Saturday, August 29, 2015

Politics, Technology, and Democracy: The Case of the Electronic Medical Record

I am not an Electronic Medical Record guru. I am a pediatrician. Some people can be both, and we will rely on them for progress in the future. But just because I am not an EMR guru doesn't mean that I should simply receive the EMR as delivered. After all, I am an end user, living and working where the rubber hits the road, caring for patients. (To be fair, I actually see patients only a half day a week at this end stage of my career, so I have time to do things like writing a blog.)

When I was a Harvard undergraduate, I audited a course given by Louis Hartz in American government. He loved to lecture, and loved the overflowing small lecture hall that attested to his enthusiasm and eloquence. I thought he was a treasure, so even though I didn't take the course, it was a good 11 AM time, only a few blocks away from my 10 AM class, and what was Harvard if not a smorgasbord for intellectual pursuits? [Besides which, I recently read on my Heidi Priebe Facebook page, that an Extroverted Intuitive Thinking Perceptive (ENTP) type like me is typified by auditing courses in college. (ENTPs also try to ask embarrassing questions and playing Devil's Advocate, she says, but I didn't do that. Harvard was too intimidating for that. Ok, I did it once in David Riesman's class, but I'm still embarrassed about that to this day.)]

But I digress. Hartz addressed himself directly and cogently to the issue of democracy and governance. Should a populace surrender its authority to technocratic elites (this term actually came later) who are better skilled and better informed to run a government? Not at all, said Hartz. View the populace as passengers on a ship and the governing elite as the captain and crew. It is up to the passengers to determine the destination; it is up to the captain and crew to get them there. The hazard of not having the passengers in charge is that the elite's decisions might serve their own interests primarily.

On the other hand, the technical elite needs to be proactive as well as the passengers. An informed elite can help guide a populace away from xenophobic or Luddite tendencies, for instance, and to sketch a more positive future. In addition, innovation comes from what is possible. Generally a technical innovation appears and then someone else figures out what to do with it. The Ipod was invented when a Japanese team showed Steve Jobs the mini hard disk they had invented; it was Jobs' imagination that translated the new technical possibility to a useful product. We in practice need to hear about the innovations just as Jobs did.

So, I look at the use of EMRs through the Hartzian lens. I might not be an EMR guru, but I know a lot more about treating patients in my specialty of pediatric primary care than most everyone who is an EMR guru. I know better than they do what I need. But, if the gurus have something to say to us users, I'm all ears and eyes.

What is the EMR's equivalent of the elite's having its own ends in mind? It might be the accumulation of clinical data. The technical elite is obsessed with processing data for research. If they could record all the treatments for a clinical condition and trace outcomes through the EMR, wouldn't that be a terrific guide to practice? There have been some successes with this in in-patient care, as my colleague Chris Longhurst at Stanford has pioneered. But in outpatient care we haven't heard of anything yet, and I would predict that the hopes of the researchers will be found to be far overblown when compared to reality. Don't forget, what they are forecasting is lots and lots more work for themselves and their acolytes, and that has to sway their unconscious minds.

A problem here is that there is a conflict: to get all this data, the EMR needs to codify the conditions and the treatments; narrative doesn't help, you need checked boxes. But to get checked boxes, you need a lot of grunt work in coding and checking. Who does all that data entry? The primary care end user, that's who. So we are roped into extreme effort, that according to so many of my colleagues takes hours a day of extra work, all on the speculation that it might somehow be translated into usable research data. The practicing doctors never signed up for this, they were signed up for this. The elite chose it and enforced it. (I'm not mentioning the new coding tool that is being enforced as part of this effort, called ICD 10, which once again has the practicing doctors spending extreme amounts of time and money in becoming ever more specific in checking the boxes – there is a different code for right ear infection vs. left ear infection, for instance, and it's up to the practicing doc to check the right box. Excruciating. And, it is projected that many docs will have to take out lines of credit to tide them over a period of non-collection while the insurance companies and Medicare adjust. Unbelievable. Who signed up for this?)

And meanwhile, what do these EMRs look like to us, the end user? My colleagues, especially the estimable Herschel Lessin, have observed that EMRs look decades out of date – decades! To my mind, the presentation of the patient chart that appears on the screen is not much different from DOS 2.0. It is basically a linear rather than graphical interface. There are lots of lists. What is clear is this: the presentation of the chart is not what I would prescribe for my purposes. It was done to me, not of me, not by me, not for me. The developers wanted those boxes checked. Hartz's elite has dictated the terms.

What would I prescribe for an EMR if asked? Here's my answer:

I have always run an office with the idea that when the clinician comes into the exam room, the table should be set for him or her. Just as you would want in eating a meal, everything you would want should be right there on the table, easy to see and grab. In the days of paper charts, this meant that all labs should be attached to the chart, all order sheets should be readily available and pre-formatted, all handouts already given to the patient and others available to the clinician if wanted, etc. And I always insisted that the idea of all the table setting should be to make it easy for the clinician to do the right thing at the right time.
How would that translate to the EMR? Don't think linear, think pattern; don't think DOS, think Windows. Don't think of lists, think dinner table.
How would I set the table for a well child exam? I would sit at the computer screen and have five or six little windows on the screen, each active so that I could click on it and enlarge it if I wanted, but sharp enough so that I could see it just in its unenlarged window.
One window would be the growth chart -- I could glance at that and see height and weight and know it looked good right from the start. If there were a problem, the window would have a red border to indicate to me that I should look at this closely, and maybe look at it first.
A second window would be the immunizations -- ditto to the comments above for growth chart, and the needed vaccines for this visit would be flashing red. Other comments would also be there as needed - we know what these might be.
A third window would be the narrative from the last visit, with a highlight of what I or the last person to see the child wanted to be checked on the next visit. Enlarging this window would bring up that note, and also give me the capacity with one click to see the narrative from the visit before that, etc.
A fourth window would be something like a problem list, but it would be concerns of the parents in the past, listed by date, and concerns of the clinician in the past, also listed by date.
A fifth window would be today's questionnaires filled out by the patient, with access in this window to questionnaires in the past.
In other words, the EMR would be working for me, I wouldn't be working for the EMR. The patient with me would be served primarily, the research interests would not be the prime consideration. My logic would be imbedded in the computer, the computer's logic would not imbed itself in me.

The unhappy recent history of primary care medicine is that we have been left in the shadows. I have documented elsewhere that recent surge of High Deductible Health Plans has put the interests of both working class patients and primary care physicians – the least powerful interests in the health care industry – last. The development of EMRs is just another instance, I'm afraid, of the same political imbalance.

Many will say to this point that it's not political, but in the immortal words of Bill Murray in Ghostbusters, “It's technical.” Me, I doubt it. Politics is life, and often unconsciously, the more powerful always put their interests first, often with the belief that if only others knew what they knew, they would agree. Me, I doubt it.

What will be the solution? American economic thought has always placed reliance on competition to make progress. The problem is, however, that as health systems get bigger, they ally with an EMR product, increasingly the Epic product, and while it is powerful, Epic is “by engineers, for engineers.” And most importantly for development and innovation, Epic is an anti-competitive enterprise.

Ideally, Epic would be a framework for all parts of a medical network, and the individual components would be subject to competition. That would mean that a pediatric practice that was a member of a network would be able to choose for itself either the embedded Epic pediatric product, or another competitive pediatric product that would fit into the overall Epic system seamlessly. That would be real competition; that would lead to progress. But as Paul Levy has just pointed out, anti-competitive behavior is what we are seeing instead. The problem is that Epic loves being a monopolist. Epic does not play well with others.

Well, this was a long blog entry – sorry! But the overall picture of practice is of rapid corporatization. If we are preserve the most essential components of medical practice as we have known it, a close connection of doctor to patient, the practicing doctors will need to rise up and lead. There are current courses available in medical leadership. Docs need to take those courses and take them to heart.

And they could do worse than to read Louis Hartz, The Liberal Tradition in America.

Budd Shenkin

Friday, August 28, 2015

Modernizing the Medical Office

I sold my practice, Bayside Medical Group, to Stanford two and a half years ago. It was time for me to sell, and Stanford has oodles of cash, which I thought would bode well for both staff and patients, and they are technology oriented, which I thought was necessary. What I couldn't avoid, and I knew I couldn't, was the fact that the buyer was a hospital, an academic hospital, a bureaucracy, a corporation. No way around it.

Today I picked up granddaughter Lola at Bayside after her last visit for shots before going to kindergarten. The visit went well, aside from the fact that her screaming over this one shot raised the dead over a significant area of Alameda, although the cri de coeur ceased immediately upon being offered princess stickers. While waiting for her, I visited with several of my younger former colleagues back in the clinicians' office. “How's it going?” I asked.

Well, actually, that's not what I said. What I said was, “How's it going with the electronic medical record?” They have had it for over a year now. My pediatric colleague said, “I hate it.” It takes her several hours more a day to do her work, and the number of patients she can see has decreased. (I had heard from another younger former colleague that because of this decreased productivity, many of the clinicians had had their salaries reduced this year.) The EMR program, called Epic, is a very unintuitive program, which is to say it's hard to figure out what is where and what you need to do to get done what you want to do. It is person vs. machine. My colleague said that she had hoped that as she became more familiar with it she would get faster and it would help her work. But she says she still feels at times like kicking it and putting a knife into it. And she said that if I wanted to hear more, I could ask the other colleague who was seeing Lola, who is a more outspoken sort. I passed.

I had delayed adopting an EMR for Bayside because I knew it would be hard and expensive, and that the investment would have a negative financial payoff. So I wisely put it off for someone else to suffer with it. If I had done it, it would have ruined my life.

Then I spotted a new phone in the office. “Is that a new phone system?” I asked a colleague from the Family Practice side.

“Yup,” she said.

“How is it?” I asked.

“It sucks,” she said.

Seems that in introducing the new system they reduced the number of lines into the office. After six rings – which should never ever happen – the Stanford operator down in Palo Alto picks up, takes a message, and then calls the message into the office. Takes time, but at least the message isn't missed. Other times, the patient records a message on the phone, and can ramble on and on and on, and then the message is forgotten and missed on this system, and if it is found, it takes forever to listen to.

This modern phone system also requires that if you are on a call and want to transfer it to someone else, you need to know the exact number of the station to transfer it to, you have to look that up, and then when you make that transfer you have no assurance that the person is actually sitting at the desk where you transferred it to. In an office office, they are usually at their desk; in a medical office, of course, not so. So what happens here now is, you transfer the call to the station you need the patient to reach, and then you run – literally run – down the hall yelling for that person to get to the desk and pick up the call.

I had heard from another colleague previously when I saw him for my own check up that the phone system was so bad he had lost patients, and had started giving out his personal cell phone number instead of the office number to many of his patients.

So the phone system sucks. But besides obvious consequence for patients and staff, on top of that, the Stanford administrators award (or don't award) clinical staff a bonus depending on the ratings given by patients to the office they work in. The administration this year declared they were not giving bonus to this office because of patients' negative rating. But if you looked at the patients' ratings, what they downgraded was not the clinicians, but the phone system! When this was pointed out to administration, they replied that , even though they were the ones responsible for a new phone system, the clinicians ought to be able to find a way to make a fix for each patient nonetheless.

I guess you could call that creative decentralization. Or you could call it absolute administrative bullshit. In any case, they eventually relented and the clinicians got their bonus.

My colleague said that on the positive side, things did seem to be getting better over the past six months, and administration is learning to listen, albeit reluctantly. She said there was just a learning curve on each side, on the administration side because they don't know outpatient medicine. I'm not sure what the learning curve is all about on the clinician side. Hard to tell.

Larger groups practicing medicine are inevitable. More capital is needed, more improvements, hopefully not just to cope with administrative, regulatory bullshit, and hopefully not just so that the larger groups can garner better insurance contracts. It's clear that to run a quality practice, a lot of effort and learning needs to be applied. In this practice and with this hospital system so far, I'd say there is far more heat than light, not heated anger, just needless friction as the necessary skilled minds don't appear to be at the table. I'm hoping it will happen eventually, I'm hoping that there is a lot of “team-building” going on, but when it comes down to it, what you are really looking for is intelligence and experience. I'm not on the inside so I don't know, but I'd say they are still looking for the proper components so far.

They are lucky that no one else in the community appears to be doing any better.

Budd Shenkin

Saturday, August 22, 2015

No Two-State Solution

Peter Beinart is a terrific liberal commentator on many issues, among them the Israeli-Palestinian quandary. In this week's New York Times book review, Beinart reviews Padraig O'Malley's new book, The Two-State Delusion. It sounds like quite a good book. O'Malley asserts that when Israelis and Palestinians talk about the two-state solution, they envision very different things. The Palestinians think about a truly independent state; the Israelis envision a state with no teeth, so that Israel would be safe. O'Malley thinks the Israelis are wise to think as they do, because Hamas would truly view a new state as a stepping stone to total expulsion of the Jews.

Further, the Israelis have denuded the Palestinian lands of 800,000 olive trees, and since the Palestinians have not replaced olive trees with other economic activity, very little economic viability would be left to them. The governance of the Arab lands is so poor that little could be expected of Palestinian uplift. They cannot desalinate water, which is crucial; 50% of the Palestinian budget is for public employment; they cannot collect taxes. There is more, but basically O'Malley says, it's just a no go, no matter how close officials claim to have been in the past to settling on a two-state solution.

Good as the book is, however, Beinart bemoans the fact the O'Malley has no alternative solution to offer. O'Malley says, “Why should I be so presumptuous as to dare to provide a vision for people who refuse to provide one for themselves?” Don't leave us like this!, Beinart says. We need a solution! Not that anyone has one, because no one does.

Myself, I am suspicious of “solutions.” “Solutions” are an end result, a formulation. There is none here, because the forces as they stand preclude one. So, instead of trying to think of a solution, we need to find a pathway.

Readers of this blog might remember that, although it is a modest step, I offered a pathway in my blog on the Israeli-Palestinian quandary from February of this year:

In it, I recommend that Israel start an affirmative action program for Arabs within its borders as a first step, a pathway toward a solution. It's basically a “do the right thing” approach. Start treating people right, advance them, show them a good life path – issue birth control, for a start, so that the Palestinian strategy of “have as many children as possible and then don't educate them can come to an end, I wish one could make it mandatory – and see what comes next.

It's a cultural issue as well as a political issue, and cultural issues are very hard to solve. Cultures change slowly. But there exist germs of reconciliation in both Arab and Israeli communities. There are Arabs who do fairly well in Israel as it is. There are many Israelis who are not racist and would give individual Arabs a fair chance. This is always the way. People actually have their good sides, they just need government to foster that good side.

Smart as Beinart is, and I like him a lot, he needs to see that a pathway to an unknown future starts with changing the conditions on the ground, hard as that may be to do. Twenty years from now the future could look a lot different from how it looks today. Thinks steps, not finality.

Budd Shenkin

Friday, August 21, 2015

The American Constitution -- What a Story!

“The Articles of Confederation were found insufficient and were replaced by the Constitution.” That's it, that's what I remembered from Mr. Abrams' high school American history course at Lower Merion High, and that's what I knew. Then it was on to the Civil War!

Yes, I had been a history major at Harvard (or history “concentrator,” as Harvard so preciously termed it, can't be like everyone else, can you?), but I studied mostly medieval and modern European history, especially French history. I figured I wanted to be An Educated Man, which is a lifetime's work, so starting at the beginnings of the modern world, and thus starting with the Old World continent of Europe, and not being seduced by American chauvinism, made sense. And in so doing I missed what is probably the most important governmental revolution in modern history. All these years later, it seems that being interested in American history isn't so chauvinistic at all. Maybe American exceptionalism has a point.

I'm having this late epiphany from reading Joseph Ellis' great new book, The Quartet: Orchestrating the Second American Revolution 1783-1789. The specific time was important, because “... the Founders occupied a transitional moment in the history of Western civilization that was postaristocratic and predemocratic.” How long had aristocratic civilization lasted? At least centuries, and I really think millennia. There was no precedent for the large scale republican democracy which began with the American Revolution. And amazingly enough, the Founders found the answer, or rather, invented it. Reading the history of this period it's hard not to believe in the Great Man theory of history, or in this case, Great Men. Maybe Margaret Mead's was right when she famously said that “A small group of thoughtful people could change the world. Indeed, it's the only thing that ever has.”

The 1776 revolution was undeniably great and heroic, no question. But in terms of significance for the future, that part of the revolution wasn't really the big one. The first one cast off the past, as most revolutionaries were fighting for “freedom from” oppression of Mother England. But casting off the past only gets you so far. The really big deal was inventing the future, and that's what happened after the war, from 1783-1789. The American Constitution in fact really was one of the most significant advances (culture bound judgement, perhaps, OK) in world history, and the Articles of Confederation weren't, not at all.

Inventing a Future

“Inventing a future” is such an interesting concept. Talk about something really hard to do. The best guide to the future is the present, because that is actual, something that has a chance of being true because it is true, and because people stick to habit. The past was once true, so that is another realistic guide, although it's problematic if a past could be true again. I think thesis-antithesis-synthesis is probably a better guide than return-to-the-past. But still, some groups look at the present and prefer the past – think Islamic State. Some groups minimize the past and the present and think of a distant future where “everything will be different.” Think Communism with the “new man,” think science fiction. Some despair of future and past and see the present as the only alternative. Think Luddites, I guess. Some just resist speculation and don't think about the future significantly. Think most of us.

The whole concept of a progressive future is unique in itself, I have read. Cultural historians tell us that most traditional societies see the world as unchanging, or at best cyclic. They say that it took the Hebrews (and the Christians) to envision progress and a future, and the Enlightenment to base it on factual understanding, analysis, and even science. A reading of history shows us that most change has be borne of the desire to conquer others, not to bring more justice to the world. Think modern miracle, the United States Constitution. (Although it has to be said, conquering the West and its Indians was central to the Quartet's thought.)

How the Quartet Evaluated the Confederation and Invented the Future

The Great Men, Mead's “small group” were Washington, Hamilton, John Jay, and Madison. Their experience during the Revolutionary War and under the Articles of Confederation showed from their individual experience how glaringly obvious it was that the Confederation could not work. Remember Valley Forge? Why were the ragtag Washington forces starving and freezing? Because Congress couldn't raise the money from the states to support them! Taxes were “voluntary!” These four saw how far that went, especially Washington and his Adjutant, Hamilton.

Jay negotiated the Peace of Paris in 1783 representing a fictitious entity, the United States of America. There was no such entity at all! Jay's genius was to make it up, and then to disobey the orders of the Congress (hey, they were six weeks away) and not include the French and the Spanish in the treaty making as he had been ordered, because he saw he could get a better deal just dealing with the British, who were willing to cede land up to the Mississippi, which the self-interested Spanish and French were not. Jay also saw how the states would take their own advantage from his station in New York. The State of New York under Governor George Clinton ignored the terms of the Treaty of Paris and confiscated the estates of Tories in New York, and they imposed state duties in the busy harbor of New York no matter what the Confederation said. Jay knew a confederation wouldn't work.

And to skip ahead to Madison's final arguments in the Constitutional Congress, he argued successfully against the immensely eloquent Patrick Henry that the entire world's history of confederations was an unending tale of failure, of discord, of dismemberment, boringly time and time again. Confederations fell apart, they were picked off by larger countries, and they disappeared. This was not what the revolutionary generation had fought for. The Quartet had sunk costs in the founding and they were damned if they were going to see their work go for naught, and that prospect of investment going for naught was was exactly what they saw right before their eyes.

Indeed, the Confederation was so weak it was hard to get a quorum! The notables of the states had better things to do than to attend the meetings of something that didn't mean much to them, that they intended to ignore anyway. There was a need to regulate interstate commerce (interesting how this very issue persists in the history of federalism, as we know, up to the present day.) Hamilton got the Confederation to call a special meeting in Annapolis to attack the problem, and there was no quorum. Rather than give up, the brilliant and audacious Hamilton got this rump body to call for the Confederation to consider how to change and strengthen themselves by a special meeting of the Confederation just for that purpose. (How they are deciding to take this guy off the ten dollar bill is a bureaucratic outrage, because, Jacob Lew says, it's the ten dollar bill's turn to be redone and they need to put a woman, any woman, “somewhere.” What have we come to, one wonders? But onward)

What chutzpah! What a coup! What a man.

And then meet they did, finally achieving a quorum, although Rhode Island, and I hadn't known this, continued its passive aggressiveness by not showing up once again. No matter. As always, the great movement turned on the intricacies of politics. Washington was very hesitant to join the meeting, because he feared that his prestige would collapse against the mounted up small minds devoted to the Luxembourgian model of small states. There would be those who wanted no change – a majority – and those who wanted to strengthen the Articles a bit, and a smaller radical faction who wanted to dump the Articles and start over. They feared the first faction would be predominant and Washington was opting out of that failure preemtively.

But Madison, who corresponded endlessly with confederates and friends in the various states, discerned a chance. The first faction, the conservatives who wanted no change, would not dignify the proceedings by their presence – one wonders if the Russians regret their boycotting the UN so the Security Council could declare a police action in Korea! The Quartet saw a chance, and Madison and Hamilton convinced Washington that his sunk costs and his posterity would only be honored by taking this chance.

Writing and Passing the New Constitution

So meet they did, in Philadelphia in the very same room where the Declaration of Independence was produced, a not so coincidental reminder of momentous work to be done. It was a foregone conclusion that Washington, the greatest man in America, would be in the chair. Again, it's really hard not to believe in the Great Man theory when you read this stuff.

At the Constitutional Convention, the policy argument was carried by many, but the spark plug was Madison. (Although let it be said, since I'm still a loyal Philadelphia native, that it was Pennsylvania's Gouverneur Morris who actually wrote the thing, and it was he alone who changed the Preamble from “We the States” to “We the People,” to quiet assent from Madison, with momentous theoretical consequences.) Madison worked harder than anyone, arriving at the convention with the Virginia Plan. He who produces the first draft has the momentum. While the Constitution was revolutionary, it also built on English and American precedents, and especially English political theory. To appreciate how indigenous it was, is to understand how one can't just up and create a constitution in a place that doesn't have established habits of working that comport with the new creation (any chance for the Iraq constitution, I wonder?) It was especially difficult to span the gulf between states' rights and federal rights, and in many ways it an agreement of the delegates simply couldn't be reached. Therefore, what Madison brilliantly did was to be vague, and to say in effect that much of this would be decided “later,” when specific cases arose. Thus, Ellis states, Scalia's “originalism” is a chimeric vision of what never was. (Here, here.) Madison thought his compromise was a failure, but in fact the resulting federalism, with its flexibility, might have been one of the great inventions of all time in governance.

His most brilliant theoretical invention, perhaps, was the vision enunciated in the famous Federalist 10. (After Harvard I didn't stop studying, and when I was in Washington with the US Public Health Service I took a class in American Political Theory at Georgetown, so Federalist 10 was of course fully discussed there. Interestingly, though, the genius of this invention was not highlighted – that had to come to me from Ellis.) Montesquieu had thought that democracy was only possible in small areas where everyone knew each other, but Madison's insight was that democracy would actually work better in a larger state than a smaller one, because interests would balance one another out, whereas in a smaller arena a tyranny of a majority was much more possible and dangerous. It actually sounds like a rationalization, because they wanted a republic, and they saw that large size was crucial, but how to reconcile that dilemma with Montesquieu's opinion? Answer: have another opinion. But, genius seems to have worked.

And as for politics, no matter how lofty the achievement of public policy, in the end it still needs to be pushed through the political sausage machine. Just read Robert Caro's The Passage of Power to see how great legislation turns on powerful sponsors who attune their efforts to each small center of power. Clearly, the Quartet's politics in convening the Constitutional Convention was superbly orchestrated. Passing the Constitution also required clever politics, and the Quartet found that they still had it in them. For instance, even though the Articles said that all issues had to be approved unanimously to take effect, the Convention declared that if nine states ratified the new Constitution it would be declared passed. They just did it, against the rules. How this got done, I'm not sure, but it had to be done, obviously, so they did it.

Then they did something more – they fast-tracked it. They said that the states could only vote it up or down, and not amend it. Wow! It turned out that the states went ahead and did send in amendments anyway, but the Convention had leeway to handle them without rules, only with political sensitivity. They used their freedom of action responsibly, cutting down the dozens of amendments to just 10, as we know – I think this is the reason, by the way, that although many different clauses are put together in the various amendments as though they fit together logically, they really don't, it's sometimes just a list of items. We all know that the Bill of Rights came after the Constitution was written, and we think that it was Jefferson who wrote them. Nope. Jefferson wrote from Paris that he thought a Bill of Rights was a good idea, but basically, they were written with politics in mind, to assuage the opinions of the consenting states. Again, necessity breeds genius.

But that was after the fact. To jump backwards, the first problem was to get the Constitution passed, and they recognized the difficulty of doing so since the largest and most powerful states, Virginia and New York, looked to be set against it. But, Jay could manipulate some of the delegates in New York despite Governor Clinton's powerful opposition, that was one good thing. The second good thing was the power of the calendar. By God's good grace, the states that were inclined to vote for the Constitution decided on their own to hold their state conventions before those who looked to be against it. Since it only took nine to pass, the states who came later, if it had already been passed by nine states, would face the choice of joining the union and being powerful within it, or staying outside and being isolated. It seems luck played a role, as it always does, ask Lefty Gomez.

Then it came down to Maryland to be the ninth state to ratify. It was crucial that they do so. But they dithered, and were about to vote to disband the convention and come together later. This word was relayed to Washington, and he did a wonderful thing. He simply wrote to them and suggested that they not disband and that they vote at once. Ellis writes that a suggestion from Washington was regarded at this time as a virtual order from on high, so they duly voted in the Constitution. Then, under pressure of being left out, the others followed, even, eventually, little Rhodie.

So, as I said, the Articles of Confederation were found inadequate and had to be replaced, so replaced they were. On to the Civil War! Where, let us remember, we heard that “a new nation, conceived in liberty, and dedicated to the proposition that all man were created equal.” (not really, Ellis says, it wasn't a new nation for some time.) But, truly, “testing whether that nation, or any nation so conceived and so dedicated, can long endure.” Ah now, that was quite true. So conceived and so dedicated – basically, by the Quartet.

Difference from the French Revolution

I started out studying European and French history, thinking this it was more basic knowledge for an Educated Man. But it turns out that going back to the American Revolution helps me understand France. I'm almost through another book, a longer book, an 800 pager, Napoleon, A Life, by Andrew Roberts. For the first time I think I now understand the 1789-1815 era in France. I sure understand why the Americans wanted to stay away from the unending European wars! And I think I can now answer the examination question: Napoleon – embodiment of the French Revolution or death of it?

America was a middle class nation, and the aristocracy they had wasn't anything like the aristocracy in France. So France had work to do that America didn't – equality before the law, get rid of the wealth and power of the church, establish meritocracy. They did that, and it was a huge achievement, plus the agenda of the Enlightenment, such as recognizing science, regularizing law in the Code Napoleon, the metric system (which Napoleon himself didn't like) and a lot more.

But what France didn't have so much as America had was a powerful parliament as background, and English common law, and English political thought. They also didn't have an American Cincinnatus named George Washington. As a consequence, Napoleon made society better, he made government better by rationalizing it and introducing meritocracy, but as he faced the opposition of the Old Order in Europe, he became like them, pressing the national interests of France against them, but acting just like them and even becoming an Emporer.

So, Napoleon was the embodiment of the Revolution in one way, but in another, because the revolutionaries couldn't come up with a decent form of government themselves, he was was the death of it.

Interesting that when I asked Mr. Warren, my high school Modern History teacher, what was the most important thing of what we were studying, he said, look at what we spent the most time on. It was the French Revolution. I took it from there and regarded that revolution as the key to the modern world. But now I think that, although America was a sidelight in the world at the time, and great as the French Revolution was, when it comes to government, the big deal was the American Revolution.

Budd Shenkin

Thursday, August 20, 2015

Black Lives Matter

“Black Lives Matter.” Yup, good slogan. Slogans need to be succinct. Good slogan.

But like all slogans, along with concision comes simplification. There is more than one issue here. There is police racism, treating people of color differently from so-called white people. There is general racism, which means that society allows the police racism to continue.

But isn't there more? Does BLM imply that police treat white people just fine, but not black people? Doesn't BLM imply “Black Lives Matter, too?” I think so.

Would that stand scrutiny, do you think? Seems to me that police actions against the underclass whites can be pretty brutal in themselves – and even non-underclass whites. How many times have cops stormed an apartment, knocking down the doors, coming in full force, and then said, “Whoops! Wrong apartment!” And then left without cleaning up anything for recompensing anyone for their mayhem? When the Stockton police shot 600 rounds for a bank robbery and killed an innocent lady making a deposit recently, it wasn't race, it was poor leadership and probably poor training, and who knows what personal “weaknesses” in the police. Didn't hear much about BLM after this outrage.

And of course, generalizing to “police” is a pretty broad indictment. Show of force is often necessary; it's a tough job. Probably 10% are “bad cops,” varying from place to place. And place matters; some police forces are pretty good, although we know that Ferguson is clearly a place with a bad police force and bad racist government. Same in Cleveland, and Baltimore. LA seems to have cleaned up its act considerably since the bad old days of Darryl Gates. It varies.

When some politicians respond that “All Lives Matter,” it is another compacted statement. ALM might imply that maybe it's not so much racism as police actions in general. Of course there are political ramifications to saying ALM – need the white vote, after all, can't be captured by the militants, and ALM is a lot weaker than BLM, so ALM is a way for politicians to convey agreement with the general thrust and yet not be so accusatory. Opposition to the militarization of police has garnered pretty wide support.

So of course Black Lives Matter, and of course All Lives Matter. Let both of the slogans lie out there, and then let the DOJ and others work the problem day after day, demilitarize, consciousness raise, purge some departments actively, have civilian review – and most importantly long range, open up education and economic opportunity so that the underclass becomes the middle class as much as possible. 

Sorry to be so anodyne, but there it is.

Budd Shenkin

Monday, August 10, 2015

Well, Climate Change Isn't All Bad

Joblessness is a problem. Some can be ascribed to offshoring, but much of it also to increases in productivity, such as robotics, and also to the economic maturity of our country, because so much of the housing stock is already in place, for instance. Every level is affected, but it's working people, people who do physical jobs without a lot of high level thought, that are the most affected. Solutions to increase the education of these workers are destined to be only partially effective, since there is a bell curve of intelligence.

Since general wealth has increased, and the biggest problem seems to be wealth disparities, I have thought that we need to disconnect income from jobs somehow, although still maintain incentives, which is a hard task. It's not a new thought; this is what the utopian socialists thought about in their ideas of constructing the perfect societies. Leisure and play were at the heart of their proposals, although as Gay Talese pointed out, in practice sexual rights and license took a part of their rituals that did not appear in the written prospectus. But be that as it may, the idea was that life should be happy, and hard and constant work was not necessarily a great idea for everyone.

But, clearly, detaching work from wealth is a hard job. When societies such as the Dutch and Danish have tried to do that, they have found freeloading a huge problem. Even with low levels of support as we had in the US before welfare reform, expectations of sitting around and having kids and not having to work were confounding.

The history of the world, however, shows us that while ideas have a place in progress, even more powerful are unforeseen events and connections. Let's consider our number one Unintended Consequence, climate change. It's not just coming, it's here, and there are lots of troubles and displacements pending. We think first, how can we avoid what is coming, how can we abate temperature rising? Well, given the proclivities of manking, the shortsightedness and me-firstism that prevails, we probably can't, no matter how dire though the consequences in a severely illness of the planet vis-a-vis lifeforms. Some preventive steps will be taken and some will be effective, but it's hard to think how enough will be done.

But challenge is opportunity. Won't climate change require lots of work on the part of society? Thinkers will need to invent. We already see the capitalistic system working on products to decrease energy use, and that's just the start. And unlike the job-destroying change of modern productivity increases, the era of climate change will need actual, hands on workers a lot. Not just to install solar panels, but to build dikes! There will be so much actual construction that we will be likely to run out of workers. The most afflicted areas will be job-spawners – Florida will have another job renaissance.

The world might be going to hell, but at least there will be jobs.

So, I'm not thinking about utopia much any more.

Budd Shenkin