Issue LXII: The Neoliberal’s Health “Reformer”

7 Oct

Few people’s reputations are so sancrosanct in my field as the reputation of the surgical oncologist and New Yorker health policy journalist, Dr. Atul Gawande.  Nary a criticism of him gets published in either the popular or medical press (Russell Mokhiber’s one article is all I can find). But behind his strangely class-free, race-free, and context-free view of the history of American medicine lays the worst instincts of technocratic market liberalism. An avatar of progress he is not.

This week Dr. Gawande, in an echo of Hillbilly Elegy, decides to wander around his hometown in Ohio (my current state of residence) looking for a consensus on health care as a human right. Being from Texas, I have come to violently disagree with his much-hailed 2009 New Yorker article about McAllen, Texas. His naive traipse through southeast Ohio talking to people is just that: naive.

He finds that, golly gee, health care is expensive, and even conservatives cannot pay their $6000 deductibles, immunosuppressant medications are outrageously costly, and surgery bills keep people up at night. In this region where people repair their own cars and shoot their own deer (a symbol for real America), people can’t repair their own appendix! And they hate freeloaders.

Liberal or conservative, everyone agrees there has to be some sort of level playing field where everyone contributes, costs are controlled, and people will have the freedom to work or start businesses as they please without worrying about insurance. Just like how we do not worry about police and fire protection. Despite his Rhodes Scholarship in Philosophy, Politics, and Economics at Oxford, Dr. Gawande just now seems to be coming around the concept of positive rights and how these guarantees enhance liberty. But then he goes backwards and ponders if Americans have a right to garbage pickup… and then declares the idea irrelevant.

The muddled thinking of the Harvard doctor extends to his use of region and history. It may shock Bostonians, but Athens County is actually the most consistently Democratic county in Ohio. Historically, Appalachian Ohio has allied with Northeast Ohio (Cleveland) to form the bulwark of the Democratic Party in opposition to Southwest Ohio (Cincinnati). The last Democratic governor of Ohio, Ted Strickland, hails from the region and progressive Senator Sherrod Brown still wins in the region.

This coal and union region is economically liberal and socially conservative like its neighbor West Virginia but (as documented brilliantly by this magazine) has rapidly been shifting to the Republicans since 1992.

While he writes about the irrelevant Vaccine Act of 1813 to prove the point that Jefferson and Madison supported some concept of public health (as if that evidence will convert the Right!), he avoids discussing class or race as potential reasons why a logical health system never developed in the United States. When he notes that Athenians love Medicare but hate unemployed, idle people on Medicaid, he neglects look at the relevant legislative history of Medicare and Medicaid. Congressman Wilbur Mills (D-AR), chairman of the Ways and Means Committee, deliberately separated Medicare and Medicaid to create a two tier system in 1965. The elderly would get a national Medicare program while the poor (often black and minority) would get an inferior, unequally implemented, joint state-federal program called Medicaid. De-linking the poor from the elderly has cost Medicaid politically for decades, and it was deliberate strategy.

Elitism In, Elitism Out

What do we expect from a man who took time away from medical school to campaign for Bill Clinton in 1992, who proudly worked for Blue Dog Congressman Jim Cooper, and supported Al Gore in 1988? His national profile ignores his essentially conservative and elitist politics.

Dr. Gawande (who gained fame nationally bashing greedy doctors in South Texas) has never mentioned how regional hospital monopolies result in higher prices for all, including his employer Partners HealthCare. The 2000 merger of Massachusetts General and Brigham & Women’s Hospitals into Partners HealthCare, as noted by the Boston Globe’s Spotlight team, led to bullying of insurance companies to pay them much more per visit and procedure than local non-chain hospitals. Elite hospitals’ price-gouging is fine, but these unscrupulous border physicians and hospitals are just so gauche. Robbery and health care profiteering has to have a proper pedigree. In one ludicrous article, Dr. Gawande extolled hedge fund takeovers of Catholic hospital chains and how they should make hospitals more like the Cheesecake Factory. Seriously.

Stumbling on Solutions

Based on his on the ground conversations in Athens, Ohio, the logical political, moral, and marketable answer to the health care crisis would be Medicare for all. The simple appeal of everyone in and nobody out with direct tax contributions would seem to pass the moral and practical conditions of all these victims of the American health care system.

But Dr. Gawande, perish the thought, cannot make that clean leap in logic.

Instead he buries the idea in fatuous maxims about tradeoffs and the social compact. He does not even seem to answer the question of health care (or even garbage pickup) being a right. He thinks Medicare for all, Medicaid buy in by state, and even health savings accounts are all equally morally acceptable solutions. His bias, as always, is towards a hodgepodge of regional incremental solutions.

And he seems to fear a transition more than any lasting, political solution. And he never mentions Bernie Sanders’s new Medicare for all bill or the collapse of the private insurance system or non-profit hospital price gouging and mergers.

If we are to have Medicare for all and a not for profit health system, we will need to abandon “thought leaders” like Dr. Atul Gawande. They hold us back with their faith in MBA-style management of health care from above and small, incremental, unscaleable experiments in health delivery from below.

We will need a dedicated cadre of physician and public health leaders who understand the role of the public sector in finally providing and implementing the Alma Ata Declaration’s promise of Health for All in the United States. It is only with such dedicated leaders who know that only by confronting the inequalities in wealth, power, geography, and race directly, we can produce a healthy society and finally join the civilized world in guaranteeing health care as a human right.


Issue LXI: A British History of Game of Thrones

6 Aug

Upon meeting His Catholic Majesty Felipe VI, King of Spain, Castile, Léon, and Aragorn, Professor Pablo Iglesias presented him with a modest gift.  A DVD box set of Game of Thrones.

The leftist lecturer of political science and leader of the political party Podemos, professed his love for the show in 2015.  He would, like Khaleesi, ride the dragons of political power to the summit of the state.

Now what could he be talking about when ranting about Weber, Machiavelli, and Gramsci in an HBO serial?  Professor Iglesias is not off the mark at all, dear readers, and I will show you how Game of Thrones explains the creation of the modern world via British history.  But with dragons.

 From Antiquity to Modernity

George R.R. Martin has explicitly stated that Game of Thrones most resembles the War of the Roses.  The War of the Roses was an insanely complicated civil war between 1455 and 1485 for control of the British throne.  As a war between dueling relatives of House Plantagenet, there were many alliances and betrayals and short-term kings that in turn got overthrown by another.  Fighting over hereditary “legitimacy” really was a fig leaf for different groups to support different sides.

The House of York (white rose) fought with the House of Lancaster (red rose) until it ended with the Battle of Bosworth Field in 1485.  The Lancastrians defeated the Yorkists and Henry Tudor became King Henry VII.  To wrap it all up he married Elizabeth of York to unite the two families and thus claims for the throne.  The Tudors ruled until 1603.

What makes the Battle of Bosworth Field more important than other fights over kingship is that this was really the last time inheritance had to be decided by war in Britain.  We can really say that British dynastic stability begins from then until now (notwithstanding complications like Cromwell and the Glorious Revolution).

Stability is the key word in this.  A stable realm with stable rules and rulers can lead to people planning for the future.  They will not have to worry about soldiers wrecking their farm, their apprentices being drafted by the local aristocrat, and changes of religion that lead to religious persecution.  What George R.R. Martin shows, but does not tell, is how political stability will be created in Westeros by the (likely) victory of Daenarys Targaryen.

Origins of Political Order

 It all goes back to German sociologist Max Weber.  The state, in political science, is the only institution allowed to commit legal violence in a modern society in a defined geographic area.  This violence encompasses the police, prison and court system, the death penalty, or (in olden stays) corporal punishment and torture.  We are shocked at the violent actions of terrorists, criminals, or militias because, unconsciously, we believe that only the government is allowed to use violence legitimately.

This was not always the case.  In the New World, it took centuries to develop a political culture in which cowboys can’t just shoot Indians or the Hatfields shoot the McCoys and get away with it.  Being civilized means settling disputes non-violently and using the court system if disputes cannot be settled.

In the Old World, monarchs could not directly control their entire nation and had to rely on local nobles to collect taxes and draft men for their army for centuries.  These nobles could also commit violence and keep some of the tax money they collected for their estates.  They may have additional mandates to protect certain bridges, rivers, mountain passes, or borders from the king.  This is the world of Game of Thrones.

The Birth and Death of the Seven Kingdoms

A brief recap of Westerosi history draws out the parallels with British history.  The original people of the continent were the Children and the First Men.  These natives (equivalent: Celtic tribes) were disrupted by the Andal invasion of Westeros.  They are pushed to the margins of continent just as the Celts were pushed towards Wales, Scotland, and Ireland.  The First Men become the Wildings and are pushed beyond the Wall.

The Andals form the Seven Kingdoms and most likely represent the Angles, Saxons, and Jutes who invaded Britain from Northwestern Europe in 410 AD.  These Germanic tribes form the English people who are the Anglo-Saxons.  The majority of people in Westeros descend from the Andals.  The exception are the Starks in Winterfell (which most likely represents York, England) who are mixed with Andal and First Men blood and follow the religion of the First Men and the Children.

The Seven Kingdoms were all dramatically conquered by Aegon the Conquerer who invaded from Dragonstone three hundred years before the show begins.  Aegon the Conqueror, undoubtedly represents William the Conqueror.  William the Conquerer and his Norman invasion from France conquered Britain at the Battle of Hastings in 1066 AD.  William the Conqueror began much of the current British state including Parliament and government records (the Domesday Book).  One can say the British monarchy as an institution began with his rule.

Like the Normans, the Targaryens are not native to Westeros but come from Essos.  They also do not speak the Common Tongue at home (aka English) but speak Valerian (French/Latin).  In some of the backstory videos on the DVDs (you can find them on YouTube), it is made clear that the Targaryens reduced the amount of warring between the different kingdoms.  By being foreigners, they could stand above any of the individual Seven Kingdoms.  By having dragons, they have the overwhelming monopoly on violence and the ultimate weapon.  You can view the dragons symbolically as the supreme power of state violence, like nuclear weapons or a very strong army, and these dragons make lesser kings submit to the Iron Throne in Kings Landing.

The Seeds of Modernity

Unification and centralization of political power into a single state is an essential precursor for advanced civilization.  The Chinese achieved this thousands of years ago under the emperors of yore while Spain, Portugal, France, and England achieved the nation state centuries later.  What George R.R. Martin’s stories metaphorically reveal are the seeds that will lead to the destruction of the Middle Ages and the beginning of Enlightenment and modernity.

In terms of learning, the Citadel clearly represents the origins of universities and knowledge that will lead to science.  Universities descend from medieval monasteries dedicated to training priests and studying religion.  Samwell Tarley’s apprenticeship (an ancient grad school if you will) shows how medicine is developing from their studies both new and old.

In terms of technology, Cersei contracts the Alchemists’ Guild to develop technology like wildfire and the dragon-slaying ballista.  Medieval alchemy tried to convert common substances into gold.  The knowledge of these thousands of failed attempts led to a body of knowledge about substances which led to modern chemistry.  Once cannon technology began to destroy medieval fortress walls, the point of using castles for defense ended and so too did the Middle Ages.

In terms of statecraft, Lord Varys represents English philospher Thomas Hobbes and his book Leviathan.  Lord Varys, uniquely, defines the goal of governance to be the good of the common people.  Unlike the other advisors, he is a commoner.  Furthermore, he sees stability and peace in the realm to be the primary goal of politics, not who sits on the throne.  His loyalty is not to the ruler but the realm…. or as we would call it, the nation.  His switching from supporting one ruler to the next makes no sense to the others except as a way to get or keep power.  They do not understand his goal of a commonwealth.

In terms of political power, Daenrys Targaryen represents Henry VII. Raised in exile in Essos (France), she will return to her native land to end the family feuds.  She understands that the back and forth between the different families is ruining Westeros.  When Tyrion describes it as a wheel where families rise and fall with the turn of the wheel, Khaleesi responds that she does not want to stop the wheel but to break it.  Her ultimate goal will be the disestablishment of feudalism.  It helps that the families are killing each other off anyway.

An astute marriage, like the marriage of Ferdinand and Isabella in Spain in 1469, could consolidate the territorial gains (Cersei Lannister and Euron Greyjoy?  Jon Snow and Khaleesi?).  A foreign invasion by White Walkers will help consolidate her authority the way the invasions of the Moors helped unify Spain and Portugal in the 1400s.

A single, unified monarchy will rule Westeros without any challengers from below.  In essence, it will be the end of the Seven Kingdoms and the beginning of the modern nation-state of Westeros.


YouTube – Complete History of Westeros

Atlantic Monthly – “Political Order and Political Decay


Issue LX: Red October (part 3)

31 May

Passport to the Finland Station

Stranded in Switzerland for years, Vladimir Ilyich Lenin saw his chance. He immediately began writing his party platform and planning his dramatic return to the former Russian Empire.  The February Revolution, having overthrown the tsar, had incompletely resolved the issue of who ruled Russia.

On one side, rested the Provisional Government composed of certain members of the Duma (parliament).  This government represented the Russian bourgeoisie of liberals and some moderate socialists.  This moderate class had the revolution thrust into their hands in a way they could not avoid the way they did in 1905.  They tried to work with the former nobility and tsarist authorities to maintain control of the nation.  They pledged to the Allies that they would continue to fight in World War I.  An imperial war by the tsar had become a “democratic” and national war by the Russian people.  It was led by Alexander Kerensky.

On the opposite side stood the soviets of workers, soldiers, and sailors.  These workers’ councils practiced “democracy from below.”  Each military unit and factory would elect representatives to these councils in all the major cities.  The most important soviet was the Petrograd Soviet.  The Petrograd Soviet decreed in Order No. 1 that soldiers should follow orders from their officers and the Provisional Government only if they did not contradict the Petrograd Soviet.

Lenin described this situation as dual power.  Who ruled Russia?  The soviets of workers and soldiers or the Provisional Government of liberals and moderate socialists?  As all revolutions end in changing who controls state power, Lenin argued that the revolution had not been settled.

But first he had to get out of Zurich.

April Theses

V.I. Lenin negotiated with the German government to be placed on train to Russia.  Germany, still at war with Russia, bordered both Switzerland and Russia.  He negotiated safe passage through Germany on a sealed train that would make no stops and would have no passport checks.  From the German coast he would take a ferry and then train to St. Petersburg.  As an antiwar radical, Germany liked the idea of sending someone like Lenin who would promote ending the war on the Eastern Front, even if they did not care for his revolutionary socialism.      

Upon arrival at the Finland Station in St. Petersburg, Lenin was greeted by Bolsheviks and Mensheviks alike.  With the overthrow of the tsar, Bolsheviks and Mensheviks worked together again to support the Provisional Government and continue the war. Even if Russia would not aim to annex land, they would defend the nation from German attack.  The Russian Social Democratic Labor Party, split between Bolsheviks and Mensheviks, could now be mended with Lenin’s arrival and his support for the bourgeois revolution and the Provisional Government.

Instead, the fiery speech he gave shocked everyone.  The essentials of his remarks are summarized in the April Theses.  His ideas, which were widely condemned initially, eventually formed the nucleus of the party position.  What were the April Theses?  The best summary comes in the form of popular slogans and posters from the spring and summer of 1917.

  • Bread, Land, Peace – food for the workers, re-distribution of land to the peasants from the big landowners, end the war
  • Turn the Imperialist War into a Civil War – do not fight Germany on behalf of France and England, negotiate an immediate peace treaty, fight the bourgeoisie within Russian society
  • All Power to the Soviets – end the system of dual power by overthrowing the Provisional Government in the name of the soviets of workers and soldiers
  • Fraternize with the Enemy – do no fight “enemy” soldiers anymore, socialize with them instead, rebel against officers who want to continue the war

This did not go over well at all with party members, Bolshevik or Menshevik.

Revolutionaries denounced Lenin as a madman with his calls for ending the war, overthrowing the government, and immediately moving from parliamentary government to a workers’ state based on the soviets. Lenin denounced the Mensheviks (who controlled the soviets and the Provisional Government) as opportunists and social chauvinists who did not really believe in creating a government by and for the working class.  He teamed up with Leon Trotsky, recently returned from Canada, to push for proletarian revolution as the only way to end the war.

But his once radical ideas appeared to make sense to many as the war continued under the Provisional Government which started a new offensive.  The offensive ended in humiliating defeat.  The Bolsheviks began to gain strength in the soviets and the countryside.  By June, workers were beginning to rebel.  In July, they went on strike marching for “All Power to the Soviets.”  Kerensky’s government shot them down by the hundreds and ordered Lenin’s arrest.  Lenin went into hiding while Trotsky was arrested.

The Provisional Government then suffered an attempted right-wing coup by General Kornilov.  Kerensky had to release Trotsky and Bolshevik leaders from jail and then arm them to defend the city from the General Kornilov.  The debacle made the Provisional Government look even worse.  Bolshevik membership soared and soon they controlled a majority in the Moscow and Petrograd Soviets.  Lenin returned from hiding in Finland for the Congress of the Soviets.  After a debate, the soviet executive committee voted to overthrow the Provisional Government and assume state power in October.

Red October

The Bolshevik Revolution began with soldiers refusing to follow orders.  The Bolsheviks then quietly took positions around the city.  The battleship Aurora then fired a blank shot to announce the start of the uprising.  Finally, the Winter Palace of the tsars was stormed and the Provisional Government arrested.  The world’s first socialist revolution had begun.

What happened next is extremely long and complicated.  The Bolshevik Revolution led to the Russian Civil War between the Bolshevik Red Army and the White Army which did not end until 1922.  Lenin and Trotsky began immediate peace talks with Germany while the United States, Japan, and Britain tried to support the White Army.  Despite all odds, Trotsky’s Red Army defeated all parties.  Lenin declared the name of the new nation the Union of the Soviet Socialist Republics or the Soviet Union.

He and Trotsky hoped for a similar revolution in Germany. The Kaiser fell but the German soviets failed to win state power.  Isolated from the world, the Soviet Union never benefited from socialist revolutions in advanced capitalist nations.  Instead this backward nation had to bear the brunt of socialism for decades….. and was hugely unsuccessful on the whole.

Lenin had a stroke and then died soon after in 1924. The Soviet Union lasted until 1991.  All sorts of failures, disasters, and crimes occurred during the USSR’s existence including the ignominious reign of Josef Stalin.  In any case, the theoretical arguments I began this series with remain relevant to understanding why or how the Soviet Union failed.

Did Russia need a phase of liberal capitalist development? Did Lenin rush the revolution when he saw the soviets re-form?  Did the failure of revolution in Germany push Russia into a constantly defensive position?  Did the long and brutal civil war prevent formation of democracy?  Was repression and dictatorship always in the genes of the Bolshevik Party from the start or is it all Stalin’s fault?  Should Lenin have relied on the peasants or waited until the nation became majority urban?  Was Marx wrong to assume most people would become urban industrial workers under capitalism?

All of these questions are of great importance and debate, but now I feel, dear reader, that you will be ready to argue this history with the basic points in mind on this centenary. Were they all heroes, villains, or just 100 years too early?

Issue LX: Boarding the Train (part 2)

18 May

Cutting in Line

Marx and Engels predicted that liberal revolutions led by bourgeois merchants, lawyers, and the professional middle classes would end the restrictions on capitalism by the nobility and church. Human rights and parliamentary democracies would be established. These parliaments would emphasize human rights, political equality, re-distribution of large estates, and the rule of law. The growth of capitalism would plant the seeds of the next revolution by the creation of a large industrial working class.

The United States had two bourgeois revolutions. The American War of Independence separated the thirteen colonies from Great Britain, ending British hereditary feudal aristocracy, and established a Constitution and Bill of Rights. The American Civil War ended slavery and extended liberty to all citizens in the United States and eliminated the South’s feudal social system and broke up the grand planter estates for re-distribution. The Russian Empire in comparison had nothing like these revolutions on the eve of World War I. The Russian socialists were not even thinking of socialist revolution…. they were still waiting for a capitalist one!

In Russia, the Middle Ages had never really ended in any real way. Russia opposed the French Revolution and fought Napoleon’s reforms until his defeat at the Battle of Borodino and eventually Waterloo. Serfdom was not officially abolished until 1861 but without the large-scale land redistribution and public education that spread throughout the American South after the Civil War. The Russian Orthodox Church had incredible power, and the tsar was seen as God’s representative on Earth. There was no limitations on his power. No Magna Carta, no Parliament, no Cabinet, and no freedom of the press.

Military needs pressed the nation to modernize somewhat. The Russian Empire did begin limited industrial modernization after the abolition of serfdom by creating the trans-Siberian railroad to connect the east and west coast of Russia. St. Petersburg and Moscow developed large factories. But most of the population still lived in rural squalor under the oppression of big aristocratic landowners.

But after the shock defeat of Russia by the Japanese in the Russo-Japanese War led to an awakening by the Russian people. In the Russian Revolution of 1905, the people rebelled against the tsar’s imbecilic management of the war. Many members of the Navy rebelled as well. Workers formed work councils called soviets. Masses of people marched against the tsar and protested for more freedom and a parliament. The government responded with bullets and police brutality. The police crushed the revolt.

Yes, a weak Duma (parliament) was created. But it was mostly ignored. At the cusp of the revolution succeeding, the middle classes and industrialists failed to overthrow the tsar. They feared the workers more than the aristocracy. And especially the soviets. Many revolutionaries fled the country.

So again, why did the first socialist revolution happen in Russia when it never even had its liberal revolution? Probably because of revolutionary V.I. Lenin.

Lenin in Switzerland

The great response of the left was to fight amongst each other.

V.I. Lenin, a lawyer and son of small town teacher fled to Switzerland. He was a leading member of the Russian Social Democratic Party but split the party into two factions over some obscure issue. He called his group the Bolsheviks (majority) and his opposition the Mensheviks (minority), even though he had the smaller group.

All radicals continued to write and publish and smuggle banned literature back into Russia. Many performed union activities and promoted the socialist cause to the workers. All of this was illegal and highly dangerous.

In a neutral country, Lenin watched as the great powers began a march towards World War I. Other European nations had expanded overseas and divided up Africa and Asia. Now with increasing nationalism, militarism, and imperialism, the Continent was building up for a global conflagration. Lenin mostly wrote and observed in these years of exile. He argued that imperialism was the highest stage of capitalism and that the search for increased profits left to imperialism abroad. Now that the world was divided up, the only thing left was for the imperialist powers to attack each other for the spoils of empire. War was inevitably a consequence of capitalism.

What shocked Lenin was the behavior of the many socialist and labor parties that constituted the Second International. All of these parties pledged to oppose international war because war led to working class people fighting and killing working class people of other nationalities. Yet despite their international pledges of class solidarity, the British Labor Party, the German Social Democratic Party, and the French Socialist Party all voted for authorizing war in their parliaments.

And the war came. Russia supported the Allies of Great Britain, France, and Italy against Germany, the Ottoman Empire, and Austria-Hungary. Imperial Russia performed disastrously on the Eastern Front with conscripted peasants. Tsar Nicholas II took charge of the war himself and performed even worse than the generals. Food was short, and civilians, soldiers, and sailors began to rebel. Strikes became increasingly common in the capital of St. Petersburg (called Petrograd during WWI). Lenin’s and the other hardline socialists looked increasingly prophetic by 1917.

Finally in February 1917 (O.S.), the women of Petrograd went on strike for food and an end to the war on International Woman’s Day. They marched from factory to factory and told the workers inside to put their tools down and come out on strike until the tsar abdicated. Hundreds of thousands joined. This time, the police did not shoot the protestors. The strike widened until it even the soldiers and sailors refused to fight for the tsar and against the people. The Petrograd Soviet of workers (and now soldiers and sailors) re-formed spontaneously.

The Duma was paralyzed. The tsar, as usual, was paralyzed. Tsarist symbols were torn down. Finally, the Duma asked the tsar to step down. He abdicated, and with no acceptable successor, the Provisional Government was proclaimed. After three centuries, Romanov rule ended in Russia forever.

Excitedly, V.I. Lenin planned his return to Russia.

Issue LX: Prelude to the Revolution

10 May

One hundred years ago last month, revolutionary V.I. Lenin boarded a train in Switzerland and headed to St. Petersburg, Russia to begin the second phase of the Russian Revolution. Due to the centennial of World War I and the October Revolution, I felt that a summary of the events 1917 would benefit readers.  Since this is a long topic, it will be multi-post report.  In this post, I will summarize the backdrop leading to World War I and the theories behind the Russian Revolution.

The World of Yesterday

At the start of the World War I in 1914, Europe had undergone a long stretch of (mostly) peace and (mostly) prosperity and development.  From the 1815 defeat of Napoleon at Waterloo until 1914, a conservative consensus developed by the victors at the Congress of Vienna more or less held sway for almost a century.  After Napoleon, the internal challenges of industrialization, reform, and revolution preoccupied Europe.

In fact, the French Revolution kickstarted the process in Continental Europe by overthrowing the ancien régime in 1792.  By killing the king and royalty and even banning the Catholic Church, French revolutionaries ended the centuries-old system where one’s birth determined one’s place in the social order for life.  Instead, a system of merit and one’s accomplishments would determine your role in society.  The Revolution established a system of Grand Schools (grandes écoles) to open up education and government jobs in the military, science, engineering, and civil service to the public instead of passing these out to unqualified nobility.  Sounds great right?

Napoleon’s conquest of Europe allowed him to spread this model across the Continent.  His Napoleonic Code codified this in many nation’s legal systems.  Ending the discrimination of religious minorities, emancipating Jews, and ending hereditary preference across Europe ended up lasting much longer than his military victories.  The three big holdouts to this were the monarchies of Britain, Austria, and Russia, and they eventually ganged up on him long enough beat him.

As the Industrial Revolution swept North America and Europe, the social order fell apart as people moved from the countryside to cities and found new jobs as industrial workers.  Modern industry destroyed artisanal crafts like weaving and blacksmithing and turned them into textile manufacturers and steel mills.  Instead of rural self-employment in a trade or agriculture, people became employees and workers for large corporations.  By selling their labor in exchange for a wage, they ended the traditional feudal order where one worked at one’s family trade or farm.

Eliminating the feudal order while inventing manufacturing technology led to capitalism.  Without the liberal revolutions that ended feudal privileges, capitalism could not exist.  Liberal policies also encouraged public education, taxation of large landowners, infrastructure, free trade, and efficient government.  They also promoted freedom of religion.  Conservatives opposed these because it reduced the power and money of the nobility and the church.  An educated public that can travel around and work where they want will not look up to the old masters who benefited from large rural and ignorant population.

Capitalism started most strongly in Protestant northern Europe, France, and North America.  Internal trade within nations destroyed the need to make most clothes and tools at home or in the nearby town. This concentrated employment in central cities.  Railroads moved these mass manufactured goods out to the public.  This meant that for the first time in human history, people were able to buy non-local goods on a regular basis.  Fewer and fewer local jobs were needed and more things were bought and sold instead of being made at home.  But this also had negative consequences.

After a few decades, it became clear that capitalism concentrated wealth more and more of the wealth in fewer and fewer hands. People complained that instead of a feudal order running things, there was an economic class order.  Instead of aristocrats and commoners, society divided into the bourgeoisie and the proletarians.  The bourgeoisie class were owners and the proletarian class were urban workers.  Specifically the owners owned the means of production (factories, land, equipment), and workers sold their labor (for a wage) to make goods for the owners.  Because of the horrific conditions of urban factories, workers began to rebel and form working class parties.

Amidst the tumult, Karl Marx and Fredrick Engels published the Manifesto of the Communist Party in 1848.  They argued that world history is the history of class struggle.  The class struggle against aristocracy was led by the bourgeoisie and now won (he called these revolutions bourgeois revolutions).  Their victory led to the creation of the proletarians who will lead the final revolution… the revolution of socialism to create a classless society.  The working class will create a revolutionary government with the goal of eliminating all class differences.  At that point, the state would wither away and people would live in a perfect state of communism where there was no government and no class differences between people.

To summarize, feudalism ends when merchants and the middle classes overthrow them (bourgeois revolution). These classes become the bourgeoisie and create industrial workers out of the now-employed and no longer hereditary lower classes.  These industrial workers become proletarians should overthrow the bourgeoisie (socialist revolution) to create a worker’s state to eliminate all classes and create economic equality.

The perfect place to do this would be an advanced capitalist nation like France, England, or Germany because the number of industrial workers would be highest and feudal power the weakest. But oddly enough, the first revolution happened in Russia, a rural and backward nation.  But more on that in the next post.

Dear New England Journal of Medicine

24 Feb

In the January 19th edition of the New England Journal of Medicine, a ludicrous article about creating a Yelp for doctors by and for the University of Utah was published on the front page of the journal.  I have severe reservations about the use of customer service metrics on complex professional relationships such as medicine.  While improved communication and compassion can and should be improved in American medicine, I feel this has been over-emphasized and avoids addressing the real structural issues of health care.  This also contributes to the narcotic epidemic as doctors are afraid of displeasing patients who are often pain-seeking.  With life expectancy falling for the first time last year, we need to think harder and smarter about this.  Below is a satire applying patient satisfaction to the practice of law.

Dear Editor:

Suppose we transferred “patient-satisfaction” ratings on to the practice of law.   Affordable access to the legal system is a matter of life, death, or imprisonment.

The Justice Department would devise a rating system for all large group practices and courthouses based on “star ratings.” Lawyers and their practices would pay Press-Ganey to administer randomized surveys to assess “client-satisfaction.”

Even though law is a diverse field with many specialties, many types of clients (who may have pre-existing criminal records), and many kinds of cases with varying evidence-based practice, client satisfaction surveys rate the ability of their lawyer based on bedside manner, promptness, and cleanliness of their office. The general public would then judge the law firms’ courtroom outcomes independent of any case-client-evidence specifics.

Would anyone buy this? Would any lawyer sit still or justify this idea in a premier law journal?  Would we decide judicial elections and presidential nominations by their satisfaction scores?  Or would we evaluate judges by the opinions of their legal colleagues and local bar associations?

I find it incredible that there are those in medicine who would justify patient satisfaction scores and evaluation systems when they have caused so much havoc in public education and the lawyers who wrote these laws would never consent to them being imposed on their own profession. No nation’s health system has improved based using such metrics, and we should not kid ourselves that such feedback systems have anything to do with the real, unseen practices of medicine.  We deserve better or at least as much as attorneys deserve.


A working physician


Issue LIX: The French Election and Mitterand’s Shadow

11 Feb

A hopeful presidential candidate wins office and ends a long period of conservative rule.  He promises a break with the past.  Disappointments rack up, he loses control of the legislature, but he manages to win a historic second term.  By the end of his rule, racist and xenophobic white nationalist organizations have started to grow in disappointed industrial areas.  His party lays broken.  Once staunchly left and unionized areas begin to shift towards the far-right.

Am I describing, dear reader, the end of two terms of Barack Obama?  No, actually this describes the situation after the disappointments of the first Socialist President of the Fifth French Republic, Francois Mitterand.  Instead of the Tea Party and the “alt-right”, we have the National Front and Jean-Marie Le Pen and his daughter Marine Le Pen blaming immigrants and castigating corrupt political insiders for the failings of the nation.  What does this year’s French presidential election tell us about what happens when the left fails in a time of economic crisis?

Dancing in the Street

When Francois Mitterand, after decades in the political wilderness, finally won the presidency the young rejoiced and danced in the streets of Paris in 1981.  He had helped found the French Socialist Party and its critical alliance with the French Communist Party.

He promised to move France beyond capitalism and beyond Swedish social democracy.  The poor, workers, and unemployed awaited the rupture with the past and for complete fulfillment of the French Revolution’s promise of liberté, egalité, and fraternité.  There would be increases in the minimum wage, nationalization of industry, decreases in the work week, and abolition of capital punishment.

By 1983, he performed a U-turn and ended the left’s promise to end capitalism.  Mounting financial difficulties and inflation led him to turn towards austerity and cutbacks in government spending and devaluations of the franc.  After a few years, disappointed voters kicked the Socialists out of the National Assembly leading Mitterand with divided government and power-sharing with the conservatives.  But like Barack Obama, he managed to win his second presidential election.

In his second term, Mitterand gave up on socialism and decided to go for creation of the euro and the European Union. Increased free trade with neighbors (“the Common Market”) and a common currency became his signature priority.  But these treaties came at a strict cost.

Euro rules prevent large deficit spending and would eliminate currency devaluations as a monetary strategy.  Common Market rules promoted capitalism, standardization of rules across the Continent, and effectively banning aid to industry.  In short, they were a straightjacket the prevented any chance of socialism or even robust Keynesianism ever occurring again in France.  He was called the gravedigger of socialism in France and the European Union.

The Rise of the National Front  

The far-right National Front began its rise in the 1980s after the disappointments of the Socialists.  Led by the former paratrooper, Jean-Marie Le Pen, it routinely began winning 10-15% of the vote.  This eye-patched anti-Semite first gained support from Algerian colonists who returned to France after Algerian independence and Vichy France-era Nazi collaborators.  After many unsuccessful years blaming immigrants for the lack of jobs and a lack of “law and order”, Jean-Marie Le Pen’s National Front gained steam while Mitterand developed consensus politics in France.  With no radical alternative on the left, disgruntled voters on the left began to vote for the National Front.

In 1995, Mitterand left office and conservative Gaullist, Jacque Chirac, won the presidency while Le Pen scored 15%.  In 2002, Jean-Marie Le Pen shocked the world by coming in 2nd at 16.86% to President Chirac’s less than 20% in the first round of the presidential election.  In the runoff, all the parties endorsed Chirac who won easily (82%) but Le Pen increased his vote to almost 18%.   After one more presidential run in 2007, he passed off the party to his daughter Marine Le Pen who has taken the party new heights.  But that too required faltering by the left and more unemployment.

The alteration of the presidency from conservative Nicholas Sarkozy (2007) to Socialist Francois Hollande (2012) has again supercharged the far-right.  The Great Recession ultimately did in Sarkozy’s presidency and the continued lack of growth in the Eurozone and terrorism has made Hollande the most unpopular President in the history of France (approval rating of 4%).  The euro, EU treaties, and German austerity policy have ruined any chance of economic stimulation occurring under any French president.  Once again, the failure of a social democratic solution (the old idea of a rupture with capitalism is off the table) has led disgruntled voters searching for jobs into the hands of the National Front.

Marine Le Pen has broken with her father and silenced the anti-Semitic element of her party.  She has pledged to re-enact the death penalty, kick out immigrants, re-issue the franc, and leave the euro.  If she wins, she pledges a vote on leaving the European Union (“Frexit”).  Marine Le Pen now polls around 25% and will likely win the first round of the 2017 presidential election.

Will the rest of the political establishment unite around the second candidate in the runoff the way they did in 2002 against her father?  Likely, but unity will not come as easy this time.  Leading candidates Francois Fillon and Emmanuel Macron pledge nothing but austerity, tax cuts, layoffs,  and more neoliberal economics.  After a year of Brexit and Donald Trump’s election victory, can we really count on Marie Le Pen losing the second round?  Out of touch neoliberal Washington and London elites have been shocked by angry, heartland voters.  Perhaps Paris is next.

Francois Mitterand, destroyer of dreams, thought he ended the chance for a radical transformation of society by creating consensus politics in France and Europe.  This year his straightjacket tears open…. but from the right.


Monocle Radio – “The French Left”
Daniel Singer – “The Resistible Rise of Jean-Marie Le Pen”