Costlier care is often worse care, from The New Yorker

GO BACKPRINT THIS PAGE
ANNALS OF MEDICINE
THE COST CONUNDRUM
What a Texas town can teach us about health care.
by Atul Gawande
JUNE 1, 2009


It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.
McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.
The explosive trend in American medical costs seems to have occurred here in an especially intense form. Our country’s health care is by far the most expensive in the world. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government. “The greatest threat to America’s fiscal health is not Social Security,” President Barack Obama said in a March speech at the White House. “It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”
The question we’re now frantically grappling with is how this came to be, and what can be done about it. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.
rom the moment I arrived, I asked almost everyone I encountered about McAllen’s health costs—a businessman I met at the five-gate McAllen-Miller International Airport, the desk clerks at the Embassy Suites Hotel, a police-academy cadet at McDonald’s. Most weren’t surprised to hear that McAllen was an outlier. “Just look around,” the cadet said. “People are not healthy here.” McAllen, with its high poverty rate, has an incidence of heavy drinking sixty per cent higher than the national average. And the Tex-Mex diet has contributed to a thirty-eight-per-cent obesity rate.
One day, I went on rounds with Lester Dyke, a weather-beaten, ranch-owning fifty-three-year-old cardiac surgeon who grew up in Austin, did his surgical training with the Army all over the country, and settled into practice in Hidalgo County. He has not lacked for business: in the past twenty years, he has done some eight thousand heart operations, which exhausts me just thinking about it. I walked around with him as he checked in on ten or so of his patients who were recuperating at the three hospitals where he operates. It was easy to see what had landed them under his knife. They were nearly all obese or diabetic or both. Many had a family history of heart disease. Few were taking preventive measures, such as cholesterol-lowering drugs, which, studies indicate, would have obviated surgery for up to half of them.
Yet public-health statistics show that cardiovascular-disease rates in the county are actually lower than average, probably because its smoking rates are quite low. Rates of asthma, H.I.V., infant mortality, cancer, and injury are lower, too. El Paso County, eight hundred miles up the border, has essentially the same demographics. Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee—half as much as in McAllen. An unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high. (Or the reason that America’s are. We may be more obese than any other industrialized nation, but we have among the lowest rates of smoking and alcoholism, and we are in the middle of the range for cardiovascular disease and diabetes.)
Was the explanation, then, that McAllen was providing unusually good health care? I took a walk through Doctors Hospital at Renaissance, in Edinburg, one of the towns in the McAllen metropolitan area, with Robert Alleyn, a Houston-trained general surgeon who had grown up here and returned home to practice. The hospital campus sprawled across two city blocks, with a series of three- and four-story stucco buildings separated by golfing-green lawns and black asphalt parking lots. He pointed out the sights—the cancer center is over here, the heart center is over there, now we’re coming to the imaging center. We went inside the surgery building. It was sleek and modern, with recessed lighting, classical music piped into the waiting areas, and nurses moving from patient to patient behind rolling black computer pods. We changed into scrubs and Alleyn took me through the sixteen operating rooms to show me the laparoscopy suite, with its flat-screen video monitors, the hybrid operating room with built-in imaging equipment, the surgical robot for minimally invasive robotic surgery.
I was impressed. The place had virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic, and, as I walked through that hospital on a dusty road in South Texas, this struck me as a remarkable thing. Rich towns get the new school buildings, fire trucks, and roads, not to mention the better teachers and police officers and civil engineers. Poor towns don’t. But that rule doesn’t hold for health care.
At McAllen Medical Center, I saw an orthopedic surgeon work under an operating microscope to remove a tumor that had wrapped around the spinal cord of a fourteen-year-old. At a home-health agency, I spoke to a nurse who could provide intravenous-drug therapy for patients with congestive heart failure. At McAllen Heart Hospital, I watched Dyke and a team of six do a coronary-artery bypass using technologies that didn’t exist a few years ago. At Renaissance, I talked with a neonatologist who trained at my hospital, in Boston, and brought McAllen new skills and technologies for premature babies. “I’ve had nurses come up to me and say, ‘I never knew these babies could survive,’ ” he said.
And yet there’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County actually has fewer specialists than the national average.
Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.
ne night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review.
Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.
“Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said.
Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said.
“It’s malpractice,” a family physician who had practiced here for thirty-three years said.
“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.
That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?
“Practically to zero,” the cardiologist admitted.
“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.
The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”
Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.
The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.
Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.
I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?
Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.
And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.
“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.
To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice, which has three decades of expertise in examining regional patterns in Medicare payment data. I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.
The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.
his is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.
In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.
That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.
To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.
In an odd way, this news is reassuring. Universal coverage won’t be feasible unless we can control costs. Policymakers have worried that doing so would require rationing, which the public would never go along with. So the idea that there’s plenty of fat in the system is proving deeply attractive. “Nearly thirty per cent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” Peter Orszag, the President’s budget director, has stated.
Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina—all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail.
had what I considered to be a reasonable plan for finding out what was going on in McAllen. I would call on the heads of its hospitals, in their swanky, decorator-designed, churrigueresco offices, and I’d ask them.
The first hospital I visited, McAllen Heart Hospital, is owned by Universal Health Services, a for-profit hospital chain with headquarters in King of Prussia, Pennsylvania, and revenues of five billion dollars last year. I went to see the hospital’s chief operating officer, Gilda Romero. Truth be told, her office seemed less churrigueresco than Office Depot. She had straight brown hair, sympathetic eyes, and looked more like a young school teacher than like a corporate officer with nineteen years of experience. And when I inquired, “What is going on in this place?” she looked surprised.
Is McAllen really that expensive? she asked.
I described the data, including the numbers indicating that heart operations and catheter procedures and pacemakers were being performed in McAllen at double the usual rate.
“That is interesting,” she said, by which she did not mean, “Uh-oh, you’ve caught us” but, rather, “That is actually interesting.” The problem of McAllen’s outlandish costs was new to her. She puzzled over the numbers. She was certain that her doctors performed surgery only when it was necessary. It had to be one of the other hospitals. And she had one in mind—Doctors Hospital at Renaissance, the hospital in Edinburg that I had toured.
She wasn’t the only person to mention Renaissance. It is the newest hospital in the area. It is physician-owned. And it has a reputation (which it disclaims) for aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given. (In 2007, its profits totalled thirty-four million dollars.) Romero and others argued that this gives physicians an unholy temptation to overorder.
Such an arrangement can make physician investors rich. But it can’t be the whole explanation. The hospital gets barely a sixth of the patients in the region; its margins are no bigger than the other hospitals’—whether for profit or not for profit—and it didn’t have much of a presence until 2004 at the earliest, a full decade after the cost explosion in McAllen began.
“Those are good points,” Romero said. She couldn’t explain what was going on.
The following afternoon, I visited the top managers of Doctors Hospital at Renaissance. We sat in their boardroom around one end of a yacht-length table. The chairman of the board offered me a soda. The chief of staff smiled at me. The chief financial officer shook my hand as if I were an old friend. The C.E.O., however, was having a hard time pretending that he was happy to see me. Lawrence Gelman was a fifty-seven-year-old anesthesiologist with a Bill Clinton shock of white hair and a weekly local radio show tag-lined “Opinions from an Unrelenting Conservative Spirit.” He had helped found the hospital. He barely greeted me, and while the others were trying for a how-can-I-help-you-today attitude, his body language was more let’s-get-this-over-with.
So I asked him why McAllen’s health-care costs were so high. What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. “The people in charge of the purse strings don’t know what they’re doing.” (2) If anything, government insurance programs like Medicare don’t pay enough. “I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays.” (3) Government programs are full of waste. “Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste.” (4) But not in McAllen. The clinicians here, at least at Doctors Hospital at Renaissance, “are providing necessary, essential health care,” Gelman said. “We don’t invent patients.”
Then why do hospitals in McAllen order so much more surgery and scans and tests than hospitals in El Paso and elsewhere?
In the end, the only explanation he and his colleagues could offer was this: The other doctors and hospitals in McAllen may be overspending, but, to the extent that his hospital provides costlier treatment than other places in the country, it is making people better in ways that data on quality and outcomes do not measure.
“Do we provide better health care than El Paso?” Gelman asked. “I would bet you two to one that we do.”
It was a depressing conversation—not because I thought the executives were being evasive but because they weren’t being evasive. The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.
And, I realized, few people in their position do. Local executives for hospitals and clinics and home-health agencies understand their growth rate and their market share; they know whether they are losing money or making money. They know that if their doctors bring in enough business—surgery, imaging, home-nursing referrals—they make money; and if they get the doctors to bring in more, they make more. But they have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. A doctor sees a patient in clinic, and has her check into a McAllen hospital for a CT scan, an ultrasound, three rounds of blood tests, another ultrasound, and then surgery to have her gallbladder removed. How is Lawrence Gelman or Gilda Romero to know whether all that is essential, let alone the best possible treatment for the patient? It isn’t what they are responsible or accountable for.
Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.
f doctors wield the pen, why do they do it so differently from one place to another? Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.
Sirovich asked doctors how they would treat a seventy-five-year-old woman with typical heartburn symptoms and “adequate health insurance to cover tests and medications.” Physicians in high- and low-cost cities were equally likely to prescribe antacid therapy and to check for H. pylori, an ulcer-causing bacterium—steps strongly recommended by national guidelines. But when it came to measures of less certain value—and higher cost—the differences were considerable. More than seventy per cent of physicians in high-cost cities referred the patient to a gastroenterologist, ordered an upper endoscopy, or both, while half as many in low-cost cities did. Physicians from high-cost cities typically recommended that patients with well-controlled hypertension see them in the office every one to three months, while those from low-cost cities recommended visits twice yearly. In case after uncertain case, more was not necessarily better. But physicians from the most expensive cities did the most expensive things.
Why? Some of it could reflect differences in training. I remember when my wife brought our infant son Walker to visit his grandparents in Virginia, and he took a terrifying fall down a set of stairs. They drove him to the local community hospital in Alexandria. A CT scan showed that he had a tiny subdural hematoma—a small area of bleeding in the brain. During ten hours of observation, though, he was fine—eating, drinking, completely alert. I was a surgery resident then and had seen many cases like his. We observed each child in intensive care for at least twenty-four hours and got a repeat CT scan. That was how I’d been trained. But the doctor in Alexandria was going to send Walker home. That was how he’d been trained. Suppose things change for the worse? I asked him. It’s extremely unlikely, he said, and if anything changed Walker could always be brought back. I bullied the doctor into admitting him anyway. The next day, the scan and the patient were fine. And, looking in the textbooks, I learned that the doctor was right. Walker could have been managed safely either way.
There was no sign, however, that McAllen’s doctors as a group were trained any differently from El Paso’s. One morning, I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.
“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.
He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.
No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.
Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.
Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears and colonoscopies.
Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.
In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.
In a few cases, the hospital executive told me, he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ ”
“How much?” I asked.
“The amounts—all of them were over a hundred thousand dollars per year,” he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.
He didn’t pay any of them, he said: “I mean, I gotta sleep at night.” And he emphasized that these were just a handful of doctors. But he had never been asked for a kickback before coming to McAllen.
Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions—Boston, San Francisco, San Diego—became leaders in biotechnology while others with a similar concentration of scientific and corporate talent—Los Angeles, Philadelphia, New York—did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.
Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream.
Agencies that want to compete on quality struggle to remain in business, the rep said. Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.
“I explained the rules and regulations and the anti-kickback law, and told them no,” she said of her dealings with such doctors. “Does it hurt my business?” She paused. “I’m O.K. working only with ethical physicians,” she finally said.
About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.
he real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.
I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.
“I’ll be there,” the cardiologist said.
Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.
The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.
The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.
“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.
“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.
Skeptics saw the Mayo model as a local phenomenon that wouldn’t carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.
The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.
Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.
This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.
hen you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.
There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.
Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.
This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.
One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.
“Medicine has become a pig trough here,” he muttered.
Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.
We began talking about the various proposals being touted in Washington to fix the cost problem. I asked him whether expanding public-insurance programs like Medicare and shrinking the role of insurance companies would do the trick in McAllen.
“I don’t have a problem with it,” he said. “But it won’t make a difference.” In McAllen, government payers already predominate—not many people have jobs with private insurance.
How about doing the opposite and increasing the role of big insurance companies?
“What good would that do?” Dyke asked.
The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”
He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”
Instead, McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.
This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.
Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.
omething even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.
In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”
As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future. ♦
To get more of The New Yorker's signature mix of politics, culture and the arts: Subscribe Now

"Regular Guy", a Saratoga Springs community affair

Saratoga Arts and the Saratoga Springs Film Forum hosted the local premiere of “Regular Guy”, a film directed by Leigh Rathner, written by David Kalish, and produced by Jason Ward. The Saturday showing was packed with friends and family of the production team and the actors: a true Saratoga Springs community event.

Films have taken up in the 21st century the role the novel played during the 19th and 20th centuries: chronicler and witness of the societies as they evolved through the generations and the frequent historical catastrophes. The tale of the young writer who sets out to write “the great American novel” has been oft told and quoted. Now, the literary form of choice is the film script and everybody believes he/she has one, mostly autobiographic.

“Regular Guy” reminds us how fortunate it is that only few of them get made into films at great effort and expense. Most remain in unpolished form in drawers and under the transom. Still this film must have been fun to make, and we were reminded often during the evening that the collective effort, conceived and concocted in the local coffee-shop, forged friendships and bonded disparate individuals into a team.

The most unforgivable sin of any tale told is that of outstaying its welcome. The original idea, stated as parenthesis at the beginning and the end of the film, is quirky, comparing a cancer growing in the male to the pregnancy in the female, with opposite outcomes. Its exploration, however, draws out into eternity. The team labored hard, they say, to shorten the original takes, but it still feels oversized by about ten minutes.

I guess that the main objection that I have against this film is the premise, very common in TV sitcoms, that men never grow out of adolescence, and that women patiently steer them into doing the right thing, against their will. Writing a script and making a film about a man’s cancer of the rectum, lets a guy use all the unforgotten sophomoric jokes about his lower end and its functions. Are “regular guys” really that emotionally and inspirationally handicapped? I refuse to believe it.

Remarkably, Rick Fenton’s performance as the proctologist, resigned to his chosen fate of having to look at humans from the wrong end, is stellar. His faint disgust comes through as disengaged professional tedium, a cold glass of unsweetened lemonade.

The lack of chemistry between the protagonists, Amy Rosen and Sky Vogel, does not help. Their relationship (couple, item, marriage) is difficult to ascertain. They are shown sleeping in the same bed, but they never seem to be emotionally attuned to each other. When they (he, really) decide to extract some sperm with a view to a possible after chemotherapy preservation of the species, the gulf becomes a chasm. At no point does the wife/partner/companion offer her physical help in obtaining the desired result, except by copulation and that as an after-thought. The script probably means to exalt family values and conjugal love, but the emotional inhibition of the scene brings the film to a shuddering end.

Another cup?

The most far-flung of my correspondents tells of difficulties in obtaining a good cup of joe in Accra. Nescafé is king in a coffee producing country like Ghana, which neighbors Cote d’Ivoire, Cameroon, and Equatorial Guinea, BIG coffee producers all of them. But then I also heard that in Uganda, whose export trade largely rests in coffee beans, the laborers picking the pods in the fields often have no clue what the beans are used for.

Nestlé, one of the most low profile multinationals (compared to CocaCola or even Cadbury’s) has a big footprint in Africa. It started making baby formula in Switzerland during the 1850’s, then tinned condensed milk, and branched out into chocolate, coffee and tea. All are products that were useful in tropical and sub-tropical countries without widely available commercial or private refrigeration. Tins of condensed milk were used as exchange currency in some places. During the Spanish Civil War in famished Madrid they were hoarded like gold bars and the whores accepted them as payment for services rendered.

In a coffee obsessed country like Spain, coffee was also traded on the black market, counterfeited, and mislabeled. CAFE stood for “caro, amargo, fuerte y escaso.” i.e., expensive, bitter, strong and scarce. A whole generation grew up drinking brewed roasted malted barley in small cups, and when a restaurant wanted to boast of excellence it advertised that it served “café,café”, emphasizing the real stuff by reassuring repetition.

From mother to daughter the tradition of buying the coffee beans exclusively at certain establishments, affirmed not only status but ideology. In Madrid “La Mexicana” on the calle Preciados was the preferred roaster of the civil service bourgeoisie. Seville’s upper class only drank Saimaza brews. Behind the respectable facade of those firms a network of smuggling, counterfeiting and corrupt import licenses kept the demand satisfied and enriched many.

Spain had a colony in tropical Africa, what is today the Republic of Equatorial Guinea, including the islands of Fernando Pó and Annobon. Coffee of the Robusta variety was extensively farmed and traded, with other forest products, to a captive mainland market. The trade fell as spoils of war to General Franco’s lieutenant, Admiral Carrero Blanco, whose heavy hand closed the Spanish market for coffee to other producers and other varieties like Colombia or the Arabica beans.

Nestlé was no stranger to these practices. In exchange for import licenses for coffee beans it invested in Spain, developing the dairy trade by producing sweetened condensed milk in the Northern provinces, and later by setting up instant coffee producing facilities. When the new brand Nescafé Gold was introduced with great fanfare in the early 1960s young professionals like myself believed that a new kind of delectable, exquisitely distinguished flavor opened up avenues of social mobility.

The swiss-ness of Nestlé has sheltered it from the most of the opprobrium cloaking food multinationals. In spite of its visibility in most countries of the world, few attach labels of exploitation to the name. Worth noting is that this Swiss company relies on its operations outside of Switzerland for 95% of its profits.

12 Reasons to Get Out of Iraq

Tomdispatch.com is for anyone seeking a deeper understanding of our post-9/11 world and a clear sense of how our imperial globe actually works. Read more about the site's founder and editor Tom Engelhardt and his guest authors. Click here to e-mail Tom.
posted April 20, 2008 3:55 pm

Tomgram: 12 Reasons to Get Out of Iraq

12 Answers to Questions No One Is Bothering to Ask about Iraq

By Tom Engelhardt
Can there be any question that, since the invasion of 2003, Iraq has been unraveling? And here's the curious thing: Despite a lack of decent information and analysis on crucial aspects of the Iraqi catastrophe, despite the way much of the Iraq story fell off newspaper front pages and out of the TV news in the last year, despite so many reports on the "success" of the President's surge strategy, Americans sense this perfectly well. In the latest Washington Post/ABC News poll, 56% of Americans "say the United States should withdraw its military forces to avoid further casualties" and this has, as the Post notes, been a majority position since January 2007, the month that the surge was first announced. Imagine what might happen if the American public knew more about the actual state of affairs in Iraq -- and of thinking in Washington. So, here, in an attempt to unravel the situation in ever-unraveling Iraq are twelve answers to questions which should be asked far more often in this country:

1. Yes, the war has morphed into the U.S. military's worst Iraq nightmare: Few now remember, but before George W. Bush launched the invasion of Iraq in March 2003, top administration and Pentagon officials had a single overriding nightmare -- not chemical, but urban, warfare. Saddam Hussein, they feared, would lure American forces into "Fortress Baghdad," as Secretary of Defense Donald Rumsfeld labeled it. There, they would find themselves fighting block by block, especially in the warren of streets that make up the Iraqi capital's poorest districts.

When American forces actually entered Baghdad in early April 2003, however, even Saddam's vaunted Republican Guard units had put away their weapons and gone home. It took five years but, as of now, American troops are indeed fighting in the warren of streets in Sadr City, the Shiite slum of two and a half million in eastern Baghdad largely controlled by Muqtada al-Sadr's Mahdi Army militia. The U.S. military, in fact, recently experienced its worst week of 2008 in terms of casualties, mainly in and around Baghdad. So, mission accomplished -- the worst fear of 2003 has now been realized.

2. No, there was never an exit strategy from Iraq because the Bush administration never intended to leave -- and still doesn't: Critics of the war have regularly gone after the Bush administration for its lack of planning, including its lack of an "exit strategy." In this, they miss the point. The Bush administration arrived in Iraq with four mega-bases on the drawing boards. These were meant to undergird a future American garrisoning of that country and were to house at least 30,000 American troops, as well as U.S. air power, for the indefinite future. The term used for such places wasn't "permanent base," but the more charming and euphemistic "enduring camp." (In fact, as we learned recently, the Bush administration refuses to define any American base on foreign soil anywhere on the planet, including ones in Japan for over 60 years, as permanent.) Those four monster bases in Iraq (and many others) were soon being built at the cost of multibillions and are, even today, being significantly upgraded. In October 2007, for instance, National Public Radio's defense correspondent Guy Raz visited Balad Air Base, north of Baghdad, which houses about 40,000 American troops, contractors, and Defense Department civilian employees, and described it as "one giant construction project, with new roads, sidewalks, and structures going up across this 16-square-mile fortress in the center of Iraq, all with an eye toward the next few decades."

These mega-bases, like "Camp Cupcake" (al-Asad Air Base), nicknamed for its amenities, are small town-sized with massive facilities, including PXs, fast-food outlets, and the latest in communications. They have largely been ignored by the American media and so have played no part in the debate about Iraq in this country, but they are the most striking on-the-ground evidence of the plans of an administration that simply never expected to leave. To this day, despite the endless talk about drawdowns and withdrawals, that hasn't changed. In fact, the latest news about secret negotiations for a future Status of Forces Agreement on the American presence in that country indicates that U.S. officials are calling for "an open-ended military presence" and "no limits on numbers of U.S. forces, the weapons they are able to deploy, their legal status or powers over Iraqi citizens, going far beyond long-term U.S. security agreements with other countries."

3. Yes, the United States is still occupying Iraq (just not particularly effectively): In June 2004, the Coalition Provisional Authority (CPA), then ruling the country, officially turned over "sovereignty" to an Iraqi government largely housed in the American-controlled Green Zone in Baghdad and the occupation officially ended. However, the day before the head of the CPA, L. Paul Bremer III, slipped out of the country without fanfare, he signed, among other degrees, Order 17, which became (and, remarkably enough, remains) the law of the land. It is still a document worth reading as it essentially granted to all occupying forces and allied private companies what, in the era of colonialism, used to be called "extraterritoriality" -- the freedom not to be in any way subject to Iraqi law or jurisdiction, ever. And so the occupation ended without ever actually ending. With 160,000 troops still in Iraq, not to speak of an unknown number of hired guns and private security contractors, the U.S. continues to occupy the country, whatever the legalities might be (including a UN mandate and the claim that we are part of a "coalition"). The only catch is this: As of now, the U.S. is simply the most technologically sophisticated and potentially destructive of Iraq's proliferating militias -- and outside the fortified Green Zone in Baghdad, it is capable of controlling only the ground that its troops actually occupy at any moment.

4. Yes, the war was about oil: Oil was hardly mentioned in the mainstream media or by the administration before the invasion was launched. The President, when he spoke of Iraq's vast petroleum reserves at all, piously referred to them as the sacred "patrimony of the people of Iraq." But an administration of former energy execs -- with a National Security Advisor who once sat on the board of Chevron and had a double-hulled oil tanker, the Condoleezza Rice, named after her (until she took office), and a Vice President who was especially aware of the globe's potentially limited energy supplies -- certainly had oil reserves and energy flows on the brain. They knew, in Deputy Secretary of Defense Paul Wolfowitz's apt phrase, that Iraq was afloat on "a sea of oil" and that it sat strategically in the midst of the oil heartlands of the planet.

It wasn't a mistake that, in 2001, Vice President Dick Cheney's semi-secret Energy Task Force set itself the "task" of opening up the energy sectors of various Middle Eastern countries to "foreign investment"; or that it scrutinized "a detailed map of Iraq's oil fields, together with the (non-American) oil companies scheduled to develop them"; or that, according to the New Yorker's Jane Mayer, the National Security Council directed its staff "to cooperate fully with the Energy Task Force as it considered the 'melding' of two seemingly unrelated areas of policy: 'the review of operational policies towards rogue states,' such as Iraq, and 'actions regarding the capture of new and existing oil and gas fields'"; or that the only American troops ordered to guard buildings in Iraq, after Baghdad fell, were sent to the Oil Ministry (and the Interior Ministry, which housed Saddam Hussein's dreaded secret police); or that the first "reconstruction" contract was issued to Cheney's former firm, Halliburton, for "emergency repairs" to those patrimonial oil fields. Once in charge in Baghdad, as sociologist Michael Schwartz has made clear, the administration immediately began guiding recalcitrant Iraqis toward denationalizing and opening up their oil industry, as well as bringing in the big boys.

Though rampant insecurity has kept the Western oil giants on the sidelines, the American-shaped "Iraqi" oil law quickly became a "benchmark" of "progress" in Washington and remains a constant source of prodding and advice from American officials in Baghdad. Former Federal Reserve chief Alan Greenspan put the oil matter simply and straightforwardly in his memoir in 2007: "I am saddened," he wrote, "that it is politically inconvenient to acknowledge what everyone knows: the Iraq war is largely about oil." In other words, in a variation on the old Bill Clinton campaign mantra: It's the oil, stupid. Greenspan was, unsurprisingly, roundly assaulted for the obvious naiveté of his statement, from which, when it proved inconvenient, he quickly retreated. But if this administration hadn't had oil on the brain in 2002-2003, given the importance of Iraq's reserves, Congress should have impeached the President and Vice President for that.

5. No, our new embassy in Baghdad is not an "embassy": When, for more than three-quarters of a billion dollars, you construct a complex -- regularly described as "Vatican-sized" -- of at least 20 "blast-resistant" buildings on 104 acres of prime Baghdadi real estate, with "fortified working space" and a staff of at least 1,000 (plus several thousand guards, cooks, and general factotums), when you deeply embunker it, equip it with its own electricity and water systems, its own anti-missile defense system, its own PX, and its own indoor and outdoor basketball courts, volleyball court, and indoor Olympic-size swimming pool, among other things, you haven't built an "embassy" at all. What you've constructed in the heart of the heart of another country is more than a citadel, even if it falls short of a city-state. It is, at a minimum, a monument to Bush administration dreams of domination in Iraq and in what its adherents once liked to call "the Greater Middle East."

Just about ready to open, after the normal construction mishaps in Iraq, it will constitute the living definition of diplomatic overkill. It will, according to a Senate estimate, now cost Americans $1.2 billion a year just to be "represented" in Iraq. The "embassy" is, in fact, the largest headquarters on the planet for the running of an occupation. Functionally, it is also another well-fortified enduring camp with the amenities of home. Tell that to the Shiite militiamen now mortaring the Green Zone as if it were… enemy-occupied territory.

6. No, the Iraqi government is not a government: The government of Prime Minister Nouri al-Maliki has next to no presence in Iraq beyond the Green Zone; it delivers next to no services; it has next to no ability to spend its own oil money, reconstruct the country, or do much of anything else, and it most certainly does not hold a monopoly on the instruments of violence. It has no control over the provinces of northern Iraq which operate as a near-independent Kurdish state. Non-Kurdish Iraqi troops are not even allowed on its territory. Maliki's government cannot control the largely Sunni provinces of the country, where its officials are regularly termed "the Iranians" (a reference to the heavily Shiite government's closeness to neighboring Iran) and are considered the equivalent of representatives of a foreign occupying power; and it does not control the Shiite south, where power is fragmented among the militias of ISCI (the Badr Organization), Muqtada al-Sadr's Mahdi Army, and the armed adherents of the Fadila Party, a Sadrist offshoot, among others.

In Afghanistan, President Hamid Karzai has been derisively nicknamed "the mayor of Kabul" for his government's lack of control over much territory outside the national capital. It would be a step forward for Maliki if he were nicknamed "the mayor of Baghdad." Right now, his troops, heavily backed by American forces, are fighting for some modest control over Shiite cities (or parts of cities) from Basra to Baghdad.

7. No, the surge is not over: Two weeks ago, amid much hoopla, General David Petraeus and Ambassador Ryan Crocker spent two days before Congress discussing the President's surge strategy in Iraq and whether it has been a "success." But that surge -- the ground one in which an extra 30,000-plus American troops were siphoned into Baghdad and, to a lesser extent, adjoining provinces -- was by then already so over. In fact, all but about 10,000 of those troops will be home by the end of July, not because the President has had any urge for a drawdown, but, as Fred Kaplan of Slate wrote recently, "because of simple math. The five extra combat brigades, which were deployed to Iraq with the surge, each have 15-month tours of duty; the 15 months will be up in July… and the U.S. Army and Marines have no combat brigades ready to replace them."

On the other hand, in all those days of yak, neither the general with so much more "martial bling" on his chest than any victorious World War II commander, nor the white-haired ambassador uttered a word about the surge that is ongoing -- the air surge that began in mid-2007 and has yet to end. Explain it as you will, but, with rare exceptions, American reporters in Iraq generally don't look up or more of them would have noticed that the extra air units surged into that country and the region in the last year are now being brought to bear over Iraq's cities. Today, as fighting goes on in Sadr City, American helicopters and Hellfire-missile armed Predator drones reportedly circle overhead almost constantly and air strikes of various kinds on city neighborhoods are on the rise. Yet the air surge in Iraq remains unacknowledged here and so is not a subject for discussion, debate, or consideration when it comes to our future in Iraq.

8. No, the Iraqi army will never "stand up": It can't. It's not a national army. It's not that Iraqis can't fight -- or fight bravely. Ask the Sunni insurgents. Ask the Mahdi Army militia of Muqtada al-Sadr. It's not that Iraqis are incapable of functioning in a national army. In the bitter Iran-Iraq War of 1980-88, Iraqi Shiite as well as Sunni conscripts, led by a largely Sunni officer corps, fought Iranian troops fiercely in battle after pitched battle. But from Fallujah in 2004 to today, Iraqi army (and police) units, wheeled into battle (often at the behest of the Americans), have regularly broken and run, or abandoned their posts, or gone over to the other side, or, at the very least, fought poorly. In the recent offensive launched by the Maliki government in Basra, military and police units up against a single resistant militia, the Mahdi Army, deserted in sizeable numbers, while other units, when not backed by the Americans, gave poor showings. At least 1,300 troops and police (including 37 senior police officers) were recently "fired" by Maliki for dereliction of duty, while two top commanders were removed as well.

Though American training began in 2004 and, by 2005, the President was regularly talking about us "standing down" as soon as the Iraqi Army "stood up," as Charles Hanley of the Associated Press points out, "Year by year, the goal of deploying a capable, free-standing Iraqi army has seemed to always slip further into the future." He adds, "In the latest shift, the Pentagon's new quarterly status report quietly drops any prediction of when local units will take over security responsibility for Iraq. Last year's reports had forecast a transition in 2008." According to Hanley, the chief American trainer of Iraqi forces, Lt. Gen. James Dubik, now estimates that the military will not be able to guard the country's borders effectively until 2018.

No wonder. The "Iraqi military" is not in any real sense a national military at all. Its troops generally lack heavy weaponry, and it has neither a real air force nor a real navy. Its command structures are integrated into the command structure of the U.S. military, while the U.S. Air Force and the U.S. Navy are the real Iraqi air force and navy. It is reliant on the U.S. military for much of its logistics and resupply, even after an investment of $22 billion by the American taxpayer. It represents a non-government, is riddled with recruits from Shiite militias (especially the Badr brigades), and is riven about who its enemy is (or enemies are) and why. It cannot be a "national" army because it has, in essence, nothing to stand up for.

You can count on one thing, as long as we are "training" and "advising" the Iraqi military, however many years down the line, you will read comments like this one from an American platoon sergeant, after an Iraqi front-line unit abandoned its positions in the ongoing battle for control of parts of Sadr City: "It bugs the hell out of me. We don't see any progress being made at all. We hear these guys in firefights. We know if we are not up there helping these guys out we are making very little progress."

9. No, the U.S. military does not stand between Iraq and fragmentation: The U.S. invasion and the Bush administration's initial occupation policies decisively smashed Iraq's fragile "national" sense of self. Since then, the Bush administration, a motor for chaos and fragmentation, has destroyed the national (if dictatorial) government, allowed the capital and much of the country (as well as its true patrimony of ancient historical objects and sites) to be looted, disbanded the Iraqi military, and deconstructed the national economy. Ever since, whatever the administration rhetoric, the U.S. has only presided over the further fragmentation of the country. Its military, in fact, employs a specific policy of urban fragmentation in which it regularly builds enormous concrete walls around neighborhoods, supposedly for "security" and "reconstruction," that actually cut them off from their social and economic surroundings. And, of course, Iraq has in these years been fragmented in other staggering ways with an estimated four-plus million Iraqis driven into exile abroad or turned into internal refugees.

According to Pepe Escobar of the Asia Times, there are now at least 28 different militias in the country. The longer the U.S. remains even somewhat in control, the greater the possibility of further fragmentation. Initially, the fragmentation was sectarian -- into Kurdish, Sunni, and Shia regions, but each of those regions has its own potentially hostile parts and so its points of future conflict and further fragmentation. If the U.S. military spent the early years of its occupation fighting a Sunni insurgency in the name of a largely Shiite (and Kurdish) government, it is now fighting a Shiite militia, while paying and arming former Sunni insurgents, relabeled "Sons of Iraq." Iran is also clearly sending arms into a country that is, in any case, awash in weaponry. Without a real national government, Iraq has descended into a welter of militia-controlled neighborhoods, city states, and provincial or regional semi-governments. Despite all the talk of American-supported "reconciliation," Juan Cole described the present situation well at his Informed Comment blog: "Maybe the US in Iraq is not the little boy with his finger in the dike. Maybe we are workers with jackhammers instructed to make the hole in the dike much more huge."

10. No, the U.S. military does not stand between Iraq and civil war: As with fragmentation, the U.S. military's presence has, in fact, been a motor for civil war in that country. The invasion and subsequent chaos, as well as punitive acts against the Sunni minority, allowed Sunni extremists, some of whom took the name "al-Qaeda in Mesopotamia," to establish themselves as a force in the country for the first time. Later, U.S. military operations in both Sunni and Shiite areas regularly repressed local militias -- almost the only forces capable of bringing some semblance of security to urban neighborhoods -- opening the way for the most extreme members of the other community (Sunni suicide or car bombers and Shiite death squads) to attack. It's worth remembering that it was in the surge months of 2007, when all those extra American troops hit Baghdad neighborhoods, that many of the city's mixed or Sunni neighborhoods were most definitively "cleansed" by death squads, producing a 75-80% Shiite capital. Iraq is now embroiled in what Juan Cole has termed "three civil wars," two of which (in the south and the north) are largely beyond the reach of limited American ground forces and all of which could become far worse. The still low-level struggle between Kurds and Arabs (with the Turks hovering nearby) for the oil-rich city of Kirkuk in the north may be the true explosion point to come. The U.S. military sits precariously atop this mess, at best putting off to the future aspects of the present civil-war landscape, but more likely intensifying it.

11. No, al-Qaeda will not control Iraq if we leave (and neither will Iran): The latest figures tell the story. Of 658 suicide bombings globally in 2007 (more than double those of any year in the last quarter century), 542, according to the Washington Post's Robin Wright, took place in occupied Iraq or Afghanistan, mainly Iraq. In other words, the American occupation of that land has been a motor for acts of terrorism (as occupations will be). There was no al-Qaeda in Mesopotamia before the invasion and Iraq was no Afghanistan. The occupation under whatever name will continue to create "terrorists," no matter how many times the administration claims that "al-Qaeda" is on the run. With the departure of U.S. troops, it's clear that homegrown Sunni extremists (and the small number of foreign jihadis who work with them), already a minority of a minority, will more than meet their match in facing the Sunni mainstream. The Sunni Awakening Movement came into existence, in part, to deal with such self-destructive extremism (and its fantasies of a Taliban-style society) before the Americans even noticed that it was happening. When the Americans leave, "al-Qaeda" (and whatever other groups the Bush administration subsumes under that catch-all title) will undoubtedly lose much of their raison d'être or simply be crushed.

As for Iran, the moment the Bush administration finally agreed to a popular democratic vote in occupied Iraq, it ensured one thing -- that the Shiite majority would take control, which in practice meant religio-political parties that, throughout the Saddam Hussein years, had generally been close to, or in exile in, Iran. Everything the Bush administration has done since has only ensured the growth of Iranian influence among Shiite groups. This is surely meant by the Iranians as, in part, a threat/trump card, should the Bush administration launch an attack on that country. After all, crucial U.S. resupply lines from Kuwait run through areas near Iran and would assumedly be relatively easy to disrupt.

Without the U.S. military in Iraq, there can be no question that the Iranians would have real influence over the Shiite (and probably Kurdish) parts of the country. But that influence would have its distinct limits. If Iran overplayed its hand even in a rump Shiite Iraq, it would soon enough find itself facing some version of the situation that now confronts the Americans. As Robert Dreyfuss wrote in the Nation recently, "[D]espite Iran's enormous influence in Iraq, most Iraqis -- even most Iraqi Shiites -- are not pro-Iran. On the contrary, underneath the ruling alliance in Baghdad, there is a fierce undercurrent of Arab nationalism in Iraq that opposes both the U.S. occupation and Iran's support for religious parties in Iraq." The al-Qaedan and Iranian "threats" are, at one and the same time, bogeymen used by the Bush administration to scare Americans who might favor withdrawal and, paradoxically, realities that a continued military presence only encourages.

12. Yes, some Americans were right about Iraq from the beginning (and not the pundits either): One of the strangest aspects of the recent fifth anniversary (as of every other anniversary) of the invasion of Iraq was the newspaper print space reserved for those Bush administration officials and other war supporters who were dead wrong in 2002-2003 on an endless host of Iraq-related topics. Many of them were given ample opportunity to offer their views on past failures, the "success" of the surge, future withdrawals or drawdowns, and the responsibilities of a future U.S. president in Iraq.

Noticeably missing were representatives of the group of Americans who happened to have been right from the get-go. In our country, of course, it often doesn't pay to be right. (It's seen as a sign of weakness or plain dumb luck.) I'm speaking, in this case, of the millions of people who poured into the streets to demonstrate against the coming invasion with an efflorescence of placards that said things too simpleminded (as endless pundits assured American news readers at the time) to take seriously -- like "No Blood for Oil," "Don't Trade Lives for Oil," or ""How did USA's oil get under Iraq's sand?" At the time, it seemed clear to most reporters, commentators, and op-ed writers that these sign-carriers represented a crew of well-meaning know-nothings and the fact that their collective fears proved all too prescient still can't save them from that conclusion. So, in their very rightness, they were largely forgotten.

Now, as has been true for some time, a majority of Americans, another obvious bunch of know-nothings, are deluded enough to favor bringing all U.S. troops out of Iraq at a reasonable pace and relatively soon. (More than 60% of them also believe "that the conflict is not integral to the success of U.S. anti-terrorism efforts.") If, on the other hand, a poll were taken of pundits and the inside-the-Beltway intelligentsia (not to speak of the officials of the Bush administration), the number of them who would want a total withdrawal from Iraq (or even see that as a reasonable goal) would undoubtedly descend near the vanishing point. When it comes to American imperial interests, most of them know better, just as so many of them did before the war began. Even advisors to candidates who theoretically want out of Iraq are hinting that a full-scale withdrawal is hardly the proper way to go.

So let me ask you a question (and you answer it): Given all of the above, given the record thus far, who is likely to be right?

Tom Engelhardt, who runs the Nation Institute's Tomdispatch.com, is the co-founder of the American Empire Project. His book, The End of Victory Culture (University of Massachusetts Press), has been updated in a newly issued edition that deals with victory culture's crash-and-burn sequel in Iraq.

[Tomdispatch recommendations: For another numbered piece on Iraq, check out Gary Kamiya's eminently sane reprise of the Ten Commandments as applied to the launching of the 2003 invasion -- to be found at Salon.com. ("Commandment I, "Thou shalt not launch preventive wars…"; Commandment VI: "Do not allow neoconservatives anywhere near Middle East policy… Special Bill Kristol Sub-commandment VI a: Stop giving these buffoons prestigious jobs on newspaper-of-record Op-Ed pages, top magazines and television shows. They have been completely and consistently wrong about everything. Must we continue to be subjected to their pontifications?"). Also let me offer a Tomdispatch bow of thanks to Cursor.org's daily "Media Patrol" column. Someone at that site with a keen eye for the less noticed but newsworthy pieces of any day (and an always splendid set of links) makes my life so much easier, when gathering material for essays like this one.]

Copyright 2008 Tom Engelhardt

Dick Cavett - Opinion - New York Times Blog

Dick Cavett - Opinion - New York Times Blog
Memo to Petraeus & Crocker: More Laughs, Please
Once again it is time to bid aloha to that sober team of mirthless entertainers, Petraeus & Crocker.

It’s hard to imagine where you could find another pair of such sleep-inducing performers.

I can’t look at Petraeus — his uniform ornamented like a Christmas tree with honors, medals and ribbons — without thinking of the great Mort Sahl at the peak of his brilliance. He talked about meeting General Westmoreland in the Vietnam days. Mort, in a virtuoso display of his uncanny detailed knowledge — and memory — of such things, recited the lengthy list (”Distinguished Service Medal, Croix de Guerre with Chevron, Bronze Star, Pacific Campaign” and on and on), naming each of the half-acre of decorations, medals, ornaments, campaign ribbons and other fripperies festooning the general’s sternum in gaudy display. Finishing the detailed list, Mort observed, “Very impressive!” Adding, “If you’re twelve.”

(As speakers, both Petraeus and Crocker are guilty of unbearable sesquipedalianism, a word wickedly inflicted on me by my English-teaching mother. It’s one of those words that is what it says. From the Latin, literally “using foot-and-a-half-long words.” We all learned the word for words that sound like what they say — like “click” or “pop” or “boom” or “hiss” — but I’m sure the mercifully defunct Famous Writers School surely forbade using the “sesqui” word and “onomatopoeia” in the same paragraph. (You can have fun with both of them at your next cocktail party.)

But back to our story. Never in this breathing world have I seen a person clog up and erode his speaking — as distinct from his reading — with more “uhs,” “ers” and “ums” than poor Crocker. Surely he has never seen himself talking: “Uh, that is uh, a, uh, matter that we, er, um, uh are carefully, uh, considering.” (Not a parody, an actual Crocker sentence. And not even the worst.)

These harsh-on-the-ear insertions, delivered in his less than melodious, hoarse-sounding tenor, are maddening. And their effect is to say that the speaker is painfully unsure of what he wants, er, um, to say.

If Crocker’s collection of these broken shards of verbal crockery were eliminated from his testimony, everyone there would get home at least an hour earlier.

Petraeus commits a different assault on the listener. And on the language. In addition to his own pedantic delivery, there is his turgid vocabulary. It reminds you of Copspeak, a language spoken nowhere on earth except by cops and firemen when talking to “Eyewitness News.” Its rule: never use a short word where a longer one will do. It must be meant to convey some misguided sense of “learnedness” and “scholasticism” — possibly even that dread thing, “intellectualism” — to their talk. Sorry, I mean their “articulation.”

No crook ever gets out of the car. A “perpetrator exits the vehicle.” (Does any cop say to his wife at dinner, “Honey, I stubbed my toe today as I exited our vehicle”?) No “man” or “woman” is present in Copspeak. They are replaced by that five-syllable, leaden ingot, the “individual.” The other day, there issued from a fire chief’s mouth, “It contributed to the obfuscation of what eventually eventuated.” This from a guy who looked like he talked, in real life, like Rocky Balboa. And there’s nothing wrong with that.

Who imposes this phony, academic-sounding verbal junk on brave and hard-working men and women who don’t need the added burden of trying to talk like effete characters from Victorian novels?

And, General, there is no excuse anywhere on earth for a stillborn monster like “ethnosectarian conflict,” as Jon Stewart so hilariously pointed out.

What would the general be forced to say if it weren’t for the icky, precious-sounding “challenge” that he leans so heavily on? That politically correct term, which was created so that folks who are legally blind, deaf, clumsy, crippled, impotent, tremor-ridden, stupid, addicted or villainously ugly are really none of those unhappy things at all. They are merely challenged. (Are these euphemisms supposed to make them feel better?) And no one need be unlucky enough to be dead or hideously wounded anymore. Those unfortunates are merely “casualties” — a sort of restful-sounding word.

(I have a friend who would like the opportunity to say to our distinguished warrior, “General Petraeus, my son was killed in one of your challenges.”)

Petraeus uses “challenge” for a rich variety of things. It covers ominous developments, threats, defeats on the battlefield and unfound solutions to ghastly happenings. And of course there’s that biggest of challenges, that slapstick band of silent-movie comics called, flatteringly, the Iraqi “fighting forces.” (A perilous one letter away from “fighting farces.”) The ones who are supposed to allow us to bring troops home but never do.

Petraeus’s verbal road is full of all kinds of bumps and lurches and awkward oddities. How about “ongoing processes of substantial increases in personnel”?

Try talking English, General. You mean more soldiers.

It’s like listening to someone speaking a language you only partly know. And who’s being paid by the syllable. You miss a lot. I guess a guy bearing up under such a chestload of hardware — and pretty ribbons in a variety of decorator colors — can’t be expected to speak like ordinary mortals, for example you and me. He should try once saying — instead of “ongoing process of high level engagements” — maybe something in colloquial English? Like: “fights” or “meetings” (or whatever the hell it’s supposed to mean).

I find it painful to watch this team of two straight men, straining on the potty of language. Only to deliver such . . . what? Such knobbed and lumpy artifacts of superfluous verbiage? (Sorry, now I’m doing it…)

But I must hand it to his generalship. He did say something quite clearly and admirably and I am grateful for his frankness. He told us that our gains are largely imaginary: that our alleged “progress” is “fragile and reversible.” (Quite an accomplishment in our sixth year of war.) This provides, of course, a bit of pre-emptive covering of the general’s hindquarters next time that, true to Murphy’s Law, things turn sour again.

Back to poor Crocker. His brows are knitted. And he has a perpetually alarmed expression, as if, perhaps, he feels something crawling up his leg.

Could it be he is being overtaken by the thought that an honorable career has been besmirched by his obediently doing the dirty work of the tinpot Genghis Khan of Crawford, Texas? The one whose foolish military misadventure seems to increasingly resemble that of Gen. George Armstrong Custer at Little Bighorn?

Not an apt comparison, I admit.

Custer sent only 258 soldiers to their deaths.

Famine! Paul Krugman's Monday morning take.

April 7, 2008
OP-ED COLUMNIST
Grains Gone Wild

By PAUL KRUGMAN
These days you hear a lot about the world financial crisis. But there’s another world crisis under way — and it’s hurting a lot more people.

I’m talking about the food crisis. Over the past few years the prices of wheat, corn, rice and other basic foodstuffs have doubled or tripled, with much of the increase taking place just in the last few months. High food prices dismay even relatively well-off Americans — but they’re truly devastating in poor countries, where food often accounts for more than half a family’s spending.

There have already been food riots around the world. Food-supplying countries, from Ukraine to Argentina, have been limiting exports in an attempt to protect domestic consumers, leading to angry protests from farmers — and making things even worse in countries that need to import food.

How did this happen? The answer is a combination of long-term trends, bad luck — and bad policy.

Let’s start with the things that aren’t anyone’s fault.

First, there’s the march of the meat-eating Chinese — that is, the growing number of people in emerging economies who are, for the first time, rich enough to start eating like Westerners. Since it takes about 700 calories’ worth of animal feed to produce a 100-calorie piece of beef, this change in diet increases the overall demand for grains.

Second, there’s the price of oil. Modern farming is highly energy-intensive: a lot of B.T.U.’s go into producing fertilizer, running tractors and, not least, transporting farm products to consumers. With oil persistently above $100 per barrel, energy costs have become a major factor driving up agricultural costs.

High oil prices, by the way, also have a lot to do with the growth of China and other emerging economies. Directly and indirectly, these rising economic powers are competing with the rest of us for scarce resources, including oil and farmland, driving up prices for raw materials of all sorts.

Third, there has been a run of bad weather in key growing areas. In particular, Australia, normally the world’s second-largest wheat exporter, has been suffering from an epic drought.

O.K., I said that these factors behind the food crisis aren’t anyone’s fault, but that’s not quite true. The rise of China and other emerging economies is the main force driving oil prices, but the invasion of Iraq — which proponents promised would lead to cheap oil — has also reduced oil supplies below what they would have been otherwise.

And bad weather, especially the Australian drought, is probably related to climate change. So politicians and governments that have stood in the way of action on greenhouse gases bear some responsibility for food shortages.

Where the effects of bad policy are clearest, however, is in the rise of demon ethanol and other biofuels.

The subsidized conversion of crops into fuel was supposed to promote energy independence and help limit global warming. But this promise was, as Time magazine bluntly put it, a “scam.”

This is especially true of corn ethanol: even on optimistic estimates, producing a gallon of ethanol from corn uses most of the energy the gallon contains. But it turns out that even seemingly “good” biofuel policies, like Brazil’s use of ethanol from sugar cane, accelerate the pace of climate change by promoting deforestation.

And meanwhile, land used to grow biofuel feedstock is land not available to grow food, so subsidies to biofuels are a major factor in the food crisis. You might put it this way: people are starving in Africa so that American politicians can court votes in farm states.

Oh, and in case you’re wondering: all the remaining presidential contenders are terrible on this issue.

One more thing: one reason the food crisis has gotten so severe, so fast, is that major players in the grain market grew complacent.

Governments and private grain dealers used to hold large inventories in normal times, just in case a bad harvest created a sudden shortage. Over the years, however, these precautionary inventories were allowed to shrink, mainly because everyone came to believe that countries suffering crop failures could always import the food they needed.

This left the world food balance highly vulnerable to a crisis affecting many countries at once — in much the same way that the marketing of complex financial securities, which was supposed to diversify away risk, left world financial markets highly vulnerable to a systemwide shock.

What should be done? The most immediate need is more aid to people in distress: the U.N.’s World Food Program put out a desperate appeal for more funds.

We also need a pushback against biofuels, which turn out to have been a terrible mistake.

But it’s not clear how much can be done. Cheap food, like cheap oil, may be a thing of the past.


Copyright 2008 The New York Times Company
Privacy Policy Search Corrections RSS First Look Help Contact Us Work for Us Site Map

The Long Defeat

March 25, 2008
OP-ED COLUMNIST
The Long Defeat

By DAVID BROOKS
Hillary Clinton may not realize it yet, but she’s just endured one of the worst weeks of her campaign.

First, Barack Obama weathered the Rev. Jeremiah Wright affair without serious damage to his nomination prospects. Obama still holds a tiny lead among Democrats nationally in the Gallup tracking poll, just as he did before this whole affair blew up.

Second, Obama’s lawyers successfully prevented re-votes in Florida and Michigan. That means it would be virtually impossible for Clinton to take a lead in either elected delegates or total primary votes.

Third, as Noam Scheiber of The New Republic has reported, most superdelegates have accepted Nancy Pelosi’s judgment that the winner of the elected delegates should get the nomination. Instead of lining up behind Clinton, they’re drifting away. Her lead among them has shrunk by about 60 in the past month, according to Avi Zenilman of Politico.com.

In short, Hillary Clinton’s presidential prospects continue to dim. The door is closing. Night is coming. The end, however, is not near.

Last week, an important Clinton adviser told Jim VandeHei and Mike Allen (also of Politico) that Clinton had no more than a 10 percent chance of getting the nomination. Now, she’s probably down to a 5 percent chance.

Five percent.

Let’s take a look at what she’s going to put her party through for the sake of that 5 percent chance: The Democratic Party is probably going to have to endure another three months of daily sniping. For another three months, we’ll have the Carvilles likening the Obamaites to Judas and former generals accusing Clintonites of McCarthyism. For three months, we’ll have the daily round of résumé padding and sulfurous conference calls. We’ll have campaign aides blurting “blue dress” and only-because-he’s-black references as they let slip their private contempt.

For three more months (maybe more!) the campaign will proceed along in its Verdun-like pattern. There will be a steady rifle fire of character assassination from the underlings, interrupted by the occasional firestorm of artillery when the contest touches upon race, gender or patriotism. The policy debates between the two have been long exhausted, so the only way to get the public really engaged is by poking some raw national wound.

For the sake of that 5 percent, this will be the sourest spring. About a fifth of Clinton and Obama supporters now say they wouldn’t vote for the other candidate in the general election. Meanwhile, on the other side, voters get an unobstructed view of the Republican nominee. John McCain’s approval ratings have soared 11 points. He is now viewed positively by 67 percent of Americans. A month ago, McCain was losing to Obama among independents by double digits in a general election matchup. Now McCain has a lead among this group.

For three more months, Clinton is likely to hurt Obama even more against McCain, without hurting him against herself. And all this is happening so she can preserve that 5 percent chance.

When you step back and think about it, she is amazing. She possesses the audacity of hopelessness.

Why does she go on like this? Does Clinton privately believe that Obama is so incompetent that only she can deliver the policies they both support? Is she simply selfish, and willing to put her party through agony for the sake of her slender chance? Are leading Democrats so narcissistic that they would create bitter stagnation even if they were granted one-party rule?

The better answer is that Clinton’s long rear-guard action is the logical extension of her relentlessly political life.

For nearly 20 years, she has been encased in the apparatus of political celebrity. Look at her schedule as first lady and ever since. Think of the thousands of staged events, the tens of thousands of times she has pretended to be delighted to see someone she doesn’t know, the hundreds of thousands times she has recited empty clichés and exhortatory banalities, the millions of photos she has posed for in which she is supposed to appear empathetic or tough, the billions of politically opportune half-truths that have bounced around her head.

No wonder the Clinton campaign feels impersonal. It’s like a machine for the production of politics. It plows ahead from event to event following its own iron logic. The only question is whether Clinton herself can step outside the apparatus long enough to turn it off and withdraw voluntarily or whether she will force the rest of her party to intervene and jam the gears.

If she does the former, she would surprise everybody with a display of self-sacrifice. Her campaign would cruise along at a lower register until North Carolina, then use that as an occasion to withdraw. If she does not, she would soldier on doggedly, taking down as many allies as necessary.


Copyright 2008 The New York Times Company
Privacy Policy Search Corrections RSS First Look Help Contact Us Work for Us Site Map

hThe Media and the Maverick

March 26, 2008
OP-ED CONTRIBUTOR
The Maverick and the Media

By NEAL GABLER
Amagansett, N.Y.

IT is certainly no secret that Senator John McCain, the presumptive Republican presidential nominee, is a darling of the news media. Reporters routinely attach “maverick,” “straight talker” and “patriot” to him like Homeric epithets. Chris Matthews of MSNBC has even called the press “McCain’s base” — a comment that Mr. McCain himself has jokingly reiterated. The mainstream news media by and large don’t cover Mr. McCain; they canonize him. Hence the moniker on liberal blogs: St. McCain.

What is less obvious, however, is exactly why the press swoons for him. The answer, which says a great deal about both the political press and Mr. McCain, may be that he is something political reporters really haven’t seen in quite a while, perhaps since John F. Kennedy.

Seeming to view himself and the whole political process with a mix of amusement and bemusement, Mr. McCain is an ironist wooing a group of individuals who regard ironic detachment more highly than sincerity or seriousness. He may be the first real postmodernist candidate for the presidency — the first to turn his press relations into the basis of his candidacy.

Of course this is not how the press typically talks about Mr. McCain. The conventional analysis of his press popularity begins with his military service. If campaigns are primarily about narratives, he has a good and distinguished one, and it would take a very curmudgeonly press corps to dismiss it, even though that is exactly what a good portion of it did to Senator John Kerry’s service record in 2004. Reporters also often cite Mr. McCain’s bonhomie as the reason for their affection. As Ryan Lizza described it last month in The New Yorker, a typical campaign day has Mr. McCain rumbling from one stop to another on his bus, the Straight Talk Express, sitting in the rear on a horseshoe-shaped leather couch surrounded by reporters and talking “until the room is filled with the awkward silence of journalists with no more questions.”

The Washington Post columnist Richard Cohen, citing the conviviality during the 2000 campaign, wrote that “a trip on his bus is, well, a trip.” And as the party master, Mr. McCain is no longer the reporters’ subject. He is their pal.

While other candidates have tried to schmooze reporters this way without success, what has made Mr. McCain’s fraternization so effective is that it comes with candor — or at least the illusion of it. Over the years, reporter after reporter has remarked upon his seemingly unguarded frankness. In 1999, William Greider wrote in Rolling Stone that, “While McCain continues examining his flaws, the reporters on the bus are getting a bit edgy. Will somebody tell this guy to shut up before he self-destructs?”

Imagine, reporters protecting a candidate from himself! But, then again, since the reporters on the bus liked Mr. McCain too much to report on his gaffes, he really didn’t need protection. His candor was without consequence. It was another blandishment to the press.

Yet however much his accessibility, amiability and candor may have defined the news media’s love affair with him in 2000, and however much they continue to operate that way in 2008, there is also something different and more complicated at work now. Joan Didion once described a presidential campaign as a closed system staged by the candidates for the news media — one in which the media judged a candidate essentially by how well he or she manipulated them, and one in which the electorate were bystanders.

By this standard, Mr. McCain’s joviality and seeming honesty with the press in 2000 constituted a very effective scheme indeed, until it came time to woo actual Republican voters. As Time’s Jay Carney once put it, “You get the sense you’re being manipulated by candor, rather than manipulated by subterfuge and deception, but it is a strategy.”

What makes 2008 different — and why I think Mr. McCain can be called the first postmodernist presidential candidate — is his acknowledgment of the symbiosis between himself and the press and, more important, his willingness, even eagerness, to let the press in on his own machinations of them. On the bus, Mr. McCain openly talks about his press gambits. According to Mr. Lizza, Mr. McCain proudly brandished an index card with a “gotcha” quote from Mitt Romney that the senator had given Tim Russert of “Meet the Press,” a journalist few would expect to need help in finding candidates’ gaffes. In exposing his two-way relationship with the press this way, he reveals the absurdity of the political process as a big game. He also reveals his own gleeful cynicism about it.

This sort of disdain might be called a liberal view, if not politically then culturally. The notion that our system (in fact, life itself) is faintly imbecilic is a staple of “The Daily Show,” “The Colbert Report,” “Real Time With Bill Maher” and other liberal exemplars, though they, of course, implicate the press in the idiocy. Mr. McCain’s sense of irony makes him their spiritual kin — a cosmological liberal — which may be why conservatives distrust him and liberals like Jon Stewart seem to revere him. They are reacting to something deeper than politics. They are reacting to his vision of how the world operates and to his attitude about it, something it is easy to suspect he acquired while a prisoner of war.

Though Mr. McCain can be the most self-deprecating of candidates (yet another reason the news media love him), his vision of the process also betrays an obvious superiority — one the mainstream political news media, a group of liberal cosmologists, have long shared. If in the past he flattered the press by posing as its friend, he is now flattering it by posing as its conspirator, a secret sharer of its cynicism. He is the guy who “gets it.” He sees what the press sees. Michael Scherer, a blogger for Time, called him the “coolest kid in school.”

The candidates who are dead serious about politics, even wonkish, get abused by the press for it. Mr. McCain the ironist gets heaps of affection. In this race, though, it has forced some press contortions. While John McCain 2000 was praised for being the same straight talker off the bus as he was on it, John McCain 2008 is praised precisely because he isn’t the same man. Off the bus he plays to the rubes (us) by reciting the conservative catechism; on the bus he plays to the press by giving the impression that his talk is all just a ploy to capture the Republican nomination.

Yet the reporters, so quick in general to jump on hypocrisy, seem to find his insincerity a virtue. When an old sobersides like Mitt Romney flip-flops, he is called a panderer. When Mr. McCain suddenly supports the tax cuts he once excoriated, or embraces the religious right, or emphasizes border security over a path to citizenship for illegal immigrants, we are told by his press acolytes that he doesn’t really mean it, that his liberal cosmology will ultimately best his conservative rhetoric. “Discount his repositioning a bit,” Jacob Weisberg, the editor of Slate, wrote two years ago, “and McCain looks like the same unconventional character who emerged during the Clinton years.” The article was subtitled “Psst ... He’s Not Really a Conservative.”

This suggests that love is blind. It also suggests that seducing the press with ironic detachment, the press’s soft spot, may be the best political strategy of all — one that Mr. McCain may walk on water right into the White House.

Neal Gabler is the author, most recently, of “Walt Disney: The Triumph of the American Imagination.”


Copyright 2008 The New York Times Company
Privacy Policy Search Corrections RSS First Look Help Contact Us Work for Us Site Map