Phil is upset by his inevitable death by car. You should be, too.

I saw Jim Gaffigan in concert last week. He made a series of jokes about how motorcyclists have chosen their preferred cause of death (he also made fun of spandex shorts on cyclists, which I’ll admit was fair).

But his talk about bikers’ inevitable deaths wasn’t half as tragicomic as Phil Gaimon’s soliloquy above. I ride a lot less than Phil, and even I’ve been hit hard enough to come off my bike three times. I’ve had more encounters close enough to feel the heat of the engine than I can count.

In spite of the negativity Phil and I are displaying here, the rate of cycling deaths relative to the number of people cycling is going down:

The dashed line stays steady because the number of cyclists on the road rises year-over-year. (Source: https://www.cdc.gov/MMWR/preview/mmwrhtml/mm6431a1.htm#Fig1)

It’s easy (but lazy) to turn this into a plea for more cyclists to wear helmets. Nope. Don’t get me wrong: I wear a helmet most of the time, and 100% of the time if I’m riding hard. But helmets alone do precious little to save commuting cyclists’ lives:

Source: https://i0.wp.com/usa.streetsblog.org/wp-content/uploads/sites/5/2016/06/Cj-L75WVEAADWl_-1.jpg

In fact, up-armoring cyclists to prevent deaths is an extremely questionable practice. Helmet laws kill cycling rates and bikeshare use. And it would be interpreted as absurd to expect walkers or joggers to wear helmets, even though car crashes and falls by elderly walkers collectively account for far more head and neck injuries than cycling:

Source: http://cdn3.vox-cdn.com/assets/4459545/Screen_Shot_2014-05-15_at_3.04.49_PM.png

What saves lives? Critical mass, laws, and protected bike lanes. Let’s get on it.

Links for Monday, October 15, 2018: Uber quantifies the curb, non-yelling coaches, criminal malpractice, and handlebar shapes

Uber—not a bus company—has proposed a formula for optimization of curb space that makes buses look pretty good:

(quoting directly from the article)

Activity/(Time x Space)

“Activity” is the number of passengers using the curb space by a specific mode, “time” is the duration of their usage, and “space” is the total amount of curb footage dedicated to that use.

Here’s the example that the consultants use in their report, where a 20-foot length of curb is used for four hours as a parking spot by a single car carrying two people:

2 passengers/(4 hours x 20 feet) = .025 passengers/hour-feet, or 0.5 passengers per hour per 20 feet of curb

But if that space is instead used as part of an 80-foot bus stop serving 100 people in that four-hour block, the equation looks like this:

100 passengers/(4 hours x 80 feet) = .3125 passengers/hour-feet, or 6.25 passengers served per hour per 20 feet of curb

Clearly, the bus stop is a better use of public space. And naturally, those Uber cars that don’t take up curb parking look good, too. No surprise there, considering the source.

John Gagliardi is dead, which means that the Nick Saban school of coaching just got a little stronger. That’s a tragedy

My antipathy toward football is cresting (just search for “football” in this site and you’ll see why). But who can argue with a philosophy like this one?

“Gagliardi essentially preached a philosophy of anti-coaching, one that prized self-reliance and self-motivation and abhorred cruelty and authoritarianism. These were not bullshit, repackaged, supposedly out-of-the-box ideas like you find coming out of Silicon Valley. Gagliardi’s philosophy was deeply HUMAN, and deeply trusting. It also happened to be highly effective, so much so that similar techniques are now widely used in parenting books, academic teaching, and other fields.”

One thing the best coaches I’ve had did well—in sports, medicine, music, or other—was to make me feel good about what I was doing. They made me feel good about the process of improvement, no matter my starting point in terms of skill. They essentially told me, “I know you’re a person who tries hard. Let me help you direct that effort in the way that will get the most out of your foundational ability.”

A Texas neurosurgeon was so bad at his job that he got life in prison

When I was a resident, a local doc prescribed so many narcotics to so many patients at such outrageous doses that admitting one of his patients was a near certainty on any overnight call shift. But what did the guy in wasn’t that he was committing malpractice on a daily basis; it was that he improperly supervised his wife as a mid-level provider, leading to money laundering and conspiracy convictions.

We in medicine do a bad job of policing our own. The surgeon who body-checked Dr. Death away from the operating table in Texas deserves major credit.

On a lighter note, What Bars? lets you compare the shape, drop/rise, and weight of a few dozen different handlebars

My remarks from the Wichita Business Coalition on Health Care's Obesity Forum this morning

Thanks for inviting me to kick off this very important event. Let’s start with a healthy dose of intellectual honesty. Obesity is a disease. It has arguably been so since the beginning of time, but it was made official in this country in 1985 when the National Institutes of Health issued a statement following its Consensus Development Conference on Obesity. This was followed by the report of the World Health Organization’s Consultation on Obesity and then the report of a committee of the Institute of Medicine, now known as the Health and Medicine Division of the National Academy of Sciences. Finally, the American Medical Association in 2013. Obesity is a disease because it is a “definite, morbid process with characteristic symptoms which affects the entire body; and has a known pathology and prognosis.” Obesity shouldn’t need this label in order to be taken seriously. Whether we--our institutions and organizations--pay for obesity treatment should ultimately depend more on what outcomes we value and the cost of achieving those outcomes. That is, the material inputs and outputs of the process, not our opinions of the people or behaviors that lead to them. A materialist versus spiritualist argument. I recently spoke at the Chronic Disease Alliance of Kansas meeting. Some of you were there. I made the argument that even if you are a spiritualist by nature, if you’re interested in medicine or public health, you must invest in a materialist point of view. That means you have to provide evidence for your assertions. How does this little philosophical cul-de-sac apply to obesity? Because I would argue that in spite of ample evidence and the label of disease applied by the NIH, the National Academy of Sciences, the AMA, and others, we don’t treat obesity in this country as a disease.

Think of what happens if you have, say, osteoarthritis of the knee. If you go to the doctor complaining of knee pain that fits the pattern of knee osteoarthritis, within some small confidence interval, you’ll get the same treatment regardless of what doctor you visit: x-rays to confirm the diagnosis, then some initial combination of anti-inflammatory drugs plus or minus strength training or physical therapy; then possibly an injection of hyaluronate or another agent; then a surgical procedure. All backed by some degree of clinical evidence as to their efficacy, with a set of professional guidelines that dictate the order and intensity in which they’re used.

And treatment for the disease--osteoarthritis still--is not limited to the clinical environment. We live under a robust set of laws, regulations, and expectations surrounding the humane treatment of people with osteoarthritis: handicapped parking stalls, construction standards around accessibility (curb cuts and whatnot). Furthermore, an enormous industry exists which caters to osteoarthritic people’s needs: handrails, higher toilets, special bathtubs, purpose-designed kitchen utensils, and others. For all its imperfections, this set of guidelines and expectations has the hallmarks of science: organization of knowledge, adaptability, the ability and willingness to change as evidence evolves.

But what happens if a patient goes to see his or her doctor for obesity? Even if the patient is lucky enough to encounter a doctor that considers obesity a disease and not a personal character failing, no such predictability exists. Doctor one may prescribes meal replacements, a la Nutrisystem, Weight Watchers, or dozens of competitors. Doctor two recommends avoiding “carbs.” (once called Atkins, now called paleo or ketogenic diet; it never goes away, we just change the name every ten years or so to convince people to avoid whole grains, the single most protective dietary component against diabetes) Doctor three prescribes phentermine, or if the patient is lucky, one of the drugs actually approved by the FDA for weight loss, all of which are exorbitantly expensive and modestly effective. Doctor four recommends the Diabetes Prevention Program. Doctor five recommends bariatric surgery. Doctor six recommends probiotics or another microbiome-directed treatment.

When the patient leaves the doctors office, she enters a built environment designed to be maximally obesogenic. Four-lane arterial roads replacing walkable, bikeable streets, even though we know beyond certainty that trips taken by car, rather than by bike, foot, or public transportation, are perfectly, directly related to the obesity rate in any community. And the amount of money any community spends on car-related transportation is perfectly aligned with obesity rates. Our patient pays sales taxes on obesogenic foods (red meat, refined carbohydrates, sugared beverages, and fats) at exactly the same rate as protective, high-fiber, unprocessed fruits, vegetables, and whole grains, in spite of evidence that Pigovian taxation, in which unhealthy foods are taxed at a rate equal to their the social cost and healthy foods are subsidized, has a powerful effect. Similarly, crop insurance and subsidy programs--in whatever form they take--favor meat and dairy production over fruits and vegetables.

When a peer gets cancer, we offer words of encouragement and give her rides to the doctor. We judge those with obesity and say they’re getting what they deserve for their weakness and sloth. We consider people who are competent, functioning members of society to be somehow constitutionally flawed and subject them to various levels of social discrimination. Obesity, along with intelligence, seems to be one of the final acceptable targets of discrimination; we casually make jokes about fat people and stupid people with none of the anxiety that accompanies insensitive remarks about race or sexual orientation. This is surely short-lived; over 80 million people in the U.S. have an I.Q. less than 90, and over 100 million are obese by body mass index criteria. These are groups large enough to fight back.

Viewed by an outsider, this set of circumstances does not resemble science. This is not the end result of a materialist view of the world. It resembles religion: a cultural system of competing behaviors, world views, and ethics that relate humanity’s problems not to the laws of the universe, but to supernatural elements. This elevation of the spiritual realm above the material realm is perfectly fine on Sunday mornings. I’m not here to make an anti-religion argument. Religion and spiritualism are vital in mobilizing public passion and opinion. NIH director Francis Collins, who discovered the gene mutation responsible for cystic fibrosis and later directed the Human Genome Project, is an evangelical Christian who advocates that religious belief can not only be reconciled with acceptance of scientific evidence, but that spirituality is vital to the responsible advancement of science. But spiritual thought in the absence of material evidence is unacceptable in the pursuit of a public health solution.

So how should we handle obesity as a health problem? As Kansans, we’re lucky to have perhaps the best model in our collective memories. We have Samuel Crumbine, early 20th century Dodge City physician who revolutionized the treatment of tuberculosis and other infectious diseases. At the outset of Dr. Crumbine’s career, infections were the leading cause of death by far and were dealt with in a quasi-spiritual manner. The consumption of tuberculosis was seen as God’s wrath. But Dr. Crumbine applied common sense strategies to limit the spread of the disease. He helped established sanitaria for tuberculosis patients, to isolate them from the public until they were no longer contagious. He spearheaded laws against spitting on the sidewalk (remember the bricks?), against shared drinking cups (you have him, indirectly, to thank for the modern bubbler-style drinking fountain), and against shared towels in public bathrooms. He advocated for fly-swatting campaigns. And all the while, he still promoted medical interventions for people already infected. Better antibiotics were developed. The entire specialty of cardiothoracic surgery grew not out of a need for coronary artery bypass grafting, but out of the need to drain tuberculous abscesses from the chests of infected patients.

When applied to obesity, I’m aware that lines blur. Calling something a disease moves individuals across a gauzy barrier between personhood and patienthood. You’re a person up until you’re labeled with a disease, then you’re a patient. The label inherently causes the patient to adopt a role in which he or she is excused from responsibility for his/her condition. This is healthy and appropriate; we know that the vast majority of lung cancers are caused by cigarette smoking, but we do not argue that smokers should be denied treatment. And the label creates an obligation for treatment that many obese people may not want. Roxane Gay and others have argued eloquently against the over-medicalization of body weight. And if this process (labeling of a disease, applying that label to people) entails an obligation for treatment, who will consent to pay the costs for that treatment? This social negotiation is just as big a part of what we need to address as any specific decision on the appropriateness or order of interventions.

I’m no Samuel Crumbine. I don’t even have a mustache. But if I channel Dr. Crumbine, I can see continued progress starting today. I can see the further development of a bike and pedestrian infrastructure, sensible parking policies, and street design that encourages higher density development with widely available green spaces. This can be partnered with local laws and regulations, a more sensible crop subsidy program, and a food tax system that encourages the production and consumption of quality foods over obesogenic foods. For patients who choose to seek help from their doctor, I can see a set of community-wide standards that promote a practical, stepwise approach to treatment that incorporates dietary and behavioral interventions alongside policies that make proven drug and surgical interventions more affordable. I can advocate for the development of a unified, science-based approach to obesity, motivated by spirituality but guided by material evidence.

Disclaimer: Health ICT was also a presenter, and the Forum was supported through a grant offered by the National Alliance of Healthcare Purchaser Coalitions and Novo Nordisk.

Competent, compassionate, obsessives > whiz kids

On my morning bike ride today I rode up on a chunk of concrete that had fallen off an overpass onto the bike path. Somehow I've lost the picture of it, but no matter. I used WichitaReport to report it, and that got me thinking: the app is great, but simple. So much of what we get out of government is accomplished by compassionate, competent, experienced people--not stereotypical "whiz kids"--who obsess over solving difficult problems. Their work proceeds in spite of who leadership is (though the current EPA may be an exception). The result is that life gets better for the rest of us.

And then I saw this article on Kottke.org. 

Relevant quote: "When innovation does occur in city and state government, it looks small, boring, like the parts of life you don’t really want to think about. In some cases it doesn’t even look like innovation."

I don't think it ends at government. In medicine, the care that ultimately saves the most lives is routine (some would say boring) care delivered in anonymous health departments and clinics: immunizations, blood pressure control, diabetes screenings, eye examinations, and others. It's easy to do all these things poorly and astonishingly hard to do them well. But those of us who are lucky get the care of obsessive, compassionate nurses, doctors, pharmacists, and others who pay attention to details and competently treat around all the obstacles that come between us and good care.

This observation is so powerful that people have (rightly) started to think that we should put values other than raw intelligence, like emotional intelligence, at the top of our list of qualifications for medical school. It's worth a thought.

I'm changing the way I talk about walking

I spend a lot of time trying to convince people to be more physically active. I spend time on top of that trying to convince people that we should change the built environment, parking policies, and traffic laws to allow people to be more physically active.

One of my old standby stories is of a person who's spent most of his life sitting on the couch watching TV. He goes in for a routine operation, has a catastrophic adverse event, and ends up paralyzed as a result. When he wakes up the surgeon and the anesthesiologist gather to tell him the bad news. The first question out of this man's mouth, a man who has not walked further than from the bed to the bathroom, the bathroom to the kitchen, the kitchen to the sofa, or the car to his office cubicle in years, is this: "When will I walk again?"

I've even posted the story here from time to time. 

My point with the story has always been to get people to approach the world from a perspective of abundance. Don't take for granted the gifts you have today. Our bodies were designed by millions of years of evolution to move bipedally. If we forsake that, we end up less healthy and less happy. 

But yesterday I listened to Enter the Exos, a new-ish episode in Rose Eveleth's always thoughtful series Flash Forward. 

In the episode, Rose spends a predictable amount of time talking about the possibility that robotic exoskeletons, or even powered clothing, will make us faster, stronger, and less prone to injury:

I'm talking about the one on the left.

But she spends an even greater amount of time talking with people with various disabilities about their perception of exoskeletons. This is the part that got me. William Peace, blogger of Bad Cripple, has this to say: 

Your typical bipedal person exposed to a barrage of misleading news stories is led to believe all paralyzed people share one goal in life--walking. Please cue the soaring inspirational music accompanied by the brave and noble young man or woman struggling to walk surrounded by health care professionals, computer scientists, and engineers who share the same ritualized ideal. 

There is so much to unpack there. I walk, and I like doing it, so I've always thought that other people without the ability would want it. And maybe they would, if the technology were developed that could be applied to people with all kinds of disabilities (cerebral palsy is a lot different than spinal cord injury is a lot different than post-polio, etc). But bipeds like me have a hard time imagining that someone wouldn't want to get closer to the way I move, just like people with normal hearing are mystified by deaf culture. When I put myself in the position of someone who is in a wheelchair or needs another assistive device, I can see and hear the condescension in my words.

So I'm changing my pitch. I'm going to lean more on the "move through space" message and delete the "walking" part. I plan to work harder on the infrastructure message, with curb cuts and tactile crosswalks and protected walking lanes and a hundred other easy fixes that make life better not only for differently abled people, but for people who can walk and bike without difficulty like me.

And I'm going back to my perspective of abundance: we don't have functioning exoskeletons or other sexy fixes for paralysis or weakness yet, but we're all cyborgs already. Most of us carry a device in our pocket that literally has the world's knowledge at our fingertips. We should harness that technology to find safer routes for human-powered transportation of all kinds. And people who can't walk have a 235 year history of constantly improving wheelchair technology whose potential could be unleashed with a little more attention paid to the way we design our environment and laws.

I tried Jump Bikes. Now I think e-bikes may be the future of commuting.

I'd never been on an e-bike before I went to Washington, D.C., last week. I've seen a lot of them. I thought they looked goofy: the giant downtube, or the giant hub on the wheel providing power:

electricbike.com

And I'm consistently annoyed by the gas-powered "Whizzer" style bikes that people ride on the bike paths in Wichita, blowing blue smoke and making noise.

ebay.com

So I was a skeptic. E-bikes seemed lazy and ugly. They seemed to fill a niche that didn't really exist: why not just buy a moped or scooter? But just before I left for D.C. I saw reports that Uber, the beleaguered ride share company, had bought Jump, a dockless e-bike share company that is only in a few markets (D.C., San Jose, and San Francisco). Uber riders have been able to book JUMP bikes via the Uber app since January 2018. For the time being, JUMP’s app will continue to exist, but I suspect they'll eventually be completely integrated into the Uber app. When I got off the train to my hotel, sure enough, I saw one. The bikes are aesthetically pleasing, with their little aerodynamic basket in front: 

The Jump is on the other side of the fat (phat?) downtube. 

Dockless bike shares are controversial among a certain set of people, who complain about the possiblity of "abandoned" bikes littering cities. This has naturally and appropriately drawn sarcastic scorn from critics of car culture, who point out that cars themselves are mostly "dockless":

Uber's motivation for buying up Jump was apparently that a big fraction of Uber's trips are very short (maybe under 3 miles). And since the demographic that would tend to use the bikes is at smartphone saturation (for better or for worse), it makes sense for Uber to try to divert those rides to e-bikes, where the company wouldn't have to divert 80% of revenue toward drivers (because the "driver" of the e-bike is you, and you're paying for it. Get it?).

So, needing to entertain myself for a couple hours, I tried one. Step one was to download the app, just like Zagster and a million other such companies. 

Obviously, I tried a few other sharing services while I was there, too. All those apps on my phone? That's not even all of them I could have put on there. I know I missed D.C. Insider, Ofo, Mobike, and Capital Bikeshare (I used Capital Bikeshare, but you don't need the app to do it). There may have been others. D.C. is to bike/scooter share what the Idaho panhandle was to anti-government militias in the '90s. 

Ofo trying to capture the Blind Melon revivalist market.

And that's not even counting the scooters.

Once the app was downloaded, I got an account number emailed to me, and I chose a PIN. The same email warned me to "start slowly to get familiar with its boost." 

I scoffed. Please. I've ridden a million bikes. I've ridden almost as many motorcycles. I know power.

Next was checking out the bike. The app tells you that you can either walk up to a bike and check it out, or reserve one through the app. No need in my case, since I was standing by the bike. But in case I couldn't find a bike right away, I could have held one for up to 20 minutes ahead of time, with the knowledge that the clock would start ticking once the reservation was made (if I didn't make it to the bike in time, the reservation would cancel automatically).

Next, I needed to actually rent the bike. I was instructed to enter my account number and PIN using the keypad on the back of the bike, then to remove the U-lock and slip it into the two holster loops on the left:

This is actually from the end of the ride, since I was too big a bonehead to remember to photo it up front. FYI: The solar panel only powers the electronics.

Then I was to adjust the seat height to one that works best for you. This was a little complicated because, as a #bikesharerenegade who often lets his kids ride bike shares with him, I needed to adjust the seat several times for my kids and me. I was not reassured that Jump bikes use the same janky, slippy clamp and post as virtually every other bike share:

Then: "Test your brakes. And get ready for the smiles." Oh, I was ready:

That goofy smile is system-delivered. Tan lines are an upgrade. 

The jump bikes have a threaded bottom bracket. Yay! 

A spring keeps the front wheel from flopping around.

We headed for the proving ground, Rock Creek Park:

This is from the bottom of the park, looking up north and east.

That gentle upslope you see is no joke. It's actually a pretty legit climb, a little over a quarter mile at a near-seven percent grade. It would easily qualify as the biggest hill in Wichita were you to transport it 1500 miles west: 

We coasted down the hill without really even pedaling, then turned back uphill. And wow. When you step on the pedals, the bike really jumps. I immediately regretted my initial scoffiness. It was legit, even a little unnerving the first time. When my daughter did it, she couldn't help but laugh with delight at the acceleration. That same eleven year-old daughter of average athleticism absolutely hammered this hill on the Jump Bike. I should have timed her, because I legitimately think she would have been in Queen of the Mountain range, thanks to the e-bike boost. My friendly neighborhood wattage calculator, assuming 75 watts from my daughter, gives me this (the Jump Bikes generate 250 watts, according to WikiPedia):

The bikes have three speeds, courtesy of Sturmey-Archer:

But honestly, you don't need the bottom two unless you want to climb Quintana-style. Even a modestly fit rider can crush hills on this thing.

The bike was cheap: $2 to rent, which buys 30 minutes, or 11 miles at 250 watts:

That's enough to get me halfway across Wichita. If you go over 30 minutes, you're $0.07/minute for additional use. If you run out of pedal assist power, you can note that when you end the rental and Jump will "take care of it from there," which I assume means swap out the battery. If you leave the service area of the bikes, you're warned that you might get charged a fee for retrieval. This is dirt cheap; about half what it costs over time to ride a scooter share (yep, they have those in DC too). This leads me to my final point on e-bikes, and potentially e-bike shares: they're the future. They're the future because they're so democratic. They're cheap, and almost anyone with even rudimentary bike skills and basic fitness can ride one. My mom is in her seventies and has not been on a bike since her teens, I suspect. But she could easily pedal an e-bike 20 miles in an hour or so. And if she couldn't, it probably wouldn't be because of leg, lung, or heart fatigue. It would be a matter of regaining some basic bike handling skills and butt toughness. 

A full charge gets you about 30 miles of range, just slightly below what my Chevy Volt gets on a charge. I drive said Chevy Volt because I can travel the vast majority of miles I travel under electric power. The reason I drive a Volt instead of, say, a Nissan Leaf is because I like the insurance policy of a gas engine behind the electric battery. If I go beyond the 40-ish miles the battery gives me I can get another 240 miles from the gas engine. The beauty of e-bikes is that I’m that insurance policy. If the battery quits, there’s a couple hundred watts of human power on the pedals to get me home. 

The advantage of the "e" in e-bikes is mostly sweat. Or lack thereof. Jump bikes make me think a future garage may have not two cars, but a car and an e-bike. The e-bike will be adjustable so that the bike can be used by multiple members of the family:

The lovely and talented Tracy Williams, MD.

The bike could be shared like the car was. But the cost of owning the bike would be essentially zero compared to the cost of a fancy gas-powered wheelchair. And you can criticize the decreased work of riding an e-bike versus an unmotorized bike, but riding an e-bike is still a helluva lot more exercise than piloting a gas-powered wheelchair. And it gets you out to interact with humanity in a non-fist-shaking, non-furious way. Ever see somebody on an e-bike with road rage? Me neither. It goes fast enough, relatively sweat-free, to get you places in a reasonable amount of time, but not so fast that it turns you into a raving lunatic at every 20-second delay for a crosswalk or light. 

At the end of our test session, we locked the bike back to a rack:

Biggest criticism? That U-lock is tough to get in place if the space is tight. You have to wrassle a really heavy bike around to get the tines on the lock to line up with the holes through the frame and wheel. It's tough. A much better design would be like Zagster's here in Wichita:

I don't think security would be an issue, since 1) the bikes are tanks, and 2) they're tracked with GPS. The Jump bike automatically ends your ride when the lock is put in place, though, which is nice. To incentivize people to put the bikes back where they'll be easy use (and presumably easy for the Jump folks to pick up and charge), they offer $1 credit for returning any bike parked outside of a virtual fenced-in "hub" back to a hub. Try as I might, I cannot find a map for these. 

Updated 5/14/18 with a picture of the Sturmey-Archer shifter.

"Every parking space is a wasted $30,000"

I have a low-grade smoldering obsession with parking right now. Blame it on strongtowns.org. It drives me crazy that when you look at a google image of my hometown, the parking takes up more space than the buildings themselves:

Acres of empty lots for temporarily abandoned cars in downtown (downtown!) Wichita.

The tax revenue from that parking? Zero, basically. The revenue from paid parking? I can't find the number, but I know it is low, because most of the spaces don't have a meter, and the ones that do have a meter tend to be 1950s models that only take quarters.

Anyway, I've fallen into a YouTube rabbit hole recently around parking. Other noteworthy bullets from the brief video above from Jeff Tumlin:

• For a single family, getting rid of one car = affording an additional $100,000 in mortgage
• Parking "search traffic" accounts for 8-74% of downtown traffic
• All parking meters need to accept forms of payment that people actually carry. Most of us don't carry change anymore
• The "right" price for parking is the lowest price that achieves about a 15% availability target

If you're really into this, and want to hear some health-related data, and you have an hour to spare, wade into this:

Strava's global exercise heatmap is addictive

Take a good long look at Strava's global exercise heatmap

Just here in Wichita, there are so many hidden little gems. I'm not much of a runner anymore, but love the 400 meter tracks:

That's the Friends University track near the center. To the left is the Mayberry Middle School track. 

At Wichita State University's Cessna Stadium, you can make out lines going up and down the bleachers, especially on the west (left) side. 

And the trails along the river are well-represented, no doubt thanks in part to BikeShareICT:

As are the mountain bike trails at Miller's Meadow (RIP):

And Air Capital Memorial Park: 

For giggles, I found my childhood home in western Kansas. I'm not the only person who's recorded activity there, but I'm one of few. This isn't a surprise considering how few people live there:

Links for Thursday, November 2, 2017: Why Amsterdam works for bikes, dirty mustaches, dockless bike sharing, weird fertility quotes, and menstrual synchrony

Norman Garrick, author of one of my favorite papers on the built environment's effect on health, on why Amsterdam is so good for bikes:

1. All streets are bike streets

2. Separated cycle tracks, not bike lanes

3. When possible, go completely car free

4. Two speeds, both slow

5. Stress-free intersections

That favorite paper? Right here: Community design, street networks, and public health

“A French scientist caused a sensation in 1907 when he recounted an experiment showing that the lips of a woman kissed by a mustached man were polluted with tuberculosis and diphtheria bacteria as well as food particles and a hair from a spider’s leg.”

Is dockless bike sharing the next Uber?

FWIW, I hate the "Uber for ...." thing. But I'm told that it's interesting shorthand for investors. The part of this article I'm fascinated by is the "dockless" part. To my reading, dockless bike stations eliminate so many of the traditional obstacles of traditional bike shares. Less permitting, less infrastructure, less up front expense. I even wonder if they're the way that small- to medium-sized towns get into the bike share game. But you can't just ignore the city governments:

'Technically the dockless companies can enter a market without asking permission. They only need to leave some bikes around the city, and anyone with the app can start riding. But since bikes are portable and can be left anywhere, they’re vulnerable. An unhappy city regulator could round them up and haul them away at any time. “[This is] ask permission, not forgiveness,” Jordan says, reversing a popular Silicon Valley mantra. “It’s not like Lyft, where the cars are moving around, or Airbnb, where you don’t publish the address.”'

The fertility business is booming, especially on the sperm donor side

Up front: I'm totally, 100% on board with whatever fertility treatments people need to receive in order to reproduce. But there are soooo many weird quotes in this:

"Want your sperm donor to have a B.A. in political science? Want your egg donor to love animals? Want the genes of a Division I athlete? All of these are possible. Prospective parents overwhelmed by all the choices can leave it to the heavens and pick a donor by astrological sign."

and:

'The Seattle Sperm Bank categorizes its donors into three popular categories: “top athletes,” “physicians, dentists and medical residents,” and “musicians.”'

But some of the quotes from donors are heartbreakingly sweet:

'The donor said she was a “homebody” who loves taking pictures and being with family on the beach. Her personal goals, she wrote, include being “the best possible mom I can be for my children. I want to be ‘present’ when I am with them and invest into their lives. . . . I want my life to matter.”'

Here is the original Nature paper describing the synchronization of women's menstrual cycles

 

Links for Thursday, October 26, 2017: walkability and city growth, eating alone is bad for you, BMX is back, and diet avocados

Is wichita's poor walkability holding it back economically?

From the Chung Report: 

Our respondents believed Wichita is fairly inaccessible on foot, with 77.4 percent saying they either disagreed or strongly disagreed to the idea that Wichita is walkable. This means this aspect of Wichita likely won't attract millennials over other cities that are more progressive when it comes to transportation. And our peers do seem to be more progressive.

WalkScore.com, a website that determines walkability and bikeability for U.S. cities, calls Wichita a "car-dependent city," which means most errands require a car. Cities with scores of 70 to 89 are considered very walkable while scores of 90 to 100 are a "walker's paradise." Wichita scored a 35 on walkability and a 44 on bike infrastructure, meaning the city has minimal bike infrastructure. This same site gave Des Moines and Omaha walk scores of 45 and Cleveland a walk score of 60.

These trends aren't going unnoticed. Advocacy groups like Bike Walk Wichita (disclosure: I'm on the board) have made tremendous progress in getting more attention paid to walkability and bikeability over the last decade (including a bike share and dozens of miles of new bike lanes and paths). But clearly there is work to be done. 

Eating alone may increase your risk of metabolic syndrome

Metabolic syndrome, FYI, is a catch-all term for people at risk of developing diabetes and heart disease. It's a constellation of extra weight around your waist, higher-than-normal blood sugars, abnormal triglyceride levels in the blood, and higher-than-normal blood pressures. A few observations about this study: we've known for a while that being alone in general is bad for you. Like, 30% increased risk of dying on any given day bad. So it's not a surprise that eating alone is associated with risk. But is it any different than being alone in general? I don't think the authors make that case. 

Individuals who ate alone 2 or more times per day in their dataset were more likely to live alone, were more likely to be unmarried, and were more likely to skip meals. Interestingly, alone eaters ate out less, which is generally considered a good behavior. Women who ate alone ≥2 times per day were 29% more likely to have metabolic syndrome than women who didn't eat alone. But once they accounted for other factors, like XXXXX, the assocation went away, statistically-speaking. Eating alone two or more times a day was associated with a 45% increased risk for abdominal obesity and a 64% increase for metabolic syndrome in men. This was especially true in men without spouse. The men without a spouse were 300% more likely to have metabolic syndrome, while married men were only 48% more likely to have metabolic syndrome.

BMX is "back"

(it never left) Link posted here because I like the video. 

Someone created "diet" avocados and I just want to die

My disgust with this isn't related to the specter of GMOs or hybrid crops. I'm actually generally in favor of both (see the Hawaiian papaya story to understand why). I just find the idea of taking a food that is perfectly good for you in its native state and monkeying with it to make it "diet" depressing. Avocados aren't a wonder food, and their trendiness will eventually fade. But they're fine the way they are. Their high fat content has never hurt anyone, and it might even make you feel full longer. So for heaven's sake. Eat a normal avocado. Don't fall for this. 

Links for Friday, October 6, 2017: no thyroid testing in obese kids, where "blade runner" came from, Uber and drunk driving, and blazing fast Citi bikes

Don't test the thyroids of generic obese children, says Choosing Wisely

The endocrine section American Academy of Pediatrics has listed its five "Choosing Wisely" tests to avoid. TSH levels in obese kids is one of them. I completely, completely agree. But telling a mom or dad that is equivalent to malpractice in their eyes. It really illustrates one of the central problems with the way we practice medicine: order the test, make mom happy, keep the family as patients, but cost the system some extra money that could be better spent on something else. Refuse the test and you make mom unhappy (sometimes very unhappy), you lose the family as patients, and the family simply goes somewhere else with a provider that will comply with their wishes. Sure, you can have a prolonged conversation with the family about why you're not doing it, but the cost of physician time exceeds the cost of the lab test pretty quickly. Whew. OK. Rant concluded. 

The title of "Blade Runner" comes from an obscure physician-penned novel about a future dystopian society that has eugenics as the core of its national healthcare strategy.

It follows the adventures of a young man known as Billy Gimp and his partner in crime, Doc, as they navigate a health-care dystopia. It’s the near future, and eugenics has become a guiding American philosophy. Universal health care has been enacted, but in order to cull the herd of the weak, the “Health Control laws”—enforced by the office of a draconian “Secretary of Health Control”—dictate that anyone who wants medical care must undergo sterilization first. As a result, a system of black-market health care has emerged in which suppliers obtain medical equipment, doctors use it to illegally heal those who don’t want to be sterilized, and there are people who covertly transport the equipment to the doctors. Since that equipment often includes scalpels and other instruments of incision, the transporters are known as “bladerunners.” Et voilà, the origin of a term that went on to change sci-fi.

The name Blade Runner actually came not from the story itself, but from the title of a nearly incomprehensible adaptation by William S. Burroughs, The Blade Runner: a Movie.

Uber's effect on drunk driving is disappointingly inconsistent

The team delved into whether ride-hailing affected crash rates in four cities: Las Vegas, Portland, Ore., Reno, Nev., and San Antonio, Texas — American cities in which Uber, the nation's largest ride-sharing company, launched, ceased, then resumed operations. And the results were mixed. Crashes involving alcohol decreased as Uber resumed services in Portland and San Antonio, but not Reno. And in no case did Uber's resumption of service result in fewer total injury crashes or serious crashes overall.

It's easy to look at this kind of story and be really, really disappointed. But I think it's just further proof that changing human behavior is complex. It is not a matter of greater knowledge = better decisions. If it were, the smoking rate and the rate of texting while driving would both be nearly zero. I'm optimistic for ride sharing and autonomous vehicles' role in reducing drunk driving deaths. 

Citi bikes have so penetrated New York City that over 50% of peak-hour taxi trips would be faster if taken by Citi bike. 

See graphic above. No word on how the bikes compare to ride sharing, though. This statistic kills me. But then again, I'm from the least congested city in America.

Circling the parking lot = circling the drain

A couple weeks ago, I spent some time in a YMCA parking lot to do the Wichita Area Metropolitan Planning Organization's bike/pedestrian count. I was in a pretty rural area, and the bike/ped traffic was light. It gave me a chance to watch the steady stream of cars in and out of the lot, though. The Y was rocking, which made me happy, but I couldn't help but wonder about the goals of the people in the cars screeching in and out of the driveway.

A woman who worked in the office of a YMCA recently told me that one of the biggest safety issues the organization deals with is parking lot safety for pedestrians. So many people circle the parking lot in their fancy gas-powered wheelchairs during busy times that pedestrians crossing the lot were in danger of being run over.

This is not the kind of wheelchair I'm talking about. I might respect someone who circled the health club parking lot in this rig. By the way, there was a third dog riding on the scooter. Respect. This must have been a logistical nightmare to get out the door. 

She was talking about people circling the lot, mind you, so that they could walk the minimum distance to get into the building and walk...on a treadmill. Or ride a stationary bike or something. 

This problem is a bit of a throwback for me. I remember as a kid, when the remote controls for TVs were still mostly up-and-down affairs (hit the up arrow to scroll upward through channels, hit the down arrow to go the other way; ditto volume), I would, out of habit, walk all over the room looking for the remote so I could change the channel on the TV. I would walk multiples of the distance it would have taken me to simply get off the couch and walk to the TV and push a button. But like the Kodak people who couldn't imagine a world without film, I couldn't imagine a world without the satisfying weight of that remote, with its sleek aluminum Sony case, in my hand. 

Is there a name for this particular brand of self-defeating convenience? I've stretched Google's abilities to the limit and I can't identify one. But it clearly pre-dates modern technology. And don't get me wrong. I've ridden, and continue to ride, an absurd number of miles in cars. But I've felt like an asshole for almost all of those miles that didn't involve traveling outside of town. 

But back to parking. Scott Wadle of the City of WIchita likes to say that there's no such thing as free parking. While he means that we all subsidize the space that cars take up whether we mean to or not, I think of it in more cosmic terms. All that space could be used for something else. And the physical activity it would take us to park in vertical garages and walk to our destination, or the slightly greater physical activity it would take for us to bike to work would be a small price to pay to get green space and health back. An optimist's view of the coming autonomous fancy gas-powered wheelchairs is that we'll need far less parking, thus opening up more and more space for commerce and for public use. A pessimist's view is that we'll eventually transition to a WALL-E situation in which your autonomous gas-powered wheelchair picks you up at your door to deposit you in front of the door to your office, at which point a smaller, more Segway-inspired motorized device takes you to your desk. Where you sit. All day. 

I'm not going to talk about "productivity" or "optimization" here. There are plenty of places to get a dose of that perspective. But just consider this when it comes to the YMCA or your local health club: grinding away on a treadmill for 30 minutes a day after driving an oversize luxury wheelchair to the building is not my idea of freedom. It's a chore. But if I turn that chore into the choice to walk or ride by the health club while I watch all the wheelchair circle: that choice makes me unspeakably happy.

Links for September 18, 2017: American sperm, movement is life, neighborhoods and vascular disease risk, and Taiwanese fruit ghosts

Canada needs our sperm. America!

Background: It is illegal to pay for sperm donations in America's hat. 

"What Canada should do is legalize compensation for renewable bodily fluids in our own country. It would be the morally right thing to do. It would help make and save more lives, without harming anybody.

Until we realize our mistake, we need you Americans to keep rolling up your sleeves and unzipping your pants not just for the sake of lucre, but also for the sake of the thousands of current and future Canadians whose lives depend on you."

The more you move, the longer you live.

Bottom line up front (BLUF): Over 4.0 years of accelerometer use, total sedentary time was associated with an increased risk of dying. Not only that, but the longer the usual sedentary bout, the higher the risk of dying (roughly double for the highest quartile). This study is encouraging, in a way: you don't have to move that much to really affect your risk, you just have to move often. But this doesn't apply to you, dear reader, since you ride your bike to the grocery store and forsake social media. Don't you?

If you live in a disadvantaged neighborhood, the usual risk factors for heart disease probably underestimate your risk.

BLUF: In a group of patients from the Cleveland Clinic, the Pooled Cohort Equations Risk Model, or PCERM of the American College of Cardiology and American Heart Association underpredicted vascular disease risk in patients from disadvantaged communities (those with a high "Neighborhood Disadvantage Index," or NDI). For a patient from a disadvantaged community, the model only achieved a "concordance index," a measure of how well it predicts vascular disease, of 0.70. In Affluent communities, on the other hand, the concordance index was 0.80. That doesn't sound like a huge difference, but the NDI was much more powerful at predicting variation between census tracts than was the PCERM tool itself.

Fruit names do not invite ghosts, says Taiwanese government

"The seventh month of the lunar calendar is called Ghost Month, when the gate of the underworld is said to open and people prepare offerings for the dead.

People have refrained from offering bananas, plums, pears and pineapples, because the fruits’ names sound like they are inviting ghosts in Hoklo (also known as Taiwanese), the market’s Fu-te Temple (福德宮) chairman Lin Lai-fa (林來發) said.

In Hoklo pronunciation, banana sounds like “inviting” (tsio), plum like “you” (li), pear like “come” (lai) and pineapple like “prosperity” or “more” (ong), the combination of which sounds like an invitation for ghosts to stay in someone’s home."

Whatever, Taiwanese Agricultural and Food Agency. I've seen a Dragon Fruit. That thing's bound to attract demons.

Links for September 12, 2017: Little Library Locator, Kerry to Cannondale's rescue, bike manners in China, and ICT flash dine

Ever wonder where to find a little library near your house? My 10-year old did. She found the answer at Little Locator.

Did John Kerry help save Cannondale-Drapac?

If so, bravo, Mr. Secretary. With Rigoberto Uran's podium at the 2017 Tour de France, things are looking up for one of only two American-sponsored teams in the UCI peleton.

Are stationless bike shares brining out people's bad manners in China?

I've never traveled to China, but my hunch is that the bikes being scattered all over Beijing have a lot more to do with 1) a lot of people in a small space, and 2) the Wild West unregulated atmosphere of bike shares there:

In many cities, the supply of bicycles far exceeds demand, bringing chaos to sidewalks, bus stops and intersections and prompting grumbles that excessive competitiveness — seen as a national trait — is spoiling a good thing. In Shanghai, where officials have struggled to maintain order, there is now one shared bike for every 16 people, according to government statistics.

In some places, the authorities have confiscated tens of thousands of bicycles and imposed parking restrictions. News outlets have documented the waste with astounding images of mountains of candy-colored bicycles, each hue representing a different bike-share company.

I'm signed up for the ICT Flash Dine. You should sign up, too:

Links for September 1, 2017: building a better block, football broadcaster crisis of conscience, kibbutzing for happiness, meldonium, stem cell clinics, FSH, and whoppercoin

Ed Cunningham quit college football over concussion concerns.

That little click you just heard was another tiny domino falling in the decline of football. I've said before that the NFL was one thing, but it's such a small, relatively well-paid population that it doesn't mean much. Once concern starts spreading upstream into college, high school, and beyond, football is in trouble.

Can a Kibbutz make us happier?

In my neighborhood we've experimented with our version of Kibbutzing: we used to have a monthly (or so) breakfast where everyone in the neighborhood was invited to a single house for pancakes, breakfast burritos, etc. Like so much in life, though, it was overtaken by other Saturday morning chores. It's hard for even a breakfast burrito to compete with kids' soccer, the Home Depot, and volunteer duties. It's time to resurrect our Kibbutz. 

Caitlin Thompson doped like Maria Sharapova and liked it.

Caitlin brings up the possibility of this having been a placebo effect. I agree. It's hard to find clinical trial data on meldonium in English; almost all the trials are published in Russian:

And there are no systematic reviews. Wolfgang Schobersberger, Tobias Dünnwald, Günther Gmeiner, and Cornelia Blank wrote a nice narrative review (paywalled) on meldonium's transition to a performance-enhancing drug, though. The take-home from their article is right in the abstract:

The benefit of taking meldonium in view of performance enhancement in athletes is quite speculative, and is discussed without sound scientific evidence.

The FDA is (finally) taking on stem cell clinics.

A few years ago, a stem cell clinic opened here in Kansas, with surprising fanfare. IIRC, they convinced the Governor and even Kansas State Head Football Coach Bill Snyder to attend a grand opening. Coach Snyder is even in a video on their website. Not long after, I reached out to the docs in the clinic through their website to ask to talk about the evidence they were using to justify their treatment regimens. I never got a response. That clinic is not on the list, as far as I can see, of clinics that have been contacted by the FDA.

Is follicle stimulating hormone responsible for post-menopausal weight gain?

I'm skeptical. And I suspect the downstream effects of blocking FSH, which aren't completely known yet, might be worse than an extra 15 pounds.

Burger King is launching its own cryptocurrency that can only be used to buy whoppers. For real. 

I hope I'm not being burned by fake news here.

Links for Monday, August 14, 2017: Hippo meat, better air from more cycling (and fewer cars), Mark Twain cycling, and CRISPR pigs

America once seriously considered importing hippopotamuses as livestock. 

"The idea was to import hippopotamuses from Africa, set them in the swamplands along the Gulf Coast, and raise them for food. The idea was to turn America into a nation of hippo ranchers."

The fact that we don't have hippos living in the Mississippi River eating water hyacinths and being harvested for meat is no tragedy; introduced species have a rough history in America, as anyone in Hawaii can tell you. But as author John Mooallem notes, the fact that we no longer live in an America where kinda-sorta crazy ideas like this can be debated non-ironically is kind of sad. (link from longform.org)

Notice the 2016 link. But it sounds as though 2017 was no different. Link from globalcyclingnetwork.com

When London took cars off the road for Ride London, the air quality got better. As in, shockingly better. 

"Air pollution is believed to be a contributing factor in some 9,000 deaths in the UK capital alone annually.

According to a story published in The Times today £383,000 of taxpayers’ money has been spent by Government ministers on fighting efforts to clean up the UK’s air. Despite this, Britain recently announced plans to ban the sale of petrol and diesel cars by 2040 following a similar commitment in France."

Mark Twain's "taming the bicycle" is one of the best pieces of cycling writing ever.

This essay makes me so happy. It's a joyful, self-deprecating account of learning to ride a pennyfarthing, complete with copious use of Pond's Extract. But this essay makes me so sad. It's better than anything I'll ever write, and Mark Twain didn't even try to publish it. Sigh. Link from bikesnobnyc.blogspot.com.

Adorable piglets modified via CRISPR eventually may be organ donors for humans. Or delicious, non-carcinogenic bacon. One of those.

That's where my mind went when I read this. The immediate application for CRISPR technology in animals may be to reduce their production of greenhouse gases, or decrease their carcinogenicity. But for now, organ transplantation seems to be where it's at, for obvious reasons:

Doctors won’t have to do much persuasion, however, to get patients to accept organs from another species. “There is so much desperation among people on transplant lists, and 20 a day are dying as they wait,” said Dr. Adam Griesemer, a xenotransplantation researcher and transplant surgeon at Columbia University Medical Center. “This could be a path to a transplant for them. Colleagues keep asking me when we’re going to do it.”

Link from kottke.org

Links for Tuesday, August 8, 2017: jug handles for cyclists, love is vegetables, sugary drinks on children's menus, and sane investing

How a jug handle fixed a bike crash problem in Tennessee. 

"If you love someone," Brigitte says, "you feed them vegetables."

Amen, sister. 

Real progress is being made in getting bug juice off children's menus:

There's more progress yet to be made, obviously.

A throwback to sane investing, courtesy of Harold Pollack:

Financial health is a big part of health that we tend to forget about. 

Wichita has a bike share!

Bike Share ICT is official. Errr...was official on May 4. But since I've been out of town in sunny San Diego (stay classy), I haven't had a chance to post on it.

That speaker is Becky Tuttle of Health ICT (and who's soon *sniff* leaving for the YMCA), who was the driving force behind getting this done. 

Did you know...

That Bike Share ICT is using no (as in zero) taxpayer funds? Check out the sponsors on the homepage.

That bike shares are associated with a reduction in traffic congestion, even when car lanes are converted to bike lanes?

That bike share users are far less likely to be injured than people riding their own bikes?

That bike lanes and bike share are associated with an increase in life expectancy, even for people who don't use them, presumably because of reduced air pollution?

The reason I'm excited about bike share is that my body was made for movement. When we see people in motorized wheelchairs, we feel bad for them. When that fancy motorized wheelchair says "BMW" on the hood, we envy them. That's dumb.

I need one of two things in a commute: Either make it fast, or make it slow. That is, I want it done and over with quickly, like when I ride my bike to my local grocery store (~1 mile away), or I want it to last long enough for me to get something done, like the guy Cal Newport writes about it Deep Work who bought a round-trip ticket to Tokyo so he'd have undistracted time to finish a book (thus giving it the biggest carbon footprint of any book, ever).

Driving a car usually accomplishes neither. Most people can maintain a 10 mph average on their bikes without killing themselves, at least after some practice. So 10 miles takes an hour, 5 miles takes thirty minutes, 1 mile takes six minutes, etc. You can start using this to budget your time. The library's 2.5 miles away (15 minutes). The grocery store is one mile away (6 minutes). It saves me less than three minutes on that ride to the grocery store. The amazing thing is that the times are so short. In my car clown days, I was accustomed to allowing 15 minutes wherever I went, short trip or long trip. Commuting by bike makes me more thoughtful. But even when I tell you it takes me 45 minutes to commute one-way by bike to work some days, does that sound like a lot of time to you? What if I told you that the average American spends three hours a day on social media? What if I told you the average American spends five hours and four minutes of each day watching TV? What if I told you that 79% of Americans don't meet the Physical Activity Guidelines for Americans, which encourage 2.5 hours a week of vigorous activity? 

What if I told you that, if you would only ride your bike to work, none of that would matter?

Yeah, you'll sweat a little on your Bike Share bike. On hot days, you'll sweat a lot. Trust me: if the Olympics awarded medals for sweating, I'd be in the running for the gold, year-in and year-out.

I'm the Usain Bolt of perspiration.

If there's an eightfold difference in sweating between people, I'm so far on the "eight" end of that spectrum that I'm practically a "nine."

But that little hint of sweat you carry around: that's your reminder that you've done something with your day. While everyone else was phone-droning for three hours or watching five hours of TV, you were at least getting something done. You were getting your body to and from work, or the grocery store, or the post office, at the same time that you were making yourself healthier and making the planet *this much* healthier. And you saved money, too.

The weakest link-fest April 27, 2017

Man, Kottke.org has been on fire lately with health-related videos and links. Above is a sweet demo of four ways to put roads on diets to reduce congestion and increase safety. 

And then there's this little micro-documentary on a guy who tries to do a DIY-style fecal (and skin and nasal) microbiota transplant. This definitely falls outside the guidelines for the procedure. 

And finally, the story of a science writer who turned a Seinfeld episode into a "case report" for an open-access journal and got it published. I've linked Kottke's page because he does such a good job of explaining it and has all the relevant links. The chief complaint and history (but minimal physical examination) are here:

My March WAMPO presentations

I was thrilled to get to speak to the Wichita Area Metropolitan Planning Organization about health effects of active transportation infrastructure. It was a great, receptive crowd. They gave me reason to hope for the future of a transportation system in which cars are a peripheral accessory and not the primary feature. 

Aaaaand I look a little like a wild-haired madman in the video, which I like.