plans for the new year

I'm planning on cleaning this blog up, removing some of the more personal (and less charming) laments. I'm also planning on working primarily on a separate blog. The idea of blog-segregation seems silly, but at the same time, I'm not sure that the intention of this site is the same as the intention of the newer one. Maybe I'm just creating internet litter, but I think framing matters, and this is one way to proactively frame my work. In addition, I'd like to lose the pseudonymity. I think 2011 is time to publish...it's taken me long enough.

Physicians' conviction of perfection

I added this back in December, but I saved the draft since I had some reservations about so simplistically maligning physicians. My goal certainly isn't to denounce medicine, but rather I do think conversations like this one highlight some of the worst of medical practice. I've already written on my affection for Atul Gawande's perspectives on medicine, and I have immense respect for the practice of medicine. What I don't understand (in any field, really) is the arrogance that one's understanding and insights are impeccable.

From one of our transcripts:
"M: Do you think it influences your assessment if the results are more consistent along what you would expect?
DR: Oh, absolutely.
M: If it had been reversed and we saw higher response rates in that XX group?
DR: The data is actually very believable. Obviously every one of us forms our own hypothesis as we read these, and if it doesn't come out the way we thought then we know that we don't have any errors in our judgement so it has to be the data. I learned that in medical school.
M: That you have perfect judgement?
DR: Yes, and if not you gave me the wrong data.
M: It's good for you to be confident. You're making important decisions.
DR: There you go."

in other news of confronting my own philosophical inconsistencies

Public Citizen notes that pharma is the biggest defrauder of the U.S. government. Worse than the defense industry, and well, we all know how ethical they are. Deeply unsurprised.

I will write more about this later...but figured I wanted to remember to come back to it, and in the meantime, perhaps interest others in this topic.

something about anthropology

As my previous post, a mere 12 hours or so ago, indicated, I don't really do anthropology lately. As much as one is ever "doing" it. Tonight, after a long day at work, I stopped at a nearby tiny sushi place (one of the best I think in SF). I'd done this once before, showing up alone, sitting at the bar, and just eating. Not reading, not looking at my phone, not worrying about work, not planning the future (escape). I used to get to do this all the time. Sitting. Observing. Listening. Thinking. Not rushing. I miss all those things. In doing them, I started remembering what I like about fieldwork, about actively engaging with anthropology. My back was to most of the tables, and so I could only hear conversations among the diners, without seeing expressions or what they were eating.

It reminded me how much I love the observational part of anthropology, how it's a skill and a superpower simultaneously. I like having to pay attention to nuances to read and to absorb the information around me. Having my back to people forced me to do that. It also provided the pleasure of tacit voyeurism. I know I forget in restaurants that the confessional moments with friends can be heard by anyone around me. The assumption that the public space creates anonymity is pretty naïve, but the frequent public cell phone conversations that we all engage in suggests that we all believe it -- or don't care if we forgo privacy and anonymity. I like how much I can read from conversations, little interpersonal dynamics that get lost when it's happening to me, seem so transparent and poignant when I'm listening to or watching others' interactions.

Long overdue

My new(ish) job has eaten up my life. I can't actually remember much about the last six and a half months, which I find disturbing. It seems to be a traumatic-coping mechanism. It's unfortunate, though, that I haven't been writing throughout the experience. Its challenges though probably not worth the "growth" that it's provided are still going to be rich and long-lasting material for understanding healthcare in the U.S.

I am (somewhat bafflingly) working in the pharma/biotech consulting field. I am helping pharma to better market products for metastatic oncology. Except that I don't really believe in their mission nor do I believe in our methods for collecting and analyzing market research. I don't know if I believe in "market research," at least not in its purely market-driven form. It's been frustrating both finding our research methods mechanized and rote and at the same time being highly skeptical of the purpose and goals attached to what we do. Kind of contradictory -- I suppose.

Last summer, I read Atul Gawande's article in The New Yorker, and I cried. It's resonated deeply with me, and I'm posting it here to share. I was reminded of it by this thoughtful post on Arthur Kleinman on Somatosphere, a great collaborative blog on anthropology + science. One of my great frustrations with my work is that we ask doctors whether they would use a product that has a small improvement in survival for patients who are going to die. They are going to die soon. Pharma Company X comes in and asks whether if you could give your patients Product X with these benefits for a few more months, would you do it? Even in our "probes" to explore whether the very unpleasant side effects or the outrageous costs would be prohibitive, the implication always is, well, how could you not offer your patients two, three, 1.5 more months? Not many American doctors would say, 'huh, no. No, I recognize that [as Gawande suggests] a less invasive death is actually better for my patients and their families.'

At the core of the metastatic cancer market is the denial of death. One product I've been working on is with a small biotech company that has a pretty remarkable drug -- an immunotherapy product for a cancer with limited treatment options. The drug costs nearly $100,000. The company's capacity for production is highly limited, even if everyone could pay the exorbitant fee...and yet....aren't we supposed to celebrate and embrace this product for its novel mechanisms and extension of life? Isn't that for what we are all striving?

Underneath all these products and the highly competitive and strategic pharmaceutical marketplace is really the question of whether putting technology in the service of life-extension for any cost is really worth it. Death is everywhere in this work, and no one talks about it.

NPR covers the HPV vaccine debate and fails to mention key data

I just responded to NPR's story about the HPV vaccine for boys. I'm re-posting here because I have to do other things, but I'll work on elaborating my argument a little better soon...

I think it's unfortunate that nowhere in this story did Ms. Wilson mention how highly successful Pap smears have been in the U.S. in reducing cervical cancer rates. Since their institution as a standard of care in the 1970s, Pap smears have reduced cervical cancer deaths dramatically in the U.S. Guttmacher Institute recently published data, as well, that showed the decrease in cervical cancer rates partly due to the Pap smear.

I think it's irresponsible to cover this vaccine and fail to mention this. It's a critical omission in Merck's promotion of the vaccine. It has value in countries where women do not regularly get gynecological care, but we have much cheaper interventions for reducing cervical cancer. Now, if Merck would honestly acknowledge that their vaccine protects against an STI that has high costs in morbidity, it would be a different promise and a different and more reasonable claim. I am disappointed that NPR did not fully report this information.

The conundrum of the female condom

The female condom initially received approval in the U.S. in the early 1990s, shortly after its approval in Europe. It's been tenacious, though not a wide-spread success. I remember the earlier advertisements with Drew Barrymore as one of its spokepeople, and I think she had a college tour through which my sexual health counselors' group tried to get her to come visit our campus. (Thank you, wayback!!)

In public health school, my group decided to focus our communications' class project on the vaguely outré device. During the health promotion project, it became clear to me that though conceptually interesting (female-control of sexually transmitted infections is difficult, nay impossible to find), the device did not really fill the more pragmatic side of motivating people to protect themselves during sex (awkward + noisy object does not really trump the protests of uncomfortable male condoms). Among safer sex promoters, their message often frames the female condom as an excellent and important alternative to the male condom. Even better, the female condom can be used for anal sex, as well as vaginal sex, making it as unisex as the male condom...maybe even more so. It also covers part of the external genitalia, possibly better protecting against STIs (HPV!!).

The female condom's manufacturers have gone back to the drawing board multiple times, improving the material of the condom (previously criticized as "too crinkly"). A number of major U.S. cities are promoting the condom as part of their safer sex campaigns. Consistently over the years, no one really addresses one of the most significant obstacles of using the female condom: it blocks female lubrication.

The female condom requires extra lubrication to be applied inside the condom before inserting the condom. From men's perspectives, the lack of a condom on their penis is supposed to be motivating and exciting. From a female perspective....well, I'm unclear how one's arousal patterns get taken into account. No one really knows what's going on, since there's a very large sheath covering the vaginal walls. This seems to me a rather significant impediment to female empowerment. How can one feel in charge of her own sexuality and sexual activity when there's no means to prioritize one's own sexual response? Most of the commentary about the female condom (see the CNN article linked above) make vague references to its awkward and large shape (it is supposed to dangle outside of the vagina, a very sexy prospect if I've ever heard one), but no one states the obvious: no natural lubrication.

While many people may use lubrication regardless of the absence or presence of a female condom sheath, shouldn't we be promoting more awareness of the importance of female sexual response?

Government requirement for vaccine insurance

Under the new health plan, insurers are required to pay for government recommended Advisory Committee on Immunization Practices (ACIP) vaccines. As the Vaccine Ethics blog points out, this increases the influence of the ACIP even further.

This also presents a couple of interesting problems. In 2008 the U.S. Citizenship and Immigration Services (USCIS) incorporated the ACIP recommendations on the HPV vaccine for women seeking to become citizens in the U.S. This decision led to a lot of resistance because the vaccine is not a requirement for women who are already citizens, it's not a vaccine that protects against any airborne contagion, and it's an extremely expensive vaccine. It was also discriminatory. The National Organization for Women (NOW) has a good synopsis of the problem. After much resistance, the requirements were eventually removed, but it shows the danger of giving too much power to the ACIP. After all, these are recommendations, not requirements. On the flipside, insurers are not eager to cover preventive health care, so issuing a federal requirement is not such a terrible thing.

In other countries, such as the Netherlands, research around vaccines has been a government-driven project, rather than a private industry responsibility. Corporations are disinclined to spend money on vaccines because they are not a moneymaker, and ostensibly (though increasingly less often in today's vaccine market) once one's customer gets vaccinated, he or she does not come back for another vaccine. (This is less true with vaccines such as the chickenpox vaccine, which appears to have waning immunity just in time for one to be at risk for shingles. There is now also a shingles vaccine, conveniently preserving or at least extending the market for the manufacturer's vaccine...Chickenpox is an example of an expansion of a market that seems unnecessary.) So the government requirement of insurers is a great way for pharma to insure their vaccines get funded. The U.S. is an important market for pharmaceutical companies and provides the incentive to develop vaccines, since companies can charge a lot for the vaccines here (as long as insurance companies will pay for them), making the vaccines more affordable in countries where there is less opportunity to make money, though often a greater need for the vaccines. There is also the Advanced Market Commitment (AMC) for certain vaccines, which has structured the pricing of vaccines so that countries that have a robust market can help subsidize certain vaccines (including the HPV vaccine) for countries that cannot easily afford the market price.

The new requirement poses an interesting conundrum with the HPV vaccine, as it's recommended for women but does not have recommendations for men, in spite of being FDA approved for men. In this instance, an FDA approval does not actually mean insurers will have to cover it. As has been the case with all sorts of attempts to require the HPV vaccine or to slot it into government regulation, the uncertainty about male vaccination pokes holes at the HPV vaccine's great promise, further revealing its status as a commodity instead of a necessary health intervention.

Moments of chagrin and remorse

I'm coming back. I miss writing. I miss thinking. I'm now misanthropic anthropologist, phd, and having grown weary of academia, I launched myself into the world of the private sector. It's been a month, and I mourn the loss of my old life all the time. I think I suffer from the grass-is-always-greener syndrome of being a malcontent. Paycheck=awesome. No free time and tedium=not awesome.

Lest my honed-skillz of writing atrophy while at a fairly unchallenging job, I think I need to re-visit this blog. I've been posting tons of links to facebook about sexual health and women's health developments, and I even got a piece published about the vaccine on a health-oriented website. But writing was so hard, and I realized I need to overcome this paralysis. And maybe need to figure out a long-term career that lets me be my curmudgeonly, cynical self, while impressing people with my insights. We'll see....for now, I'll enjoy the cash in the pocket, the student loans paid off, the ability to indulge in bourgeois bohemianism. And maybe it'll work itself out. At the very least, I'll finally have nice underwear and hot shoes.

The kicking and screaming recalcitrant anthropologist

In spite of silence, I have in fact been working on my dissertation. Much more slowly than I would like or thought possible.

I re-surface only to share this link, in which a well-known anthropologist, Jean Briggs, recounts her own ambivalences and challenges in becoming an "Anthropologist".

Reflections on my failure to post

I've mentioned this before, but I think it bears repeating. I am finding the blog format totally counter-productive to the development of real thoughts or writing the dissertation. The pithy short blurbs, hardly developed simply don't fit with the attempt to work on more extensive arguments. Sure, I could write page-long posts, but no one wants to read lengthily on the internet. I get impatient with long interviews that other blogs sometimes post, and it has all made me very wary of the effects of internet reading. It's like watching t.v., really. I know that there was a recent book that came out, asking whether the internet has made us stupid. I'm not arguing that we're stupid, but I do think our attention spans for reading have surely been affected. The counter-example is the ridiculously long New Yorker articles that often beat a topic to death, which is not necessarily preferable. It seems that a good piece of writing should also lead you to raise your own questions about the material, to be able to generate new directions to take the inquiry that the author has initiated. I guess blogs do this, but they also seem to encourage the sound-bite length information.

So besides the obvious fact that I am no longer actively doing fieldwork (I arrived in LA a year ago today), I'm also not eager to post my preliminary dissertation writing thoughts. I'm finding the internet is increasingly becoming less and less interesting to me. And the solipsism of posting on it has also lost its luster.

Re-framing my interpretations

I've been struggling, for the last few weeks, to re-frame my interpretation of my data. I am exceedingly comfortable being a critic. Why something is wrong or perverse, these are easy for me to point to, but explaining why something might have meaning or be positive, that's far more difficult. I need to integrate the positive into my own work, as the organizations I tried to work with were quite enthusiastic about the vaccine and its availability. All I could see were the flaws and limitations of the vaccine, making it uncomfortable for me to work with the groups who wanted to promote the vaccine. It does beg the question: why did I keep working with people who want to promote it? I suppose part of it is circumstantial -- there aren't clear-cut anti-vaccinators. They tend to be mixed in with the more general anti-vaccine people -- people with whom I did do work. Part of the issue is the way that the identifications with certain beliefs and practices do not hew along clear lines. In fact, that is one of the things I intend to write about, how this vaccine falls apart when you try to hold it along more traditional vaccination definitions and categories.

At a recent cancer survivor support meeting, held by one of the groups I tried to work with, I encountered a mother whose 19 year old daughter had been diagnosed with cervical cancer. It reminded me that this vaccine, though not directly beneficial to these women who were so enthusiastic about it, is not "all bad". It's just awfully hard to figure out how to imagine it as problematic. The best I can write is a lukewarm appraisal of how it is not the worst thing. Faint praise does not really seem compelling, and yet, it has meaning to some people, and I have not tapped into that sufficiently.

Incredibly bizarre

I've been avoiding reading blogs, not checked my google reader, and sort of blissfully checked out of the internet as much as is humanly possible (while still being lured back by facebook, damn them). I found a personal essay on Plan B, aka the "morning after pill," and was eager to read the personal account. I'm not entirely sure if I should recommend it -- as the author ultimately seems conflicted about her choices and believes that the conservative anti-Plan B opinion that its borderline similarity with abortion, "Here you actually have the potentiality for a pregnancy," is a logical position.

When conservatives try to avoid condemning hormonal birth control outright, they argue that it does not have the "potentiality" for pregnancy, which makes absolutely no sense at all. It would seem that by taking hormonal contraceptives, one is exposing oneself to much higher rates of "potentiality," even though the body is not physically capable of becoming pregnant (except when the hormonal contraception fails or the user fails to take it properly, neither of which is a condemnation of the user or the object, but simply a point to keep in mind). Hormonal contraception does in fact lead, I believe, to many acts of potential pregnancies (assuming one is taking it to contracept and not for other purposes)...maybe that can be my tagline, should I ever really finally work in sexual health research for real. "Hormonal contraception leads to acts of potential pregnancy." If everyone else can play fast and loose with semantics, I don't see why I shouldn't.

But...trying not to become a totally tangential poster, given that I post so rarely, I think the Plan B article is worth reading. If for no other reason than hearing someone's experience with acquiring it before it was available over the counter is pretty powerful. I find it odd that it's framed as a "fateful moment when she [the author] made the choice," but I am pleased that there is a firsthand account of the experience, which I've rarely read anything about. I think Plan B is still not available everywhere without a prescription. It's state-by-state, but I know that Planned Parenthood has a campaign to allow you to call them and get a doctor to prescribe it without an office visit. The difficulty in getting contraception (more generally) in this country is really damn disturbing and the ways in which access to it has gotten tied up in other aspects of gynecological care makes me crazy.

Letting go of larger aspirations

I've realized, as I write the grant proposals, re-hashing what I'm going to do, and as I start the outlining of the thesis itself, that I need to let go of the sense that I am having an impact on the world. A friend whom I haven't seen in a while told me about her research project. And while I found her work interesting and unusual, I wasn't sure...why it matters. I know there have been moments when I've realized that dissertations are about rites of passage, proof of diligence and dedication. But somehow, I get stuck in my work when I ask the question -- "who cares?" The fact that my dissertation topic has some applied, real-world relevance has been a source of pride. I think it has also been a form of arrogance, assuming that my work was more "real" than some of my peers' work. I simply need to prove that it matters to me, and that I've satisfied that criterion with rigorous research.

The problem with that, however, is that it makes it much harder to complete. If I know why it matters to me, why should I care what others think? I'm not sure if this is a defeatist attitude, a lazy attitude, or (again) an arrogant attitude. I need someone to tell me why I should bother.

I just can't stand it anymore

I have never catalogued how many versions of writing I have produced on my research topic. You would think that after writing grants and exams and half-assed papers on the subject, that I would have a clear and coherent way to convey my ideas. No. No, I continue to write in belabored circles. I know that there is a way into this that I can't quite find, yet. But time is pressing on me to figure that the fuck out. Seriously, I've been writing something about this at some point or another for almost 3 years. THREE YEARS.

I'm trying to pull together a grant that I sort of forgot was due on Monday. It's only for $3000, and yet, I need a) prestige and b) whatever dribs and drabs I can find. Especially since it's one of two grants for which I'm eligible. It's producing huge amounts of anxiety. I'm staying in on a Friday with the grand assumption that I will accomplish this statement of project in a coherent manner. I'm just not adept at sustained writing. I find it miserable and unpleasant. I was telling someone the other night that I prefer lectures -- I like the rough draft and no edits. I prefer the kamikaze approach to intellectual development. Throw oneself out of the plane and figure out if there's a parachute. Hence further evidence that I ought to be a pundit. I could do the on-the-spot talking points so damn well. Measured, diligent academic endeavors make me so unhappy. Besides, we live in a time of sound-bites. Why should I be methodical?

Outlining

I have created a plausible outline for the monstrosity. Obviously, it's a first stab at the thing. But I'm sort of excited that I am exploring shapes of the future. After meeting with 5 professors a couple of weeks ago, I'm finally finding time to sit down to think about what they said. 5 different ideas, 5 different approaches to the behemoth, 5 different attitudes about the whole process. I can't say that any of them were particularly revelatory. It seems the hard part is really up to me (which is not what I wanted to hear). The problem is that when it comes to the methodicalness, I'm damn lazy. I like the abstractions, but I have to confront that as an anthropologist, I'm expected to create a thingy that is grounded in people. I have been struggling with this problem a lot. I think my interpretations are very empirically-based, but I find the individuals' interpretations of the phenomenon a little boring. It just seems that what people (mis)understand only points to my main argument again and again. And as I've been trying to acknowledge lately is that the stuff I'm passionate about is not necessarily the concrete stuff I've been studying.

Circularity and circularness. And I get so distracted so easily. I currently have 2 other projects (both of which I feel ambivalent about my involvement, and yet which require me to complete them in some way or another), 2 grant proposals, and then all the personal projects that have nothing to do with academia, filthy lucre, or fantasies of renown. I really yearn for the mundane lately. Things that don't seem weighty. Or at least sort of weighty, yet not persuading me fully of their weightyness.

Too controversial

I haphazardly pulled together a syllabus yesterday during jury duty (after an intensive phase of napping while waiting for the judge to return to her courtroom...it's like I'm geriatric). My ex-advisor, whom I have no qualms about using when the moment suits to help me pull in grants, has been encouraging me to apply for a university teaching fellowship. While the money would be nice, being in Baltimore next year is not in the game plan. Yet I apparently suffer from a deep inability to resist potential income streams, even when they are not in my best interest. I figure I can always turn down the offer.

I presented to this ex-advisor the syllabus, and she immediately lighted upon the first sentence describing the central point of inquiry: most people in the U.S. spend more time in their lives contracepting than reproducing. She immediately told me that the first sentence was too political and would upset the committee. Basically, I was going to alert the old white men at the institution to my renegade intentions and freak them out. As she read through subsequent parts of the course description, she whittled away at all potentially "radical" concepts. She urged me to make this more of an overview of reproductive health anthropology, rather than my more interesting approach. I want to spend a lot of time showing how the focus on reproduction is naive, and that we need to integrate theories of sexuality and recognize sexual health more holistically in medical discourses. If she takes that away from it, it becomes an insanely boring class.

I know that her impulse was less about quashing me, and more about helping me to make a politic and compelling proposal, but this is exactly what I hate about the academic world. It is not really all that open to ideas, and certainly not at this university. I like to think that my more innovative stuff is what will make me a good instructor, but not if I can't engage with it. On the flipside, perhaps the lesson is that one needs to present a conformist front and then fuck shit up when you get the bodies in the class. Perhaps deviance is the answer.

David Simon comments further on "The Wire"

Really, I am going back to my work imminently. I thought this post-production reflection on the interpretation of "The Wire" in the US and the UK good to read. Simon acknowledges the limitations of the show (gender issues, immigration, etc), but he also points out why the stories they told were important to represent.

I received an email from someone who has lived most of his life in the Baltimore area (though grew up outside the city), and it disturbed me how pessimistic and critical he was of the state of the city. Ironically, there was a time when I offered similar critiques, and he vociferously defended the city. What upset me most about this person's critique was that it felt so hateful. My past critiques of Baltimore have always felt deeply emotional and sad, but this person just sounded bitter. In contrast, Simon does acknowledge that things in the city don't change, even as there are public claims to decreased crime and mayors become governors, but he also pushes the problem a little further and tries to unpack the complexity of the city's dynamic.

Unlike the email I received in which the final position was ultimately, "fuck Baltimore," Simon actually seems concerned with both the global and local challenges of Baltimore. What I found so compelling about the show was that as the seasons developed, it was clear that what happens in the streets branches back to those who live in the plush neighborhoods of Roland Park or Guilford. And I guess I see public health and public policies so often concentrating on the individual actors who are caught up in structural phenomena that are far more intricate than just "getting people off the streets".

Perhaps when I'm not thinking so chaotically, I'll write about this more, as it merits more discussion than a lazy nod to its link.

---
oh, but WTF, at the bottom of the page of the article, there's a slideshow of "Snoop" and "Marlo" modelling "cutting edge" fashion...um, not that (fictional) gangsters shouldn't be dapper, but there is something super-contradictory to have Simon's political economy critique coupled with high-end fashion and consumerism.

Proving everything worth thinking has already been thunk

I've cut back on my google reader reading. I've stopped keeping up with many of the academic blogs and the world of politics, etc, etc. But, I glanced at my feed for Savage Minds, which always explores critical topics in contemporary anthropology, and of course, they've provided a snippet of the same problem I discussed below, negotiating being a public anthropologist. I agree with the commentator, however, that their link to the Australian sex anthropologist might not be worth the click. Though maybe my suspicion of her work is just the uninteresting latent jealousy, though I don't think so.

Ethical quandries

One of the organizations I tried to do fieldwork with asked me to write a little blurb for the powerpoint presentation I did for them. As I started to write the blurb, and as I realized I was going to attend their annual conference to present the powerpoint materials, I was reminded of why my fieldwork didn't work out with them.

I wasn't able to do fieldwork with them because they kept wanting me to produce materials, and ultimately, I found that I didn't completely support their mission. They are very pro-vaccine, and they have explicitly acknowledged that there are compromises in getting their message out. Though they are not necessarily big pharma supporters, per se, they have accepted funding from the manufacturers of the vaccine. This uneasy alliance has been a major obstacle in my fieldwork, as I kept trying to dodge the inevitable overlap between the advocacy work and the corporate machine. Advocacy is a loaded term, as much shaped by corporate interests, government biases, and misinformation, as anything else. Health research and innovation in the U.S. are always messily entangled, and I don't know how well I've avoided being implicated. My work with the public health department, the CDC, and this nonprofit has put me in the position of supporting something that I have huge reservations about. As a researcher, participation has allowed me access to information and processes that I could only speculate about if I hadn't been involved. But how do I now sit down to write when I want to criticize the production of knowledge that I have also created. I am not immune from these very critiques (yes...bad pun).

So as I start to confront the monstrosity that is the dissertation, I also want to figure out how to make cogent arguments that don't make me feel like a huge hypocrite. The problem I've had with this project all along is that I seem to be an eternal relativist. Every position I try to stake out seems rife with contingencies. Everything seems to have a "yes, but..." component, and it exhausts me. Is this a form of insecurity? Or is this just a general uneasiness with commitment and claiming a position? My recommendations, when I dare formulate them, always come back to the concern with what precedes the vaccine -- what does not change, what remains the same, and how problematic all that earlier stuff is. It's as though I cut myself off before I can begin, but it also prevents me from moving forward. Strangely, however, the very argument I want to make is all about pre-emption and disruption. It's as though the very concept I'm trying to work out is haunting my thinking and writing. Or maybe it's just all a complicated distraction that I'm creating to avoid the daunting task.