You hear stories about "bug chasers"; men who deliberately seek out HIV-infected partners for unprotected sex because they want to "poz up," or get infected, so that they can stop feeling guilty about not using condoms. It makes for a good story, but these are the exceptions. Most of the new infections among the "survivor" generation are just a slipping of the guard. One friend told me that his own infection came in sex with an escort who wanted unprotected sex as a mark of intimacy. The very next day, another friend, a journalist, told me a similar tale. "Of course you use condoms, mostly. But if you're fucking four guys in an afternoon, there's usually one you want to mark out as special, and not using condoms is a way of telling someone they are special." Who qualifies as special? "Oh, usually the guy who's name you can remember."I wonder how prevalent this practice really is? But, it's interesting - if it's not a fact, it's a truth that should be a fact, because if a person really is having many, many sexual partners, despite his promiscuity, insofar as its innate to want to communicate one's committment to another person, there's an incentive to signal one's "type" to the sexual partner. Signalling necessarily involves making costly sacrifices which enable the receiver of the signal to decipher what type of person the sender is. Here, Pisani suggests gay men in post-AIDS will engage in unprotected sex with people they care about in order to signal their genuine interest. The "signal" is basically bought at some expected value price, which is a function of the per-act probability of transmission inherent in the sexual practice about to be engaged in (ie, anal receptive intercourse), the prevalence rate of HIV in the homosexual network, and the value placed on being HIV-positive status. While we say the price is falling due to HAART's success, at the same time, it's not zero, and thus is not a small gesture to be made.
Monday, June 2, 2008
Signalling in post-AIDS
J and I were talking about signalling theory over the weekend in regards to microfinance, and so I think it was fresh on my mind when I read this in the Prospect article he posted:
Public Health and Local Customs
In This Painted Veil, Edward Norton plays an infectious disease specialist who has relocated to inland China because of a cholera epidemic. He immediately is forced to face the problems related to public health and local customs when he discovers that the families of the dead have been burying their family members near the river because their spirits, it is believed, need the water to find rest. I'm not sure what exactly the belief was, but it doesn't matter on one level because by burying the dead so close to the water supply, cholera was seeping into the river, and had infected the water supply. Norton's character had previously learned that the town's well was also infected with cholera, so this was now officially a bad discovery.
Public health decisions are usually top-down, or at least, historically. Partly this is because the public health decisions are necessary because of market failure problems, and market failure problems have arisen because it's in no decentralized agent's best interest to change their behavior. So, we tax polluters, rather than rely on the market to internalize these externalities. In the same way, we public health agencies provide public goods by trying to isolate the public good aspects of an infectious disease epidemic, and thereby attempt to control the epidemic by discriminating on those public good nodes - like the water supply, or maybe locating patient zero. In one of my favorite, neglected, papers on risky sex, Ayres and Baker recommended penalizing unprotected sex during first-time sexual encounters as a misdemeanor, since first-time sexual encounters were both the main instances when date rape happened (and thus requiring a condom increased information flow between both parties, thus helping deal with these problems of communication that are often related to date rape), as well as targeted the groups who were at the center of the storm of an STD epidemic.
But when these attempts at helping the community necessarily violate the individual liberty of local citizens, it's extremely delicate, and the movie really only glossed over this. There's a scene where it's very clear it's about to hit the hand, but thankfully Norton's character had an epiphany that would let him divert water upstream into town, and therefore circumvent the bodies. But what if he hadn't come up with such an idea? He was only able to do that, because the giant water wheel that was being used to draw water out of the river to irrigate the crops, existed. But not every problem has a water wheel waiting there, so what is to be done? As the young economist, fresh out of grad school, I come down on the side of efficiency pretty much every time. Screw the locals and their customs. They either accept this, and thus thousands of lives are spared, or they get locked in jail. (Note this is only one reason among numerous reasons why no one asks me to do anything of any consequence, methinks).
In the post-AIDS article, Pisani says similar kinds of confrontations between public health and community morals are at work today. It's not the same, obviously, as bereaved families refusing to move the bodies of their dead relatives, whose corpses are rotted with cholera, but its effects are nonetheless the same. It may mean discouraging anal sex, since it's such a significant driver of STD within the network given the much higher per-act probabilities of infection associated with the practice. It may mean tracking down all the current and previous partners of a newly infected HIV-positive patient, which necessarily violates many standards of privacy we associate with both sexual partnerships, which is even more complex within a highly disenfranchised group like the men who have sex with men (MSM) network. Nevertheless, it seems like nowhere do you see the tension between medical necessity and community ethics come to an impasse as you do in regards to public health. Some of this seems to me to be due to the problems of the two equilibria both being the consequence of decentralized behavior. Both the development of the ethical standards in the community and the behaviors that drive an epidemic are the consequence of people's chosen behaviors - utility maximizing behaviors, you might say.
Public health decisions are usually top-down, or at least, historically. Partly this is because the public health decisions are necessary because of market failure problems, and market failure problems have arisen because it's in no decentralized agent's best interest to change their behavior. So, we tax polluters, rather than rely on the market to internalize these externalities. In the same way, we public health agencies provide public goods by trying to isolate the public good aspects of an infectious disease epidemic, and thereby attempt to control the epidemic by discriminating on those public good nodes - like the water supply, or maybe locating patient zero. In one of my favorite, neglected, papers on risky sex, Ayres and Baker recommended penalizing unprotected sex during first-time sexual encounters as a misdemeanor, since first-time sexual encounters were both the main instances when date rape happened (and thus requiring a condom increased information flow between both parties, thus helping deal with these problems of communication that are often related to date rape), as well as targeted the groups who were at the center of the storm of an STD epidemic.
But when these attempts at helping the community necessarily violate the individual liberty of local citizens, it's extremely delicate, and the movie really only glossed over this. There's a scene where it's very clear it's about to hit the hand, but thankfully Norton's character had an epiphany that would let him divert water upstream into town, and therefore circumvent the bodies. But what if he hadn't come up with such an idea? He was only able to do that, because the giant water wheel that was being used to draw water out of the river to irrigate the crops, existed. But not every problem has a water wheel waiting there, so what is to be done? As the young economist, fresh out of grad school, I come down on the side of efficiency pretty much every time. Screw the locals and their customs. They either accept this, and thus thousands of lives are spared, or they get locked in jail. (Note this is only one reason among numerous reasons why no one asks me to do anything of any consequence, methinks).
In the post-AIDS article, Pisani says similar kinds of confrontations between public health and community morals are at work today. It's not the same, obviously, as bereaved families refusing to move the bodies of their dead relatives, whose corpses are rotted with cholera, but its effects are nonetheless the same. It may mean discouraging anal sex, since it's such a significant driver of STD within the network given the much higher per-act probabilities of infection associated with the practice. It may mean tracking down all the current and previous partners of a newly infected HIV-positive patient, which necessarily violates many standards of privacy we associate with both sexual partnerships, which is even more complex within a highly disenfranchised group like the men who have sex with men (MSM) network. Nevertheless, it seems like nowhere do you see the tension between medical necessity and community ethics come to an impasse as you do in regards to public health. Some of this seems to me to be due to the problems of the two equilibria both being the consequence of decentralized behavior. Both the development of the ethical standards in the community and the behaviors that drive an epidemic are the consequence of people's chosen behaviors - utility maximizing behaviors, you might say.
"The Journey"
I told a friend I really liked this one church in town, except I kind of get exhausted by so much talk about "the journey." I was only joking, tongue-in-cheek, really, but then I saw this article about a church in St. Louis literally called The Journey. It's about a church that is probably becoming more and more common. It's a church that, on the one hand, seems very comfortable with preaching and teaching historic views on faith and spirituality, but on the other hand, is very uncomfortable with the complete superimposition of evangelicalism with Republican politics in the United States (here here). Here the article has some hard facts to back it up.
“Evangelicalism is becoming somewhat less coherent as a movement or as an identity,” said Christian Smith, a sociology professor at the University of Notre Dame. “Younger people don’t even want the label anymore. They don’t believe the main goal of the church is to be political.”I wonder what is going on here. Why did evangelicalism become successfully tied to the Republican party? It seems like abortion had a lot to do with it. Since 1992, abortion rates have been plummeting, so maybe part of this is simply that there really are few alternatives to abortion that can credibly get evangelicals together, since "evangelicalism" is inherently so diverse on its face. It seems like gay marriage was floated as the next big Christian issue to keep the evangelical bloc together, but I can't see that one really having the strength like the former did at creating a sizeable bloc. But is abortion really it anyway? I know tons of people have studied this, but what's the main finding exactly?
About 17 percent of the nation’s 55 million adult evangelicals are between the ages of 18 and 29, and many are troubled by the methods of the religious right and its close ties to the Republican Party.
In a January 2007 survey of 1,000 young people for the book “Unchristian,” one of its authors, David Kinnaman, president of the Barna Group, which studies Christian trends, found that 47 percent of born-again Christians ages 40 and under believed that “the political efforts of conservative Christians” posed a problem for America.
Google Android Scan, or I'M FREAKING OUT1!!
Okay, I'm freaking out. Android Scan was a winner of some kind of open source Android contest - particularly awesome since Google Android will be open source, which my friend Matt tells me he thinks maybe forced iPhone to follow suit. Here's what Scan does:
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Update: Here's the author of the awesome program, Scan, Jeffrey Sharkey. You can also listen to his voice mail message from Google telling him he won $25,000. Nice.
Scan is an Android application that finds pricing and metadata for anything with a barcode. Here are some key features that make Scan stand out:Check this video out. I feel like I'm living in the 30th century or something. Is this some kind of elaborate hoax? Am I going to wake up tomorrow and learn this is all made up? Because this is blowing my freaking my mind.
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Update: Here's the author of the awesome program, Scan, Jeffrey Sharkey. You can also listen to his voice mail message from Google telling him he won $25,000. Nice.
Post-AIDS
J points to an article in the June 2008 Prospect Magazine entitled "The Plague is Over, Let's Party" by Elizabeth Pisani, an epidemiologist. Pisani notes the curious state of affairs in a "post-AIDS" world. On the one hand, the advent of highly active antiretroviral treatments (HAART), particularly the discovery of the protease inhibitor, has effectively halted AIDS progression. The time to development of AIDS now appears to either have no upper bound, or is so high that we haven't reached it yet. As I like to tell people, Magic Johnson still doesn't have AIDS. If caught early enough and if treated aggressively with HAART, an HIV-positive person can remain healthy and keep his/her viral count low without seeing the infection progress to the advanced stage of autoimmune system failure. See the 2006 HIV Surveillance Report, Table 7, for a short window showing AIDS cases falling.
That AIDS is theoretically no longer a fatal disease, but rather a chronic disease, seems to be an unambiguous good, but Pisani notes how this has also led to the unexpected changes in behavior (unexpected, at least, to epidemiologists, but I'll get back to that in a second). The complexities of post-AIDS is that while AIDS mortality and even AIDS rates are plummeting, HIV rates are rising. Both the number of new HIV cases and the HIV incidence rate is on the rise in the United States and other industrialized countries. See Table 8 from the 2006 HIV Surveillance Report showing a rise in HIV cases for 2003-2006. What is going on? Well, one of these explanations is innocuous and the other is more problematic. First, the decrease in AIDS mortality and AIDS progression translates into simply more and more people each year with HIV who would've previously perished pre-HAART. AIDS kills its host, but the protease inhibitor stops the replication of the HIV virus in the host's body, thus halting the progression to AIDS and therefore causing mortality to fall. These people who previously would be dead are alive, which translates into increased HIV prevalence in the population. Because these people are also healthier now post-AIDS, they are able to have healthy sex lives, which increases the spread of HIV throughout the sexual network.
Interestingly, HIV is a rather low infectivity STD, meaning the per-act probability of infection is fairly low compared to other sexually transmitted infections. The chance of an HIV-negative female contracting HIV from an infected HIV-positive male, while having unprotected intercourse, is 0.002 - that that is, if the female had 1000 unprotected sexual encounters with her infected male partner, the cumulative risk of infection at the end would 0.86 (86%). If she always wore a condom, it'd be only .18 (18%), assuming a condom failure rate of 10 percent per exposure. Laumann, Gagnon and Micahels' The Social Organization of Sexuality: Sexual Practices in the United States, chapter 11 for more. Gonorrhea, on the other hand, has an infectivity rate of as high as 0.50, meaning it only takes a few acts of unprotected sex before the uninfected person contracts it. After 10 acts of unprotected sex with an infected partner, a female will be infected with gonorrhea. If they used a condom consistently (assuming a 10 percent failure rate), she'd have .99408 probability of infection after 100 sexual encounters.
Thus it's not surprising that whereas gonorrhea is extremely common and in both homosexual and heterosexual networks, HIV has historically been concentrated among high risk groups. High risk groups tend to have multiple partners, thus increasing the probability of transmission, and also tend to engage in unsafe practices, like unprotected sex and anal intercourse. Certain sexual practices on the African continent may be partly to blame for the greater prevalence of HIV in heterosexual networks, such as higher rates of concurrency and polygamy, as well as possibly the practice of herbally drying vaginal lubrication and create more dangerous conditions during vaginal intercourse. But in the US, despite what you may have heard, HIV is still a predominantly homosexual infection - see Table 9. This is important because, as the article notes, most of the increase in HIV now appears to be among homosexual males, as it appears homosexual males infected with HIV are now surviving with HIV, are also healthy and therefore able to engage in sex lives, have much higher numbers of partners over times than heterosexuals, are more likely to engage in anal insertive and anal receptive intercourse, and finally and maybe most important, appear to be engaging in riskier sex in response to the advent of HAART. This last point was not obvious to the epidemiologists whose models, as the article notes, were always based on the assumption that sexual behavior wouldn't change. Pisani notes:
1. Ahituv, Hotz and Phiipson, "The Responsiveness of the Demand for Condoms to the Local Prevalence of AIDS, Journal of Human Resources, Vol. 31, No. 4 (Autumn, 1996), pp. 869-897.
2. Chesson, Dee and Aral, "AIDS Mortality May Have Contributed to the Decline in Syphilis Rates in the United States in the 1990s." Sexually Transmitted Diseases. 30(5):419-424, May 2003.
3. Cornwell and Cunningham, "Did Abortion Legalization Cause Second Generation Gonorrhea Rates to Fall? An Application of Donahue-Levitt (2001), 2007 Working Paper.
4. Mechoulan, "Risky Sexual Behavior, Testing
and New HIV Treatments," Forum for Health Economics & Policy, Volume 10, Issue 2 2007 Article 5.
5. Lakdawalla, Sood and Goldman, "HIV Breakthroughs and Risky Sexual Behavior", Quarterly Journal of Economics August 2006, Vol. 121, No. 3, Pages 1063-1102.
Those are just a few of the papers showing a causal relationship between AIDS mortality and falling STD risk and STD incidence, as well as showing a causal relationship between HAART and increased STD risk, particularly among gay US males, both HIV-positive and HIV-negative. It's not clear to what degree the rise in STD risk is due merely to more men surviving and living with HIV as healthy men, and therefore causing increased spread of HIV, and how much is actually due to men now facing a lower price of being infected taking fewer precautions at all. Mechoulan (2007) shows that when the protease inhibitor was discovered, it basically immediately led to decreased condom usage among gay males, both HIV-negative and HIV-positive, whereas Lakdawalla, Sood and Goldman focuses on just the HIV-positive population of individuals receiving HAART treatment, who later more than doubled the number of partners they had over some short period of time as a result. Either way, the causal link is very strong.
To answer J's question, I think the answer is that unless we find a cure, greater availability of the HAART regiment will lead to simultaneously lower AIDS prevalence in the population, including lower AIDS mortality, and higher HIV prevalence and HIV risk in the population. This complicates matters when thinking about the appropriate policy response to HIV epidemics.
That AIDS is theoretically no longer a fatal disease, but rather a chronic disease, seems to be an unambiguous good, but Pisani notes how this has also led to the unexpected changes in behavior (unexpected, at least, to epidemiologists, but I'll get back to that in a second). The complexities of post-AIDS is that while AIDS mortality and even AIDS rates are plummeting, HIV rates are rising. Both the number of new HIV cases and the HIV incidence rate is on the rise in the United States and other industrialized countries. See Table 8 from the 2006 HIV Surveillance Report showing a rise in HIV cases for 2003-2006. What is going on? Well, one of these explanations is innocuous and the other is more problematic. First, the decrease in AIDS mortality and AIDS progression translates into simply more and more people each year with HIV who would've previously perished pre-HAART. AIDS kills its host, but the protease inhibitor stops the replication of the HIV virus in the host's body, thus halting the progression to AIDS and therefore causing mortality to fall. These people who previously would be dead are alive, which translates into increased HIV prevalence in the population. Because these people are also healthier now post-AIDS, they are able to have healthy sex lives, which increases the spread of HIV throughout the sexual network.
Interestingly, HIV is a rather low infectivity STD, meaning the per-act probability of infection is fairly low compared to other sexually transmitted infections. The chance of an HIV-negative female contracting HIV from an infected HIV-positive male, while having unprotected intercourse, is 0.002 - that that is, if the female had 1000 unprotected sexual encounters with her infected male partner, the cumulative risk of infection at the end would 0.86 (86%). If she always wore a condom, it'd be only .18 (18%), assuming a condom failure rate of 10 percent per exposure. Laumann, Gagnon and Micahels' The Social Organization of Sexuality: Sexual Practices in the United States, chapter 11 for more. Gonorrhea, on the other hand, has an infectivity rate of as high as 0.50, meaning it only takes a few acts of unprotected sex before the uninfected person contracts it. After 10 acts of unprotected sex with an infected partner, a female will be infected with gonorrhea. If they used a condom consistently (assuming a 10 percent failure rate), she'd have .99408 probability of infection after 100 sexual encounters.
Thus it's not surprising that whereas gonorrhea is extremely common and in both homosexual and heterosexual networks, HIV has historically been concentrated among high risk groups. High risk groups tend to have multiple partners, thus increasing the probability of transmission, and also tend to engage in unsafe practices, like unprotected sex and anal intercourse. Certain sexual practices on the African continent may be partly to blame for the greater prevalence of HIV in heterosexual networks, such as higher rates of concurrency and polygamy, as well as possibly the practice of herbally drying vaginal lubrication and create more dangerous conditions during vaginal intercourse. But in the US, despite what you may have heard, HIV is still a predominantly homosexual infection - see Table 9. This is important because, as the article notes, most of the increase in HIV now appears to be among homosexual males, as it appears homosexual males infected with HIV are now surviving with HIV, are also healthy and therefore able to engage in sex lives, have much higher numbers of partners over times than heterosexuals, are more likely to engage in anal insertive and anal receptive intercourse, and finally and maybe most important, appear to be engaging in riskier sex in response to the advent of HAART. This last point was not obvious to the epidemiologists whose models, as the article notes, were always based on the assumption that sexual behavior wouldn't change. Pisani notes:
"mathematical modelling showed that if behaviour stayed the same and infected people got treated, HIV transmission would trickle to a halt. But the models didn't factor in the possibility that you need less virus to get infected in the more dangerous act of anal sex. They also forgot that humans don't behave like mathematical models."Or maybe these models just wrong and useless for predicting the effect of the drugs on the course of the epidemic. These models were flawed explanations of sexual behavior because they explicitly assumed human beings did not respond to incentives. That is, even though the risk of AIDS mortality was rising, epidemiologists assumed that that change in "price" wouldn't change people's behaviors. But we know this is wrong. Here's just a few papers showing this is wrong.
1. Ahituv, Hotz and Phiipson, "The Responsiveness of the Demand for Condoms to the Local Prevalence of AIDS, Journal of Human Resources, Vol. 31, No. 4 (Autumn, 1996), pp. 869-897.
2. Chesson, Dee and Aral, "AIDS Mortality May Have Contributed to the Decline in Syphilis Rates in the United States in the 1990s." Sexually Transmitted Diseases. 30(5):419-424, May 2003.
3. Cornwell and Cunningham, "Did Abortion Legalization Cause Second Generation Gonorrhea Rates to Fall? An Application of Donahue-Levitt (2001), 2007 Working Paper.
4. Mechoulan, "Risky Sexual Behavior, Testing
and New HIV Treatments," Forum for Health Economics & Policy, Volume 10, Issue 2 2007 Article 5.
5. Lakdawalla, Sood and Goldman, "HIV Breakthroughs and Risky Sexual Behavior", Quarterly Journal of Economics August 2006, Vol. 121, No. 3, Pages 1063-1102.
Those are just a few of the papers showing a causal relationship between AIDS mortality and falling STD risk and STD incidence, as well as showing a causal relationship between HAART and increased STD risk, particularly among gay US males, both HIV-positive and HIV-negative. It's not clear to what degree the rise in STD risk is due merely to more men surviving and living with HIV as healthy men, and therefore causing increased spread of HIV, and how much is actually due to men now facing a lower price of being infected taking fewer precautions at all. Mechoulan (2007) shows that when the protease inhibitor was discovered, it basically immediately led to decreased condom usage among gay males, both HIV-negative and HIV-positive, whereas Lakdawalla, Sood and Goldman focuses on just the HIV-positive population of individuals receiving HAART treatment, who later more than doubled the number of partners they had over some short period of time as a result. Either way, the causal link is very strong.
To answer J's question, I think the answer is that unless we find a cure, greater availability of the HAART regiment will lead to simultaneously lower AIDS prevalence in the population, including lower AIDS mortality, and higher HIV prevalence and HIV risk in the population. This complicates matters when thinking about the appropriate policy response to HIV epidemics.
This Painted Veil (4 stars out of 4 stars)
Spoilers Await!
This weekend, J, his wife, H, my wife and me watched the 2006 film adaptation of Someset Maugham's 1925 novel of the same name, This Painted Veil. The film starred the beautiful Namoi Watts who plays Kitty, a shallow and spoiled British aristocrat who marries a boring, infectious disease specialist and civil servant named Walter played by the incredibly talented Edward Norton. When Walter learns that Kitty is having an affair, he gives her a choice: either travel into inland China with him, where he is going as a volunteer for a peasant hospital that is currently experiencing the worst cholera epidemic in known history, or be divorced by him the following day. When she resists, he gives her a third option, which is to marry her lover, but this it turns out isn't really an option, after Watts realizes the philanderer wants her only as his mistress whore, and not his wife. And so Kitty agrees and ventures into inland China with her husband into a cholera epidemic - into almost certain death.
I'll just lay out my impression of the film, but I don't mean this as it's the only impression. I saw the movie as a story of redemption, providence and grace. Walter responded to Kitty's' adultery with poisonous bitterness. The bitterness grew up in his soul like a diseased tree and was so all consuming that he in essence plotted an elaborate trap to murder her by increasing the chances of her becoming infected with cholera, which at the time was a horrible death. But while there, several things happen to each. For one, Walter witnesses firsthand cholera's effects. As an infectious disease specialist, he was not a clinician and thus had never actually seen the disease except under a microscope or in a book. While the movie doesn't stress this, one has to believe that witnessing the cruel fate he has imposed on his wife must have shook him. Secondly, Kitty meets her neighbor, the portly and ugly Mr. Waddington. Waddington has an exotic and usually naked Chinese woman who lives with him, whom Kitty appears to mistake for a prostitute. One can almost imagine Kitty's thoughts, in fact - how else would this ugly man have such a beautiful seductress as a lover? But we later learn that this is not true - the woman with Waddington is either his wife or his common-law wife. Waddington, many years earlier, had helped a poor Chinese familiy with some government issues, after which the youngest daughter apparently gave her life to him. She was a very young girl at the time, and three times followed Waddington, each time resulting in him sending her back home. Finally, he caved and they became lovers, and by all appearances, husband and wife. Kitty asks the drunk Waddington one night what his wife sees in him (an insulting question, but one Waddington clearly understands, since the union is so unbalanced on the surface). Waddington translates the question into Chinese so that his wife can answer, to which she answers, "you are a good man." Kitty smiles and laughs, saying "What woman has ever loved a man for his virtues?" We already begin to see, though, that such a realization is changing her slowly, for all her husband's faults superficially - he is not interesting in any way at all that is relevant to her and her hierarchy of values - he is a good man. His motives for coming to China are complex. He wants to kill his wife, but even that is borne out of his genuine love for her. Bitterness is, after all, proportional to the love one has a person. People may hate Hitler, but no one was ever bitter towards him for what he did. Bitterness is an emotion and state of mind that is produced when people we deeply love disappoint or sin against us, and that is clearly what is driving Walter's actions in this movie.
Finally, Kitty's personal transformation is initiated after she volunteers to work with the Catholic orphanage. She witnesses first hand true sacrifice, character, and virtue in the lives of the nuns and the children they care for. She has never seen anything like it, apparently, and it along with the experiences in China are mirrors both exposing her shallowness and a fire burning away the dross in her heart. When her husband eventually catches cholera, she stays with him, despite the risks, sleeping with him, washing his face and messy body, til he dies of dehydration the next day. Before dying, he asks her to forgive him for what he did. He dies, is immediately buried, and she returns to London. Five years past and we see her with her five-year-old son, Walter, in a flower shop. She has gotten pregnant through her adulterous relationship in London, and had discovered this while in China after she and Walter had reconciled after the night at the Waddingtons. Walter knew the baby wasn't his, and despite both of their anguish over the consequences of her sinful liason in London, Walter said none of it mattered anymore, and they embraced in silence. While nothing is said, I suspect that this moment consummated Walter's forgiveness of Kitty. Confronted with her adultery one last time, he has a choice as to whether forgiveness and love will win in the struggle against his wounds and bitterness, and in embracing her and saying "None of it matters," the man of few words we are led to believe has finally killed the bitterness in his heart and forgiven his wife. Now we see the boy in a flower shop with is mother. His mother echoes an earlier conversation in the movie, in which in a flower shop five years earlier with the older Walter, she says that her own mother had never let her buy flowers because "why buy something you can grow for free," but since they never actually grew the flowers, they never had flowers. Now she poses the same question to her son - why buy something which will only die in a week? To which her son tells her "because it's beautiful" and so they buy the flower. We realize here what is different about her. She has given herself to something which perished - to the Chinese orphans, to her husband, and now to her son - and it had changed her. I am reminded of the bible verse that (paraphrase) says "lest a seed perish, it cannot grow into an abundance" or something to that effect. The paradox of love and life is that for others to be free, we must become their slaves. In order for my wife or my son to be free and to have happiness, I must give up my life and my happiness. But if I seize my own happiness as though it is a right, then I will have neither happiness, nor will anyone else in my life. This is the weirdness of Christian joy - that we experience joy only indirectly when finding happiness in our relationship with Christ. Only out of that can we love and be loved. When outside the flower shop, she runs into her old lover and the father of her son, Walter, she rejects his flirtatious advance to reignite their affair. When asked by her son who the man was, she simply tells him, "He was no one." He was truly no one, just as she was certainly no one. The scene reminded me of Augustine's Confessions in which Augustine ran into his old lover one day on the street, long after his conversion to Christianity. The old lover propositions him, but Augustine tells her that the man he once was he is no longer. We get the sense this is Kitty's own explanation - the one who loved everything about that old lover is dead and replaced by a woman of almost magical depth and virtue.
As an old pastor of mine used to say, if you see a turtle sitting on a fencepost, you know it didn't get there by itself. The movie was like a spiritual fable of the Christian's journey from complete and total shallowness to one of mature depth, and at a personal level, it reminded me that spiritual transformation is possible through the sacramental work of God himself in us. It reminded me of Kierkegaard's own taxonomy of spiritual progression, from the empty life to the aesthetic and then to the religious life. Kitty, as well as Walter, both experience this. And what is most encouraging and exciting to see was the One who directed this and actually redeemed the cruelties and selfishnesses of the characters. Kitty's adultery led to Walter's bitterness, which led to the impossible choice of either accepting his public divorce or going into the cholera epidemic. Had Kitty not committed adultery, who knows if Walter - being a good man - would have even volunteered. Surely some of his motivation was not just duty, but also suicidal wishes on his part. But in so doing, Walter provides a crucial public service to the Chinese, who absolutely despise his coming there - because they are nationalists, and he is British; because they are superstitious and he has to closer their water supply because it's infected with cholera. He goes, nonetheless. In one conversation with Kitty about the work of the nuns, he tells her that while they look very altruistic, in fact they have complex motives. In retrospect, I think Walter was really talking about himself. While he looks like a good man for going into the heart of a cholera epidemic, his motives are complex - even selfish. Yet God uses those selfish motives to save these Chinese villagers who benefit immensely from his difficult choices regarding the public water supply. Through his own sins, God ultimately gave Walter a wife who loved him. He, in other words, never gave up on Walter, and in fact directed his path in order to lead him to see his own sin, and to experience mercy. We get the sense that Walter genuinely believes, in the end, that his sins against Kitty are the worse, and really, how else can two people live together in love and not approach the relationship in that way? Through this, God also "saves," if I can use that language, Kitty. What we see in this is not merely the spiritual journey of two regularly flawed people - people very much like us - but primarily the gracious, stubborness of a God whose motivations are complex. He calls us into the cholera to be sacrificed for the sake of strangers, and in the process boils off the dross and reconstructs us.
For me, the movie was one of the most spiritually insightful movies I've ever seen. I was full of hope. It was like a sermon. I loved it in every way. Perfectly cast, perfectly told. Four stars.
This weekend, J, his wife, H, my wife and me watched the 2006 film adaptation of Someset Maugham's 1925 novel of the same name, This Painted Veil. The film starred the beautiful Namoi Watts who plays Kitty, a shallow and spoiled British aristocrat who marries a boring, infectious disease specialist and civil servant named Walter played by the incredibly talented Edward Norton. When Walter learns that Kitty is having an affair, he gives her a choice: either travel into inland China with him, where he is going as a volunteer for a peasant hospital that is currently experiencing the worst cholera epidemic in known history, or be divorced by him the following day. When she resists, he gives her a third option, which is to marry her lover, but this it turns out isn't really an option, after Watts realizes the philanderer wants her only as his mistress whore, and not his wife. And so Kitty agrees and ventures into inland China with her husband into a cholera epidemic - into almost certain death.
I'll just lay out my impression of the film, but I don't mean this as it's the only impression. I saw the movie as a story of redemption, providence and grace. Walter responded to Kitty's' adultery with poisonous bitterness. The bitterness grew up in his soul like a diseased tree and was so all consuming that he in essence plotted an elaborate trap to murder her by increasing the chances of her becoming infected with cholera, which at the time was a horrible death. But while there, several things happen to each. For one, Walter witnesses firsthand cholera's effects. As an infectious disease specialist, he was not a clinician and thus had never actually seen the disease except under a microscope or in a book. While the movie doesn't stress this, one has to believe that witnessing the cruel fate he has imposed on his wife must have shook him. Secondly, Kitty meets her neighbor, the portly and ugly Mr. Waddington. Waddington has an exotic and usually naked Chinese woman who lives with him, whom Kitty appears to mistake for a prostitute. One can almost imagine Kitty's thoughts, in fact - how else would this ugly man have such a beautiful seductress as a lover? But we later learn that this is not true - the woman with Waddington is either his wife or his common-law wife. Waddington, many years earlier, had helped a poor Chinese familiy with some government issues, after which the youngest daughter apparently gave her life to him. She was a very young girl at the time, and three times followed Waddington, each time resulting in him sending her back home. Finally, he caved and they became lovers, and by all appearances, husband and wife. Kitty asks the drunk Waddington one night what his wife sees in him (an insulting question, but one Waddington clearly understands, since the union is so unbalanced on the surface). Waddington translates the question into Chinese so that his wife can answer, to which she answers, "you are a good man." Kitty smiles and laughs, saying "What woman has ever loved a man for his virtues?" We already begin to see, though, that such a realization is changing her slowly, for all her husband's faults superficially - he is not interesting in any way at all that is relevant to her and her hierarchy of values - he is a good man. His motives for coming to China are complex. He wants to kill his wife, but even that is borne out of his genuine love for her. Bitterness is, after all, proportional to the love one has a person. People may hate Hitler, but no one was ever bitter towards him for what he did. Bitterness is an emotion and state of mind that is produced when people we deeply love disappoint or sin against us, and that is clearly what is driving Walter's actions in this movie.
Finally, Kitty's personal transformation is initiated after she volunteers to work with the Catholic orphanage. She witnesses first hand true sacrifice, character, and virtue in the lives of the nuns and the children they care for. She has never seen anything like it, apparently, and it along with the experiences in China are mirrors both exposing her shallowness and a fire burning away the dross in her heart. When her husband eventually catches cholera, she stays with him, despite the risks, sleeping with him, washing his face and messy body, til he dies of dehydration the next day. Before dying, he asks her to forgive him for what he did. He dies, is immediately buried, and she returns to London. Five years past and we see her with her five-year-old son, Walter, in a flower shop. She has gotten pregnant through her adulterous relationship in London, and had discovered this while in China after she and Walter had reconciled after the night at the Waddingtons. Walter knew the baby wasn't his, and despite both of their anguish over the consequences of her sinful liason in London, Walter said none of it mattered anymore, and they embraced in silence. While nothing is said, I suspect that this moment consummated Walter's forgiveness of Kitty. Confronted with her adultery one last time, he has a choice as to whether forgiveness and love will win in the struggle against his wounds and bitterness, and in embracing her and saying "None of it matters," the man of few words we are led to believe has finally killed the bitterness in his heart and forgiven his wife. Now we see the boy in a flower shop with is mother. His mother echoes an earlier conversation in the movie, in which in a flower shop five years earlier with the older Walter, she says that her own mother had never let her buy flowers because "why buy something you can grow for free," but since they never actually grew the flowers, they never had flowers. Now she poses the same question to her son - why buy something which will only die in a week? To which her son tells her "because it's beautiful" and so they buy the flower. We realize here what is different about her. She has given herself to something which perished - to the Chinese orphans, to her husband, and now to her son - and it had changed her. I am reminded of the bible verse that (paraphrase) says "lest a seed perish, it cannot grow into an abundance" or something to that effect. The paradox of love and life is that for others to be free, we must become their slaves. In order for my wife or my son to be free and to have happiness, I must give up my life and my happiness. But if I seize my own happiness as though it is a right, then I will have neither happiness, nor will anyone else in my life. This is the weirdness of Christian joy - that we experience joy only indirectly when finding happiness in our relationship with Christ. Only out of that can we love and be loved. When outside the flower shop, she runs into her old lover and the father of her son, Walter, she rejects his flirtatious advance to reignite their affair. When asked by her son who the man was, she simply tells him, "He was no one." He was truly no one, just as she was certainly no one. The scene reminded me of Augustine's Confessions in which Augustine ran into his old lover one day on the street, long after his conversion to Christianity. The old lover propositions him, but Augustine tells her that the man he once was he is no longer. We get the sense this is Kitty's own explanation - the one who loved everything about that old lover is dead and replaced by a woman of almost magical depth and virtue.
As an old pastor of mine used to say, if you see a turtle sitting on a fencepost, you know it didn't get there by itself. The movie was like a spiritual fable of the Christian's journey from complete and total shallowness to one of mature depth, and at a personal level, it reminded me that spiritual transformation is possible through the sacramental work of God himself in us. It reminded me of Kierkegaard's own taxonomy of spiritual progression, from the empty life to the aesthetic and then to the religious life. Kitty, as well as Walter, both experience this. And what is most encouraging and exciting to see was the One who directed this and actually redeemed the cruelties and selfishnesses of the characters. Kitty's adultery led to Walter's bitterness, which led to the impossible choice of either accepting his public divorce or going into the cholera epidemic. Had Kitty not committed adultery, who knows if Walter - being a good man - would have even volunteered. Surely some of his motivation was not just duty, but also suicidal wishes on his part. But in so doing, Walter provides a crucial public service to the Chinese, who absolutely despise his coming there - because they are nationalists, and he is British; because they are superstitious and he has to closer their water supply because it's infected with cholera. He goes, nonetheless. In one conversation with Kitty about the work of the nuns, he tells her that while they look very altruistic, in fact they have complex motives. In retrospect, I think Walter was really talking about himself. While he looks like a good man for going into the heart of a cholera epidemic, his motives are complex - even selfish. Yet God uses those selfish motives to save these Chinese villagers who benefit immensely from his difficult choices regarding the public water supply. Through his own sins, God ultimately gave Walter a wife who loved him. He, in other words, never gave up on Walter, and in fact directed his path in order to lead him to see his own sin, and to experience mercy. We get the sense that Walter genuinely believes, in the end, that his sins against Kitty are the worse, and really, how else can two people live together in love and not approach the relationship in that way? Through this, God also "saves," if I can use that language, Kitty. What we see in this is not merely the spiritual journey of two regularly flawed people - people very much like us - but primarily the gracious, stubborness of a God whose motivations are complex. He calls us into the cholera to be sacrificed for the sake of strangers, and in the process boils off the dross and reconstructs us.
For me, the movie was one of the most spiritually insightful movies I've ever seen. I was full of hope. It was like a sermon. I loved it in every way. Perfectly cast, perfectly told. Four stars.
Economics of Kindle
Tyler links to this NYT article about the Kindle and how it's affecting the book industry. Do we really understand the economics of these kinds of "monopsony portals of purchase"? If electronic reading became popular, then who else would we buy our electronic books from but Amazon? And if they did like Apple with iTunes and tied the price directly to the Apple's proprietary MP3 technology that only let you play it on an iPod, then they'd be able to get the price down considerably since they, like Wal-mart, would have such tremendous bargaining power given their dominance as a portal of purchase.
One side note. My understanding of intellectual property is that the perpetual copyrights awarded to authors and musicians enables them to charge monopoly prices in perpetuity. That in and of itself is inefficient. I've always thought that if you have a monopoly on the selling side, another solution is to have a monopsonist on the buying side. I may be wrong on that, but since both parties are moving outcomes towards greater inefficiency, but in opposite directions, it'd seem that they'd be able to effectively push the outcome towards that efficient outcome. Probably not perfectly, but given the state of the technology and market structure as it is, it's got to be Pareto improving to have monopsonistic technologies like Amazon's Kindle or Apple's iTunes/iPod to combat the inefficiencies of the current IP regime.
One side note. My understanding of intellectual property is that the perpetual copyrights awarded to authors and musicians enables them to charge monopoly prices in perpetuity. That in and of itself is inefficient. I've always thought that if you have a monopoly on the selling side, another solution is to have a monopsonist on the buying side. I may be wrong on that, but since both parties are moving outcomes towards greater inefficiency, but in opposite directions, it'd seem that they'd be able to effectively push the outcome towards that efficient outcome. Probably not perfectly, but given the state of the technology and market structure as it is, it's got to be Pareto improving to have monopsonistic technologies like Amazon's Kindle or Apple's iTunes/iPod to combat the inefficiencies of the current IP regime.
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