China’s Third Plenum: Reform is Coming

This past week, Washington was gripped with President Obama’s surprise announcement that you can really keep your health care plan, period. Halfway across the world, China and China-watchers were gripped with another set of announcements:

The results of the Third Plenum of the 18th Central Committee of the Chinese Communist Party (CCP).

So What in the World is a “Third Plenum”?

The Plenary Sessions are meetings of the Central Committee, a subgroup of the National Congress. The Third Plenary Session (“Third Plenum”), which occurs once every five years, is the meeting during which leaders introduce new economic and political reforms. This year’s Third Plenum opened one week ago (Nov 9) and ended last Tuesday (Nov 12).

(For more details, here’s a great explanation of the Plenary Sessions, complete with infographic.)

To underscore the importance of this past week, it’s important to understand what’s happened during prior Third Plenums (Plena?):

  • In the 1978 Third Plenum, Chairman Deng Xiaoping consolidated power, introduced radical economic reforms that propelled China’s remarkable economic growth, and implicitly attacked the cult of Mao, repudiating the Cultural Revolution.
  • In the 1993 Third Plenum, Premier Zhu Rongqi announced the socialist market economy (no contradiction there) and loosened China’s state-owned sector.

So it’s no surprise that analysts excitedly awaited the results of this year’s Third Plenum, especially notable for being timed with the first year of Chairman Xi Jinping’s rule.

They Were Disappointed…Prematurely?

Shortly following the conclusion of the Third Plenum, the CCP released a vaguely-worded communiqué through Xinhua, its state news agency. It was immediately attacked for being heavy on jargon and short on specifics, tempering its promises of economic and political reforms with repeated nods to the “leading role of the state-owned economy”.

Notably, what the communiqué did not mention included:

  • No mention of financial sector liberalization (the Swattie in me wonders if this is necessarily a bad thing)
  • No push for further urbanization (likely because this would require overhauling the age-old hukou system)
  • No indication that President Xi would take on the state-owned enterprises (which dominate China’s oil, aluminum, coal, banking, telecommunications, electricity, transportation and other fields)

Immediately following the release of the vague communiqué, global stocks dipped, headlines called the Third Plenum “disappointing” and “a dud”, and analysts called previously optimistic expectations “sanguine and naïve”, claiming they overestimated Xi and Beijing’s actual power over the rest of the country.

But in the best post-communique analysis I’ve seen, Zachary Keck at The Diplomat argues that disappointment with the Third Plenum is premature. And precisely because it lays the groundwork for helping Xi consolidate enough power to drive through subsequent reforms.

Specifically, the communiqué created two new political bodies that helps Xi consolidate power:

  1. A new state security committee, analogous to the U.S.’s National Security Council. As Keck argues, this new committee is likely meant to “ensure stability as the reforms progress”, which bodes poorly for human rights, but signals the CCP is serious about implementing reforms.
  2. A central leading group reporting directly to top leadership, rather than to the government. This would assist Xi in pushing through reforms by sidestepping the bureaucratic red tape—precisely addressing the problem of limited central power that Beijing faces.

Hot off the Presses: A Blueprint for Reform

And right on cue, the CCP released a new blueprint for reform yesterday, with many more details on specific reforms. These include:

  1. Loosening of the one-child policy. Urban parents can now have two children if either spouse is an only child (previously, both had to be only children).
  2. Abolishment of labor camps, which have been used to imprison people for up to four years without formal arrest or trial. (Unclear how heavily this will be enforced in practice.)
  3. Strengthened rural property rights, allowing farmers to gain more profit from land sales to local governments (hopefully resulting in fewer of these).
  4. Loosening of the hukou system, which may eventually alleviate social and health care access issues for migrants.
  5. Economic liberalization and reforms. A system for insuring back deposits, fewer restrictions on offshore securities investments and M&As, looser pricing controls for energy, water, and telecommunications, and other financial changes I’m not well-versed enough to understand.
  6. Environmental protection-based growth incentives. Specifically, local governments wouldn’t be judged on economic performance alone, but also on environmental protection efforts. That’s cool.

And finally…accelerated health reform. Overhaul of public hospital system, more community hospitals, changes in doc pay, and catastrophic health insurance. I hope to explore the details more in a later post, but for now, this great interview with Shanghai’s former mayor Shen Xiaoming about health reform in Shanghai may provide some indication of where China’s health system is headed.

What the Stock Market Crash Reveals About Medical Errors

This post was first published on Project Millennial.

Proponents of high-deductible health plans want to give patients more skin in the game, to solve our system’s problem of escalating costs. Should our system have more skin in the game to do right by our patients?

The Best Risk-Management Rule Ever?

It is not only economically efficient, but morally imperative, to have “skin in the game”. That’s what Nassim Taleb, author of Fooled by Randomness (2001) and The Black Swan (2007), argues in a recent paper and interview on EconTalk.

Dr. Taleb opens by recounting the “eye for an eye” philosophy of Hammurabi’s code—or, in his opinion, “the best risk-management rule ever.” Three thousand years later, Immanuel Kant posed it in a slightly less morbid way through his notion of a “categorical imperative”: “Act only according to that maxim whereby you can, at the same time, will that it should become a universal law.” Or put more simply, do unto others as you would have them do unto you.

Corporate managers, academics, predictors, warmongers, and politicians, Dr. Taleb argues, are exempt from this moral imperative. They take risks and stand to benefit from the upside of those risks, but are shielded from the downside.

The Moral Hazard of “Fat-Tailed” Phenomenon

In fact, this problem is particularly severe for phenomena Dr. Taleb defines as “fat tailed domains”. A fat-tailed phenomenon is one in which an extremely rare but high-impact event dominates the effect of all other events. Repeated instances of a fat-tailed phenomenon (such as stock market outcomes every year) might look like this (source):

fat tail

A problem exists in that the reputation of market forecasters is based on how often they correctly predict the direction of the market movement, and not by how accurately they predict the final value of the market. (More technically, they are judged by a “binary metric” for what is actually a very skewed distribution.) A forecaster who is frequently right wins widespread admiration, even as people who follow that forecaster’s predictions ultimately see their savings wiped out by that rare, “blow-up” event. The forecaster, meanwhile, is insulated from the full pain of the investment loss.

The more skewed the phenomenon, the easier it is to hide the true impact of a mistake behind a façade of “pretty good performance”.

“Forecasters with steady strings of successes become gods.” –Taleb and Sandis, 2013

Skin in the Game for Patient Safety

Medical errors are a prime example of a fat-tailed phenomenon. For 98.6-99.4% of hospitalizations in the U.S., the patient is discharged without a lethal adverse event. But for the family of the patient who falls into that 0.6-1.4% of hospitalizations, getting killed due to medical error is an extremely “high-impact event”. I would imagine that the physician and care team—if they were aware that their error had caused the patient’s death—would feel very terrible. I’m sure even the hospital administrator would feel pretty bad as he/she looks over their adverse event reports. But will their suffering come close to what the patient’s family feels from the loss?

I’ve previously written about why we haven’t eliminated medical errorsNews flash: hospital errors don’t cause 44,000-98,000 deaths each year, as we previously thought. They cause 210,000-440,000 deaths per year. That makes hospital error the number three killer in the U.S., after heart disease and cancer.

Slow innovation is arguably one of the most effective ways to spur adoption of safer practices. But it is, by its very nature—well, slow. The nation’s third leading cause of death may warrant a bit more urgency. And that brings us back to the moral imperative of skin in the game. Today, individual hospitals and clinicians are rarely judged by the impact of their medical errors. When they are, they are evaluated based on the frequency of their medical errors—a binary metric (error vs. no error) for a very skewed phenomenon (the magnitude of suffering to the patient and family). Given the immense suffering caused by medical errors, it would seem that providers should share the burden in some way—perhaps not literally by Hammurabi’s standards, but, as Dr. Roberts suggests, “substitut[ing] the physical eye for the economic value of the eye”. And yet, the vast majority of public and private payers today are still paying hospitals (even rewarding them) for medical errors.

Dr. Ashish Jha recently wrote an article arguing that incentivizing hospitals for patient satisfaction more than patient safety has led them to invest in lavish amenities over patient safety improvements. To be fair, Medicare finalized a rule this August that will penalize hospitals in the lowest quartile for medical errors or hospital-acquired infections by withholding 1% of their overall payment. But that may not be a strong enough incentive to catch hospital executives’ attention, as Dr. Jha points out in this blog post. If we believe that market forecasters should invest in the same stocks they predict, and that warmongers should be subject to the draft themselves, then why shouldn’t health care providers have some skin in the game when it comes to patient safety?

Geniuses and Hard Work

“Success is a lousy teacher. It seduces smart people into thinking they can’t lose.” -Bill Gates

“You’re Going to Lose More Often Than You Win”

In a recent New York Times op-ed, Ashley Merryman, co-author of NurtureShock: New Thinking About Children and Top Dog: The Science of Winning and Losing, rails against the use of “participation awards”. That is, awards which are given out to all children simply for showing up, regardless of performance. (I’ve got a bunch of participation awards strewn around my basement from my early Tae-Kwon Do years.) It turns out that the science is on her side; Ms. Merryman cites research that shows:

  • Nonstop praise can cause students to collapse at the first sign of difficulty
  • Praising a student for having innate talent can lead them to fixate more on their mistakes
  • Excessive praise can create an expectation of success without real effort

In life, “you’re going to lose more often than you win, even if you’re good at something,” says Jean Twenge, author of Generation Me. “You’ve got to get used to that to keep going.”

True Grit

Incidentally, the reason this article caught my eye was because that same day, the MacArthur Foundation announced its 2013 MacArthur Fellows (journalists love calling them the “Genius Grants“, although the Foundation is loath to do so for reasons that will soon become clear). Among them was Dr. Angela Duckworth, Associate Professor of Psychology at the University of Pennsylvania, whose research focuses on grit: “sticking with things over the very long term until you master them.” Consider some of her lab’s findings:

  • Among cadets at West Point, grit was a better predictor of performance in a rigorous summer training program than intelligence, leadership ability, or physical fitness.
  • Among Scripps National Spelling Bee contestants, grit was a better predictor of advancing to the finals than intelligence.
  • Among Penn students (the perennial test subjects of Penn researchers), grit was a better predictor of GPA than IQ. In fact, those with higher IQs actually had less grit than their peers with lower IQ.

This last point suggests an interesting phenomenon: innate talent–and the frequent early success that comes with it–may reduce the opportunities for an individual to develop his or her grit. This means two things. First, that grit is something that is malleable and can be developed over time (while theories abound over ways to maintain self-control in the short-term, evidence on ways to build grit over the long term has been much harder to find). And second: Bill Gates was right.

A Patient Grit Measure?

And of course, since I’m a health care nerd, I can’t close without connecting this all back to health care in some way. And what got me thinking was the “Grit Scale”, an 8-12 item questionnaire developed by Dr. Duckworth and colleagues that assesses your grit. It’s freely available, and you can take the 12-item version here. I haven’t heard of the Grit Scale being used in health care, but there are other questionnaires that are regularly used. The Patient Health Questionnaire (PHQ-2 and PHQ-9), for example, which has been validated for screening for depression in a primary care setting. Or the Patient Activation Measure (PAM), which gauges a patient’s knowledge, skills, and confidence in managing his or her own health.

I’m venturing into the realm of speculation, but I wonder if the Grit Scale–or some component of it incorporated into existing health questionnaires–can give us a useful measure of which patients are likely to succeed in sticking to a treatment regimen and which patients need extra support. Given that behavior change may be one of the most promising ways to address the coming chronic disease crisis, I think it’s certainly worth exploring.

In the closing minutes of her MacArthur Foundation video, Dr. Duckworth describes the next two areas of her research:

  1. Exploring better ways to measure grit–in particular, “objective measures that don’t require people to measure questionnaires…but looking at their behavior.”
  2. Evaluating interventions to improve grit.

I greatly look forward to seeing what her team finds.

Meanwhile, halfway down their FAQ page, the MacArthur Foundation explains its rationale for avoiding the term, “genius grant”:

“We avoid using the term ‘genius’ to describe MacArthur Fellows because it connotes a singular characteristic of intellectual prowess. The people we seek to support express many other important qualities: ability to transcend traditional boundaries, willingness to take risks, persistence in the face of personal and conceptual obstacles, capacity to synthesize disparate ideas and approaches.” (emphasis mine)

Maybe they should have called them “Grit Grants”.

What If We’ve Been Wrong? Implications of an Imperfect Science

Watch this. If you are pre-med, in medical school, in the health care field, or have ever felt a twinge of disdain for someone who was obese, watch this:

Back in April, as thousands of thinkers, innovators, and TED junkies descended upon DC for the 2013 TEDMED conference, I tweeted about my excitement to see the full talk by Dr. Peter Attia, a surgeon, researcher, and co-founder of the Nutrition Science Initiative (NuSI).

The full talk is finally out. And, man, is it powerful.

A Medical Establishment of Treating Bruises

Dr. Attia raises a provocative suggestion: What if we’ve been wrong about the causation behind obesity and diabetes? What if instead of obesity causing diabetes, obesity is actually a symptom of insulin resistance and other metabolic malfunctions?

Dr. Attia gives the somewhat comical yet strikingly apropos analogy of bruises and banging into coffee tables: Imagine a world in which we thought bruises were the problem. We would evolve “a giant medical establishment and a culture around treating bruises: masking creams, painkillers, you name it, all the while ignoring the fact that people are still banging their shins into coffee tables.” (emphasis mine)

It’s funny until you remember that less than two months ago, the AMA officially classified obesity as a disease. While the decision is unlikely to have much impact on currently research or public health efforts against obesity, I see one area where it could have a marked impact: spurring insurance payments for medical treatment of obesity, i.e. weight loss drugs and bariatric surgery.

  1. Weight loss drugs: Two new weight loss drugs, Qsymia and Belviq, entered the market last year. A day after the AMA decision, a group of lawmakers introduced bills in the Senate and House to require Medicare Part D to pay for weight loss drugs. Qsymia costs about $160/month, or $1920/year. Belviq costs about $200/month, or $2400/year. Our history with weight-loss drugs has not been that great, with many being ultimately pulled due to side effects or leading to rapid weight regain after discontinuation.
  2. Bariatric surgery: Currently, bariatric surgery coverage by Medicare or private payers is limited–something that may change given the new classification. However, the cost-effectiveness of bariatric surgery was called into question by a JAMA article published this February. The surgery and 30-day postoperative care cost $29,517. There was no significant reduction in health care costs for surgery patients compared to non-surgery patients in the 6 years following surgery.

Alarmingly, the vote went against the conclusions of the AMA’s Council on Science and Public Health, which studied the issue for a year and concluded that the main measure used to define obesity (BMI) is simplistic and flawed. More specifically: “Some people with a B.M.I. above the level that usually defines obesity are perfectly healthy while others below it can have dangerous levels of body fat and metabolic problems associated with obesity.” Which brings us back to Dr. Attia’s provocative suggestion: maybe we have cause and effect backwards.

“So what I’m suggesting is maybe we have the cause and effect wrong on obesity and insulin resistance. […] What if being obese is just a metabolic response to something much more threatening, an underlying epidemic, the one we ought to be worried about?” – Dr. Peter Attia

Revisiting an Imperfect Science

Intrigued, I went onto NuSI’s website to see what they’re actually doing. After overcoming my initial reaction that I had tripped upon another miracle weight-loss scam company, I dug deeper and realized that NuSI is actually gathering researchers to tackle significant shortcomings in the literature on the cause and effect of obesity.

Dr. Attia goes hard after the idea that carbohydrate restriction, independent of caloric restriction, is the way to reduce incidence of metabolic disorder, which then causes obesity. NuSI provides a great review of nearly 100 studies on diet and obesity and summarizes key points on why the existing research approach is insufficient. For those who want a summary of the summary, here are some key points:

  • The vast majority of dietary trials are “free-living studies“, in which researchers tell ordinary people to stick to a dietary regimen and then evaluate their adherence through questionnaires or food diaries. If people actually listened, we probably would have solved the obesity crisis by now.
  • The more stringent option is to isolate people in metabolic wards to monitor their intake. Any volunteers?
  • Even studies with sufficient sample size and decent adherence fail to parse out the effects of caloric restriction and carbohydrate restriction. This is a crucial nuance, as it precludes us from testing the hypothesis whether restricting a particular micronutrient (e.g. carbs) is more important for preventing obesity than reducing caloric intake overall.
  • A few studies have managed to make this distinction, but they relied on lean individuals. “Similar results might not have been obtained in a group of obese individuals or lean individuals susceptible to obesity.”

This last point is particularly provocative, as it suggests that obesity may be much less a result of “poor self-control” than we are inclined to assume. I had the opportunity to do a little research in the glorious field of gut bacteria research, and there’s rapidly growing evidence that of two perfectly identical people (at least from the outside) who consume the same foods, one may become strikingly more obese because of the gut bacteria in his/her gut. I recently began reading Dr. Eric Topol’s The Creative Destruction of Medicine, and I can easily foresee a world in which individuals have their gut bacteria characterized (which you can do for $80), and then have metabolic therapies tailored for them. But seeing as I’m already pushing 1000 words, that’s a story for another time.

What If We’ve Been Wrong?

Have you watched the video yet? If not, take two minutes and click to 13:30.

I think the power of Dr. Attia’s speech doesn’t come primarily from the provocative nature of his hypothesis, or from the facts he musters to support it. It comes from his tangible humility, and the painful implication that by staking our belief in an imperfect science, we may be letting our patients down.

“We can’t keep blaming our overweight and diabetic patients like I did. Most of them actually want to do the right thing, but they have to know what that is, and it’s got to work. […] If obesity is nothing more than a proxy for metabolic illness, what good does it do us to punish those with the proxy?” -Dr. Peter Attia

Blog Post Published on Project Millennial!

A big thanks to the folks at Project Millennial for publishing my newest blog post: “Why Haven’t We Eliminated Medical Errors?“. Project Millennial is a health care blog seeking to get the allegedly apathetic millennial generation excited about health care. There are some fantastic regular contributors to the blog, and I’m honored to have a post included by them.

I’ve included the opening of my post here:

To Err is (Still) Human

Last week, Consumer Reports released its new “surgery ratings”, encompassing 2,463 hospitals in all 50 states and the District of Columbia. The ratings measure the rate of hospital deaths and unexpected discharge delays for 27 common surgeries, including hip and knee replacements, back surgery, and angioplasty. Scrolling through the publicly available ratings list, I was struck by the number of dark shaded circles filling my screen—each one representing a hospital that performed poorly by their standards.

It’s been 14 years since the Institute of Medicine published its landmark “To Err Is Human” study, which estimated that a shocking 44,000-98,000 Americans die each year as a result of medical errors (0.2%-0.5% of hospitalizations). The study called for a 50% reduction in errors by 2004, asking, “Must we wait another decade to be safe in our health system?” It appears so; a 2010 NEJM study measured the rate of errors in ten North Carolina hospitals from 2002 to 2007. North Carolina was specifically chosen for having a “high level of engagement in efforts to improve patient safety.” Yet out of 2341 admission records reviewed, 588 harms were identified for a rate of 25.1 harms per 100 admissions. 14 involved harms that caused or contributed to a patient’s death, leading to a 0.6% hospitalization death rate due to medical error.

The dial hadn’t moved.

(Continue reading here.)

Prevention Isn’t the (Only) Answer: Two Sobering Findings

True or false:

  1. The best way to reduce health care costs is to prevent costly admissions for the sickest patients.
  2. Diet and exercise will help accomplish this goal for patients with diabetes.

Have you guessed?

Two studies out this week, which have flown under the radar of many news stations, suggests the answer may not be what we intuitively thought.

Almost 90% of Hospitalization Costs are Unavoidable

A new study from Dr. Karen E. Joynt and colleagues, published concurrently with their presentation of the results at the Academy Health conference, suggests that only about 12% of total acute care costs are actually “preventable”. They looked at 2009-2010 spending data for over 1 million Medicare beneficiaries and categorized their ED and hospitalization costs as “preventable” and “non-preventable” based on validated algorithms. This is what they found:

  • The top 10% most costly patients (“high-cost”) were responsible for 73.0% of total acute care costs. No surprise there, for anyone who’s read Atul Gawande’s “The Hot Spotters“, or heard of the 80-20 rule.
  • For both high-cost and non-high-cost  patients, slightly more than 40% of ED visits and costs were deemed preventable. Sounds promising…
  • However, total ED costs (~$124 million) paled in comparison to total hospitalization costs (~$3.0 billion). For these costs, “preventable” costs constituted only 9.6% of costs for high-cost patients and 16.8% for everyone else.

I’ve thrown together a graphic to illustrate this. Preventable costs are shaded darker:

Data source: Joynt KE, Gawande AA, Orav EJ, Jha AK. 2013. Contribution of preventable acute care spending to total spending for high-cost Medicare patients. JAMA. 2013 June 24;309(24):doi:10.1001/jama.2013.7103.

Data source: Joynt KE, Gawande AA, Orav EJ, Jha AK. 2013. Contribution of preventable acute care spending to total spending for high-cost Medicare patients. JAMA. 2013 June 24;309(24):doi:10.1001/jama.2013.7103.

This means that even if a health system succeeds in preventing 100% of its unnecessary ED visits, and in preventing all hospitalizations related to congestive heart failure, bacterial penumonia, COPD, urinary tract infections, etc. (diseases deemed to be “preventable” given effective outpatient management), total costs would only drop by 12.5%. That’s not very enticing, especially considering the formidable investment required to develop such care management capacity.

The main issue appears to be that the most costly hospitalizations, such as orthopedic conditions and cancer, can’t be prevented simply with better outpatient care management. You can do as much health coaching as possible, but short of confining granny to solitary confinement, she might eventually need that hip replacement.

The authors offer some cautious takeaways:

“These findings suggest that strategies focused on enhanced outpatient management of chronic disease, while critically important, may not be focused on the biggest and most expensive problems plaguing Medicare’s high-cost patients. Indeed, while a proportion of these very expensive inpatient episodes may be potentially preventable (such as acute myocardial infarction or degenerative joint disease leading to orthopedic procedures), their prevention would likely require a long time horizon and substantial investments in population wellness.” (emphasis mine)

Of course, hit those expensive diseases early with the one-two punch of diet and exercise! But just how long of a time horizon is needed? If you’re trying to prevent heart attacks in diabetics, it appears the answer is: longer than 9.6 years.

Diet and Exercise Failed to Reduce Heart Attack/Stroke Among Diabetics

It was not a heartening day for proponents of care management and prevention. Another study, from the Look AHEAD (Action for Health in Diabetes) Research Group, implemented a randomized intervention of diet and exercise for overweight diabetic patients and set out to track them for 13.5 years, hoping to prove some health benefits. They stopped it at a median of 9.6 years based on a futility analysis; it didn’t work.

Most strikingly, the diet and exercise intervention seemed to work just fine. When the study ended, intervention patients had achieved significantly greater weight loss (-6.0% vs -3.5%), reduction in waist circumference (-1.8% vs -0.9%), and improvement in fitness score (+3.7% vs -2.0%). Not only that, they had significantly greater improvements in almost all measured cardiovascular risk factors (including glycated hemoglobin, blood pressure, and triglycerides).

So it’s puzzling that the incidence of cardiovascular-related hospitalizations or death was statistically indistinguishable between the two groups (P=0.51).

Don’t Put All Your Eggs in the Care Management/Prevention Basket

Despite these sobering findings, I’m still of the opinion that care management and prevention are worthy efforts, as Drs. Carroll and Frakt point out in an accompanying editorial. After all, 12.5% of a very large number is still a very large number. And the diabetes study did show many indicators between the intervention and control groups converging after the first year; if we could figure out a way to sustain the benefits of exercise and diet, perhaps the longitudinal effects on outcomes would be more pronounced.

That said, maybe we should focus on two additional sources of cost savings:

  1. Streamline care processes and avoid costly errors during (non-preventable) hospitalizations. In fact, one of the study authors wrote the book on how a 5-step checklist prevented 43 central line infections and saved ~$2 million over 2 years. He’s now bringing the approach to birth and end-of-life care. And he’s not the only one achieving breakthrough results with simple solutions.
  2. Take a closer look at post-acute care. A provocative article last month pointed the finger at post-acute care for variations in Medicare spending. Since post-acute care made up 13.4% of national health expenditures in 2012 (compared to hospital care’s 31.5%), there could definitely be substantial opportunity to reduce costs there.

But perhaps the most important takeaway is: Never assume a strategy will work, even if it sounds logical, until you’ve looked at the data.

Price Transparency: An Interactive Timeline

“Price transparency.” Search the term on google news and almost all of the hits deal with health care. In the less than four months since Steven Brill published his Time expose on hospital prices (which I commented on), health care price transparency has vaulted to the center of national health care debate.

Today, Mr. Brill is on Capitol Hill testifying at a Senate Finance Committee hearing on price transparency. Sounds like he had some pretty harsh words on Obamacare.

Given the growing momentum on the topic, I’ve thrown together an interactive timeline of key events that have happened in the last few weeks. (Really wish WordPress would allow me to embed flash.) Enjoy!