Andrew Sullivan asks (“Goodbye to All That,” December Atlantic), “How do we account for the bitter, brutal tone of American politics?” His answer is to blame “the biggest and most influential generation in America: the Baby Boomers.” As he explains, “The divide is still—amazingly—between those who fought in Vietnam and those who didn’t, and between those who fought and dissented and those who fought but never dissented at all.”
While certainly interesting, Sullivan’s explanation of American polarization ignores the political-science literature on the sources of polarization. Probably the best explanation for the growing divide in American politics comes from Nolan McCarty, Keith Poole, and Howard Rosenthal, who argue that growing economic disparities and rising immigration rates are strongly correlated with political polarization. In their book, Polarized America (2006), they show that ideological divisions decreased between 1913 and 1957, when income disparities and immigration rates fell, and that the divisions have increased sharply since the 1970s, as income disparities and immigration rates suddenly grew.
These socioeconomic trends have directly affected voting patterns, with high-income voters tending to back Republicans, and low-income voters tending to support Democrats. Thus, as the gap between rich and poor has increased in America, so has the gulf between the GOP and the Democratic Party. What this means is that the debates over gay marriage and abortion—which pundits all too often blame for today’s polarization—have not actually played a significant role in dividing the country.
In short, growing class divisions in the United States are producing growing political divisions. This finding may be disconcerting to a country that prides itself on its great social mobility and boundless opportunities. But until there is broad acknowledgement of these growing socioeconomic disparities, politics in America will likely remain fiercely divided.
Andrew Sullivan’s conclusion that Barack Obama is the right man at the right time is based on a premise—“the practical stakes in this election are minor”—that is fundamentally flawed.
Notably, Sullivan’s analysis of the two parties’ positions on health care is dead wrong. The GOP candidates use tax policy (eliminating or increasing deductions for insurance and health savings accounts) as the basis for their initiatives. The more-comprehensive plans rely on “consumerism” and deregulation, confident that the market will solve the intertwined issues of the uninsured and cost inflation. By contrast, all of the Democratic candidates rely on regulation and government mandates. Each advocates universal coverage, either initially or over time, while strengthening the regulation of insurers (eliminating medical underwriting and exclusions for preexisting conditions) and calling for community rating (premium levels set independent of age, sex, or medical status).
These differences are anything but “more technical than fundamental.” They reflect a deep disagreement about the causes and effects of uninsurance and health-care cost inflation, and the role of markets and regulators. Sullivan’s conclusion that Obama is necessary may be correct, but not for the reasons he cites. There are real, fundamental differences between the parties’ positions, differences that reflect the deep disagreements among Americans.
Andrew Sullivan states that, with Barack Obama’s candidacy, “America’s soft power has been ratcheted up not a notch, but a logarithm.” In fact, logarithms increase far more slowly than the numbers from which they are derived. Is this a subtle deprecation of Obama’s abilities, meant to be understood only by those of us with some small knowledge of mathematics?
To support the counterintuitive notion that the United States has too many physicians, Shannon Brownlee focuses on a series of strongly contested conclusions (“Overdose,” December Atlantic). A large body of research has established the need to expand physician supply, and prominent national organizations, such as the Association of American Medical Colleges and the American Medical Association, are calling for more physicians to be trained.
Brownlee cites the conclusion of Dartmouth’s David Goodman that some academic hospitals, such as those at NYU and UCLA, employ two to three times as many doctors per patient as others. In reality, academic medical centers cluster into two groups. Those in cities like Madison, Wisconsin; Salt Lake City; and Hanover, New Hampshire, use relatively fewer resources, while those in large urban centers, like Newark, Detroit, and Los Angeles, where extreme poverty and affluence co-exist, use more resources, particularly for the poor. Reducing the number of physicians in the latter cities could hardly lead to better care. (Los Angeles, Newark, and similar cities also have more police officers than Madison and Hanover do, but cutting the police force is unlikely to reduce crime.)
Brownlee also cites Elliott Fisher’s work concerning the relationship between expenditures and quality. Like Goodman, Fisher compares the noncomparable. His “high spending–low quality” category consists mainly of these same urban centers—Chicago, Detroit, Philadelphia, Newark, etc. In contrast, his “low spending–high quality” category includes all of Alaska, Washington, Oregon, Wyoming, Montana, Idaho, Utah, Minnesota, Maine, New Hampshire, and Vermont, and parts of neighboring states. How does one even begin to compare health care, or anything else, in such dissimilar geographic aggregates?
But most troubling is Brownlee’s quote of the Baicker-Chandra paper, which she says reports that “measures of quality … tended to fall in direct proportion to a rising ratio of specialists.” The Baicker-Chandra model looked at a hypothetical, computer-generated construct that predicts what would happen if a specialist replaced a family physician. Such a scenario never happens in the real world. It’s a statistical game. What happens when the outcomes of real physicians are examined? When states with more specialists per capita are compared with states that have fewer, it turns out that the states with the most have the best quality of care. Nonetheless, Brownlee suggests that “more doctors lead to worse care, and fewer doctors to better care.” This statement is categorically wrong and utterly irresponsible.
Richard A. Cooper, M.D. Professor of Medicine
University of Pennsylvania
Shannon Brownlee asserts that the number of doctors being trained in the United States is increasing. That is not the case. While the number of medical-school graduates in the U.S. is increasing, the number of physicians coming out of residency training programs is essentially capped by limits on federal funding for physician training at the nation’s teaching hospitals. The growing number of medical-school graduates in the U.S. will merely displace international medical graduates who now fill residency training slots not taken by U.S. graduates. Unless the number of training slots is significantly increased—and there are no plans for such an increase—the number of doctors being trained in the U.S. will remain fixed where it has been for more than two decades.
Phillip Miller Vice President of Communications
Double Oak, Texas
The Association of American Medical Colleges’ recommendation for a 30 percent increase in medical-school enrollment, cited by Shannon Brownlee, was never meant to be a cure-all for what ails the nation’s health-care system. We agree with Brownlee that any plan to improve our current system should include better-coordinated care, enhanced incentives to draw doctors to underserved areas, and a more efficient use of resources. But high-quality health care requires, first and foremost, that physicians be there for the patient.
It has been clear for some time that the United States is not educating enough doctors. The number of medical-school graduates has remained flat since 1980, while the U.S. population has grown by 70 million. To meet the public’s need for accessible health care, our nation has become reliant on physicians who obtained their medical education in other countries, many of which are less- developed nations where health-care professionals are also in short supply. Last year, almost 7,000 foreign-educated physicians entered our health-care system.
An acute shortage of doctors in the United States would have a profound effect on access to health care, including longer waits for appointments and the need to travel farther to see a doctor. The elderly, the poor, and rural residents would face even greater challenges.
The need to build the capacity of our nation’s medical schools is real, and will become more urgent in the decades to come. Any proposal to reform our health-care system must address this need to ensure that all Americans have access to the high-quality health care they deserve.
Darrell G. Kirch, M.D. President and CEO
Association of American Medical Colleges
Shannon Brownlee replies:
Richard Cooper incorrectly characterizes the research I cite as “strongly contested.” The groundbreaking work by the Dartmouth group is widely acknowledged and honored, and it offers a robust argument for rethinking plans to expand the physician workforce. During two telephone interviews, Cooper offered no data to suggest that reducing the per capita number of physicians would lead to harm in cities like Los Angeles. His conclusion is based on the assumption that the market has set the number of doctors practicing in such cities in response to levels of sickness. In fact, prevalence of severe chronic illness accounts for less than 5 percent of the variation in the amount of care delivered to Medicare recipients in different regions of the country, one of several lines of evidence suggesting that the physician labor market is not particularly sensitive to the population’s actual demand for care. And physicians, unlike cops, are able to generate demand for their services.
Finally, Cooper’s characterization of the work of Harvard economists Katherine Baicker and Amitabh Chandra as nothing more than a “statistical game” seems odd, since they employed an analytical technique that is a staple of economics research. Baicker and Chandra asked what would happen if you held the number of doctors steady but changed the ratio of specialists to generalists. Their finding—that more generalists lead to better-quality care—has been replicated in a variety of ways by other researchers.
Phillip Miller correctly points out that increasing the number of graduates without boosting residency slots won’t change the number of doctors. The Council on Graduate Medical Education, which advises Congress on physician-workforce policy, specifically recommends that the number of physicians entering residency programs go up by more than 10 percent in the next decade.
I agree with Darrell Kirch that reducing dependence on foreign doctors is a worthy goal, and that a shortage of physicians would not be good for the nation’s health. What we’re arguing about here is the definition of shortage. Projections by the AAMC, COGME, and others seem not to take into account the growing body of evidence that too many doctors may be as harmful under our current fee-for-service reimbursement system as too few. A more effective strategy for ensuring our future health might be to reform the payment system; to encourage young physicians to go into primary care and to settle in regions of the country where their services are most needed; and to teach them to practice collaborative medicine. Simply increasing the number of physicians will accomplish none of those goals.
In his review of Denis Johnson’s fine novel Tree of Smoke (“A Bright Shining Lie,” December Atlantic), B. R. Myers flouts one of John Updike’s (admittedly rough) rules of literary criticism: “Never, never try to put the author ‘in his place,’ making him a pawn in a contest with other reviewers. Review the book, not the reputation.” Myers begins his screed with an evisceration of Tree of Smoke based on others’ praise of it—this, after he admits to never having read any of Johnson’s other books—and then utterly fails to comprehend Johnson’s effort. I also take issue with his disparagement of recent literary history. It seems that he is unaware (or purposefully ignorant) of the last century of American literature, in which crises of meaning were played out on the printed page to wonderful effect.
New York, N.Y.
Given that B. R. Myers will no doubt stand alone in his criticism of Denis Johnson, I wanted to send in my thanks for such a fine polemical shredding of such a perfectly uninteresting book. Myers’s conclusion is especially apt. Evidently mainstream America can now take seriously only crude anti-intellectualism, tasteless bad jokes, and shabby writing, even in our literature; little wonder we elect the cynical fools we do. One is reminded of the famous Confucian doctrine of “rectification of names”: when language is badly used in a country, everything else will be, too.
Kansas City, Mo.
B. R. Myers replies:
I have no idea why Jed Cohen thinks I have disparaged a hundred years of American literature, especially since I praise Michael Herr and Tim O’Brien in the same review. As for John Updike’s rules, I am not bound by them. Saying that reputations must never be reviewed would place reviewers above criticism. A bad book is a trivial thing, but to hold up a bad book as good is, as Larson Powell points out in his letter, to perpetrate an attack on values themselves. If other critics don’t fight back, who will?
While James Fallows paints a charming picture of life among the captive giant pandas at the Wolong Nature Reserve (“Among the Pandas,” December Atlantic), he apparently failed to ask some obvious questions about the Chinese breeding program.
Fallows might have asked, for example, why all those young pandas, many of whom are still on a milk diet because they don’t yet have the teeth they need to crush bamboo, are not living with and being nursed by their mothers. The answer is that cubs at Wolong are taken from their mothers when they are only 4 to 6 months old, so that their mothers will cease to lactate and will come into breeding condition again. In the wild, a panda cub stays with its mother for two to three years. The mother teaches the cub how to care for itself and find food. At China’s breeding facilities, a cub gets a few short months of motherly care. Then the baby is whisked away to be raised by humans, and Mom is artificially inseminated (again) and produces another cub, and the cycle is repeated.
The Chinese are bent on producing as many panda cubs as possible in as short a time as possible. They speak optimistically of releasing these pandas into the wild. Yet these are animals that are raised almost exclusively by humans. The cubs are carried about, played with, hand-fed treats, photographed, and in general, treated like pets. The thought of turning these animals loose to fend for themselves in the wild should make anyone with a conscience cringe. How can any amount of preparation transform such an animal into a wild, self- sufficient creature?
James Fallows replies:
Sandra Parshall presents the most familiar criticism of the Wolong Nature Reserve and Chinese panda-protection operations in general. I raised this point with Chinese officials during my visit to Wolong and again, after receiving Parshall’s letter, with the U.S. support organization Pandas International. I find their response, which I paraphrase below, more convincing than the criticism:
The Wolong center’s main goal is indeed to breed more pandas. By this standard it has been remarkably successful, as my story described. Its efforts have the incidental benefit of increasing the number of animals that can be sent to zoos around the world and later procreate as well. Each surviving panda is a significant addition to a world population on the verge of extinction. Toward this end, Wolong does resort to artificial insemination if natural mating fails. When a mother panda has had cubs for two straight years, she is not mated or inseminated in the third.
At least half of the cubs being raised by human attendants in a Wolong nursery would have died in the wild. Mainly they are the “un-chosen” cubs from sets of twins. (Panda cubs frequently arrive as twins, but a mother is capable of feeding only one. In the wild, she quickly chooses one to care for, and the other dies.) They also include cubs of first-time mothers that for various reasons do not accept or care for their young. According to Suzanne Braden of Pandas International, the cubs are typically left with their mothers for eight months, not four to six, as Parshall contends.
The biggest contrast between what Parshall says about Wolong and what I saw there involves the preparation of pandas for ultimate release into the wild. Whenever Tang Chunxiang, the chief veterinarian at Wolong, talked about future reintroduction efforts, he emphasized the difference between two groups: the regular breeding population of pandas at the reserve, and the small group being prepared for possible release. The breeding pandas were deliberately exposed to human contact from an early age, so that their attendants could safely deal with them in the future. Pandas being considered for return to the wild were shielded from human contact as much as possible. During my visit, Tang told me that Wolong was preparing a vast, 300,000-square-meter enclosure in which young pandas could live for several years before release, in a setting as close as possible to the wild, while still under the reserve’s protection and control. The people who work with the pandas obviously understand that the herds of young animals who interact with trainers every day are not the ones who can fend for themselves in the wild.
Reading Bill McKibben’s excellent piece “Radio Free Everywhere” (December Atlantic), I’m reminded of how many nights in years past I spent twiddling the AM dial to extract 50,000-watt signals from faraway stations—a lost art now. One thing that’s overlooked, though, regarding the shift to digital radio, is the potential for disenfranchising over-the-air listeners. Many rural areas and small communities still lack the broadband access that’s a virtual must for reliable online listening, and high-speed Internet can be yet another utility bill burdening income-challenged households. Web-based listening provides a fine alternative as the AM/FM airwaves become increasingly homogenized, but this trend compromises what radio has always been in this country: a free, easy-to-use public service.
Bill McKibben replies:
What an excellent reminder to all of us to send in our pledges to public radio, and to patronize the advertisers who actually support what’s worth listening to on the local dial.
Robert Kaplan’s article on “America’s Elegant Decline” (November Atlantic) overlooks several salient facts. For instance, Kaplan does not mention that, during the Cold War, the U.S. Navy maintained its size by including large numbers of relatively old vessels in its inventory. One of the budgeting decisions made in the 1990s was to retire many warships ahead of schedule and invest the savings in newer platforms. The result is that the modern U.S. Navy enjoys a higher relative average of quality in its ships than 20 years ago, even if it is absolutely smaller.
Furthermore, the modern U.S. Navy represents a staggering 50 percent of the world’s naval combat power. Qualitatively, our margin of superiority is even greater. These are facts that will not change substantially within the next generation, possibly even for two generations. That is hardly a case for saying our Navy is in “decline.” What exactly would we do with a 500-ship Navy that we are not already doing with a 300-ship Navy, and incidentally, where would we find the money to pay for it?
Robert Kaplan replies:
Richard Thomas makes some excellent points. I deliberately used the adjectives elegant and relative to denote just how tenuous this decline is, adding furthermore that this decline itself can be “overrated.” Yet it isn’t just that we have gone down from a 600-ship to a 279-ship Navy; it’s that when one considers cost overruns for both big warships like the new destroyers and smaller ones like the littoral combat ship, we may be heading for a Navy in the low 200s or less. There comes a point when quantity matters qualitatively: as powerful as a warship might be, it cannot be in two places at once. As I wrote, we are entering an era in which sheer presence matters more than ever. And in a time of increasing piracy and other low-grade threats, don’t discount the value of older ships, which may be just as capable of dealing with such menaces as the most-modern warships.
Caitlin Flanagan makes it clear that she finds Hillary Clinton inadequate as a woman (“No Girlfriend of Mine,” November Atlantic), but Flanagan’s ideas about women—e.g., they are nurturers who speak fluently about panty hose—appear rather rigid. Her real gripe seems to be that she does not find Senator Clinton feminine enough, which is an old trope by now. Senator Clinton’s silence during the Lewinsky affair was not complicity: by choosing not to excoriate her adulterous husband publicly, she demonstrated that she values the privacy of the home. I have a hard time believing that makes her a lesser woman.
New York, N.Y.
Caitlin Flanagan replies:
Hillary wasn’t silent during the Monica Lewinsky episode; she publicly and loudly blamed the incident on the vast right-wing conspiracy, thus attempting to make a liar—or worse—of a young woman everyone in the world knew was telling the truth. Hillary did what she has always done when Bill has been caught with his pants unzipped: fought to make the woman involved look crazy or stupid or vindictive. Vote for Hillary if you want to; if she ends up as the Democratic nominee, I probably will as well. But don’t try to sell those tired lies about her private life; they only serve to hurt women.
In “The Selfless Gene” (October Atlantic), Olivia Judson takes a step in the right direction, but the question goes much further. At present, two of my students are in India, living with and learning about urban slum children and impoverished village children. Within the limits of their resources, they have given tangible help to people in need, while putting their own health at risk. To me, they are heroes, equivalent to those who join the armed services to defend the nation. “Kin selection” may explain altruism that protects kin, and “parochial altruism” may explain altruism that protects a society or an in-group. Both fail to explain the altruism exhibited by these students. In my life, I have witnessed (directly and through the media) thousands of altruistic efforts like these, and the historical record multiplies the number many times. I’m not sure such altruism toward out-group members can be reconciled with evolutionary theory, though I fully accept the reality of evolution. Yet we should not try to keep the theory tidy by ignoring or diminishing heroic altruism that reaches far outside the welfare of the in-group.
Donald Attwood Professor of Anthropology
In her search for “The Selfless Gene,” Olivia Judson fails to mention that in order for humans to develop an inclination to be generous, even toward non-kin, no gene is required. Humans and other primates are social, and their societies have cultures, which embody and pass on the successful (or, at any rate, nonfatal) behaviors of their members. Judson cites the example of a group of baboons that conveyed to newcomers their relatively laid-back standards over a period of 10 years. She notes that 3-year-old human children will learn and enforce the standards of the group. When animals can learn successful behaviors and pass them on to members of their group, then what we have is not Darwinian evolution—evolution through random genetic change—but Lamarckian evolution—inheritance of acquired characteristics. Because humans evolve primarily by passing on what they learn to the next generation, we are freed from the glacial pace of evolution through random genetic change. Judson’s own evidence in the examples cited above argues for a Lamarckian evolution of generosity.
Thomas M. Thurston
Olivia Judson replies:
Thomas Thurston is right in saying that culture can be an important evolutionary force in and of itself. However, he misses the more general point: namely, that in order for culture to evolve, the underlying substrate—the brain—must evolve the capacity both for learning and for a wide behavioral repertoire. The basis of this is genetic. Therefore, for a full understanding of the evolution of human culture, we must also understand the evolution of the brain. I agree with Donald Attwood that kin selection and parochial altruism do not supply a complete explanation for the full repertoire of behaviors that we see today; however, they provide useful frameworks for thinking about how altruistic tendencies may have begun to evolve. One aspect of the flexibility of human nature—which is, to my mind, its most important attribute—is that once the capacity for a behavior evolves, its expression is bound to vary widely.
Clive Crook mistakenly refers to the borrower of a home loan as the “mortgagee” (“Housebound,” December Atlantic). That term refers to the lender; the borrower is actually the “mortgagor.”