Tuesday, July 31, 2018

Trump Doesn't Care About Lies, He's Crafting An Image

E.J. Dionne's latest column bemoans once again that Trump's habitual violations of truth are his way of life. E.J.'s introduction to his column on Twitter:

For #Trump, a lie is as good as the truth, as long as a majority of his base believes it. He buries old falsehoods under new ones. And when it comes to creating new and unhinged narratives to displace those rooted in fact, Trump has no equal. My column:

Agreeing with him, I answered his tweet with my own 140 characters: “Good. But need to look at real game he's playing. It's show-biz. How do I look? Aggressive? In charge? Determined? Declare 'this is for you' and there's the image. People buy image more than logic. The challenge: Can Dems counter? Need better image, not better facts.”

OK, that's the gist of it. But, because the subject is so pressing, let me lay it out in 1,380 words rather than 140 characters.

First, there is a conflict between what Trump does and what the commentariat wants him to do because there are two different games being played. The commentariat – and people like me – admire politicians who make governing for the good of the country their number one goal. Running for office is their necessary prerequisite for governing. Communicating with the electorate and the commentariat needs to be more or less truthful, because that is part of good governance. We flatter ourselves that good communication and discussion leads to better policies supported by the country.

But it's obvious that Trump's game is much different. I doubt that he has any conception of the common good or the good of the country. His primary goal in life is “to win” and be seen as a winner. Winning an election is great, but making money is the true measure of winning, and scoring with women another indication of a winner. (That's the only mention of sex here; I felt I had to mention it to be complete, but we'll let it lie there.)

Everyone has a mix of motives in trying to be President, but few have Trump's particular balance. Few also have the tools that Trump brings to the task. He has long experience with the slime world of tabloids, he is a clever schoolyard bully, he channels the Borsht Belt as an entertainer, and he knows reality TV really well. With these tools, he can craft an image. That's what Trump really does, that's his major number one concern – what kind of image is he crafting. He wants to be seen as being in charge, of being a hero, of being bold, of fighting against enemies, and destroying what seems artificial and elite.

So that's his game – he wants to create that image. Everything else is secondary (except making money; even if the image fails at some point, if he's made a lot of money that he can keep, he's still a winner.)

(As an aside, this image probably also has psychic resonance to him, since as a pediatrician I think he probably suffered and continues to suffer from the childhood condition of oppositional-defiant disorder [https://www.mayoclinic.org/diseases-conditions/oppositional-defiant-disorder/symptoms-causes/syc-20375831]. [Others say it's tertiary syphilis, and it could be, given his prior medical care, but I'll pass over that for now.] There are probably many other complexes developed in childhood that continue to manifest themselves in him, that lead to his wanting to destroy, but that's not necessary for this analysis.)

So, if that's your goal, why tell the truth? That is so secondary. Keep the image going the way you would on a TV show, keep it moving, go side to side, keep everyone occupied. If the country as a whole understood the issues, followed the issues well, and judged by logic, he'd be a dead man. But not everyone does. Most people go by images. That's what they vote for, images. Probably includes you and me, as much as we might think otherwise. I think you get the picture.

The next question is, what to do about it if you are a politician opposing him, and if you are part of the media? First the media and commentariat: I'd stop saying “this is not normal.” The best disinfectant is sunlight, so apply sunlight. If I ran MSNBC, for instance, I'd divide my commentary into sections. I would fully and continually expose what Trump is doing – he is creating an image. I'd run 10 minute segments regularly as “Image Time,” as opposed to the slightly longer segment on policy, and the very much longer segment on horserace time. On “Image Time,” I would have real pros as the commentariat. Who's that? Perhaps reality TV producers; perhaps some political consultants who specialize in image. Perhaps some fiction writers. Scriptwriters. Not psychologists, not policy analysts. Limn how he's crafting his image, what he's doing, what he's aiming for – and how others are either aiding him or aping him or reacting to him otherwise. How is he controlling the show. There would be no need to judge whether or not what he's doing is a good thing, just report it straight.

It would also be interesting on Image Time to look how others are doing with their images – Pelosi, Schumer, all the old and the young. Especially the newly-emergent Dems, and especially the new younger women as they emerge. Just show-biz image coverage, not whether or not their plans make sense or whether or not they are telling the truth. Do they convey images that would lead voters to lay their trust in them, or are they turnoffs? Real, professional opinions, maybe backed by surveys and such. Wouldn't that be fascinating?

While all the professionals know that this is element is there, I have a feeling they currently don't know quite how to deal with it. They may think that if they get too far into it, they will be devaluing the serious policy and politics issues it is their job to elucidate. So, I put it to you commentariat – face it head on, establish a separate section where you are looking just at image, and then you can leave your serious discussions of policy and politics unsullied by the show-biz element.

Then for the politicians. You, too, have to look at the image issue squarely, both as it is used by Trump and how you use it. It's very helpful for you, too, to set image as an issue to be discussed. You can say, here's Trump's image, unfettered, strong, decisive, innovative, unafraid, etc. You can imitate the jut of his jaw if you like. Doing this is making a meta-communication, reflecting on the current process. This is what Chris Christy did so effectively in destroying Rubio on stage – he just repeats his memorized bits, said Christy, and as a gift to him that startled him and us, Rubio delivered just such a bit. Over and out for Rubio; it will be replayed for years, I'd guess, at least if opponents are smart. That's the power of a meta-communication.

And then, having dealt with that, you can say, that's what he says and how he poses, but is that really what he does? I personally would then use Mitt Romney's statement about Trump: He's a phony, a fraud. Mitt gets a lot of things wrong, I'd say, but this one he nailed. Having done that, the door is then open for the facts. Facts themselves cannot win the day, but when mixed with a meta-communication, they have a better chance. It should make for great short ads.

And then comes the hard part for the Dems – fixing yourself. Given the fact that image presentation and communication is such an important part of the job, it's amazing how amateurish so many professional pols are. Could they maybe take some acting lessons? I did that years ago and I never learned so much about others and myself. Just learn what an acting “action” is, what effect are you trying to have on the others, and you would go far. Don't think that just because Trump is hateful he doesn't have something to teach, because he does.

OK, that's pretty much it. I could go on – I have loads of paragraphs on the cutting room floor, and that would solidify my image of prolixity – but I won't.

What do you think? Makes sense to me.

Budd Shenkin

Monday, July 23, 2018

Pediatrics -- The Persistent Problem of Connecting Academia to Practice

Many of my readers are medical types.  This might be of interest to you people, especially the pediatricians.  50 years ago, Robert Haggerty and a colleague published one of his most important articles in the Journal of Pediatrics.  As a professor, Haggerty took the unusual step of investigating practitioners in his area, to see what their perspective was, what their problems were, how well they felt prepared for practice by their teaching programs, and how they handled what he had labelled the "new morbidities."  He had postulated that as acute disease became less of a problem, chronic diseases and social concerns would come to constitute more of pediatric practice, and that training programs should concentrate more on these issues.

Michael was asked to comment on this paper and he brought me in as his colleague, since I am older and remember that era personally, and since I have been in practice and Michael has been an academic so we can cover both sides of the ledger.  What we found -- and comments are yet to come in, and I will not be surprised to hear from lots of academics telling us that we don't understand how much things have changed -- was that the article largely describes the world today as much as it described it 50 years ago.  The emphasis of training program is still largely on science and in-patient services, hi-tech and rare diseases, and primary care is still neglected.  50 years ago practice was largely organized in quite small groups, and training programs didn't do much to help their residents learn how to run such practices.  Today, with practice largely organized into larger groups and hospital owned and other owned practices, there is still precious little teaching of how a pediatrician can exert leadership in such a group, and if one is not to be a leader, at least how one can understand the workings of organizations.  The unhappy consequence of this lack of preparation might be that leadership passes to non-clinical hands, to administrators, who will inevitably have different approaches and different understandings about practice, not to mention different ethics.

With that as introduction, here is what we wrote:

50 Years Ago
50 Years Ago in The Journal of Pediatrics: General Pediatrics: A Study of Practice in the Mid-1960's

Hessel SJ, Haggerty RJ. J Pediatr 1968;73:271-9

Fifty years ago, Hessel and Haggerty bridged the town-and-gown divide by surveying their surrounding primary care practices. Unlike today, 50 years ago male pediatricians predominated, most practices were small, and house calls were common. Most impressive, however, is what has not changed in 50 years.

The article describes a busy primary care enterprise that was gradually seeing fewer acute problems, leaving the chronic problems for hospital clinics, concentrating more on preventive visits, and struggling to deal with the so-called “new pediatrics,” which featured psychosocial, behavioral, and learning problems. The practitioners felt unprepared to handle these issues and ill-prepared for office management. The authors called for improved training to meet the challenges of the new morbidities, to run offices efficiently, to incorporate paraprofessionals, and to help practitioners get involved with community programs, especially for the underserved.

The continuation of these trends today underscores the prescience of Hessel and Haggerty, especially as vaccines reduce once-common acute conditions. Prevention is more advanced but is still a challenge. The “new” morbidities still plague primary care, with obesity and anxiety as additional components. Residency programs still undereducate on these problems and neglect administrative training. The primary care system struggles with population health.

The researchers hoped that “planning” would bring progress. That hope was not fulfilled. Instead of planning, the 2 major influences on primary care practice are what residency programs inculcate during training and the priorities enforced by third-party payment policies. Residency training is important: young pediatricians look for what they know, and fix what they know how to fix. But even with training reform, new skills will not bear fruit until payers find ways to redress the inequities of a payment system that underpays cognition and prevention. An organization needs to get paid for what it does.

Knowledge has always guided action. The more that academic pediatricians involve themselves in practice-based research similar to this classic study, the more they can identify ways for pediatricians to be effective in everyday modern practice, find effective measures of value to guide activities and payment, impact primary care outcomes, and promote needed primary care change.

Budd Shenkin

Saturday, July 21, 2018

Red Tide Out, Blue Wave In

If something can't last forever, it won't. That's an economics/stock market truism; the problem always is, when will it stop lasting? Many a person has gotten the first point right but missed the second point and gone bust. Timing is everything for hitters, comedians and traders, and some people have it and some people don't. The pundits got it wrong for over a year with Trump, so they're hesitant to step up now.  There's a lot of tentativeness around.

So it is with full knowledge of the hazards of prediction, with full knowledge of the stock market saying “Nobody rings a bell at the top,” that I say that I think we've seen the top of Trump, at long last. It might have been when the tax bill finally passed and the Trump Crime Family got their biggest payoff. That might have been the top. We know that he could shoot somebody in broad daylight in the middle of Fifth Avenue and get away with it, but time and the tides wait for no man, and the tide might have finally turned. As we sit here watching TV and our Twitter feeds, just as one sits drink in hand and watches the sea, we might just be seeing an inkling, and who knows if it's simply a short-term pullback before another advance, but I think it's the tide turning, not just a momentary lapse in momentum. 

We'll have to see a few further events. Does Kavanaugh really get roughed up? Does a Putin visit provoke a profound reaction? Does registration of millennials advance significantly? Do other unforeseeable events signal a profound retracement of the Trump takeover of the Republican party and the government? Or, does it just become more visible that there is a cadre of senior officials who are providing a significant defense to Trump from within the government, and people start wanting to align with them? Something will happen sometime and people will say “that was it,” but there was always going to be something that was “it,” because sometime it us just going to be, time's up, Mr. Man.

If I'm right, that we have hit the top, what we'll see now is some gradual erosion, lessening of the shock of Trump tirades and outrages, and some small erosions of support here and there. The conservative columnists are increasing their defections. Polls might not show marked decreases of support, but they will stop showing upticks. And then, if the tide is really running out, the next major event would be a big wave that would come in after the tide went out, and instead of a Red one, it will be a Blue Wave. Then we'll know. The Dems would take the House by a significant margin. Not only would the disadvantaged Dems not lose seats in the Senate, they would gain control, and knock Obnoxious Ted out of the Texas seat. Red Tide out, Blue Wave in – that's when it will become evident that the tide has turned. That's when it will seem that Trump has been an aberration and not a long term trend.

One hopes, of course, that it will happen that way, Red Tide out, Blue Wave in. But like any human event and any stock market, nothing is written in stone. It may be that the top has been reached, but it takes a long time to reverse; gains are not made, but neither are significant losses incurred, and a holding pattern ensues with stagnation. Or it may be that we are in for far more trouble than we now know, and Trump actually makes gains. That could happen, too, although the odds are against it. Or the Dem gains could be very moderate. In the stock market there are “V” bottoms, but not many “V” tops – tops take time to develop, and that might be the way here. Both markets and politics are exercises in mass psychology. Maybe we'll get a quick reversal though, if we think that Trump's ascent has actually been a quick descent of normality – markets take the fast elevator down, but the slow escalator up, so maybe that's what we've been seeing, a real bear market in politics with the Trump Crime Family, so we can hope for a V bottom, a fast recovery. But we'll just have to see.

In any case, whatever happens, one wonders if there will be a reformation of the Democratic Party establishment. If the Dems don't win this election after all the impetus Trump has supplied, there will have to be wholesale change, no question. Even if they do win in a wave, however, it's possible that enough people will see that wholesale change is necessary. It's now perfectly obvious how the Republicans have eaten the Democrats' lunch for many years. There have been the last two disastrous elections, 2014 and 2016. Longer term, while the Kochs and Republicans figured out how to take all the statehouses and local elections throughout the country, how to promote conservative policies at that level (ALEC), and how to get ahold of redistricting, the Democrats did, essentially, nothing. For all Obama's electoral success personally, he did nothing to strengthen the party apparatus. The Democratic seniors have monopolized power for a very long time, and have not fulfilled a key leadership function – to identify, attract, nurture, and promote younger people with ability in order to pass on leadership to them. Instead, for instance, Nancy Pelosi's choices for younger members to promote were, hold your breath, Anthony Weiner and Debbie Wasserman-Schultz. I was amazed to read in a recent Dan Walter column (California state politics columnist) that the Democratic leadership put pressure on the now-85 year old Diane Feinstein to run for Senate again so the party could be secure in her winning and would be able to shift funds elsewhere. If DiFi had retired, as she should have, there would have been a contest for younger people to step up – but no, the Dems even with their short bench and pressing need to find national-level leaders, had to push the 85 year old. As depressing as it is amazing.

If the Blue Wave doesn't materialize, with this history, complete reorganization of the Democratic organization will clearly be on the line – fire everyone, get Obama back to chair a reorganization committee, and get to work. To my mind, even if a Blue Wave does materialize, that's what should be done, but the likelihood for doing it would decrease. There is still a lot of work to be done by the Dems. There needs to be a better and more effective way to rise within the party. Obama had to do it very much on his own. Bernie came from the outside as well. There have to be better pathways to the top. The bench needs to be longer and more active. The gerontocracy needs to release power to the younger people.

Intensity and organization can make the Blue Wave come. Trump has certainly done his share to make the opposition intense. The Dems need to make their contribution; there needs to be good turnout, which is driven by intensity and organization. Although I obviously have reservations about the ability of the Democrats, I'm predicting a Blue Wave. I'm hoping for a Blue Wave. One of these days, I might even bet on a Blue Wave. But first, I'll have to see the Red Tide go out a little more, and then see in the distance, a blue swell rising in the ocean beyond. I'll be looking for it. But meanwhile, I'm very hopeful.

Budd Shenkin

Tuesday, July 10, 2018

Work the States, Pack The Court

So, as my friend Paul Levy says, Facebook is the gateway drug for Twitter.  A few months ago I started tweeting, as I mentioned before, and although it doesn't seem like being addicted, I don't get withdrawal, it is definitely a source of excitement.

What does that mean for this blog?  I've kind of wavered thinking about that, but I'm thinking that it should/could be a source of enrichment.  Twitter could be front line skirmishing, and Budd's Blog could be deeper (or at least less compressed) reflecting and ruminating back at headquarters.  Get it - "head quarters?"  It's all in the head?  I guess that's not such a linguistic insight, haircutters and marijuana shops having already discovered the double entendre.

So, SCOTUS.  You have to hand it to the Republicans.  They may be an insidious self-aggrandizing lying scumbag of a party, but they sure can use their money and their energies to advance their undemocratic designs on retaining control of the USA for the moneyed and the white.  As opposed to the Democrats, who I think could be fairly portrayed as "hapless."  Trump captures the party for White Nationalists and the official Democratic response is "A Better Way."  "Hapless" is the kindest description one can find.  Michael Avenatti has launched feelers for a presidential campaign and is asked why he's doing it.  He answers, "Who's better?  The career politicians?"  Which is precisely the point.  It might be faut de mieux, but when you come down to it, it's a question of choices of real possibilities, and the Clintons -- I'm increasingly angry with them and how they have smothered the party for decades, although everyone just does his or her best, I know -- and the octogenarians (Diane Feinstein running at 85 is execrable in her selfishness, as is Nancy Pelosi in her arrogance and heavy-handedness) have derailed a party by smothering the younger potential leaders.  "Smother."  That's the word that keeps recurring to me.  A smothered party.  Smothered both from without and from within.

The Federalists capture SCOTUS.  What to do?  What to do?  Will the whole country retreat to Calvin Coolidge days?  No abortion (talk about words, how did they manage to make "anti-abortion" into "pro-life?"), no healthcare, no one-person-one-vote?  Are we doomed to 30 years of Five Horsemen or more of Reaction?

No.  Hardly.  Lose a round, come back stronger the next.  All the roiling has to lead to a wave, or several waves, a tide, major blowback, a volcano of suppressed desire and rage and I'm not going to take it anymore.  It has to happen, and it will happen.  Let them ride high, let them think their capture is permanent and decisive for a generation.  It isn't.

What to do?  Mobilize.  We still have the vote.  People can vote, after all, and voting and winning should lead to more voting and winning.  Really, that's what it takes.  If you're not part of the solution, Nancy and Diane, at least get out of the way.  It will come from below, and believe me, it will come.

While the national scene will be one of resistance when the House is captured, and maybe the Senate even - it's possible - the positives should come from the state level.  Our Federal system has great strengths, even if we got there by compromises, and even if It came from facts on the ground in 1787, rather than a great theoretical plan.  What we have now is dysfunctional democracy, where smaller and more rural areas have disproportionate influence in government.  But the Federal system makes it possible for states to act independently, and it's even true that the rightward turn centrally could lead to more freedom to act peripherally, this time in an anti-racist state's rights movement.

The urban and "progressive" states -- that word has been captured by a political program, and I'm struggling to find something more generic, help me here -- can undertake programs on their own in health, environment, education, information and communication, civil rights and liberties, everything but foreign relations and defense although who knows what the future holds.  Imagine a Medicare For All type program adopted by 12 or 13 states acting collectively, representing more than half the American population, and pooling funding and administration, a nation within a nation.  Why not?  It would be legal.  If other states wanted to join, they would have to apply!  And they could tell the poor states (the "takers," from a tax and redistribute point of view) to deal with it, if they want to join they have to meet democratic standards, redistrict by non-partisan committee, meet minimum funding levels for various endeavors, take the positive aspects of the EU.

They could adopt in common programs for cap-and-trade, or carbon taxes, on public financing of trade and higher education -- and in most situations wouldn't need to do more than pass the same model system independently, and wouldn't need to fund it collectively.  Embody the "Laboratories of democracy" insight of Justice Brandeis in New State Ice Co. v. Liebmann:"a state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country."

That's the positive side, in the states.  What about the Feds, and what about what I started out saying, that I've been spewing on Twitter?  The central government is still a positive force, despite our current setbacks and the imminent capture of SCOTUS.  It's a point of resistance for the moment.  Rather than taxing your attention span further, dear reader, let me simply cite a recent tweet and response for what to do about the takeover.  As Avenotti says, you have to be active, and the Democrats have to stop bringing a cap gun to a real gun fight - I can't even dignify their actions as a knife.  I'd say about SCOTUS, stop the deification!  Stop the reverence.  It's a political capture by the Republican Party.  They started it by nominating Bork, Thomas, et al.  Formally, we would term them assholes.  Really, these are insidious men -- all men, all Catholic men with the Catholic arrogance of dogma brought to the public realm, and not only attitude, but actual policies.  So, screw it!  There is no alternative to fighting back.  Here it is in compact form:

18h18 hours ago
However you might feel about the eventual SCOTUS nominee, court packing is a truly, monumentally terrible idea. I'm shocked it has gained this much steam. We cannot and will not defend our institutions by destroying them.
Disagree. 9 justices is a norm, not a law. So many norms are being violated re court, are we really going to put up with violation of norms of decency and equal voting, by respecting the one norm that the Republicans have left unbroken?

Budd Shenkin

Wednesday, July 4, 2018

The Future of Exurbia

First a note to readers:  I've become active on Twitter -- @buddshenkin.  It's an interesting format, informal, edging one toward more extreme expressions, and definitely compressing composition.  I find it generally a salutary influence - amazing how it helps one get to the heart of the matter quickly.  Which I need.  I invite you to follow me there.  But remember, Twitter is addictive.  Maybe it diverts your time badly, or maybe it just keeps up your interest and keeps you going.  YMMV.

Another note: as I write this I'm listening to “The Hits of the Crystals,” the great Phil Spector girl group of the 60's in what I think is the second wave of rock 'n' roll. Please make allowances for probable overstatements and over-enthusiasm.

So, I just tweeted about an article by the terrific NYT Upshot columnist, economist Neil Irwin.  Here is the article: https://www.nytimes.com/2018/06/29/upshot/one-county-thrives-the-next-one-over-struggles-economists-take-note-.html.

It's basic thrust is this: it's a mistake to view the US as one big average. The varieties of individual experiences, and especially the variation in regions, is very striking. He looks at a case in point in comparing two adjacent counties. “Economically, Loudoun County is humming from the technology boom in Washington’s suburbs....” By contrast, adjacent Jefferson County, WV has lost businesses. Loudon County was strong for Hillary, and Jefferson strong for Trump. This divergence is typical in the US.

Amazingly, Irwin relates that top economists are just beginning to realize that looking at averages across the US has obscured this local variation. Irwin must be exaggerating; it's been so obvious and talked about. He also relates that policy makers are wondering what to do about it. Increase tax benefits to people in lagging counties to help them thrive, or tax incentives to build businesses in these lagging areas? “Would it be better, for example, to help people stay, or to help them go? Invest in transportation infrastructure or better schools, or ease relocation to more dynamic places?” “...a public fund to support small-business loans in the struggling regions, nationwide broadband internet and vouchers to help the unemployed move to places where there are more jobs?”

So I return again to the idea of high-speed rail and regional transportation networks. It's not clear if shrinking the time-space remoteness exurban areas would actually help the current residents or simply gentrify the space and further displace the left-behind. But it is perhaps relevant to think about the data which shows that placing former ghetto residents in more middle class areas leads to increased success for these people – as long as there are not too many of them, which would lead to a persistence of ghetto culture and persistence of inequality.

Personally, I can't help but think that education is the key. Give people good schools – and I mean good schools, not just current American schools, but schools like Marjorie Stoneman Douglas High School, with the best teachers, the highest ideals, with drama, debate, music, style, intensity – a culture of achievement and celebration – give people these schools, and give them access to urban centers, and my prediction would be a renaissance of society.

But there I go again, with that vision thing. The reality is, who is in charge of envisioning education and giving incentives and funding and pushing the agenda? Betsy DeVos, local school boards, teacher unions. We're doomed.

Budd Shenkin