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Remembering Thomas E. Kurtz

By MIKE MAGEE

This has been a challenging week for me, but not for the reasons you might think. Compartmentalization skills have allowed me to push the 2024 Presidential election into the back reaches of my mind as I worked to complete teaching a course on “AI and Medicine” at the Presidents College at the University of Hartford. The complexity of AI, its risks and potential benefits, are staggering. So it was comforting for me to remember how far we have come with data and information in my own lifetime. That reminder came wrapped in the loss of one of the great pioneers in the field.

The week of my final AI lecture began with the announcement of the death of 94 year old Thomas E. Kurtz. You may not have heard of him, but you likely recall his seminal invention, the first computer programming language for the masses–BASIC (Beginners’ All-purpose Symbolic Instruction Code). As Bill Gates himself reflected this week, “The approachability of BASIC and time-sharing began what the PC and the internet took to a whole new level.”

Bill would know. His high school had a teletype connection to the original time-sharing main frame computer at Dartmouth. But Gates was not alone or first in line. As Kurtz remembered, “I once estimated that even before Bill Gates got into the action at all, five million people in the world knew how to write programs in BASIC. There was something like 80 time-sharing systems in the U.S. that offered BASIC as one of their languages. And it was all over the world. I even got a letter from somebody in Siberia.”

It wasn’t until 1978 that Gates teamed up with Microsoft founder, Paul Allen, and received permission to install BASIC in the first customizable personal microcomputer, the MITS Altair 8800.

Kurtz was the son of German immigrants, and displayed high aptitude in mathematics early in life. He graduated from a local college in Illinois in 1950, and by 1956 had earned a PhD in statistics at Princeton. He was recruited to Dartmouth that same year by the chairman of Mathematics, John Kemeny, who had previously been a research assistant at Princeton himself under none other than Albert Einstein. Kurtz launched a new field at Dartmouth that year – computer science.

He was starting at ground level – or more accurately, below ground level since the solitary computer the university possessed was housed in the basement of College Hall where it filled an entire room. Training students in computer science required hands on engagement. As Kurtz explained some years later, “Lecturing about computing doesn’t make any sense, any more than lecturing on how to drive a car makes sense.”

In later interviews, Kurtz make it clear that his idea didn’t meet with applause at the outset. He admitted, “The target (in computing) was research, whereas here at Dartmouth we had the crazy idea that our undergraduate students who are not going to be technically employed later on should learn how to use the computer. Completely nutty idea.”

Two barriers at the time were computer language and computer time. The main frame on campus ran on complex FORTRAN and COBOL which only a few experts had mastered. And if you wanted access, you had to wait in line.

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Will Trump and RFK Jr. Revive His Covid Pandemic Performance?

By MIKE MAGEE

It has been a collision of past, present and future this week in the wake of Trump’s victory on November 6, 2024. The country, both for and against, has been unusually quiet. It is unclear whether this is in recognition of political exhaustion, or the desire of victors to be “good winners” and no longer “poor losers.”

Who exactly are “the enemy within” remains to be seen. But Trump is fast at work in defining his cabinet and top agency officials. In his first term as President, Trump famously placed himself at the front of the line of scientific experts sowing confusion and chaos in the early Covid response.

His 2024 campaign alliance with Robert F. Kennedy Jr. suggests health policy remains a strong interest. As his spokesperson suggested, his up-front leadership led to a resounding victory “because they trust his judgement and support his policies, including his promise to Make America Healthy Again alongside well-respected leaders like RFK Jr.”

For those with a memory of Trump’s checkered, and disruptive management of the Covid crisis, it is useful to remind ourselves of those days not long ago, and consider if throwing Bobby Kennedy Jr. in the mix back then would have been helpful.

I have been revisiting the Covid pandemics I have prepared for a 3-session course on “AI and Medicine” at the University of Hartford’s Presidents College. The course includes a number of case studies, notably the multi-prong role of AI in addressing the Covid pandemic as it spun out of control in 2020.

The early Covid timeline reads like this:

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My Father and Arnold Palmer – Embodying Honesty and Respect

By MIKE MAGEE

My father and Arnold Palmer had a great deal in common – and none of it involved golf. They were both men of faith and lived into their 80’s. My father was Catholic, and Arnold Palmer was Presbyterian. But on the day that Palmer died (September 25, 2016), Benedictine Archabbot Douglas R. Nowicki of St. Vincent’s Archabbey in Latrobe, Pennsylvania, was at his bedside.

Nowicki and Palmer’s friendship dated back a half century. He and his wife would often attend 7:30 a.m. Sunday Mass at the abbey.

At the time of Palmer’s death, the Benedictine monk said, “Arnie sort of appealed to everyone. There were no barriers, race, color, creed — those were things that never entered into his mind. He was welcoming to everybody and treated everyone with tremendous warmth and respect.”

But eight years and one month after his death, Palmer’s daughter, Peg Palmer Wears felt compelled to rise up and defend her father’s honor. In the Latrobe Airport, named after him, Donald Trump (according to FOX News) “discussed the golf legend’s manhood and how other players would react to Palmer in the showers.” Specifically, in an effort to relate to the local audience, Trump said, “He was all man. This man was so strong and tough, and I refused to say it, but when he took showers with the other pros, they came out of there; they said, ‘Oh my God, that’s unbelievable.’”

The reaction from his daughter, a registered Independent from North Carolina, was swift. She labeled his words, “disrespectful” and “inappropriate”… “appropriating someone he admires to bolster his own image, people deserve better.” Her words in defense of her father, who was no longer there to speak for himself, called to mind my sister Sue’s Eulogy to our father. It focused on the values and qualities in him that she admired – honesty, hard work, compassion, integrity, humility, kindness, and love for others.

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“Accelerationalism”: Is Your Money on Altman or Musk?

By MIKE MAGEE

Has America turned into an “Island of Musk?” He seems to be everywhere and nowhere at the same time. As Trump’s new best friend, he’s opened up the gates of Twitter-hell, morphed into a steady stream of crypto-cash, and demonstrated his dance moves alongside Trump at featured venues.

He’s also launched “a robot for every citizen” as part of a cover for sagging expectations for the Tesla Cybertruck, and issued a new round of hollow promises on his Robotaxi scheme. In short, Musk’s ADHD aside, he seems a bit more unhinged than usual.

In contrast, his arch foe, 38-year old OpenAI CEO, Sam Altman, is (if you’re to believe him) almost professorial. In his own words, “Technology brought us from the Stone Age to the Agricultural Age and then to the Industrial Age. From here, the path to the Intelligence Age is paved with compute, energy, and human will.”

Part of the clash revolves around a single word, accelerationalism. Destined to become the 2025 “word of the year,” this label is increasingly assigned to thought leaders in AI who have convinced themselves that AI will soon rule the world, our politics, and the battle field, and therefore “faster is better” is now the mantra when it comes to world-dominating generative AI.

This was not always the case. Back in 2015, when Elon Musk and a young Sam Altman teamed up to launch a non-profit called OpenAI “to benefit humanity,” they both realized that the leased offices were not big enough for two alpha males. But in launching their decade long battle for dominance, they agreed that slow, transparent, and deliberative was better than fast and reckless. Altman wrote at the time, “In an ideal world, regulation would slow down the bad guys and speed up the good guys.”

Back then, Musk famously warned, “Mark my words, AI is far more dangerous than nukes. I am really quite close to the cutting edge in AI, and it scares the hell out of me.” Where Musk was ”in your face,” Altman was “extremely nice and accommodating” which masked a startlingly aggressive underbelly according to those who knew him well. As his former partner in the 2011 start-up “Y combinator”, Paul Graham said, “You could parachute him into an island full of cannibals and come back in five years and he’d be the king.” Sam was 23 at the time.

In February, 2018, Musk jumped ship, apparently disagreeing on strategy with Altman. And then Altman’s board, in an all-out coup, fired him on November 17, 2023. Twelve days later, they were forced to rehire him when major stakeholder, Microsoft, threatened to pull their considerable support. Altman, for his part, displayed a conciliatory tone on Musk’s own X-platform, tweeting on his return “For my part, it is incredibly important to learn from this experience and apply those learnings as we move forward as a company. I welcome the board’s independent review of all recent events.”

On June 7, 2023,  38-year old Sam told his Congressional questioners that money wasn’t his motivator. Rather “I’m doing this because I love it.” Sen Richard Blumenthal swooned, “It’s so refreshing. He was willing, able, and eager.” Altman, playing to the cameras, said, “We think that regulatory intervention by governments will be critical to mitigate the risks of increasingly powerful models.”

Just 9 months later, his Senate supporters were no doubt confused to open the Wall Street Journal and discover the headline, “Sam Altman Seeks Trillions of Dollars to Reshape Business of Chips and AI. Open AI chief pursues investors including the U.A.E for a project requiring up to $7 trillion.”

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The Silicon Curtain Descends on SB 1047

By MIKE MAGEE

Whether you’re talking health, environment, technology or politics, the common denominator these days appears to be information.  And the injection of AI, not surprisingly, has managed to reinforce our worst fears about information overload and misinformation. As the “godfather of AI”, Geoffrey Hinton, confessed as he left Google after a decade of leading their AI effort, “It is hard to see how you can prevent the bad actors from using AI for bad things.”

Hinton is a 75-year-old British expatriate who has been around the world. In 1972 he began to work with neural networks that are today the foundation of AI. Back then he was a graduate student at the University of Edinburgh. Mathematics and computer science were his life. but they co-existed alongside a well evolved social conscience, which caused him to abandon a 1980’s post at Carnegie Mellon rather that accept Pentagon funding with a possible endpoint that included “robotic soldiers.” 

Four years later in 2013, he was comfortably resettled at the University of Toronto where he managed to create a computer neural network able to teach itself image identification by analyzing data over and over again. That caught Google’s eye and made Hinton $44 million dollars richer overnight. It also won Hinton the Turing Award, the “Nobel Prize of Computing” in 2018. But on May 1 2023, he unceremoniously quit over a range of safety concerns.

He didn’t go quietly. At the time, Hinton took the lead in signing on to a public statement by scientists that read, “We believe that the most powerful AI models may soon pose severe risks, such as expanded access to biological weapons and cyberattacks on critical infrastructure.” This was part of an effort to encourage Governor Newsom of California to sign SB 1047 which the California Legislature passed to codify regulations that the industry had already pledged to pursue voluntarily. They failed, but more on that in a moment.

At the time of his resignation from Google, Hinton didn’t mix words. In an interview with the BBC, he described the generative AI as “quite scary…This is just a kind of worst-case scenario, kind of a nightmare scenario.”

Hinton has a knack for explaining complex mathematical and computer concepts in simple terms.

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Miscarriage or Abortion? The Crisis in 14 States Post Dobbs.

By MIKE MAGEE

“What did they know, and when did they know it?”

These are the questions Americans have become accustomed to asking of their leaders, dating back to Nixon and extending to Trump, and all Presidents in between. But now the same questions have surfaced, to the extreme discomfort of conservative Justices, as death and destruction of lives begins to mount in the wake of the Dobbs decision.

As predicted, graphic cases of young women bleeding out in parking lots after being refused life-saving acute care for miscarriage in 14 states across the nation are being documented and described. These stories are not only affecting the lives of couples across the land, but also threatening the “political lives” of downstream Republicans facing an upcoming election.

The responsible Supreme Court Justices (Alito, Thomas, Gorsuch, Kavanaugh, and Barrett) and their legions of Ivy League clerks had scoured the literature far and wide before making the decision to eliminate women’s reproductive freedom in the U.S. and inflict lasting harm to their life-saving relationships with their local doctors.

Their review had to include Blue Cross & Blue Shield’s timely publication, “Trends in Pregnancy and Childbirth Complications in the U.S.” That report, surveying over 1000 pregnant women ages 18 to 44 in April, 2020, was, in part, designed to understand the impact the Covid epidemic had had on prenatal care nationwide. But what it revealed was that pregnancy complications were up 16% over prior years, in part due to “social barriers such as availability of appointments, lack of transportation or nearby providers.”

A comparison of 1.8 million pregnancies in 2014 versus 2018 demonstrated a severely compromised women’s health support system. 14% did not receive prenatal care in their first trimester, and 34% missed scheduled prenatal visits with 1 in 4 of these suffering complications in pregnancy. The BC/BS summary “underscores the importance of focusing on the health of pregnant women in America, especially as health conditions increase in this population…”

The Conservative Justices were forewarned. Yet they still elected to throw fuel on a maternal health system which was already in flames. They were also aware of a 2021 study that confirmed that miscarriage was 43% more likely in Black women than in their white counterparts.

On May 2, 2022, Justice Alito and his allies engineered the release of a draft of a majority opinion in part to freeze attempts by Chief Justice Roberts to secure a compromise. The leaked document labeled Roe v. Wade “egregiously wrong from the start.”  As predicted, the ruling spawned chaos.  When 14 Red states established total bans on all abortions, miscarrying women seeking help in ER’s literally had to fight for their lives. Their doctors were criminalized. Was this an abortion gone bad?

A miscarriage, or pregnancy loss before 20 completed weeks, is not an uncommon affair. Approximately 15% of pregnancies end in miscarriage, mainly the result of chromosomal or genetic abnormalities. That amounts to some 540,000 women in crisis, which most believe is under-counted. 80% of miscarriages occur in the first 13 weeks of pregnancy.

25% of pregnant women experience some vaginal bleeding in the first trimester. For most (6 in 10) this is self-limiting and they go on to deliver a healthy baby. But for 4 in 10 (or 10% who present with bleeding) they go on to miscarry. All pregnant women who experience vaginal bleeding in early pregnancy need to have a medical examination. Doctors and midwifes check blood work, perform a physical examination, and do an ultrasound examination.

Most pregnancy loss (95%+) occurs before 20 weeks gestation. If miscarriage occurs before 13 weeks, there is a good chance of clearing the blood clots and uterine tissue with medication and no surgical intervention. But if bleeding is severe, or the loss is occurring beyond 13 weeks, dilation and curettage (D&C) is both necessary and at times life-saving. Under anesthesia, the cervix is dilated and any remaining pregnancy-related tissue is gently scraped and suctioned from inside the uterus. Patients are then closely monitored for several weeks for any evidence of continued bleeding or infection.

What did the Justices know, and when did they know it?

  1. They knew that Miscarriages were a medical emergency and exceedingly common.
  2. They knew that 80% occur during the first trimester, and that existing state abortion laws on the books would restrict access to acute life-saving treatments in 14 states.
  3. They knew that pregnancy loss was far more common in non-whites and in rural underserved communities.
  4. They knew that the medical community opposed overturning Roe v. Wade in overwhelming majorities, and predicted maternal loss of life if the Justices proceeded.
  5. They read, two years after their deadly decision, the Commonwealth Report which stated that “The United States continues to have the highest rate of maternal deaths of any high-income nation, despite a decline since the COVID-19 pandemic. And within the U.S., the rate is by far the highest for Black women. Most of these deaths — over 80 percent — are likely preventable.”

They knew all this, and they did it anyway.

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

The Art of Political Jiu-Jitsu: Project 2025 and Donald Trump

By MIKE MAGEE

Funny think about that Project 2025’s  “Mandate for Leadership.” Trump declared in this week’s  debate, “I know nothing about it.” But in addition to the vast majority of authors and editors of the document having served in the prior Trump administration, the former President’s name is mentioned in the 887 page document over 300 times.

Described by Pulitzer Prize winning economics columnist, Carlos Lozada, the work itself is an “off-the-shelf governing plan.” It’s packed with conservative fan favorites, not simply “militarizing the southern border” and reversing what they call “climate fanaticism”, but especially placing DEI (diversity, equity, inclusion) efforts in the waste bin, banning abortion nationally, and pushing deregulation and tax cuts for the richy rich.

None of that is surprising if you’ve run into these characters on K street and beyond. This is who they are, and largely who they have always been. Over the years, I’ve bumped elbows with them in Washington and in corporate C-suites galore. What makes this effort a bit unique is, of course, the presence of a cooperative headliner who will clearly endorse “the elevation of religious beliefs in government affairs” and actively diminish “the powers of Congress and the Judiciary.”

This is political jiu-jitsu practiced at its highest level. Rather than dismantling the “deep state,” these operators are fast at work “capturing the administrative state” for their own self-serving purposes.

Understanding jiu-jitsu takes one a long way toward understanding the Heritage Foundation and Freedom Institute’s puppet masters. The word “Jū” means “gentle, soft, supple, flexible, pliable, or yielding.” It’s companion, “jutsu” is the “art or technique.” Combine the two, and you have the ”yielding-art.” The intent in bodily (or political) combat is to harness an opponent’s power against himself, rather that confronting him directly.

Political jiu-jitsu may be deceptive and confusing in the absence of visible weaponry, but it is anything but gentle. In the physical version, you are instructed in joint locks and chokeholds of course, but also biting, hair pulling, and gouging. Kevin Roberts, the President of the Heritage Foundation and editor of Project 2025, is a master of the political version. While he and Trump outwardly employed a “nothing to see here” stance, demographic realities were cued up in the document. The solution to the growing minority status for Republicans? “Voter efficiency” and a rigged census. Or in the Project’s words: “Strong political leadership is needed to increase efficiency and align the Census Bureau’s mission with conservative principles.”

Robert’s language is soft, but its impact hard indeed. In the introduction he suggests that the Declaration of Independence’s words “pursuit of happiness” were better understood to be “the pursuit of blessedness” while providing corporations a market free hand “to flourish.” Career civil servants are recast as “holdovers” without “moral legitimacy.” And the Justice Department suffers this put-down – “a bloated bureaucracy with a critical core of personnel who are infatuated with the perpetuation of a radical liberal agenda.”

Majority rules and demographic changes being what they may, alternative facts and voter suppression have been added to the tools of “political jiu-jitsu” artists. But Kelly Anne Conway was nowhere to be seen this week, and their headliner was long-winded, boring, and tired. As for voter integrity, the Democrats are fully funded and lawyered up. Finally, good Republicans everywhere have begun to recognize that towing the MAGA line much further puts their down-ballot hopes in the direct line of fire.  Those 300 mentions are beginning to look like a liability instead of an asset.

Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

How’s Human Evolution Going? The Harris-Walz Health Policy team wants to know.

By MIKE MAGEE

Clearly the Harris-Walz ticket has been doing their homework. Last week, the book above was spotted on one prominent thought-leader’s pile: “Human Evolutionary Demography.” It’s a 780 page academic Tour de force read by veteran scientist Oskar Burger, leader of the Max Planck Institute for Demographic Research and the Laboratory of Evolutionary Biodemography.

That’s the Institute founded in 1917 in Berlin whose first director was Albert Einstein. These days, its researchers work (in an age of “alternate facts”) to separate justified belief from opinion. Their major focus is on “categories of thought, proof, and experience” at the crossroads of “science and ambient cultures.”

This is the field of Human Evolutionary Demography, a blending of natural science with social science. Demographers study populations and explore how humans behave, organize and thrive focusing heavily on birth, migration, and aging.

This has been a year of just that in American politics. First, the fallout of the Dobbs decision caught Republicans with their electoral pants down in reproductive freedom referendums in Kansas, Michigan, Kentucky and Vermont. Southern migration of Democrats to former red states like Michigan, Arizona, Georgia, and North Carolina have turned them various shades of purple. And this summer, octogenarian candidates from both parties have been all the rage, literally.

Up until July 21, 2024, the race for the Presidency was between two aging candidates with visible mental and physical disabilities. The victor was destined to a term of office that would extend into his 80’s.

The emergence of Kamala Harris as the Democratic nominee was a reflection of the electorates growing discomfort with turning a blind eye to the realities of aging. It also suggested that Americans, especially Gen X’ers, have grown tired of Boomer dominance in the lives of an increasingly multi-cultural America – tired as well of growing income disparity, attacks on reproductive freedom, and declining life expectancy in America.

But why the sudden interest in “Human Evolutionary Demography?” The answer lies in the numbers. Back in 2012 Oskar Burger studied Swedes and noted that in 1800 their life expectancy was 32 years. They gained an additional 20 years in the century that followed, and 30 more years by 2000.

What stumped Burger was not the gains over these two hundred years. Instead he focused on the question, “Why did it take the human race so long to progress?” The bottom line is this, we left chimpanzees behind in the evolutionary dust some 6.6 million years ago. We limped along, not faring very well, for all but the last 200 years. In the past century, a moment in time spanning just 4 of our historic 8000 plus human generations, we took off.

This period coincided with rapid scientific and technologic advances, cleaner air and water, greater nutritional support, improved education and housing, expanded public health related governmental policy, and establishment of a safety net for our most vulnerable citizens.

But in the past decade, growth in U.S. life expectancy has all but stalled. For the first time, we actually saw declines each year from 2014 to 2019. For the decade just past, the numbers improved overall by less than 1/2 of 1 %. When first studied, declines were blamed on losses in working age adults due to trauma, addiction, suicide or “deaths of despair.”

But recent studies reveal losses due to poor maternal/fetal care, especially in red states, and made worse by fallout of the Dobbs decision. A second complicator has been losses starting at age 65 from complications of cardiovascular disease and diabetes, made worse by obesity and poor health care follow-up.

This has led the Max Planck Institute to issue an alert to U.S. health experts: “Our findings suggest that the U.S. faces a ‘double jeopardy’ from both midlife and old-age mortality trends, with the latter being more severe.”

Women’s reproductive advocates say it’s really a “triple jeopardy” demanding grass roots advocacy focused on access today, and political victory up and down the ballot in November. In their words, “Today, and every day, we work to ensure that every patient who seeks sexual and reproductive health care can access it, and to build a just world that includes nationwide access to abortion for all — no matter what.”

If this is true, a careful read of “Human Evolutionary Demography” could direct a 3-prong approach for the health policy leaders in the Harris-Walz campaign:

  1. Expanded safety net to address “deaths of despair.”
  2. Expansion of the ACA toward Universal Health Insurance to address the chronic disease burden of older Americans.
  3. Federal guarantees of reproductive freedom and open access to reproductive care.

Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

“Moral Distress” Has Arrived On Health Care’s Stoop

By MIKE MAGEE

When Andrew Jameton, a Nursing Professor at the Department of Mental Health and Community Nursing at UCSF in 1984 published “Nursing Practice: The Ethical Issues”, the term “Moral Distress” was a novel term in clinical health care. It focused primarily on “care that they were expected to provide but ethically opposed.”

Over the past four decades, the definition has expanded and now encompasses the “inability to provide the care that one feels morally compelled to provide.” Beyond its’ impact on individual health professionals, it has growing health policy implications, explosively reverberating in the wake of the recent Dobbs decision.

There are approximately 1600 health care facilities nationwide that provide abortion care in the U.S. In the wake of the Dobbs decision overturning Roe v. Wade, 14 states have near complete bans on all abortions and this reproductive care is severely restricted in an additional 11 states “with few or no exceptions for maternal health or life endangerment.”

The impact of these rulings has created not only a moral dilemma for health professionals, but also intense legal jeopardy. As one Tennessee Obstetrician recently put it, “There are weeks when I commit multiple felonies.”

There now exists a validated psychometric tool to measure the mental health impact of the Supreme Court’s actions called the Moral Distress Thermometer(MDT). Experts recently surveyed 310 practicing clinicians involved in women’s reproductive health care, with a focus on comparing moral distress in those from restricted versus unrestricted states. What they reported in JAMA was that those in restricted vs. protected states had scores on the MDT that were more than double their comparators.

As one might expect, high scores on the MDT also correlate with higher rates of job burnout and attrition. This means lower rates of abortion care, but also a smaller maternal health workforce overall. This is in states that had already been lagging behind in access to obstetrical and reproductive health care in general. Clinical shortages are expected to rise in the months approaching an historic Presidential election.

Project 2025’s agenda for future women in America is much more expansive and aggressive than restriction of abortion alone. Trump’s denials aside, his selection of JD Vance as a running mate signals an intent to thoroughly engage in restriction of women’s reproductive rights in allegiance with a Supreme Court that appears equally committed.

With that in mind, the massive response to the Harris-Walz ticket appears to be offering a response that appears to be go well beyond simple “weird” labeling. Those words are a promise to each other, “We’re not going back.”

Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

Why Sam Altman Cares So Much About Voice

By MIKE MAGEE

When OpenAI decided to respond to clamoring customers demanding voice mediated interaction on Chat GPT, CEO Sam Altman went all in. That’s because he knew this was about more than competitive advantage or convenience. It was about relationships – deep, sturdy, loyal and committed relationships.

He likely was aware, as well, that the share of behavioral health in telemedicine mediated care had risen from 1% in 2019 to 33% by 2022. And that the pandemic had triggered an explosion of virtual mental health services. In a single year, between 2020 and 2021, psychologists offering both in-person and virtual sessions grew from 30% to 50%. Why? The American Psychological Association suggests these oral communications are personal, confidential, efficient and effective. Or in one word – useful.

As Forbes reported in 2021, “Celebrity endorsements, like Olympic swimmer Michael Phelps’ campaign with virtual therapy startup Talkspace, started to chip away at the long standing stigma, while mindfulness apps like Calm offered meditation sessions at the click of a button. But it was the Covid-19 pandemic and collective psychological fallout that finally mainstreamed mental health.” As proof, they noted mental health start-up funding has increased more than fivefold over the prior four years.

Altman was also tracking history. The first “mass medium” technology in the U.S. was voice activated – the radio. He also understood its’ growth trajectory a century ago. From a presence in 1% of households in 1923, it became a fixture in 3/4 of all US homes just 14 years later.

Altman also could see the writing on the wall. The up and coming generations, the ones that gently encouraged Biden to exit stage left, were both lonely and connected.

The most recent Nielson and Edison Research told him that the average adult in the U.S. now  spends four hours a day consuming audio and their associated ads. 67% of that listening was on radios, 20% on podcasts, 10% on music streaming and 3% on satellite radio.

Post-pandemic, younger generations use of online audio had skyrocketed.  In 2005, only 15% of young adults listened online. By 2023, it had reached 75%. And as their listening has risen, loneliness rates in young adults have declined from 38% in 2020 to 24% now.

A decade earlier, screenwriter Spike Jonze ventured into this territory when he wrote Her. Brilliantly cast, the film featured Joaquin Phoenix as lonely, introverted Theodore Twombly, reeling from an impending divorce. In desperation, he developed more than a relationship (a friendship really) with an empathetic reassuring female AI, voiced by actress Scarlett Johansson.

Scarlett’s performance was so convincing that it catapulted Her into contention for 5 academy awards winning Best Original Screenplay. It also apparently impressed Sam Altman, who, a decade later, approached Scarlett to be the “voice” of ChatGPT’s virtual lead. She declined, seeing the potential downside of becoming a virtual creature. He subsequently identified a “Scarlett-like” voice actor and chose “Sky” as one of five voice choices to embody ChatGPT. Under threat of a massive intellectual property challenge, Altman recently “killed off” Sky, but the other four virtual companions (out of 400 auditioned) have survived.

As for content so that “what you say” is as well represented as “how you say it,” companies like Google have that covered. Their LLM (Large Language Model) product was trained on content from over 10 million websites, including HealthCommentary.org. Google engineer, Blaise Aguera y Arcas says “Artificial neural networks are making strides toward consciousness.”

Where this all ends up for the human race remains an open question. What is known is that the antidote for loneliness and isolation is relationships. But of what kind? Who knows? Oxford’s Evolutionary Psychologist Robin Dunbar believes he does.

Altman likely paid close attention to this review by Atlantic writer Sheon Han in 2021: “Robin Dunbar is best known for his namesake ‘Dunbar’s number,’ which he defines as the number of stable relationships people are cognitively able to maintain at once. (The proposed number is 150.) But after spending his decades-long career studying the complexities of friendship, he’s discovered many more numbers that shape our close relationships. For instance, Dunbar’s number turns out to be less like an absolute numerical threshold than a series of concentric circles, each standing for qualitatively different kinds of relationships.… All of these numbers (and many non-numeric insights about friendship) appear in his new book, Friends: Understanding the Power of Our Most Important Relationships.”

But what many experts now agree is that voice seems to unlock the key. Shorthand for Altman: Pick the right voice and you might just trigger the addition of 149 “friends” for each ChatGPT “buyer.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex.(Grove/2020)