Flying into Zurich one is immediately impressed with the orderliness of the country. Nothing appears to be out of place, even out in the fields, around the barns, and along the sides of the roads. I was reminded of Oslo, Norway, which comes close in this regard. I had a great reception in Switzerland, which must have the highest density of neurofeedback professionals outside of the Czech Republic, numbering more than in all of Germany even with a population one-tenth the size. Many practitioners there are oriented toward Val Brown’s NCP, and Pete Van Deusen is popular as well.

The fact that almost nothing is out of place in Switzerland gives the land a sense of stasis. The whole country still looks traditional, with new houses being built in the old style. Villages look like they always have, except for the asphalt and indoor plumbing. Roads remain narrow and curvy, in that full respect is paid to the buildings that were there first. But this is also the country with the highest median income, if one disregards capital havens such as Monaco and the Cayman Islands. The country is almost completely middle class. That is to say, there are no poor people. And it is too cold for street people. Obviously the well-to-do are here also, but they don’t show it off.

Years ago one saw Switzerland missing out on the high-technology switch toward digital watches. But look who won out in the end. One does not see digital watches anywhere anymore. The orientation toward precision, predictability, and reliability pay off in terms of continued technical progress despite a rule-bound society. Switzerland has the highest density of Nobel prize winners in the sciences. This is where high-temperature superconductors were discovered, and where the Internet got an essential boost through software developments at CERN.

While I was in Switzerland I heard the story that a survey of on-time performance of the local railway came up with the result that 95% of trains were within 2.5 minutes of scheduled arrival. One would think that they might be pleased, but in fact it was cause for complaint! The schedule is based on an assumption of on-time performance to within one minute. This is the country where time rules, where clocks are everywhere. My return flight on Delta left forty minutes late, but it arrived a few minutes early. It was serving a Swiss constituency.

It is still not clear how neurofeedback will take off in the European countries, given everyone’s expectation that their medical expenses will be paid for by third parties. There is an odd state of affairs in Europe, in the sense that a lot of the techniques considered alternative in the US are accepted as mainstream here (homeopathy, radioactive baths, spas of various kinds, and sundry supplements such as St. John’s wort). But there is no burgeoning category of alternative approaches seen as such. This means that neurofeedback does not have a sea to swim in. It must come into usage either as a recognized mainstream solution, or it must come into play under a non-medical rubric such as cognitive skills training. The solution in Switzerland to date appears to be to ally neurofeedback to other interventions such as kinesiology. If it is done in connection with another intervention that is reimbursable, then the time spent doing NF can be reimbursed also.

We had an enthusiastic psychiatrist attend the course, and he intends to pursue NF vigorously in his thriving practice outside of Zurich. We’ll see what happens. He is making grand plans, and is already resigned to the fact that retirement will not be an option once he undertakes neurofeedback!

Thoughts on timing, as well as on the coexistence of both a relatively static society and rapidly moving technology, are themes for what follows. Most of the rapidly changing technology that we have experienced in our lifetime is nevertheless imbedded in a culture where a lot of things move much more slowly. Bear with me on the following story. I just had a major car repair on an old car that over-heated. The thermometer on the dashboard duly registered the problem, but one really only notices these things once the engine starts acting funny. Sue and I tend to hold onto our cars, so I recall having a problem of this kind sooner or later with each of our old cars. In every case the answer is the same. If one had caught the problem early enough, there would not have been major expense. So why is it still the case today that when one buys a car, one will still get a little dashboard gauge that tells you when the water temperature is too high. Why is there not a screaming auditory signal that tells you the very moment that the temperature rises beyond tolerance, or when the oil pressure drops, so that you can react in a timely manner, before the head gasket warps or the engine seizes up? In all of the years of Internet development, the passage of entire generations of computer design, we still get the same old temperature and oil pressure gauges on our automobiles.

The same issue arose again when it came time to set the alarm for the return flight from Zurich. How does one know that the battery is still going to be working the next morning when you need it? Why don’t battery-operated “critical functions” notify you of imminent battery exhaustion, like on our smoke alarms?

A recent story in the Los Angeles Times dealt with long-term changes in murder rates in the city. The rate has been in long-term decline for over a decade, but a more detailed look reveals that the credit is due to better trauma work, not to a more docile populace. This mostly means quicker and more effective intervention for people in the process of dying of internal bleeding. It is estimated that if trauma care were still at the level of where it was two decades ago, our city’s murder rate would be triple its current level. The declining murder rate is giving an entirely false impression by virtue of counting only successes rather than attempts. But the salient point at the moment is the importance of timely intervention.

Timely sensing of a problem would save inordinate sums in the maintenance of not only our automobiles, but also of our bodies. And timely intervention may also be critical. We just had a report in the paper of a child who visited a science museum, where his heart rate was put on display for the whole class. The mother was along as a chaperone, and was struck by the fact that her child’s heart rate appeared to be quite elevated, clocking away at 150/minute. She had her child checked out medically, and his level of Ritalin was reduced. His heart was racing at times up to 225 times per minute. I think that’s up there with the hummingbirds. If this occasion had not presented itself, this child might well have become one of the mysterious Ritalin casualties that you never hear about.

There is probably more of an analogy than I care to think about between what happens in old cars and what happens in old people. At some point sooner or later there will be an abrupt loss of function, not merely a gradual decline. In contrast to automobiles and other technology, however, such a loss of function is likely to be transitory, a momentary excursion into one or another of our familiar instabilities. It seems to me that if monitoring of function is a good idea in automobiles, then it is an even better idea in humans, most particularly while they are driving and putting others at risk. The most obvious applications would be to heart function, to brain function, to autonomic function, and to the breath. And with respect to brain function, the most obvious would be the tracking of arousal level, perhaps first and foremost to detect incipient sleep transitions in long-distance drivers.

Santa Monica’s District Attorney is filing charges against the man who plowed through the Santa Monica street vendor district last year, sending some 63 people to the hospital and ten to the morgue. There is no question about the fact that intent was not the issue here, but rather some kind of episodic lapse in brain function. So if the focus is entirely on the event itself, it would be a stretch to hold the man responsible for what happened. Nevertheless, I am with the D.A. A crime was most likely committed, in the sense that in all likelihood this was not the first such brain lapse, and the 87-year-old “perp” probably knew that he shouldn’t be driving, but was not willing to give it up. Monitoring of brain function over time would have disclosed the risk before it had such a horrible fallout.

A natural concomitant to “always-on” physiological monitoring would be “always available” biofeedback/neurofeedback. I recently saw an ad by General Electric saying simply that the time to address a heart attack may be fifty years before it starts. I wonder what they had in mind specifically because I don’t think they would have gone to press if they did not already have a clear idea of what precursors they would like to target in a preventive effort. By the time President Clinton was brought into the hospital with heart complaints the options were indeed limited, and the cardiologists were in full command, swaggering before the microphones, august in manner, perfectly coiffed, voices suitably modulated, their stethoscopes dangling phallically. Medicine in full command of its stuff. But the President admitted that he had been aware of symptoms months before. With physiological monitoring along with sophisticated signal analysis, the detection threshold could have been much lower. A self-regulation-based remedy plus dietary intervention might very well have been sufficient at some earlier time.

Such a remedy cannot come out of the field of cardiology itself. That would be the equivalent of putting iron lung manufacturers in charge of developing the Salk vaccine. The $70B heart surgery enterprise will not conspire to put itself out of business. But one senses a kind of inevitability about our prospects of becoming the “surveillance society,” and in that context we will also mobilize the tools to do monitoring of our own functions, perhaps those of our infant children learning to sleep, and of our elderly loved ones facing decline in self-regulatory capacities.

A Swiss Health Status Survey

I perused a summary of health-related data on Switzerland, which yielded some interesting insights.
– With only about 20% increase in population between 1970 and the present, there was a tripling of the number of physicians in the country over that time span. With respect to large-scale social change, little compares with the growth in health care.
– Surprisingly, the lung cancer death rate in men matches the sum of cancer death rates from all causes in women. Further, the prostate cancer death rate exceeds that of breast cancer–or of any other category for that matter–in women.
– Psychiatric diagnoses constituted 11% of all medical diagnoses, and 20% of medications prescribed targeted the central nervous system.
– The mortality categories seeing the largest growth in incidence between 1980 and 2001 were psychiatric causes, from 0.4% to 4.1%, and diseases of the nervous system, 1.4% to 4.1%. If one adds suicide as a mental disorder, at 2.7%, one obtains in excess of 10% of causes of death involving the CNS and its functions. In future, we may reinterpret a lot of cardiovascular failure as originating in the CNS as well.
– Nearly fifty percent of the population was unwilling (for purposes of cost reduction) to restrict choice of doctors, choice of hospitals, restricted access to medical interventions, or restriction of the catalog of basic health service entitlements.
– In a balancing of quality versus cost orientation, there was a 45-to-one ratio in favor of quality focus versus a cost reduction focus among those who felt most strongly.
– Taking everyone into account, the ratio was 90:6, with only 4% being indifferent on the matter of quality versus cost.
– With respect to whether health industry change should be driven by market considerations or by state directive, there was a slight favoring of market guidance. The opinion extremes favored control by the market over the state by a ratio of 14:10.
– Health and social welfare represented the second largest category of employment growth, exceeded only by another category of service jobs (i.e. those related to finance, construction, business transactions, and rents), over the last thirty years.
– Presently one-third of all medical expenses are already direct-pay to the service provider, with the remaining two-thirds of costs being serviced through the state or through private insurance.
– A breakdown of household expenditures finds that 15.7% goes to health care, of which 2.7% goes to medications. Alcohol and tobacco together consume 1.8% of the household budget.
– US per capital health expenditures are 30% higher than those of Switzerland, which ranks second among developed countries. US expenditures exceed those of France by a factor of two. They also show the highest growth rate, and the highest growth in the growth rate.
– Finally, the total health expenditures in Switzerland amount to $40B, or about $5400 per capita per year. This state of affairs is not giving rise to a lot of complaints.

In the US, the drumbeat is always that health expenditures are too high. But as in Switzerland, I suspect the American public is making the choice in favor of medical access vis-à-vis cost reduction. We just need to sort out better what costs should be socialized, and what costs should be a matter of individual choice.

An indication of whether these costs are out of line can be obtained by comparison to other categories of more voluntary expenditures. For example, Swiss health expenditures are fifty percent larger than what the public lays out for restaurants and hotels. It is 60% larger than the expenditure on automobiles. It is comparable to the sum of: newspapers and books, alcohol and tobacco, gardening and pets, telecommunications, and sport and cultural expenditures. It is difficult to argue that such a commitment to the health care budget is irrational or indefensible.

A final anecdote on the earlier trip to Mexico:

As the bus brought all of us back to the airport hotel in Mexico City, one of the attendees bid me good-bye in Russian, and I answered him in the little bit of Russian that remains with me. I could only wonder, though, what might have prompted this strange greeting. The Mexican trip had the effect on me of stirring the foreign language lobe, only what came up was a mélange of Spanish, French, and a bit of Italian. I could no longer keep them straight. So I never ventured to say anything in Spanish for fear of encouraging someone to continue the conversation.

Significantly, German did not come up. It is not located in the foreign language networks. And when I was in Switzerland it took only a few days for me to start thinking again in German. It just seems amazing to me that memory traces can lie dormant for decades and then still be available for recall.

This entry was posted on Wednesday, November 24th, 2004 at 1:14 am and is filed under Uncategorized. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.