James Fallows

James Fallows is a national correspondent for The Atlantic and has written for the magazine since the late 1970s. He has reported extensively from outside the United States and once worked as President Carter's chief speechwriter. His latest book is China Airborne. More

James Fallows is based in Washington as a national correspondent for The Atlantic. He has worked for the magazine for nearly 30 years and in that time has also lived in Seattle, Berkeley, Austin, Tokyo, Kuala Lumpur, Shanghai, and Beijing. He was raised in Redlands, California, received his undergraduate degree in American history and literature from Harvard, and received a graduate degree in economics from Oxford as a Rhodes scholar. In addition to working for The Atlantic, he has spent two years as chief White House speechwriter for Jimmy Carter, two years as the editor of US News & World Report, and six months as a program designer at Microsoft. He is an instrument-rated private pilot. He is also now the chair in U.S. media at the U.S. Studies Centre at the University of Sydney, in Australia.

Fallows has been a finalist for the National Magazine Award five times and has won once; he has also won the American Book Award for nonfiction and a N.Y. Emmy award for the documentary series Doing Business in China. He was the founding chairman of the New America Foundation. His recent books Blind Into Baghdad (2006) and Postcards From Tomorrow Square (2009) are based on his writings for The Atlantic. His latest book is China Airborne. He is married to Deborah Fallows, author of the recent book Dreaming in Chinese. They have two married sons.

Fallows welcomes and frequently quotes from reader mail sent via the "Email" button below. Unless you specify otherwise, we consider any incoming mail available for possible quotation -- but not with the sender's real name unless you explicitly state that it may be used. If you are wondering why Fallows does not use a "Comments" field below his posts, please see previous explanations here and here.
  • St. Marys Interlude: The Okefenokee

    Ever wondered what one of America's most famous swamps looks like? Wonder no more.

    In the Okefenokee Swamp (James Fallows)
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    Reinvention and resilience across the nation
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    When we have told people who are not from Georgia that St. Marys, where we spent time last month, adjoins the Okefenokee Swamp, the most typical reaction has been: I've always wanted to see the Okefenokee!

    Same on our side. We missed it during our visits to this region during the 1970s. Last month, with prominent local citizen Wyman Westberry, we spent a day at the Okefenokee, whose Waycross entrance is not far east of St. Marys. This is how it looks.

    The "blackwater" of the swamp, due to tannins leaching from the vegetation:

    Although black, the water is clear and clean, and reflective, and hosts wildlife. Including this baby.

    Another illustration of the reflectivity, and the general effect:

    And a reflectivity gimmick:

    At tree level, an infinity of Spanish moss:

    From above-treetop-level, the effects of many dry years (although many of the leafless trees in the foreground are deciduous trees that had not yet leafed out):

    Plus animals fictional:

    And real. These were not babies. The smallest was about the same size as me.

    Meanwhile, today on our partner Marketplace's broadcast, Kai Ryssdal had a very nice interview with Deb Fallows, shown here in the Okefenokee, about the subject of one of her previous posts: the complex embedded meanings of the questions you ask strangers on first being introduced. It was also the subject of a nice presentation by the Atlantic's video team, here.

    So if you are wondering what the Okefenokee looks like, this gives you a start. Tomorrow, more on the complex economic ambitions of the small neighboring town of St. Marys, and how they can match the  accomplishments of its impressive county-wide high school.

     

     

     

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  • How to Check If a Site Is Safe From 'Heartbleed'

    If your site reads Safe, it makes sense to change your password. Even if it doesn't yet, a change still makes sense.

    This post follows one a few hours ago about the Heartbleed security failure, and for safety's sake it repeats information I have added to that post as an update.

    Point 1: If you would like to test to see whether a site is exposed to the loophole created (over the past two years) by the OpenSSL bug, you can go here and enter the URL you are concerned about. (This tip via Bruce Schneier.) As explained in the FAQ, the test sometimes delivers "false positives" for vulnerability  -- that is, it may report problems with a site that actually is OK, or that is in the middle of taking steps to protect itself. But the site's creator explains why "false negatives" -- OK signals when there actually is a problem -- should be very rare, and especially if you perform the test several times. Update Here is another good test site.

    Point 2: If a site tests through as Safe, then it makes sense to change your password there. And all of my email and financial sites are now saying Safe, so the changes I am making there will stick.

    But even if a site does not say Safe, the people I have asked say that it still makes sense to change -- even though you'll need to change again when the SSL for that site is fully repaired.

    Reasoning: If you change it now, it's possible that a still-active hacker will capture info today. But if you don't change it now, anything exploited in the past two years is vulnerable. Also, many sites that are not yet fully protected are on higher alert than they would have been before this news, so hackers may have a tougher time in the new environment than when this was an unknown-unknown.

    Point 3: The guy who created the test site, a young Italian cryptologist based in Milan, has a donation button on the site.

    UPDATE: Here is another industrial-strength test site. I tried the same domain on it, and the score you see here is way, way close to the top of those it has tried. And here is another test site.

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  • The 5 Things to Do About the New Heartbleed Bug

    Should you take the latest security scare seriously? I do, and here are the steps I am taking.

    [Please see important UPDATE in a newer post, and repeated at the bottom of this post.] Most flaps about scary new Internet bugs are just typical scary Internet flaps. This latest one, the Heartbleed bug, I am taking seriously. Potentially it means that username/ password combos for the sites everyone considered secure have in fact been hacked and stolen.

    Update: Just this second, I see that Bruce Schneier has declared the bug "catastrophic." Consider yourself warned. Schneier adds:"On the scale of 1 to 10, this is an 11." He has no track record as an alarmist.

     You can read more about how it happened, and why it matters, at this helpful master site and the dozens of useful tech links it includes. Here is also an overview from TechCrunch. (Update: and here is one of several useful test facilities to let you check the status of sites you're concerned about.)

    Simplest way to understand the problem: one of the protocols that many sites use to protect their own security, in an implementation known as OpenSSL (for Secure Socket Layers), itself has a previously unknown bug. That bug, in place for the past two years, could in theory allow an attacker to harvest large amounts of name/password combos plus other info from sites believed to be perfectly safe. Because exploitation of the bug would have left no trace, no one (except a potential hacker) yet knows how many names have been taken, or from where.

    A patched OpenSSL version exists and is being deployed. Until then, what should you do? Here's a five-point checklist, followed by explanations.

    1. Change the passwords for the handful of sites that really matter to you. I'll explain how you can do this in a total of ten minutes or less. This probably isn't necessary, but just in case...
       
    2. Do not ever use the same password at two sites that matter to you. Ever. Heartbleed or not, this lowers the security level of any site with that password to the level of the sleaziest and least-secure site where you've ever used it. 
       
    3. Use a password manager, which can generate an unlimited set of unique, "difficult" passwords and remember them for you.
       
    4. Use "two-step" sign-in processes wherever they're available, starting with Gmail.
       
    5. Read what happened in our family three years ago, when one of our Gmail accounts was taken over by someone in Africa, if you would like a real-world demonstration of why you should take these warnings seriously. It's from an article called "Hacked."  

    That's the action plan. Now the details.


    What I am personally doing about Heartbleed, and why.

    -  I am changing my password for a handful of "important" sites. My finance-related sites: bank accounts, credit cards, mortgage-payment, investment accounts. The email accounts I actually use, three of them in total and all Gmail-based. Plus all social-media accounts. Even though on most of these accounts I am dormant rather than active, I'd rather not have someone take over the account and cause problems in that way.  (UPDATE: In response to questions, you would need to do this again once the OpenSSL patch has been distributed or the sites have in other ways confirmed their safety. Nonetheless it seems worth doing even now, even given the possibility that a site is still vulnerable and could have new info intercepted as you're changing it, because otherwise you're exposed to any info collected over the past two years.)

    - I am abiding by the watchword of never using the same password on two accounts that matter. Whoever is in charge of security at, say, HottestCheerleadersPlusCheapMedicineFromThailand.com (not an actual site I have visited) might not know how to protect against hacks, or might even dishonestly sell its user info to hackers. They could then blindly try the combos elsewhere.

    - I am making all this easy on myself by using a password manager. The one I have used and liked for several years is LastPass, which was also the top choice in this recent PC Mag review. You can read reviews of a wide range of alternatives here and here. The idea behind all of them is that they store a vast range of passwords you could not possibly remember yourself; they automatically fill them in for your sites; and they have a range of very tough security measures to protect this precious central vault. In well under 1 minute per site, I can have Last Pass generate a new, "difficult," never-before-used password for important sites -- let's say u!YKhtAs7xQA , though that's not a real one -- and set my systems up to use that automatically.

    For now I'm not getting into the conceptual question of whether one centralized password trove is theoretically more vulnerable than the "distributed" approach of trying to manage this all on your own. In reality, I'm convinced that it's better to use a password manager, and safer than the alternative of trying to keep track of a whole list of passwords on your own. (For instance, you can read Last Pass's explanation of how it does encryption right on each user's computer, not at the central site, so that even someone who got the main controls wouldn't know your passwords.) The only password I keep in my mind is a very long password for Last Pass itself. It's so long that it could never be cracked by brute force, much as no one will win Warren Buffett's billion-dollar bet on the NCAA tournament. But it's very easy for me to remember, because it's a long passage I can reel off by heart.

    -- I am using two-step sign-in processes for every system that allows them, and you should too. Gmail does this, and in fact pioneered this as a free feature for mass, non-commercial users. Last Pass also does so. How this works: In certain circumstances, logging in requires not simply your password but an extra, real-time code that is sent to or generated by your mobile phone or other device. What it means: For all practical purposes, someone cannot take over your account from afar. Since so many destructive scams and hacks are carried out remotely -- from Russia, China, West Africa, Israel, the Stans, you name it -- this is the easiest possible protection you can take against a very broad category of attack.

    Two-step systems can be mildly inconvenient, but a lot of that has been buffed away. For instance, you can set Gmail so that it doesn't need the second password as long as you are using your own computer or phone. For more details, see this and this

    More as the story develops. The point for now: none of us can do anything about larger architectural questions of security, surveillance, vulnerability, and so on for the Internet. But along the spectrum of what that architecture makes possible, we can make ourselves less rather than more vulnerable. These steps will help.


    Update: Via Bruce Schneier, it is very much worth checking out this test site, to see whether a site you deal with frequently has been repaired to avoid the SSL bug. For instance, here -- fortunately -- is what you would see for the Atlantic's site:

    In theory, changing a password on a not-yet-fixed site could create new vulnerability, if a hacker has just decided to start watching it today. In practice, most of the people I have checked with say it's worth doing, because otherwise you're exposed to anything captured within the past two years. Then, when a site becomes safe -- as shown above -- it certainly makes sense to change the password. For further explanation, see this follow-on post

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  • What an Autopilot Could Never Do

    Fun with flying, extreme crosswinds edition.

    Last week I posted a video of airliners whose pilots skillfully executed the "crab into kick" technique for landing in a crosswind. As a reminder: the airplane approaches the runway at a "crab" angle, to offset the wind and keep its heading lined up with the runway. Then, when the wheels are just a few feet above the ground, the pilot "kicks" the airplane's own axis into alignment with the runway (so sideways force doesn't shear off the wheels when they touch down), with pressure on the rudder.

    Now some illustrations of how things look if the wind is even stronger and gustier. These take-offs and landings, and numerous "go-arounds," were filmed this winter at Birmingham airport in England, under what were evidently extremely gusty conditions. The wind's strength is one challenge. The continual changes in strength -- the gusts -- are the real problem.

    Whoa. This is the kind of thing no autopilot could ever handle. Thanks to reader BB for the tip.

    And great camerawork, by the way. Also, I know that the camera angle foreshortens things, so it can look as if the planes are descending helicopter-style. Still, that runway is impressively hilly. For instance, as shown in the approach starting at time 6:00. 

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  • But Seriously Now, Why Do Doctors Still Make You Fill Out Forms on Clipboards?

    "Meditative practices emphasize returning to one’s breath. The clinical equivalent of this is to return to one’s patient. "

    Growth of "Hospitalists," a relatively new medical specialty discussed in the last note below. ( Society of Hospital Medicine )

    We'll get back to St. Marys, Georgia, later today. For now, let's dip back into the mailbag for the latest array of views -- most from doctors or other medical professionals, some from technologists, some from "ordinary" patients -- on the pluses and minuses of the shift to electronic medical records. For background: my original Q&A with Dr. David Blumenthal, who directed the electronic-records program at the start of the Obama administration. That article also has links to four previous rounds of discussion -- and, why not, here they are again. One, two, three, and four. Now, eight more ways of looking at electronic medical records.

    1) "Unremitting folly" and "lack of leadership," and apart from that it has some problems. A negative verdict:

    I am a recently retired family physician and was formerly a physicist. Fifty years ago I was programming a mainframe computer in Fortran and am currently using the Python language to pursue several interests. I have experience with 4 different EHRs. Though not a computer expert, I am neither a technophobe nor a Luddite. 

    My purpose in writing to you is to draw your attention to the elephant in the room. In brief, the rollout of electronic health records (“EHRs”) in the United States is a story of unremitting folly, lack of leadership, opportunities wasted, and a stiff dose of medical academic hubris.

    Anyone involved with medicine or information technology (“IT”) has surely been aware for 3 decades or more that EHRs were coming, someday, somehow. The potential advantages were always clear enough. Broadly speaking, they were ready access to individual patient data at the point of care and aggregated patient data, “big data", to be mined somehow for new medical knowledge.

    Standards for medical records were developed, but were overly broad and insufficiently specific (see, for example, HL-7).  The Department of Defense and the Department of Veteran Affairs were interested in developing a systems-wide EHR, which probably discouraged any entrepreneur reluctant to develop a product only to see the government version become a national standard. 

    The lack of a clear standard is a major issue. EHRs, like computer operating systems, are a highly path-dependent technology.  The system you buy today will be yours to live with for the next 20 years, even if no system available today meets your needs.  A good example of this path dependence is the history of Unix-like versus Microsoft versus Apple operating systems.  Unfortunately, the EHR mandate ignores the lesson.

    We now see a technology not ready for deployment being imposed on hospitals and other health care systems. They can buy in with some help from the federal treasury or wait and be penalized for not being on line, an interesting new form of under funded federal mandate. Health care systems are scrambling to enlarge IT departments. Different vendors’ systems are largely not interoperable. This is more than a nuisance when patients self-refer between health care providers.

    For a physician seeing patients in clinic an EHR can be an astonishing impediment. We are rebuked, often deservedly, for being insufficiently engaged with our patients, yet now must spend more time in front of computer displays. (“Why can’t I find a nurse? They are in the patients’ rooms because the computer system is down.”)  

    The practice of medicine involves intensely personal encounters; indeed the patient-physician relationship is what makes being a primary care physician such a privilege.  The EHR does not accommodate narrative analysis of a patient encounter, also known as the personal touch. 

    Voice recognition requires time-consuming, highly distracting concurrent proofreading, quite unlike dictation transcribed by human intelligence.  

    Examination rooms are small (and are not going to grow), requiring that the physician’s back be toward the patient when addressing the computer. [JF note: several previous reader-messages have suggested solutions to this problem.] In the examination room the EHR is marginally effective and utterly inefficient. The human-machine interface is crude and by itself should have precluded widespread deployment of EHRs at this time. 

    EHRs have real potential for “encouraging” adherence to guidelines purported to improve “quality of care.” This is at best a mixed blessing. Many, probably most, guidelines are not solidly grounded in evidence or serve the self-interests of their authors. Until the guidelines industry is brought to heel, patients are at risk of negative benefit.  The diabetes-industrial complex is a good illustration of this. 

    The entire history of EHRs in the United States is worthy of a full-length book. An overdue technology, it is here to stay, as it should.  However, the fact remains that it was overpromised and recklessly deployed.  There are lessons to be learned, if and only if analyzed and reported by persons without a personal stake in the matter.

    2) "A patient's visit to the doctor is morphing into a billing session." From another practitioner:

    Maybe I’m late to the party here, but I thought I’d add a few additional perspectives regarding the matter of electronic medical record systems (EMRs).

    First, the good: A tremendous upside to EMRs is that they make the record so easily accessible. When I was a resident, I seemingly spent half of my time running around the hospital searching for patient charts and scans. Scans were the most maddening—the radiology file room was far from where my patients mostly were. Often, the file clerk wasn’t there. Other times, there were several teams ahead of me, and I’d waste 20 minutes standing there waiting for my turn. And then the scan may or may not even have been there—another team may have checked it out and taken it to their work room or the operating room.

    At my current institution (a large academic center) all of our scans are digital and can be viewed from any terminal in the complex and, via an encrypted connection, from any internet-connected computer anywhere. If one of my residents or a radiologist calls me regarding an important finding, I can be looking at the images and discussing the case in under a minute. I can show the images to colleagues, display them at a teaching conference, and use them to educate the patient and his family without worrying whether I’ll be able to get my hands on the films when I need them and without impeding anyone else’s access.

    Now the bad: Others have mentioned that EMRs make it easier to bill for higher levels of service. The larger issue is that, sadly, the patient’s visit to the doctor is morphing into a billing exercise with a clinical encounter appended to it. EMRs facilitate this process, but I think the causes lie upstream—with physicians, with the hospitals that increasingly employ us, and with our political choice to largely preserve a fee-for-service medical system.

    More recently, the billing imperative has been joined by the safety and quality imperatives. These are sorely needed, but they do sometimes distort medical practice and can even strain the doctor-patient relationship. Again, EMRs potentiate this but aren’t the cause. For example, one commonly used quality metric is a hospital or program’s ratio of observed to expected mortality. The numerator is straightforward, but arriving at the denominator requires prognostication based on the patients’ ages and the number, type, and severity of their various morbidities. Just as EMRs make it easier to document in such a way as to capture the highest possible charges, they also make it easier to document in such a way as to portray the highest possible severity of illness (and hence mortality risk). The hospital’s coders are constantly asking me to clarify various diagnoses that are unrelated to the patient’s presentation and that are often outside of my area of expertise. This diverts my attention away from direct patient care and instead toward the practice of massaging electronic medical records in order to optimize mortality ratios.

    For many physicians, the result of this pivot away from the individual patient and his clinical needs and toward the increasingly complex documentation of such is that medicine ceases to be an emotionally and intellectually fulfilling practice and becomes instead clerical work. We no longer spend a few extra minutes getting to know the patient and his family, perhaps learning something seemingly small but ultimately clinically important in the process. We instead spend unsatisfying time asking irrelevant questions (the review of systems) that allow us to check more boxes, bill a higher level of service, and make the patient appear as sick as possible.

    There’s a mental antidote to this pessimistic mindset, which is easier said than done given the cognitive loads under which we all labor—loads that are increased not only by the demands of using EMRs, but also by pagers, cell phones, various inboxes, etc. The antidote is to listen deeply and re-connect with the person in front of you. Meditative practices emphasize returning to one’s breath. The clinical equivalent of this is to return to one’s patient. A corollary to this is that my generation of medical educators, witnessing the end of the paper chart era while having many years of service ahead, must practice and teach the fundamentals of clinical medicine while helping trainees learn to marshal EMRs and other technologies appropriately.

    3) Comparison from France, and from Seattle

    Quote from one of your other readers: "[At] Group Health Cooperative in Puget Sound, electronic medical records were adopted decades ago, and are widely used and highly effective."

    Response: When I lost my insurance and the ability to stay with Group Health, I wanted to take my medical records. But they charged $45 to put them on a CD. Inexcusable even five years ago. They could just as easily have written a simple program to route records to a printer and handed me the stack of paper at nearly zero cost. Let alone providing the option to buy a USB stick for $5, with all records on it.... 

    Of (possible) interest: "The French way of cancer treatment", by Anya Schiffrin, from February 12, 2014.

    "In New York, my father, my mother and I would go to Sloan Kettering every Tuesday around 9:30 a.m. and wind up spending the entire day...feeling woozy, we'd get home by about 5:30 p.m.

    "[In Paris] A nurse would come to the house two days before my dad's treatment day to take his blood. When my dad appeared at the hospital, they were ready for him. The room was a little worn and there was often someone else in the next bed but, most important, there was no waiting. Total time at the Paris hospital each week: 90 minutes."...

    "When my dad needed to see specialists, for example...the specialists would all come to him. The team approach meant the nutritionist, oncologist, general practitioner and pharmacist spoke to each other and coordinated his care. As my dad said, 'It turns out there are solutions for the all the things we put up with in New York and accept as normal.' "

    Competition cannot provide these results, nor any market forces whatsoever. Regarding people as fellow humans can.

    4) And from Vietnam:

    [How it works there.] Go to the doctor. Begin the discussion at his/her desk. Your previous records have been reviewed in the data base. The doctor's hands rest on the desk.  She/he looks you in the eye and asks questions. Diagnosis made. Treatment recommended. If prescriptions are needed, they are input and transmitted electronically to the receptionist and the pharmacy. You make your co-pay pick up your drugs and depart.

    The efficiency is remarkable. I once had a CT scan at a gigantic clinic with a branch here and in California. The radiologist finished and said

    "Go get a cup of coffee and come back. I'll have your films in half an hour."

    EMR is a tool. A hammer is a tool. In the hands of persons with evil or avaricious intent, either one can do tremendous damage.

    5)  And Boston:

    About 4 years ago I changed health insurance plans and moved my business to a doctor who was a member of Partners Healthcare in the Boston area. I eventually discovered that the practice was connected to a medical records system that would allow any practitioner connected to that system to have immediate access to doctor’s notes, lab results, etc. related to my care. I could also email doctors, make appointments, obtain referrals, request subscriptions over the internet. I grew very comfortable with this. 

    Then my wife had a brain seizure and the EMTs took her to the nearest hospital. The hospital and the doctors who worked at that hospital were not connected to the EMR system we had been using. Problems ensued. 

    The hospital had no access to her history of care.

    I had to track down a doctor on a Sunday night and request complete information about my wife’s medications. The doctor had to send an email to my cell phone so that I could verbally communicate this critical information to the attending physician. 

    Drastic changes in medication were made with negative consequences. 

    I had not realized how much better care could be when you are using doctors who have access to an EMR system. But it is important that every doctor and hospital you use be connected to that system. 

    I will not consider using any medical service that is not connected to this EMR system in our area.

    6) And from a doctor's perspective in Boston:

    I am a surgeon who practiced in a solo private practice in a low income area in Massachusetts for 30 years. I bought an EHR in 2011 and participated in the incentive payment program from CMS and a subsequent audit in which the payment was recouped.

    As other physicians have pointed out , the EHR increased my workload by at least 20%.Dr Blumenthal and his team could have worked to make the VA EHR system, that the taxpayers paid to develop, available universally. Instead perhaps thousands of vendors were certified by the government . The price of these systems was always magically about the same: the $45000 in incentive payments that were promised by the CMS over 5 years.

    Once purchased, myriad other charges arose. The systems were clearly designed to maximize billing through justifying documentation modules. They also were set up to create reports to be forwarded to the government regarding "quality of practice." These mostly involved fairly crude measures like  bean counting how many patients had mammograms or colonoscopies.  With all this crammed in, the goal of creating  clear, informative documentation across a variety of specialties was bound to be lost .

    When these systems failed to serve particular practices or specialties well, , physicians were encouraged to develop their own templates and modifications. More time away from patient care and expense loomed.

    In Boston, there are three major hospital and physician practice systems based on the three medical schools: Tufts, Harvard, and BU. When a patient gets chest pain acutely , he will be taken by ambulance to the nearest facility.He may be transferred during his treatment to a different facility that may or may not be part of the hospital system where he was initially brought. His subsequent outpatient may again be not necessarily with physicians who work for the hospital system where he was treated. It is very likely that the various computer systems involved with the documentation of his care have no interconnectivity.

    At one of the many dinner meetings that we were invited to in 2010 and 2011 exhorting us to adopt the EHR , I queried an employee of the Mass ecolloborative, a federal  grant funded entity, about what priority CMS and the government were giving to the issue of interconnectivity. It seemed unlikely that the big, fiercely competitive  hospital systems and  the IT vendors would pursue this on their own . I specifically asked, when would an ER doctor seeing a patient at BU be able to see the records of the patient's previous care at Tufts or Harvard and she shook her head. So I ask if it would be in five years and she shook her head again . I tried ten years and she said "maybe" and then ,on prompting, said "they are talking about this."

    It seems: you are what you mandate, and the approach of Dr Blumenthal and his team, in my view, has  endorsed and augmented the free market model as regards IT and the large hospital chains and their internecine rivalries. The consequences to patients and independent practitioners are enfolding .

    So, what's a patient to do? In China, in the barefoot doctor days, they gave the paper charts to the patients  and let them carry them around.Not unlike in  the third world, many of my low income patients have smart phone access. In France, as TR Reid has reported, you can go to a doctor in their system and put your ID card through their reader and your updated EHR can be read off your chip. Patients need apps that can download and store these various differently configured EHRs. Like a lot of things regarding your health, when patients are empowered, things really can change.

    7) The technology has problems similar to the Pentagon's:

    1. Yes, some of the large health care systems such as Kaiser Permanente have deployed relatively effective electronic health record systems but what is seldom discussed are the huge cost-overruns associated with these deployments. 

    Health care IT procurement in the large delivery systems is similar to the problems that the Pentagon experiences when it buys weapons systems---the systems usually work, but the costs are often much higher than expected (therefore, the net benefits are lower than expected).  This problem is not unique to the health care sector---as you know, development and installation of enterprise software systems is notoriously complex and even some of the most IT savvy corporations and government agencies have experienced huge cost overruns and outright failures in this area. 

    Unfortunately, there is sort of a conspiracy of silence in the health care sector about cost overruns.  Both the software vendors and the executives who run these organizations are loathe to acknowledge this problem, instead they would rather focus on the benefits (which to be sure are real in many instances) and not talk about the costs---for example, Kaiser Permanente's staff has published 3 books touting the benefits of its electronic health records system, but none of the books discuss the costs or many of the daunting technical and organizational challenges they confronted in building their system.  

    2.  The interoperability problem in health care IT has two dimensions.  The first dimension (and the one that gets the most attention) is the lack of interoperability across health care organizations (as noted by the one of the physicians who commented on the VA's system).  The other dimension, which receives relatively little attention, is the lack of interoperability within organizations. 

    Most large health care delivery organizations decide to keep some of their legacy systems when they decide to implement a new EHR---for example, they may decide to keep their existing radiology and lab order systems, which means they have to spend alot of money creating middleware that can facilitate communication between the old systems and the new EHR.  The cost of developing the middleware is often huge because of the absense of industry standards---this is major reason why cost overruns in this space are so common.

    8) And to round things out, illustrating the complexity of working any change in today's health-care system, the complicating fact of that rapidly growing medical specialty, the "hospitalist":

    After years of only needing to see my doctor (the same one since 1977 until 2013) I've had an up close and personal experience with the new system that has required new doctors (a new medical condition and the retirement of my family physician). 

    What has that meant to me as a patient?  Like the doctor you quoted, when I see my new family physician (still the same practice that is the home of thirty some years of handwritten charts), she is looking at the computer instead of me.  She's also asking the same redundant questions over and over again.  There is a third party in the room--the computer--that is getting the major share of the attention. 

    On the other hand, I love having prescriptions entered immediately.  The scary part: I have caught a number of mistakes: which prescriptions I'm actually taking, what the dosages are, what diagnoses I've had in the distant past at another medical facility.  As they say: garbage in, garbage out. The only good thing is that people are mentioning the "garbage" and asking me if it is true because it is more obvious.

    But the computer is just one part of the problem.  Here's a much scarier thing.  An elderly man with Parkinson's is admitted for emergency surgery that has nothing to do with the Parkinson's.  He suffers from constipation--a common side effect of the disease.  He has a regular routine of over the counter medication to help with the problem.  His wife explains to the medical staff that this is what is prescribed by his regular physician. 

    But his care is now overseen by a hospitalist.  His wife is told that the constipation issue is being handled as usual.  It isn't.  After five days, he is extremely bloated and uncomfortable and nothing has been done.  His wife pleads for help for him in the form of an enema. Did I mention that she is the kind of person who doesn't like to be demanding? The hospitalist (who has almost never visited him and operates through the computer and the nursing staff) orders an x ray and then an enhanced x ray.  Meanwhile the patient gets more and more uncomfortable.

    Eventually, relief is prescribed in the form of--an enema.  A human  conversation in the form of a doctor to doctor discussion of the patient's prior conditions and accommodations would have made his recovery from the surgery so much more comfortable.  Instead the inevitable discomfort of the surgery was made worse by adding more discomfort.

    My conclusion: medicine human to human connection as well as technology. I want my doctors to use technology effectively, but I also want them to listen to me and connect with me as a patient rather than as a disease.  I am very fortunate to have found a new doctor who has this combination, but I worry for all those who aren't getting that kind of care.  I'm also convinced that a human connection with doctors and nurses and other medical people helps us trust our care better and helps us follow through with our treatments.  It's not just warm and fuzzy stuff; it's part of our healing.

    Thanks to all. This is about 5% of the mail that has arrived on the topic. Will keep looking through it. 

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  • The Transformation of a Company Town: St. Marys, Part 1

    What happens when the company shuts down?

    Derelict former site of the Gilman Paper Company plant, in St. Marys, Georgia. (James Fallows)

    Last week I mentioned the very impressive "career technical" high school my wife and I had visited in Camden County, on the Georgia coast just north of Florida. Now, some of the background on why the changes in this area have been more striking to us than in many other places we have visited.

    The picture at the top of this post shows the ruins of the Gilman Paper Company, in the coastal Camden County town of St. Marys. "Ruins" is the only possible term. Back in the early 1970s, when a young Jimmy Carter was running for governor of Georgia, Gilman was a fearsome political force in the state and essentially the only employer for many miles around. "Gilman Paper Company is the only major Georgia industry south of Brunswick and east of Waycross," its manager said in a speech around that time. "It can safely be stated that not less than 75 percent of the economy of Camden County is directly dependent on Gilman Paper Company." The picture below, from a Harper's article about St. Marys in 1972, is the same site as in the shot above, when the mill was running full-tilt and employing most of the working-age people in town.

    Back at that same time, when I was just out of college and my soon-to-be wife had a year still to go, we were -- along with my sister and half a dozen other contemporaries -- part of a Ralph Nader team dispatched to write about pollution, tax evasion, economic peonage, and other aspects of company-town life in now-hyper-stylish Savannah and other paper-mill towns in Georgia. The result was this book.

    Inside Marriage Special Report bug
    Reinvention and resilience across the nation
    Read more

    St. Marys was the most bleakly Dickensian of the places we visited. The mill paid good wages, in exchange for all-encompassing political and social control. Its corporate attorney was also the State Representative, and was the county attorney too; the result in tax policy and environmental regulation was predictable. The mill's manager was the local Big Man. The company's owners -- the Gilman brothers of Manhattan -- lived an art-patron life far removed from the harshness of their family's company town. In the past few years, whenever I have gone to brutal, polluted, boss-run factory towns in remote China, I have thought back to St. Marys. It wasn't that long ago that China's current reality was tolerated in the U.S.

    Wyman Westberry, from The Washington Monthly.

    What happened next is too convoluted to attempt to explain here. In brief: a young millwright named Wyman Westberry, who had become disgusted by what we'd now consider China-scale despoliation of the local river and marshlands, drew press attention to what was happening in this little enclave. That's him at left, around the time we first met. He called me late one night, we went down to learn about his town, and we wrote about him in our report. Eventually 60 Minutes and national and statewide media got interested in St Marys. In the midst of the furor, the local Big Men put out a contract to have Westberry killed (the going rate was $50,000, but the would-be hit man decided to keep the money but not carry out the hit). The administration of new Governor Jimmy Carter began paying attention; and -- at the end of an Elmore Leonard-worthy tale -- Wyman Westberry ended up surviving, and much of the local establishment either ended up in prison or died before coming to trial.

    You can read the subsequent blow-by-blow -- and I actually hope you will -- in a Washington Monthly article I wrote ten years after all the drama*, or in a (subscribers-only) Harper's article by Harrison Wellford and Peter Schuck from 1972, or this more recent Forbes piece on the "Fall of the House of Gilman," or from our original The Water Lords book.  [*UPDATE The scanned PDF of this issue of the Washington Monthly, by Unz.org, is a little squirrelly in its layout. But when you come to what seems to be the end, on page 19, you can click the > button at the top of the page and it will take you to the rest of the story. Or, you can click on the Entire Issue button, which should do the trick too. I am biased, but I think it's a gripping tale. For a while it had a movie option, which is something can't say about a lot of things I've written.] 

    As I'll describe in future dispatches, Wyman Westberry has stayed in town, and become a formidable figure -- and in a very different role from mill wright at a paper mill. That's him, on the left, a few weeks ago with me near St. Marys in the Okefenokee Swamp.

    The city too is transformed. When we first visited, the pollution from the paper mill was so thick and caustic that, as in a scene from modern China, even the Spanish moss had been poisoned from the trees. Now the trees look like this.

    Back then, there was a perpetual layer of ash on cars and houses downwind of the mill. Now the historic part of St. Marys -- the part not subject to strip-mall sprawl near the Interstate and the Kings Bay naval base -- looks like this:

    And, downtown:

    And across what had once been a fouled and polluted marsh:

    All of this is set-up to the story we have looked at during our recent trip to St. Marys. What happens when the company at the heart of a Company Town shuts down? How different is the new "company town" life that has come with the area's dependance on a large Navy base? What does the resilience of a man like Wyman Westberry tell us more generally? And is there any chance that a place like this, with its impressive high school and its ambition to become America's next space port, can become a "talent magnet" like Greenville or Burlington?

    More in upcoming installments. Here is the route to St. Marys, in red -- with the last little jog to avoid a prohibited zone over the Navy base.

    And what the scenery on the way down looked like.

    More of the St. Marys saga, starting with the "spaceport," to come. 

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  • 'I Love Sioux Falls,' Word-Cloud Style

    What residents' words tell you about their town.

    John Tierney and Deborah Fallows

    Deb Fallows -- whose relevant ID for the moment is as a linguistics expert and a fellow-traveler and co-pilot on our American Futures journeys [plus, my beloved wife since we were 21 years old] -- has a new post up, on the role of descriptive word clouds about the cities we have visited.

    She starts with the wonderful town of Sioux Falls, South Dakota, shown in word-cloud form above and in a late-summer photo last year, below. 

    The cloud, which she prepared with John Tierney, is based on combing through the interviews and notes we collected while there. She also has a form for submitting characteristic words about other towns. I could possibly be biased, but I think it's very much worth checking out. 

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  • Who's the Most Accomplished Republican Strategist of the Day?

    Is it Rove? Ailes? Either of the Koch brothers? Anyone in Congress? Or a statehouse? No, in fact it is...

    If a 15-year term for Supreme Court justices had applied when Roger Taney was appointed in 1836, he would no longer have been chief justice at the time of the Dred Scott case, for which he is now best known. (Matthew Brady via Wikimedia Commons)

    Tomorrow morning, we start in with a big installment of American Futures reports. For now, followup on two previous items, one and two, on what we have learned about the Supreme Court and Chief Justice John Roberts via the latest McCutcheon ruling.

    1) The most consequential Republican. A reader writes:

    I enjoyed  ...  the excellent Emily Bazelon piece that explains how he expertly cloaks his actions, seeming reasonable, judicious, and measured, while pursuing a radical, conservative political agenda.

    If you remember, I wrote you before the ACA case and predicted that Roberts would find a way to uphold it for purely political reasons.  In short, he recognized that throwing out the ACA would have two serious consequences—serious long term political costs to the conservative political cause, and undermining the credibility of the Supreme Court itself.

    When you step back and look at his judicial actions as Chief Justice, you come to one conclusion. Roberts can be properly seen as the most consequential and successful Republican politician of our time.  It may be that, given his overt political agenda, there will be an erosion of the reputation of the Supreme Court, as they continue to move laws in a direction that a majority of Americans (certainly younger Americans)  oppose.  But, in the phrase Krugman used when he criticized W and those around him, Roberts and his colleagues are "serious men", and we are stuck with his effective political activism for many years to come. Oh, well...

    2) John Roberts, John Marshall. From another reader: 

    My reaction at the time of the ACA decision was that Roberts had pulled a trick not unlike the one Marshall pulled with Madison v. Marbury. In the latter, Marshall found in favor of the plaintiff, which was against the interests of the Federalists who had appointed him, while creating the principle of Judicial Review which gave the Court, and himself in particular, ultimate power over Congressional "balls and strikes". In Sebelius, Roberts granted himself the power to define words. Thus "mandate" became "tax" and all was well with the law. What passed unobserved was that this new power to redefine the words in any given law meant that no law is worth the paper upon which it is printed until Roberts has interpreted it.

    Thus, "money" becomes "speech" and "corporations" become "persons".  "Rights" become "Grants", "Birth" becomes "Conception", "Privacy" becomes "License" and/or "Property".

    Of course, I agree with Marshall and I disagree with Roberts, but I have to admit that the sword cuts both ways. In his defense, Marshall was generally wise to create judicial unanimity in his decisions which gave them greater strength when the Court was weakest. On the whole, I would say that the Nation was fortunate to have Marshall on the bench for 35 years acting as a break against the autocrats in Virginia who leveraged their 3/5s electoral advantage in every direction. Had it been left to Jefferson, Dred Scott would have been decided in 1802 and the rest of history would have been very different.

    Today, Roberts has appropriated the dignity granted by Marshall and uses it to forge divisive and cynical rulings when the Court could not be stronger. For the time being, I am satisfied to let Roberts continue to redefine "democracy". I think this is a necessary part of the process. The excesses of the oligarchs will eventually bring their ruin. All I can hope is that it won't take a second Civil War to bring this about.

    3) The humblebrag was the tell. Another reader:

    It seems to me that there is a more obvious lesson from review Mr. Roberts' confirmation hearing: It is appropriate to be suspicious of anyone who brags about his or her humility and modesty. One could expand Mr. Roberts' cynicism by noting that he didn't explicitly say that *he* was humble and modest, only that these were appropriate qualities for a judge, and leading us to believe that he claimed these qualities for himself without actually making the claim. It is less damning if he intended to claim those qualities for himself, rather than intentionally misleading his audience.

    Criticism of your assessment calls for an analogy with False Equivalence, in which the scope of discourse has shifted so much that simply identifying something is labeled extreme.  A harsh assessment would be that Roberts, Alito, Thomas and Scalia have almost quit trying to look like anything except partisan hacks. Their decisions are inconsistent with one another as well as with precedent (which they ignore or misrepresent) and with reality. To suggest that Mr. Roberts is cynical is among the most restrained explanations for his conduct.

    4) Meanwhile, the realities.  From a reader in Virginia:

    I do want to make one point, being on the firing line of John Roberts' ACA decision to let states decide whether or not to accept the Medicaid expansion part of ACA. He knew exactly what he was doing, cynical to the core.

    In states where the Medicaid expansion was not approved (trending conservative/Southern), thousands of the poorest still have no healthcare coverage. Example: under $11,550/year income for a single person, no ACA subsidy for low cost insurance. You're on your own, same as before. Free clinics, or if you are too proud, go without, or get care, go bankrupt.

    People are suffering, sad and angry. They feel they were promised affordable healthcare and have been betrayed by Obama. Sometimes I patiently explain why our legislature in Virginia is having a battle over Medicaid right now, and sometimes I am too tired. I volunteered for several enrollment events sponsored by a non-profit organization here called Celebrate Healthcare. [I was recently in a newspaper photo], enrolling a young lady, one of the lucky ones. 

    Many of the rest are deeply disappointed. 

    Thanks, John Roberts, you innocent balls and strikes guy.....

    5) Not cynicism but something else.  A reader objects to my saying that John Roberts must have been either very naive, or simply cynical, in saying nine years ago that his ideal was the non-interventionist, "just call the balls and strikes" judge:

    Those are certainly two valid ways of looking at it. I find it very, very hard, given everything we know about the man, both personally and professionally, before and after his appointment to the Supreme Court, not to suspect he perjured himself. Entirely unprovable, of course. (At least, presumably.) But, honestly, I think in many ways it's the most respectful conclusion, rather than pretending a man of his intellect, training and experience could have been that naive. And if he WERE that naive, that alone makes him unqualified to lead the highest court in the land. 

    6) Life tenure is a problem; there is no solution. If I could rewrite the Constitution, one of my first changes would be shifting the Supreme Court to a set of staggered 15-year terms rather than life tenure. Each president would get at least one pick, probably two; and there would not be such a premium on grim-reaper assessment of candidates, to see how long they're likely to stay active on the bench. A reader talks about life appointments more generally:

    In my view life tenure is a very, very dangerous thing. 

    I say that as someone who was recently granted academic tenure. I see it in academia now that mandatory retirement has been removed (by the Supreme Court in 1991 no less). Given the world I live in I'll take it, but it doesn't fundamentally change the fact that I think it is wrong.

    The upside of tenure is that it gives protection from an administration that can be vindictive when someone does research that is controversial. This is important. It also gives some freedom to try riskier projects that might not pay out for a while, which is very much how basic science is.

    The downside is that senior professors are often expensive and not very productive. The variations of deadwood faculty---the semi-senile senior professor wistfully reminiscing about when he was relevant while keeping a hand on the throat of the department or the embittered associate with the stalled career---are tropes for a reason. One of the reasons the academic job market is as congested and abusive as it is is because administrations can't get high priced senior faculty to retire. Extended contracts after a provisional period? Sure. So something like a contracts that were 3 years, 3 years, 7 years, 7 years, 5 years, 5 years, 3 years, 3 years, etc., would give a lot of its benefits with more flexibility. (In a sense, due to the way that funding works now, tenure isn't what it used to be anyway. At a lot of schools if you don't bring in enough to cover 80% of your salary you are terminated on financial exigency grounds anyway.)

    General officers in the first half of the 20th Century in the US Army are perhaps an even better illustration. John Pershing, was acting as a general officer with a set of captain's bars on his collar in the Philippines due to the strict seniority system. He was promoted to general by an act of Congress at Theodore Roosevelt's urging. When he was chosen as the commander of the AEF in 1917 he had to relieve an extraordinary proportion of general officers who would have been division commanders, many of whom where unable to handle the demands of the job due to being seriously overage. Then, lest we forget, there is the American Caesar: ”The problem with MacArthur was that he had been a general too long. He got his first star in 1918 and that means he’s had almost thirty years as a general. Thirty years of people playing to him and kissing his ass, and doing what he wants. That’s not good for anyone.” - Lieutenant General Joseph "Vinegar Joe" Stilwell, US Army, 1944

    So for the federal bench, something like 10 year appointments [JF: or 15 for the Supreme Court] makes sense to me, with an opportunity for a 5 year reappointment, much like the FBI director's time in office. (Odd numbers were chosen carefully to be out of sync with the American electoral calendar.) It provides substantial insulation from politics, but as you have already indicated, the Court has played politics before. This is nothing new, as Roger Taney's reasoning in the Dred Scott case showed clearly. Having some turnover would help lower the stakes of appointments, too, which might well turn down the heat on the massively overheated confirmation process, while still preserving judicial independence and presidential legacies. 

    My assessment of the chances of this ever happening short of some kind of massive constitutional crisis? Nil. 

    I agree with all parts of this note, including the final paragraph.

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  • Back in a Few Days

    Enjoy the springtime weekend.

    Your correspondent, on the road in southern Georgia. Explanation to come. (Deborah Fallows)

    For day-job reasons, I don't expect to have anything in this space for the next few days. 

    In the meantime, I offer two resources on the MH370 front. One is an extremely detailed "Markov Chain Monte Carlo"-style analysis, by Conor Myhrvold at Fast Company. Its upshot is a contention that the plane must have made several "intentional" turns after it dropped out of normal contact. Under what circumstances, and why, and at whose intention is unknown. But worth considering.

    The other is the Twilight Zone episode below, from back in 1961. It's "The Arrival," about an airline flight whose fate was a profound puzzlement. Has topical resonance.

    As I post this, the full episode is available via YouTube. I don't know how long that will remain true, but it's there for now. Thanks to reader PG for the tip.


    On return in a few days, we're back to our American Futures travels, with more about upstate South Carolina, site of the business news indicated below; southern Georgia around St. Marys; and the Central Valley of California from Fresno to Winters. Plus more on "career technical" education and electronic medical records. Stay tuned.

    And an explanation of the photo at the top.

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  • On Anger, Cynicism, and Public Discussion

    A calmer version of a point about Chief Justice John Roberts

    Associated Press

    I have a several-day stretch ahead of being away from the Internet, but before I go I wanted to follow up on one point.

    Some people liked, and some people very much did not like, an item I did late last night on Chief Justice John Roberts. It's almost always a mistake to let yourself sound angry, and I almost always regret doing so. Here's why I take this tone on this subject.

    In the modern politics of judicial nominations, all candidates for life-tenure posts are forced to play dumb, or at least coy, in their confirmation hearings. That's the reality of life. And for great stretches of his hearings back in 2005, John Roberts handled questions in the required, unexceptionable way. "I don't like to deal with hypotheticals, Senator." "Senator, that's a question that might come before the Court for adjudication, and so ..." "Under the principle of stare decisis, Mr. Chairman..."

    What candidates are not required to do is to present themselves as distinctive embodiments of a modest, "humble," precedent-revering, non-interventionist approach to the role of the courts. That is precisely what then-Judge John Roberts did so memorably in 2005. To check this for yourself, you can go back and look at the clip in the previous item (and below), or the whole C-SPAN archive of the hearings, or read his opening statement. That stance is completely at odds with the role Roberts has actually played as chief justice, and I am repeatedly struck by the contrast. It is very hard for me to find a non-cynical interpretation of the growing gap between the way he presented himself then and the way he writes decisions now.

    Also: In that item, I should have mentioned the Shelby County decision as the most radical illustration of Roberts's willingness to overturn precedent, congressional will, and any conceivable notion of judicial "restraint." Andrew Cohen's assessment of that ruling was very angry-sounding, and for good reason. Roberts's opinion in this case bore directly on these questions of judicial humility and modesty. An elected Congress had repeatedly decided that Voting Rights Act protection remained necessary in parts of the South. Roberts said, in effect, No, you're wrong—and this judgment is up to us, so your laws don't apply.

    You want to read something really angry about judicial overreach, read Ruth Bader Ginsburg's Shelby County dissent.

    I was imprecise in suggesting that Roberts had laid out a record of opinions specifically indicating that he would cast the deciding vote against Obamacare. The point I was trying to make is that Roberts's deciding vote the other way, to avoid dismantling the Affordable Care Act, seemed more easily explicable as a political act—in the institutional interests of the Court, to keep it from seemingly nakedly partisan in the tradition of Bush-v.-Gore—than as the natural outcome of his judicial logic. That seemed to be how most legal analysts parsed it, whether they agreed with the outcome or not.

    It rarely advances an argument to seem personally het-up about it, so here is a calmer version of my point. The man who, at age 50, presented himself for lifetime tenure as chief justice said that he conceived of his role as a minimalist "balls and strikes" umpire. No one who has observed him in office could plausibly describe him that way. He has been as precedent-disregarding as they come. So was he naive in saying what he did nine years ago? Or was he cynical? To me those seem to be the options.

    Extra reading: Dahlia Lithwick, Emily Bazelon, Jeffrey Toobin, Lawrence Lessig

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  • Cynicism-in-Public-Life Contest, John Roberts Edition

    Life tenure in any public post is bad public policy, and other implications of the latest Supreme Court rulings

    Wikimedia Commons

    [Update: please see this follow-up item too.] If People magazine were based in D.C., instead of their Sexiest Man Alive specials they might run Most Cynical Person Alive contests. Obviously there are lots of candidates, but at this moment you would have to give the nod to John Roberts. 

    Let us travel back in time all the way to the summer of 2005. Take literally one minute to listen to these famous words from earnest young appeals-court judge John Roberts:

    Humility. Modesty. Restraint. Deference to precedent. "We're just calling balls and strikes."

    That guy sounded so great. Really, watch this minute-long video and think what it would be like to have a person like that on the bench.

    Instead we have a chief justice who:

    • in the "Obamacare" ruling two years ago, apparently decided that the institutional risk to the Court of blatantly coming across as just another branch of party politics outweighed the objections implicit in his prior rulings to the healthcare plan. So he found a way not to overturn the main legislative accomplishment of a president's first term, with all the hubbub that would ensue. As it happens, I was glad that the politics added up that way for him. But ...
    • in this week's McCutcheon ruling, following Citizens United, he made up out of nowhere his own interpretation of how electoral politics and favor-trading works*—trumping that of Congress, composed 100 percent of elected members. Plus he invented his own post-Founders, no-input-from-Congress, precedent-be-damned theory of what "corruption" means. As it happens, I disagree with the results of this one. But the main point is that in their activist political sensibility neither this judgment nor the Obamacare one had the slightest connection to the person who so self-effacingly presented himself for confirmation nine years ago.

    [* This interpretation, from the opinion:

    [T]he only type of corruption Congress may target is quid pro quo corruption. Spending large sums of money in connection with elections, but not in connection with an effort to control the exercise of an officeholder’s official duties, does not give rise to such quid pro quo corruption. Nor does the possibility that an individual who spends large sums may garner “influence over or access to” elected officials or political parties.

    See if anyone who has worked in politics recognizes that bright-line definition of the role of money in affecting politicians' behavior. The elected politicians who passed the campaign-finance laws didn't understand it that way. Then watch that video again. About judicial "modesty."]

    Alito, Thomas, Scalia—not cynical. We know the deal with them. Kennedy—permanently enjoying his status as the man whose deliberations constitute the tie-breaking vote.  

    Roberts was the one who came in talking in such forelock-tugging terms about restraint and precedent, balls and strikes.

    Nearly a decade in, his record is that of one more politician. But—unlike James Byrnes, Fred Vinson, Hugo Black, Earl Warren, and Sandra Day O'Connor—one who didn't have to bother getting the public's votes. 


    For later discussion: Depending on actuarial trends, and the outcome of the next presidential election, whether Ruth Bader Ginsburg and perhaps Stephen Breyer will eventually be seen as having put personal over national interest.

    Life tenure for any public post is bad public policy. Individual justices can't do anything about that—though, who knows, John Roberts might try. They can do something about how long each of them decides to stay. Earl Warren left the Court at age 78, Potter Stewart at 66, Byron White at 76, Sandra Day O'Connor at 76, David Souter at 70. Any of us would like to keep doing satisfying work, and being important, as long as possible. I am sure Bill Clinton still rues the passage of the 22nd Amendment. But only nine of us, in a nation of 300-plus million, occupy positions with such decades-long effect on everyone else, and subject to such vagaries of national politics, as those on the Supreme Court. 

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  • Today's 777s-in-Peril Update: Asiana 214, MH 370

    Lawyers offer their contention of why a pilot is not to blame for one accident. A former NTSB investigator directs blame at the pilot in another.

    How a plane looks just before touchdown into a strong crosswind. This is hard. The Asiana landing at SFO should have been easy. ( YouTube )

    1) Asiana 214. If you'd like to see professional pilots landing big airplanes, under difficult circumstances, with hundreds of lives at stake, watch any 20-second portion of this video below, taken at Dusseldorf airport during a very strong crosswind. Even the first 15 seconds will give you the idea. Or the elegant maneuver by an Air Berlin crew from 1:40 to 1:55.

    What you'll see in all cases are pilots executing the familiar "crab-into-kick" procedure for crosswind landings. First the plane "crabs" -- it approaches at an angle, to keep its direction of flight aligned with the runway. Then, just as the plane is about to touch down, the pilot "kicks" the rudder to align the airplane itself with the runway. That allows the plane to land without putting impossible cross-stress loads on the landing gear.

    Some of the landings in this clip are more precise than others, and some of that variation is beyond the pilots' control, depending on last-minute gusts and shifts in wind. But all of them show the proficiency expected of professional flight crews. 

    Watch a little of that, including artful landings of Boeing 777s, and then consider the claim from Asiana airlines' lawyers, as reported yesterday in the NYT, that autopilot software was somehow to blame for the crash of an Asiana 777 at SFO last year.

    Remember that this crash -- which killed three people, injured many more, destroyed the airplane, and shut down the airport for a time -- happened on a clear day, with light winds, in what would be considered the very most benign flying conditions. Remember that according to cockpit recordings, other members of the flight crew were warning the captain that he was mis-flying the approach and letting the plane get too "low and slow." And consider that in the two decades of the 777's operation, with many hundreds of thousands of landings worldwide by the more than 1000-strong airplane fleet, there appear to have been zero reported incidents of autopilots causing the plane to land short of the runway. You can read a 777 accident/incident list here. The one other episode involving auto-throttles and landing problems, in 2008, was traced to ice that obstructed the fuel system and kept the engines from responding properly. This was not a factor for the Asiana at SFO.

    Of course we shouldn't prejudge the legal process. And if you were a lawyer for Asiana, you'd probably try to push this "the autopilot made me do it" argument too. But, c'mon.

    [For the record, I am an admirer of NYT reporter Matthew Wald, but -- as he knows -- I disagree with the implication of the lead of his story. It was this, with emphasis added:

    While the world has been fixated on the disappearance of Malaysia Airlines Flight 370, the Korean carrier involved in the crash of a different Boeing 777, the Asiana flight into San Francisco last July, raised design issues on Monday that put another question mark over the model of jetliner.

    The Asiana and Malaysia episodes have absolutely nothing in common, and from my perspective nothing in the Asiana lawyers' filing "puts another question mark" over one of the world's most widely used and best-safety-record airplanes. To me, this connection is like saying that a car-jacking put "another question mark" over a certain model of car, if that car had also experienced carburetor problems.]

    2) Malaysia 370. No theory of the plane's disappearance makes sense. But I've mentioned several times that I thought the "Chris Goodfellow scenario" required few logical leaps than most. Goodfellow, a Canadian who now lives in Florida, has hypothesized the following sequence: a sudden inflight emergency, followed by a turn back toward airports in Malaysia, followed by a still-unexplained incapacitation of the crew, and a still-unexplained flight out over the ocean.

    If you would like to see an argued-out (rather than merely speculative) version of a contrary hypothesis, check out this on Leeham News and Comment. The item is based on an interview with Greg Feith, a former NTSB investigator, who argues (a) that the wreckage might well never be found, and (b) that the most likely scenarios, in his view, involve one of the pilots deliberately bringing the plane down. Sample:

    Feith believes there will be several plausible theories that all will point to a deliberate act by someone with intimate knowledge of flying the Boeing 777, most likely one of the pilots.

    Too many deliberate actions maneuvering the airplane and turning off communications systems occurred to have any plausible mechanical failure explanation. He completely discounts theories that a fire, either in the electronics bay or involving lithium-ion batteries being transported in a cargo bay, disabled the airplane.

    He also discounts a theory that there was a depressurization that incapacitated the pilots and allowed the 777 to meander over the skies of the Gulf of Thailand, Malaysia and the Strait of Malacca before turning south 3,000 miles over the Indian Ocean before running out of fuel.

    No one knows what happened, and it's possible that we may never, or not for a very long time, get conclusive evidence one way or another. But this article is worth considering as a strong counter to the inflight-emergency view.

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  • Why the Anti-Corruption Drive in China Is So Important, and So Potentially Destabilizing

    Is the country moving from "efficient corruption" to something worse?

    Protests on Tuesday in Maoming, in Guangdong province in southern China, against a proposed new chemical plant. ( Reuters )

    Here is a crude but effective classification scheme that I have used in distinguishing different economic systems. It is between "efficient" levels of corruption in government and business, and "inefficient" corruption. 

    Through its era of fastest post-war growth, Japan was highly corrupt. Twenty years ago, authorities raided the home of the party boss Shin Kanemaru—and found gold bars and other loot worth something like $50 million. Yet in Japan, and South Korea and Taiwan and even Malaysia, the corruption was efficient. Bridges cost too much and enriched local barons, but they got built. Factories jacked up prices thanks to cartel rules, but they ran and kept people at work. Anybody who has studied the economic/political history of Chicago or Los Angeles will recognize versions of this bargain.

    On the other side were countries like Indonesia under Suharto, or the Philippines under Marcos, or North Korea under the Kims, or a lot of others you can think of, with inefficient corruption. The people who could, looted so much that there was not enough left over to keep the system running.

    Either sort of corruption has a self-reinforcing nature. When an efficient system is running smoothly, officials have a stake in its long-term survival, which allows them to keep taking their cut. Thus they steal but don't loot. But when an inefficient one is deteriorating, all involved have an incentive to grab everything in sight while the grabbing is good. 

    Through its 30-plus years of economic modernization, China has seemed to stick to efficient levels of corruption. Connected families got very rich, but most families did better than they had before.

    An increasingly important question for Xi Jinping's time in office, which bears on the even more urgent question of whether China can make progress against its environmental catastrophe, involves the levels and forms of Chinese corruption. Has it begun passing from tolerable to intolerable levels? If so, does Xi Jinping have the time, tools, or incentive to do anything about it? Will exposing high-level malfeasancelike the astonishing recent case of Zhou Yongkang, who appears to have taken more than $14 billion while he held powerful petroleum and internal-security rolesencourage the public? Or instead sour and shock them about how bad the problem really is? Is it even possible to run a government and command a party while simultaneously threatening the system that most current power-holders have relied on for power and wealth?

    These are yet another set of Big Questions for and about China. Recent useful readings on the theme:

    1) Timothy Garton Ash on "China's Gamble of the Century." Thirty-plus years ago, Deng Xiaoping tightened up politically but overall did so toward the end of enacting economic reforms. Xi Jinping is tightening up politically. This piece examines the possible ends.

    2) The views of former President Jiang Zemin on the same topic, as reported by Jamil Anderlini and Simon Rabinovitch in the FT and as shown by the headline below:

    3) A big piece by Jonathan Ansfield on the front page of the NYT on Tuesday, about the drive against high-level corruption inside the People's Liberation Army, which itself is far more impressive as a business empire than as a fighting force. This is a detailed and enlightening story on an effort whose success or failure will be important in a variety of ways. As the story puts it:

    [Xi's] goal, military analysts said, is to transform a service larded with pet projects and patronage networks into a leaner fighting force more adept at projecting power abroad and buttressing party rule at home, while strengthening his own authority over the army.

     4) An op-ed in the WSJ by Desmond Tutu and Jared Genser about the ongoing struggles not simply of Liu Xiaobo, who won the Nobel Peace Prize in 2010 while serving a long prison term for "subversion," but also of his wife Liu Xia (below). Even as her health deteriorates, she too remains effectively imprisoned under a form of house arrest. E.g.:

    Despite living in the middle of one of the busiest and most populous cities in the world, Liu Xia, a poet and a painter, is cut off and alone. Chinese security officials sit outside her front door and at the entrance to her apartment building.

    Liu Xia, with photo of herself and her husband in better times. AP via WSJ

    5) An essay by Perry Link in the NYRB called "China After Tiananmen: Money, Yes; Ideas, No." Sample:

    At a deeper level, though, Chinese people (like any) do not feel secure in a system built on lies. The wealthy send their money abroad—and their children, too, for education. In 2013 several surveys and reports showed sharp increases in the plans of whole families, especially among the wealthy, to emigrate, and there is no reason to think that poorer people would not follow this trend if they had the means.

    6) Reports like this one from Reuters on the ongoing protests in China against environmental hazards and despoliation. Christina Larson also has a (paywalled) article in Science about farmland in China rendered unusable by pollutants, especially heavy metals.


    For now I am not trying to weave these into a larger prospects-for-China assessment. (I did attempt something like that in the second half of China Airborne.) But individually and as a group, items like these suggest the scale, complexity, and importance of the changes the Chinese leadership must undertake.

    Exposing corruption without delegitimizing the very system that still runs the country; changing the military without alienating it; controlling disastrous pollution without too noticeably slowing the economy; allowing the growth of civil society quickly enough to satisfy the public but gradually enough not to frighten the party—the obligation to do all these things at once, and more, and fast—makes the challenges for European or U.S. leaders look like easy tasks. 

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  • A High School That Teaches Students to Fly, and Other Innovations in 'Career Technical' Education

    "A lot of problem-solving skills grow out of the experience of doing things rather than thinking about things."

    Head coach and players from the Davis Aerospace Technical High School in Detroit. They lost this game by 36 points, but "the Aviators always play with heart." ( Facebook photo )
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    Background: this story on Camden County High School, in Georgia, and its "career technical" academies, followed by this from readers; plus Deb Fallows on an elementary school for engineers, in South Carolina; and John Tierney on the Maine Marine Academy and related aspects of "vocational" education. Now more from readers:

    1) "Vocational ed is 'discriminatory.'"  From a reader in New York City:

    My late husband was for 36 years a teacher of physics at [a public high school in NYC]. According to him, vocational ed has been considered by the "educational establishment" to mean minority education, and thus is objected to by these high-minded folks. In other words, vocational ed is "discriminatory."

    Thus in NYS it has been phased out, and, in its place, all students are required to take, e.g., four years of science in order to graduate. Since most of them cannot handle physics or chemistry, the standards have been dumbed down in order to get a passing rate.

    From a society that has traditionally prided itself on "equality," we have become worse than Europeans about class differences....

    So, yes, vocational ed is a good idea, and I notice in NYC that some high schools are offering "career" alternatives, thus avoiding the stigma of the phrase "vocational ed."

    2) Learning comes from doing things, as much as thinking about things. From a reader in Pennsylvania:

    Thank you for your follow-up post about Camden County High School. It was more impressive than this article in Slate, which combines support for alternatives to college with the elitist assumption that the trades are mostly for below average students:

    My grandfather, who trained workers during World War II for the war effort (including, I think, teaching some women to be machinists), complained about the prejudices of his fellow educators, who thought all bright students should go to college. He said the trades needed smart people. CCHS sounds like a model he would have approved of.

    I certainly approve. I think education in hands-on work should begin in middle school with skills for daily living, including cooking, parenting and child development, sewing, wood shop, nutrition, sewing, gardening, personal finance, small gas engine maintenance and repair, house and apartment maintenance, art and music courses, basic auto maintenance, and health. Students should come out of middle school ready to tackle algebra and more advanced science classes and be pursuing a combination of academic preparation and hands-on study, but they should have learned enough life skills to feel they could cope.

    A lot of problem-solving skills grow out of the experience of doing things rather than thinking about things. I'm convinced some of the students [the Slate author] is so dismissive about could find strengths if exposed to a wide range of skill-building classes in middle school, when students have a lot of energy, want to become more independent, and are wondering about their futures. The students who need remediation might not need quite as much assistance in life if they have life skills to help them cope with particular academic subjects that frustrate them.

    Sure, we don't all live in Lake Wobegon. But below average shouldn't mean a student gets an inadequate education and critical trades shouldn't be filled with below average students who became plumbers or carpenters. CCHS sounds like a good educational model for the school districts where the children aren't all above average.

    3) Fewer people with military experience means fewer people with practical skills. From a reader in the Southeast:

    For many persons, vocational or technical training occurs in the military. Perhaps this accounts, partially, for the smaller number of persons with these skills, since proportionately, the number of persons with military technical training has gone down over the years.

    Best, XXXX,

    (Electronics Technician, US Navy, 1978-1984)

    4) "I wish more parents would consider their sons' and daughters' gifts and interests." From an administrator in a well-known East Coast public school system:

    Having worked in the trades for many years prior to and during attending graduate school, I know how important it is to have opportunities for people who are not “college material.” 

    I wish more parents would consider their sons’ and daughters’ gifts and interests when they help them to plan their transition from high school.  I also think that schools tend to be highly disrespectful of the intelligence, interests, and abilities of those students who are more geared toward tangible, practical work than to working with abstractions.  When I worked in the trades I met some of the brightest people I’ve known.  I also have friends who work in the trades and make much more money than I do, with a Ph.D. 

    I wish our education system would realize how very, very expensive it is for our society to continue to turn out students who are not equipped for the next step in their careers, whether that is college or work in the trades.  Young people without a viable life plan, without a source of competency and pride, are very vulnerable to all sorts of potential downward spirals.  Also, stagnant 20-somethings who end up settling into their parents’ basements don’t contribute much to the tax base, and don’t always maintain the best pro-social lifestyles. 

    Sorry for the excess verbiage here, I know I’m “preaching to the converted”.  I just don’t seem to hear a whole lot about this here in the very much status-conscious [BOS-WASH East Coast] area. It really bothers me to see so much talent and potential wasted.  I’ve seen a lot of really great kids who really didn’t get much of a shot at their dreams because of this bias.

    5) My new favorite high school. From Dexter O'Connell in Detroit:

    I work at Davis Aerospace Technical High School in Detroit. It is a Detroit public school. The most impressive aspect of the school is that there is a full, four year, aviation program that is a fully integrated part of our comprehensive curriculum. 

    Students can graduate with a pilot's license, paid for by the Detroit Public Schools. Our Flight Instructor takes students with good grades and a demonstrated interest in flight, and trains them to be pilots. This year, we will graduate three licensed pilots from our class of 40 graduating seniors. Several others will have substantial flight hours to put towards a license at a later point. 

    Additionally, we have a full Airframe and Powerplant maintenance program. Students begin in a general maintenance course in ninth grade, and then choose Airframe or Powerplant in 10th and 11th grade, to study in depth. In senior year, they can continue studying and then take the certification test. I don't know yet how many certified mechanics we'll be graduating this year, but hopefully it will be many. Students can also take an optional aviation welding class.

    This is all at a comprehensive high school, where aviation technical education is integrated into the curriculum. We also offer arts, Spanish (I'm the Spanish teacher, actually, and I've just begun work at Davis this school year) and a full slate of academic classes....

    At the end of this year, our flight instructor is retiring, and some of our maintenance staff may as well, but hopefully our school will be able to find another instructor and take off again next year. This program is a critical one which provides high-quality education to students who can use it to get well-paying jobs that can't be outsourced. 

    Here is a Detroit Public Schools video showing the school's flight instructor and  several of his students. Seriously, devote three minutes to watching this, and see if it doesn't affect your view of the innovation and commitment underway in places or systems usually written off as struggling or troubled. I found every bit of this, from students and teacher in their respective ways, touching and encouraging. 

    Davis Aerospace from Detroit Public Schools on Vimeo.

    O'Connell adds:

    Most of our students don't come to our school to learn to fly or work on airplanes. There is still a sizable minority of students who come for that (I would imagine that we are one of the few DPS schools that draws kids from the suburbs for our program) including some who commute hours in each direction. However, the majority of our students now attend because we are a DPS school with small class sizes (my largest section is 24, our largest academic class right now is only 32, many classes are in the 15-20 student range)  and a fairly good academic and disciplinary/behavioral reputation. There is little violence and there are no gangs or gang influence. 

    There is certainly more that can be done to strengthen the technical program going forward, and ensure that it's appropriately funded, equipped, and staffed. We could probably do more to attract students. A big billboard over the 94 or the 75 freeways that said "Learn To Fly A Plane For Free In High School" would probably go a long way towards making our student body more sustainable and aviation-focused.

    I do think, though, that what we do now is incredibly worthwhile for our kids, in both the aviation and the comprehensive parts of our school, and I think the blending of our dual curriculum is an important example of a possible way forward for other schools in other places.

    Finally, about the picture at the top of this item:

    Boys basketball is our only sport, and we had a school-record four wins this year! Our small student body means we usually don't stand much chance against 1000-kid comprehensive schools, but the Aviators always play with heart. 

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  • Where to Get Your Next Fix of MH370 News

    Chris Goodfellow, who has offered the so-far least-unlikely explanation of what happened, does a 90-minute Q&A.

    Evolving search areas for Malaysia Air 370. ( via VOA )

    Executive summary of what you'll find below: If you're looking for more discussion of MH370, please swap the first 90-minutes of this "Google Plus Week" (embed below) for the next 90 minutes you would spend with cable news. It features the person who came up with the at-the-moment-least-implausible explanation of what happened, and its BS/insanity quotient is practically nil, in stark contrast to the normal cable level.

    Now the details.


    Yesterday I was on CNN's Reliable Sourceswith Brian Stelter (and Poynter's Andrew Beaujon), talking about the way CNN, in particular, has decided to go wall-to-wall in covering the missing airplane. Stelter pointed out that when CNN dealt with MH370, its ratings went up; when it didn't, the ratings went down. Therefore the network had quite rationally decided to make itself into the Missing Plane Channel for the foreseeable future, much as it became the Gulf War Channel in the early 1990s, in the period that first established its worldwide role.

    I replied: I understand this business logic, which fits the reality of the modern highly diversified news ecology. If you want to find out, right now, what's up with sports, or weather, or the stock market, or political trends, you know where to go. If you want to find out about the MH370 search, you know you can go to CNN.

    But my main complaint was that CNN had been so undiscriminating in filling these hours with nutso speculation -- black holes, "radar shadow," attack on Israel -- right alongside people who kept their discussion within the realm of the plausible. It's one thing to say that almost nothing is known about what happened with the plane. It's something else to have people gas on about things with no evidence to support them and with strong common-sense obstacles to being true.

    Political analogy: no one knows who will be elected president in 2016. But if we treated electoral handicapping the way cable news has often treated MH370, we'd have panelists speculating how Megyn Kelly might do against Stephen Colbert in the crucial swing states. ("Kelly will help the Republicans with the youth vote, and women, without in any way depressing interest from their traditional base of older white men. But Colbert, who is from South Carolina, could open new possibilities...") After all, you can't prove they won't be the nominees.

    Which brings us to Chris Goodfellow. Nearly three weeks ago, when most discussion concerned hijacking or pilot criminality, he offered on Google+ a different MH370 hypothesis. In essence it was: that some mid-flight emergency (probably a fire) had broken out on the plane; that the pilots had immediately turned back toward the nearest big airport, which was on an island off Malaysia; that for some still-unknown reason they had become incapacitated or disabled; that also for unknown reasons, possibly fire that disabled their radios, they had not been able to communicate; and that the plane, on autopilot, had flown on until it either ran out of fuel or crashed for another reason.

    Soon thereafter, I wrote that this was the first hypothesis that made face-value sense to me. Maybe things didn't play out this way --  but this scenario started out with the Occam's Razor advantage of requiring fewer assumptions or suspensions of probability than others.

    An item in Slate immediately and with great certainty declared that Goodfellow's scenario could not be true. Its author, Jeff Wise, became a regular on CNN making that same point -- and meanwhile promoting the hypothesis that the plane had landed in Central Asia. Eg, "the 777 is capable of landing on small airstrips and on relatively unimproved surfaces, such as packed dirt and dry lake beds. In such a scenario, the odds are good that, unless they were murdered, the passengers remain alive." (Also here. For the record, in his original anti-Goodfellow item Wise included me among people who he thought had been taken in by Goodfellow. He knows that I disagree with him.)

    This weekend Chris Goodfellow did a Q-and-A session on the "Google Plus Week" channel on YouTube. The next time you're looking for 90 minutes' worth of discussion of what could have happened, what we know and don't, and why the plane's reported cargo of lithium ion batteries deserves attention, I'd recommend this over any comparable time with cable news.

    It could turn out that Goodfellow's view is entirely wrong, but his pattern of thinking about the puzzle is systematic and worth hearing.

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