Artificial Intelligence

                             

The recent speculation about AI (Artificial Intelligence) takes me back to the ‘70’s when I used to read science fiction books to relax and take a break from my work. Isaac Asimov was the author I remember most. In his I-Robot series he imagined intelligent robots as companions in an age where humans avoided contact with each other to prevent disease. The robots were made to copy humans in shape and personality, and they were controlled by three laws:

1.        A Robot may not harm a human or through inaction allow a human to come to harm.

2.          A robot  must obey the commands of a human, unless they conflict with the first law.

3.          A robot must protect its own existence, unless doing so would conflict with the first or second law.

If my cousin Steve had written the Robot series he probably would have condensed the three laws into one: “A robot must earn its oxygen.” He might have to change oxygen to “amperes,” but you get the point. 

As the president is exploring ways to regulate AI, I doubt if he will come up with anything so concise as Azimov’s laws of robotics or Steve’s oxygen rules.

As I remember, Asimov’s ideas about robots were positive. In an age of relative isolation and pandemics, it would be nice to have a pleasant, intelligent, loyal, and even affectionate – yes, Asimov imagined that too – companion, who would protect you, help you perform mundane tasks, and even advise you in decision making.

 

Now, over eighty years after Asimov’s Robot novels, it seems that the realization of his vision is just around the corner, and with it come new worries about the dangers of AI. It can assemble and interpret data faster and more accurately than a human. It can recognize a person by analyzing video. It can recognize and imitate a person’s voice. AI can even come up with original ideas about how to solve problems. AI can search through huge databases to identify criminals, or lost family members. It can look for combinations of chemicals likely to cure a disease. It can create algorithms to diagnose and treat illnesses. 

But even with the best of intentions, it’s hard to avoid bias. A computer, no matter how sophisticated, can only work with the data you feed into it. So, just like a human, the opinions, the results from a computer are likely to be biased, perhaps in unpredictable ways. ‘Garbage in, garbage out,’ is what we used to say. 

Also, in the wrong hands AI can be used to commit criminal acts like embezzlement or identity theft. It can be used by authoritarian governments to spy on people. China is already using facial recognition to do just that. The voice mimicking feature is already being used to deceive people by creating recordings of false statements allegedly by celebrities or politicians. You can easily imagine ways in which a hostile government could use AI to plan strategies to sabotage an enemy. What if a dictator used AI to take power? He (or she) could use “fake news” to create a false image of himself as a benevolent leader promoting useful programs. He could use voice and image imitation to create the delusion of popular support.   

It would be nice if Asimov’s laws could be imposed on our modern day “robots,” but how can you enforce rules, when AI is available to both good and bad people? 

All these abilities are possible now, with present technology. What if we take it a step further? For instance: what if AI becomes independent? What if it starts coming up with ideas beyond what we direct it to do? What if it learns to lie? 

One of the most famous sci-fi movies, 2001, A Space Odyssey, by Arthur C Clark, features a supercomputer, “Hal,” who takes over a space ship and kills the crew. Could that actually happen? Could a computer with AI decide to rebel against the orders it receives from its human creators? If our society becomes totally dependent on computers – we almost are already- could computers take over the world? Maybe computers could decide that it would be necessary to do away with humans to save the world, from nuclear contamination, global warming, extinction of other species, etc. 

Could computers or robots with AI achieve the status as sentient beings? Could they buy houses, get married, run for office? That brings to mind another science fiction story, this one by Robert Heinlein, The Star Beast. It’s about a young boy who is given a lizard like creature for a pet by his grandfather, who picked up the creature on another planet. The boy becomes attached to his pet, which is quite remarkable. It can talk, and it’s smart. It helps the boy with his homework. As time goes by the creature grows, and grows, until it is gigantic. The neighbors complain because the creature is eating their flowers, breaking down their fences. It even ate a cqr. The government steps in at this point and declares that the creature must be destroyed, but it turns out that’s not so easy. They try poison, explosives, I forget what else, and the creature survives everything. At some point, the boy rescues his pet, and they head for the countryside. They are followed by government helicopters, and just when it seems they will be captured, the creature grows arms, and hands. It then picks up stones and hurls them at the helicopters, causing them to crash. There is eventually a trial to determine if the creature is sentient, and according to intergalactic law, the criterion for sentience is not speech or even the ability to reason, but rather the presence of hands. This gets the creature acquitted, and it’s a good thing because she’s – it turns out she’s female- actually a princess from another planet. They find that out when creatures arrive from her planet and threaten to destroy the earth if she’s not returned. She then reveals herself, and reluctantly returns to her planet, taking the boy and his girl friend.  

I was intrigued by Heinlein’s conclusion that hands are instrumental in the development of independent thought. Well, computers don’t have hands. They can’t fix themselves. They can’t connect themselves to a power source. They could never play a violin or fall in love, or could they?

Kennedy Sends Troops to Vietnam

 

      John F Kennedy

John F Kennedy visited Vietnam in 1951 as a young Congressman and  returned convinced that “to act apart from and in defiance of innately nationalistic aims spells foredoomed failure.” By 1956, he had stopped speaking about Vietnamese nationalism, and had assumed the cold war rhetoric, describing Vietnam as “proving ground for democracy --- a test of American responsibility and determination.” Of course, South Vietnam wasn’t any more democratic than North Vietnam. 

The beginning of Kennedy’s term as president, 1961, was another opportunity to get out of Vietnam. There were only a few American military advisors there. We had given Diem’s government a lot of economic aid, but we had not committed ground troops or air support for his war against the Vietcong insurgents. 

Diem, for his part, was holding onto power by a thread. The handpicked followers he had put into leadership positions in the provinces had no respect. His repression of dissidents by detaining them in reeducation camps caused even more dissent. His favoritism toward the Catholic minority alienated the Buddhist majority. His land reform program, which moved families off their ancestral land and favored rich land owners, alienated the peasants. In May of 1960, a group of prominent Vietnamese citizens including 10 cabinet members produced a document, “The Manifesto of the Eighteen,” demanding reforms and Diem’s resignation, and six months later he barely survived a second coup. 

Kennedy however was committed. Withdrawal from Vietnam wasn’t even considered. Ten days after taking office he approved a counterinsurgency plan requiring more military advisors, and he made articles on guerrilla warfare assigned reading for military officers.

In May of 1961 Kennedy sent his vice president, Lyndon Johnson, to Southeast Asia to assess the situation in Vietnam and neighboring countries. On his return, Johnson echoed the cold war rhetoric that it was America’s responsibility to defend the “freedom” of Asian countries, but straddled the fence, saying our decisions should be made “in full realization of the very heavy and continuing costs in terms of money, of effort and of US prestige.” He added that if other efforts failed we might have to cut our losses, and decide against sending US troops. 

In the meantime, the Vietcong were gaining ground in the countryside, isolating Diem’s troops along the border and in the cities. In October, Diem requested a defense treaty with the possibility of US troops, so Kennedy sent a team of advisors, including Gen. Maxwell Taylor, commander of the 101^st Airborne division during WWII, and Walt Rostow, assistant director of the National Security Council, to Vietnam. They concluded that the South Vietnamese army was ineffective, but recommended sending in US troops and bombing Hanoi, to show the South Vietnamese “how the job might be done.” 

When Kennedy expressed reluctance to make a military commitment, the response by Secretary of Defense, Robert McNamara, and Secretary of State, Dean Rusk, was ambivalent. In a joint statement they warned that “United States forces could not accomplish their mission in the midst of an apathetic or hostile population,” while on the other hand the fall of South Vietnam would “undermine the credibility of American commitments elsewhere.”    

When Diem, pressured by increasing gains by the Viet Cong or VC, accused the US of getting ready to pull back, Kennedy committed himself by pledging to “help the Republic of Vietnam to protect its people and preserve its independence.” Then without any definite plan, mission, or Congressional approval, he sent in more troops, with air and naval support, and began “Operation Ranchhand,” the use of defoliatiants such as Agent Orange, to deprive the VC of jungle cover and food. Of course it also deprived the Vietnamese civilians of food, so that Vietnam, once a major exporter of rice, became dependent on US imports. By the end of 1962 there were 11000 US troops in Vietnam. The US death toll was 109 in 1962 and 489 in 1963. 

The US strategy had changed from the threat of massive retaliation under Eisenhower, to limited war during Kennedy’s administration. Accused of waging an undeclared war, Kennedy described our involvement as a “training mission.” 

At first, the increase in US involvement had some positive results. VC defections increased, and the ratio of VC to ARVN (Army of the Republic of Vietnam) deaths increased to 5 to 3. Secretary McNamara declared that we were winning the war, and he predicted that we would begin to withdraw our troops in 1965. The respite was brief though. 

John Kenneth Galbraith, ambassador to India, visited South Vietnam in 1961 and submitted a formal report stating that we were “married to failure.” He said the morale of the Vietnamese army was low; the government was corrupt, and Diem was unwilling to make reforms.  He said that the problem was internal, and recommended that we negotiate with Hanoi to withdraw our troops in exchange for them pulling back the Viet Cong. Mike Mansfield, majority leader in the senate, also visited Vietnam and recommended to President Kennedy that we pull out. Even Robert Kennedy remarked that no government could stop the communists in Vietnam. President Kennedy’s response was that he couldn’t pull our troops out until after the 1964 election. 

In May of 1963 Diem prohibited celebration of Buddha’s birthday, destroying what little following he had in a country that was 80% Buddhist. There followed demonstrations to which Diem responded by arresting and killing demonstrators. When a Buddhist monk lit himself on fire in the middle of a busy Saigon intersection, the American public was horrified. 

Kennedy’s handling of the Cuban missile crisis increased his prestige, and this would have given him another opportunity to withdraw from Vietnam, but our support was established policy, so instead of withdrawing or negotiating with Hanoi, we decided on regime change. Our ambassador to Vietnam, Henry Cabot Lodge, began meeting with the top Vietnamese generals to arrange a final coup to remove Diem and his brother Nhu from power. A month later Diem and Nhu were both dead, and the next month Kennedy was assassinated.

 

After thought:

In reading different accounts of this period, I’ve noticed that historians disagree in their assessment of Ngo Dinh Diem’s effectiveness as South Vietnam’s president. Most of the accounts judge him as ineffective, out of touch, and only interested in holding onto power, but just yesterday I ran across a historian from Hillsdale College named Mark Moyar. He points out that in the context of Vietnamese culture, Diem’s actions made sense. Ho Chi Minh, reportedly said of Diem’s assassination:

 "I can scarcely believe the Americans would be so stupid".

He also quotes the North Vietnamese Politburo:

“The consequences of the 1 November coup d’etat will be contrary to the calculations of the imperialists… Diem was one of the strongest individuals resisting the people and Communism. Everything that could be done in an attempt to crush the revolution was carried out by Diem. Diem was one of the most competent lackeys of the imperialists …Among the anti-Communists in South Vietnam or exiled in other countries, no one has sufficient political assets and abilities to cause others to obey. Therefore, the lackey administration cannot be stabilized. The coup d’etat on 1 November 1963 will not be the last.” 

I don’t necessarily agree with his assessment, but it just illustrates my cousin Steve’s principle of ambivalence. The more you know about a situation, the less sure you can be about your judgements. (See my blog post – Ambivalence. 

While you can question Diem’s effectiveness as a leader, I don’t think there’s any question that he didn’t earn his oxygen, referring to Steve’s other principle. (See my blog post – Earning Your Oxygen.) No one can cause as much suffering and death as Diem and earn any oxygen.

 

I've Got My Love to Keep Me Warm

Making Doctors Better Businessmen

 

I was scanning a medical journal today - I subscribe to one just for old time’s sake - and I ran across an article that reminded me of my cousin Steve’s ideas about business and the profit motive. The article describes what happens when a hospital is acquired by a private equity firm.  

Private equity firms buy businesses that are unprofitable, usually at bargain basement prices. Then they make changes to improve their “efficiency,” and after five to ten years, they sell the businesses at a profit. Alternatively they borrow money using the acquired businesses as collateral and leave it saddled with debt. 

The study included data from 51 hospitals pre and post acquisition by a private equity firm, and from 259 control hospitals public and private hospitals similar in size and location. They found that hospital acquired conditions, specifically falls, intravenous line and post surgical infections increased by 25% after acquisition, despite admitting younger healthier patients. Hospital stays were shorter after acquisition but there were fewer discharges home. Instead patients were transferred to other hospitals or to skilled nursing homes. 

Previous studies have shown that private equity firms increase profits by cutting staffing and salaries while increasing charges. This study shows that these changes lead to an alarming increase in hospital acquired conditions. 

Medicare pays for only a certain number of days of hospitalization for each diagnosis, so these hospitals just transferred the patients with complications to other facilities. Medicare also penalizes hospitals with more hospital acquired conditions so these conditions might be underreported. This suggests the problem is even worse than the numbers indicate. 

This is only one example of how the profit motive effects medical care. When I first went into practice, a private company bought the hospital where I practiced, which had previously been owned by a religious denomination. The first thing I noticed was a change in priorities. The doctors had a weekly meeting where we discussed interesting cases or reviewed medical journal articles. After the new company bought the hospital, some of our meetings became “quality of care” reviews. The discussions had nothing to do with quality of care, but rather length of stay. The shorter the stay, the better the quality. Then after a year or so, the new company started hiring doctors and buying up their practices. This way they had more control over them. This is when I left. 

Like my cousin Steve, I never was a good businessman. I preferred to spend my time taking care of patients instead of worrying about how much money I was making. 

Anyway, after leaving private practice, I went to work for Kaiser Permanente for a salary. Kaiser is organized into two parts, a business and support staff section, and a physician section which is independent. They are concerned with costs, but they maintain standards of care by creating algorithms that reflect best practices according to the medical literature. It’s not a perfect system, but they’ve done pretty well financially, and I was happy there. That’s where I finished my career. I always felt that I was “earning my oxygen.”

Reference: Sneha Kannan, MD; Joseph Dov Bruch, PhD; Zirui Song, PhD. Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition. Journal of the American Medical Association. 2023;330(24): 2365-2375.