The Cost of My Mother's Cardiac Care in the United States and India - <AUTHOR> http://www.annfammed.org/content/12/5/470.long <comment><USER2> Coming from India, I have really come to hate the medical system here in the US. There are countless times I have been screwed over by the lack of transparency in cost and the layer of bureaucracy and BS imposed by having to deal with an insurance company rather than __the doctor/hospital who treated me__!!

It has been a few months since I have seen a doctor, but I still receive some new goddamn bill every other day. They are usually cryptic and leave me wondering what the hell they are for, and why they were not just presented to me on the day of the test. Don't even bother asking anyone what a procedure costs. Hospital staff will redirect you to someone who deals exclusively with insurance (completely unnecessary if we just had simple bills like any other transaction FFS), and the insurance people don't have enough specifics to ever really give you an answer, not to mention the time it will take waiting on hold etc. When you are getting multiple procedures, its just not worth the time. So you are practically forced to go in completely blind about potential costs.

To top it all off, my insurance coverage has expired as I recently graduated. So my options are to either pay $600 for 30 days of medicine that I need, or get the exact same medicine shipped to me from India, for $10-$20. They produce it by the millions in blister packs. This should not be so difficult! If we just had realistic prices in the first place instead of inflating them and bringing them down with insurance, this crap would not happen.

And don't even get me started on "pre-existing conditions". What that means for me is constantly lying to doctors and being unable to give them a complete medical history - otherwise I'll have f __* "pre-existing condition" stamped on my head and never get sane rates again.

I fail to see why health care is not treated more like a series of simple business transactions in an economic system instead of this colossal mess.

/rant

<comment><USER3> > And don't even get me started on "pre-existing conditions".

First, I would delete the sentence after this if I were you, since it could come back to haunt you legally[0].

Second, unless things are different for foreigners in the US (which AFAIK is not the case), this is not how pre-existing conditions actually work (anymore), post-ACA.

[0] (I am not a lawyer, I am not your lawyer, and this is not legal advice.)

> So you are practically forced to go in completely blind about potential > costs.

This (price transparency) is actually the real problem more than the sticker prices themselves.

If patients had the ability to know expected prices beforehand, market forces would work to bring prices down. As it stands, we have a very awkward situation in which _insurers_ compete to keep premiums down to attract customers, and therefore negotiate lower prices with providers, but patients are completely blind to this entire process and are unable to "vote with their wallets", because the prices that patients pay and the prices that insurers pay are not always directly linked in practice.

<comment><USER4> "If patients had the ability to know expected prices beforehand, market forces would work to bring prices down."

If patients knew to ask. Really. If you are covered by insurance (including medicare/tri-care/etc) you won't get an answer. But if you are paying out of pocket (and most hospitals require credit if you are doing something serious - like open heart)you can negotiate the price.

Let me say again, the hospital will negotiate. The doctors and labs (not done in the hospital) are another matter.

Also, if you see an aspirin on your bill costing $75 you need to call. You'd be surprised how effective this is. Most Americans never question the price of anything. Even cars these days people take at face value.

Of course, if you in the ER with chest pain, I'll admit, the last thing on your mind is the bill. And the hospitals know that.

So what's the lesson here? In America have insurance. Even if you are 20 years old. A simple care wreck can destroy you financially. You think student loans are bad? Try a drug overdose. Or a heart attack. Or a fractured back ( a car wreck). If you young, insurance is cheap. Dirt cheap.

<comment><USER5> I haven't had much success getting prices when I had a high deductible insurance. Most doctors won't tell you anything or they will quote you one price today and 5 times as much tomorrow. You certainly won't get a binding quote you can plan with.

</comment></comment></comment></comment><comment><USER6> I recently wrote on my blog about the cost of having a benign mole removed. I got so angry when I heard the cost of that simple procedure that I went online and calculated the cost to do it in Colombia, where I have some family. Long story short, I estimated that it would be 34% cheaper to fly to Colombia, have the same procedure done, _and_ have a full week's vacation (at hostel rates, which is how I travel). _Everything, including airfare and a full week of food and lodging, for 34% less than just the procedure in America!_

The best part is that I guesstimated the cost of the procedure in Colombia. But _even if I tripled my guesstimate_ , it would still be cheaper to fly!

For time-insensitive or elective procedures, you can and should go abroad. The real cruelty is people who don't have a choice--emergency situations, cancers, etc. They're trapped in our hideous system and often have to choose between their life savings and a lifetime of debt, and dying.

Our American approach to healthcare disgusts me. Every time I think about it I get filled with rage.

<comment><USER7> If you can shop around in the US for something like that it can matter too. To correct my son's tongue tie the first ENT would have been over $1500 out of pocket, including anesthesia. The second one did it in his office as part of another appointment we had related to his hearing, total out of pocket $50.

IMO, The biggest problem is really lack of transparency for this stuff. If a hospital takes government money (and pretty much every one of them does), it should be required to publish its rates like a utility does.

<comment><USER8> The more they deal with insured patients, the less ready they will be to give you quotes. I was trying to find a news story of someone calling around to get price quotes on procedures and many places just immediately hung up at the question.

</comment></comment></comment><comment><USER9> I was traveling through India with my sister, and she got terrible food poisoning. I put her in a private hospital, where she was given incredible service and recovered within a four days. The hospital bill was only 8000 rupees, or ~$150. My sister told me of one nurse who gave her exceptional care, so I tried to give that nurse a 5000 rupee ($100) tip. Without a moment of hesitation, she flat-out refused. Her response brought tears to my eyes -

"Sir, this is my duty. There are poor people right outside, your money would really help them."

As I talked to my relatives about what I experienced, I learned that Indian medical staff see their job as their _dharma_ (duty), a belief that stems from their medical training and originally from the _Bhagavad Gita_ , a religious text that is central to Hinduism. If I had to state a particular reason for the quality of Indian medical treatment, that's what it would be - that they consider their jobs a sacred duty. When someone truly believes that their job is a sacred duty, they will do it with a passion that cannot be artificially reproduced by a huge salary or per-patient compensation.

<comment><USER10> It is also because being a doctor is considered high status in India. Higher than lawyers, businessmen, engineers. Also they also command a high income. So what you did of offering a tip is more of an insult.

<comment><USER11> >>Higher than lawyers, businessmen, engineers.

This was true at one point in time. May be around 2 decades back. But engineering has gotten very lucrative due to the IT boom, overall growth in economy and general demand for engineers in a high growth environment.

Also engineering has a lower barrier to entry and pays better than what many physicians make these days. To make anything decent as a doctor you have to do your MD, which is expensive both in terms of investment of time and money. And even after that, the job at the hospital won't pay you anything close to what your average engineer at a MNC would get paid.

And then don't forget the fact that many engineers can make money through side projects, freelancing and take adhoc risks like doing start ups which isn't even an option to most doctors.

</comment></comment></comment><comment><USER12> Awhile back I was struck by the sprawling medical campus at my University (in the US). First I passed by the original hospital, a large six story structure. Then I passed the new Children's hospital, an even larger building. Finally I walked by the latest building under construction - a twelve story behemoth spread over several city blocks.

It seems that every few years a new building is added, and each one is bigger than the last. Something about the pattern felt vaguely familiar. What I asked myself also exhibits unrestrained exponential growth like the pattern of construction that I saw - then I realized the answer. A tumor!

<comment><USER13> I voted you up. What you say is disturbing and true. American medicine treats the symptoms and intentionally strings people along rather than cure the underlying cause. There is no profit in curing cancer -- only in the treatments. I'm convinced of this after having a few people I dearly loved die in the American medical system. We need more of a system whereby our taxes are used solely for the good of the people -- to improve our lives. It's sad, really. As much money as the US has, we could have the highest standard of living on the planet, but we're nowhere near that because of greed on the parts of tax-dodging corporations, greedy capitalists, and a whole host of other reasons.

</comment></comment><comment><USER14> Her experience is the same as mine.

I've had most of my medical care over the last few years done in India. This includes LASIK (34k per eye), a selective nerve root blocker injection (8k) and a micro lumbar discectomy (85k). I expect to have a second discectomy done in the next month (being really tall sucks), provided my condition doesn't worsen and I'm able to fly.

Overall, my experience with India's medical system has been fantastic. I've found clean hospitals (not all of them!), total price was all completely transparent (+/\- 10% of quoted price), and the doctors have generally been as good as in the US.

Overall, for anyone needing significant medical work done, I strongly recommend medical tourism.

Also, while you are there, have a custom suit made (particularly if you are really tall, and ordinary clothes don't fit). But be warned - I spent more on my suit than on the root blocker injection.

[edit: numbers in INR. Quick reference: 1 lac INR = 1600 USD. In spite of a few years worth of inflation, I don't expect to spend more than 2k USD on back surgery.]

[edit 2: 1 lac = 100,000.]

<comment><USER15> Are these in USD or INR?

<comment><USER16> I love how they work out to be about what it would cost in both countries using their own currency.

</comment></comment></comment><comment><USER17> When he was born, my son had cardiac surgery. Had another one 4 months later and a catheter later on. The two surgeries were done by one of the top 10 surgeons in the world. All in all, he was 6 weeks in the hospital. He's now in very good health. Since we live in Canada, it costs us nothing except the parking at the hospital (about $120 total with a pass) and the lost work time.

<comment><USER13> Free as it ought to be -- payed for out of yours and everyone's taxes. Parking should have been free, to be honest. Nothing I hate more than seeing basic services turned into money-making opportunities for the shady.

<comment><USER18> Since Canada doesn't spend trillions in wars and bailing out banks, they can afford to provide healthcare to it's citizens.

<comment><USER19> Actually, Canada pays less on a per citizen basis than the US does on it's health care. America can still have it's wars, bank bailouts and health care, if they weren't politically gridlocked with the issue.

</comment></comment></comment></comment><comment><USER20> When two parties mutually agree on some deal they both feel satisfied and have incentives to make each other happy. When the government decides what is the "interest" of one party and steps in to "protect that interest", very likely it will end up pissing off one party which eventually loses interest in any kind of innovation.

US has achieved the rare distinction of screwing up both the parties in case of healthcare.

Indian government in reality has even more laws and nonsense but it is too incompetent to implement any of those laws. This mostly leaves the things in a Laissez-faire situation. Like it happens in any Laissez-faire situation the third parties see too many problems but the people who are actually affected are more than happy because they are a better judge of their situation.

In my village in India, we have only 1 doctor. This doctor is a homeopathic doctor who even today charges Rs 10 ( $0.16) per visit. He spends less than 5 minutes per patient and his treatment is allopathic. He moved from a distant city to this village purely because homeopathic doctor giving allopathic medicine is illegal.

Over last 30 odd years not only he has got rich but he is the most powerful person in the village. He is very good at his job, has saved countless lives, delivered babies, removed aching teeth and written countless death certificates. Yes, there have been cases of wrong diagnosis and side-effects too but overall he has lead to net positive benefit to the society in my village and hence is revered.

Many proper doctors tried to setup their shop in my village and have failed purely because this doctor turned out to be better than them.

In India, Indian Medical Council controls the total number of doctors in the country but for a bribe of around $2M you can easily get a license to start a medical school. Medical Schools make insane amount of money and thousands of poor people enter the hospital everyday where you can get away making mistakes because the choice before these poor people is "either get this treatment or die in your home".

</comment><comment><USER20> Another Note: Unlike best engineers in India, best doctors in India can not migrate to US. Because of the sheer population, Indian doctors see 4x more daily patients than their American counterparts perform far too many surgeries very likely to have seen more corner cases than American doctors.

Indian doctors in average private hospitals are far more competent than average American doctors.

It is good that American government is protecting jobs of American Doctors at the expense of public health by barring entry to Indian doctors. We Indians get cheaper and better healthcare. :P

Disclaimer: I worked for a large Cancer hospital in India.

</comment><comment><USER18> I moved to US last year, and figured the healthcare system in US is the biggest train wreck. It is not only super expensive, but also super complicated. You have to jump through many hoops likes insurance, appointment waiting list, mail order pharmacies (who always mess up your order), pre- existing conditions etc.

We were denied treatment by our insurance because of pre-existing conditions. Thankfully, Obamacare fixed it and we began to receive healthcare in 2014.

The prices of healthcare are artificially inflated so high so that it is not affordable for most Americans, so they can be forced into the bizarre health insurance system. This system only makes healthcare even more expensive due to administrative costs and make it complicated for everyone. There should be no place for a middleman in healthcare.

I recently went to see a doctor for a non-serious problem, and here is how it worked out.

Steps to get medical care in US:

1) Call a specialist's office for appointment, and you will usually get a wait list of 3 to 6 months.

2) After months of wait, you get to see the doctor who will diagnose you.

3) Doctor sends in your prescription to your mail order pharmacy.

4) Pharmacy messes up your order; it could be incorrect dosage, pre- authorization, incorrect billing etc.

5) Your medication is delivered to you after few days, sometimes it can even take weeks.

6) You get bills, which could be 10x higher than what you were expecting. Your insurance company provides no explanation of the mysterious charges.

Costs: $50 co-pay, $450 for prescription.

Insurance claims: $700 specialist, $2750 prescription.

Here's how it works in India:

1) Call into doctor's office, you will usually get appointment for same day or next day. You can even walk in without appointment.

2) The doctor diagnoses you, and write a prescription.

3) You take that prescription to any pharmacy, and buy the medications.

Costs: $10 to $20 fee for specialist, and $20 for prescription.

No Insurance required

Edit: I've compared prices of various medications in US and India. Most of the medications in US cost 10x to 20x more than India.

<comment><USER21> > 1) Call a specialist's office for appointment, and you will usually get a > wait list of 3 to 6 months.

In the past year I have seen both a dermatologist and an orthopedist for the first time. I never had to wait more than a week.

> 3) Doctor sends in your prescription to your mail order pharmacy.

Mine have always gone to the local pharmacy of my choice. Same for my wife.

> 5) You get bills, which could be 10x higher than what you were expecting. > Your insurance company provides no explanation of the mysterious charges.

I rarely get bills after the fact, but they always itemize and explain the charges. I also get statements showing what my insurance company paid.

<comment><USER18> > In the past year I have seen both a dermatologist and an orthopedist for the > first time. I never had to wait more than a week.

Appointment times vary by type of specialist, location and luck. I've never got any specialist's appointment before a month here in New York.

> Mine have always gone to the local pharmacy of my choice. Same for my wife.

I tried sending the prescription to local CVS pharmacy. CVS said that my insurance only approved medication for 1 month, while my prescription was for 3 months. Moreover, they were charging me 4x copay than the mail-order pharmacy that works with my insurance company. I guess this is another tactic of my insurance company to maximize their profit by forcing us to buy medication from their partner pharmacy.

> I rarely get bills after the fact, but they always itemize and explain the > charges. I also get statements showing what my insurance company paid.

My Insurance company's partner pharmacy keeps charging me random amounts for same mediation. I've been getting few medications for $37 each since past 6 months, but now they suddenly starting charging me $185 each for the same medications without any explanation. I could buy the same medications in India for less than $10 each.

</comment></comment></comment><comment><USER22> I feel like there is a lot of beating the dead horse with this issue.

Is there (holding the jingoistic flag wavers aside) any real disagreement on the conclusion that the US healthcare system is terrible for the average user - such that we need continual reminder?

Didn't the whole ACA debate prove that yes, we get it it's broken and there is major popular support for changes, even if the actual changes made were not themselves popular by a plurality?

<comment><USER8> Everyone agrees that it needs to change.

There is little agreement on _how_ to change it. Most proposed changes are "let's gore the other side's ox."

<comment><USER23> > There is little agreement on how to change it.

That's because, generally speaking, the more collectivist proposals rely on evidence from the many, many countries that pay less for healthcare per-capita and get better outcomes, while the side that feels a more lassaiz-faire approach are relying on an essentialy religious position.

<comment><USER8> The former group also ignores countries like India and Singapore, and pretend that there is just one kind of health-care system everyone else uses, sometimes calling vaguely calling it "single-payer." People like Ezra Klein desperately try to correct these people, to no avail.

And after all, why should they care to learn the facts? All they need is enough buzzwords to call the other side stupid on message boards, and they are perfectly happy.

</comment></comment></comment></comment><comment><USER13> Great read. This just show how evil for-profit medicine really is. The fact that the pay is so high in the west is disturbing. I really pray we see a single-payer socialised system in our lifetime in the US. Growing up with socialised medicine has shown me the truth. No doctor, no matter how talented, needs to make what they do. All of this should be government run as a non- profit. Government should mandate and force all pharmaceutical companies into non-profit status as well for the good of mankind.

I'm sick to death of not being able to go to hospital here in the US, even with insurance, because what with the co-pays and deductibles, it costs a fortune. I just don't go, and I am in need of surgery that I cannot afford.

QUESTION:

Would an Indian facility in India treat me for a relatively small amount of money? Even after the flights, it would still be cheaper than the $22k I've been quoted here by multiple sources.

<comment><USER14> _Great read. This just show how evil for-profit medicine really is._

I think you mean how evil semi-socialized, heavily regulated medicine really is. India's medical system is as close to free market health care as I've ever encountered.

You walk into a hospital, ask the price, pay it. If you don't like the price, you can go to a different hospital and ask them. If you have insurance, you send them the bill afterwards. That's basically it, and most hospitals are for-profit. In my experience, the government hospitals are significantly dirtier than the private ones. Employer sponsored health insurance isn't a big thing. Doctors who won't talk to you without insurance [1] are more or less nonexistent.

Most likely an Indian facility can treat you. The cost is unlikely to be more than 1 or 2 lac (e.g. $3k tops), depending on your condition. Throw in another $1k for the flight + $1k for a decent hotel. If you want to learn more, send me an email.

[1] In the US I'm willing to pay cash for care before treatment, but most doctors won't talk to me. I'm told it attracts undesired regulatory attention.

<comment><USER24> The U.S. insurance system is not semi-socialized on that part, it is a result of collusion between hospital administration and insurance companies to maximize profits instead of health of the nation. Corporatism keeps laws on the books that reduce competition and take the decisions out of the hands of patients and doctors and puts it into bureaucrats.

Medicaid and Obamacare are the socialization aspects, which try to work within the Corporatist solution... we should have and should just tear the whole system apart.

Too many good minds work in billing and adminstrative research and development, not in medical development.

Disclaimer: I make medical billing and administrative software. I have a job because of a broken system... I'd sacrifice my comfort for a better system.

<comment><USER14> The US insurance system is heavily tuned to make some people pay for others. Employer sponsored insurance, together with accompanying regulations about individual costs, is tuned to make sure the smoker and the healthy person pay the same price. See also community rating in the private market. On top of that, the US government pays more for it's own socialized medical programs than most other nations do.

And this isn't even getting into all the ways regulations micromanage doctors and other parts of the system. Not to mention micromanage financial services - India actually has innovation in that space.

Any theories which claim that for-profit systems are horrible need to be tested against the Indian system. It's mostly for-profit, free market, etc - all the incorrect claims people make about the US are pretty much true there.

<comment><USER25> _Employer sponsored insurance, together with accompanying regulations about individual costs, is tuned to make sure the smoker and the healthy person pay the same price._

That is kind of what insurance is for though - to level out the cost for everyone.

It's a common misconception that smokers cost society. The truth is, smokers die earlier and cost tax payers less in insurance benefits and health care than non-smokers. [1] We should be encouraging people to smoke if we want to save money. (I'm joking!)

[1] [http://www.plosmedicine.org/article/info:doi/10.1371/journal...](http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050029)

<comment><USER14> _That is kind of what insurance is for though - to level out the cost for everyone._

No, the point of insurance is to reduce the variance of an individual's future cost. Due to the law of large numbers, averaging across independent identically distributed people is equivalent to averaging over the future, but that's a side effect.

Averaging over independent non-identically distributed people is NOT part of insurance at all - that's what I'm describing as "the socialist part".

An example illustrating the difference - say you have 10 dice, and if a die rolls a 6 it costs $1,000. You also have 10 coins, and if the coin comes up heads, it costs $1,000. Insurance is when you charge the dice $166 and the coins $500. Socialism is when you charge everyone $333 - that's redistribution from the dice to the coins.

The link about smoking costs is interesting, however that applies at the level of government paying for lifetime costs. Annual costs are higher. So insurance _for this year_ should cost the smoker more than the healthy person.

</comment></comment></comment></comment></comment></comment><comment><USER26> This reminds me of the case of a friend (who is from India) who went on vacation to India. There, something went wrong and he suffered a herniated disk in his back. He immediately went to the hospital. They took an MRI, and advised surgery. He underwent the surgery, and then had a 1 month stay at home with a nurse in attendance. Total cost came to about 200,000 rupees (about $4000).

He came back to the US and then told the insurance company what had happened. (He didn't know he had to inform the company when it happened). They balked at paying his expenses, and came up with all sorts of excuses. Then he told them the cost: $4000. The person he was talking to told him was shocked, saying just an MRI here would have cost them more. They asked him to get an post- surgery evaluation done by his primary physician, and paid the bill no questions asked.

</comment><comment><USER27> But India is 24 hrs away by flight. If there was a list of countries with the flight duration and cost of medical care, what countries would lie on the Pareto front? What if you sorted by a "$-hr" metric?

<comment><USER19> You hear good things about Thailand and some South American countries.

</comment></comment><comment><USER28> We should still consider the fact that the author has a husband who's a doctor, and has family from India and is herself from India. Not sure if the costs would be the same if someone who hadn't been to India in a while or had no family were to go to seek treatment. Someone could easily take advantage of you and you'd hardly have any recourse.

<comment><USER14> I have no relatives in medicine (my sister trained as an EMT, but doesn't work as such), I'm not from India and have no family there. They've been pretty straightforward with me. The price they give me comes out of the same price list as the price they give to everyone else.

Also, if they rob you it's still a great deal. Do you really care a lot whether you spend $1k or $2k on surgery?

I haggle with autowallahs on principle, not because I care about paying 30rs extra.

</comment></comment><comment><USER29> Thank you for sharing. Not only cost is important but people seem to forget about waiting times, the silent killer.

</comment><comment><USER30> i am an indian living in the US for more than 10 years. Costs are cheaper in India and the big hospitals usually have good quality care. The problem is what happens when you have complications or side effects. In the US, you can sue the hospital/doctor and expect to get paid. You can't do that in India (cases drag on for decades).

</comment><comment><USER31> Had a similar case with someone in Nicaragua. The procedure (including diagnosis, medication etc) was $3,000 there whereas it would have been at least $30,000 in the US. I think it goes well beyond cost of living comparisons, because most things there cost perhaps 2-4 times less than here. Even if we factor in that per-capita medical costs in the US are roughly double the rest of the developed world ($6,000 vs $3,000) there is still another multiplier of perhaps 2-3x for procedures.

I'm becoming more convinced every day that the US has become a two-tier society. I (and many of my friends) have had some very lean years, earning perhaps $7-15,000 and surviving. During those times, saving even $3,000 was next to impossible, because we were already $5, $10, $20,000 in debt or more. Multiply that by 10 and it's effectively out of reach for, I don't know, 90% of the country. The standard deductible (which is looking like it's going to be about $6,000 under Obamacare) will often mean the loss of a home, vehicle, or college savings, especially for chronic conditions.

Meanwhile the people who determine these rates (doctors, hospitals, medical supply companies, insurance agencies) enjoy comfortable incomes of $50, $100, $250,000 or more. I don't think they are capable of setting rates ethically. Throw in the fact that aging people are desperate and will basically pay anything to live longer, and it's an unavoidable conflict of interest.

I think the simplest solution to all of this (and probably the most controversial) is to decouple medical research from practice. Ban all medicine-related patents. Create low interest government matching funds for the loans provided by supply companies to dentists and other independent practitioners. Remove the regulations that prop up monopolists and rent seekers. Start reducing the administrative layer that adds so much cost but so little quality of care. Then protect doctors from frivolous lawsuits with a bond system like plumbers and electricians use for catastrophic accidents so they can perform the procedures they feel are needed instead of the ones deemed "safest" or most profitable. Go after the true medical costs, the Erin Brockovich type of coverups that cost the economy billions. And especially go after the sources of illness - radiation from burning coal, carcinogens released by fracking, a hamstrung FDA that doesn't have the resources to test interactions between thousands of household chemicals, carcinogenic herbicides and pesticides used on genetically modified food, and so on.

I've heard the standard arguments about how all of this might disincentivize medical research but I don't buy them. The system we have now rewards treatments more than cures, as evidenced by big pharma ads on TV for irritable-whatever. If we really want to start over, we need to go back to pre-Nixon, before HMOs and profit-driven care. We need to spend substantially more on medical research than we do now (rather than practice), through universities and big-data approaches where biologists and chemists can run simulations and avoid human trials. Dump the current grant system and make funding far more accessible so researching don't spend all of their time fundraising.

If we do all of this, we may just have a shot at cracking the underlying mechanisms that cause illness, basically map every virus and bacteria, the mechanisms through which genes control proteins, how we age and repair damage, etc etc. We should be growing replacement organs by now. We should have cured chronic conditions like diabetes and arthritis years ago and gotten cures for allergies, asthma and autism for free since similar pathways are at work. Right now we are doing little to no prevention, charging just enough to keep people from going to the doctor at early stages of illness, and then charging an arm and a leg for the medical equivalent of disaster cleanup. It's really quite remarkable, and sad.

<comment><USER32> Generally agree, but a couple quibbles:

> protect doctors from frivolous lawsuits with a bond system

Malpractice suits only make something like 1% of healthcare costs, and malpractice insurance is already everywhere.

> big-data approaches where biologists and chemists can run simulations and > avoid human trials

We don't know enough about the human body to be able to accurately do this. Might help for initial tests (and already does, I'd imagine), but you still always need clinical trials.

<comment><USER8> _Malpractice suits only make something like 1% of healthcare costs, and malpractice insurance is already everywhere._

This isn't measuring the right thing. Pretend that some lawyers managed to win a case locally that the "standard of care" for a shoulder injury was an MRI, even through there is no medical reason, because a bunch of doctors in one hospital did it for whatever reason.

Now all the doctors in town rapidly move to MRI'ing every shoulder injury so they don't get sued. This doesn't show up in the malpractice premium numbers.

"Standard of care" is strictly a one-way ratchet. If enough doctors in your town/county/field do something, you have to do it, too. You can have comparative results research as long as your arm showing it has no benefit (and even creates slight radiation risks) and it won't do you any good. "Standard of care" is the legal term of art, and it always increases, never decreases.

Two more pieces of evidence that lawsuits matter [1]

1\. Vaccine manufacturers were going to stop making vaccines because the lawsuit risk was getting too high. (Vaccines do have risks, although minor.) The vaccine courts were set up and everyone seems pretty happy with it.

2\. Hillary Clinton's health care plan from 1993 had a whole bunch of tort reform. This is _not_ because the Clintons hated trial lawyers! But they didn't want the courts to be the ultimate arbiters of how much medical care someone should get. You would not be allowed to sue for malpractice without first going through an arbitration process.

[1] I'm not blaming everything on lawsuits. But you couldn't run an NHS-like system privately in the US.

</comment></comment></comment><comment><USER33> I hope she knows all the lyrics to The Ramones' "Teenage Lobotomy".

"Then I guess I'll have to tell 'em / That I've got no cerebellum."

[https://www.youtube.com/watch?v=6ssoBUb2cJk](https://www.youtube.com/watch?v=6ssoBUb2cJk)

<comment><USER8> You can delete your own posts.</comment></comment>


T-Mobile Now Lets You Stream Video Without It Counting Toward Your Data - <AUTHOR> http://gizmodo.com/t-mobile-now-lets-you-stream-video-without-it-counting-1741734406 <comment><USER2> This is the reason we need strong net neutrality legislation. The biggest challenges were always going to be things like this that look incredibly consumer friendly but would be the beginning of dramatic shift in how the Internet works.

</comment><comment><USER3> What's their end game here? It seems like they now offer a quota waiver for all of the top bandwidth hogging services. Why not just make everything unlimited at this point?

<comment><USER4> They still have excess bandwidth. These deals will attract customers away from other carriers and there is almost certainly a kickback to T-Mobile by the paid content providers.

T-Mobile is sharp when it comes to making data-driven decisions: look at the profitability of their offerings for people with less than excellent credit-- make no mistake, every "uncarrier" move follows from careful number crunching; i.e. creates value both to customers and shareholders.

<comment><USER5> This right here.

Their ads and PR are very publicly criticizing AT&T and Verizon but they're actually chasing the hearts of Sprint's customers. That's where their target market is.

Sprint is noticing too:

[http://www.zdnet.com/article/sprint-fends-off-t-mobile- for-n...](http://www.zdnet.com/article/sprint-fends-off-t-mobile-for- no-3-spot-eyes-hispanic-market-growth/)

</comment></comment></comment><comment><USER6> The Verge on how T-Mobile isn't really all that different: [http://www.theverge.com/2015/11/10/9706296/t-mobile-binge- on...](http://www.theverge.com/2015/11/10/9706296/t-mobile-binge-on-streaming- net-neutrality-problem-john-legere)</comment>


A Lisp framework for the creation of electronic art, visual design and more - <AUTHOR> https://github.com/vydd/sketch <comment><USER2> If Sketch interests you, you may also be interested in joining the Lisp game development community at #lispgames on Freenode. We had our first Lisp game jam in January and will be having another one soon.

<comment><USER3> Are there people/organizations I can follow on Twitter to watch out for the next jam? I would love to participate in a future event, but have a hard time keeping up with IRC.

<comment><USER2> David O'Toole's twitter account is a good one to follow for updates. [https://twitter.com/dtotoole](https://twitter.com/dtotoole)

<comment><USER3> Thanks!

</comment></comment></comment></comment><comment><USER4> Hi all, author here. Thanks! Finding Sketch on top of HN was very unexpected. If you need help running it, have suggestions, or just want to chat, ping me at #lispgames on freenode, or here.

<comment><USER3> Sketch looks fun and intuitive. I'm looking forward to experimenting with it! :)

I'm very close to being able to run the examples, but I'm seeing the following issue when running `(ql:quickload :sketch)`: "debugger invoked on a LOAD- SYSTEM-DEFINITION-ERROR in thread #<THREAD "main thread" RUNNING {10039CE893}>: Error while trying to load definition for system st atic- vectors from pathname /home/peter/quicklisp/dists/quicklisp/software/static- vectors-1.6/static-vectors.asd: COMPILE-FILE-ERROR while compiling #<CL- SOURCE-FILE "cffi-toolchain" "toolchain" "asdf-compat">"

Any idea why that might be happening? AFAIK, I've installed the appropriate dependencies. I'm running Debian 8, Linux 3.16.0-4-amd64 and SBCL 1.2.4.

<comment><USER4> Thanks!

Static-vectors, on which Sketch depends, needs to have a working C toolchain (C compiler, linker, etc.) installed. Maybe that's the problem here?

If you do have the toolchain installed, and can call the compiler with "cc", then maybe sbcl's PATH is wrong. You can try copying your env PATH to .sbclrc:

(require :sb-posix) (sb-posix:setenv "PATH" YOUR-PATH-STRING 1)

<comment><USER3> Thanks for following-up.

I've got gcc 4.9.2 installed and tried adding both my $PATH and the path to gcc to .sbclrc using the above, to no avail.

Maybe I'm doing something incorrectly? (Quite possible, as I haven't used CL in a few years.)

[https://gist.github.com/ethagnawl/0af37c12cf2bd1b8063c](https://gist.github.com/ethagnawl/0af37c12cf2bd1b8063c)

<comment><USER4> I think PATH should only contain folders, not the full path to your binary. But now I'm not sure if even that would help. It would be the best if you could join #lispgames or #lisp on freenode so we can debug it in realtime. We might even find someone there who has more experience with cffi.

<comment><USER3> OK. I'll check out #lispgames either tonight or tomorrow.

Thanks, again, for your help!

</comment></comment></comment></comment></comment></comment><comment><USER5> Anything simillar for Scheme?

<comment><USER2> It's pretty rough and volatile but I have my own somewhat unique game engine for Guile Scheme. [https://dthompson.us/pages/software/sly.html](https://dthompson.us/pages/software/sly.html)

<comment><USER5> Nice, but my Guile version is too old. I guess I'd have to install GUIX ;)

</comment></comment></comment><comment><USER6> For a lua equivalent see [http://polycode.org](http://polycode.org)

</comment><comment><USER7> Looks super cool!

</comment><comment><USER8> Looks like there's a lot of manual setup to get this going. That seems to be the case for a lot of CL stuff I've seen. Clojure actually has a few Linengen packages for this stuff, Overtone is one I recall for music/sound and Quil for visual design/art. Luminus is great for webapps as well.

Overall I think Clojure has taken most of what was good about lisp and turned it into a much more usable and friendly environment.

<comment><USER9> > _Looks like there 's a lot of manual setup to get this going._

Which is one of the things the Processing[0] environment, whose API this apparently mimics, does better than most other applications I think: you download the PDE, a (completely portable) application, and when you open it you immediately see a basic notepad with a big "Compile And Run" button above it. None of the not-yet-relevant stuff you might see in a more overwhelming IDE[1].

EDIT: comment sniped by giancarlostoro! Dr Racket is a good point of comparison too, for sure!

> _Clojure actually has a few Linengen packages for this stuff, Overtone is > one I recall for music /sound and Quil for visual design/art. Luminus is > great for webapps as well. Overall I think Clojure has taken most of what > was good about lisp and turned it into a much more usable and friendly > environment._

There's also thi.ng[2]. I'm very curious to see how all of these compare, tbh.

[0] [https://processing.org/](https://processing.org/)

[1] [https://processing.org/tutorials/gettingstarted/](https://processing.org/tutorials/gettingstarted/)

[2] [http://thi.ng/](http://thi.ng/)

<comment><USER10> thi.ng was just getting started when I last looked at Quil/Clojure. It looks a _lot_ more interesting now, and Karsten Schmidt is something of a legend among creative coders.

>Overall I think Clojure has taken most of what was good about lisp and turned it into a much more usable and friendly environment.

For creative coding I completely agree. I think it's a much more rewarding environment than Processing, both from a programming point of view, and also creatively.</comment></comment></comment>


Why switching jobs makes you a worse programmer - <AUTHOR> https://forrestbrazeal.com/2018/11/24/why-switching-jobs-makes-you-a-worse-programmer/ <comment><USER2> For a very specific definition of "worse".</comment>


An ag company could prove itself more disruptive than Netflix or Airbnb - <AUTHOR> https://newfoodeconomy.org/indigo-agriculture-disruptive-startup/ <comment><USER2> Interesting article. You rarely hear about innovations in the agricultural sector, even though it's so fundamental to our society - thanks for sharing!</comment>


A truth that works: Making sense of the world with William James - <AUTHOR> https://www.the-tls.co.uk/articles/sick-souls-healthy-minds-john-kaag-review-andrew-stark/ <comment><USER2> [https://archive.is/qucAO](https://archive.is/qucAO)

<comment><USER3> why? honest question

<comment><USER4> Paywalled...

<comment><USER3> I didn't see that, thanks.</comment></comment></comment></comment>


It's Reboot Time for "Operating Systems" - <AUTHOR> https://medium.com/@reinman/its-reboot-time-for-operating-systems-6a516ad8e89c <comment><USER2> I can't tell if this article is too deep for me or is conspiracy theory gibberish. What does Goldman Sachs and the 2008 crash have to do with operating systems and dynamic languages? How is "category theory" "explained" in a single paragraph?

</comment><comment><USER3> Yeah I'm in over my head. He says basically:

1\. We have too many programming languages

2\. Goldman Sachs is developing some cities to do programming language research (ish?)

3\. Jumps off the deep end into how MULTICS handles control flow vs context better, and UNIX isn't good enough due to a recession in the 70s?

Sorry, I'm just lost here apparently.</comment>


Identifying a Large Number of Fake Followers on Instagram - <AUTHOR> https://srfdata.github.io/2017-10-instagram-influencers/ <comment><USER3> Fake followers and fake engagement are widespread on Instagram - much more prolific than advertisers realize. I've worked with "influencers" for years. In the past few months brands, advertisers and agencies I speak to are voicing their concern. So, I'm helping build a product (based on analysis of 80 million profiles so far) which will allow brands steer clear of fake influencers, e.g. those women being paid $X/month to walk around NYC and promote handbags/yoga clothes/etc. based on the 50k fake followers they've bought from some website.

<comment><USER4> > based on the 50k fake followers they've bought from some website. This, and > its not just limited to buying fake followers.

There is an effect with _real_ followers unintentionally following pages by either churn&burn or clickfarms, as well.

Facebook has this occur more widespread. The churn n' burn goes as follows: 1) Build Meme or image sharing page, 2) Accrue 50K+ followers, 3) Sell page to an influencer, influencer updates pictures and profile 4) Followers of old page have no idea the influencer they're following, and now see ads mixed in with the old content.

All and all, the overinflation in that industry is reaching bubble levels, if it hasn't already passed it.

</comment></comment><comment><USER5> I can't help but think of the movie the Big Short. There's a large pool of social media marketers, influencers and other tangentially related businesses, all in some way propped up by this fake activity. They're not unlike all the hands that got involved in the mortgage business and securitizing of sub-par, high risk loans. If only there was a way to "short" the Instagram industry.

p.s. To those debating what constitutes a "fake" account, don't forget that the term was only recently invented: [https://www.avclub.com/merriam-webster- points-out-that-trump...](https://www.avclub.com/merriam-webster-points-out- that-trump-didnt-invent-fak-1819298951)

<comment><USER6> Similarly, I caught some non-technical friends recommending some other friends that they should buy into bitcoin / altcoins as an easy way to make money, reminded me of the same film.

<comment><USER7> Well they haven't been wrong yet, just doubled in the last month.

Regardless these are all small bubbles that will only have localized effects when they collapse. Much more important bubbles to worry about like the derivatives market.

</comment></comment></comment><comment><USER8> Their definition of fake is too limited, and they ackowledge that and then rely on it anyway because there isn't an agreed upon definition of fake.

That is very strange, given that there are already better ways to determine if the accounts "will provide value to advertisers", and that is by raising the bar a bit more to look at the account's recent likes and activity.

just because an account has less than 10 posts or is private doesn't mean that they aren't actively engaged humans. that is the root flaw of this analysis.

<comment><USER9> I think the classification can still be supported by the analysis of the behavior of these accounts and the other statistics on the accounts of "influencers" with high ratio of fake accounts. For example, the latter tend to have significantly higher than average ratio of likes to followers on their recent publications. Also, purchases of followers usually happen in batches, so it is easy to observe the spikes in followers numbers. The behavior of "like" bots also produces some observable patterns.

<comment><USER8> > Also, purchases of followers usually happen in batches, so it is easy to > observe the spikes in followers numbers.

I would disagree with this. It is very easy to have a steady stream of followers on instagram, I've run a few campaigns myself.

When an account is private, and promoted, instagram queues up follower requests to 100 at a time, and you can't see how many are queued but you can predict how many users have been attracted to the account. Bot accounts or otherwise.

(Note: this is part of a larger strategy of getting instagram's algorithm to self-promote your posts in the explore section, or as popular in a hashtag. As you can post something new and your new followers will like your post and then you can switch your account public soon after and it is boosted in activity on many feeds, attracting more people to your account)

The user - who is the influencer - account can manually approve the pending followers, or take their account public. When taking the account public, 100 pending followers are added automatically, and it has to be switched back to private to show the next pending followers, only for them to be added when the account is toggled to public yet again. If the account stays public, the other pending followers will stay pending indefinitely and the user can't see that they are pending.

Therefore, this gives the account the ability to control a steady growth of followers, 100 at a time, indefinitely. If they keep the account private during their actual campaign. The authors might be surprised that this strategy obtains more humans than bots.

The main thing here is that there are many ways to "buy followers". And I think the analysis here assumes way too much about a single way that followers are bought. The authors have probably never created their own influencer account, to know about the infrastructure that really exists.

<comment><USER10> Could you share more thoughts about the larger strategy of post and hashtag promotion? Interested to hear your experiences, as we've been dabbling in some FB and Instagram marketing.

<comment><USER8> On instagram, It is easy for an account to come out of nowhere in hashtag promotion.

Just like I was explaining it can basically bake in followers while private. An account can go from 0 - 10,000, or 20,000 pending followers almost overnight, but more practically in a week's time. This won't register on any analytics site.

The account can accept as many of the new followers as it likes (this takes time though) and can make a new post and stack it with hashtags while private. The post will begin getting a lot of likes in a short time span, and then the profile can go public.

For maximum efficiency, this should still be in conjunction with at least one other campaign, still funneling new followers in while the account is public. The post will go to the popular section of every hashtag except the most popular hashtags, as well as trend in the explore section for many users who don't follow you yet.

Given the way that campaigns work, using stories and tags in photos, these should mostly be human followers.

</comment></comment></comment></comment></comment><comment><USER11> >Secondly we are suprised by the high number of fake followers in the business. Almost a third of 7 million followers of Swiss influencers appear to be fake. About 30 of the analyzed influencers appear to have more than 50% fake followers. Among those are quite some who advertise products of smaller and larger Swiss companies on a regular basis.

So, in a country (with all due respect) hardly "at the center of the universe" for (say) design, fashion, and similar with approximately 8.5 million people, 115 "influencers" have 8.5 million followers.

Even taking into consideration foreigners (after all it is the internet and it is "global"), is it a surprise that a large part of them are "fake"?

<comment><USER12> The US has a population of roughly 323 million. @katyperry, @justinbieber, @BarackObama, and @taylorswift13 have 387 million followers. What does that tell us?

Nothing. As you say, the internet is global.

<comment><USER11> Well, I find hard to believe (remember that this is limited to Instagram and to "market influencers", none of the ones mentioned are rock stars, presidents of the US, etc. that I believe have a more transversal audience) that the total amount of followers is so large.

The intended audience seems to me pretty much "narrow" at least from the few examples given on the article under "Illustrative examples of Swiss Instagram influencers".

These are seemingly all fashion related, targeted to an audience (my personal estimate) of women in the 16-40 years old range, maybe even a more restricted age range.

And Switzerland is not - I believe - considered an international (worldwide) reference for fashion.

Of course my reasoning is based not on any data, so it may be well off, but I would have expected an even higher number of "fake" followers, not a smaller one than what the researchers found.

</comment></comment></comment><comment><USER13> It's amazing to me that more of this hasn't taken place. With valuations being driven by total # of users, where is the due diligence to verify these claims?

<comment><USER14> Valuation is more-so driven by ARPU so all this does is shift ARPU up.

Also, there are network effects. It's unknown whether Instagram would be a better service (to investors) if all (half, a quarter, etc.) fake accounts were removed.

<comment><USER15> If they know numbers are inflated falsely, arent they duping advertisers than? If using CPM and 50% of impressions are fake, that halves their revenue. Facebook, Twitter, etc, all the same

<comment><USER14> I can't speak for instagram facebook etc. but the industry is continuing to move away from cost per impression (which can be duped by fake accounts) to cost per "action", where action happens further down the funnel (registration, 28-day retention, in-app-purchase, etc.)

<comment><USER16> Yeah - we worked with a company that bought some traffic on a cost per impression basis relatively recently, and all of a sudden we had a significant burst in errors being reported.

The user agent for the devices experiencing the errors were all an old version Firefox.

Turns out that version of Firefox was the default for some version of Selenium, and all of that traffic was coming from bots running in data centers.

Moral of the story, don't buy cost per impression from any company with anything but the best reputation, because that market is saturated with bots.

</comment></comment></comment></comment></comment><comment><USER17> It's easy to tell on an individual basis if an Instagram account has something screwy going on.

\- Check comments to followers ratio. \- Check comment quality (are people tagging friends or leaving generic/spam "great pic" comments?). \- Follow the account and turn on post notifications. By doing this you'll see how many spammy ads they post then delete an hour later. Many of these posts will have fake social proof on them.

</comment><comment><USER18> The first fake account is impressive because it links to a real Facebook account. Don't they have any kind of verification?

<comment><AUTHOR> They don't say that "fake" followers have to be bots - they could also be humans that "sell" their profile to platforms so they can re-sell it again for following. If you buy "quality" followers on buzzoid.com, for example, you get exactly that. Accounts that appear to be real people - and are probably - <USER2> who follow several thousand of other profiles. And that is just weird.

</comment></comment><comment><USER19> Alternative idea for a service: Identify other "influencers" in your market niche and buy them thousands of obviously fake followers, when in discussions with advertisers point this out: "X has more followers, that is true, but look at the quality of them most of these are obvious bots. That is why my rates are 20% higher."</comment>


Economists Suggest Silicon Valley Startups Aren't Really Creating Many Jobs - <AUTHOR> http://recode.net/2015/12/07/economists-suggest-silicon-valley-startups-arent-really-creating-many-jobs/ <comment><USER2> "The nature of these companies is what's changed."

Jaron Lanier calls this nature "sirenic." Shrinking markets is the business of Siren Servers.

We mostly notice how these companies seem to do more with less (with automation) but Lanier argues that the shrinking of markets is more closely associated with incomplete accounting of value (and its origination).

Think about all the users of "fake free" systems contributing value without formal compensation.

It's not simply that automation is obviating human effort but rather humans are contributing value (e.g. by being monitored and tallied or uploading creative work) and absorbing most of the risk of the venture.

</comment><comment><USER3> I thought this was obvious. Why else would they be worth so much unless they were more efficient than traditionally structured firms. Silicon Valley got rich through automation of previously manual processes. Automation is about removing people from previously man-hour heavy processes. Less man hours equals less jobs. Productivity is now almost totally decoupled from man hours. It's not rocket science.

<comment><USER4> That's a shame isn't it, if all they do is do existing things more efficiently?

One would hope there would be more startups that made entirely new things possible, things we couldn't do before.

<comment><USER3> We stand on the shoulders of giants. Everything is a iteration of something old. Sometimes a pretty big one, which we call innovation. That's not to say that they aren't on an order of magnitude better and more efficient than previously but that's exactly the point. We do way more with way less these days. I do believe new industries will emerge from the ashes of old ones but there will inevitably be a transition period where things will not work very well for those not working on the cutting edge of tech.</comment></comment></comment>


Show HN: Animated visualisations of global lightning strike location data - <AUTHOR> https://spatialawareness.io/blog/thunderbolts-and-lightning/ <comment><AUTHOR> Hello!

The past few weeks a friend and I have been working on a series of animated spatial visualisations using global lightning strike location data.

You can see and read more about them here: [https://spatialawareness.io/blog/thunderbolts-and- lightning/](https://spatialawareness.io/blog/thunderbolts-and-lightning/)

We poured a load of hours in these, and overall it's been a really interesting exercise to see how we approach the same dataset differently.

Craig's visualisation is a beautiful global view of lightning data over a few weeks.

My visualisation shows air traffic actively avoiding stormy weather and lightning over Dallas Fort Worth in 2019.

\---

Flight data: OpenSky Network

Lightning data: World Wide Lightning Location Network (WWLLN)</comment>


An Introduction to Content Security Policy - <AUTHOR> http://www.html5rocks.com/en/tutorials/security/content-security-policy/ <comment><USER2> As effective as CSP can be I always felt this was an awkward way to achieve the goal. The API is not very intuitive. Possibly due to the limitations of being an HTTP header or the broad scope offering fine-grained control for every type of element (CSS, JS iframes, etc). It seems to be trying to appease every type of situation.

Just look at how OWASP describes it:

> Content Security Policy _requires careful tuning and precise definition of > the policy_. If enabled, CSP has significant impact on the way browser > renders pages

If they want wide adoption they should really keep it simple. How often would sites need multiple URL whitelists for each (img/script/stylesheet)? A single whitelist would be fine. This is what I would have proposed:

        Content-Security-Whitelist: self analytics.google.com mixpanel.com;
        Content-Security-Policy:
                scripts=<whitelist|*|none>;
                styles=<whitelist|*|none>;
                img=<whitelist|*|none>;
                plugins=<whitelist|*|none>;
                iframes=<whitelist|*|none>;
                inline-scripts=<allow|deny>;
                inline-styles=<allow|deny>;
                insecure-requests=<upgrade|allow|deny>;

</comment><comment><USER3> I wrote a flask extension that makes it a little easier to set these headers:

[https://github.com/GoogleCloudPlatform/flask- talisman](https://github.com/GoogleCloudPlatform/flask-talisman)</comment>


Bitcoin Jesus Roger Ver Talks About US Not Letting Him Back In - <AUTHOR> https://www.zapchain.com/bitcoin-show/episode-2-with-roger-ver/

<comment><USER2> Should probably be tagged with VIDEO in the title</comment>


Was Thomas Kuhn Right about Anything? - <AUTHOR> https://themultidisciplinarian.com/2016/09/03/was-thomas-kuhn-right-about-anything/ <comment><USER2> I see Kuhn as much less dangerous than Popper.

</comment><comment><USER3> As soon as the second sentence the author talks about 'social justice warrior[s]', and I'm not inclined to take the rest of the post very seriously.</comment>


We'll never see another $100B technology Vision Fund - <AUTHOR> https://www.businessinsider.com/softbank-vision-fund-will-be-first-last-of-its-kind-2020-5 <comment><USER2> Love the culture there. Look at their slides:

[https://www.businessinsider.com/softbank-earnings-slides- pre...](https://www.businessinsider.com/softbank-earnings-slides-presentation- features-flying-unicorns-valley-of-coronavirus-2020-5)

</comment><comment><USER3> ...and there was much rejoicing</comment>


A Defense of the Reality of Time - <AUTHOR> https://www.quantamagazine.org/a-defense-of-the-reality-of-time/ <comment><USER2> I think our habit of discussing such arguments as being about the "reality" of time is confusing and silly.

For the most parts people (except maybe Julian Barbour) are arguing about whether the the concepts of "now" and "change" come from outside of physics, in such a way that the present is in some sense more real that the future or past.

If so we can and must think of physics as how "real things now, change".

The alternative is that time is part of physics, and that every part of the history of universe is equally real, and that "now" and "change" are perceptions of observers within that history.

Both views accept the reality of time. Things don't become less real just because they are physical facts rather than metaphysical necessities.

<comment><USER3> Consider an analogy to the 'reality' of right/left orientation. We stand on opposite sides of a table, and I say "There's a cup on the right" and you say "There's a cup on the left". Who's right?

Well, there's not _really_ a deep disagreement because facts about left/right are observer-relative. Furthermore, we might reasonably conclude that left/right orientation isn't part of the fundamental structure of the world.

Now, if I looked at a timeline of events and said "Trump became president after Obama" and you (or any other observer from any other point in time) said "Trump became president before Obama", who is right?

Barbour is saying that this disagreement is like the left/right dispute. Maudlin is saying that it isn't.

I think it's fair to characterize this disagreement as being about whether time is really part of the fundamental structure of the world. And it's clear that there's a meaningful disagreement here.

<comment><USER2> I am going to leave Barbour aside here, because I don't fully understand what his stance is. But if Maudlin is simply arguing that there is a fundamental time asymmetry in physics, then he his hardly arguing about the reality of time.

But I understood him as disagreeing, not just with Barbour, but with a whole lot of physicists (including me) who are "B-theorists" which is a horrible term that means you consider the whole history of the universe as the fundamental reality and see change as a thing observed by beings within it.

But that doesn't mean I think physics, or the history of the universe are time symmetric. My own view is there is some fundamental (but not very well understood) time asymmetry in physics. Yet I am still a B-theorist.

But the alternative called "A-theory" (which I think Maudlin believes) is that time, and change are more fundamental than physics, so the fundamental reality is "the state of the universe _now_" and the laws of physics tell us how it has changed and will change.

A-theory is also perfectly cogent, but it is separate from time symmetry. The only link being: IF physics is time symmetric (which it isn't) THEN B-theory implies there is no fundamental difference between time directions, while A-theory still allows it.

<comment><USER3> I should disclose: I'm an A-theory-supporting philosopher. (Sigh. Why are philosophers and physicists always disagreeing?! We should be friends!)

My above analogy to the left/right issue is the example I use to introduce students to the A- vs. B-theory.

The A- vs. B-theory debate is, of course, complicated, and you point to one possible complication: can we separate the issue of temporal asymmetry from the issue of temporal change?

As I see it, the answer to this question is "No".

We can talk about how some physical object 'changes' its spatial properties as we move from one spatial slice to another. For instance, as we move from the pointy-end of a cone to its base, each circular slice of the cone 'changes': they keep getting bigger until you reach the base.

This use of 'change' is symmetrical. There's no preferred direction of 'change' here. It makes equal sense to speak of changes "from bigger circle- slices to smaller-circle slices" as it does the other way around.

But in the context of the temporal dimension, talk of 'change' is not symmetrical. It's fine to say "The President changed from Obama to Trump", but you can't say "The president changed from Trump to Obama".

The point of all this just is: the issue of whether (temporal) change is symmetrical is tied up with the issue of whether time itself is symmetrical. You can't have your cake and eat it too. There's either an objective temporal ordering of physical events from past to future (as A-theory posits) or there isn't (as B-theory posits). If you're a B-theorist, you have to say that "Trump came after Obama" is like saying "The cup is on the left".

This is not a refutation of B-theory. But it, I hope, makes clearer what the stakes are. And when those stakes are made clearer, B-theory, in my view, looks less attractive.

<comment><USER2> Ok, I think I accept your point about distinguishing a symmetrical concept of "change" applied to asymmetrical things from a truly asymmetrical concept of change. That clarifies what I was getting at in my last paragraph. But I am still surprised to see it as a characterisation of the A vs. B debate[1]

So please help me check I am understanding the terms of that debate correctly.

(1) Even if it is not the way you explain it to students, do you accept my claim that A-theory considers time and change as being more fundamental than physics?

(2) If I further said "... as opposed to considering time change to be properties of the history of the universe", then would you accept the implied dichotomy?

[1] And I say the A-B is in turn not truly a debate reality of time, which was just an unfortunate framing by McTaggart.

<comment><USER3> 1\. I wouldn't put it in terms of time being "more fundamental than physics". We can mean two things by 'physics': the thing that is the object of study in the Physics department or the theory that gets generated by that study. Time, I take it, is one aspect of the object of study, one aspect of the natural world. So the question is: does the natural world, at the most fundamental level, have asymmetric temporal order? Or, rather, is asymmetric temporal order mearly an 'illusion' that gets explained away once you have the most fundamental picture of the world?

That's likely still unclear, but that's to be expected. We typically can't ask questions about fundamental structure without invoking that fundamental structure itself. That's why I find the analogy to left/right so helpful. We have a pretty good idea of what it means for left/right orientation not to be built into the fundamental structure of nature. And so that can provide a way of testing various claims about the fundamentality of asymmetrical temporal ordering.

2\. I'm not sure I have a grip on what this additional thing is supposed to add. But I'll note that you reference 'history' and one might reasonably think that that is a temporal notion. If you meant 'history' to mean something like "the universe's extension in the temporal direction", that doesn't quite seem to allow for the distinction I took you to be trying to make.

(And, yes, McTaggert's framing is highly unhelpful.)

</comment></comment></comment></comment></comment></comment><comment><USER4> If you are interested in an opposing viewpoint, the British physicist Julian Barbour has been trying to work out the math for a timeless physics: [https://en.m.wikipedia.org/wiki/Julian_Barbour](https://en.m.wikipedia.org/wiki/Julian_Barbour)

He lays out his theory in his book, The End of Time.

<comment><USER5> side note: Wiki mobile view renders quite nicely on a desktop for reading

<comment><USER6> "The idea that the block universe is static drives me crazy. What is it to say that something is static? It's to say that as time goes on, it doesn't change. But it's not that the block universe is in time; time is in it. "

I like how this guy thinks.

</comment></comment></comment><comment><USER7> > In special relativity, the time directions are structurally different from > the space directions. In the timelike directions, you have a further > distinction into the future and the past, whereas any spacelike direction I > can continuously rotate into any other spacelike direction.

This is something I've never understood about including time as just another dimension.

<comment><USER8> When evaluating the coordinate-invariant length of [x,y,z,t] (where time is just another number), we use the minkowski metric: xx+yy+zz - tt, where time is treated differently with the minus sign. (By xx, I mean x*x=x^2.)

So, that's essentially where, "time is a dimension" comes from, and that's where it goes.

Aside, if you're wondering what coordinate-invariant length really is: just think about the fact that looking at a house from different angles will not change the distance between the doors. This length is calculated with the Pythagorean theorem involving xx+yy+zz, and when you extend it to lengths which are also invariant under different choices of the time coordinate you arrive at xx+yy+zz-tt.

To complete what has turned into a brief introduction to SR, note how differences in the most natural choice of the direction of time might arise:

We want the path of a stationary object to involve no movement through space, only the required advance into the future (through time). So, we note that time is parallel to the path of a stationary object. However, people moving relative to each other will disagree about which objects are stationary. Therefore, they will end up thinking differently about which way time points.

Returning to my earlier analogy, this disagreement about which direction time points can be compared to the different viewers of the house, who may disagree about which direction forwards or left points.

It isn't too unnatural when you think about it, which is a good thing because it is, well, natural.

</comment></comment><comment><USER9> Put another way, at absolute zero, in the void of deep space, does time effectively stop for a quantum system that does not otherwise change.

Does time exist for systems with no events?

If a tree falls in the forest, and no one is around to hear it, does it make a sound?

<comment><USER10> > Does time exist for systems with no events?

Yes, haven't you been to any pointless meetings? :)

> If a tree falls in the forest, and no one is around to hear it, does it make > a sound?

Obviously yes, sound is just resonating air and if physics is not broken it does make a sound.

<comment><USER11> No it doesent make a sound. That requires something to convert it into that sound otherwise its just soundwaves.

<comment><USER10> This problem is a human made one and relies on the definition of the word, sound. Sound does not require an observer. Sound-wave is just scientific / pedantic way of saying sound. It's not just English, it means the same in my language.

<comment><USER11> Sound does require an observer indeed. Soundwaves even require observers and definition of them as soundwaves. Otherwise there is nothing.

<comment><USER10> Why? If nobody is there air stops being compressed?

<comment><USER11> Because there is not interpreter to make it a sound.

</comment></comment></comment></comment></comment></comment></comment><comment><USER12> > ...time is going on, and we know what it means to say that time is going on. > I don't know what it means to say that time really doesn't pass and it's > only in virtue of entropy increasing that it seems to.

I always thought the same and guess most practical scientists do as well. There is nothing in thermodynamic puzzles that indicates there is some problem or insight to be gained on the 'nature of time', whatever that is.

</comment><comment><USER13> To be honest, this guy sounds like a bit of a crank. His 'solution' isn't to any particular problem with the physics, just a personal preference about how time should be.

</comment><comment><USER14> Given that we can _measure_ time, how can we think that we measure something that may be not real?

<comment><USER15> Just speaking from Julian Barbour's _The End of Time_ perspective:

When they say time isn't real, they mean something more like "not ontologically fundamental" \-- i.e. you can produce a model with no explicit reference to time, and it can produce all the same predictions as a "timeful" model -- of course, you'd have to do some final transformation at the end to express the time values if you want it to compare to a timeful one.

Yes, you can measure it, but that measurement is wholly implied by all the other (ontologically fundamental) ones.

Compare to a word in which people used four dimensions to describe space. In that case, you could correctly argue that, "hey, space is only three dimensions. Yes, you're _measuring_ a fourth one, but that's redundant with the first three; once I know the first three, I can tell you what your measurements of the fourth one will be."

Barbour's argument, then, is that you can derive the laws of physics in terms of a rule for "which universe configurations are possible", and make that your primary model; time then just becomes a label for a measure you apply between different configurations (the "Machian distinguished simplifier"), but is wholly implied by them.

<comment><USER14> Even if time is an emergent phenomenon, it does not mean that it is not real or somehow "less real". I mean, yeah, we ourselves are "not ontologically fundamental", since we are built from atoms, but I dare to say we are real nonetheless.

</comment></comment></comment><comment><USER16> One of them claim made is that time is real and fundamental. I think SR and GR teaches us that the fundamental concept is causality.

<comment><USER17> But causality is inherently temporal. If we imagine a cosmic pause button, it is only because of the passage of time that there can be a causal relationship between my dropping this teacup and its smashing on the floor. If I hit pause half-way there we can talk about how much potential and kinetic energy it has and so on, but (since the rest of the universe is paused) nothing we day can affect anything so no causal relationships can exist until we let things run again.

</comment></comment><comment><USER18> With regards to gravity affecting time, by this interpretation is it then saying time is itself constant but the movement/perception of object A within a stronger gravitational field is slowed compared to object B within a weaker one?

</comment><comment><USER19> See also Lee Smolin and Roberto Unger: The singular universe and the reality of time</comment>


Swift has a special category of "starter bugs" for newcomers - <AUTHOR> https://bugs.swift.org/browse/SR-1691?jql=resolution%20%3D%20Unresolved%20AND%20labels%20%3D%20StarterBug <comment><USER2> Should get added to [http://up-for-grabs.net/](http://up-for-grabs.net/)</comment>


Why Airplane Boarding Got So Ridiculous - <AUTHOR> http://nymag.com/intelligencer/2019/05/heres-why-airplane-boarding-got-so-ridiculous.html <comment><USER2> In News From A Near Future:

Airlines discover (by means of queueing theory, modelling and big data analysis) that if _they pay you_ a small fee -- in the form of a tiny discount on your ticket (a few dollars) -- for _putting your luggage in the cargo hold_ instead of taking it on-board with you, they save tons of money because planes get to load/unload faster, so reducing their time at the gate, essentially trading their gate-time for your baggage-claim time, so increasing profitability.

Seriously, these fads come and go like the order that shelves are stocked in supermarkets. It's all just a fashion industry and frequently only the thinnest of actual data/logic to back up some accountant/marketer's assertions that _it is so_. Watch in a few years' time when the fashion reverses...</comment>


Slides from FourSquare's presentation on using the Lift framework (Scala) - <AUTHOR> http://docs.google.com/present/view?id=dcbpz3ck_24f3v83ggz

<comment><AUTHOR> Here's the video to go along with it: <http://www.vimeo.com/8057986></comment>


Kill Me Softly – Kill processes in a reliable manner - <AUTHOR> https://github.com/alanfranz/killmesoftly <comment><USER2> If you are the one designing your applications, don't rely on SIGTERM and clean shutdowns. Design them so SIGKILL is the default way to stop them such that no data is corrupted and persistent state stays consistent. Then you don't have to rely on some rarely executed "recovery" code, or even worse take chances of what might happen if SIGTERM doesn't work.

Handle SIGTERM only if you get a blackbox-like application (a database that will break if you pull the power plug on it) and so on.

<comment><USER3> If you think of it from a developer's view, you'll come to conclusion that you can't create a program that doesn't need to cleanup things before termination. Unless it's very useless program that doesn't process any incoming data. That's why there is SIGTERM in operating systems.

<comment><USER4> That's nonsense. All ACID databases handle the requirement that a SIGKILL doesn't corrupt data. There may be a non-trivial recovery cost if you experience an unexpected shutdown, but that's about it for any application that's serious about data integrity.

EDIT: In fact they handle a much stronger requirement that a power failure doesn't corrupt data, but the point stands.

<comment><USER5> ACID databases can do this because they have the powerful hand of math giving them superpowers. Most developers don't.

<comment><USER6> Sqlite is a library that you can just link to. Use that for your state- handling, and you need not fear a thousand SIGKILLs. This is a very popular approach.

Or, if you're on a server, you can use another database. Or use atomic file writes, if you have fancy needs. If you have _really_ exotic needs then sure, do your own thing -- but most of the time, killability is easy and beneficial.

<comment><USER5> If you do that, then you have to model program state not as objects, but as database rows. Have fun using ORM on all your projects, for everything.

</comment></comment></comment></comment></comment></comment><comment><USER7> I know it's normally a good idea to avoid code duplication, but in this case I would have copied the function inside kms_functions into both kmsn and kmsp, since this removes the dependency on readlink and also makes it possible to move the executables around without care.

<comment><USER8> One of the best things I learned from a very senior engineer was "There are far worse things in life than duplicating code." Dependencies are frequently one of those things.

<comment><USER3> Oh thank you, these are gold words. I was amused recently when my collegues wanted to avoid code duplication of one small library and ended up with creating a new repository, learning awful Python packaging and releasing a new package for every small change. Much more pain gained IMHO.

</comment></comment></comment><comment><USER9> Alternative modes of operation that would be useful:

* Send SIGUSR1 if TERM doesn't work

* Send SIGCONT if TERM doesn't work

* Attempt to reap the process

* Attempt to ptrace the process

* Give a hint as to why it can't be killed (like blocked I/O, a zombie, etc)

* Kill the process group (dangerous!)

<comment><USER10> SIGUSR1 is often caught by applications for their own IPC. SIGQUIT would probably be a safer one to send, but that can also be caught and repurposed. Sending other signal types would definitely have to be opt-in to prevent unintended side effects.

</comment></comment><comment><USER11> Often I need to kill processes, and wait until they're dead. I want to send a SIGTERM first, then a SIGKILL if it fails. And I want this process to be automated. That's it.

</comment><comment><USER12> I really want to like this. But SIGKILL is such a special instrument in the administrator's toolbox that I don't want it automatically sent after a short timeout. Moreover I don't think anyone should want that. This tool will hide or allow you to ignore important issues with your system.

I do unequivocally like the blocking behaviour though, I might implement that for myself.

Edit: so just something like this:

      function killwait() {
        kill $1
        while ps -p $1 &>/dev/null; do
          sleep 1
        done
      }

<comment><USER13> I'd recommend adding some kind of max retries mechanism because otherwise, if process ignores SIGTERM for instance, you can wait forever.

<comment><USER12> I personally prefer utilities like this just do one simple task and perform it well. And adding a timeout would just complicate things unnecessarily, compared to the alternative of pressing Ctrl-C when you feel you've waited long enough.

</comment></comment></comment><comment><USER14> So instead of two kill messages, we now have two scripts to run, dependent on name or pid?

Just put everything in one script - these scripts are shorter than an init boilerplate section - and use an option to switch. Do process names by default, then perhaps use a -p arg to switch the script into 'pid' mode. Bash's 'getopts' is pretty easy to implement.

As it stands, you currently have to waste mental power to figure out whether you want the 'n' or 'p' version anyway, so may as well just make it an arg.

<comment><USER15> Is the functionality even needed? Doesn't take much to type..

ksm `pidof cupsd`

</comment></comment><comment><USER16> A lot of these bash scripts could be replaced with Go programs. It doesn't take much code for a bash script to get ugly.

<comment><USER15> Sure they could, but then you would need different compiled versions for different architectures, and this is kind of OTT for the task it accomplishes as it is!

<comment><USER16> This would be an incentive to package the code, which would mean being able to check it against SHAs. There are a lot of go programs on homebrew now. I'd like to see a trend of smaller ones getting added there.

</comment></comment></comment><comment><USER17> In my opinion, current process handling is braindead, both in POSIX and Windows. That could be "fixed" with an additional unique identifier during the OS uptime, in order to allow other processes track instances, and not just the ones doing the fork.

<comment><USER18> As you point out, using the pid alone is not reliable. FWIW, Solaris and illumos systems have process contracts that allow you to reliably track processes[0]. If the child forks, it's the new child is still in the same contract (unless configured otherwise). And both the child or parent (the watcher) can restart and then return to the normal state (parent watching child processes).

Solving this problem requires kernel support because the kernel is generally the only fault domain in the system that cannot crash while the system is still running.

Edit: forgot the link the first time. [0] [http://illumos.org/man/4/process](http://illumos.org/man/4/process)

<comment><USER19> Linux has this capability in recent kernel versions (3.x?). I don't know what the implementation is called (prctl?), but DragonflyBSD add this in procctl(2) in release 4.0. FreeBSD already had a procctl(2) and added the same functionality to be compatible.

[http://lists.dragonflybsd.org/pipermail/commits/2014-Novembe...](http://lists.dragonflybsd.org/pipermail/commits/2014-November/343844.html)

So now FreeBSD and DragonflyBSD have plans to utilize this exactly like Illumos and build lightweight process supervision without the need for something as disruptive as systemd.

</comment></comment></comment><comment><USER11> Thank to everybody for the feedback. Standalone executable scripts that are both OSX and Linux compatible are now available.

</comment><comment><USER20> > Those should be available on almost any Linux system, even on minimal > installs:

> [..]

> Bash

Maybe I'm nitpicking here, but why Bash _should_ be available?

</comment><comment><USER21> Those should be available on almost any Linux system, even on minimal installs:

Linux

<comment><USER22> Tautologies aren't false.</comment></comment>


Show HN: Extension to not see Google results as ads - <AUTHOR> https://chrome.google.com/webstore/detail/google-classic-results/mncmlbggmdcmddddanjcgabpajadljhm <comment><USER2> Please consider a different search engine.

Recently I tried to remove as many Google products from my life as possible, and I found it surprisingly easy to transition to Firefox browser and Duckduckgo as a search engine.

My search results are now back to how they used to be ~5 years ago on Google: they are no longer "personalised", so I always have the same baseline view of the internet. Ads are obvious, and only a maximum of one ad per screen (compared to more than an entire page's worth of ads as is the case with Google).

</comment><comment><USER3> Consider using [https://duckduckgo.com](https://duckduckgo.com) instead.

If you must use Google's search, prefix your duckduckgo search with: !g

</comment><comment><USER4> It's so sad that this is a thing that we now need.

</comment><comment><USER5> Question is Why they added such a bad change...

<comment> m-p-3 Revenue and ad clicks</comment></comment>