The horizon is not so far as we can see, but as far as we can imagine

Month: March 2018

Doctors Paid More by Opiate Manufacturers Prescribe More Opiates

Quelle Surprise?

In 2014 and 2015, opioid manufacturers paid hundreds of doctors across the country six-figure sums for speaking, consulting and other services. Thousands of other doctors were paid over $25,000 during that time.
Physicians who prescribed particularly large amounts of the drugs were the most likely to get paid.

Now the article and researchers are quick to point out that causation is not proved, but…

This isn’t an unknown effect. Doctors who get paid more for surgery are more likely to perform surgery, even if non-surgical alternatives are considered a better idea. If they own a share in the institution doing the surgery, even more so.

I don’t like to get down on opiate prescribing, because I think the larger problem is all the doctors who won’t prescribe them. Even in Canada, it seems like every doctor’s office has a notice saying they don’t prescribe narcotics.

Huh? And if the patient is obviously in a lot of pain, you’re just going to let them suffer? We’re in a period of hysteria over narcotics.

That said, it’s also important to note that, yes, you tend to perpetuate the behaviour that you reward.

This is why money should largely be kept out of doctors’ decisions about appropriate care (and everyone else’s). It should not be a consideration except in the most extreme cases. A doctor with no skin in the game, monetarily, will tend to make better patient care decisions, because patient care will be their primary concern.

And, oddly, not only is that good for patients, in most cases that don’t involve end of life care, it is also cheaper, though that’s not why you do it.

Money doesn’t belong in large number of places. It should not be a concern for frontline care workers in almost all cases.

Exhibit five million somethingty.


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Trump Is Right to Talk to Kim

“Only Nixon could go to China.”

North Korea and America never made peace after the Korean war. It’s just an armistice.

The North Koreans have repeatedly said they want a peace, Americans have repeatedly said no–long before it was about nukes.

Bill Clinton had a nuclear deal, Bush Jr. tore it up. Then he invaded a country that had no nukes: Iraq after the UN made damn sure there weren’t any.

Then Qaddafi gave up his nuke program. His reward for that was death, but only after being sodomized by a knife. Hillary Clinton and Obama get the nod for that one. (Clinton convinced Obama, who was initially inclined not to support “regime change” in Libya.)

So, frankly, I’m not sure that, if I were Kim, there’s any way I could be convinced to give up my nukes. It looks dangerous. Still, perhaps a deal can be made, and North Korea is armed to the teeth conventionally, with huge amounts of conventional artillery pointed at Seoul.

But the bottom line is this: Whether you like Trump or not, trying to make peace with North Korea is the right thing to do. Another president should have done it long ago. I have my doubts that Trump will manage it, but he’s right to try, and if he succeeds he will deserve praise.

Now if he’d just grow up about Iran and stop talking about tearing up that nuke deal.


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What the Tao Teaches Us About the Good Society’s Devolution to the Bad

In the Tao Te Ching there is a famous passage, as follows:

When a truly kind man does something, he leaves nothing undone.
When a just man does something, he leaves a great deal to be done.
When a disciplinarian does something and no one responds,
He rolls up his sleeves in an attempt to enforce order

Therefore when Tao is lost, there is goodness.
When goodness is lost, there is kindness.
When kindness is lost, there is justice.
When justice is lost, there is ritual.
Now ritual is the husk of faith and loyalty, the beginning of confusion.

The idea that when one is in the Tao nothing is done causes a lot of confusion. This is a psychological / physical state, where there is no feeling of effort. One takes the actions appropriate to the circumstance without any sense of doing anything, even though things are still done. Because this is a very clear mental state, what is appropriate tends to be obvious.

The key word, for social ethics, however is “appropriate.” What is appropriate isn’t always what is good, but what is good makes up the vast majority of what is appropriate.

When one no longer knows what is appropriate, one devolves to the good and is still doing most of what should be done.

Kindness makes up most of what is good, so when one loses what is good, one devolves to kindness and retains most of what is good.

Losing kindness, one retreats to justice. The loss here is steep. Justice is maybe half of what is kind, because justice without kindness is about balance and tends to not restore people, but punish them: “an eye for an eye” and all that.

And then there is ritual, and ritual, in this context, is without any of the higher virtues, and thus leads to injustice, cruelty and evil, because it has lost almost all of appropriateness: it simply accepts that action A should lead to action B, and that will often be the wrong action, unguided by appropriateness, goodness, kindness or even justice.

I would add that when even ritual is lost; when people no longer obey the rules and are guided by no sense of ethics, that all chances of a good society and good results are lost.

Regular readers will know that I tend to emphasize kindness as a golden rule. I think it’s the highest guiding star the vast majority of people in our society can use: most people still know how to act kind, they just don’t do it and they have many justifications for not doing so. But they do know what it is, with exceptions like warped market disciples, libertarians, and so on, who are so identified with ritual ideologies (market outcomes are just) that they cannot see when they are not even that.

The reform of society comes through the proper use of ritual, ironically. You work your way back up. Ritual done right attaches appropriate emotions to appropriate circumstances to appropriate objects of attention, and once that is the case, one can climb back up the ladder. Indeed, done right, one can jump past justice back to kindness.

But only when done right. Ritual is an obsidian knife: It cuts everything and it’s dangerous, and it’s only a useful tool when both made and used just right. Only someone operating at a level higher than ritual can design rituals which will do more good than harm.

In the meantime, unless you’ve been deformed by the wrong ideology, you probably still understand kindness. I suggest living there. It’s also a rather nice place to live.


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The Paradox of Brexit

(YEP IT’S A MANDOS POST)

Hardly a week ever goes by when I am not alerted to the increasingly absurd cruelty of the social welfare services of the UK. I’ve lived in economically below-average, minority-populated parts of the US, off and on, and the US has a bad reputation for social welfare—mostly due to its absence—but in all that time, I never heard of the kind of sheer, deliberate twist-the-knife cruelty that is apparently daily life for some of the UK’s most vulnerable citizens. I’m starting to think that no welfare is better than evil welfare. Which I suppose was the entire point of the exercise.

The very same people who advocated for this cruelty and have had years to make it worse are the people now in charge of making Brexit happen in the UK. And everyone knows they’re making a mess of it—predictably, with the same twist-the-knife cruelty that is certainly no ward against incompetence. As I have written before, even if they were to run the Brexit show well, what they want from Brexit contains no redeeming value whatsoever. They’re still proud of their austerity and are only at best grudgingly willing to restrain it when it looks like they might lose a critical handful of voters here and there. Yes, even such a debased character as the British Tory voter can show rue where his drivers, on their own, cannot. The British Tory voter, however, will still let his leaders guide him into the sewage lagoon of the tax paradise which they are chomping at the bit to build.

A Brexit with less dislocation was possible, give or take an Irish peace accord or two. That Brexit requires a Britain that did not stake its economic foundation on being local banker to a currency union it didn’t join. This would require a Britain that, long before the Brexit referendum, had not gone down the neoliberal route in the first place, had not succumbed to the ideology of austerity, and had not perfected welfare cruelty.

But therein lies the paradox of Brexit. Brexit was only going to come after a referendum for it. But the conditions to reach the “Yes” vote are precisely these conditions of frustrated failure, if you are inclined, as many are, to see the phenomenon fundamentally through an economic-stress lens. In a non-austerian, non-neoliberal political alternate history—one that, I emphasize, has always mostly been within the UK’s power to execute, despite EU membership—a “Yes” vote would probably have been unachievable. That is why you could never really have a good Brexit, and why, when Brexit really takes place for good, a possible future Corbyn government is going to be left holding a nasty bag of failure that will likely preclude any major reforms in a left-wing direction.

From a progressive/left-wing/whatever perspective, from the perspective of a humane political economy, the flaw in anti-EU/pro-Brexit thinking is one of “dictionary-definition” conservatism. I was mostly opposed to the pro-globalization policies for goods and capital on the whole. But now that it has occurred, it’s a reactionary mistake to attempt to roll it back, rather than assess where the world is now and consider new ways of creating a humane economy in the future. That reactionary mistake plays into the hands of the Rees-Moggs and Boris Johnsons of the world, and worse.

Why Is There so Much Gun Violence in the US?

Alright, let’s talk about the elephant in the room. The simple fact is that, compared to other developed countries, the US has a lot of gun violence.

One can wave ones hands and say “well, cars kill more people”, or point out that statistically you’re damn unlikely to die in a mass shooting (just like you aren’t going to die from terrorism), yet, relatively speaking, the US has more mass shootings and school shootings than any other developed nation.

It is important to understand the scale, however. This chart from the Intercept is useful:

Screen-Shot-2018-02-27-at-1.30.01-PM-1519756226 James Alan Fox and Emma E. Fridel, “The Three R’s of School Shootings: Risk, Readiness, and Response,” in H. Shapiro, ed., “The Wiley Handbook on Violence in Education: Forms, Factors, and Preventions,” New York: Wiley/Blackwell Publishers, June 2018.

Alright, so first off, it is INSANE to arm teachers. School shootings, while a problem, are relatively rare, but what we do know is that when people have guns they are more likely to use them. If we were to, say arm five teachers per school, at approximately 128,000 schools in America, we’d have 640,000 teachers with guns. This to stop an average of ten deaths a year from school shootings.

How many of those five teachers with guns would use them? Use them on themselves, their students, their families or other people? I guarantee, absolutely, that it will be more than ten people a year. Far, far more.

“Hardening” schools is deranged. Having cops and guns and so on in schools is a pathetic admission of social pathology that is off the scale and it’s bad for students. Schools should not be prisons: well, not any more than they already are by design, keeping young kids cooped up and sitting down when they’d rather be doing something else (and probably should be, but that’s another article).

All right, so much for that argument. let’s move back to our original question. Why is the US a pathologically fucked up mess? Most adult Swiss males have assault rifles, they do not go on killing sprees like Americans do (they do kill themselves a lot, though). Nor do the Swiss have nearly as high gun homicide rates.

Of course, those Swiss have those guns locked up and understand they are to be used for their military duties only.

A comparison of international rates finds that the US has about three times more gun deaths per capita than the next highest nation—Finland, with Austria close behind. But the Fins and Austrians are three times more likely to blow their own brains out, rather than someone else’s, while Americans kill with guns almost as much as they commit suicide with guns.

The summary of a WHO study is worth reading.

Even though it has half the population of the other 22 nations combined, the United States accounted for 82 percent of all gun deaths. The United States also accounted for 90 percent of all women killed by guns, the study found. Ninety-one percent of children under 14 who died by gun violence were in the United States. And 92 percent of young people between ages 15 and 24 killed by guns were in the United States, the study found.

Right…

So, there are two factors here. Social pathology and deadliness. China (not on the above list) has strict gun controls and a lot of violent people. It doesn’t have a lot of gun deaths, instead it has mass killing sprees with knives.

But when you look at those sprees what you find is that they’re less deadly, because while knives are dangerous (very hard to defend against), it’s also hard to kill a lot of people with them.

So the idea that having less guns available would make attacks less deadly passes the sniff test. Of course it would. Remember the Las Vegas shooting? One asshole in a hotel room shooting into a concert crowd?

I have little time for those who say that if deadly automatic weapons with large clips were hard to get there would be less gun deaths from shootings. It is also true that wounds from assault rifles are far worse than wounds from handguns, by the way.

One may wish to argue that there is social utility to people having guns that is worth the deaths. We think the convenience of getting around in cars is worth car deaths. But one has to make that argument. If the social utility is “can fight the government”, well, that’s an argument that isn’t clearly the case. (See this long article for the full “will guns let Americans defeat their government?” argument. ) But, perhaps most tellingly, Americans have been in a long slide to loss of their rights and having guns hasn’t stopped that slide.

One might also argue that owning military guns is an intrinsic good. Owning them and knowing how to use them has social utility in some fashion.

But, again, the more guns, and the more guns whose purpose is to kill large numbers of people quickly, the more gun deaths are possible. And whatever level of social pathology you have in a society which makes people want to be violent, guns will make that violence more deadly.

So let’s talk social pathology. First off, it isn’t intrinsically “multicultural society” because Canada is multicultural and has a lot less gun deaths and murders than the US. I live in Toronto, which is more multicultural than any major American city, and has a lot less gun deaths than many US cities.

It may be that Americans are just a bunch of violent assholes and always have been. The country was won with genocide, and founded in slavery (no, don’t even) and that’s just who Americans are, and they’ve never gotten over it.

I… suppose? Culture is a thing, violence does get handed down from father to son, and from perpetrator to victim, who then goes on to victimize. Beat your kid, and your kid is quite likely to be violent to other people. This is robust in the scientific literature.

But parenting has changed, and parents are less violent to their children than in the past. They’re controlling assholes who give their children no freedom these days, of course, but they generally don’t hit them.

The thing is, the evidence supports this:

Gun violence, in fact, is declining. It rose with the boomer cohort, both because young people commit more crime, and because American society went off the rails starting in the late 60s, but it’s declined since a peak in the early 90s, despite Millenials, a large generation, coming on line.

America is less violent. The 90s was, in fact, the peak, and this is true of school shootings as well.

So, no problem, right?

Wrong. Here’s the mass shooting data.

Well—that doesn’t look so good. Americans are killing less retail, and killing more wholesale. Of course, we’re talking a few people, very few, but the far end of the curve has been pushed into mass homicide territory, and it looks bad.

So, how about something simple.

Around the late 60s America’s economy starts to go to shit. Yes, I know this is my go-to argument for a lot of America’s problems, but that’s because, well, it’s true. ’68 is where working white class wages peak. The 70s see social struggle, especially around African American liberation, and a lot of violence (including bombings).

And in 1980, Reagan is elected and he and his movement does this—

BOOM!

Here’s a simple thing well known to criminologists. You put people in prison, they tend to come out nastier than they went in. You criminalize victimless crimes (like drugs) and a lot of people who would never be violent, become violent because they are forced to become criminals to engage in behaviour the state doesn’t want, but which isn’t innately harmful to anyone but themselves.

So, we have a criminalizing trend, an economy which is getting shittier, and a change in parenting from violent to non-violent.

And the kids raised by violent parents (yes, that is the GI generation, don’t say otherwise) are violent when under economic pressure or when stuff they think is their right, and which was legal when they were young, is made illegal.

But as the children become adults who were not raised violently, retail violence decreases despite social pathology.

This is probably aided by the widespread use of legal mood altering drugs, often from childhood, of anyone who shows any spirit or unwillingness to sit like a tranquilized animal in a classroom while a teacher drones on, or in an office, doing meaningless work for an asshole boss for a shitty wage.

Unhappy with your life because your life is, actually, shit? No, no, no. The best way to solve that isn’t to change your life, or society, it is to drug you.

So, kids who weren’t treated violently become adults, and they are, in large numbers, drugged to the gills.

Is this “the cause?” Who knows. But it’s a narrative that fits a lot of the facts and a narrative that doesn’t explain the mass shootings…

Homicide rate drops, mass shootings increase. And very much an American thing, though other nations dip their toe into the pool on occasion.

Why?

Well, perhaps part of it is that the US continues to get worse and worse off. You see this in the opiate epidemic, which I consider to be clearly caused by economic despair moving from blacks to working, lower and lower middle class whites. (The economy dropped off a cliff for blacks in the 80s.)

It isn’t, of course, that the poors always do the deed, it is that everyone is aware that their economic situation is precarious. Lose their job and get blackballed or wind up sick with more than their insurance will cover (easy even with good insurance) and that middle-class American lifestyle is gone. And for more and more people it has just slid away. A hundred thousand here, a million there, a financial crisis over there, and hey, you’re on the street.

Even if it hasn’t happened to you, the knowledge that it can is always there. Economic life in America is a game of musical chairs, with some chairs having spikes on them, and there are not enough chairs period. And if you don’t have a chair to sit in when the music stops, well, your life is endless misery—well, until your life ends.

And the guns are there. And people are angry. And the far-end of the bell curve moves over and over and over and it lands on just a few people. But they have access to military weapons and the knowledge is out there of how to train and prepare in order to do maximum damage. There is a “gun culture,” the internet, and easy access to everything they need.

And—BOOM, a few of them go off.

Solutions? Well, again, they come in two flavors. End the pathology and/or make it harder to be really lethal. So, less access to the most lethal weapons, or stop treating people like shit.

People who are happy, have people they love and are optimistic about their future, outside of war, do not go on mass killing sprees. Does not happen. Provide a society where people know that one slip up or bad bounce doesn’t mean social, economic, and possibly literal death; a society where people are happy, and optimistic, and don’t have to put up with bad bosses because they don’t need to keep a specific job, because they can always support themselves, and there’ll be a lot less mass shootings, suicides, and drug addicts.

Lot nicer society to live in, too. Might have to give up having as many billionaires, though. I’m sure there are a few people who will miss them, but really, having to kneel or bend over for billionaires to make a good living gets old fast and they aren’t needed for a good economy. The 50 and 60s had far fewer really rich people and were a lot better.

Final word. I had my first gun when I was 12. I grew up with hunters. I’m not “anti-gun.” But no one I knew ever felt the need to own an assault rifle. Most didn’t even own any handguns: hunting rifles and shotguns. Rural people need guns. They don’t need guns designed to kill people, unless the society is pathological. And if it is, perhaps you should make it less pathological?

It isn’t, actually, that complicated to do so. Your great-great grandparents and great-grandparents did it during the Great Depression and World War II. If they can, you (we) should be able to.

Perhaps get on that, rather than arguing about whether or not a teacher with a gun, barricaded in a classroom, can hold off a shooter. Because when it gets to that debate, your society is in the shitter.


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Modern Violence, Resistance, and the Calculus of Revolution

Given the gun control debate, it seems time to put this back up for newer readers. Originally posted Nov 4, 2013.

Let us talk, today, about violence, resistance, and revolution. It has been observed that armed populations often seem to be more free. Equally it has been observed that armed populations live in a state of misery and anarchy, as in most failed states, where virtually everyone is armed.

An armed population, alone, means little. For all of the talk about how important it is to have Americans armed so they can “resist tyranny,” the fact that America is awash in guns has done nothing significant to stop the erosion of civil liberties and the rise of plutocracy. Indeed, many of those screaming the loudest for policies which ensure their own poverty, the power of the rich, and thus the decline of effective democracy are the most heavily armed.

Guns alone mean little.

America’s founding fathers wanted Americans to have guns and be in well-regulated militias. In this, as in many things, they were wise. A militia, properly oriented towards the community it serves, is an organized body of citizens who have military training and are used to fighting as a group. They have ties to the community, and as there is not more than one militia per community, they also have ties to whatever local government exists. If enough of these militias decide, as groups, to resist the government, they can do so.

Individual violence is not a threat to the state. The threat of assassination can act as a brake on the activities of politicians (though I, of course, would never suggest it). It is notable that the concrete barricades and ludicrous overprotection of DC politicians, especially the President, picks up exactly as plutocracy gets underway. Say what you will about Nixon: he went to meet protesters, at night, with a single aide and no bodyguards. He was not afraid of his own citizens, even those who disagreed with his policies. It is unimaginable that Clinton, Bush, or Obama would do such a thing.

To some extent the right-wing gets some of what they want because they are armed, and every once in a while their crazies “go off.” Rhetoric justifying violence is regularly issued by the right-wing, and it works: When a political attack occurs, it’s almost always against someone perceived as a left-winger. The days when there was any chance of being beaten up by a “union thug” as a pol are long gone, let alone having a genuine anarchist blow up your building, but you can still be shot in the head by a right-winger.

Moreover, people have simply not understood the lessons of Iraq, Afghanistan, Lebanon, and Mexico. The modern toolkit of violence is amazing at area denial. If the US government starts losing control of chunks of the US, what it will look like is Mexico or Iraq: Places where they can’t go without police cars or tanks blowing up, sporadic attacks by people who fade away, and terror against the police and their families. It will not be some great glorious slugging match between armies, because anyone stupid enough to fight the US that way will lose.

The problem with modern insurgency technologies, however, is that you can’t protect anything. So you can deny the writ of the state, you can create places where they can only go in force, you can make it so they control the ground their boots are on and nothing more, but you can’t create a sub-state, because they will find it and destroy it: Any facilities you build or staff they’ll bomb, any public leadership they’ll assassinate, and they’ll kill as much of the secret leadership as they can.

Modern states, and especially the US state, after Iraq and Afghanistan, are very aware of this. This is one of the main reasons for the rabid scramble to surveil everything–not just online, but offline. Put cameras, drones, satellites, listening devices (many cameras now eavesdrop) everywhere they can, add in recognition software and behaviour algos, and scoop everything up. The first sweep is algos, looking for behaviour that seems consistent with being a threat or even that is just unusual (i.e., “Fred’s not doing what he usually does, let’s flag that.”).

With this surveillance, the hope is to be able to stay on top of the new technology of violence and area denial: We know where you go physically, online, what you buy, and who your friends and family are. We know you, we can predict you, and if you get out of hand we know where to find you so we can grab you or kill you.

Historically, the more the state needs its citizens to fight, the more power they have. You get universal male suffrage, generally, when you have the draft, you get selective male suffrage when part of the population fights and is required to fight (is not replaceable. You can replace US soldiers, but Greek hoplites came from a class which could not be replaced with someone else.)

Even so, human soldiers are a clear point of failure. They may not shoot their fellow citizens, and the more of them you have, the more likely it is they won’t shoot. Thus automated warfare: not just aerial drones, but ground robots, which are no more than a couple decades out. It’s a lot easier to kill someone from remote, when you don’t smell what humans smell like when their guts are ripped open, when you can turn the sound off the screams.

If there is violence against the state, it will look like Iraq or Afghanistan, not like the American Revolution. Add in other new techs like 3D printing, and you have an insurgency where virtually anyone with a minimum of tech skills and a few parts can make weapons. Some household chemicals which can’t be banned, and you have bombs. Drones will not, ultimately, be weapons of the strong, either, but weapons of the weak: They are not hard to make and if technically savvy people get motivated, they will be more than able to make their own air and ground drones.

The… issue, here, is the inability hold ground and protect infrastructure. What happens in this type of war is that it is difficult to land a knockout punch. So the country becomes a place where you have low (or high) grade terror, places where no one can go, and constant atrocities on both sides as they try and destroy the will of the other side to resist, punish their enemies, and cow the local population into obedience.

An armed population gives the ruling class pause when it is not fully under their control and is organized by local elites not fully under the control of the central elites. But if those local elites go too wrong, you get armed militias imposing local shakedowns at best, tyranny at worst (see: Klu Klux Clan). It gives them more pause when they need that armed population to fight external foes who are actually an existential threat (Islam, again, is not an existential threat to the US.) It gives them further pause when they fear assassination and need to maintain close contact with the population and not hide behind guards and walls all the time.

One must also recognize that, despite its apparent overwhelming power, the US military is absolutely horrible at anti-insurgency. Take a map of Afghanistan or Iraq and plunk it down on a map of the continental US.

The US is…big, very, very big. If the US military could not crush insurgencies in Iraq or Afghanistan, if one ever gets seriously underway, why do you think it could do in the US? Hmmm?

Thus, again, blanket surveillance and remote or (ultimately) automated killing machines.

If anyone wants to defeat a first world State, on its own ground, they will either need the mass active (not passive) support of the population, before the killing machines become active, or they will need to rethink, or more likely, adaptively learn, how to defeat the surveillance state. The model for this, of course, is Hezbollah, who runs a secret army and in certain respects, almost a secret state. You must have your own ways of communicating which cannot be tapped. You must know how to avoid the surveillance of the enemy, or take it out. You must know how to move without triggering the algorithims, and you must figure out some way to protect the organs of your nascent state, whatever they are, from destruction.

It may come to this, but we should hope it doesn’t, because civilization will be laid waste by it. The other route is the failure of ideology. The USSR did not fall in battle, it fell when the decision was made not to use the troops, by men who no longer believed enough in the USSR to kill or die for it. A vast ennui had swept the USSR, they simply no longer believed in their form of communism. Done.

One problem with that is that it happens when it happens, and it may not happen for a long time: Plutocrats don’t need any grand belief in anything more than money and passing it on to their heirs, and the people who fight for them don’t need to believe in much more than money either. Absent a belief system that unifies them against the ruling class, they’ll kill for their lords and masters.

The second problem was also displayed in Russia: If you don’t have an ideology to replace the old one that’s better than the old one, your society can go downhill fast. Russians were vastly worse off after communism than during communism. By some metrics they still are. If the US fails and accepts, say, Chinese state capitalism, that might not be a good thing.

The best way of overthrowing a state is to undermine belief in it and replace that belief with belief in something new and something better. Do those things, and while some violence may be necessary, you will find, when push comes to shove, that the state is rotten and can hardly fight, because those running it do not believe in it and those fighting against it are fighting for something not just against something.

Absent powerful external enemies, belief is what makes states, and it is what destroys them. Even in cases where there are external enemies, great nations tend to rot from within before falling to outside foes–if they do not renew themselves first.


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