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George Halvorson’s Perfect Health Care Plan
George C. Halvorson is chairman and chief executive officer of Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals, headquartered in Oakland, California. Kaiser Permanente is the nation’s largest nonprofit health plan and hospital system, serving more than 8.6 million members and generating $40 billion in annual revenue.
George Halvorson serves on the Institute of Medicine Task Force on Evidence Based Care and the Commonwealth Commission for a High Performing Health System. He serves on the American Hospital Association’s Advisory Committee on Health Care Reform. He chairs the World Economic Conference Health Governors for 2009 and chairs the International Federation of Health Plans. He has received the Modern Healthcare/Health Information and Management Systems Society CEO IT Achievement Award. The Workgroup for Electronic Data Interchange also awarded him the 2009 Louis Sullivan Award for leadership and achievements in advancing health care quality.
Halvorson has written several health care reform books, including the newly released Health Care Will Not Reform Itself: A User’s Guide to Refocusing and Reforming American Health Care. He also wrote Health Care Reform Now!, Health Care Co-ops in Uganda, Strong Medicine, and Epidemic of Care as guidebooks for health care reform.
Halvorson served as an advisor to the governments of Uganda, Great Britain, Jamaica, and Russia on issues of health policy and financing. His strong commitment to diversity and inter-ethnic healing has led him to his current writing project, a new book about racial prejudice around the world.
Prior to joining Kaiser Permanente, Halvorson was president and chief executive officer of HealthPartners, headquartered in Minneapolis. With more than 30 years of health care management experience, he has also held several senior management positions with Blue Cross and Blue Shield of Minnesota.
Question: What are the elements of a perfect system?
George Halvorson: A perfect system is patient-focused. It's not built around the caregivers, it's not built around opportunities, it's not built around revenue streams, it's built around the patients. The perfect system focuses on the patient. And the perfect system has all of the information about each patient so that knowledgeable caregivers working with the patient can figure out the optimal care pattern for that patient is. And if you're a healthy person and pre-diabetic, the right plan for you is to avoid diabetes. If you have diabetes and you've got co-morbidity, the right plan for you is a plan that links your caregivers and manages the complications. And everybody has different perfect outcome, everybody should have care plan. Everyone should have somebody working with them, a care team, a support team working with them to optimize their care. The perfect system can do that.
In an imperfect system, patients stumble into the Emergency Room, that’s unconnected to anything else they do, they get care for their asthma in one place and get care for their kidney failure in another place-- completed unrelated care. An imperfect system is built around the individual provider business sites and not around care. The perfect system has a data flow, has information going to the patients, has patients able to make informed choices. So, when you’ve got one hospital that has a death rate for heart disease of three or four times the next hospital over, patients should know that. There should be an informed set of choices for patients. There are huge differences in oncology outcomes. If you have stage 3 cancer, you’re likelihood of living six months is significantly different depending on the oncologist you chose. Nobody knows that. If you have a mammogram read, the accuracy of the mammogram varies significantly based on the reader. Some readers have twice as many mammograms getting to stage 3 and death as other readers. And nobody knows that. People don’t know that. So, people assume, “I had a mammogram and are protected.” The perfect system would keep track of mammogram success rates, cancer survival rates, bone surgery success rates. If you sort through the process – heart surgery success rates. And make that information part of the data flow that patients can use.
So, you need the right data, you need the right incentives, you need patient-focused care plans and you put all that together and combine that with the current medical science and there’s a great opportunity to do some really wonderful things for people.
What we have instead is a silent system. At Kaiser Permanente, because we are vertically integrated, can do a lot of this work now and we are doing it. The rest of the world isn’t vertically integrated, so it’s harder to do a lot of those pieces. But what the rest of the world can do is virtual integration. If you can’t be vertically integrated, you can still create integration links using the computer, care registries, data flows, and create care plans for patients and then provide feedback to that from other sources, like the claims processing system.
If you go to the doctor and you have a claim filed on our behalf by the doctor, there’s the diagnosis, there’s the treatment, there’s the cost of care, there’s the person who did it, the timeframes. Most of the information that’s in a medical record is in the claim. It’s not timely, the accuracy level is a little lower, it’s not real time, but it’s there. And so, if you’re having asthma attacks, multiple asthma attacks will show up on both of the electronic medical record and the claims database. And right now, the electronic medical record can use it to make an improvement of care. The claims database is wasted. That data is not being used and it could be used and should be used. So, part of the American Health Care Reform agenda should be to create access to that database and require everybody who pays for care in America to use that database and focus on issues like asthma care to make sure every asthmatic basically ends up with at least a computer tracking their care and some kind of a care plan that will improve asthma care.
Question: Should we pursue realignment where care providers and insurers combine?
George Halvorson: It makes huge sense to have as much alignment as you can possibly get between the revenue stream and the care delivery. We need to reward the best providers for being the best providers. Some processes are into very individual, like knee surgery, topically involve the knee surgeon and the patient and doesn’t involve quite a few other areas, although there are therapists involved in the recovery. Other conditions like diabetes take an entire team of caregivers. And so you need team coordination, team dataflow, team reward system. The very best payers ought to reward a partner with teams of caregivers for the chronic conditions and then create a marketplace that rewards the best performance by the individual performers. And if you did both of those things, you would have better knee surgery, and better diabetic care. And if the insurance company stands back from that whole process and isn’t part of it relative to the benefit package or dataflow, information flow, channeling patients to the best providers, I think that does the patients a disservice because the teamwork should be there and that partnership should be there.
So the ideal model going forward is a linked model. And also there are quite a few vertically integrated care systems in America that ought to be thinking about stepping up to the plate and taking prepayments, much like Kaiser. And I think as we go forward, depending on how healthcare reform shakes out, that could happen.
Question: What are the solutions that will be ideal for the long term and not just stop gap measures?
George Halvorson: I think there is an understanding on the part of President Obama and some of the key Senate leaders, and some of the key House leaders that the care delivery system is not organized optimally right now and that we ought to be working toward a better model. And I think there is an appreciation of team care, and I think there is an appreciation of data flows, datasets, data tracking, informed patient choice. I think all of that is in the air, but it’s not sufficiently in the bills. And so we’ve had discussions, conversations, hearings about those kinds of issues, and then when the bills finally got written, some of those pieces didn’t get incorporated. Even when Senator Backus did his hearing the other day, or his press conference, and he talked about how he would like to see healthcare organized in the future, one of the things he cited was us, Mayo, Cleveland Clinic, Geysinger, some of the other care systems, and said it would be good for America to reorganize and to move down those paths.
I think though that the way America can get there is not by trying to reorganize the system from that perspective. It’s by saying, we need to fix a couple of things in this country. We need to have half as many kids with asthma attacks. We need to figure out how to put all of the pieces in place to get there. And if we set a goal like that, diagnose every kid, make sure that every kid has a treatment plan, make sure there is a database, make sure you’re tracking what happens to every kid, when you put all of those pieces in place they lend themselves to a system because you can’t achieve those things unless you have tools, data, information, somebody accountable. And if we set a few goals for the country and then work backward from the goals to the plan and take that very seriously and have reward systems based on achieving those plans, I think what will happen then is there will be a natural gravitation of caregivers into more tightly organized and coordinated care teams. But that’s not going to happen until there is a reason to do it.
A caregiver is not going to reorganize just for the theory of it, or because somebody gave a nice speech and it sounded good, or because Mayo has a great brand, or we have a great brand. They’re going to do it because doing it makes it more likely that they will cut the number of heart failure attacks in half. And if they do that, and if they band together to do that and they are rewarded for doing that, that model will work. So, I think we’ve got to get there; goal first, rewards, tools, and then I think there will be an aggregation that will come out of it, but it will be an aggregation that results from the goal, not one that creates the outcome.
And if you look at any other business, if you look at any – if you go to a factory, there are no factories in the world that will build a tool and throw the tool randomly into the factory and hopes that somebody picks it up and uses it in some smart way. Every factory says, this is a product we want, we want to produce this hubcap, we want this hubcap to have a 99.9% degree of variability. To do that, what are the tools have to be. And then they work backward from the hubcap to the tool kit. Healthcare is the only thing that throws a new wrench in and says, “I hope somebody in there uses it and somehow in the end the hubcap is better.” It doesn’t work. So we have to start. We have to start with the hubcap, we have to start with the outcome, we have to cut the number of congestive heart failure patients, or the number of asthma attacks and then build the toolkit from that and then the benefit package, that Blue Cross pays has to reward those outcomes. Because if they ignore the outcomes, or do as we do now and actually reward perverse outcomes, care delivery will not change.
Topic: Easing the transition to another model
George Halvorson: Healthcare in this country responds very quickly to incentives. So, if you created a care environment where the care teams who cut the number of asthma attacks in half win; get more money, get more patients benefit. If you create a situation where the care teams that have half as many kidney failures win, everybody will gravitate to that model. Healthcare providers are very, very smart. You don’t get through medical school or hospital administration school without being very smart. So, everybody very carefully studies the compensation system and understands exactly what is rewarded and what’s not. And if you try to force people on just for the sake of putting them into teams and there is no reward involved and there is no positive outcome, people won't go to teams. But if you create a reward system that rewards the result of teams then people will figure 15 very creative ways to the form teams. And so it has to be in the results. You've got to build the architecture as every other market does a product that is sold.
Now think about cell phones. The cell phone market is based on the product that’s sold. You will not sell a cell phone today of the kind that we used three or four years ago in the market because that's not what people want to buy today. And so the cell phone market is constantly changing, constantly improving because they are rewarded by the change. They're not changing because they like to change—they’re changing because they trying to get to that next market share than because there is a win for them by coming up with a better phone, engineering a better phone. There is no win in healthcare right now coming up with a better outcome. There is none. There's actually a loss. And so you've got to change that; that has to change. Healthcare people are just as smart as cell phone engineers. So if you change that then the entire system will follow that and that's what the change has to happen. And it's got to be in rewarding a different set of outcomes and then people will organize differently and put toolkits in place to get to those outcomes.
Recorded on: September 21, 2009
The CEO of Kaiser Permanente thinks the ideal health care plan would be built around the patient. What we have now is a silent system, he says.
Higher education faces challenges that are unlike any other industry. What path will ASU, and universities like ASU, take in a post-COVID world?
- Everywhere you turn, the idea that coronavirus has brought on a "new normal" is present and true. But for higher education, COVID-19 exposes a long list of pernicious old problems more than it presents new problems.
- It was widely known, yet ignored, that digital instruction must be embraced. When combined with traditional, in-person teaching, it can enhance student learning outcomes at scale.
- COVID-19 has forced institutions to understand that far too many higher education outcomes are determined by a student's family income, and in the context of COVID-19 this means that lower-income students, first-generation students and students of color will be disproportionately afflicted.
What conditions of the new normal were already appreciated widely?<p>First, we understand that higher education is unique among industries. Some industries are governed by markets. Others are run by governments. Most operate under the influence of both markets and governments. And then there's higher education. Higher education as an "industry" involves public, private, and for-profit universities operating at small, medium, large, and now massive scales. Some higher education industry actors are intense specialists; others are adept generalists. Some are fantastically wealthy; others are tragically poor. Some are embedded in large cities; others are carefully situated near farms and frontiers.</p> <p>These differences demonstrate just some of the complexities that shape higher education. Still, we understand that change in the industry is underway, and we must be active in directing it. Yet because of higher education's unique (and sometimes vexing) operational and structural conditions, many of the lessons from change management and the science of industrial transformation are only applicable in limited or highly modified ways. For evidence of this, one can look at various perspectives, including those that we have offered, on such topics as <a href="https://www.insidehighered.com/digital-learning/blogs/rethinking-higher-education/lessons-disruption" target="_blank">disruption</a>, <a href="https://www.nytimes.com/2020/02/20/education/learning/education-technology.html" target="_blank">technology management</a>, and so-called "<a href="https://www.insidehighered.com/sites/default/server_files/media/Excerpt_IHESpecialReport_Growing-Role-of-Mergers-in-Higher-Ed.pdf" target="_blank">mergers and acquisitions</a>" in higher education. In each of these spaces, the "market forces" and "market rules" for higher education are different than they are in business, or even in government. This has always been the case and it is made more obvious by COVID-19.</p> <p>Second, with so much excitement about innovation in higher education, we sometimes lose sight of the fact that students are—and should remain—the core cause for innovation. Higher education's capacity to absorb new ideas is strong. But the ideas that endure are those designed to benefit students, and therefore society. This is important to remember because not all innovations are designed with students in mind. The recent history of innovation in higher education includes several cautionary tales of what can happen when institutional interests—or worse, <a href="https://www.insidehighered.com/news/2016/02/09/apollos-new-owners-seek-fresh-start-beleaguered-company" target="_blank">shareholder</a> interests—are placed above student well-being.</p>
Photo: Getty Images<p>Third, it is abundantly apparent that universities must leverage technology to increase educational quality and access. The rapid shift to delivering an education that complies with social distancing guidelines speaks volumes about the adaptability of higher education institutions, but this transition has also posed unique difficulties for colleges and universities that had been slow to adopt digital education. The last decade has shown that online education, implemented effectively, can meet or even surpass the quality of in-person <a href="https://link-springer-com.ezproxy1.lib.asu.edu/article/10.1007/s10639-019-10027-z" target="_blank">instruction</a>.</p><p>Digital instruction, broadly defined, leverages online capabilities and integrates adaptive learning methodologies, predictive analytics, and innovations in instructional design to enable increased student engagement, personalized learning experiences, and improved learning outcomes. The ability of these technologies to transcend geographic barriers and to shrink the marginal cost of educating additional students makes them essential for delivering education at scale.</p><p>As a bonus, and it is no small thing given that they are the core cause for innovation, students embrace and enjoy digital instruction. It is their preference to learn in a format that leverages technology. This should not be a surprise; it is now how we live in all facets of life.</p><p>Still, we have only barely begun to conceive of the impact digital education will have. For example, emerging virtual and augmented reality technologies that facilitate interactive, hands-on learning will transform the way that learners acquire and apply new knowledge. Technology-enabled learning cannot replace the traditional college experience or ensure the survival of any specific college, but it can enhance student learning outcomes at scale. This has always been the case, and it is made more obvious by COVID-19.</p>
What conditions of the new normal were emerging suspicions?<p>Our collective thinking about the role of institutional or university-to-university collaboration and networking has benefitted from a new clarity in light of COVID-19. We now recognize more than ever that colleges and universities must work together to ensure that the American higher education system is resilient and sufficiently robust to meet the needs of students and their families.</p> <p>In recent weeks, various commentators have suggested that higher education will face a wave of institutional <a href="https://www.businessinsider.com/scott-galloway-predicts-colleges-will-close-due-to-pandemic-2020-5" target="_blank">closures</a> and consolidations and that large institutions with significant online instruction capacity will become dominant.</p> <p>While ASU is the largest public university in the United States by enrollment and among the most well-equipped in online education, we strongly oppose "let them fail" mindsets. The strength of American higher education relies on its institutional diversity, and on the ability of colleges and universities to meet the needs of their local communities and educate local students. The needs of learners are highly individualized, demanding a wide range of options to accommodate the aspirations and learning styles of every kind of student. Education will become less relevant and meaningful to students, and less responsive to local needs, if institutions of higher learning are allowed to fail. </p> <p>Preventing this outcome demands that colleges and universities work together to establish greater capacity for remote, distributed education. This will help institutions with fewer resources adapt to our new normal and continue to fulfill their mission of serving students, their families, and their communities. Many had suspected that collaboration and networking were preferable over letting vulnerable colleges fail. COVID-19's new normal seems to be confirming this.</p>
President Barack Obama delivers the commencement address during the Arizona State University graduation ceremony at Sun Devil Stadium May 13, 2009 in Tempe, Arizona. Over 65,000 people attended the graduation.
Photo by Joshua Lott/Getty Images<p>A second condition of the new normal that many had suspected to be true in recent years is the limited role that any one university or type of university can play as an exemplar to universities more broadly. For decades, the evolution of higher education has been shaped by the widespread imitation of a small number of elite universities. Most public research universities could benefit from replicating Berkeley or Michigan. Most small private colleges did well by replicating Williams or Swarthmore. And all universities paid close attention to Harvard, Princeton, MIT, Stanford, and Yale. It is not an exaggeration to say that the logic of replication has guided the evolution of higher education for centuries, both in the US and abroad.</p><p>Only recently have we been able to move beyond replication to new strategies of change, and COVID-19 has confirmed the legitimacy of doing so. For example, cases such as <a href="https://www.washingtonpost.com/education/2020/03/10/harvard-moves-classes-online-advises-students-stay-home-after-spring-break-response-covid-19/" target="_blank">Harvard's</a> eviction of students over the course of less than one week or <a href="https://www.nhregister.com/news/coronavirus/article/Mayor-New-Haven-asks-for-coronavirus-help-Yale-15162606.php" target="_blank">Yale's apparent reluctance</a> to work with the city of New Haven, highlight that even higher education's legacy gold standards have limits and weaknesses. We are hopeful that the new normal will include a more active and earnest recognition that we need many types of universities. We think the new normal invites us to rethink the very nature of "gold standards" for higher education.</p>
A graduate student protests MIT's rejection of some evacuation exemption requests.
Photo: Maddie Meyer/Getty Images<p>Finally, and perhaps most importantly, we had started to suspect and now understand that America's colleges and universities are among the many institutions of democracy and civil society that are, by their very design, incapable of being sufficiently responsive to the full spectrum of modern challenges and opportunities they face. Far too many higher education outcomes are determined by a student's family income, and in the context of COVID-19 this means that lower-income students, first-generation students and students of color will be disproportionately afflicted. And without new designs, we can expect postsecondary success for these same students to be as elusive in the new normal, as it was in the <a href="http://pellinstitute.org/indicators/reports_2019.shtml" target="_blank">old normal</a>. This is not just because some universities fail to sufficiently recognize and engage the promise of diversity, this is because few universities have been designed from the outset to effectively serve the unique needs of lower-income students, first-generation students and students of color.</p>
Where can the new normal take us?<p>As colleges and universities face the difficult realities of adapting to COVID-19, they also face an opportunity to rethink their operations and designs in order to respond to social needs with greater agility, adopt technology that enables education to be delivered at scale, and collaborate with each other in order to maintain the dynamism and resilience of the American higher education system.</p> <p>COVID-19 raises questions about the relevance, the quality, and the accessibility of higher education—and these are the same challenges higher education has been grappling with for years. </p> <p>ASU has been able to rapidly adapt to the present circumstances because we have spent nearly two decades not just anticipating but <em>driving</em> innovation in higher education. We have adopted a <a href="https://www.asu.edu/about/charter-mission-and-values" target="_blank">charter</a> that formalizes our definition of success in terms of "who we include and how they succeed" rather than "<a href="https://www.washingtonpost.com/opinions/2019/10/17/forget-varsity-blues-madness-lets-talk-about-students-who-cant-afford-college/" target="_blank">who we exclude</a>." We adopted an entrepreneurial <a href="https://president.asu.edu/read/higher-logic" target="_blank">operating model</a> that moves at the speed of technological and social change. We have launched initiatives such as <a href="https://www.instride.com/how-it-works/" target="_blank">InStride</a>, a platform for delivering continuing education to learners already in the workforce. We developed our own robust technological capabilities in ASU <a href="https://edplus.asu.edu/" target="_blank">EdPlus</a>, a hub for research and development in digital learning that, even before the current crisis, allowed us to serve more than 45,000 fully online students. We have also created partnerships with other forward-thinking institutions in order to mutually strengthen our capabilities for educational accessibility and quality; this includes our role in co-founding the <a href="https://theuia.org/" target="_blank">University Innovation Alliance</a>, a consortium of 11 public research universities that share data and resources to serve students at scale. </p> <p>For ASU, and universities like ASU, the "new normal" of a post-COVID world looks surprisingly like the world we already knew was necessary. Our record breaking summer 2020 <a href="https://asunow.asu.edu/20200519-sun-devil-life-summer-enrollment-sets-asu-record" target="_blank">enrollment</a> speaks to this. What COVID demonstrates is that we were already headed in the right direction and necessitates that we continue forward with new intensity and, we hope, with more partners. In fact, rather than "new normal" we might just say, it's "go time." </p>
Iranian Tolkien scholar finds intriguing parallels between subcontinental geography and famous map of Middle-earth.
- J.R.R. Tolkien hinted that his stories are set in a really ancient version of Europe.
- But a fantasy realm can be inspired by a variety of places; and perhaps so is Tolkien's world.
- These intriguing similarities with Asian topography show that it may be time to 'decolonise' Middle-earth.
Mental decolonisation<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMzQzMDM0OS9vcmlnaW4ucG5nIiwiZXhwaXJlc19hdCI6MTY1MDU4Mjg3N30.pKS1PLxKYeJ6WDPAcleg7NCxzDn7Pddcg9rSJaul6no/img.png?width=980" id="56ee5" class="rm-shortcode" data-rm-shortcode-id="1d2ba98946accd12f7e0070c8d10154d" data-rm-shortcode-name="rebelmouse-image" alt="Menu page for Arda.ir, the website of the Persian Tolkien Society." />
Menu page for Arda.ir, the website of the Persian Tolkien Society.
Image: Arda.ir<p>Where on earth was Middle-earth? Based on a few hints by Tolkien himself, we've always sort-of assumed that his stories of "The Hobbit" and "The Lord of the Rings" were centered on Europe, but so long ago that the shape of the coasts and the land has changed. </p><p>But perhaps that's too easy and too Eurocentric an assumption; perhaps, like so many other things these days, Tolkien's fantasy realm too is in dire need of mental decolonisation.</p><p>And here's an excellent occasion: an Iranian Tolkienologist has found intriguing hints that the writer based some of Middle-earth's topography on mountains, rivers, and islands located in and near present-day Pakistan. </p><p>As mentioned in a previous article – recently reposted on the <a href="https://www.facebook.com/VeryStrangeMaps" target="_blank">Strange Maps Facebook page</a> on the occasion of the death of Ian Holm – Tolkien admitted that "The Shire is based on rural England, and not on any other country in the world," and that "the action of the story takes place in the North-West of 'Middle-earth', equivalent in latitude to the coastlands of Europe and the north shores of the Mediterranean."<br></p>
Non-European topography<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMzQzMDM1MC9vcmlnaW4ucG5nIiwiZXhwaXJlc19hdCI6MTY1NTQ4MzcyMX0.891LPW42L78fdrwUhXdgOab7cbhs3YOqZK4ukIQx-Rw/img.png?width=980" id="6741c" class="rm-shortcode" data-rm-shortcode-id="2b50c57cb3b8a3a1cc8a4696c89ad954" data-rm-shortcode-name="rebelmouse-image" alt="Map of Tian-shan, the Himalayas, and the Pamirs" />
If you look at it like that, yes: that does resemble Mordor...
Image: Mohammad Reza Kamali, reproduced with kind permission<p>Extrapolating from the location of the Shire in Middle-earth and from other clues dropped by Tolkien, geophysics and geology professor Peter Bird matched the geography of Middle-earth with that of Europe (more about that in the <a href="https://bigthink.com/strange-maps/121-where-on-earth-was-middle-earth?utm_medium=Social&utm_source=Facebook&fbclid=IwAR0ZFYK1EXrf4J3B3X5_U4hSAgidgBs24ZNTYV9QEFbz2qI34OA_DpZsn70#Echobox=1592583835" target="_blank">aforementioned article</a>).</p><p>However, seeing Middle-earth as a mere palimpsest for present-day Europe is to place an undue limit on the imagination of its creator. As Tolkien also said about the shape of his world: "[It] was devised 'dramatically' rather than geologically or paleontologically."</p><p>In other words, certain parts of Middle-earth may very well have been inspired by other places than European ones. It is telling that it took a non-European connoisseur of Tolkien's topography to find some examples. <br></p>
"Seen that map before"<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMzQzMDM1MS9vcmlnaW4ucG5nIiwiZXhwaXJlc19hdCI6MTY1MTQ3Njc3NH0.azDO1_NWm9q9FwMpmqBOV2troOX0ajAXS4lP2bLstJI/img.png?width=980" id="1b193" class="rm-shortcode" data-rm-shortcode-id="21c3d38b14503ba8edac18c0ef1cceb0" data-rm-shortcode-name="rebelmouse-image" alt="Map of Indus river" />
The Indus river is a prominent geographical feature of Pakistan. Its course is similar to that of the Anduin, the Great River of Middle-earth.
Image: Mohammad Reza Kamali, reproduced with kind permission<p>In an article published on <a href="https://arda.ir/" target="_blank">Arda.ir</a>, the web page for the Persian Tolkien Society, Mohammad Reza Kamali writes that during several years of cartographic study, "I found that maybe there are real lands [that] could have inspired Professor Tolkien, and some of them are not in Europe."</p><p>Around 2012, Kamali's eye stopped when it came across a Google Map of Central Asia that showed the mountain chain of the Himalayas, the peaks of the Pamirs bunched together in an almost circular area, and the huge, flat oval of the Takla Makan desert, bounded to the north by the Tian-Shan mountains. </p><p>"I had seen that map before," he writes. "This is of course Mordor, the land of Sauron and the dark powers of Middle-earth, where Frodo and Sam destroy the One Ring." </p><p>In <a href="http://lotrproject.com/map" target="_blank">Tolkien's world</a>, the Himalayas transform into Ephel Duath, the Mountains of Shadow; and the Tian Shan into Ered Lithui, the Ash Mountains. And the circle-shaped Pamirs "are the same shape and in exactly the same corner as the Udûn of Mordor, where Frodo and Sam originally tried getting into Mordor, via the Black Gate."<br></p>
Similar shapes<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMzQzMDM1Mi9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxMDQyODMzNX0.KHrY7rDCNNaKKJQz-xn431APM2TqxGPCaMsqNvBe1xA/img.jpg?width=980" id="7a9fa" class="rm-shortcode" data-rm-shortcode-id="e87f1af97902201abc042640255606b2" data-rm-shortcode-name="rebelmouse-image" alt="Marine Corps helicopter flying over Tarbela Dam" />
A US Marine Corps helicopter flying over the Tarbela Dam on the Indus river in Pakistan. At its center: a former river island which may have been the inspiration for Cair Andros, a ship-shaped island in Middle-earth's Anduin river.
Image: Paul Duncan (USMC), public domain<p>Mulling over these similarities, Kamali became convinced that Tolkien's map work was heavily inspired by Asia. Looking further, he found more evidence. Consider Anduin, the Great River of Middle-earth, in whose waters the One Ring was lost for more than two thousand years. </p><p>On Tolkien's map, the Anduin bends toward the sea in a shape similar to that of another great river: the Indus, which runs the length of Pakistan. Like the Anduin, it flows to the west of a major mountain chain. A prominent feature of the Anduin is the river island of Cair Andros, just north of Osgiliath. Its name means 'Ship of Long Foam', a reference to its long and narrow shape, and the sharpness of its rocks, which split the waters of the Anduin like a prow. <br></p><p>Kamali is not entirely sure, but proposes that Tolkien may have been inspired by a similar-shaped island in the Indus. Now integrated into the Tarbela Dam, which was inaugurated in 1976, it would still have been a separate island in the 1930s and '40s, when Tolkien dreamed up his map.</p>
Kutch as Tolfalas Island<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMzQzMDM1NC9vcmlnaW4ucG5nIiwiZXhwaXJlc19hdCI6MTYwOTU5NjcyNn0.869W8iiowQb9_T3laFKOUe5o5UMXuMlSITb1VxRlC2g/img.png?width=980" id="9c49e" class="rm-shortcode" data-rm-shortcode-id="548bafc6042cc7515e07f77657aa161c" data-rm-shortcode-name="rebelmouse-image" alt="Map of Kutch" />
During the rainy season, the coastal region of Kutch, near the mouth of the Indus, turns into an island that resembles Tolfalas Island, near the mouth of the Anduin.
Image: Mohammad Reza Kamali, reproduced with kind permission<p>Turning our eyes to the mouth of the Anduin and Indus, we see another pair of islands, and Kamali is more certain about the real one having inspired the fictional one. The fictional one is Tolfalas Island, the largest island in Belfalas Bay. <br></p><p>At first glance, it doesn't seem to have a real-life counterpart near where the Indus joins the Arabian Sea. But take a look at the coastal part of the Indian state of Gujarat. It is known as <em>Kutch</em>, a name which apparently refers to its alternately wet and dry states. In the rainy season, the shallow wetlands flood and Kutch becomes an island – the biggest island in the Gulf of Kutch, and not too dissimilar to Tolfalas Island. </p>
General knowledge<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMzQzMDM1NS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYyMDIwODkyOH0.aInJedv3tiQo1LmW-M6D5LV699oeWNltxeYcVKWwtF0/img.jpg?width=980" id="9bc6e" class="rm-shortcode" data-rm-shortcode-id="01d97d3941f9ba732b4df35c3aedd977" data-rm-shortcode-name="rebelmouse-image" alt="British Indian Empire 1909 Imperial Gazetteer of India" />
1909 map showing British India in pink (direct British control) and yellow (princely states). Circled: Kutch, clearly recognisable as an island.
Image: Edinburgh Geographical Institute; J. G. Bartholomew and Sons, public domain<p>But are these similarities really more than coincidences? Why would Tolkien, who was based in Cambridge and steeped in English lore and Germanic mythology, turn to the Indian subcontinent for topographical inspiration? Perhaps because cartographic knowledge of that part of the world was far more general in Britain then than it is now. Until the late 1940s, the countries we know today as India and Pakistan were part of the British Empire. Detailed maps of the region would have been standard fare for British atlases. </p><p>Kamali is convinced that the topographical features on Tolkien's map of Middle-earth are not mere fantasy, but derive from actual places in our world, and were 'riddled' onto the map. In that case, we may look forward to more discoveries of Tolkien's real-world inspiration. <br></p>
From Frodingham to Frodo<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMzQzMDM1Ni9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTU5NzgzMzE2OH0.uMd43VxS9WQSWr1Z0IQ-UxIhBYkERhxTU7hoPvNachk/img.jpg?width=980" id="05037" class="rm-shortcode" data-rm-shortcode-id="ff9aace7fc7c111df3639a276cedf63c" data-rm-shortcode-name="rebelmouse-image" alt="Photograph of J. R. R. Tolkien in army uniform" />
J.R.R. Tolkien in 1916, when he was 24. Around that time, he was stationed near the village of Frodingham, which may have given him the inspiration for the name of the main protagonist in Lord of the Rings.
Image: public domain<p>Here's one example of Tolkienography—if that's what we can call the effect of actual geography on this particular writer's imagination—which I gleaned myself, some years ago in East Yorkshire. A local historian told me that Tolkien had been stationed in the area during the First World War, and had apparently stored away some local place names for later use. The name Frodo, he said, derived from a town where he had attended a few dances – Frodingham, a village across the Humber in northern Lincolnshire, not far from Scunthorpe (<em>Scunto</em>? We dodged a bullet there). </p><p>Whether that story is entirely true or not is beside the point. As fantasy fans know, any grail quest is ultimately about the quest, not the grail. In fact, to quote Mr Kamali, the treasure is important only because it's well hidden, "by a clever professor who enjoys riddles."</p><p><em>Unless otherwise indicated, illustrations are from Mr Kamali's <a href="https://arda.ir/the-tale-of-the-annotated-map-and-tolkien-hidden-riddles/?fbclid=IwAR3RmtU0ZdyzQGlK-iCsUjho4LA2W279fwO9dt8vv90FX2IeO3zrfMuMToU" target="_blank">article</a> on <a href="https://arda.ir/" target="_blank">Arda.ir</a>, reproduced with kind permission. </em><br></p><p><strong>Strange Maps #1036</strong></p><p><em>Got a strange map? Let me know at </em><a href="mailto:firstname.lastname@example.org">email@example.com</a><em>.</em></p>
The ocean's largest shark relies on vision more than previously believed.
- Japanese researchers discovered that the whale shark has "tiny teeth"—dermal denticles—protecting its eyes from abrasion.
- They also found the shark is able to retract its eyeball into the eye socket.
- Their research confirms that this giant fish relies on vision more than previously believed.
A. Anterior view of the whale shark, showing the locations of the eye (arrows). Note that whale shark eye is well projected from the orbit. Photo was taken in the sea near Saint Helena Island. B. Close-up view of the left eye of a captive whale shark (Specimen A).<p>Considering their dietary habits, vision was not thought be that important for whale sharks. This species is unique for not having any sort of eyelid or protective mechanism—until now, that is. Not only do dermal denticles protect their vision, the team, led by Taketeru Tomita, discovered that whale sharks have another trick:</p><p style="margin-left: 20px;">"We also demonstrate that the whale shark has a strong ability to retract the eyeball into the eye socket."</p><p>The researchers studied these massive sharks in an aquarium, offering them a rare look at one of the ocean's largest fish (They also studied deceased sharks). The eye denticle is different from the rest of the scales covering their body: they are designed for abrasion resistance, not ocean stealth. </p><p style="margin-left: 20px;">"The covering of the eye surface with denticles in the whale shark is probably useful in reducing the risk of mechanical damage to the eye surface." </p><p>Despite their massive size, whale sharks have relatively small eyes, measuring less than 1 percent of their total length. Their brain's visual center is also relatively small. With this discovery, the researchers realized vision plays a more important role than previously assumed. </p><p style="margin-left: 20px;">"The highly protected features of the whale shark eye, in contrast to the traditional view, seems to suggest the importance of vision in this species. Interestingly, Martin showed that whale shark eyes actively track divers swimming 3–5 m away from the animal, suggesting that vision of the whale shark plays an important role in short-range perception." </p><p>While you likely won't bump into a whale shark while swimming just off the coast, this is yet another reminder of how species adapt to their environment. </p><p><span></span>--</p><p><em>Stay in touch with Derek on <a href="http://www.twitter.com/derekberes" target="_blank">Twitter</a>, <a href="https://www.facebook.com/DerekBeresdotcom" target="_blank">Facebook</a> and <a href="https://derekberes.substack.com/" target="_blank">Substack</a>. His next book is</em> "<em>Hero's Dose: The Case For Psychedelics in Ritual and Therapy."</em></p>
On Friday, NASA's InSight Mars lander captured and transmitted historic audio from the red planet.
- The audio captured by the lander is of Martian winds blowing at an estimated 10 to 15 mph.
- It was taken by the InSight Mars lander, which is designed to help scientists learn more about the formation of rocky planets, and possibly discover liquid water on Mars.
- Microphones are essentially an "extra sense" that scientists can use during experiments on other planets.
Listening for sounds on Mars<p>It's not the first time NASA has tried to capture audio on the Martian surface. The agency's Mars Polar Lander was outfitted with a microphone, but that craft ultimately crashed into the planet in 1999 after shutting its engines off too early. The Phoenix Lander managed to stick its landing in 2008, but NASA chose not to engage the craft's camera or microphone after a mission malfunction.</p><p>NASA plans to capture more audio from the red planet on its Mars 2020 mission. That lander will be equipped with two microphones that will, among other things, listen to what happens when the craft fires a laser at rocks on the surface. When that happens, parts of the rock will vaporize, causing a shockwave that makes a popping sound. The noises captured from interactions like these can <a href="https://www.space.com/32696-microphone-on-nasa-mars-rover-2020.html" target="_blank">help tell scientists about the mass and makeup of the rocks</a>.</p><p>In other words, microphones give scientists another "sense" to use during experiments on the Martian surface.</p>
A gigantic star makes off during an eight-year gap in observations.
- The massive star in the Kinsman Dwarf Galaxy seems to have disappeared between 2011 and 2019.
- It's likely that it erupted, but could it have collapsed into a black hole without a supernova?
- Maybe it's still there, but much less luminous and/or covered by dust.
A "very massive star" in the Kinman Dwarf galaxy caught the attention of astronomers in the early years of the 2000s: It seemed to be reaching a late-ish chapter in its life story and offered a rare chance to observe the death of a large star in a region low in metallicity. However, by the time scientists had the chance to turn the European Southern Observatory's (ESO) Very Large Telescope (VLT) in Paranal, Chile back around to it in 2019 — it's not a slow-turner, just an in-demand device — it was utterly gone without a trace. But how?
The two leading theories about what happened are that either it's still there, still erupting its way through its death throes, with less luminosity and perhaps obscured by dust, or it just up and collapsed into a black hole without going through a supernova stage. "If true, this would be the first direct detection of such a monster star ending its life in this manner," says Andrew Allan of Trinity College Dublin, Ireland, leader of the observation team whose study is published in Monthly Notices of the Royal Astronomical Society.
Between astronomers' last look in 2011 and 2019 is a large enough interval of time for something to happen. Not that 2001 (when it was first observed) or 2019 have much meaning, since we're always watching the past out there and the Kinman Dwarf Galaxy is 75 million light years away. We often think of cosmic events as slow-moving phenomena because so often their follow-on effects are massive and unfold to us over time. But things happen just as fast big as small. The number of things that happened in the first 10 millionth of a trillionth of a trillionth of a trillionth of a second after the Big Bang, for example, is insane.
In any event, the Kinsman Dwarf Galaxy, or PHL 293B, is far way, too far for astronomers to directly observe its stars. Their presence can be inferred from spectroscopic signatures — specifically, PHL 293B between 2001 and 2011 consistently featured strong signatures of hydrogen that indicated the presence of a massive "luminous blue variable" (LBV) star about 2.5 times more brilliant than our Sun. Astronomers suspect that some very large stars may spend their final years as LBVs.
Though LBVs are known to experience radical shifts in spectra and brightness, they reliably leave specific traces that help confirm their ongoing presence. In 2019 the hydrogen signatures, and such traces, were gone. Allan says, "It would be highly unusual for such a massive star to disappear without producing a bright supernova explosion."
The Kinsman Dwarf Galaxy, or PHL 293B, is one of the most metal-poor galaxies known. Explosive, massive, Wolf-Rayet stars are seldom seen in such environments — NASA refers to such stars as those that "live fast, die hard." Red supergiants are also rare to low Z environments. The now-missing star was looked to as a rare opportunity to observe a massive star's late stages in such an environment.
In August 2019, the team pointed the four eight-meter telescopes of ESO's ESPRESSO array simultaneously toward the LBV's former location: nothing. They also gave the VLT's X-shooter instrument a shot a few months later: also nothing.
Still pursuing the missing star, the scientists acquired access to older data for comparison to what they already felt they knew. "The ESO Science Archive Facility enabled us to find and use data of the same object obtained in 2002 and 2009," says Andrea Mehner, an ESO staff member who worked on the study. "The comparison of the 2002 high-resolution UVES spectra with our observations obtained in 2019 with ESO's newest high-resolution spectrograph ESPRESSO was especially revealing, from both an astronomical and an instrumentation point of view."
Examination of this data suggested that the LBV may have indeed been winding up to a grand final sometime after 2011.
Team member Jose Groh, also of Trinity College, says "We may have detected one of the most massive stars of the local Universe going gently into the night. Our discovery would not have been made without using the powerful ESO 8-meter telescopes, their unique instrumentation, and the prompt access to those capabilities following the recent agreement of Ireland to join ESO."
Combining the 2019 data with contemporaneous Hubble Space Telescope (HST) imagery leaves the authors of the reports with the sense that "the LBV was in an eruptive state at least between 2001 and 2011, which then ended, and may have been followed by a collapse into a massive BH without the production of an SN. This scenario is consistent with the available HST and ground-based photometry."
A star collapsing into a black hole without a supernova would be a rare event, and that argues against the idea. The paper also notes that we may simply have missed the star's supernova during the eight-year observation gap.
LBVs are known to be highly unstable, so the star dropping to a state of less luminosity or producing a dust cover would be much more in the realm of expected behavior.
Says the paper: "A combination of a slightly reduced luminosity and a thick dusty shell could result in the star being obscured. While the lack of variability between the 2009 and 2019 near-infrared continuum from our X-shooter spectra eliminates the possibility of formation of hot dust (⪆1500 K), mid-infrared observations are necessary to rule out a slowly expanding cooler dust shell."
The authors of the report are pretty confident the star experienced a dramatic eruption after 2011. Beyond that, though:
"Based on our observations and models, we suggest that PHL 293B hosted an LBV with an eruption that ended sometime after 2011. This could have been followed by
(1) a surviving star or
(2) a collapse of the LBV to a BH [black hole] without the production of a bright SN, but possibly with a weak transient."