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.

James Fallows: Politics

  • Maine Governorship Watch: Let's Hear From the Democrats

    The Michaud campaign asks for and gets equal time.

    Last night I wrote about the upcoming race for the governorship in Maine. Four years ago, the Independent candidate (and my longtime friend) Eliot Cutler narrowly lost to the Tea Party Republican Paul LePage. Now LePage is running for reelection, Cutler is running against him as an independent, and the Democrats have nominated Mike Michaud, the incumbent representative from Maine's northern, rural Second District.

    I said that I admired and supported Cutler, but that on venerable Atlantic "of no party or clique" principles I'd be happy to post a 30-second video from the other candidates like the one I posted from Cutler's. I give you now David Farmer, a senior adviser with Michaud for Maine, who wrote by email as follows:

    In a recent article that you wrote about Eliot Cutler, you offered to post a video from U.S. Rep. Mike Michaud's campaign for governor. I would like to take you up on your offer. Here's a link to the video from YouTube. You can also link to the ad from our website, which is www.michaud2014.com.

    And while I certainly understand your allegiance to your friend, I would also add that Congress Michaud isn't your typical politician ....

    Congressman Michaud comes from a blue collar background. He worked in a paper mill for 29 years. He first ran for office when he was just 24 years old with the goal of cleaning up the river that was being polluted by the mill where he worked. He has a compelling life story and decided to leave Congress to try to get Maine back on the right track after four terrible years under Tea Party Gov. Paul LePage. He's one of the few members of Congress who isn't a millionaire and who brings a real determination to represent working families.

    But I suspect that there's little need to argue the merits of Congressman Michaud or the dynamics of the race that show him to be in the best position to defeat Gov. LePage.

    Instead, I'd just ask that out of fairness, you post our video alongside Mr. Cutler's.

    There you go. If and when I hear from the LePage campaign, I'll post their clip as well. People of Maine, over to you.

  • Third-Party Watch in Maine

    In most states, independent candidacies are pipe dreams. Maine is one of the rare states in which they can and do win. Here's what this year's race for the governorship shows.

    First, a disclosure. Eliot Cutler, who nearly won the race to become Maine’s governor four years ago and is now running for the job again, is a close family friend. My wife and I often hung around with him and his wife Melanie when we were all living and working in Beijing. He ran an American law firm's office there; she was in practice as a doctor. The Cutlers’ daughter Abby, now herself a doctor, was once a young editorial staffer at The Atlantic.

    Eliot Cutler

    During the 2010 race, I did an item saying that if I were from Maine, I would enthusiastically vote for Eliot for governor. This was in keeping with my Official Policy that journalists should steer clear of endorsing candidates except (a) in presidential races, where every American gets a say, and (b) for personal friends, as explained in this 2006 item about then-Senate candidate Jim Webb.

    The drama of the 2010 Maine governor’s race was that Cutler was running as an Independent, against the Tea Party Republican Paul LePage and the Democrat Libby Mitchell. In most states, third-party candidacies are pipe dreams. Maine is an exception. Angus King, who succeeded Olympia Snowe as U.S. senator, is an independent who had previously been a popular independent governor. James Longley, governor in the 1970s, was also an independent.

    Paul LePage is about as right-wing a governor as now serves anywhere in the U.S., and is considerably to the right of the other major statewide officials, Senators King and Susan Collins. (Maine does not have a lieutenant governor.) LePage made it into office with only 38.3 percent of the vote, as Cutler and Mitchell split the anti-Tea Party majority. Eliot started out behind; closed fast in the final month of the campaign; and ended up just short of LePage, with 36.5 percent. That was almost twice the Democratic total (19 percent), and by most accounts he would have won if the race had gone on a few days longeror if fewer people had voted early, before it became clear that he was the stronger anti-LePage candidate.

    This year the Democrats have put a more concerted effort into fielding a candidate, Representative Mike Michaud. The Democrats argue that they offer the better prospect for getting rid of LePage; Cutler argues that he would be the more policy-experienced and ambitious governor.

    In that contest, I'm with Eliot, whom I've known and respected since were both young staffers in the Jimmy Carter administration. He worked in the White House on Carter's prescient energy policy, and had previously worked for Maine Senator Ed Muskie on the original Clean Water Act. I've talked with him a million times about the problems and opportunities for his state. He was the one who first suggested that we visit Eastport, Maine, as part of our American Futures series.

    Of course what I think doesn't matter to anyone in Maine. What might is the endorsement yesterday from Angus King. Because polls have consistently shown that most Maine voters would rather not have LePage as their governor, King addressed the "strategic voting" question: whether a vote for the Independent candidate would make it more likely that LePage stays in.

    King, one of Maine’s most popular politicians and a former two-term governor, said that Maine voters need to choose the best candidate for the job, regardless of political party or whatever perceived chance of winning the candidate has three months before Election Day.

    “What people have to cross over is this idea of trying to think of all the political angles,” King said. “If the people of Maine look at these candidates and say, ‘Who will make the best governor, who has the ideas, who has the best thinking?’—Eliot wins. That’s why I believe he’s going to. That’s the calculation.”

    For me this race holds mainly personal interest. For the country, it's worth watching as a test case of possible alternatives to major-party duopoly. Everyone wishes the two main parties were less encrusted and impregnable. Maine is one of the few places where a third-party alternative actually has a chance. We'll see how it goes.

    Here is a sample of Eliot Cutler's current campaign themes. Having admitted my bias, I'll make this offer: If the LePage and Michaud campaigns have comparable 30-second campaign videos, I will post them as well.

  • When U.S. Law Enforcement Had a Different Look

    Americans have often thought of themselves as level-headed and BS-detecting. What would a modern Mark Twain or Will Rogers make of policemen all dressed up for war?

    Sheriff Andy Taylor and equipment-loving Deputy Barney Fife (Wikipedia)

    If you haven't yet seen it, please read this Storify account, by Kelsey Atherton, of how veterans of real combat—in Iraq, Afghanistan, and elsewhere—view today's wildly over-militarized American police. For instance:

    A reader on the East Coast responded to my post last night, which said that perhaps the scenes of stormtroopers among us would startle the public into realizing how far this security-state trend had gone. This reader, S.C., suggests a contrasting visual cue:

    Maybe you’re right to conjecture that police-state images might horrify the country into restoring good sense about cops in combat gear, riding in tanks on streets. Here’s a thought about that. It’s not new, but it might be worth mentioning.

    I’ve pasted in an image [shown at the top of this post] that may fit slantwise with your insight. It’s not what you meant, but it conveys the message in a country that still likes seeing if calm wisdom and brains can head off any need for ostentatious official bellicosity. From the old and much-loved The Andy Griffith Show, it’s Sheriff Andy Taylor, who spurns sidearms in police work, and whose face expresses all that needs to be said about Deputy Barney Fife’s comically enthusiastic wanna-be militarism.

    I love it that Sheriff Taylor always allowed Deputy Fife to carry only one bullet, and required him to keep it in his pocket. Maybe you’ll want to keep this photo in yours, in case it’s needed (and assuming it’s not already there).

    It’s unrealistic, of course, to try too hard to map this half-century-old sitcom onto present problems. But it’s also unwise not to recall what Sheriff Taylor stood for, and not to recognize the extent of the country’s respect for it.

    Agreed. On that same theme, here is a clip from an episode of The Andy Griffith Show 50 years ago, in 1964, in which Barney Fife has a different helmet but the same enthusiasm for dress-up military gear. 

    That gentle, dismissive, pretense-puncturing humor—something I associated with Andy Griffith in my childhood and that my parents did with Will Rogers in theirs—doesn't have an exact current counterpart, or not one I can think of just now. Stephen Colbert is closer than Jon Stewart; in his earliest, funny-rather-than-angry days, Rush Limbaugh could sound this way. Among politicians, Ronald Reagan was actually good at it—"There you go again!"—as was John F. Kennedy in some of his press conferences. It's an effect Barack Obama strains for and sometimes achieves, for instance when poking fun at the latest Birther-style claim. (And yes, before you point it out, I'm aware that in an actual small Southern town 50 years ago, the real-world counterparts of Andy Taylor and Barney Fife would have been enforcing segregation laws.)

    We would like to think that such level-headed, amused BS-detection is part of our national cast of mind. A Yank at Oxford! The Duke and the King in Huckleberry Finn! The Tweet shown above, by @BFriedmanDC, may offer a glimmer of hope for its reappearance. It is the kind of comment Sheriff Andy Taylor might have made if he had seen legions of Barney Fifes dressed for war.

  • Turning Policemen Into Soldiers, the Culmination of a Long Trend

    Another poisoned fruit of the post-9/11 sensibility

    Ferguson, Mo. police watching over their city (Reuters)

    The images from Missouri of stormtrooper-looking police confronting their citizens naturally raises the question: how the hell did we get to this point? When did the normal cops become Navy SEALs? What country is this, anyway?

    There will be more and more mainstream coverage of the modern militarization of the police, a phenomenon mainly of the post-9/11 years. For reference/aggregation purposes, here is a guide to further reading:

    1) The Book on this topic: Rise of the Warrior Cop, by Radley Balko. It came out a year ago and is more timely now than ever.

    2) "Lockdown Nation," a Peter Moskos review of Balko's book last year in PS magazine.

    3) "How the War on Terror Has Militarized the Police," an Atlantic dispatch by Arthur Rizer and Joseph Hartman three years ago. 

    4) "Tanks in Small Towns," a web item I did in 2011 on signs of this trend, including this photo of a police force in South Carolina:

    And this one from a small town in Virginia:

    And this from Florida:

    5) Some other Atlantic coverage here, here, here

    6) Update: An important and well-illustrated report by Matt Apuzzo in the NYT two months ago, called "War Gear Flows to Police Departments." 

    7) Update^2: A new report from Alec MacGillis in TNR on how "anti-terrorist" funding from DHS has equipped police forces with this CENTCOM-style war gear.

    This Ferguson, Missouri episode is obviously about race, and is (another) occasion for pointing readers to Ta-Nehisi Coates's powerful "Reparations" article. It is also about how we govern ourselves, and about how far the ramifying self-damage of the post-9/11 era has gone.

    "Self-damage"? All the literature about terrorism emphasizes that the harm directly done in an attack is nothing compared with the self-destructive reactions it can induce. From Fallujah to Ferguson, that is part of what we're seeing now.

    I won't belabor that theme for the moment but will say: Perhaps these incredible police-state-like images will have some attention-focusing or "enough!" effect, like their counterparts from another era (below). Meanwhile, check out Balko's book. 

     

  • Two Ways of Looking at the Hillary Clinton Interview

    Whichever way you see it, the presumptive Democratic nominee has shown us something significant.

    Two first families: the Obamas and the Clintons at a ceremony on the 50th anniversary of John F. Kennedy's death (Reuters)

    On return from a long spell away from the Internet, I was going to recommend that you read Jeffrey Goldberg’s interview with Hillary Clinton, and not just the setup but the transcript as a whole. But such a recommendation is hardly necessary, since for several days the interview has been making news worldwide.

    There are two ways to think about the political and policy implications of Hillary Clinton’s deciding to say what she did, during this strange limbo period when she is clearly preparing to run for president but has more to lose than gain by officially saying so.

    • One approach would be to think that we’re primarily witnessing a media event—journalists doing what journalists do. It's in our nature as reporters, even when representing an institution as august as a 157-year-old magazine, to highlight what has changed rather than what’s constant, what is controversial rather than what’s agreed on, the one juicy, taken-in-isolation sentence that will make people stop and say, Did you see that? And it is in nature of the political commentariat to seize on any sign of rancor or big-shot melodrama.

    Therefore if our Atlantic site runs a headline suggesting that Hillary Clinton is all but blaming Barack Obama for the ISIS/ISIL  menace (“Hillary Clinton: 'Failure' to Help Syrian Rebels Led to the Rise of ISIS”), or if we emphasize the few places where she departed from his policy rather than the many more where she supported it, maybe we’re just revealing the way we journalists think. When politicians start complaining that some comment was “taken out of context,” this is the point they’re trying to make. And in fairness, anyone who reads the whole transcript will find that the tabloid version of her comments—weakling Obama lost Syria!—is cushioned in qualifiers and complexities.

    If this is the way the Clinton camp feels about our presentation of the interview, they are perfectly well versed in all the the formal and informal ways of getting that message across. Indeed, just this afternoon, a little while after I started typing this item (but several days after the interview ran), the first such indication appeared, in a "no criticism intended" story via Politico

    •  The other approach is to think that Hillary Clinton, as experienced a figure as we now have on the national scene, knew exactly what she was saying, and conveyed to an interviewer as experienced as Goldberg exactly the impression she intended to—including letting the impression sink in through several days' worth of op-ed and talk-show news cycles before beginning to offset it with an "out of context" claim. 

    That impression is a faux-respectful but pointed dismissal of Obama's achievements and underlying thought-patterns. It's a picture of the president approximating that of a Maureen Dowd column. It also introduces into Democratic party discourse the “Who (re-)lost Iraq?” “Who lost Syria?” “Who lost Iran?” and “Who is losing the world?” queries that the Republicans are perpetually ready to serve up. All this is presumably in preparation for Clinton's distancing herself from a "weak" Obama when she starts running in earnest to succeed him.

    If the former interpretation is right, Clinton is rustier at dealing with the press than we assumed. Rustier in taking care with what she says, rustier in taking several days before countering a (presumably) undesired interpretation.

    I hope she's just rusty. Because if she intended this, my heart sinks. 

    It sinks for her, that she thought this would make her sound tough or wise; it sinks for the Democratic Party, that this is the future foreign policy choice it’s getting; and it sinks for the country, if this is the way we’re going to be talked to about our options in dealings with the world.

    The easiest and least useful stance when it comes to foreign policy is: Situation X is terrible, we have to do something. Or its cousin: Situation X is terrible, you should have done something. Pointing out terribleness around the world is not even half of the necessary thought-work in foreign policy. The harder and more important part—what constitutes actual statesmanship—is considering exactly which “something” you would do; and why that exact something would make conditions better rather than worse; and what Pandora’s box you might be opening; and how the results of your something will look a year from now, or a decade, when the terribleness of this moment has passed. 

    E.g.: Yeah, we should have “done something” in Syria to prevent the rise of ISIS. But the U.S. did a hell of a lot of somethings in Iraq over the past decade, with a lot more leverage that it could possibly have had in Syria. And the result of the somethings in Iraq was … ? A long story in the NYT tells us that the current leader of ISIS, Abu Bakr al-Baghdadi, the caliph himself, drew his political formation from America’s own efforts to “do something” in Iraq:

    “He was a street thug when we picked him up in 2004,” said a Pentagon official who spoke on the condition of anonymity to discuss intelligence matters. “It’s hard to imagine we could have had a crystal ball then that would tell us he’d become head of ISIS.”

    At every turn, Mr. Baghdadi’s rise has been shaped by the United States’ involvement in Iraq — most of the political changes that fueled his fight, or led to his promotion, were born directly from some American action. And now he has forced a new chapter of that intervention, after ISIS’ military successes and brutal massacres of minorities in its advance prompted President Obama to order airstrikes in Iraq. 

    Of course everyone including Clinton “knows” that you should only do something when it’s smart and not when it’s stupid. In her books and speeches, she is most impressive when showing commanding knowledge of the complexities and contradictions of negotiating with the Russians and Chinese, and why you can’t just “be tough” in dealings with them. In those specifics, she can sound like the description I just came across, in Christopher Clark’s The Sleepwalkers, about some pre-World War I Balkan leaders: “It is a characteristic of the most skillful politicians that they are capable of reasoning simultaneously at different levels of conditionality. [One Serbian figure] wanted peace, but he also believed—he never concealed it—that the final historical phase of Serbian expansion would in all probability not be achieved without war.” 

    But in this interview—assuming it's not "out of context"—she is often making the broad, lazy "do something" points and avoiding the harder ones. She appears to disdain the president for exactly the kind of slogan—"don't do stupid shit"—that her husband would have been proud of for its apparent simplicity but potential breadth and depth. (Remember "It's the economy, stupid"?) Meanwhile she offers her own radically simplified view of the Middle East—Netanyahu right, others wrong—that is at odds with what she did in the State Department and what she would likely have to do in the White House. David Brooks was heartened by this possible preview of a Hillary Clinton administration's policy. I agree with Kevin Drum and John Cassidy, who were not. Also see Paul Waldman.

    But really, go read the interview. Either way, the presumptive nominee has, under Jeffrey Goldberg's questioning, shown us something significant. 

  • The Courts Speak Up for California High-Speed Rail

    And so do some readers.

    Artist's rendering of a high-speed train station (AP)

    As a reminder, this is #7 in a series on the most ambitious and consequential infrastructure project now under consideration in our infrastructure-degraded land. It is the plan for a north-south California High-Speed Rail system, which had its genesis before Jerry Brown’s second coming as California’s governor but is now his signature project as he runs for re-election to an unprecedented fourth term. For previous installments see No. 1No. 2No. 3No. 4, No. 5, and No. 6 

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    The big HSR news of this past week was a ruling from a three-judge panel of California's 3rd district court of appeals. Late on Thursday, the judges unanimously overturned a lower-court ruling that had prevented the HSR authority from selling bonds to begin construction of the system.

    The issues in the case are, well, legalistic. For more about them you can check the thorough accounts from the LA Times, the San Jose Mercury News, KQED, and the Fresno Bee. The Bee's and KQED reports have embedded versions of the full text of the ruling. 

    As all the stories make clear, the ruling does not end the legal problems for the high-speed rail program, nor the political controversy about it. But the appeals court decision was widely reported as a significant step forward for the project and a win for Governor Brown. E.g. this headline from the Mercury News:

    And this summing up from the Fresno Bee:

    The ruling represents the second legal victory in a week for the rail program at the appellate level. On July 24, a different three-judge panel from the 3rd District ruled in the rail authority's favor and upheld [lower court judge] Kenny's approval of an environmental impact report that selected the Pacheco Pass between Gilroy and Los Banos as the preferred corridor for high-speed trains between the Bay Area and the San Joaquin Valley. The San Francisco Peninsula communities of Atherton and Palo Alto had challenged Kenny's approval of environmental work for the Bay Area-to-Central Valley section of the rail line.

    For now, that is enough of the legalities. On to further reader discussion of the merits of the plan. First, from a reader in Southern California:

    One of the arguments I keep running across is the idea that the High Speed train should run non-stop along the I-5 corridor instead of along the 99, which was only included to get legislators on board.

    Federal Highway Administration

    No, it runs along the 99 corridor to get passengers on board. There are a million people in the Fresno metro area, plus all the people in Bakersfield and a major seaport city in Stockton. Depending on how you count the borders, the San Joaquin Valley is home to nearly 4 million potential customers.  

    [JF note: see the Federal Highway Administration map of I-5 and Highway 99, at right. I-5 is in red and bypasses, to the west, most of the major cities of the San Joaquin Valley. Highway 99, shown in yellow, goes from city to city through the valley.]

    And the San Joaquin Valley is in a natural cul-de-sac, cut off from the south by mountains and mired in a 19th century agricultural economy. One of the biggest benefits of the HSR project is reconnecting the Central Valley with SoCal to allow a modern economy to develop.

    While limiting the number of stops helps keep the average speed high, providing more connections helps keep revenues high. The train has to at least serve the big five; Bakersfield, Visalia, Fresno, Modesto and Stockton; plus possibly Merced.

    Asking the people of the Central Valley to drive to their destination to board the train is not going to improve the transportation options for the people who could be the key to profitable ridership.

    And now, from a reader who was traveling in Europe as he sent the message. He responded a comment from a previous reader, who had said: "The difference of HSR in Europe and Asia to the US is the access to the stations: European cities were built around train stations: see Frankfurt, Hannover, London, Amsterdam." This latest reader, Robert Mahnke, replies:

    I don’t know why this sentence really bugged me, but perhaps it’s because it reflects a mistaken belief that we are doomed to live in poorly designed cities because it’s our birthright, rather than a choice we have made.

    I am in Brussels, and arrived here by the Eurostar last night after spending several days at the St Pancras Renaissance Hotel in London, located on top of St Pancras station, so right now I am very much appreciating the planning decisions made around rail in Europe.

    Of course, most European cities were *not* built around train stations. Londinium was the capital of Roman Britannia. Frankfurt, Hannover and Amsterdam all date from medieval times. Steam trains were a nineteenth- century innovation. To build train stations in these cities surely involved expensive, disruptive engineering projects. (Conversely, American cities like Denver, Phoenix and Tulsa *did* grow up around railroads.)

    Amsterdam is an example. Amsterdam Centraal station was built in 1889. In his history of the city, the Dutch journalist Geert Mak laments the decision to build it essentially in the city’s harbor, blocking the city’s waterfront on the IJ. [JF note: I was in Amsterdam last week when I received this message; the IJ, pronounced roughly "eye," is the lake/bay to the city's north.] Since then, reclamation projects have filled in much of the IJ around the city, so modern maps make it hard to see what he means, but here is a 16th-century view of the city:

    Amsterdam Museum

    The perspective is from over the IJ — reflecting that Amsterdam’s trade was with the sea (and the Amstel River), not over the swampy land. If you look at a modern map (the IJ is to the north and west), you’ll see that the train station was built in the harbor, cutting off the city from the IJ:

    Wikimeda

    So as Mak writes, it was a large and hard choice to put Amsterdam’s train station where it is.

    Amsterdam Centraal is not at the center of downtown, surely because it would have been so disruptive to site it there. Typically, one doesn’t find train stations at the very center of cities. For older cities, it’s surely because the demolitions that would have been necessary didn’t make sense. So you find multiple rail stations at somewhat more peripheral locations, e.g., in London:

    London Toolkit

    Which is to say that European planners confronted the same problem of building railroads into a built environment that HSR rail now faces. US cities that predate the railroad are similar. I grew up in Boston, where you go to North Station for a train to Portland and South Station for a train to New York.

    Much of the reason that it feels like some of these cities were built around the train stations is that later public transit serves them so well. When I go to Amsterdam, I can take HSR from Brussels or Cologne and get onto a tram, and if I then fly out of Schiphol, there’s a fast and convenient train from Amsterdam Centraal right into the airport terminal. When I landed at London Heathrow the other day, I got right on the Underground’s Piccadilly line and got off at St Pancras / Kings Cross station, and my hotel was next door. (And not every European city does it right. When I fly to Berlin, I have to take a cab from the airport. But getting it right is not a uniquely European phenomenon. You can take the El in Chicago right to an O’Hare terminal.)

    It is possible to “retrofit” cities to make this work. The Silver Line didn’t exist when I last lived in Boston. I flew back and forth from SFO to Logan on a recent weekend to bring my kids to their grandparents. I got on a Silver Line bus a curbside, and it took me via dedicated lanes to South Station, where I got right on the Red Line to Cambridge. When I went back, it worked just as seamlessly.

    California’s struggles with HSR make me wonder if our political system gives too much power to those who would block public-works projects. That said, I will also say that I have been in both Singapore and Beijing recently, and in both cities it seemed to me that the political system makes bad redevelopment too easy. Two cities apparently at opposite ends of the political spectrum, but both downtowns were full of massive projects which made no sense to a pedestrian at street level but might have looked great to someone arriving in a limousine.

    Still to come in the series: some reader mail critical of the project, some other international and historical comparisons, and my own "this I believe!" explanation of why on balance I think this is an investment worth making and a risk worth taking for the state.

  • Smaller Towns as Talent Magnets: The Chance to Make Things Work

    "The kind of people who might have gone to NASA in the 1960s, Wall Street in the 1980s, or Silicon Valley in the late 1990s are now, I think, more likely than ever to work in municipal government." So says a well-educated young small-town mayor.  

    Downtown Greer, South Carolina, a rapidly growing small town between Greenville and Spartanburg.

    As we've spent time in smaller towns that are undertaking economic or cultural recoveries, my wife Deb and I have repeatedly been struck by a certain migration pattern. This is the presence, and importance, of ambitious people at the beginning of their careers who have chosen to fulfill those ambitions not in Brooklyn or the SF Bay Area or one of the other best-known assumed national talent destinations. Rather they've chosen to live and work in Greenville SC, or Duluth MN, or Burlington VT, or Sioux Falls and Rapid City SD, or Redlands and Winters CA, or Holland MI, or West Point and Columbus MS, or other even less-celebrated places.

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    For some people the reasons are family ties to the town. For others, the search for a safer, more pastoral, or more affordable environment in which to raise children. For some, utopian escapism of the type we mainly associate with my Boomer contemporaries of the 1960s and 1970s. But in quite a few places we've heard sentiments like the ones expressed below. Which boil down to, the chance to make a difference, and be part of a success.

    This note comes from a young mayor of a smallish Midwest city who is now serving with the U.S. military in a combat zone. We have not yet been to his city, but what he says resembles what we have heard elsewhere:

    I'm writing in response to your Atlantic article on small cities ["Why Cities Work Even When Washington Doesn't"], which belatedly reached me here in [Afghanistan] in hard copy in a recent care package. I'm on leave from the city for military duty this year.

    As a fairly new small city mayor who is trying to push our city  forward with moves like reintroduction of two-way streets downtown and reimagination of public spaces, I predictably loved it. I also wanted to draw your attention to an important, related story.

    There has been lots of good buzz and coverage lately about cities and mayors, but a story still waiting to be told is the quality of people coming to work for them. Doubtless there have always been extraordinary people drawn to local government, but something truly unusual is happening, in my view, in the caliber of young professionals drawn to this work now.

    The kind of people who might have gone to NASA in the 1960s, Wall Street in the 1980s, or Silicon Valley in the late 1990s are now, I think, more likely than ever to work in municipal government. See, for example, the Code for America phenomenon.

    In recruiting talented professionals, we have been able to punch above the weight of a small city like ours, drawing people with international careers in architecture, government, consulting, and engineering to work for five-figure salaries in a small Midwestern city willing to try new things.

    Is this a side-effect of federal dysfunction, that public-minded young professionals are far less attracted to the Hill as a place to make their mark and now look to the local level instead? Or something to do with the economy? I don't know, but I think there is something to this untold story of the kinds of people newly drawn to local civic work. 

    I agree, and will have more to say about this soon.

                                                                   ***

    I've been offline for more than a week because of duties 24/7 at the Aspen Ideas Festival. Here is a sample that is now up at the Ideas Festival site, an hour-long discussion two days ago with former Treasury Secretary Timothy Geithner.

    I say in the set-up for the interview that Geithner's book, Stress Test, is actually very good, considered just as a book. This is a point that Michael Lewis made in his NYTBR treatment of it too. All appropriate credit to Geithner's co-author, Michael Grunwald, author of The New New Deal.

    The next Aspen interview I'll be looking for, when it goes up on their site, is one I conducted an hour later that same day with Amanda Lindhout, on her truly extraordinary memoir A House in the Sky. Stay tuned. 

  • Sunday Readings on Media, Sports, and War

    Talk shows aren't bringing on Captain Hazelwood to discuss safe shipping. But they still can't get enough of the Hazelwoods of foreign policy. Also, whether the "New York Times paradox" applies to public radio.  

    Marilyn Monroe statue in Chinese scrapyard. Explanation below. (Reuters)

    A harvest of items worth attention:

    1) Media Decline Watch, public radio edition. Anyone who has spent time in Seattle knows the voice and sensibility of Steve Scher. He has been a long-time urbane host and interviewer on the public radio station KUOW. He has made a place in the public awareness similar to that of Michael Krasny on KQED in San Francisco, or Diane Rehm on WAMU in Washington, or Larry Mantle on KPCC in Southern California, or their mainstay counterparts across the country. I was on the show sometimes, and listened to it frequently, in the years we lived in Seattle.

    This story by David Brewster, himself a stalwart of Seattle journalism, on the regional news site Crosscut is a sobering account of why Scher decided to take himself out of the radio business. You can read the story yourself, but it helps illustrate public radio's version of what I think of as the modern "New York Times paradox."

    The paradox is that digital technology has made the NYT more influential worldwide than it has ever been before, and more than any other single news organization in history. And that same technology has put the Times in terrible economic straits. In the Times's case, I've always assumed that this paradox will be resolved in its favor. It will find a way to convert its global brand into some kind of sustainable business.

    The Scher story is a reminder that there may be a comparable "public radio paradox." In influence, public radio in all its incarnations is more important than ever. (The incarnations include the mother-ship NPR, PRI, APM (host of our American Futures-partner Marketplace), the numerous local stations, some state and regional alliances, and others.)  And yet NPR layoffs and cutbacks are always in the news, and many other parts of the public radio ecosystem are in financial trouble. This paradox will be harder to resolve than the NYT's, for a variety of reasons: because there are so many players, because there are rivalries among some of them, because they're not run as normal businesses, and because their governing structure is more cumbersome than that of a family business. But it's in everyone's interest that they succeed.

     

    2) A walk on the Aussie side, Baffler edition. On first exposure to Australia, many Americans think, "Hey, it's a nicer version of home." In many (pleasant) visits over the years, I've come to think that—both to its credit and not—Australia is a very deeply different place from the United States. In The Baffler, Sarah Burnside, an Aussie, explains some of the reasons why.

     

    3) Oh calm down, Boomer-finances edition. Scare-mongering is one of our national pastimes, in realms from aviation safety ("My plane almost crashed!") to China's rise or budget deficits. In the American Scholar, my friend Lincoln Caplan debunks a fiscal version of scare-talk: the idea that Boomer-era retirement and medical demands will bankrupt us all. Calm down, he says:

    A demographic tool has become an economic one, treating a demographic challenge as both an economic crisis and a basis for pessimism justifying drastic reductions in bedrock government programs, including those supporting children and the poor. Even at state and local levels, the aging boomer demographic is repeatedly blamed for our economic difficulties. That is a lamentable mistake... 

    The dependency ratio does not justify the solutions that the alarmists propose. Just as important, perhaps, it fails to account for the striking benefits accruing from the dramatic increase in life expectancy in the United States during the 20th century—what the MacArthur Foundation’s Research Network on an Aging Society called “one of the greatest cultural and scientific advances in our history.”

     

    4) Seriously, why are we still hearing from Cheney, Kristol, et al? After the Exxon Valdez, cable news wasn't bringing us Captain Hazelwood as expert commentator on maritime safety. After the next big air disaster, we're not going have the Malaysian aviation authorities on to offer advice. But when it comes to foreign policy, the analysts who have always been wrong and the officials who put wrong policy into effect keep commanding air time. Today, incredibly, ABC gave Dick Cheney an extended platform on This Week with more deferential questioning than Megyn Kelly had applied on Fox News.  

    Why? Why? If TV is not serving up Hazelwood or the Malaysian savants, or O.J. on managing a post-sports career, why are they bringing us Kristol and Cheney? In Foreign Policy, Stephen Walt offers not excuses but diagnostic-style explanations. You can see them here

     

    5) Sports news, throwing department. For background on the "Throwing Like a Girl" concept, please see this original article and follow-ups like this and this.

    The last of these links takes you to a slo-mo video of the Giants' Tim Lincecum throwing. Tim Heffernan suggests points to an incredible GIF of the Dodgers' Clayton Kershaw and says we need a new category, "throwing like a machine." I can't embed it, but you can see it here

     

    6) OK, what about Marilyn Monroe? My friend Adam Minter, author of Junkyard Planet, says that the standard outside reaction to photos of the statue in a Chinese scrap yard, has been some variation on: Oh, those wacky Chinese! To the contrary, Adam says. He explains why here.

  • The Graciousness and Dignity of Richard B. Cheney

    "Rarely has a U.S. president been so wrong about so much at the expense of so many."  

    An expert on being wrong shares his thoughts. (Reuters)

    A few hours ago I said (sincerely) that a number of prominent officials who had set the stage for today's disaster in Iraq deserved respect for their silence as their successors chose among the least-terrible of available options.

    I unwisely included Dick Cheney, former vice president and most ill-tempered figure to hold national office since Richard Nixon, on that list.

    If I'd waited a little while, I would have seen a new op-ed by Cheney and his daughter Liz in (where else!) the WSJ denouncing the Obama administration's fecklessness about Iraq and much else. They say, unironically, about the current occupant of the White House:

    Rarely has a U.S. president been so wrong about so much at the expense of so many. 

    You want a specimen of being so wrong about so much at the expense of so many? Consider the thoughts of one Richard B. Cheney, in a major speech to the VFW in August 2002, in the run-up to the war:

    Another argument holds that opposing Saddam Hussein would cause even greater troubles in that part of the world, and interfere with the larger war against terror. I believe the opposite is true.

    Regime change in Iraq would bring about a number of benefits to the region. When the gravest of threats are eliminated, the freedom-loving peoples of the region will have a chance to promote the values that can bring lasting peace.

    As for the reaction of the Arab "street," the Middle East expert Professor Fouad Ajami predicts that after liberation, the streets in Basra and Baghdad are "sure to erupt in joy in the same way the throngs in Kabul greeted the Americans." Extremists in the region would have to rethink their strategy of Jihad. Moderates throughout the region would take heart. And our ability to advance the Israeli-Palestinian peace process would be enhanced, just as it was following the liberation of Kuwait in 1991 

    "The freedom-loving peoples of the region will have a chance to promote the values that can bring lasting peace." Yes, that is exactly how historians will register the lasting effects of the invasion for which Cheney was a major proponent and decision-maker. Along with the rest of his forecasts. What a guy.

  • 'The Past Is Never Dead,' Bill Faulkner Told Us—but He Didn't Know About the Iraq War

    Some people have earned the right not to be listened to.

    If you're anything like me, when you hear the words "wise insights about the Iraq war," two names that immediately come to mind are Paul Wolfowitz and Scooter Libby. 

    Fortunately the Hertog Institute has engaged them both to teach a course, "The War in Iraq: A Study in Decision-Making." 

    I will confess that when someone told me about this today, I assumed it was an Onion-style joke. As in, "The Work-Family Balance: Getting It Right," co-taught by John Edwards and Eliot Spitzer. But it turns out to be real. Or "real."

    In the cause of public knowledge, I am happy to offer royalty-free use of several items for the reading list. Like:

    • "The Fifty-First State?" from the year before the war. The Wolfowitz-Libby "study in decision-making" might consider why on Earth so many obvious implications of the war were blithely dismissed ahead of time, including by these two men. Or ...
    • "Blind into Baghdad," about the grotesque combination of arrogance, ignorance, and incompetence that characterized decision-making about the war. Or ...
    • "Bush's Lost Year," about the sequence of advantages squandered, opportunities missed, and crucial wrong bets made in the months just after the 9/11 attacks. Students might find this one particularly interesting, since it begins with a long interview with their own Professor Wolfowitz. For the Cliff's Notes version, see after the jump.

    Somehow I am guessing that the professors might pass up my generous offer. So instead, here's another "at first I thought this was a joke" candidate: a new essay by William Kristol and Frederick Kagan in Kristol's Weekly Standard with advice about Iraq:

    I'll give Kristol and the Kagan brothers this: They are consistent, in attitude as well as typography and headline writing and page layout. Here is what Kristol and Robert Kagan were writing 12 years ago, shortly after the 9/11 attacks:

    Sample of their level-headed and confirmed-by-history views: "The Iraq threat is enormous. It gets bigger with every day that passes." 

    Am I sounding a little testy here? You bet. We all make mistakes. But we are talking about people in public life—writers, politicians, academics—who got the biggest strategic call in many decades completely wrongWrong as a matter of analysis, wrong as a matter of planning, wrong as a matter of execution, wrong in conceiving American interests in the broadest sense. None of these people did that intentionally, and many of them have honestly reflected and learned. But we now live with (and many, many people have died because of) the consequences of their gross misjudgments a dozen years ago. In the circumstances, they might have the decency to shut the hell up on this particular topic for a while. They helped create the disaster Iraqis and others are now dealing with. They have earned the right not to be listened to.

    * * *

    Brian Beutler in The New Republic goes into this standing-to-speak issue very clear-headedly. For the record, he takes my side of the argument, sort of. Also, last week in New York magazine Frank Rich talked about the strange non-accountability of the liberal-hawk faction. His colleague Eric Benson interviewed me on that theme. For Kristol as a special case of someone so wrong so often that he's a reliable reverse-predictor guide to reality, see this, which doesn't go into his enthusiasm even now for Sarah Palin.

    And if you would like to see something not testy but deservedly bitter, consider what Andrew Bacevich says most recently about unrepentant war mongers.

    Update: I hadn't seen until now that Paul "Let's Disband the Iraqi Army, What Could Go Wrong?" Bremer has offered his wisdom about Iraq in the WSJ. Jeesh! Also see this by Steve Benen at the Maddow blog, and this by Katrina Vanden Heuvel in the WaPo.

    * * *

    My article "Bush's Lost Year" was about the very subject of this class, decision-making in the Iraq war. Here is the way it ended:

    To govern is to choose, and the choices made in 2002 were fateful. The United States began that year shocked and wounded, but with tremendous strategic advantages. Its population was more closely united behind its leadership than it had been in fifty years. World opinion was strongly sympathetic. Longtime allies were eager to help; longtime antagonists were silent. The federal budget was nearly in balance, making ambitious projects feasible. The U.S. military was superbly equipped, trained, and prepared. An immediate foe was evident—and vulnerable—in Afghanistan. For the longer-term effort against Islamic extremism the Administration could draw on a mature school of thought from academics, regional specialists, and its own intelligence agencies. All that was required was to think broadly about the threats to the country, and creatively about the responses.

    The Bush Administration chose another path. Implicitly at the beginning of 2002, and as a matter of formal policy by the end, it placed all other considerations second to regime change in Iraq. It hampered the campaign in Afghanistan before fighting began and wound it down prematurely, along the way losing the chance to capture Osama bin Laden. It turned a blind eye to misdeeds in Saudi Arabia and Pakistan, and to WMD threats from North Korea and Iran far more serious than any posed by Saddam Hussein, all in the name of moving toward a showdown with Iraq. It overused and wore out its army in invading Iraq—without committing enough troops for a successful occupation. It saddled the United States with ongoing costs that dwarf its spending for domestic security. And by every available measure it only worsened the risk of future terrorism. In every sense 2002 was a lost year.

    That was how it looked to me 10 years ago. And still does.

    More »

  • The Endless Civil War, Continued

    "Should the people in Mississippi stay poor? I would suggest taking a serious look at the answer 'yes'." So says a reader who lives elsewhere.

    Sharecroppers in Georgia, just before World War II. Are their grandchildren better off, because industries have arrived? Hint: my answer is Yes. ( Farm Security Administration, 1941 )

    Over the past few weeks, my wife Deb and I have been reporting on Mississippi's efforts to move itself up from the bottom in rankings of educational achievement, and similarly to move itself up from being overall the poorest state in the nation.

    Question for the day, from readers: whether any success it achieves will necessarily come at the expense of other places, especially in the North. Of course movement in rankings is by definition zero-sum. The real question is whether greater prosperity for Mississippi has to mean less somewhere else.

    For background, here are some installments about the Mississippi educational efforts: one,  two, three, and four. (No matter what region you're from, be sure to read at least the first couple of essays by students in that final, fourth item.) And these on industrialization: one, two, three, and four

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    Now, a note representative of several I've received. It concerns how to think or talk about economic activities in the non-union, low-wage, politically conservative, ever-shadowed-by-racial-injustice (cf. Ta-Nehisi Coates) areas of the Deep South. Here goes, quoted in full for context: 

    I have an odd relationship with your blog. I read it avidly and yet I find myself alienated. You prick my despair about the country, in fact. In your most recent entry in the 'Lo and Behold, Industry in Mississippi' series, you asked for feedback and so here is a little exploration of my vexed relation to your work and perspectives.

    First off, I'm a native of a Rust Belt city and much of my family originally migrated here from the South. In fact they were slaveowners who left the South to industrialize the North - and they were very successful at it, probably even a factor in the victory of the North over the South in the Civil War.

    But I grew up in a different time - the time of decline of industry. I grew up with the decades of desolation and loss. I understand the impact of abandonment, wholesale and profound, that has infected the Rust Belt in the post war era. I know the economic decline of Rust Belt cities to be deeply imprinted with American racism as well as the relentless and devastatingly effective rightwing campaign against unionization. The deindustrialization of the North cannot be separated from the success of Southern style politics and ideologies over the last 40 years. The American people have suffered serious economic harm as a result.

    So forgive me if Joe Max Higgins does not seem charming. To be honest my chief reaction to reading this piece was to wish that TVA funding was quickly and permanently yanked. I do not support federal funds in order to develop this political cesspool into an influential center of the American economy. I think the South should be quarantined, politically and economically. They suck on the federal tit whilst fanning resentment of the poor, among many (many!) other political sins.  (The best thing about the Dixiecrats is that there were less effective nationally when stranded within the Democratic Party than they are today, when they control Republican ideology and the Supreme Court. )

    I wasn't satisfied by your reply to this comment [from another reader, a man in New York]:

    "The theme that I find missing in your series is any recognition that the Southern states have been in a continuing economic war with the Northern manufacturing base for at least since the Civil Rights Act. Undermining and destroying unions has been a signature part of that strategy and it has been very successful. The great cities of the North have been hollowed out just as they were beginning to provide a haven for lower class families, not to mention the overall starvation of the middle class."

    You didn't address the above point. The South has had a baleful influence. Perhaps what is in process is the lasting destruction of American broad based prosperity, thanks in no small part to rise of Southern political values. There are no signs of a turnaround for most in this economy - it is only getting worse. Yet continuing on this path would be tragic. It would fundamentally undermine the whole American experiment. I would like your series a lot more if you addressed this.

    I keep telling myself I won't do this any more, but I wrote right back to the woman who sent the message:

    I have a reaction of "And therefore, what....?" to your views.

    Suppose one, like me, is in favor of unions, is in favor of more progressive taxation and a fairer economy, is against what many Southern politicians now stand for, has written endlessly about the "new nullification" menace, and so on. Should I say: "Well, I hope these people in Mississippi stay poor?"

    I'd be interested to know what, specifically, you'd like to do to, or with, Mississippior St Marys, Georgia, or Greenville, SCas the action part of your view. 

    To which she replied: 

    As to your question - should the people in Mississippi stay poor? I would suggest taking a serious look at the answer 'yes'. If industrial jobs in Mississippi are in fact a part of a national race to the bottom and if that race is destructive to the larger good then the race itself should be stopped. And one consequence of that could be a slow down in the industrializing of Mississippi. 

    I don't enjoy making careless arguments and there are a number of 'ifs' in the above paragraph. The point is that there is a larger picture. What conventions, regulations, and laws enable corporations to make states compete against each other for their investment? Some of that should simply be outlawed. Some of that sort of thing is actually disallowed under trade pacts - why should it be allowed for states?

    It's taken decades to build an economy of downward mobility. Financial deregulation, corporate trade deals, and union busting has required not only policies but ideology and economic theory. It has been a bipartisan effort and academics and the media have contributed. Virtually all of the conventional thinking in my view is tainted by this history. But the issues we are discussing impact the real economy of jobs and wages. We must not avoid painful disputes even though bringing up these difficult issues is a downer in the context of a feel good story of a poor corner of the country doing better. 

    If you've gotten this far, I hope you'll indulge a further word about the ongoing juggling act for a writer like me. Over the past three-plus decades, in at least four of my books and at least a dozen long Atlantic articles, I've tried my best to apply reporting, reading, thinking, and observation to questions of exactly this sort. The movements of industries among nations; the movements from region to region within a nation; the forces that make whole economies seem to progress or stagnate; the forces that are uniquely necessary if America is to seem "fair"; the burdens of history, race, public policy, and private institutions in shaping American mobility, and so on.

    I know that I've written all this stuff. Most readers, probably including this one, don't. But if I say, "go read 'How the World Works' or More Like Us or 'How America Can Rise Again,'" I sound insufferable. And if I don't, I'm left with people who "are not satisfied" because I haven't dealt with a topic at a time when they happened to be noticing or in a post they're seeing on its own. As the world's problems go, it's small. But it is one I have to think about it.

    Enough about me! Let's turn now to a reader in Florida. He writes: 

     I agree with you —I wouldn't lead every Mississippi piece I wrote with a racial disclaimer either. After all, TNC's writing has focused as much on Chicago as Mississippi—which makes sense because parts of Chicago are historically, literally Mississippi north. 
     
    That said, two things about two of these posts really struck me and both relate to the historical relationship of Missisippi and Chicago. Key quote from your post:
     
    "Part of the 'Northern narrative' on what we're doing here is that we're just buying industries," [Joe Max Higgins] told me.
     
    In 1914, with the onset of World War I, European immigration halted overnight. By 1915, booming, shorthanded northern industry was "buying" southern black farm labor and creating the Great Migration—and changing America, north and south, forever.
     
    Southern government and industry (mostly agriculture) fought with every legal and extra legal tool it had to halt the migration. "The southern narrative was you will cripple our society by stealing our niggers." It was routine for southern local governments to ban labor recruiting; to ban migration itself through brutally enforced vagrancy laws. My hometown in Florida passed an ordinance in 1916 requiring a $1,000 license for any recruiter seeking black labor. Not getting the license was a crime.
     
    You ask, don't people know these things
     
    No, they don't. They know about water fountains and epithets. They know nothing about the migration that made both redlining and the successful civil right movement possible by breaking up the status quo.
     
    In my opinion, WWI and the Great Migration are the two most important forces of 20th century. One caused the other. They are, I think, without question the most important racial forces of the 20th century. And we as a country know nothing about them. We know so little about them that an economic developer in Mississippi doesn't see the exquisite historical irony in the South "buying" the industry that the north used to buy its labor and grow the industrial power of the US. 

                                                                  ***

    This is plenty to chew on for now. I was tempted to add a "This I Believe!" summary of my economic views, but I am going to save that for tomorrow. I have actually written it already, so I will actually post it after I let it cool.

    I will though close with one transition point, tied to the first reader's note. I respect her clarity in following her logic to its conclusion. Still, I completely  disagree that the rest of the country might have stayed richer and fairer if our poorest state stayed dirt poor. While I'm at it: I also don't think America would be richer, fairer, or happier if China were still dirt poor. That's a topic-sentence assertion for now. Supporting sentences soon.

  • The Civil War That Does Not End

    How to talk, in the 21st century, about the war that divided the country in the 19th century, and the racial patterns set up by slavery long before

    Students from the Mississippi School for Math and Science, performing historical re-enactment in honor of Emancipation Day.

    Two emails came arrived within minutes of each other over the weekend. Both have to do with the reports my wife Deb and I have been doing from the "Golden Triangle" of Mississippi: the cities of Columbus, Starkville, and West Point. The reports started here, with a catfish fry; included this and this about schools and this and this about industry (and beer); and this about seeing small towns by air. There is more to come, from factories and from an orphanage and a college, plus a Marketplace report soon.

    The two letters I'm quoting now are long but worth reading back-to-back. The first is from a man who grew up in the area—Lowndes County is one of three counties in the Triangle—and now lives several states to the north:

    As a native of Lowndes County, MS and an alumnus of the Mississippi School for Mathematics and Science, I wanted to let you know how thrilling it is to read the series of articles by you and your wife about my hometown and high school. I especially appreciate the clear lack of schadenfreude in the series so far. This is one of the few times in my adult life that I have had the privilege to read coverage of Mississippi in a national publication in which Mississippi was not used merely as a foil to highlight racial, social, or economic progress elsewhere. I understood perfectly what Joe Max Higgins meant by,"When Eurocopter came in, people started walking upright a little bit."

    The population and income maps included with the most recent article are excellent, illuminating, and depressing. I'm curious to see whether you will further explore the intersection of race and economy in the Golden Triangle. I would love to know whether the benefits of the economic development in the Golden Triangle have accrued to blacks as well as whites. Does the economic development help race relations or strain them? I assume it's a mixed bag, but I would love to hear more details.

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    Those questions of race and economy are in store for upcoming installments. For the moment, let's turn to the second letter, from a reader in New York. He said he had read some but not all of our Mississippi reports, and also has read Ta-Nehisi Coates's justifiably praised article on reparations:

    [T]alking about the success of a few Mississippi towns in attracting industry where the average annual income is $14,000 and comparing this with the reparations article which provides a pretty severe indictment of Mississippi (not to mention Chicago, etc.) provides a hell of a contrast.

    The theme that I find missing in your series is any recognition that the Southern states have been in a continuing economic war with the Northern manufacturing base for at least since the Civil Rights Act. Undermining and destroying unions has been a signature part of that strategy and it has been very successful. The great cities of the North have been hollowed out just as they were beginning to provide a haven for lower class families, not to mention the overall starvation of the middle class.

    When I travel in the south among my all white family and friends who never interact with anyone more ethnic than a Catholic, I am struck by how rigidly that part of the world is regulated into two societies. Not as if this does not occur in cooler climates. In New York, however, there is no room for that.

    Maybe I am missing the larger message in your series, and I know that you are averse to polemics, but I feel that glossing over the underlying original sin while applauding local civic restoration based on a depressed workforce and continuing segregation in schools and the workplace is not as helpful as you might like to be.

    I try to avoid the "Oh, yeah?!" temptation to send nasty instant feedback to emails, and generally succeed. You never get in trouble for the peeved message you don't send. In this case I wrote right back, testily. 

    I didn't dwell on one point of detail I thought was completely wrong, the "never interact with anyone more ethnic" part. Having just come back in Mississippi, where I had spent a fair amount of time in the civil-rights-era late 1960s*, I was reminded of how much more cross-racial minute-by-minute exposure people are forced to have in the typical small Southern town than the typical big Northern city. Obviously this does not mean that race relations are more "equal." My point is simply that the big-city phenomenon of seeing mainly people like yourself all day long is harder to pull off in a small mixed-race town.

    Instead I wrote back to say: Okay, would you like me to begin every dispatch with a reminder of Mississippi's troubled past? The Klan, the lynchings, Jim Crow? Don't you think people know this? He replied:

    No, I don't think people "know" this. I think most people have a very short view of history which basically includes only those things that happened in their immediate observable universe. I also think that there are about 60 million people in the South who know this perfectly well and either deliberately ignore it, blame the victim, don't care because "those people" are not part of their tribe or are deeply invested in perpetuating it and all of whom benefit from it directly and live with that guilt. Not to mention those who still do the work of the Secessionists.

    In the contrast between these notes are many of the themes and tensions of our politics now, and many generations in the past, and probably many generations to come.

                                                                       * * *

    As Ta-Nehisi Coates's article has underscored, we're dealing in the 21st century reverberations of divisions set up 300-plus years ago, in patterns of economics, agriculture, civic organization, and of course racially based slave-holding. Yesterday Andrew Sullivan posted a fascinating map reminding us how closely the blue/gray divisions of 150 years ago match the red/blue political divisions of today. Recently I posted a map showing that the parts of America where the highest proportions of African Americans live in the 21st century are the parts where Africans were brought to work as slaves several centuries ago. A reminder, via screenshot, with darker shadings meaning higher black proportions, and the three dots being the Golden Triangle.

    As an illustration of another kind of persistence, consider this Esri "swipe map," which shows racial makeup on one side and obesity rates on the other. Click on "Hide Intro" to see more of the map; zoom in to see county-by-county patterns. Darker shading on the right-hand map means higher African-American percentage; on the left-hand map, it means higher obesity rates. You'll see that in some parts of the country there's a strong correlation in the patterns; in others, not. (For instance, parts of Kentucky and West Virginia have relatively low black populations, and relatively high obesity rates.) 


     

    There are many books' worth of possible responses to the themes in these notes—as I am reminded by reading The Hamlet and Absalom, Absalom! for the first time since college. For now, two points only. One about journalism, and one about race.

                                                                       * * *

    The journalistic point involves what we are looking for, in Mississippi and the other places we are visiting for this American Futures project. Is it supposed to be a "balanced" or "comprehensive" view of America? No. 

    Through the years we were living in China, I never once imagined that my wife or I could offer a comprehensive view of what was going on. The country is too big, dynamic, unknowable, and contradictory for any sane person to dare that.

    The U.S. is more familiar and knowable, at least for me, than China. But it is no less contradictory and complex. So I don't imagine for a second that I can offer a "balanced" view of this country of any of the places where we have spent a week or two.

    But I can tell you things I didn't know before we got there. And by both design and happenstance, more of those have been positive than negative.

    • By design, because we have been looking for smaller cities or areas where turnarounds of one sort or another have been underway. Downtowns that have come back; new industries that have started up where older ones had closed; schools that prepared students for jobs, or mobility in the broadest sense; places that have retained or revived a "thick" sense of civic engagement. Finding and reporting on these places doesn't eliminate America's countless other problems. But does anyone not know about those countless other problems? To me, successes at the moment are more interesting, more instructive, more "news."
    • By happenstance, because every place we've been—including, notably, the town where I grew up—has provided some surprise we'd had no idea of before arrival. Let's be specific about Mississippi. If you already knew that there was a big industrial boom underway in eastern Mississippi; and that a Russian company making steel and a European company making helicopters had decided this was the place to do business; and that there was a school like MSMS in the nation's poorest state, producing students who wrote essays like this—well, you're ahead of me. Neither my wife or I had any idea of this before our first trip a few weeks ago.  

                                                                       * * *

    Now, the point about race, which is also the point about the Civil War and everything before and after.

    Start with the nationwide comparison: Americans know, or should, that racial unfairness, starting with slavery, is the country's original sin and its ongoing social and political axis. It was at the heart of our bloodiest war. Countless other things are going on in America, many of them not at all connected to race. But many, from the pattern of our cities to the growth of our prison-industrial complex to the nature of our schools, are still obviously related to our long racial history.

    We all know that, or should. But if some Chinese or German or Israeli sociologist shows up and says: "Here I am in America, and I observe that they have racial issues ..." Our natural response is: Thanks a lot for that great insight! That had never occurred to any of us. What can you tell us that's useful or new? As outsiders sometimes do, notably in this theme with An American Dilemma.

    So too with the American South. For someone like me to show up in Mississippi and begin every dispatch by saying, "Here I am in the South, and I observe that they have a history of racial injustice ..." does not get anyone very far. 

    What we can try to do is observe the ways the schools, the industries, the churches, the institutions are evolving and operating in this environment, and their effect on the various groups living there. Which will be the point of some upcoming installments.


    When not otherwise noted, any photos in our American Futures coverage are by me or my wife Deb Fallows, including the one at the top of this post.

    * For the record: I happen to have spent two years of my toddlerhood in Mississippi. During the Korean War my dad was a Navy doctor, and he was posted to what was then the naval hospital in Jackson. As a teenager I worked for several months in 1968 for the Southern Courier civil-rights newspaper. It was based in Montgomery, but I spent much of my time covering voter-registration and food-stamp-rights efforts in Mississippi and Alabama. 

  • If Doctors Don't Like Electronic Medical Records, Should We Care?

    "Yes, there are problems in any technology implementation and there always will be. But fewer people die. Yes, it is important to connect with the patient. But fewer people die. Yes, the opportunity to pad billing is obscene. But fewer people die."

    How critics imagine the new record-keeping system. ( Wikimedia commons )

    Dr. David Blumenthal, who now is head of the Commonwealth Fund, has been a friend since we both were teenagers. It was a sign of his medical / tech / policy skills that the newly arrived Obama administration put him in charge of encouraging a shift toward use of electronic medical records. It is evidence of his admirably good-humored big-tent personality that David still takes my calls after the many rounds of back-and-forth we've posted here in response to his original Q&A in our April issue, about why the shift has been so difficult and taken so long.

    For those joining us late, you can check out installments onetwothree,  four, and fiveHerewith number six, on the particular question of how the non-expert public -- those of us who experience the medical system mainly as patients and bill-payers -- should assess the opinions of physicians, nurses, and other inside participants. Should we give them more weight, because of their first-hand expertise? Less weight, because of possible institutional bias or blind-spots? Both at once? See for yourself.

    First, the concerns of two physicians. One on the West Coast writes:

    I am a family practice physician in western Washington state. I have been practicing for 25 years.  Ten years ago I was excited about about the potential of electronic technology to improve patient care. Today I am profoundly disappointed.  

    I am currently working in three different EHRs (electronic health records). Two are OK, i.e. allow me to efficiently document a patient visit with clinically relevant data.  The other one is cumbersome beyond belief. It is a company with outstanding marketing capability that won over our administrators. It falls far short of meeting the needs of those of us trying to improve patient care.  Intrinsically it fails to produce a note useful for other doctors. To achieve that end, I use time-consuming work arounds. Sad I think. 

    I believe that primary care is valuable to patients but also has potential to limit costs.....

    I have included a reference to one of my favorite articles from the New England Journal of Medicine, including the first paragraph of the article:

    "It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their 'civilian' life.

    And from a doctor in Kentucky:

    As a 50 y/o it infuriates me when I read that only physicians less than 40 are comfortable with EMR’s because they grew up with them. Well that’s crap. My first computer was a Commodore 64 which I learned to program. I am very familiar with computers and have 4 networked together in my home.

    That being said I would agree with Dr. Wait [from this post] in that EMR’s are not ready for primetime. If EMR’s were so great, no one would have to bribe and penalize us to use less. They generate a tidal wave of information. The important data gets lost in the overwhelming volume of mostly useless information. I used to dictate my notes and they would then scanned into the computer. The note was legible and concise. I could find it anywhere. Then the EMR came. It takes 20 minutes to do what used to take 30 seconds. I get a note that is less than useful. It is full of errors that I can’t correct. Information that others have entered that is clearly wrong that I can’t remove. I no longer try. The only important part now of my notes are the HPI and the plan. The rest is just garbage.

    To give you an example my EMR won’t let me enter a subtotal hysterectomy in the past surgical history. Even when I supply the correct CPT code the EMR calls this  a Total hysterectomy, which is not correct and can lead to errors in determining who needs a pap smear.

    So EMR remain not ready for primetime. I’m not sure why I can’t continue to dictate and allow the transcriptionist to fill in the EMR. It would work so much better.

    Now for a different view, from an informed non-expert. This reader, a physics professor at a university in the South, uses the distinctive phrase of the day to suggest that we apply a discount to complaints from today's practitioners:

    I've been reading the back and forth over electronic medical records. It seems the opposition comes, by and large, from doctors. Because why?

    Because problems. There's lots of smoke and mirrors about interconnectivity, about interacting with the computer instead of the patient, about sleazy increased billing but all of that is in service of a single point of view: let's never change until we can change to something perfect. In other words, the underlying point is "don't make me change the way I'm used to doing things."

    This all misses the main point. To me, what is overriding importance is the undeniable fact that ANY system that does NOT rely on the memory of the patient for long term medical history storage is NECESSARILY a better system no matter how badly it sucks. The VA has proved this over the last couple of decades as measured by the fact that fewer people die. Better information management beats clever doctoring every time.

    Yes, there are problems in any technology implementation and there always will be. But fewer people die. Yes, it is important to connect with the patient. But fewer people die. Yes, the opportunity to pad billing is obscene. But fewer people die. Any large scale IT rollout has problems. The question is do the benefits outweigh the time invested in ironing out those problems. Most of us would say yes because fewer people die. I wonder why physicians are so reluctant to say that? Didn't they swear an oath or something?

    I also wonder how many of these physicians, when directing their gimlet eye to another field such as public education, are equally skeptical of, say, massive online courses or teachers attending to the computer instead of their students, or teaching to the test? I somehow doubt it.

    I think when you are the person dealing with a system day after day, it is easy to let your detailed knowledge of its problems overwhelm the vaguer notion of its benefits. You don't have a direct experience of a patient who didn't die, but you do have a direct experience of a technical snafu. 

     Thanks to experts and non-experts for writing in, and to David Blumenthal for opening this view into a world that affects us all.

    Previous post

  • 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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  • 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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