I consider myself to be a fairly proficient user of English as a second language, but there are some things I will never get right:

• Using a “W” when a “V” would do (like in woodoo voodoo; and yes, just like Chekov).
• Pronouncing “iron” correctly.
• Understanding whether “substituting X for Y” means that you used to have “X” and now you have “Y” or vice versa.
• Using em-dashes without—yes, without—any surrounding spaces.

The first two are entirely my fault, the third runs contrary to most other languages, but the last one is just dumb and that rule should be abolished.

There are books you read once and toss out ⊕ See also: anything by Malcolm Gladwell, Michael Lewis, or any other permanent airport book store resident. and those which keep on giving, and René Girard’s I See Satan Fall Like Lightning falls firmly in the latter category.

One concept I have come to appreciate more thanks to the book is that of the scandal. ⊕ As in: “the reaction of moral outrage and indignation about a real or perceived transgression of social norms”, not the TV show. Though I’m sure the show has its fans. Girard has a book — or rather, a collection of essays — with “scandal” in the name, but both he and Luke Burgis focus more on mimetic desire and how it can lead to conflict; the build-up of scandal is “just” a stepping stone, something natural and completely expected of humans. This may be related to their catholicism, but I am neither a theologian nor a philosopher, so I’ll refrain from speculating further.

What I won’t refrain from, however, is flipping my thinking from human desire causing scandal to the human desire for scandal. It a phenomenon not exactly like, but closely related to, schadenfreude — the pleasure in the misfortune of others. In fact, a search for Skandalfreude does return some relevant hits — one of them from Stefan Zweig, no less — so let’s use that word to describe the pleasure in being scandalized or, more broadly, the desire to be scandalized. And I suspect that, similar to schadenfreude, there is a Gaussian curve of people’s propensity for experiencing it in general and, flipping the axes, a Gaussian curve of the number of people with the propensity for it when it comes to a particular topic.

The first bell curve pits the “Karens”, ⊕ I am misusing the term Karen here, and contributing to it becoming a suitcase word. For this, I apologize. You could replace it with “the woke” in your mind’s eye — again, a misuse! — and get the same intended result. Funny how that works.scandalized by everything, opposite the phlegmatics, scandalized by nothing. On the ends of the second curve lie the haters — who think that a particular company, person, ideology, etc. is evil — and the fanboys, to whom that same entity can do no wrong.

Regarding the second, entity-based curve: the higher the profile, the fatter the tails. This we all know intuitively. When Apple causes an uproar for their “shot on the iPhone” Scary Fast event, it is the skandalfreude fat tail poking its head. Knowing how many people pour over every one of Apple’s actions just wanting to be scandalized — to the point of paying to be scandalized — it is a small miracle these storms in a teacup don’t happen more often.

So with those two curves in mind, Girard’s insight is this: mimetic desire makes only one of their ends “sticky”, the one that “likes” scandal. With a critical mass, it is no longer a bell-shaped curve at all, but leans towards the exponential. The entity to which this happens becomes a scapegoat and is stoned to death, in the true sense millennia ago, nowadays only metaphorically. This is why Apple and the rest of Big Tech should tread lightly: their tails are fat enough that even small missteps, or perceived missteps, cause controversy. A full-blown mistake or, worse yet, a true transgression, would hurl the skandalfreudeian mass ⊕ Or has that already happened?towards the deep end and make them into a scapegoat for all of the society’s ills.

The practice of doomscrolling could be viewed in this light: trawling thorough the timeline, waiting for the next opportunity to experience some skandalfreude, maybe even jump onto a stoning bandwagon or two, at no personal cost. Much of online behavior seems less bizzare when viewed through this mental model, and for that alone it is a good one to have.

As a long-time fan of Goodhart’s law — see here, here, and of course here — I can only nod my head in appreciation of Adam Mastroianni’s concept of self-Goodharting. My first encounter with the concept, and still an excellent introduction, was an article on Ribbonfarm.

We like to do things in medicine, and medicine’s big contribution to science was figuring out how best to answer the question of whether the things we do actually work. But of course things aren’t so simple, because “Does it work?” is actually two questions: “Can it work?”, i.e. will an intervention do more harm than good under ideal circumstances, and “Does it work in practice?”, i.e. will an intervention do more good than harm in usual practice.

We also like to complicate things in medicine, so the person to first delinate this distinction, Archie Cochrane of the eponymous collaboration named them efficacy and effectiveness respectively — just similar enough to cause confusion. He also added efficiency for good measure (“Is it worth it?) Fifty years later, people are still grappling with these concepts and talking over each other’s heads when discussing value in health care. Which is to say, it’s best not to use the same prefix for overlapping terms, but if you had to, “eff” is most appropriate.

The most recent example is masks. Cochrane Colaboration’s review said they didn’t “work” ⊕ The paper caused an uproar and language has since been toned down, but that was the gist. for preventing respiratory infections. Now, knowing what Cochrane was all about the first question to ask is: what sense of “work” did the authors intend, and this particular group is all about effectiveness (working in “the real world”), not about efficacy (working under ideal conditions). This caused some major cognitive dissonance among the covid-19 commenters. Vox had the typical sentiment:

Furthermore, neither of those studies [included in the meta-analysis] looked directly at whether people wear masks, but instead at whether people were encouraged or told to wear masks by researchers. If telling people to wear masks doesn’t lead to reduced infections, it may be because masks just don’t work, or it could be because people don’t wear masks when they’re told, or aren’t wearing them correctly.

There’s no clear way to distinguish between those possibilities without more original research — which is not what a meta-analysis of existing work can do.

But this is the difference between ideal (you force a person to wear a mask and monitor their compliance) and typical conditions (you tell the person to wear a mask and keep your fingers crossed), and Cochrane is interested in the latter, ⊕ Though of course, the chasm between ideal and typical circumstances varies by country, and some can do more than others to bring the circumstances closer to ideal, by more or les savory means. which is the one more important to policy-makers.

This is an important point: policy makers make broad choices at a population level, and thus (do? should?) care more about effectiveness. Clinicians, on the other hand, make individual recommendations for which they generally need to know both things: how would this work under ideal conditions, how does it work typically, and — if there is a large discrepancy — what should I do to make the conditions for this particular person closer to the ideal? We could discuss bringing circumstances closer to ideal at the population level as well, but you an ask the people of Australia how well that went.

The great colonoscopy debate is another good example of efficacy versus effectivness. There is no doubt that a perfectly performed colonoscopy at regular intervals will bring the possibility of having colon cancer very close to zero, i.e. the efficacy is as good as you can hope for a medical intervention. But: perfection is contingent on anatomy, behavior, and technique; “regular intervals” can be anything from every 3 months to every 10 years; and there are risks of both the endoscopy and the sedation involved, or major discomfort without the sedation. And thus you get large randomized controlled trials with “negative” results ⊕ Though they do provide plenty of fodder for podcasts and blogs, so, thanks? that don’t end up changing practice.

So with all that in mind, it was… amusing? to see some top-notch mathematicians — including Nassim Taleb! — trying to extrapolate efficacy data out of a data set created to analyze effectivness. The link is to the preprint. Yaneer Bar-Yam, the paper’s first author, has a good X thread as an overivew. To be clear, this is a worthwhile contribution and I’ll read the paper in depth to see whether its methods can be applied to cases where effectiveness data is easier to come by than efficacy (i.e. most of actual clinical practice.) But it is also an example of term confusion, where efficacy and effectiveness are for the most part used interchangeably, except in the legend for Table 1 which say, and I quote:

The two by two table provides the incidence rates of interest in a study of the efficacy (trial) or effectiveness (observational study) of an intervention to reduce risk of infection from an airborne pathogen.

Which seems to imply that you measure efficacy exclusively in trials and effectiveness in observational studies, but that is just not the case (the colonoscopy RCT being the perfect example of an effectiveness trial). And of course it is a spectrum, where efficacy can only be perfectly measured in impossible-to-achieve conditions of 100% adherence and a sample which is completely representative of the population in question so any clinical trial is “tainted” with effectiveness, though of course the further down you are on the Phase 1 to Phase 4 rollercoaster the closer you are to 100% effectivness.

I wonder how much less ill will there would be if the authors on either side realized they were talking about different things. The same amount, most likely, but one could hope…

Update: Not two seconds after I posted this, a JAMA Network Open article titled “Masks During Pandemics Caused by Respiratory Pathogens—Evidence and Implications for Action” popped into my timeline and wouldn’t you know it, it also uses efficacy and effectiveness interchangeably, as a matter of style. This is in a peer-reviewed publication, mind you. They shouldn’t have bothered.

On this day 85 years ago, at 8pm Eastern Time, Orson Welles performed The War of the Worlds live on radio. Things escalated quickly. I will give major nerd points to Apple for even an oblique reference to the radio drama at tonight’s event, but I am not holding my breath.

One of the most level-headed descriptions of the “current situation” comes from the former French prime minister Dominique de Villepin in an interview with Appolline de Malherbe. His answer to the question of whose fault it was:

But Ms. Malherbe, I am trained as a diplomat. The question of fault will be addressed by historians and philosophers.

Unsurprisingly, he never held elected office. That kind of nuanced thinking will never get you enough votes.

This list of NCI’s Lasker Clinical Research Scholars has some familiar faces, and I couldn’t be more proud. These are all MDs and MD/PhDs who are forgoing lucrative careers in industry and private practice and exposing themselves to metric tonnes of federal red tape, all to find cures for rare and neglected cancers (looking at you, T-cell lymphomas and AIDS-related malignancies). May their Tartars show up.

Chris Arnade walked through Japan again, and his notes are as good as ever.

In both cases, the working and middle class Japanese and English are forced by a lack of options, to develop their own sense of self. Which includes lots of hobbies.

They are not inflicted with the US-style careerism, where you’re never supposed to be satisfied with what you have. Where the belief that you can, with the right amount of dedication, move up into ever and ever higher classes, presumably with the intent to reach a materialistic nirvana. Which I guess is a five-bedroom home, with a four-car garage, and a big lawn. A big lawn you pay someone else to take care of, because who has the time for gardening?

That’s why I came back to Japan, and that’s why I walked England twice, and why I will keep coming back to both.

And I’ll keep coming back to Chris’s newsletter!