist (i.e. natural selection) is so well established as a scientific reality that it is disappointing to hear magical thinkers deny it. There isn’t any jury out there in the scientific community still wrestling with any questions of validity. Validity isn’t based on majority vote or acceptance, but on evidence.
Scientists have confidence (not faith in the religious sense) that the idea of evolution aptly describes what is going on, and has relevance in all areas of science, including cosmic evolution. If the model fell short, it would have been modified to account for its weaknesses, or even discarded. Science is self-correcting and relies on confidence derived from how well a model fits the observed behavior. This is “contingent faith”, not “religious faith.”
The earth-centered Universe is another example. It took two centuries to discard it, even after convincing evidence of its fallacy was provided by Galileo and others in the 17th Century. That was not merely an “inconvenient truth,” but was an “unspeakable truth,” owing to its potential to destabilize the society of the time. Magical thinking prevailed, as it often does
Currently, the inconvenient truth about global warming and climate change due to human activity is running into the magical thinking of those who simply don’t want it to believe that it is happening. This is one of those issues that requires a more serious approach because of the catastrophic consequences associated with it that are beginning to be felt (the typhoon in the Philippines and the tornados in Illinois this past week were unique events in the context of weather history record keeping). Recently, a magically thinking Texas legislator told a religious television host that global warming and climate change are the consequence of God punishing humankind for the aborting of human fetuses.
There is a significant number of magical thinkers who contend that the earth and Universe are 6000 years old. When challenged with the evidence to the contrary, their magical thoughts suggest to them that God has simply made things appear older. They, too, are ignorant.
Television commentator Bill O’Reilly recently interviewed Richard Dawkins, the physicist who wrote “The God Delusion.” Challenging Dawkins’ atheist mind set, O’Reilly asserted that there must be a divine influence in the natural world because we observe the tides to come in and go out, and there is no natural explanation for that phenomenon. Dawkins was so amazed that he hardly knew how to react. O’Reilly’s ignorance of what we have known for centuries is inexcusable for someone pretending to inform the public on important issues .
Other examples of magical thinking are superstitious behavior, belief in ghosts**, communicating with those who have “passed over,” healing by the laying of hands, and rain dancing. (** EXPAND REFERENCE WITH AN ASIDE)
One of my more memorable professional experiences occurred in the spring of 1988 when I was chosen to testify before the Space, Science and Technology Committee of the United States House of Representatives on the future of science and technical education in America, as well as the need to encourage bright young people to pursue careers in the hard sciences.
Six of us were selected to testify, including University of Iowa space scientists Dr. James Van Allen**, Dr. Donald Gurnett**, Dr. Louis Frank**, and Dr. Dwight Nicholson**. The other member was Dr. Gene Wubbels from Grinnell College who had mentored a Nobel Prize winning chemist (Tom Chech) as an undergraduate. (**EXPAND REFERENCES WITH ASIDES)
Our agenda was to seek government support and public money to train technical people and provide research funds to insure our future as the prime scientific and technological society in the world.
I had been a “Sputnik” scientist** and had had my advanced education paid for by fellowships from NSF, NASA, and The AEC. I worked with Manhattan Project scientists on rare and exotic metals research during the 1960s, holding a top secret Q clearance. This provided me with an awareness of how government support worked in enhancing specialty research that had the potential for significant breakthroughs (the neodymium alloy magnets in your cell phone is an example)
In my remarks, I urged these leaders to not only encourage programs that were aimed at educating bright young minds, but also to support programs that had the broader goal of developing critical thinking skills in all citizens. This would help us meet the challenges and opportunities in the 21st Century with a new generation of people who would combine creative and rational thinking to address the needs of a growing population, an increasing energy demand, adequate nutrition and clean water, and the other social pressures. That was 25 years ago, before the wide-spread internet and in the early stages of personal computer and cell phone usage. Things really have gotten complicated since then, without much happening to improve the situation.
What concerns me today is the apparent decline in efforts to develop critical thinking skills and the resurgence of magical thinking as a growing influence in our society. I associate the concept of “intellectualism” with rationality and critical thinking. I also recognize that some forms of magical thinking are not a threat to intellectualism. They may play a role in allowing discussion and learning to occur. When this kind of thinking trumps the political, social and economic processes that determines the directions we are taking as a society and as a global community, there is reason to be alarmed.
China, India and countries in Europe and South America are turning out many more scientific and technical students than we are. It is only a matter of time before we become a follower, and not a leader. We still win more than our share of Nobel Prizes, but that will not continue unless we are willing to enhance our support the development of critical thinkers.
We should not need a Manhattan Project, or the Apollo Moon landings to justify increased efforts. The recent discovery of Higgs boson at CERN in Switzerland is an indication of the consequences of our bailing out of the Super Conducting Super Collider Project in Texas 20 years ago. The future discoveries to be made at CERN that have the potential to revolution our technology and greatly enhance our understanding of the Universe could have been made in our universities in this country and the best minds that are attracted to such facilities.
We are still actively exploring Mars (a satellite was launched just yesterday) but that effort is often maligned and criticized by the magical thinkers who fail to make the correct correlations between our future and the success of such endeavors.
Neil DeGrasse Tyson gave a Bauxbaum Lecture three weeks ago tonight at Drake University, hitting on some of the same themes in my presentation tonight. I greatly appreciated hearing his assessment about our future role in science and technology, even if it was not too optimistic. Within a decade, we will be publishing a much smaller fraction of the scientific research papers compared with other countries that are developing a new generation of critical thinkers.
Can critical thinkers and magical thinkers co-exist without causing too much societal stress? This remains to be seen, since the conflicts have been around for centuries. Religious and spiritual issues have occupied human minds for eons, although the scientific elements of our culture have gained respect, if even if begrudgingly. Some scientists try to embrace both kinds of thinking and are successful at it from a personal standpoint. Others, such as me, don’t follow such a path, out of a commitment to consistency.
I will conclude by attempting to explain how a critical thinker can appreciate the meaning life simply by allowing it to remain in the category of being mysterious. To ponder the existence of a God figure, as described in religious doctrines requires an examination of the information upon which this figure’s existence is based. It all stems from magical thinking that serves a purpose of providing meaning to the lives of those who embrace an unprovable idea. One accepts the notion for personal reasons that relate to a meaningful state of mind.
In my in case, I am intrigued and excited about the mystery of my existence and feel a sense of spirituality that connects me to others. I do not jump to any conclusions that are beyond my ability to justify in a rational way. I have heard the notion that believing in God is a matter of faith and is not based upon reason. That statement clearly contrasts magical thinking with critical thinking. There is no basis to debate it any further.
As I observe the many religions and denominations in the world in which find myself, I prefer to embrace my confidence in our ability to expand our understanding of a 14 billion year old Universe that has only seen our presence for such a short time (as far as we know) .
On Friday, April 13, 2029, an asteroid named “Apophis” which recently passed through our orbital vicinity will eventually return and intersect with our orbital path. Given what we know and can know about its behavior, there is a one in 45,000 chance that it will collide with our planet. Those odds could significantly change in the next 16 years, given what we don’t know.
If this one doesn’t hit us, one eventually will and the future of our existence on this planet will be in doubt. But, life has no doubt evolved all over this huge system and such events are probably a common occurrence throughout the Universe. Dinosaurs and the rest of the 99% of species that have existed on this planet (as far as we can tell) had a long reign but eventually fell victim to the inevitable (random) asteroid collision. We are not even approaching the time span of those life forms.
Maybe, just maybe we can develop a population of creative, critical thinkers who will find ways to extend the human presence in the Universe, beyond the hostile environment on this planet, which is well known for its antagonistic characteristics toward life (earthquakes, volcanos, mega storms, droughts, etc.). Maybe we came from somewhere else in the past and will need to continue our journey through the cosmos by traveling elsewhere. Life is a mystery, indeed.

Thursday, May 23, 2013

Fracking the Country

Hydraulic fracturing of rock is a major new source of natural gas and oil for the US and will change life in this country.

Delivered by Rich Winsor, May 21, 2013

Energy is critical to economic development. This is because the cost of energy is a major determinant of the cost of everything we purchase and especially for important items like food, housing, and transportation. Some economists have observed that energy cost generally determines whether an economy prospers or performs poorly.

With energy being so important, I was originally going to talk about nuclear power, because that appeared to be a major energy source for the future. However, I changed topics because now natural gas and oil from "fracking" shale has become much more important to the energy future of the country.

First we need to understand what "fracking" is and how it works, and then we need to discuss the advantages and disadvantages of using it. Please note that most of this material is quoted from Wikipedia, which I find is often a good source of information with relatively little bias.
Hydraulic fracturing is the propagation of fractures in a rock layer, by a pressurized fluid. Some hydraulic fractures form naturally—certain veins or dikes are examples—and can create conduits along which gas and petroleum from source rocks may migrate to reservoir rocks. Induced hydraulic fracturing or hydrofracking, commonly known as fracking, is a technique used to release petroleum, natural gas (including shale gas, tight gas, and coal seam gas), or other substances for extraction. This type of fracturing creates fractures from a wellbore drilled into reservoir rock formations.
The first use of hydraulic fracturing was in 1947, but the modern fracking technique, called horizontal slickwater fracking, that made the extraction of shale gas economical was first used in 1998 in the Barnett Shale in Texas. The energy from the injection of a highly pressurized fracking fluid creates new channels in the rock, which can increase the extraction rates and ultimate recovery of hydrocarbons.
Proponents of fracking point to the economic benefits from vast amounts of formerly inaccessible hydrocarbons that the process can extract. Opponents point to potential environmental impacts, including contamination of ground water, risks to air quality, the migration of gases and hydraulic fracturing chemicals to the surface, surface contamination from spills and flowback and the health effects of these. For these reasons hydraulic fracturing has come under scrutiny internationally, with some countries suspending or even banning it. Let's discuss fracking in greater detail.
Fracturing as a method to stimulate wells dates back to the 1860s, and using acid to open fractures was introduced in the 1930s. The first hydraulic fracturing experiment was conducted in 1947 in southwestern Kansas, and in 1949 Halliburton performed the first two commercial hydraulic fracturing treatments in Oklahoma and Texas. Since then, hydraulic fracturing has been used to stimulate approximately a million oil and gas wells.

The technique of hydraulic fracturing is used to increase or restore the rate at which fluids, such as petroleum, water, or natural gas can be produced from subterranean natural reservoirs. Reservoirs are typically porous sandstones, limestones, or dolomite rocks, but also include "unconventional reservoirs" such as shale rock or coal beds. Hydraulic fracturing enables the production of natural gas and oil from rock formations deep below the earth's surface (generally 5,000–20,000 feet). At such depth, there may not be sufficient permeability or reservoir pressure to allow natural gas and oil to flow from the rock into the wellbore at economic rates. Fractures provide a conductive path connecting a larger volume of the reservoir to the well. However, the yield for a typical shale gas well generally falls off sharply after the first year or two.
A hydraulic fracture is formed by pumping the fracturing fluid into the wellbore at a rate sufficient to increase pressure downhole to exceed that of the fracture gradient of the rock. The rock cracks and the fracture fluid continues further into the rock, extending the crack still further, and so on. Operators typically try to maintain "fracture width", or slow its decline, following treatment by introducing into the injected fluid a proppant – a material such as grains of sand, ceramic, or other particulates, that prevent the fractures from closing when the injection is stopped and the pressure of the fluid is reduced. During the process, fracturing fluid leakoff, i.e. loss of fracturing fluid from the fracture channel into the surrounding permeable rock occurs.
Horizontal drilling involves wellbores where the terminal drill hole is completed as a "lateral" that extends parallel with the rock layer containing the substance to be extracted. Laterals extend 1,500 to 5,000 feet in the Barnett Shale basin in Texas and up to 10,000 feet in the Bakken formation in North Dakota. The location of one or more fractures along the length of the borehole is strictly controlled by various methods that create or seal off holes in the side of the wellbore. Typically, hydraulic fracturing is performed in cased wellbores and the zones to be fractured are accessed by perforating the casing at those locations.
The two main purposes of fracturing fluid is to extend fractures and to carry proppant into the formation. The purpose of proppant is to stay there without damaging the formation or production of the well. The fluid injected into the rock is typically a slurry of water, proppants, and chemical additives. Additionally, gels, foams, and compressed gases, including nitrogen, carbon dioxide and air can be injected. Typically, the fracturing fluid is 98–99.5% is water and sand with the chemicals accounting to about 0.5%. Hydraulic fracturing uses 1 to 5 million gallons of fluid per well, and additional fluid is used when wells are refractured; this may be done several times.:
A proppant is a material that will keep an induced hydraulic fracture open, during or following a fracturing treatment. Types of proppant include silica sand, resin-coated sand, and man-made ceramics. These vary depending on the type of permeability or grain strength needed.
The friction reducer is usually a polymer, the purpose of which is to reduce pressure loss due to friction, thus allowing the pumps to pump at a higher rate without having greater pressure on the surface. The main way most friction reducers work is by changing turbulent flow to laminar flow, also many of the friction reducers are polyacrilamide which are good suspension agents ensuring the proppant does not fall out.
Chemical additives are applied to tailor the injected material to the specific geological situation, protect the well, and improve its operation, varying slightly based on the type of well. The composition of injected fluid is sometimes changed as the fracturing job proceeds. Often, acid is initially used to scour the perforations and clean up the near-wellbore area. Afterward, high-pressure fracture fluid is injected into the wellbore, with the pressure above the fracture gradient of the rock. This fracture fluid contains water-soluble gelling agents which increase viscosity and efficiently deliver the proppant into the formation. As the fracturing process proceeds, viscosity reducing agents such as oxidizers and enzyme breakers are sometimes then added to the fracturing fluid to deactivate the gelling agents and encourage flowback. At the end of the job the well is commonly flushed with water (sometimes blended with a friction reducing chemical) under pressure. Injected fluid is to some degree recovered and is managed by several methods, such as underground injection control, treatment and discharge, recycling, or temporary storage in pits or containers. Over the life of a typical gas well, up to 100,000 gallons of chemical additives may be used.
Since the early 2000s, advances in technology has made drilling horizontal wellbores much more economical. Horizontal wellbores allow for far greater exposure to a formation than a conventional vertical wellbore. This is particularly useful in shale formations which do not have sufficient permeability to produce economically with a vertical well. The wellbore is divided into sections that are fractured sequentially. There be more than 30 stages in the horizontal section of a single well. This multi-stage fracturing technique has facilitated shale gas and light tight oil production development in the United States and may make us energy independent. Recently, China was estimated to have twice the unconventional oil and gas resources of the United States.
Hydraulic fracturing has raised environmental concerns and is challenging the adequacy of existing regulatory regimes. These concerns have included ground water contamination, risks to air quality, migration of gases and hydraulic fracturing chemicals to the surface, mishandling of waste, and the health effects of all these.
A University of Texas study led by Charles Groat described the environmental impact of each part of the hydraulic fracturing process, which included:
  • Drill pad construction and operation
  • Construction, integrity, and performance of the wellbores
  • Injection of the fluid once it is underground (which proponents consider the actual "fracking")
  • Flowback of the fluid back towards the surface
  • Blowouts, often unreported, which spew hydraulic fracturing fluid and other byproducts across surrounding area
  • Integrity of other pipelines involved
  • Disposal of the flowback, including waste water and other waste products
Several organizations, researchers, and media outlets have reported difficulty in conducting and reporting the results of studies on hydraulic fracturing due to industry and governmental pressure, and expressed concern over possible censoring of environmental reports. Researchers have recommended requiring disclosure of all hydraulic fracturing fluids, testing animals raised near fracturing sites, and closer monitoring of environmental samples. After court cases concerning contamination from hydraulic fracturing are settled, the documents are sealed. The American Petroleum Institute denies that this practice has hidden problems with gas drilling, while others believe it has and could lead to unnecessary risks to public safety and health.
One New York Times report claimed that the results of a 2004 United States Environmental Protection Agency study were censored due to political pressure. An early draft of the study had discussed the possibility of environmental threats due to fracking, but the final report omitted this. The study's scope had been narrowed so that it only focused on the injection of fracking fluids, while omitting other aspects of the process. The 2012 EPA Hydraulic Fracturing Draft Plan was also narrowed thusly.
The air emissions from hydraulic fracking are related to methane leaks originating from wells, and emissions from the diesel or natural gas powered equipment such as compressors, drilling rigs, pumps, etc. In some areas, elevated air levels of harmful substances have coincided with elevated reports of health problems among the local populations. In Dish, Texas, elevated substance levels were detected and traced to fracking compressor stations, and people living near shale gas drilling sites complained of health problems, though a causal relationship to fracking was not established.
The large volumes of water required have raised concerns about fracking in arid areas, During periods of low stream flow it may affect water supplies for municipalities and industries such as power generation, as well as recreation and aquatic life. It may also require water overland piping from distant sources. An average US well requires 3 to 8 million gallons of water.
There are concerns about possible contamination by hydraulic fracturing fluid both as it is injected under high pressure into the ground and as it returns to the surface. To mitigate the impact of hydraulic fracturing to groundwater, the well and ideally the shale formation itself should remain hydraulically isolated from other geological formations, especially freshwater aquifers. While some of the chemicals used in hydraulic fracturing are common and generally harmless, some are known carcinogens or toxic. The most common chemical used for hydraulic fracturing in the United States in 2005–2009 was methanol. An investigative report on the chemicals used in hydraulic fracturing states that out of 2,500 hydraulic fracturing products, "more than 650 of these products contained chemicals that are known or possible human carcinogens, regulated under the Safe Drinking Water Act, or listed as hazardous air pollutants". The report also shows that between 2005 and 2009, 279 products had at least one component listed as "proprietary" or "trade secret" on their required material safety data sheet.
Without knowing the identity of the proprietary components, regulators cannot test for their presence. This prevents government regulators from establishing baseline levels of the substances prior to hydraulic fracturing and documenting changes in these levels, thereby making it more difficult to prove that hydraulic fracturing is contaminating the environment with these substances.
Another 2011 study identified 632 chemicals used in natural gas operations. Only 353 of these are well-described in the scientific literature. The study recommended full disclosure of all products used, along with extensive air and water monitoring near natural gas operations; it also recommended that fracking's exemption from regulation under the US Safe Drinking Water Act be rescinded.
As the fracturing fluid flows back through the well, it consists of spent fluids and may contain dissolved constituents such as minerals and brine waters. These fluids, commonly known as flowback or wastewater, are managed by underground injection, wastewater treatment and discharge, or recycling to fracture future wells. Treatment of produced waters may be feasible through either self-contained systems at well sites or fields or through municipal waste water treatment plants or commercial treatment facilities. However, the quantity of waste water needing treatment and the improper configuration of sewage plants have become an issue in some regions of the United States. Much of the wastewater from hydraulic fracturing operations is processed by public sewage treatment plants, which are not equipped to remove radioactive material and are not required to test for it.
Groundwater methane contamination is also a concern as it has adverse impact on water quality and in extreme cases may lead to potential explosion. However, methane contamination is not always caused by fracking. Drilling for ordinary drinking water wells can also cause methane release. Several studies have determined that methane migration into freshwater zones has occurred some areas, most likely as a result of substandard well completion practices.
Hydraulic fracturing fluid might release heavy metals and radioactive materials from the deposit which may reflow to the surface by the flowback. Concerns have been expressed that radioactive tracers may return to the surface with flowback and during blow outs. Recycling the wastewater has been proposed as a solution but has its limitations. The EPA has asked the Pennsylvania Department of Environmental Protection to require community water systems in certain locations, and centralized wastewater treatment facilities to conduct testing for radionuclides.
Hydraulic fracturing causes induced seismicity called microseismic events or microearthquakes. The magnitude of these events is usually too small to be detected at the surface. The injection of waste water from gas operations, including from hydraulic fracturing, into saltwater disposal wells may cause bigger low-magnitude tremors.
The United States Geological Survey has reported earthquakes induced by human measures, including hydraulic fracturing and the waste disposal wells, in several locations. According to the USGS only a small fraction of roughly 40,000 waste fluid disposal wells for oil and gas operations have induced earthquakes that are large enough to be of concern to the public. Although the magnitudes of these quakes has been small, the USGS says that there is no guarantee that larger quakes will not occur. In addition, the frequency of the quakes has been increasing. There are also concerns that quakes may damage underground gas, oil, and water lines and wells that were not designed to withstand earthquakes.
Several earthquakes occurring throughout 2011, including a 4.0 magnitude quake on New Year's Eve that hit Youngstown, Ohio, are likely linked to a disposal of hydraulic fracturing wastewater, according to seismologists at Columbia University. A similar series of small earthquakes occurred in 2012 in Texas. Earthquakes are not common occurrences in either area.
To control the hydraulic fracturing industry, some governments are developing legislation and some municipalities are developing local zoning limitations. In 2011, France became the first nation to ban hydraulic fracturing. Other countries have placed a temporary moratorium on the practice. The US has the longest history with hydraulic fracturing, so its approaches to hydraulic fracturing may be modeled by other countries.
In the public argument over "fracking", there is some divergence in the use of the word "fracking". In one study the term "fracking" was narrowly defined as only referring to the injection of fluid under pressure to create pathways. The study's definition excluded the impact of equipment failure, the nature of the fluids themselves, the preparations prior to injection, and procedures and events following the injection. Others, including the U.S. Environmental Protection Agency, hold "fracking" to mean the entire process of resource extraction, specifically of gas in shale, starting with building the well pads through recovering the gas, and dealing with the wastewater. This differing usage allows newspapers such as the Vancouver Sun to state that fracking has never contaminated groundwater, while The New York Times reports that it likely has.
In summary, hydraulic fracturing is a major economics and energy issue for the US and may provide energy independence in the next 10 - 20 years. The question is "can we obtain this energy without excessive damage to our water, air, and climate?"

Saturday, February 16, 2013

David W Kabel MD

February 19, 2013

During the recent election campaign deficit and reduction and the growing national debt were among the topics that were hotly debated.   Entitlement spending, and especially the rising cost of Medicare and Medicaid were identified as major causes for the growing debt. The debate over Medicare and Medicaid that took place during the campaign highlighted two different approaches to the problem.  The Romney campaign, in large part adopting the approach put forth by Vice Presidential candidate Paul Ryan, relies heavily upon the private sector.   Under the Romney/Ryan plan, Medicare would essentially be ended as we know it and further Medicare recipients would be given premium support or vouchers by the federal government to purchase private policies.  To deal with Medicaid a proposal was made to end Medicaid as we know it and to provide block grants from the federal government to the states to subsidize Medicaid, letting each state decide on eligibility and benefits.   The goal of this approach was primarily to reduce federal expenditures for Medicare and Medicaid without taking a system wide approach to reduce overall healthcare spending.  

The Obama approach, as embodied by the Affordable Care Act of 2009, otherwise known as Obamacare, took a more system-wide approach to healthcare cost.   Through a combination of public and private approaches, the purpose of the ACA is to reduce the rate of rise of federal expenditures for healthcare by changing the way heath care is provided and changing the incentives for hospitals and physicians, thus reducing overall healthcare spending.   The ACA is a flawed piece of legislation, but is probably the best that could be passed in a bitterly divided congress at the time.   In order to get insurance companies, pharmaceutical companies, hospitals and professional societies on board, several compromises had to be made, rendering the bill flawed, but nonetheless an important first step in healthcare reform.  

Healthcare costs have in the United States have been rising faster than inflation for many decades.  There have been efforts to control costs, most of which have met with mixed success.   There has been an ongoing debate as to whether we should rely on private sector mechanisms and the free market to control costs or whether more government involvement is required.   I will give a brief history of previous efforts at healthcare cost containment.  This will be followed by an explanation of why these efforts have been unsuccessful and why healthcare differs from other sectors of the economy.  I will conclude with a look at what other countries are doing and how this might apply to healthcare reform in the United States.  

Medicare and Medicaid were passed into law and signed by President Johnson in 1965.   It was the greatest expansion of the welfare state since the New Deal.   It was bitterly opposed by hospitals and medical societies at the time.   Future costs were vastly underestimated.   No one in 1965 anticipated the advances in medical technology that would occur over the coming decades as well as the expanding lifespan of Medicare recipients.     In 1965, the average lifespan for an adult male in the United States was 70 years of age.   Today that lifespan is 78 years.   The average person reaching age 65 can anticipate living an average of 20 more years; thus receiving Medicare benefits for far longer than anyone expected back in 1965.   That is one of the primary reasons for the high cost that we face today.  

Prior to 1987, hospitals and physicians were all paid on a fee-for-service basis.   The longer the patient stayed in the hospital the more the hospital got paid.   The typical heart attack patient would remain in the hospital for 2 weeks.   After gallbladder surgery 7-10 days was common.   Compounding this was the fact that Medicare and many private insurance companies would not pay for outpatient diagnostic workups for things such as colonoscopies.  However, they would pay for inpatient diagnostic workups at a greater cost.   Therefore, many patients would be admitted to the hospital for diagnostic workups that are routinely done on an outpatient basis now.   In 1987, Medicare and Medicaid introduced diagnostic related groups or DRGs.  In this system, which is still in place, hospitals are paid a set amount for a given diagnosis regardless of length of stay or expenses incurred by the hospital.   The predictable result of this is that hospitals and doctors became much more efficient in their delivery of care and lengths of stay for a given problem became shorter.   In particularly complicated cases hospitals could apply for outlier status and receive additional money, but it was generally not enough to cover the added expenses.  

The first real attempt to bring free market principles and competition into the overall healthcare system was the concept of managed care around 1990.   This resulted in the formation of health maintenance organizations.  There have been several varieties of health maintenance organizations but they all share certain characteristics.   A hospital or group of hospitals and physicians, often employed by the hospitals would contract with insurance companies to provide care for a group of patients for a set fee per patient.   This arrangement is known as capitation.  There were usually preferred panels of physicians and hospitals as well.  The providers were willing to negotiate lower fees in exchange for being exclusive providers for a particular group of patients.  If the contracted providers were able to care for the patients in the HMO for less than the capitated amount then there was a profit to be shared by all providers.   If, on the other hand, the cost of caring for these individuals exceeded the group’s capitated amount, then the organization would lose money.  HMOs were successful in holding down the rate of rise of healthcare costs between 1993 and 1998 when healthcare inflation was at its lowest level in decades.  Initially, HMOs and managed care did bring efficiency to the healthcare system but after 1998, healthcare inflation rose back up to double digits.  It remained there until 2009, when costs again began to drop.   There is ongoing debate as to whether the recent drop is because of the recession or because of actual changes in behavior of physicians and hospitals to lower costs.  

Most of you are probably familiar with the scope of the problem with healthcare.  We spend 2.6 trillion dollars a year on healthcare in the United States which represents 17% of our gross domestic product.   It is estimated that this will rise to 25% of GDP by 2026.   The Netherlands spend the next highest amount of GDP on their healthcare which is 12% with Switzerland following at 10.6%.   Despite spending more of our GDP on healthcare than any other country we still have 50 million uninsured in the United States.   All of the European Union countries, Japan, Taiwan, and Singapore  provide universal coverage for much less than it costs in the US.

In addition to higher costs, we also have worse outcomes in the United States.  In a recent survey by the Organization of Economic Cooperation and Development,  a group of 34 countries in Europe, North and South America, and Eastern Asia, the numbers are striking.   The United States spends $8,200.00 a year per person on healthcare while the OECD average is $3,200.00.   US public money is 8% of GDP while the OECD is 7%.   Despite spending more money on healthcare we have fewer physicians and hospital beds per population, fewer hospitalizations and shorter lengths of stay, but more preventable hospitalizations.   The life expectancy in the US is 78.2 years whereas in the rest of the OECD, which includes some countries which are less developed than we are, it is 79.5.  Since 1960 the growth in life expectancy in the US has gone up 8.3 years versus and average of 11.2 years in the OECD at large.   We have fewer primary care physicians on average but more MRIs, CTs, total knee replacements, tonsillectomies, and cesarean sections take place in the US.   An average hospital stay in the United States costs $18,000.00.   In the rest of the OECD the cost is $6,200.00.   There are a few things where the US comes out on top.  It has the best survival rates in breast cancer and colon cancer, probably related to extensive use of screening tests.   However, even the breast cancer data has been called into question in that some experts feel that the widespread use of mammography has resulted in detection of small tumors that may never have caused a problem but are still treated with expensive and debilitating chemotherapy and radiation.  

So why are costs higher in the US?   I will attempt to outline some of the reasons.  As I have just alluded to, increased utilization of technology is widespread.   Again, using OECD data, we have 2-1/2 times more MRI scanners per million population than the OECD average.  Not surprisingly, we have twice as many MRI examinations.   Similar numbers apply for CT scans, and many types of surgeries, all without corresponding improvements in outcomes.  

Utilization also varies widely by geography.  This is true both nationwide and within the state of Iowa. Where there are higher concentrations of physicians, such as the East Coast, Florida, Texas, and California, utilization tends to be higher per population.   There was an article published in the Des Moines Register within the past 2 months showing the rate of utilization of prostatectomy within the state of Iowa.  In some metropolitan areas within the state, the rate of prostatectomy was 2-1/2 times higher than in others.   These differences in utilization have not been shown to result in improvements in outcome.

Physicians and hospitals do charge higher fees for their services than in other countries that have fee for service.  Some of this is due to more regulation in some of the other countries.  Drug costs are higher in the US than in any other country.  Most other countries negotiate directly with pharmaceutical companies for reduced prices.  The Medicare Part D act of 2003, in a clause championed by our own Senator Grassley, specifically forbids our federal government from negotiating directly with pharmaceutical companies.  As a result, the US subsidizes drug prices in other countries.  It should be noted that the VA has negotiated drug prices directly for years.

Another factor that leads to increased cost is mal-distribution of physicians.  As noted above the physicians tend to be concentrated in urban areas and “desirable” placed to live.   Medicare reimbursement rates in such high density areas as New York, Florida, Texas and California tend to be 1.4 times as high as those in Iowa, which is 49th in Medicare reimbursement rates among the states.   Despite low reimbursement, Iowa physicians and hospitals have consistently been in the top 5 in terms of quality of care to Medicare recipients.   The other states that rank low in reimbursement rates also rank low in quality.  Ironically, Louisiana, which has the highest Medicare costs per recipient ranks 47th in quality.  

One reason cited for high medical costs in the United States is medical malpractice.  However, the trend in malpractice premiums in most specialties has been downward for a decade.   There are some high risk specialties such as obstetrics and neurosurgery that continue to have high premiums, but for primary care providers malpractice premiums are low.  My own malpractice premium this year is 1% of total revenues.  

The medical legal climate is blamed in another way for high costs.  It is impossible to know how much of our healthcare expenditures are devoted to defensive medicine.  This is defined as procedures that might not otherwise be indicated but which are ordered because of fear of malpractice.  There is no definitive data on how much is spent this way, but some estimates are in the range of 10-20% of healthcare expenditures. Efforts at tort reform in some states have not led to significant drops in premium and many states that have enacted tort reform still have higher premiums than Iowa..  The total number of malpractice suits has been dropping in most states for about 10 years.

Healthcare administrative costs are roughly 3 times higher in the US than in other OECD countries.   On average, $900.00 per year is spent on every resident of the United States in health care administration versus $300.00 in the OECD countries.   If you take the $600.00 difference between the two figures and multiple it by 315,000,000 Americans, the savings from lowering administrative costs to OECD levels would equal $180 billion a year.    Our administrative costs are high because of the complex system that we have for delivering healthcare and private insurers who must spend on marketing and return to investors.   

End of life care is often cited as a reason for the accelerating cost of medical care.   Six percent of Medicare patients die each year and 27% of Medicare expenditures occur in the last year of life.  However, that figure has not changed in decades and hence cannot be blamed for healthcare inflation.  One percent of all Americans die each year and in that final year consume 10-12% of healthcare resources, but again that figure is constant.  

Another reason for the high cost of healthcare is that most users of healthcare are not purchasing that care directly but through third parties such as Medicare or private insurance companies.   There is little incentive for people to avoid consuming care.  Also people do not know the price of services that they are purchasing.   Insurance plans have introduced high copay and high deductible plans and health savings accounts (HSAs) in an effort to make people more aware of costs.  Some experts feel that these changes are one reason for the recent slowing in healthcare inflation.

The final reason for high cost is simply demographics.  We have an aging population which consumes more resources as it ages.   Part of this is attributable to the fact that we have much better treatment of heart disease and cancer than we did even 10-20 years ago.  In the case of heart disease, life style changes and more effective risk factor management have contributed to this.  Smaller numbers of smokers have contributed  to  longer  lifespans but that increases costs.  It might seem counterintuitive, but smokers actually consume fewer healthcare resources than nonsmokers.  While they tend to have more chronic illnesses, they also die 10 years sooner than nonsmokers and therefore have 10 years where they are not utilizing health resources at all.  

One of the consequences of aging is the increased numbers of people with dementia.    Currently, there are 4.7 million people in the US with dementia.   This is estimated to rise to 13.8 million by 2050 if effective treatment is not found for this vexing problem.  People with dementia consume a very high proportion of healthcare resources since they can require decades of institutional care.  

The debate that is going on now is what we can do to slow the rate of healthcare inflation.   Free Marketeers believe that getting government out of healthcare will release the invisible hand to weave its market magic and help us control our healthcare costs.   This is despite evidence to the contrary.  Despite having the most Free Market Healthcare system in the world we also have the highest cost, and still, 50 million people are without healthcare coverage.   In the 2012 World Health Organization rankings of national health systems the United States ranks 37th, just behind Costa Rica and just ahead of Slovenia and Cuba.   Number 1 was France and number 2 was Italy with Spain ranked 7th and Austria ranked 9th.  Japan was ranked 10th.   One other point that should be made is that despite being the most free market healthcare system in the world, 50% of our healthcare expenditures are through federal and state governments through Medicare, Medicaid and the Veterans Administration. 

One final argument that should be made regarding private versus public spending on healthcare is that Medicare has been better at controlling the rate of rise of healthcare costs than private insurance for the last 20 years.  Over the last decade, Medicare expenditures have risen at a rate of 8% a year, while private insurance expenditures have risen at a rate of 10%.  This is despite the fact that the Medicare population is obviously older and sicker.  Administrative costs for Medicare are 3%.  Administrative cost for private insurance plans can range as high as 20-30% due to marketing and return on investment needs.  One of the provisions of Affordable Care Act requires private insurance companies to spend at least 80% of premiums on providing healthcare rather than administrative costs.   Private insurers are shareholder owned and must return a dividend to the shareholders.   Medicare has no profit motive.  

The reason the free market has not been successful in holding down healthcare costs is that healthcare is unlike other sectors of the economy.    It is arguably the biggest sector of the economy now but behaves in ways that are different from other sectors.
These differences were first elaborated by Nobel Prize Winning Economist Kenneth Arrow in 1963 in the American Economic Review.  The title of his article is “Uncertainty in the Welfare Economics of Medical Care”.   In this paper he outlines how healthcare purchases differ from other purchases.  

The first difference is the nature of demand for healthcare, which its unpredictability.  Illness or accident frequently arrives unexpectedly and is not only unpredictable but very irregular, unlike demands for things such as food, clothing and shelter.   Also, medical services afford satisfaction only in the event of an illness, which is the departure from the normal state of affairs.   The only other economic transaction which could be said to be undertaken unwillingly at times would be the demand for legal services.   Arrow also points out that demand for medical services is associated with an assault on personal integrity, risk of death, and risk of impairment.  It is often accompanied by potential for loss or reduction of earning ability.   So there are not only financial, but potentially personal costs associated with the purchase of healthcare. 

A second difference between healthcare and other economic sectors is the expected behavior of the providers of healthcare.   In an acute illness the purchaser of the healthcare often does not have a chance to comparison shop and decide on the cheapest or best physician or hospital.  Therefore, the element of trust is extremely important.  Arrow points out that healthcare is unique in terms of commodities in that the product and activity of production are identical.   He also points out that the ethically understood restrictions on activities of a physician and hospitals are more severe than other licensed professionals.  He uses the example of a barber who is also a licensed professional.  However, Arrow points out that when a barber gives a consumer a bad haircut, the hair will always grow out again.   The expectations of doctors and hospitals are that they will behave ethically with the primary concern being the welfare of the consumer or patient.   Another difference that Arrow points out is product uncertainty.   While diagnosis and treatment have improved significantly since 1963, there is still an element of uncertainty in any acute illness that does not guarantee a desired outcome. With other commodities it is possible to learn from experience.  A good example would be buying a car. A car purchaser may buy a particular brand which proves unsatisfactory.   The next time the purchaser buys a car the buyer would be likely to get a different brand, whereas a good experience generally fosters brand loyalty.   In the case of severe illness, there is usually no previous experience with this illness and no way to know how it will turn out or to apply previous experience. 

In addition to uncertainty there is asymmetrical knowledge.  The medical professional knows much more about the situation than the patient and therefore the patient must rely on the physician’s knowledge to guide therapy.   Critics of Arrow point out that asymmetrical knowledge occurs in most professional and licensed occupations.   A local example of the ultimate in asymmetrical knowledge would be the case of Russell Wassendorf, whose clients were unaware of the fact that he was robbing them blind for 2 decades.  Nonetheless, the stakes in healthcare are much higher than in most situations, resulting in reliance upon the physician in situations where the patient may not be as informed as possible. 

The fourth area where Arrow points out that healthcare differs is in supply conditions.  All professions and many skilled trades require licensure and demonstration of competence, but the supply of physicians is significantly limited by length of training.  Obtaining a medical license is among the more difficult professional endeavors, requiring more years of training than virtually any other profession as well as a demonstration of competence at several steps on the way to completion of that training. 

The final area where Arrow points out the difference between healthcare and other sectors of the economy is in what he terms idiosyncrasies of payment.   There are many.  Care is paid for after and not before provision of the service and that service is nonrefundable.   Patients are given little or no information on price or costs.   The costs are paid by third parties, either the government or insurance.  The payers and providers negotiate the payments on behalf of the patients.   In acute situations patients do not have the power to say no if the price is too high.   Finally, unlike other areas of the economy, competition drives up costs rather than lowering them.   One traditional theory of currency inflation is that inflation is caused when there is too much money chasing too few goods.  You could say that medical inflation occurs when there are too many doctors chasing too few patients. This is why costs and utilization rates are higher in areas with higher concentrations of physicians.  In order to maintain their incomes, physicians in over served areas frequently find creative ways to extract maximum revenue from the insurance companies of their patients.  

Some people might say “So what if we spend this much money on healthcare?   We have to spend it on something.”  But the high costs of healthcare have deleterious effects on other parts of the economy.

The current employer base system is flawed in many respects.  Employer based health insurance discourages job mobility.  With job changes many people have waiting periods before insurance coverage starts and may be excluded for preexisting conditions.   This discourages job mobility and also discourages people from leaving an employer based system to start up their own businesses, thus discouraging entrepreneurship.   The employer based system also discourages retirement before age 65.  In many professions such as nursing and teaching, this means that new graduates have difficulties finding jobs in their chosen fields because of older workers who continue working only to retain their health insurance until reaching Medicare eligibility. In the last 10 years the number of people covered by employer based insurance has dropped from 69% to 61% and those healthcare plans that remain are generally imposing higher deductibles and copays upon the employees to control premium costs.   Also, because of rising healthcare cost employees have often opted to retain health insurance at the expense of raises in salary.  

Another problem with the ever rising cost of healthcare is the effects on Medicaid costs for the states.   As Medicaid costs rise, state budgets are stressed and cuts come elsewhere.   Education and public safety are the usual areas which are cut.  

The consequences of being uninsured are well known.   By some estimates anywhere from 18 to 40 thousand people die each year from preventable illnesses due to lack of health insurance.   Rather than getting needed preventative care the uninsured usually seek care in expensive emergency room settings.   They are often treated sub-optimally because of the cost of medications and procedures.   The uninsured often end up in the hospital and unable to pay their bills.  The hospital costs are then spread to paying customers,   resulting in increased charges to everyone else and decreased staffing for the hospitals.   The Affordable Care Act attempts to deal with this through its Medicaid Expansion Program.   As you are no doubt aware, Governor Brandstad has refused to sign onto the Medicaid Expansion so far.   In negotiating the Affordable Care Act with hospital associations, the hospitals took lower rates of pay for Medicare patients in exchange for the expansion of Medicaid that would mean they would have fewer nonpaying patients in the future.  Medical societies and hospital associations within the state are attempting to persuade the Governor to change his mind.  If he does not, then the hospitals will be forced into staff cutbacks and higher charges for everyone else.  

So what does any health care system need?   It needs 5 things. The first is finance.   The finance can be either private or government supplied or a combination of both, but ultimately it must come from individuals and households through either taxes or payroll deductions.  The healthcare system also needs risk pooling to protect individuals from high costs. This is the same as in any insurance plan.  The health system needs purchasing of healthcare, namely physician services, hospital services, pharmaceuticals, and medical devices.  It also needs production of healthcare from the same physicians, hospitals, pharmaceutical and device companies.     Finally, any healthcare system needs some form of regulation to produce socially desirable ends.  The question is who should provide financing and regulation?

There are many barriers to controlling costs while providing universal coverage.  Some barriers are political and others are cultural.  The political barriers are obvious;  deficit reduction, free market vs. public financing, and divisive issues such as abortion and contraception.   The cultural barriers are equally difficult.  Canada, Japan, Taiwan, and the EU countries provide universal coverage based on the principle of social solidarity, which says that healthcare should be financed by individuals on the basis of ability to pay and provided according to need.  This concept is widely accepted in these countries.  As Princeton economist Uwe Reinhardt points out, a large segment of the US population rejects this idea.  You may remember during a Republican presidential debate that Ron Paul, a physician, was asked what to do about a critically ill person who came to an emergency room lacking insurance.  While Rep Paul attempted to dodge the question, members of the audience shouted “Let him die!”  The individual mandate in the ACA, an idea that originated 20 years ago at the conservative Heritage institution, is widely disparaged now by conservatives who object to the infringement on freedom that they see in the mandate, but who would still undoubtedly expect to be cared for if they should show up in an ER uninsured.

While it may sound like heresy to some, I think it would be useful to look at what is being done in other countries to see what might work for us.  There are roughly 200 countries in the world.  Forty of them have an established healthcare system.  However, there are only 4 basic types of healthcare systems.  

The first is the Beveridge Model.  This is named after William Beveridge, the social reformer who designed Britain’s National Health System after World War II.   In this system healthcare is provided and financed by the government through tax payments.  It is just like any other public utility such as the police force or public library.  There is a mix of both publically and privately owned hospitals.  Many physicians are government employees but there are also private doctors.  The costs tend to be low and in fact Britain spends about 8% of its GDP on healthcare.   Roughly 10% of Britons have private health insurance, either individually purchased or sometimes provided by employers.   Countries other than Britain that have the Beveridge Model include Spain, most of Scandinavia and New Zealand.  Hong Kong has a Beveridge Model, which it retained when it was incorporated back into China. The ultimate in the Beveridge style approach is Cuba, where government control is complete.  

The next model is the Bismarck Model.  This is named after the 19th Century Prussian Chancellor, Otto Von Bismarck, who invented the modern welfare state.  Not only did Bismarck create a healthcare system, but he also invented social security and chose the age 65 as the age when social security benefits would be available.   In the Bismarck Model, health insurance is financed jointly by employers and employees through payroll deductions.   In the current German system, retirees are covered by their retirement funds.  Premiums for children are paid out of general government revenues on the theory that children are an important and valuable resource.  In Germany today there are over 200 independent nonprofit “sickness funds” from which Germans can choose.   However, these companies are highly regulated by the federal government.   The premiums that individuals pay for this insurance are based largely upon income and ability to pay.   Other countries that follow the Bismark Model include France, Belgium, Netherlands, Japan, Switzerland and some countries in Latin America. 

The third model is the National Health Insurance Model, which is a kind of cross between the Beveridge and Bismark Model.  It uses private sector hospitals and doctors but payment comes from a government run insurance program, financed by taxes.  The classic example of this is Canada.  Each Province administers its own program and there are individual variations among provinces.  Costs are controlled by limiting the fees charged by doctors and hospitals and also by limiting the expansion of technology.  Taiwan and South Korea have adopted a similar approach.  

The fourth and final model for health care is the Out of Pocket Model.  This is what we see in most third world countries and in rural areas of China and India.   The only healthcare that is provided in these countries is what can be paid for out of pocket.   The costs tend to be far cheaper than they are in the US, but access is extremely limited for most of the population.   There are up to date medical facilities in urban areas, where those who can afford it receive high quality care, but which is denied to the majority of the population.   

How do those systems apply to the United States?  We have elements of all four systems in this country.   The Veterans Administration follows the Beveridge Model.   Care is provided by government employed physicians and government owned hospitals through the Veterans Administration.   Medicare very much resembles the Canadian system or National Health Insurance Model.   For Americans who have employer related insurance, we have the Bismark Model and for the uninsured we have the Out Of Pocket Model.   The consequences of this fractured system are higher administrative costs, non-uniformity of care and quality, and 50 million people without health insurance.

It is my belief that we will not get health care costs under control and deliver quality with the current fractured system that we have.   Although the models differ from country to country, all those countries who have managed to control their healthcare costs and provided universal coveragehave required increased government involvement in the financing and regulation of the healthcare system.  

In moving forward, I think we will probably eventually end up with a two pronged system.   The Veterans Administration currently follows the Beveridge Model.   Veteran’s Organizations rightly argue that the needs of veterans are unique and I believe that the VA system should remain intact and be adequately funded through general tax revenues.  This is the least we can do for our veterans who come back from war bearing the scars of battle.

For the rest of us, we need to decide on one of the other three models.   The Beveridge Model is probably unacceptable to Americans.  It would require most physicians to become government employees and most hospitals to become government owned. That is not likely to happen.  However, I think we can eventually evolve into something more approaching the National Health Insurance Model in Canada utilizing private hospitals and physicians with government financing it.  This concept is often called “Medicare for all.”  This will obviously require additional sources of revenue, and the political will to do it.  I believe we will eventually end up with a system like this, but it will likely take a decade or more.

We have other needs that can be instituted sooner rather than later, and should not fall victim to the deficit reduction mania currently prevalent in Washington.  There is a need for increased funding for basic and clinical research.  As an example, finding a cure for Alzheimer’s Disease would result in significant savings to the healthcare system but can only happen through increased funding for research.   We also need better means of evaluating new and old therapies for their cost effectiveness.   The Independent Payment Advisory Board, labeled  “The Death Panel”  by conservative critics like Senator Grassley, established by the Affordable Care Act needs to be reinforced, not abolished. We need to start paying only for what works.   We have to be able to say no to some treatments.   As an example,the FDA recently denied approval for a drug for prostate cancer that cost $90,000.00 for a course of treatment and resulted on average in 2 more months of survival.  We need to educate the public and the medical community about what works and what does not.  The attitude that more is always better needs to be overcome as well.  As has been shown in a number of studies recently, aggressive treatment of entities such as prostate cancer and some types of breast cancer often results in more harm than good.   

There are three ways to save money in the healthcare system.   One, we can do less.  Two, we can pay less for what we do, or three, a combination of one and two. How to achieve the twin goals of lower cost and higher quality will be the topic of debate for years to come.    


Wednesday, January 16, 2013

Because I Might Need it Some Day

Supper Club
January 15, 2013
Because I Might Need it Some Day
Judith Harrington
            Those of you who attended our August meeting may recall that Bob Robinson noted how he kept shifting selection of his talk’s theme as new ideas came to mind. My situation is a bit similar. Six months ago, I was certain I knew what my theme was for this presentation, triggered by an event last July. When I was in the process of winding up some activities I’d been involved with for more than two decades, I was able to get rid of a lot of hard copy folders—so many in fact, that there were several file drawer sized boxes I no longer needed. It felt so good to see the space cleaned up, and I got to wondering about that feeling and where it comes from. So I thought I wanted to talk about organizing our lives in general. At the same time, cable TV A&E’s show Hoarders, and TLC's Buried Alive had become popular and both had caught my attention. Why would I even want to watch people living in chaos? Part of it may be voyeurism, I suppose. How many chances do we get to really see inside someone else's life? It is so dramatic to look at someone's home, see it this way, and then imagine how in the world someone could live there. While I knew my home in no way was that of a hoarder—no really, it isn’t!―as I watched some of those programs, I had to face the fact that in my own family there are two members who I believe are hoarders. Over the years, I had come to accept the situation unhappily, but circumstances late this summer brought me back to focusing on it again. So I decided I needed to learn more about this phenomenon. And that shifted my thinking about what to talk to you about tonight—hoarding.
            Let’s understand that there are collectors—for example, those with many bookshelves full of books, or those with walls full of art work, books of stamps. And then there are clutterers who accumulate things almost unintentionally; and finally there are hoarders. How are hoarders differentiated from collectors or clutterers? Have causes of hoarding been identified? What’s it like to grow up in a hoarder’s house? Who cares what you do with your stuff even if you are a hoarder? Have treatments been found? These are the questions I am attempting to answer this evening.
            Hoarding has been identified in some other countries besides the U.S. Indeed, references to hoarding are found in world literature, for example in Dante’s Divine Comedy, the Inferno, where his guide explained that there were the hoarders and wasters in life, the Avaricious and Prodigal. The term returns in Gogol’s 1842 Dead Souls, Dickens’ 1862 Bleak House, and even Conan Doyle’s Watson describing Sherlock Holmes as having a “horror of destroying documents” resulting in stacks of papers in every corner of the room. Even with such history, psychologists are just beginning to understand what motivates hoarders and how to help them.
1. How Hoarding is differentiated from Collecting and Cluttering
            These distinctions have been analyzed by a number of researchers. Briefly, collectors are discerning and display their treasures proudly. Those referred to as clutterers are chronically disorganized people who are willing and able to clean up, even welcoming assistance. And then there are hoarders, whose lives have become overwhelmed by stuff—those who strenuously resist help and turn a blind eye to the chaos.
            There has been an effort to quantify and qualify the problem of hoarding to appreciate how serious the problem is or could be. How many hoarders are there in the U.S.? I could find no reliable number. The lowest was from 700,000 to 1.4 million. Another reference stated between 6 and 15 million. Apparently, it is difficult to identify all hoarders—I don’t believe that is one of the identifiers in census forms! And even if that question was asked, many hoarders don’t view themselves that way. In an effort to qualify the problem, a group called the Institute for Challenging Disorganization developed the Clutter Hoarding Scale, an organizational assessment tool for use by professionals. It has five levels of ranking. However, since the scale doesn’t take into account the physical health of the individual or the person’s mental state, a version of the scale was developed by Matt Paxton’s company Clutter Cleaner. As an aside, some of the hoarders Paxton and his company have worked with have been on the A&E Hoarders show. This 5-level scale takes into account the social factors of American society, in which we have more leisure time, and the pressure that everyone—not just hoarders—is under to consume. The Clutter Cleaner scale isn’t intended for use by psychiatric professionals or therapists. It’s just used as a guideline—but let’s take a look at it anyway with the caveat before I begin that none of these stages is clear-cut.
            Stage One. The individual isn’t usually recognizable as a hoarder. At this stage, the problem isn’t about volume of collected stuff; it’s more about the habits hoarders are developing as they try to handle clutter. Early-stage hoarders have trouble parting with items and are beginning to build collections. They may be starting a shopping habit or a hobby that lends itself to acquiring things. The clutter will grow and hoarding will develop if these behaviors aren’t curbed.
            Stage 2. Coping with stuff like filing, particularly before “paperless” communication came into vogue: You leave it for a few days, you can cope. After a week, it becomes a pain but manageable. In a month or two, you’re ready to give up and stuff the whole lot under your desk. After all, if you didn’t need the papers for a month or however long they’d been piled up, how important could they be anyway? And this thinking—this inaction—is what leads to Stage 2. Surely, most folks have a junk drawer that holds odds and ends. Certainly, I have a kitchen drawer dedicated to pens, stamps, phone books, etc. But when a junk drawer becomes a junk room, it’s a signal that you are moving up to another stage! The Stage 2 hoarder pays less attention to housekeeping. Dishes pile up in the sink and spill over onto the counter. If there are indoor cats, the litter box remains dirty. Hoarders at this stage are starting to focus more on clutter than on life. They tend to invite fewer people over from a sense of embarrassment. Emotionally, there is some anxiety and mild depression at this stage. The hoarder may begin to withdraw from friends and family, substituting acquiring more things to fill that void. The cycle continues in earnest. As the hoarder brings homes more items, managing those takes priority over personal relationships. At this point, the hoarder begins to shift from embarrassment to justification, explaining why those possessions are needed; why they must be kept, as my title notes—because I might need it some day.
            Stage 3. It’s at this point that signs of hoarding become evident to the outside world. There may be a little structural damage to the house, e.g., a sagging porch. Some items which would be expected to be stored inside are stored or just tossed outside. Inside, paths through rooms and stairs are cluttered and difficult to navigate. Outside storage—such as a shed or garage—overflows. Stage 3 hoarders are losing track of their personal care. Bathing and hair cuts aren’t a priority. Stage 3 hoarders will sit for hours in front of the TV or computer. Bad food and lack of exercise may contribute to weight gain, and the classic stereotypical picture of the hoarder emerges. Job performance suffers. At this stage the hoarder is often depressed and claims to want to be left alone. If family members or even friends have tried to clean the house, they’ve been rejected in the efforts and so withdraw.
            Stage 4. Here there’s structural damage to the house such as floors and ceilings sagging, or unrepaired water damage. There may be mold, spider webs, bugs, rotten food in the kitchen. If major appliances break down, they can’t be accessed for repair. Things are stored in odd places: clothes hang from the bathtub curtain rod; documents are in the oven. The house is truly dangerous, with blocked entrances/exits, and mounds of paper creating a true fire hazard. The Stage 4 hoarder begins to retreat to a small area of livable space in the house. The hoarder may not launder clothes; rather more are purchased to replace them. Hoarders at this stage have stopped following societal rules. They struggle to get to work on time, or they may quit working and then be unable to pay their bills, or even if there’s enough money, aren’t paying bills because they’re lost amid piles of newspapers and clothing. Stage 4 hoarders talk mostly about past memories or unrealistic plans for the future.
            Stage 5. Not only is the house’s structural damage more severe, entire parts of the house may be blocked off with walls of clothing or other items such as piles of newspapers and magazines. The hoarder spends the entire day struggling to complete simple tasks like eating, sleeping, going to the bathroom. If any family or friends are still in contact with the hoarder, they may have tried intervention. City or county authorities have become aware. Depression is often so severe that the hoarder struggles to even get up each day.
            Please remember as I noted before listing the 5 stages, none of these stages is clear-cut. The scale shows a continuum. The initial assessment of what is being hoarded and where the hoarder is on this scale provides a sense of the problem’s severity. Hoarding isn’t just about dirt and trash; it’s about hanging on to things that seem important for one reason or another. The rest is garbage and accumulates because everything else has gotten out of hand.
            Another way to express the road from cluttering to hoarding: Hoarding is an issue when the clutter begins to affect the activities of everyday life: moving freely about the house cooking, cleaning, entertaining—being willing to permit others to enter your space. Someone who shuffles pile of junk mail around the kitchen counter or who is too embarrassed by the surroundings to invite people over might just be on the slippery slope to hoarding—or not. If the clutter gets progressively worse instead of better, it’s probably hoarding.
            Many people might claim that, at least at one point in their lives, they could be classified as a “pack rat” or a “closet clutterer.” However, compulsive hoarding is an anxiety disorder that involves much more than keeping extra papers and magazines around, or collecting CDs and DVDs under your desk. Severe compulsive hoarding can interfere with a person’s activities–such as cooking, cleaning, showering, and sleeping–because piles of newspapers or clothes are found in the sink, in the shower, on the bed, and in every corner of a home. That is, while most people can at least in due time make decisions about what to keep, what to toss, or what to donate—and then follow through on their decisions, a hoarder can’t. There appears to be something different in the hoarder’s brain that isn’t fully understood yet. It starts small, and then it gets out of hand.
            Frost and his colleague Steketee have written several books on this topic following years of research: 2006’sTreatment of Compulsive Hoarding: Therapist Guide, and more recently 2010’s Stuff: Compulsive Hoarding and the Meaning of Things. Frost and Steketee noted that all of us have special relationships with some things and those relationships in some ways seem magical. We get carried away with those attachments and—while that could get more of us into trouble with our possessions—most of us are able to decide when an object begins to interfere with our life. We do something about it at that point. That's the thing that's so troublesome for people who hoard: When objects begin to interfere, hoarders simply put up with them rather than deal with the items. Many hoarders have trouble making decisions about objects because they fear they'll later regret discarding something. Their possessions are often extremely disorganized. A subset of hoarders house large numbers of animals. Experts at the Center for Animals and Public Policy at Tufts University’s School for Veterinary Medicine reported seeing cases with many dozens of animals in a single home. Hoarders are usually oblivious to the fact that the animals are malnourished and filthy, convinced the animals are being rescued from a worse fate.
            There are some myths about hoarding—that these people are just lazy or messy or forgetful—and it's really much different than that. It's layered and it's complex. It covers not only attachments to possessions, but the inability to process information in a way that's efficient. The first systematic study and definition of hoarding was published in 1993 by Frost and Gross. Here hoarding was defined for the first time as “the acquisition of, and failure to discard, possessions which appear to be useless or of limited value” [p. 367], a definition which is commonly used today, although it’s been found that the hoarded objects may be more than worthless. Researchers talk to many people with hoarding problems who say, “I don't really have a hoarding problem; it's just that I don't have enough time to get rid of this stuff.” In fact what's happening, because of the way these individuals process information, is that it takes them so much time to decide to throw something out that they can't keep up with the in-flow.   
2. Identifying Possible Causes of Hoarding      
            While scientists and medical professionals are still figuring out exactly what hoarding is and what causes it, most agree that it is a glitch in the brain that manifests itself by making a person want to hang on to things. For some, hoarding may begin as the result of material deprivation at an earlier time of life, but that isn’t the only cause. Hoarding isn’t a character flaw. It’s not laziness or forgetfulness. Harsh as this may sound, it’s a mental disorder. Borchard noted that Nestadt and Samuels, two researchers at John Hopkins University, reported that compulsive hoarding is often considered a form of Obsessive-Compulsive Disorder (OCD) because between 18 and 42 percent of people with OCD experience some compulsion to hoard. The avoidance of and difficulties with discarding seem to be driven, at least in part, by fears of losing something significant (either information or emotional attachment) or being responsible for a bad outcome (e.g., behaving wastefully). These could be thought of as obsessional fears. Yet, hoarding appears distinct from OCD in a number of ways. For example, few hoarders experience negative, intrusive, or unwanted thoughts about hoarding, whereas this is the defining feature of OCD. [Also, parts of the hoarding syndrome are experienced as pleasurable (e.g., acquisition), something that almost never happens in people with OCD. Another reason to question the link between hoarding and OCD is that most people who suffer from hoarding (80% or more) do not have any other OCD symptoms, and hoarding shows the smallest correlation with other OCD symptoms of any of the OCD subtypes.]       
            Hoarding often runs in families and can frequently accompany other mental health disorders, like depressionsocial anxietybipolar disorder, and impulse control problems. A majority of people with compulsive hoarding can identify another family member who has the problem. However, no firm evidence has been reported yet.
            To add to the challenge of categorizing hoarding, neuroimaging studies, although still preliminary, suggest that different areas of the brain are involved for hoarding than for OCD. University of Iowa researchers compared brain-damaged patients who began abnormally collecting things following injuries/ to brain damaged patients who didn’t show those behaviors. All the abnormal collectors had damage in the middle of the front portion of the frontal lobes—called the prefrontal area, while the non-collecting patients’ damage was scattered throughout the brain. The prefrontal region of the brain is responsible for goal-directed behavior, planned organization and decision-making—all activities that represent challenges for people who hoard. There have been some other studies comparing brain patterns in hoarders to control groups, with no dramatic results.             At this point, geneticists are betting that hoarding has at least some significant genetic cause, but exactly what is inherited isn’t clear. One possibility is that hoarders inherit deficits or different ways of processing information. Perhaps they inherit an intense perceptual sensitivity to visual details, which give objects special meaning and value. Or perhaps hoarders inherit a tendency for the brain to store and retrieve memories differently. If visual cues are necessary for hoarders’ retrieval of memories, for example, then getting rid of those cues would be the same as losing their memories. Whatever might be inherited, it is likely that some kind of emotional vulnerability must accompany this tendency for full-blown hoarding to develop.
[How the Hoarder’s Decision-making might occur]      
            Here is a hypothetical or maybe not example of what a hoarder might deal with in a given situation. Most people who go to a fast-food restaurant and get a cold soda, throw away that big plastic cup when they’re done. Or they recycle it. But a hoarder has issues with that cup. The cup is useful. It’s a sturdy cup, after all, not a flimsy little paper thing. Or maybe a church feeding program or a homeless shelter could use it. Tossing the cup away would be a waste when there are so many people in this world who can use a good cup. So the hoarder keeps it, intending to get it to that church or shelter. It just never gets there. Or that cup—decorated with colorful cartoon characters—is meaningful because the hoarder went to the fast-food place with her toddler daughter as a special treat years before. The moment was an important emotional memory for the mother, and looking at the cup brings back that joyful experience. Throwing away the critical link to such an important occasion is unthinkable.
             Hard-core hoarders go through this internal debate with every single item that crosses their path: plastic bags, junk mail, fast-food relish packets. At some point, hoarders lose the self-management battle and get overwhelmed. The piles grow, the trash overflows, embarrassment builds, and they long ago stopped letting people into their homes. Without help, they have no idea where to even begin to clean up.
            Once possessions start to take over, hoarders tend to get attached to items no matter what they are. Being surrounded by piles of stuff can be strangely comforting. The stuff is there, day in and day out. It doesn’t change, it doesn’t leave, it doesn’t even move unless the hoarder wants it to.
3. What it’s like Growing up in a Home of a Hoarder
            One research thread is to look at children who grow up in the homes of hoarders. Such children are dramatically affected. Their childhoods are markedly different from those of their peers, and their adult lives can be shaped by the experience. Among their research endeavors, Frost, Steketee, and others conducted a study of relatives of hoarders that revealed the harmful consequences of growing up in a hoarded home. They found that the effects varied depending on the age of the child when the parent’s hoarding began. Children who lived in a hoarded home before age 10 were more embarrassed and less happy, had fewer friends and had more strained relations with their parents while growing up than did those whose parent’s hoarding began later. As adults, they were more likely to experience social anxiety and stress, and continued to have more strained relationships with their parents. Children who spent their early years in a hoarder’s home held more hostile and rejecting views of their parents than did children whose parents’ hoarding wasn’t apparent at that time. But even the latter group of adult children expressed a very high level of hostility toward their parents, higher even than that expressed by relatives of individuals with other forms of serious mental illness. Children with hoarding parents find ways of coping with the situation. It’s clear that the negative effects of hoarding stay with many of these children into their adulthood. The impact of growing up in a hoarder’s home can be substantial, so the researchers were not surprised to learn that internet groups have been formed to provide information, comfort, and support. One group  called Overcoming Hoarding Together [O-H-T] was created by the leaders of a hoarding self-help group to provide a place for hoarders and family members to interact with one another in a supportive way. Another, Children of Hoarders [C-O-H] was started by adult children of hoarders who recognized a need to share their experiences of growing up in a hoarded home. In March 2012, ABC’s 20/20’s program focused on grown children from hoarded homes. Children of hoarders say it’s difficult for others to understand the weirdness of growing up this way, with parents who seem to love their ‘junk’ more than their children. And, strangely, the children often feel that they’re to blame. Holmberg reported that a recent survey by psychologist Suzanne Chabaud—founder of the Obsessive Compulsive Disorder Institute in New Orleans, almost half of the adult children of hoarders suffer from feelings of guilt and shame and are frequently depressed.
4. Even if you are a hoarder, who cares what you do with your stuff?
            In theory, it shouldn’t be anyone’s concern, if you don’t care. However, there are some basic needs of survival that can be affected. Children of hoarders bear responsibility for figuring out what do with an aging parent who is living in such unsafe and unhealthy conditions. Most children are frustrated and angry after years of unsuccessful attempts to get their parents to do something about the problem. At the same time, they love their parents and are worried about them. Conflicted feelings of love and resentment put the children in an impossible position. One woman on the COH web site wrote about how her mother died in squalor, leaving the daughter full of shame, guilt, embarrassment and anger. She wrote: “I don’t care what the cost for the rest of you whose parent is still alive and living [in squalor]: WHATEVER IT TAKES have an intervention.” In addition to comments I made earlier about the hoarder’s home becoming one of filth, with issues of hygiene, other conditions such as noted in Stages 4 and 5 where the house has blocked entrances/exits, the turmoil can result in firefighters not being able to get into the home; or medical support can’t get in to reach the hoarder. Further, threats of eviction add to the hoarder’s confusion and defensiveness, as well as to family duress.
5. Treatment Efforts
            As noted earlier, those who hoard often don't see it as a problem, making treatment challenging. But intensive treatment can help people who hoard understand their compulsions and live safer, more enjoyable lives.
            Professional organizers. One option is to hire a professional organizer, particularly one experienced with compulsive hoarding. The Web site of the Institute for Challenging Disorganization has a list of organizers who have had training. Ideally, they can help the hoarder learn to prioritize the possessions—and, even if an eviction or health citation is imminent, they still will often give the client as much say as possible over their things. According to Deb Stanley, a professional organizer in Clinton Township, Michigan: "Shaming a person is never the answer. If you want the opportunity to effect change, you have to respect the person's dignity." I went to that web site’s link and found the closest certified member to live in Cedar Rapids.           
            Other team members. Who needs to be involved will depend on many factors. The most effective teams will include a range of participants. Depending on the circumstances, many of the services may be available at no charge or underwritten by an agency. Whatever the case, knowing whom to call upon and what to expect is essential. So, listing some of the possible team members:
            The family. Supportive family members will be invaluable as emotional support for the hoarder. However, family members who have been drained by failed efforts to help in the past, or those who nag and cast blame shouldn’t be part of the team. Any cleanup will be viewed as deeply personal for the hoarder. So the best team members will be close family members but only if there already is a strong relationship.  
            Friends, neighbors, and/or co-workers. If others than family members are brought into the circle, it needs to be understood that this will usually add to the hoarder’s anxiety level. The hoarder is already worried about being judged by family and doesn’t usually respond well to opening up this secret life to others. During the process of cleaning up, if the hoarder picks up something and someone else asks, “Will you throw this away?” all the attachments to that thing overwhelm any thoughts of being without it. What experts and hoarders alike agree on is that anger and resentment don't work.                                                   Therapy. Medications do not seem to be a successful route for hoarding as compared to other obsessive compulsive disorders. There even is some disagreement about the merits of Cognitive Behavioral Therapy. However, Cognitive Behavioral Therapy may be more effective for compulsive hoarding, especially when it involves a therapist going into the home of the hoarder and to help develop habits and a consistent behavioral program to try to de-clutter the hoarder’s home, car, and life. I have located a local group of licensed psychologists who work with hoarders; if you are interested, I’ll be happy to pass the information along to you afterward. There may be other groups as well.
            I want to close my formal remarks by turning back to those family members who stimulated the impetus for this presentation. From what I have learned, I believe that one member is a full-blown Stages 4 and 5 hoarder. On those rare occasions when he has had to get rid of some of his stuff due to total flood damage or as a result of city warnings of eviction, more stuff fills those cleared spaces. The other member’s hoarding has various elements of Stages 2 through 4: using a bathtub as storage, rooms stacked with journals and magazines, embarrassed to have people over, with comments like “I just don’t have time to clean it up.” Yet, when arrangements were made to assist him with clean-up this fall, even though he does care for the person who was there to provide assistance, he was defensive, insisting that he had to keep all those publications because he intends to live to 114 and has a lot of research yet to do. He was only willing to let go of junk mail that had piled up over time.
            My formal remarks now being concluded, it’s time for discussion. Thank you.


Belk, R. W., Wallendorf, M., Sherry, Jr., J. F., & Holbrook, M. B. (1991).        Collecting in a consumer culture. Highways and Buyways: Naturalistic     Research from the Consumer Behavior Odyssey, pp. 1778-215.

Berry, C., Patronek, V., & Lockwood, R. (2005). Long-term outcomes in animal      hoarding cases.
Borchard, T. (2011). 10 things you should know about compulsive hoarding.        Psych Central. Retrieved on January 2, 2013 from compulsive-hoarding/
Frost, R. O., & Gross, R. C. (1993). The hoarding of possessions. Behaviour          Research and Therapy, 31(4), 367-381.

Frost, R. O. & Steketee, G. (2010). Compulsive Hoarding and the Meaning of         Things. Boston: Mariner Books (Houghton Mifflin).

Holmberg, S. Nearly half of children of hoarders fight guilt, depression. ABC        News, March 10, 2012. Retrieved on January 2, 2013 from

Paxton, M. (2011).The Secret Lives of Hoarders. New York: Penguin Group.
            Tolin, D. F., Frost, R. O., Steketee, G., & Fitch, K. E. (2008). Family   burden of compulsive hoarding: Results of an Internet survey. Behavior        Research and Therapy, 46, 334-344.

Webley, K. (April 26, 2010). Hoarding: How collecting stuff can destroy your life. Time U.S.

[The listed contacts and Self-Help groups were mentioned in the paper.  They are not all-inclusive.]


Covenant Clinic Psychology: Dan Ekstrom, PsyS; Ronelle Langley, Ph.D.
            2750 St. Francis Dr., Waterloo 272-8922
            2802 Orchard Drive, Cedar Falls 268-9700

Institute for Challenging Disorganization.
            Address: ICD, 1693 S. Hanley Road, St. Louis, MO. Phone: 314-416-2236.

Margaret M. Jackson, the Organized Life. Certified Member, Institute for     Challenging Disorganization.       

Links to Adult Children’s Support Groups

Children of Hoarders (COH) Support Groups.  

Overcoming Hoarding Together (O-H-T) Support Groups.                                                                  

Additional Notes referring to page 2
            1. Regarding Gogol’s Dead Souls: A wealthy landowner named Plyushkin displayed all the characteristics of hoarding. The local peasants called him the fisherman for his habit of “fishing” the neighborhood for “an old sole, a bit of a peasant woman’s rag, an iron nail, a piece of broken earthenware.” He collected them all in his cluttered manor. Not long after that, “Plyushkin” became slang in Russian for anyone collecting discarded, useless, or broken objects. “Plyushkin syndrome” is still used in Russian psychiatry to refer to someone with a hoarding disorder.                                                                                                                             2. Early in the 20th century, ownership and acquisitiveness received some attention from psychologists. William James (1918) described acquisitiveness as something instinctual that contributed to one’s sense of identity. For James, one’s sense of self fused “me” and “mine.” In the mid 20th century, Erich Fromm suggested that acquisition was one way for people to relate to the world around them and was core to one’s character. In his theory, a “hoarding orientation” was one of four types of dysfunctional character. This orientation corresponded with a fundamental orientation to existence – “having.” The destructive orientation of “having” or avarice contrasted with the more healthy “being” orientation.
            3. At about the same time as Fromm was writing about the “hoarding orientation,” the New York City newspapers were filled with stories about the Collyer brothers who died among the junk in their Harlem brownstone. The Collyer brothers not only affected a generation of New Yorkers whose mothers admonished them to clean their rooms or end up like the unfortunate brothers, but they also inspired several novels, Marcia Davenport’s My Brother’s Keeper published in 1954, and the recent E.L. Doctorow’s Homer and Langley. It has been the stuff of theatre, and even now among New York City firemen, a hoarded home is referred to as a Collyer house.