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I’ve finished Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients,a well-researched effort presented in overheated language by Ben Goldacre. With all of the trillions of dollars spent on drug development and drugs themselves, have you ever wondered why people don’t seem to feel better than they did back in the 1970s? There have been so many new painkillers, for example, but none seem to work much better than aspirin, a remedy known to Hippocrates (Wikipedia).

Here’s the main thesis of the book:

Drugs are tested by the people who manufacture them, in poorly designed trials, on hopelessly small numbers of weird, unrepresentative patients, and analysed using techniques which are flawed by design, in such a way that they exaggerate the benefits of treatments. Unsurprisingly, these trials tend to produce results that favour the manufacturer. When trials throw up results that companies don’t like, they are perfectly entitled to hide them from doctors and patients, so we only ever see a distorted picture of any drug’s true effects. Regulators see most of the trial data, but only from early on in a drug’s life, and even then they don’t give this data to doctors or patients, or even to other parts of government. This distorted evidence is then communicated and applied in a distorted fashion. In their forty years of practice after leaving medical school, doctors hear about what works through ad hoc oral traditions, from sales reps, colleagues or journals. But those colleagues can be in the pay of drug companies – often undisclosed – and the journals are too. And so are the patient groups. And finally, academic papers, which everyone thinks of as objective, are often covertly planned and written by people who work directly for the companies, without disclosure. Sometimes whole academic journals are even owned outright by one drug company. Aside from all this, for several of the most important and enduring problems in medicine, we have no idea what the best treatment is, because it’s not in anyone’s financial interest to conduct any trials at all. These are ongoing problems, and although people have claimed to fix many of them, for the most part they have failed; so all these problems persist, but worse than ever, because now people can pretend that everything is fine after all.

We’re nearly 30 years into Prozac Nation. The pills are cheap and published research shows that they work well. Is everyone cheerful?

In 2008 a group of researchers decided to check for publication of every trial that had ever been reported to the US Food and Drug Administration for all the antidepressants that came onto the market between 1987 and 2004. The researchers found seventy-four studies in total, representing 12,500 patients’ worth of data. Thirty-eight of these trials had positive results, and found that the new drug worked; thirty-six were negative. The results were therefore an even split between success and failure for the drugs, in reality. Then the researchers set about looking for these trials in the published academic literature, the material available to doctors and patients. This provided a very different picture. Thirty-seven of the positive trials – all but one – were published in full, often with much fanfare. But the trials with negative results had a very different fate: only three were published. Twenty-two were simply lost to history, never appearing anywhere other than in those dusty, disorganised, thin FDA files.

How about the efforts at reform? Goldacre shows that they’ve failed on both sides of the Atlantic.

The 1997 FDA Modernization Act created clinicaltrials.gov, a register run by the US government National Institutes of Health. This legislation required that trials should be registered, but only if they related to an application to put a new drug on the market, and even then, only if it was for a serious or life-threatening disease. The register opened in 1998, and the website clinicaltrials.gov went online in 2000. The entry criteria were widened in 2004. But soon it all began to fall apart. … But the first problem for the US register, which could have been used universally, was that people simply chose not to use it. The regulations required only a very narrow range of trials to be posted, and nobody else was in a hurry to post their trials if they didn’t have to.

In 2007 the FDA Amendment Act was passed. This is much tighter: it requires registration of all trials of any drug or device, at any stage of development other than ‘first-in-man’ tests, if they have any site in the US, or involve any kind of application to bring a new drug onto the market. It also imposes a startling new requirement: all results of all trials must be posted to clinicaltrials.gov, in abbreviated summary tables, within one year of completion, for any trial on any marketed drug that completes after 2007. Once again, to great fanfare, everyone believed that the problem had been fixed. But it hasn’t been, for two very important reasons. First, unfortunately, despite the undoubted goodwill, requiring the publication of all trials starting from ‘now’ does absolutely nothing for medicine today. … But there is a second, more disturbing reason why these regulations should be taken with a pinch of salt: they have been widely ignored. A study published in January 2012 looked at the first slice of trials subject to mandatory reporting, and found that only one in five had met its obligation to post results.62 Perhaps this is not surprising: the fine for non-compliance is $10,000 a day, which sounds spectacular, until you realise that it’s only $3.5 million a year, which is chickenfeed for a drug bringing in $4 billion a year. And what’s more, no such fine has ever been levied, throughout the entire history of the legislation.

The search functions on the FDA website are essentially broken, while the content is haphazard and badly organised, with lots missing, and too little information to enable you to work out if a trial was prone to bias by design. Once again – partly, here, through casual thoughtlessness and incompetence – it is impossible to get access to the basic information that we need.

So: let’s say we want to find the results from all the trials the FDA has, on a drug called pregabalin, in which the drug is used to treat pain for diabetics whose nerves have been affected by their disease (a condition called ‘diabetic peripheral neuropathy’). You want the FDA review on this specific use, which is the PDF document containing all the trials in one big bundle. But if you search for ‘pregabalin review’, say, on the FDA website, you get over a hundred documents: none of them is clearly named, and not one of them is the FDA review document on pregabalin. If you type in the FDA application number – the unique identifier for the FDA document you’re looking for – the FDA website comes up with nothing at all. If you’re lucky, or wise, you’ll get dropped at the Drugs@FDA page: typing ‘pregabalin’ there brings up three ‘FDA applications’. Why three? Because there are three different documents, each on a different condition that pregabalin can be used to treat. The FDA site doesn’t tell you which condition each of these three documents is for, so you have to use trial and error to try to find out. That’s not as easy as it sounds. I have the correct document for pregabalin and diabetic peripheral neuropathy right here in front of me: it’s almost four hundred pages long, but it doesn’t tell you that it’s about diabetic peripheral neuropathy until you get to page 19. There’s no executive summary at the beginning – in fact, there’s no title page, no contents page, no hint of what the document is even about, and it skips randomly from one sub-document to another, all scanned and bundled up in the same gigantic file. … unlike almost any other serious government document in the world, the PDFs from the FDA are a series of photographs of pages of text, rather than the text itself. This means you cannot search for a phrase. Instead, you have to go through it, searching for that phrase, laboriously, by eye.

Clinical research trials is increasingly outsourced to private companies and increasingly done on patients outside the U.S. and EU. How much money is involved when a trial is done in the U.S.? And what’s the cost savings for going offshore?

In the US, meanwhile, the use of private community doctors to conduct trials has expanded enormously, with incentives approaching $1 million a year for the most enterprising medics.

As the former chief executive of GSK explained in a recent interview, running a trial in the US costs $30,000 per patient, while a CRO can do it in Romania for $3,000.

In the past, only 15 per cent of clinical trials were conducted outside the USA. Now it’s more than half. The average rate of growth in the number of trials in India is 20 per cent a year, in China 47 per cent, in Argentina 27 per cent, and so on, simply because they are better at attracting CRO business, at lower cost. At the same time, trials in the US are falling by 6 per cent a year (and in the UK by 10 per cent a year).

One problem with these trial is that they generally use patients who have only one condition and who may not be getting any treatment for it. Goldacre asks “Are those findings really transferable, and relevant, to American patients, on all their tablets?”

What does it take to get a drug approved by the FDA?

In general, however, a company would expect to have to provide two or three trials, with a thousand or more participants, showing that its drug works. This is where the smoke and mirrors begin. Although the notion of a simple randomised trial should be straightforward, in reality there are all kinds of distortions and perversions that can come into play, in the comparisons that are made, and the outcomes that are measured for success. For me, ‘What works?’ is the most basic practical question that every patient faces, and the answer isn’t complicated. Patients want to know: what’s the best treatment for my disease? The only way to answer this question when a new drug comes along is by comparing it against the best currently available treatment. But that is not what drug regulators require of a treatment for it to get onto the market. Often, even when there are effective treatments around already, regulators are happy for a company simply to show that its treatment is better than nothing – or rather, better than a dummy placebo pill with no medicine in it – and the industry is happy to clear that low bar.

A paper from 2011 looked at the evidence supporting every single one of the 197 new drugs approved by the FDA between 2000 and 2010, at the time they were approved.15 Only 70 per cent had data to show they were better than other treatments (and that’s after you ignore drugs for conditions for which there was no current treatment). A full third had no evidence comparing them with the best currently available treatment, even though that’s the only question that matters to patients.

This same perverse problem of inadequate comparators also exists in the EU.17 To get a licence to market your drug, the EMA does not require you to show that it is better than the best currently available treatment, even if that treatment is universally used: you simply have to show that it is better than nothing. A study from 2007 found that only half the drugs approved between 1999 and 2005 had been studied in comparison with other treatments at the time they were allowed onto the market (and, shamefully, only one third of those trials were published and

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In this blog posting from May 23, I pointed out an obvious flaw in Thomas Piketty’s Capital in the Twenty-First Century, i.e., that he calculates investment returns for the uber-rich by looking at different people who happened to make the Forbes list at different times. It turns out that a careful analysis by Stan Veuger in U.S. News and World Report was published a week earlier. Veuger follows the top 10 folks (a.k.a. “rich bastards”) from 1987 and finds out that they earned only about a 0.5-percent real return on their investments, i.e., less than what a consumer who bought and held an S&P 500 index fund would have earned. Piketty’s call to action is premised on the idea that rich people and/or rich organizations can get exceptionally good investment returns, but he has not put forth any good data to support that idea. (And even if he were right, he would have to adjust for the fact that a lot of middle class people have their money in pension funds and other professionally managed aggregations that should, in theory, have the same access to investments as the wealthiest individuals.)

[One of the largest investors in the U.S. is CalPERS, with more than $250 billion in assets and 2600 employees. Their year-end 2013 report shows that they achieved a 7.91% annual return over a 20-year period. What about a regular Joe who parked his money in a Vanguard S&P 500 fund? This calculator shows an investment held from January 1, 1994 through December 31, 2013 would have grown at 9.22%.]

Separately, Martin Feldstein published an article in the Wall Street Journal about how changes in the tax code led people to tear down Schedule C corporations and build S corps and LLCs instead. The real economy and real income/wealth distribution didn’t change that much, but individual tax returns changed dramatically in response to dramatic Reagan-era changes in the tax code.

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This Business Insider piece covers a longitudinal study by Joseph P. Allen from the University of Virginia. As noted in The Smartest Kids in the World: And How They Got That Way (see my review of the book in these postings: Finland; Poland; American Public; American Private; What can a Parent do?; Korea), Americans like to comfort themselves that though our schools perform poorly on things that are easy to measure, such as educational attainment, they perform well on things that are hard to measure, such as socialization and sports team building: “Instead of the apprenticeship/mentoring environments that prevailed throughout most of human history, we decided to put hundreds of teenagers together all day every day. What could go wrong?” Allen’s study, however, found that teenagers who were experts at impressing other teenagers did not have superior skills for impressing adults. As adults have most of the power in this country, the “cool kids” from high school struggled upon reaching their 20s.

My personal experience in this area comes from following the most popular kid from my 5th grade class. He had long blond hair, was good at sports, and got invited to every birthday party. My parents lived in the same house for more than 45 years so I thought that perhaps they might know how he was doing as an adult. My mom said “I know exactly what he is doing. He’s living in his parents’ basement, smoking dope, drinking beer, and watching TV all day.”

Separately, to celebrate the World Cup, here’s a story from 10 years ago: I was walking past a youth soccer game with a friend from Massachusetts. She said “This is wonderful. By playing on a team these kids are learning everything that they will need to succeed in business.” I replied “Yes, I’m sure that you’re right. That’s why Nigeria, Argentina, and Cameroon have the strongest economies.”

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Next time someone asks you to invest in an American “green tech” company, carefully review the Wikipedia page for the Norwottuck Rail Trail here in Massachusetts:

The trail has degraded over time. One aspect of the problem is that the original pavement was an attempt at being “green”, and incorporated crushed used glass bottles as part of its aggregate. This material has been slowly emerging over time, causing flat tires and other issues.

It will cost the taxpayers $4 million to fix…

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Folks:

I drafted a travel guide for those who don’t think that they are too old to rock and roll: “Glastonbury Festival for Old People”. Comments/corrections would be appreciated. Also note that the photos and a video that I took there are available only as hyperlinks (much easier to push everything to Google+ than to my own server, sadly).

Philip

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A friend posted the following question on Facebook: “Are you or do you know of a family who likes to travel with their 6-14 year-old children and likes to show them various landmarks and/or places of historical significance? I’d love to ask you a few questions about your experiences and challenges of traveling with kids.”

I thought that my answer might be useful to readers so I’m posting it here:

About 1.5 years ago I helped take a group of kids age 7-12 around Israel and Jordan. One mother would nag at her 11-year-old to pay attention. “This trip was expensive. You have to appreciate every minute.” She would get upset if a group of three kids would want to play an iPad game while on a 1.5-hour car ride through boring boringly-lit (mid-day sun) desert. I thought it was more reasonable to let the kids do whatever they wanted in transit and save their attention for the actual sights. I think it helps to have a larger group with more kids so that they can have fun with each other at night and in transit.

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I’ve just returned from a trip to England and spent a little time looking at the society as Thomas Piketty might (see my review of Capital in the Twenty-First Century).

England’s economic performance has been mediocre during many of the post-World War II decades, leaving it with a per-capita GDP of $37,300 compared to $52,800 in the U.S. and $62,400 in England’s former trading post of Singapore (source: CIA Factbook, purchasing power adjusted). Mancur Olson used Britain as an example of how a rich stable society can stagnate due to politically powerful groups steadily skimming off wealth (see my March 2009 posting on Mancur Olson):

“Great Britain, the major nation with the longest immunity from dictatorship, invasion, and revolution, has had in this century a lower rate of growth than other large, developed democracies. … Britain has [a] powerful network of special-interest organizations. The number and power of its trade unions need no description. [Olson wrote this book just as Margaret Thatcher was coming to power.] The venerability and power of its professional associations is also striking. … Britain also has a strong farmer’s organization and a great many trade associations.”

“[Britain’s interest groups] are narrow rather than encompassing. For example, in a single factory there are often many different trade unions, each with a monopoly over a different craft or category of workers…”

Olson notes that slow growth can’t be due to something inherent in the British character, because the country was the world’s fastest growing from 1750 until 1850.

The United Kingdom’s Gini coefficient is lower than that of the U.S.’s, so in theory it should be closer to Piketty’s ideal society. How does it feel on the ground, though?

First of all, there are some advantages to living in the U.K. that people at all income levels share. One can be outside in the summer time without getting eaten alive by mosquitoes (but bring an umbrella!). Restrictions on architecture and building mean that a lot of towns are beautiful and/or charming. Consider the value of a stroll around Paris compared to a stroll around a typical U.S. city. Due to a more or less free market in air travel and short distances, flights to interesting locations in Europe are affordable to everyone.

On the other hand, the restrictions on architecture and building mean that a single-family house with windows on four sides and a little yard is out of reach for most Britons. In a lot of places, if you can’t afford to build a beautiful house out of stone then you can’t build a house. Slapping up a McMansion for $300,000 and luxuriating in 4000 square feet is certainly out of the question. The bottom half of the income distribution seems to live mostly in apartments or attached houses (townhouses; sharing walls with neighbors so that there might be windows only in the front and back). This is advantageous because the higher density means it is more likely that a person can walk or use public transport, also a good thing because non-rich Britons seem to have pretty basic automobiles or don’t own a car at all. The road network is absurdly brittle and clogged with traffic. A “highway” between two cities might have no shoulder and lanes that are just barely wide enough for two trucks to pass. If a car breaks down or any repairs are needed, the “yummy mummy” in her $100,000 Range Rover will be stuck in a one-hour traffic jam. Internet for the home and mobile voice and data services are cheaper than here in the U.S. However, mobile data rates are absurdly slow, coverage is poor, and 4G is a theoretical concept outside of London. It hurts me to admit this, but my friend Mark might right when he says “Verizon is like democracy: the worst cellular service, except for all the others that have been tried from time to time.” Hotels, restaurants, and shops try to compensate by offering free WiFi but upload speeds are too slow (e.g., 100 kbps) to make it practical to, for example, email a photo to someone.

London is like a separate country in terms of wealth but it is hard to know whether it is fair to roll that into British wealth/income inequality. England taxes foreign residents on their English income, not on their worldwide income, so a lot of high-income/high-wealth people, e.g., from Russia or the Arab world, establish residency in London for convenience and stability. This puts tremendous demand on London real estate but if the Four Seasons built a resort in your town and a lot of rich foreigners came there to stay would you then say that your town had become less equal?

Even if we exclude the foreign billionaires, the lifestyle gap between rich and poor in England seems pretty stark. The rich Briton will have a London flat, a beautiful country house in the Cotswolds (see these photos), a couple of fancy new cars, and maybe a vacation house in France, Spain, or Italy. The lower middle class Briton will live in a dark attached house or apartment, commute via bus or train (without air conditioning!), and go on packaged holidays.

How did the rich get their money? Did they get it the honest Piketty-approved way (i.e., by getting PhDs and then working at a university)? Via marriage as Piketty describes? Or via inheritance as Piketty decries?

British Airways was kind enough to give me a free copy of the June 30, 2014 Daily Mail newspaper. The 76 pages contain the following stories that are explicitly about how people got money:

• one story about a woman who started life in public housing (“a council semi”) and after a series of divorces from wealthy men, now has at least $100 million in assets.
• a story, “Benefit grabbing extremist who hates Britain”, about a 35-year-old man who lives in public housing and collects unemployment and disability.
• a story about a mother who looted her son’s $85,000 trust fund to buy “luxury clothes” and to redecorate her home
• a story about the salary to be earned by the incoming president of the European Union

Other stories hint at the value of inheritances, e.g., an article on the Duke and Duchess of Cambridge ripping out a new $85,000 kitchen to install one with a different design. But most of the stories concern people who have risen to prominence and/or wealth via hard work. Dolly Parton is on the front page for “dazzling” the Glastonbury Festival‘s crowd at age 68 (I was part of the crowd and would agree with the Daily Mail’s editors); as Parton is childless she will not be offending Piketty by creating a dynasty with her wealth. The interior pages are studded with pictures of tennis stars at Wimbledon and soccer stars in Brazil. It doesn’t seem as though these people were born wealthy, e.g., Andy Murray attended a government-run school, the Wikipedia page on James Rodriguez doesn’t say anything about his parents being rich.

Prior to going to Glastonbury I went on a four-day cycling trip around Oxfordshire and the Cotswolds. The guides pointed out some fancy houses that were owned by people who had been successful in business or entertainment. Piketty’s theories about people resorting to what the Victorians called “fortune hunting” (a term that may have originated in the 17th century) were not directly confirmed by the guides, who did not talk about anyone having gotten rich by marrying and staying married (though they did point out some spectacular houses that had been won in litigation by divorce plaintiffs).

After the bike tour, I stayed in a luxury camp adjacent to the Glastonbury festival proper. A restaurant owner in his 50s explained how his ex-wife had made her fortune. “We were married for about 18 months. She insisted that I get her a new BMW, the most luxurious vacations possible, designer clothes. I did it to keep her happy, but then after she sued me my solicitor explained that this established a baseline lifestyle that I would have to keep her in for at least 10 years.” He chose to pay his plaintiff a lump sum rather than monthly alimony. What does a Briton stuffed full of enough cash never to work again do? “She moved to Spain and took our young daughter with her. So I bought a house in Spain to make it convenient to visit the child. Then she moved to France and I was left with this house. I tried using lawyers to stop her from moving about but wasn’t successful.” What about child support? “Roughly the first 100,000 pounds [$170,000] that I earn every year goes to pay my ex-wife and for my costs in traveling to see my daughter.” What’s the interaction with the now-15-year-old like? “She is busy with her friends and her life so sometimes when I visit there is only about 15 minutes per day of real interaction. If she wants me to buy her something, like a replacement mobile [phone], then she pays attention.”

[There was apparently an emotional toll to be paid by the defendant and child in addition to the wealth extracted by the plaintiff. “I probably have spent at least 30 percent of my energy being angry with the woman who sued me, about 25 percent of my energy working to pay all of her expenses, and another 20 percent of my energy traveling to visit my daughter. There isn’t a lot left for giving to [his current partner]” How about forgiving and forgetting? “She is always pulling some new stunt to make it difficult for me to see our daughter, which makes me angry all over again, not to mention the monthly payments to someone with whom I was barely acquainted.” He was there with a long-term girlfriend, blessed with a kind disposition. Perhaps she would be a moderating influence? “We can never get married,” she explained, “because then [the daughter’s mom] would be able to collect half of my income. Sod her.”]

What did we see on the ground about Piketty’s main point of irritation, i.e., the establishment of family dynasties? During the bike tour we visited Blenheim Palace, a spectacular example of wealth via inheritance, though the property taxes and inheritance taxes have made it tough to hang onto. We saw a lot of farms that were probably inherited. Death/inheritance taxes on these farms are probably pretty painful but on the other hand the farmers didn’t look as though they were hurting and they are presumably benefiting from EU agricultural subsidies. The folks in the luxury camp at Glastonbury all seemed to have earned their money rather than inheriting it, though among the musicians themselves (list with video links) there seemed to be a tremendous value in inheriting fame and connections from one’s parents. For example, Seun Kuti appeared on stage with his father’s old band, and Toumani and Sidiki, a father-son team from Mali, appeared on the main stage and announced that they were the 72nd continuous generation of father-son musicians in their family.

In some ways England should be a cautionary example for fans of Piketty’s proposed tax policies. In the 1960s and 70s, the country experimented with very high tax rates on its most successful citizens. Facing up to 98% tax rates, the Rolling Stones for example, effectively emigrated for business purposes (see this 2007 New York Times article on the Stones and U2 and also Life by Keith Richards). It seems as though the country has never truly recovered from this experiment and the resulting lost growth.

Piketty is a fan of bigger government and heaps scorn on the U.S. health care system (admittedly the dumbest conceivable way to run anything). But the National Health Service in Britain may be beginning to fray. People are waiting a long time for visits with primary care docs (of whom there are fewer per capita than in France, for

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One of the problems identified in Bad Pharma: How Drug Companies Mislead Doctors and Harm Patientsis the revolving door between drug regulators, such as the FDA and their European equivalent, and the pharma industry:

The EMA regulates the pharmaceutical industry throughout the whole of Europe, and has taken over the responsibilities of the regulators in individual member countries. In December 2010 Thomas Lonngren stepped down as its executive director. On the 28th of that month he sent a letter telling the EMA management board that he was going to start working as a private consultant to the pharmaceutical industry, starting in just four days’ time, on 1 January 2011.

In the USA, for example, you have to wait a year after leaving the Defense Department before you can work for a defence contractor. After ten days the chairman of the EMA wrote back to Lonngren saying that his plans were fine. He didn’t impose any further restrictions, and nor, remarkably, did he ask for any information on what kind of work Lonngren planned to do. Lonngren had said in his letter that there would be no conflict of interest, and that was enough for everyone concerned.

Coincidentally I had breakfast this morning with a Chinese-American entrepreneur. She explained that her father back in Mainland China was currently unemployed and coming for a long visit. He had worked for the government but, due to a new rule requiring a five-year waiting period, had to quit his industry job.

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If you live in Boston and/or are interested in commercial diving or big engineering projects, Trapped Under the Sea: One Engineering Marvel, Five Men, and a Disaster Ten Miles Into the Darkness is a great book.

Neil Swidey describes events from the late 1990s that were critical to completing the Boston Harbor clean-up project. Treated wastewater would travel from the Deer Island sewage plant through a 10-mile-long tunnel underneath the Massachusetts Bay and then rise up to be discharged at the seafloor, about 100 feet underwater. So that people building the tunnel wouldn’t be at risk of flooding, the riser tubes were plugged at the seafloor. These plugs could then be removed when the project was complete. What if a big ship dragged its anchor 10 miles out into the bay? The tubes were also plugged at the bottom, 10 miles into the tunnel. Kiewit, the contractor building the tunnel, wanted to pull the lower plugs while the tunnel was still lit and ventilated, then patrol the bay to keep ships clear while the lighting and ventilation were removed. They noted that it had been about 10 years since the top plugs were installed and no ship had dislodged one. The government authority managing the project disagreed, despite the fact that it would be a violation of OSHA regulations for workers to be in the tunnel without ventilation:

The irony is that each side claimed worker safety was its primary concern. Corkum, writing on behalf of Kaiser and the MWRA, said it would be unwise to endanger the lives of up to a hundred sandhogs by leaving the tunnel vulnerable to a possible flood during the long cleanup period. Kiewit, meanwhile, said it would be insane to put a small number of workers at extreme risk by sending them into a tunnel that had no air or light, all in the name of protecting a larger group of workers from an exceedingly small risk. By waiting until the end to pull the plugs, the Kiewit manager wrote, “the risk of catastrophe would be exponentially higher!” In frustration, Kiewit enlisted a former OSHA inspector named Fred Anderson as a consultant. In his report, Anderson stressed that the stakes were “enormous in terms of both money and political necessity.” By insisting on installing backup plugs without a clear understanding of how they would be removed, the parties involved in the project had painted themselves into a corner, he wrote. But the tunnel would not be viable if they couldn’t figure out a safe way to yank out the plugs. “They must come out!” After reading the contract closely, Anderson noted, it was clear that the people who wrote the specs intended for the plugs to be removed by a crew “dependent on self-contained breathing apparatus in an unknown and uncontrollable environment.” He stressed, “To me, this is a scary prospect.” He warned that the hazardous assignment could cost lives. And if workers died, regulatory agencies would likely shut down the tunnel, adding further delays. Anderson strongly advised Kiewit to stand firm and insist on pulling the plugs before removing the ventilation, lighting, and rail systems. Asking workers to venture nearly ten miles into a dark, unventilated tunnel hundreds of feet below the ocean, he said, would be sentencing them to “an operation somewhat akin to a spacewalk.

The technical explanations in the book are pretty good, e.g., why wouldn’t there be plenty of oxygen in a tunnel that was in fact open on one side?

Even though the ventilation line no longer extended past the four-mile mark, the divers found that oxygen levels were sufficient to sustain human life well beyond that point. But they knew that by the time the tunnel cleanup had been completed and the actual plug-removal mission had begun, those oxygen levels would be lower, for two reasons. First, the cleanup wouldn’t be considered complete until the entire bag line was yanked out. Second, the remaining oxygen at the end of the tunnel would essentially begin using itself up. In the dank, confined space of the tunnel, oxygen would be depleted by things like the growth of aerobic bacteria and the rusting of metals, such as bolts. There was also the very real possibility that oxygen would be displaced by highly toxic gases, such as carbon monoxide, methane, and hydrogen sulfide, which is produced when certain organisms decay.

The state government authority (MWRA) got its way and federal workers at OSHA blessed a plan to send commercial divers 10 miles into the tunnel with an experimental air supply based on mixing liquid gases. The government did not ask for any testing of the experimental air supply, but that doesn’t mean they waived other regulations:

The first day on the island was a blur of unloading and unpacking, after the divers went through the drug testing that the MWRA mandated of all workers on the job.

Predictably there were deaths, but few people cared.

[at a funeral] Hoss watched as Riggs stood to deliver a special reading. The reflection had actually been published as a letter to the editor in The Boston Globe two days after the accident. Written by a stranger named Parker Pettus, it contrasted the “lavish” wall-to-wall coverage of the death of John F. Kennedy, Jr., who had been granted a mariner’s funeral aboard a warship, with the “unadorned” news report about the deaths of Billy and Tim. These men were not rich or famous or privileged. Certainly they would have preferred not to have been in a dangerous tunnel hundreds of feet below the surface and miles from any help. They died while doing a hazardous, unheralded job, and their contribution to a clean, revived Boston Harbor will last for generations. They will not be immortalized in the media, they will not be buried at sea from the decks of a warship. These workers are the kind of heroes who are so often taken for granted. We would do well to think of Boston’s clear, blue, living harbor as a monument to the courage and sacrifice of the ordinary heroes who made it a reality.

More: Read the book

Next on my reading list: Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients

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Perhaps you aren’t able to emigrate to Finland but you still want your children to get a good education. You aren’t willing to assume that a country (the U.S.) that has been running a mediocre public school system for 100 years is suddenly going to snap out of its football-induced stupor. Does Amanda Ripley’s The Smartest Kids in the World: And How They Got That Way offer any practical tips for what a conscientious parent might do? Yes.

How about joining the PTA?

PTA parents cared deeply about their children and went out of their way to participate in school functions. During the 1980s and 1990s, American parents and teachers had been bombarded by claims that children’s self-esteem needed to be protected from competition (and reality) in order for them to succeed. Despite a lack of evidence, the self-esteem movement took hold in the United States in a way that it did not in most of the world. So, it was understandable that PTA parents focused their energies on the nonacademic side of their children’s school. They dutifully sold cupcakes at the bake sales and helped coach the soccer teams. They doled out praise and trophies at a rate unmatched in other countries. They were their kids’ boosters, their number-one fans. These were the parents that Kim’s principal in Oklahoma praised as highly involved. And PTA parents certainly contributed to the school’s culture, budget, and sense of community. However, there was not much evidence that PTA parents helped their children become critical thinkers. In most of the countries where parents took the PISA survey, parents who participated in a PTA had teenagers who performed worse in reading.

By 2009, Schleicher and his colleagues had managed to convince thirteen countries and regions to include parents in the PISA. Five thousand of the students who took the PISA test brought home a special survey for their parents. The survey asked how they had raised their children and participated in their education, starting from when they were very young. Strange patterns emerged. For example, parents who volunteered in their kids’ extracurricular activities had children who performed worse in reading, on average, than parents who did not volunteer, even after controlling for other factors like socioeconomic background. Out of thirteen very different places, there were only two (Denmark and New Zealand) in which parental volunteering had any positive impact on scores at all, and it was small.

Giving your children lots of encouragement and praise?

In one Columbia University study, 85 percent of American parents surveyed said that they thought they needed to praise their children’s intelligence in order to assure them they were smart. However, the actual research on praise suggested the opposite was true. Praise that was vague, insincere, or excessive tended to discourage kids from working hard and trying new things. It had a toxic effect, the opposite of what parents intended. To work, praise had to be specific, authentic, and rare.

Knocking yourself out like Tiger Mom?

Korean parenting, by contrast, were coaches. Coach parents cared deeply about their children, too. Yet they spent less time attending school events and more time training their children at home: reading to them, quizzing them on their multiplication tables while they were cooking dinner, and pushing them to try harder. They saw education as one of their jobs. This kind of parenting was typical in much of Asia—and among Asian immigrant parents living in the United States. Contrary to the stereotype, it did not necessarily make children miserable. In fact, children raised in this way in the United States tended not only to do better in school but to actually enjoy reading and school more than their Caucasian peers enrolled in the same schools.

While American parents gave their kids placemats with numbers on them and called it a day, Asian parents taught their children to add before they could read. They did it systematically and directly, say, from six-thirty to seven each night, with a workbook—not organically, the way many American parents preferred their children to learn math. The coach parent did not necessarily have to earn a lot of money or be highly educated. Nor did a coach parent have to be Asian, needless to say. The research showed that European-American parents who acted more like coaches tended to raise smarter kids, too.

What if, due to a lifetime of living in America, you are too lazy to do that?

Parents who read to their children weekly or daily when they were young raised children who scored twenty-five points higher on PISA by the time they were fifteen years old. That was almost a full year of learning. More affluent parents were more likely to read to their children almost everywhere, but even among families within the same socioeconomic group, parents who read to their children tended to raise kids who scored fourteen points higher on PISA. By contrast, parents who regularly played with alphabet toys with their young children saw no such benefit.

And at least one high-impact form of parental involvement did not actually involve kids or schools at all: If parents simply read for pleasure at home on their own, their children were more likely to enjoy reading, too. That pattern held fast across very different countries and different levels of family income. Kids could see what parents valued, and it mattered more than what parents said.

By contrast, other parental efforts yielded big returns, the survey suggested. When children were young, parents who read to them every day or almost every day had kids who performed much better in reading, all around the world, by the time there were fifteen. It sounded like a public-service cliché: Read to your kids. Could it be that simple? Yes, it could, which was not to say that it was uninteresting. After all, what did reading to your kids mean? Done well, it meant teaching them about the world—sharing stories about faraway places, about smoking volcanoes and little boys who were sent to bed without dinner. It meant asking them questions about the book, questions that encouraged them to think for themselves. It meant sending a signal to kids about the importance of not just reading but of learning about all kinds of new things. As kids got older, the parental involvement that seemed to matter most was different but related. All over the world, parents who discussed movies, books, and current affairs with their kids had teenagers who performed better in reading. Here again, parents who engaged their kids in conversation about things larger than themselves were essentially teaching their kids to become thinking adults. Unlike volunteering in schools, those kinds of parental efforts delivered clear and convincing results, even across different countries and different income levels.

What if you’re too busy watching TV and playing Xbox to read? Can you be savvy about choosing your child’s school? Ripley has an entire appendix on the subject.

If you are trying to understand a school, you can ignore most of the information you are given. Open houses? Pretty much useless. Spending per student? Beyond a certain baseline level, money does not translate into quality in education anywhere. The smartest countries in the world spend less per pupil than the United States. Average class size? Not as important as most people think, except in the earliest years of schooling. In fact, the highest-performing countries typically have larger classes than the United States. The research shows that the quality of the teaching matters more than the size of the class. Test data? More helpful, but very hard to decipher in most places. How good is the test? How much value is the school adding beyond what kids are already learning at home? More and more U.S. school districts have this kind of information, but do not make it public. Instead, the best way to gauge the quality of a school is to spend time—even just twenty minutes—visiting classrooms while school is in session. When you get there, though, it’s important to know where to look. Parents tend to spend a lot of time staring at the bulletin boards in classrooms. Here is a better idea: Watch the students instead. Watch for signs that all the kids are paying attention, interested in what they are doing, and working hard. Don’t check for signs of order; sometimes learning happens in noisy places where the kids are working in groups without much input from the teacher. Some of the worst classrooms are quiet, tidy places that look, to adults, reassuringly calm. Remember that rigorous learning actually looks rigorous. If the kids are whizzing through a worksheet, that’s not learning. That’s filling out a form. Kids should be uncomfortable sometimes; that’s okay. They should not be frustrated or despairing; instead, they should be getting help when they need it, often from each other.

There should be a sense of urgency that you can feel.

I saw bored kids in every country. Boredom is the specter that haunts children from kindergarten to graduation on every continent. In American classrooms, I watched a girl draw a beautiful rose tattoo on her arm with a ballpoint pen; she did it slowly, meticulously, as though she were serving a life sentence.

In the best schools, though, boredom was the exception rather than the norm. You could walk into five classrooms and see just one or two students who had drifted away, mentally or physically, rather than eight or ten. That’s how you know that you are in a place of learning.

Don’t ask, “Do you like this teacher?” or “Do you like your school?”

The first thing I usually ask is straightforward: What are you doing right now? Why? You’d be amazed how many kids can answer the first question but not the second.

 

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