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

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

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

    Wikimedia Commons

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

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

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

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

    Instead we have a chief justice who:

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

    [* This interpretation, from the opinion:

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

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

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

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

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


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

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

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  • Friday Update: Filibuster, Surveillance State, Political Macho, and Other Hardy Perennials

    A word we should use more frequently ("filibuster"), and one we should use less ("tough")

    1) Fun with filibusters. Here we go again. Fellow news writers, it is really not that hard to work the word "filibuster" into your stories that deal with minority obstructionism. Yesterday we learned from the AP:

    WASHINGTON (AP) -- Bowing to the Pentagon, the Senate agreed after impassioned debate Thursday to leave the authority to prosecute rapes and other serious crimes with military commanders in a struggle that highlighted the growing role of women in Congress.

    The vote was 55-45 in favor of stripping commanders of that authority, but that was short of the 60 necessary to move ahead on the legislation sponsored by Sen. Kirsten Gillibrand.

    In the same length or less, you can be clearer about what happened. See for yourself:

    [before] but that was short of the 60 necessary to move ahead on the legislation sponsored by Sen. Kirsten Gillibrand.

    [after] but that was short of the 60 needed to break a threatened filibuster of Sen. Kirsten Gillibrand's bill.

    Why does this matter? Because of the venerable "defining deviancy downward" phenomenon. Through the first two centuries of American history, it was not normal to apply a 60-vote filibuster threat to every routine piece of legislation. That's a recent innovation, and distortion. Each time press reports treat a 60-vote threshold as normal, they contribute to a de facto rewriting of the Constitution.

    Seriously, it's very easy to do this the right way.

    2) Fun with security over-reach. Or maybe not so fun. I am grateful to a reader and fellow Cirrus pilot who sends this note about a surveillance intrusion I find surprising, even given everything else we've learned.

    You can read all the details from Papers, Please, and in the court complaint filed last month, but here is the gist: Armed Customs/Border Patrol agents (CBP) detained and questioned a U.S. citizen whose citizenship was never in doubt, and who was not trying to leave or enter the country. They did so based on the contents of romantic messages they had somehow seen in her personal email. As it happens, this citizen was a 50-something professor at Indiana University (and former CBS employee—as you'll see, her age is relevant), and the detention took place about as far as you can get from any U.S. border, in Indianapolis.

    I've written to CBP to ask their side of the story, but at face value it seems to be another of the ratchet-like expansions of routine surveillance/security-state extensions that over time become the new normal. It's almost as if you put a frog into a pot of lukewarm water ...

    3) China, Russia, and Ukraine. The backstory here involves China's ongoing attempts to match its recently tightened internal political controls with its desire to expand its "soft power" attraction to the rest of the world. CNN's Jaime FlorCruz and Paul Armstrong do a nice job of explaining a related dilemma: how China tries to balance its desire to improve Sino-Russian relations with its longstanding Rule Number One of foreign policy, which is that countries should mind their own business and not interfere in one another's affairs. The story explains what this means for Ukraine and Crimea and what China is likely to do.

    Bonus background point: For both better and worse, the Chinese leadership has less experience as a participant in fast-breaking international crises than do European countries, Russia, or of course the U.S. Therefore its first reaction when trouble brews up is often to seem paralyzed. Sometimes that creates problems, but overall it's probably healthier than a trigger-happy impulse to do something in response to the emergencies of each news cycle.

    Which leads us to ...

    4) Fun with manliness. Usually there is no point quoting from or even mentioning NYT op-ed columns. The ones that are interesting you already know about.

    But because I found myself agreeing with every single word of the opening paragraph of the latest column by Tom Friedman, I wanted to say so, and quote the paragraph. His column began:

    Just as we’ve turned the coverage of politics into sports, we’re doing the same with geopolitics. There is much nonsense being written about how Vladimir Putin showed how he is “tougher” than Barack Obama and how Obama now needs to demonstrate his manhood. This is how great powers get drawn into the politics of small tribes and end up in great wars that end badly for everyone. We vastly exaggerate Putin’s strength—so does he—and we vastly underestimate our own strength, and ability to weaken him through nonmilitary means.

    Yes about the everything-as-sport pathology of the media. Yes about the conversion of everything into "toughness." (If you don't know anything about the substance of an issue—hey, where is this Crimea place anyway?—you can always sound authoritative about who snookered whom, who blinked, etc.) Yes about great powers and small wars.* Yes about misreading Russia's (or China's) strength, and our own.

    It would be OK with me if Friedman made this the boilerplate first (or last) paragraph of every column he writes for a while.

    While I'm at it, I might as well cite a paragraph from Nick Kristof I agreed with too. He quotes bellicose rantings from usual pro-interventionist suspects, ranging from John McCain to the Washington Post's editorial page. He replies:

    Oh, come on! The villain here is named Putin, not Obama, and we should have learned to feel nervous when hawks jump up and down and say “do something!” We tried that in Iraq. When there are no good options, a flexing of muscles by NATO or by American warships in the Black Sea would only reinforce President Vladimir Putin’s narrative to his home audience while raising the risk of conflict by accident or miscalculation.

    Here is something to think about: Friedman and Kristof, who are warning against the impulse to prove our "toughness" by shooting things up, spent significant shares of their reporting careers based in the actual world, outside the United States. Many of the people who are most insistently yelling "Do something!" or "Obama's a wimp," from commentators to politicians, have a firsthand experience of "toughness" and its consequences largely confined to the Acela Corridor, attack ads, think tanks and policy papers, and the green room.**

    Bear that in mind when you hear the next get-tough announcement on cable news or read it in a column. Does this person's imagination of "face" and toughness extend much outside the U.S. political realm?

    __

    * To spare those tempted to write in and remind me: Yes in fact I am aware that a dozen years ago Friedman was very prominently in the "do something!" camp about Iraq. I'll let you search for the "suck on this" video yourself. I disagreed with him then but very much agree with him now.

    ** John McCain is an obvious exception. That he so bravely withstood and surmounted his ordeal as a POW in Vietnam remains to his lasting credit and will always deserve respect. It also took place in an entirely different strategic world—Vietnam now often acts as a de facto U.S. ally in struggles over Chinese influence in the Pacific. His claim to AIPAC that "nobody believes in American strength" suggests to me that he needs to get out more.

  • Today in Security Theater, Air Force One Edition

    Thank you, Secret Service. But ... at airports?

    Wikimedia Commons
    Flight Aware, via Ari Ofsevit

    Ari Ofsevit, of the Boston area, sent out a Tweet this afternoon saying "If you're flying in to Boston right now, uh, you aren't." It included the image above, from Flight Aware.

    WTF? The answer is that Air Force One, bearing POTUS, was at Boston's Logan Airport, so other planes were not allowed to operate there. 

    It's always exciting to hear, on the normal Air Traffic Control frequency, calls involving AF1. "November Five Sierra Romeo, climb and maintain six thousand feet." "Climbing six thousand, Five Sierra Romeo." "Air Force One, contact Atlanta Center on one-two-two point three." "Atlanta Center, one-two-two point three, Air Force One." But the idea that the plane should paralyze normal airport operations by its mere existence is an extension of security theater that comes across as Caesarian grandiosity, no matter who occupies the White House. (I will always remember being at the Wright Brothers centennial at Kitty Hawk NC, in 2003, when suddenly AF1, bearing one-time National Guard pilot George W. Bush, arrived, and a Praetorian guard of security officials put the whole area under its control.) As Ofsevit said in a follow-up note:

    Watching POTUS fly in to Boston today (and listening in on LiveATC) I decided that it is quite silly anymore that we shut down the airport for AF1. Airports are just about as secure as it gets, and air traffic control is run in such a manner that there hasn't been a plane-to-plane collision in the US in decades. [JF note: For a riveting account of the most dramatic such collision, one between a TWA and a United flight over the Grand Canyon back in 1956, check out this.] Are we admitting that ATC is [fallible], since we ground everyone during presidential visits? Or is this a holdover from earlier days?

    I understand, say, keeping planes off the active runway and taxiway when AF1 is landing as a precaution. But keeping everyone at the gate until the president not only lands and taxis, but until his motorcade has left the airport? Does it make any sense?

    Once the plane is parked—usually on a section of airfield away from runways, taxiways and ramps, couldn't other planes push back and move towards the runways, and couldn't you land planes which have been circling?

    I think this is security theater at its finest, but maybe there's an aviation or security answer beyond that. Is there?

    On the Let's Be Reasonable side: American presidents are under a constant barrage of threats; Obama is under a special threat barrage of his own; it matters, and is a kind of miracle, that the violence against political figures that so grossly distorted the 1960s has not recurred. Thank you, Secret Service.

    But -- at an airport? Already the distillation of America's security state? To imagine that one of the other airliners conducting normal operations might constitute a threat would require: knowing in advance when Air Force One was about to arrive, which is usually announced at the last minute; knowing in advance which airline crews would be on which planes to carry out a threat, also subject to last-minute change; somehow getting something on those planes that might be dangerous; knowing exactly where those airplanes would be, on the airport's runways, taxiways, and gates, at the moment Air Force One was parked and vulnerable; disregarding ATC instructions so as somehow to impinge on Air Force One's space; and so on. Anything could happen, but ...

    In Washington DC, presidential "ground movements" -- the motorcades with all the police-motorcycle forerunners and the rest of the entourage -- have been worked out to paralyze the city as little as possible. Maybe we could apply that logic to airports too? Given that they are already so much more thoroughly controlled than our roads? Just a thought.

  • Why We Read More Than 1 Paper, Cont.

    The WSJ harmonization watch goes on.

    Thanks to Lawrence Wilkinson, @samsteinhp, and @bgavio for pointers to screenshot above and this installment in the ongoing saga. 

    Hypothesis undergoing long-term testing: Under the ownership of Rupert Murdoch, the "harmonization" of the Wall Street Journal shows up not on its editorial page, which was already the right-wing counterpart to Pravda, nor in the actual content of its articles, still the products of a generally first-rate reportorial staff.

    Instead it turns up in headlines, story play, and immediate Rorschach-test moments like this. Tonight's results once again fit the hypothesis.

    For previous steps down the harmonization road, see previous installments one, two, three, and four


    While I'm on the subject of the press, this update about US News. Lucy Byrd Lyons, a friend and former Atlantic colleague who now is communications manager for US News, wrote asking me to clarify my latest item about the magazine's zapping of its pre-2007 online archives. As part of the peroration I said, "The place where most people had assumed their work would 'live' for search and retrieval purposes, the magazine's own site, had been removed for the first 74 years' worth of the magazine's existence."

    Lucy Lyons reminds me that for most of the period after the magazine's founding in 1933, there was no Internet and thus no online version of its contents. Fair point! Even though many publications including the Atlantic have been investing for years in digitizing olden-days articles to bring them online. 

    Still, if anyone thought I meant that archives from the FDR or LBJ eras were being purged, sorry for the confusion. I didn't mean that. I meant that the first dozen-plus years of the magazine's online existence had, with no advance word, been eliminated. And while I'm at it, a representative message of the many I've received from the info-tech world:

    As someone who has been in IT technology for decades, the decision shouldn't be whether US News can afford to migrate the older archives into the new content management system (CMS) and if not, to remove them. 

    If it doesn't make economic sense to migrate them, then just leave them as is and have the new CMS provide a hook to the old system. With the low cost of servers and storage these days, running the old archive on a separate system would be cheap, although they may still have to maintain old software licenses. It may not be elegant but the new/old combination would work just fine, especially if there hasn't been a strong demand for the older archives. Access is key, performance is secondary.

    Here endeth the US News archive saga as far as I'm concerned. Although if anyone happened to store the USN appreciation I wrote of retired Air Force colonel and still-influential military theorist John Boyd when he died in 1997, I'd be glad to have it. I can't seem to find it online any more.  

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  • A Whole New Way to Think About House of Cards: 'Throwing Like a Girl'

    What "The West Wing for werewolves" tells us about political satire

    To avoid spoilers, I won't tell you why Kevin Spacey is standing here, or what comes next. ( MLB.com )

    This post will end with the significance of how Kevin Spacey throws a baseball --in real life, and on screen (above). But it will take a little while to get there, and I hope you'll bear with me along a twisty trail.

    1) A contrast in styles: drama versus melodrama. I'm watching the original U.K.-BBC version of House of Cards, and its U.S.-Netflix remake, more or less in sync. Right now I've seen about half of Season Two of the U.S. version, and three of the four episodes of To Play the King, which was Season Two for the BBC. 

    I like them and recommend them both and will be sorry when I reach the end of either. But as time goes on, the contrasts between them become more evident.) For previous comparisons, see installments one, two, and three.

    Ian Richardson, the original FU, with his
    trademark line

    One difference is simply scale: Netflix offers more than three times as many episodes per season, 13 versus 4, and about ten times as many plot twists, sub-characters, shifts of scene, and so on. It's just bigger in every way, symbolized by the modern HD color that makes the original seem like black-and-white. The sex scenes are far more numerous and explicit. (Which is also a 1990s-broadcast vs 2014-non-broadcast shift.) The characters are louder, broader, and less subtle. Michael Dobbs, who wrote the British novel that begat this whole dramatic lineage, and who worked as a consultant on both renditions of the shows, has described the Netflix version as "The West Wing for werewolves." If you've seen them both you know what he means.

    Which leads to the other, related difference, that of tone. If I say it's drama (BBC) versus melodrama (Netflix), that sounds like a put-down but isn't. And remember, I am the farthest thing from a knee-jerk "Oh, the Brits are so classy!" guy. It's a difference in the palette with which the characters are drawn. Ian Richardson, as the British politician FU—Francis Urquhart—is a study in cold, controlled malice. As Frank Underwood, the American FU, Kevin Spacey is by comparison hamming it up and camping it up in every scene. For me, he is too obviously having fun—or so I thought until last night.

    2) A weak character: defect, or diabolically clever design? By a million miles, the least convincing character in the American House of Cards is the supposed President, Garrett Walker (played by Michael Gill—a capable actor who I assume is taking direction). Movie-and-TV presidents have varied widely, like their real-life models, but except in farces all of them have projected a sense of there-ness, in the Gertrude Stein definition. Martin Sheen's President Bartlet in West Wing and Dennis Haysbert's President Palmer in 24 are the clearest examples: you see these characters and think, OK, I understand how he got elected, and why the people around him defer to his judgment. Garrett Walker? Unt-uh. This guy is a peevish assistant-secretary type.

    I had considered that this was a weakness in the show, or a sign of its melodrama-rather-than-drama aspirations. But I have begun wondering whether I'm selling their producers short. It's all because of the "Frank Underwood Learns to Throw" sequence midway through Season Two, which I've just seen and is where the picture at the top of this post comes from.

    3) "Throwing Like a Girl," redux. Back during Bill Clinton's first term, I wrote an Atlantic article called "Throwing Like a Girl." I had a wonderful time reporting it, since that involved: interviewing the actor John Goodman (a former athlete who had learned to throw with his left had for his movie role as Babe Ruth); sitting with the tennis coach Vic Braden to watch bio-mechanics videos about the "kinetic chain" that leads to a proper throwing motion; and learning the simple trick that can make almost anyone "throw like a girl." You'll have to check out the article to see what that was.

    The article began when I saw side-by-side front-page photos of Bill and Hillary Clinton throwing out the first pitch at season-opening baseball games and wondered why they threw so differently. The obvious-when-you-think-about-it conclusion I came to was this:

    Throwing is a motion nearly anyone can do, but that no one starts out knowing how to do. That is, it is not like crawling or walking -- which children innately figure out -- and is like riding a bike, which anyone can do but only with opportunity and practice. (If you've never seen a bike, you're not going to be able to ride one. The first dozen times you try, you are going to fall down.) For whatever reason, the typical 12-year-old boy has spent more of his life throwing balls, stones, and sticks than the typical 12-year-old girl. Thus more boys than girls learn how to throw, and more girls than boys throw the way you do if you don't know how.

    (If you've read this far, I'll reward you with the secret: the way to prove this to yourself is to throw a ball or stone with your "off" hand -- the left, if you're right- handed. Most people have no practice throwing that way, so generally they will "throw like a girl." That's what John Goodman did when he practiced throwing leftie -- it took him a year to get ready to do it in front of the camera -- and is what I did when "researching" my article.)

    Update! Thanks to reader KG, here is a fabulous video, via Kottke.org, of men throwing with the "off" hand. The French music background makes it special.

    Men Throwing Rocks With The Other Hand from Juan Etchegaray on Vimeo.

    4) Which brings us back to Kevin Spacey. In a Season Two episode I've just seen, Kevin Spacey throws on-screen, and he is terrible. I would use a video clip if I saw one from Netflix online, but take it from me. 

    "Bad" throwing means: having your torso face the target head on, rather than being turned at an angle; having your elbow below your shoulder as the throw comes through; pushing the ball, with bent elbow as you release it, rather than hurling the ball with your elbow whipping to a straight position as you let go; and so on. Every one of them you see from Spacey's Frank Underwood. The muddy little screen grab at right understates the problem.

    When I first saw this I thought: Spacey's kidding himself! He in inside his own information bubble and doesn't realize how bad this looks on screen, just as he hasn't realized how weakly written or weakly acted the saga's President Walker is, and how overdrawn some of the others are. To be fair, I gave the writers credit for the ball-throwing homage to the brilliant opening passages of Richard Ben Cramer's What It Takes (a very mild spoiler on my part). 

    Then, through the magic of the Internet, I started prowling around for other pictures of Kevin Spacey engaged in ball sports. And I discovered that the real-life Spacey had thrown out a first pitch at a real-world major league ball game. He did so last summer at Camden Yards, before an Orioles game. And—well, read the Charm City headline for yourself:

    So a person who in real life can throw perfectly well, is for dramatic purposes all-too-convincingly pretending that he can't. And what if ...  this means something about the series as a whole?

    5) Which really means coming back to Verbal Kint. Suddenly I was thinking of Spacey in the final few minutes of his breakthrough role in The Usual Suspects—when we see that pitiful Verbal Kint, shuffling and stuttering, is capable of a whole lot more than he has let us know. And suddenly, with this TV series as in that movie, you're looking back at the old evidence through a different lens.

    Maybe the President and other politicians come across as two-dimensional figures not because the writing and acting are bad—but because they're good, and the impression of two-dimensionality is what the series means to convey. Maybe Spacey's FU, unlike Ian Richardson's FU in England, is an exaggerated hambone villain not because he's self-indulgent but because he's being precise. That's how he sees, or wants to present, political leaders—and their consorts, like Robin Wright, and before her Kate Mara, as soap-opera villainesses?

    That's as far into the weeds as I can go right now. Any TV series that can make you wonder what it means has done something valuable, and by that standard both FUs have proved their work. On to more episodes this evening.

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  • In Honor of the Olympics, Let's Talk Filibuster

    What's the word I was looking for—the one that starts with "F" and applies when a bill gets 59 votes? Oh, yes, now it comes back to me: "Fail."

    Stop me if you've heard this one before:

    A large majority of the U.S. Senate votes in favor of a measure—in this case, senators representing nearly 70 percent of the U.S. population*. A minority threatens a filibuster to stop it. The majority falls just short of the supermajority needed to get its way. And our leading journalistic institutions tell us that ... the measure "failed."

    Yes, you have heard this before. But for the record, come on New York Times (source of the breaking-news flash above, and the story below, and which did get the word "filibuster" into the end of the second paragraph):

    And come on CNN (which did not manage to include the word filibuster):

    And come on Boston Globe—which in its defense was using the NYT story, though it presumably could write its own headlines:

     

    On the other hand, nicely done, Reuters!

    And welcome Politico!

     

    __

    *Fun fact for the day: By my ballpark count, the 59 senators who voted for the bill represented states with just less than 70 percent of the U.S. population. The 41 who voted no represented just more than 30 percent of the population. With only 70 percent support, no wonder the bill "failed."


    The nightmare of article-writing nears the end of its cycle, at least for this issue. Coming soon, more reports from up-and-coming parts of America, plus what I learned by watching the pre-opening night of the Winter Olympics.

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