Political Booknotes
POLITICAL BOOKNOTES Public affairs books scheduled to be published this month. The Medical Triangle. Eli Ginzberg. Harvard University Press, $27.50. America's health care system seems to be...
...Marcus Welby was setting up his practice...
...Sound familiar...
...There is a paradox here...
...The Oregon legislature—of which I'm a member—approved a law last year that will probably have the effect of denying certain marginally effective procedures to some Medicaid patients in return for extending scarce Medicaid dollars to 77,000 citizens who now have no health insurance at all...
...Both, write the authors, were victims of what they describe as psychic numbing, disavowal, and denial because the alternatives to mass destruction were either unachievable or unimaginable...
...The supposition that high rates erode the tax base depends on the willingness of individuals to forgo income rather than pay taxes on their extra effort...
...We didn't do this out of indifference to human life but as an acknowledgement of the cruel reality that resources for health care are truly limited...
...But Ginzberg doesn't believe the public wants difficult choices to be made...
...But in the seventies, another potential crisis suddenly loomed: a projected "surplus" of physicians...
...But to the degree that Americans won the "hearts and minds" of the Vietnamese people, they further alienated them from that very government...
...Yet another contradiction "in a society that had made contradiction its one unshakable precept...
...At the heart of his argument is his observation that despite a 1:1 faculty-tostudent ratio at most medical schools, faculty more and more engage in private practices that provide them and the medical schools with income—but do little to enhance the education of medical students, who therefore get less hands-on instruction in basic practice...
...Paul R. Lawrence, Charalambos A. Vlachoutsicos...
...Television is without parallel in showing the cost of war...
...His 1965 coverage of the burning of Cam Ne, for example, hit on the truth that American military forces were in a no-win situation when it came to subduing the internal Viet Cong insurrection...
...Like Germans who followed Hitler—perhaps like any people living in confusing times—post-World War II Americans seem to have needed an enemy to remain sane...
...The second book, tucked away near the end, reveals a different Lindsey altogether...
...Ginzberg makes a strong case for eliminating a full year of training...
...Their cruelties, as at Cam Ne, inflamed the passions of the American people...
...As Pham Xuan An, the former Viet Cong colonel, told him, "All that talk of 'liberation,' 20, 30, 40 years ago, all the plotting, and all the bodies, produced this, this impoverished, broken-down country led by a gang of cruel and paternalistic halfeducated theorists...
...People brought down the communist tyranny in East Europe...
...At one job site, several hundred workers were observed engaging in a "self-critical" production plan...
...ours were martyrs to a cause...
...This "Great Experiment," according to Lindsey, throttled inflation, restored an eroding tax base, increased business investment, barely affected the federal deficit, and led to the current economic boom...
...This was not the political harangue one might expect, but an open forum by the rank and file to reduce bottlenecks in the manufacture of electrical motors...
...The heart of the book concerns the effects of perestroika on the workers...
...No wonder the American people eventually judged the cost to be exorbitant...
...Although he points out that the ratio of corporate debt to liquid assets has been fairly constant throughout the 1980s, he omits a more compelling statistic: The ratio of corporate interest payments to cash flow rose 43 percent between 1976 and 1986, from 14 percent to 20 percent...
...Fueled by massive infusions of federal aid, medical school enrollments soared...
...On one hand, it will come as no surprise that the Harvard team found the Soviet factory older and more unwieldy than its American counterpart...
...Somehow, Lindsey manages to restrain himself from exploring the beneficial effect lower taxes had on the common cold...
...Though this book rests on a questionable premise —that there is a common explanation for why some people could murder tens of millions during World War II and why other people can build and plan for nuclear wars—it nonetheless raises painful and disturbing questions and tries to explain how men and women can live normal lives while pursuing evil goals...
...What is the significance of it politically, militarily, operationally, at these levels of numbers...
...Until recently, secrecy was the operating norm of the Soviet economy...
...Should we spend $200,000 of our Medicaid funds for a liver transplant with a 20 percent chance of success or invest the same amount of money in prenatal care for 2,000 infants...
...To an extent that astonished the authors, great strides had been made in engaging the workforce in selfmanagement and shop-floor democracy...
...I discovered that I made a revolution for a cause, for a discipline, for an ideology...
...In 1980, the Graduate Medical Education National Advisory Committee issued a report concluding that America would have more than 70,000 physicians by 1990 and almost 150,000 by the end of the century...
...Sophisticated—and increasingly expensive—medical technology is raising difficult questions about who should and shouldn't get medical care...
...But the sacrifice, so much sacrifice, must not be forgotten...
...Economy...
...There are those who genuinely believe that Morley Safer, all by himself, lost the Vietnam war...
...Col...
...Hoa left the communist party in 1979, "thoroughly disillusioned with what she called the second-rate people who had taken over...
...But The Growth Experiment isn't all nonsense...
...Here, bosses still run the shops through instructions passed down the command ladder...
...Most of this material was previously published in medical journals over the past few years, and like many academics who know their subject well, Ginzberg often lapses into jargon ("modalities of treatment") and seldom attempts to enliven his essays with anecdotes or personal observations...
...They still haven't remembered the people...
...But contrary to common perceptions, especially in the western press, the Harvard team found that perestroika has made a positive impact on factory management...
...That was true even on the battlefield...
...This is more than just an intriguing numbers game...
...Two of the decent reforms Lindsey would make are closing the loophole that allows capital gains at death to escape taxation and capping the mortgage interest deduction so that mansions are no longer subsidized by the government...
...No regrets...
...Harvard Business School Press...
...Workers become involved in the process by deciding how to achieve the desired result...
...Harry G. Summers Jr...
...But of course the people were the first to suffer...
...Murray Polner Flashbacks: On Returning to Vietnam...
...His attempt to discount the prevailing view that the economic expansion has been heavily leveraged depends on the selective use of statistics...
...The American Medical Association strongly supported the report, and the effect was dramatic: In 1905, 160 medical schools produced 5,606 graduates...
...Thus, 20 years after World War II, officials of the AMA had converted to the new prevailing orthodoxy: the more physicians, the better our medical care...
...This peace that I fought for may be crippling this country, but the war was killing it...
...There is one major point in Ginzberg's essays that I strongly dispute...
...With Westerners barred from the country's interior as security risks, little was known of the giant factory complexes that stamped out Russia's machinery, trucks, and cars, save for official propaganda out of Moscow...
...But to insist that "troubling parallels" between the two establishes the connection is murky stuff indeed...
...Certainly many of our contemporary nuclear gang live quite comfortably, thank you...
...But was the cause worth it...
...The Harvard people use a lot of fancy terminology to describe what comes down to this: Under perestroika Soviet managers tell employee groups what to do, but not how to do it...
...This was the question Safer posed to Dr...
...Physicians doubtless will respond that this is a gross oversimplification, and there's truth to that...
...would emerge from a nuclear war in discernibly better shape than the Soviet Union...
...Basic Books, $22.95...
...Credible projections put this figure at about $1 trillion by 1995, or close to 15 percent of the GNP...
...Not only that, but Colonel Tin had visited the Vietnam Memorial in Washington...
...In fairness, there are other factors at work...
...Notwithstanding the increasing complexity of modem medicine, Ginzberg believes that medical students today spend too much time in academic training...
...Asked if it was hard to keep his own men motivated during their incredible hardships moving supplies down the Ho Chi Minh trail, Colonel Tin replied, "It was not hard because our men had an idea, a cause...
...We must sort this place out ourselves...
...It was seized upon by Hanoi as a propaganda tool and by scoundrels of the left and right . . . . To the Peace Movement it was The Revealed Truth . . . . To the war movement it was blatant evidence of the perfidy of journalism...
...He predicts that medical care could consume 15 or even 20 percent of our GNP before public officials confront these dilemmas...
...The example most cited is Safer's emotionally wrenching August 1965 coverage of a U.S...
...All the same, the comparison with the Nazi murderers is spurious, to say the least...
...Many of Eli Ginzberg's observations in this book of essays are hardly new...
...Lindsey is persuasive in arguing that high rates do induce taxpayers to avoid paying taxes...
...Asked if he had any regrets, however, An said "No...
...Neither did television, although there are those like George Will and William Westmoreland who would have it otherwise...
...They may not have had much understanding of the aims of that war...
...Infant mortality in the United States is higher than in at least a dozen other countries, including Chile, Singapore, and Hong Kong...
...By 1975 I had few hopes left that the revolution would be anything but the disaster it has turned into," he told Safer...
...In 1990, "All power to the People" has taken on new meaning...
...The men who planned and executed the Holocaust were—together with the mass killer, Stalin—quite unlike the "crazy analysts" who dream and scheme about first-strike scenarios and battlefield victories...
...The major difference is that human relations people now come by for upbeat talks and occasional "round circle" meetings...
...29.95...
...In "The Reform of Medical Education," Ginzberg challenges another orthodoxy: the training of physicians...
...As Battle Lines, a 1985 Twentieth Century Fund report on militarymedia relations found, from August 1965 to August 1970, only about 3 percent (76 stories out of 2,300) of all the evening network news film reports from Vietnam showed heavy fighting, with dead and wounded displayed on the screen...
...Safer asked...
...And in general, the longer medical students stay in school, the more debt they incur...
...Morley Safer...
...In 1989, total health care spending exceeded $620 billion, or 11.2 percent of the GNP...
...The people had nothing to do with it...
...Yet physician income, measured in pretax, constant dollars, stayed virtually the same, because, according to Ginzberg, "in most market areas, as in most fields of specialization, established physicians are able to influence both the demand for their services (by encouraging return visits by their patients) and their incomes (by raising their fees...
...Beginning in 1988, members of the Harvard Business School conducted in-depth examinations of four Russian factories...
...Finally, he would increase the deduction for charitable giving, with a double deduction for contributions of more than 5 percent of income...
...An estimated 37 million Americans, most of them members of working families, have no health insurance...
...Academicians, neoconservatives, "defense intellectuals" and "strategists"—most of whom have never served on active military duty —pour out a stream of publications about "nuclear survivability," about "being ready to fight a nuclear war if necessary," and other tough game plans...
...But the cost of war, as with the cost of anything, has meaning only in relation to value...
...When, for example, onetime Pentagon research director Herbert York concluded in 1960 that the Soviets were complying with the nuclear test moratorium, the venerable war hawk John McCone, then head of the Atomic Energy Commission, warned, "saying that was tantamount to treason...
...Still, those who hunt will find thought-provoking nuggets that raise issues well suited to further journalistic inquiry...
...Hoa's and Colonel An's words, and especially their emphasis on the "people," there is hope...
...Robert Jay Lifton, distinguished professor of psychiatry and psychology at John Jay College and the City University of New York, and Eric Markusen, a sociologist teaching at Carthage College in Wisconsin, believe that, paradoxically, those who participate in the actual or potential killing of so many people can still love their wives and kids, sleep peacefully, and eschew any moral doubts...
...Part I is a detailed apology for Reagan's 1981 tax cuts—the Economic Recovery Tax Act, or ERTA...
...Although his goal is to "apply the lessons" of ERTA while designing the tax system of the future, Lindsey manages to thoughtfully critique many of the most unfair aspects of the existing tax code...
...More problematic is Lindsey's failure to acknowledge that real incomes have fallen since 1973, or that American productivity (a better indicator of economic health than GNP, since it measures technological innovation) is growing at only about 1 percent per year—much more slowly than in either Japan or West Germany...
...Mojtabai pointed out in her brilliant if largely overlooked book Blessed Assurance, which deals with Biblebelt Amarillo, Texas, home of the final assembly plant for American nuclear weapons...
...Working with Soviet scholars, the team talked to employees throughout the organizations, attended factory meetings, and examined relevant documents...
...I had to do it...
...But, as Ginzberg details, these efforts at professional birth control did not prevail...
...Almost 70 percent of Army generals who managed the war," reported Brigadier General Douglas Kinnard, later chief of the Army's Center of Military History, "were uncertain of its objectives...
...Lindsey and his supply-side friends never ask themselves how much economic disparity is really necessary, and never show why the income tax shouldn't be the mechanism to mitigate— not eliminate—economic inequality...
...By and large, Soviet managers are discarding bad bureaucratic habits —establishing direct ties with customers, for example, and paying more attention to the design and delivery of products...
...The revolution had failed...
...Indeed, if current trends continue, by the year 2000 the number of physicians per capita will be double the total in 1950...
...Yet another result of glasnost is this book, the first close-up observation of heartland Soviet industry by U. S. experts, with important lessons for America's own managers...
...Yet in Dr...
...It's not a question of whether we ration care—we already do that, in subtle, behind-the-scenes ways—but on what basis we should make those decisions...
...In urging further reductions in the number of physicians, the report struck a note that sounds surprisingly contemporary: "The present oversupply of physicians in this country is likely to lead to unnecessary services, to a lowering of the quality of medical care, and to excessive costs because people are not able to judge their needs in such a highly technical field as medicine...
...By decentralizing power through the hierarchy, the Soviets have managed to enhance labor productivity in otherwise rickety factories...
...While inflation has hovered between 3 percent and 4 percent in recent years, medical costs have risen at nearly triple that rate...
...The result is increasing specialization...
...This depends in large measure on what tax shelters are available, because not working is always less attractive than shifting income into a capital gains shelter or taking compensation in the form of untaxed fringe benefits...
...After World War II, a series of prestigious commissions warned of an impending "physician gap...
...Henry Kissinger had some of the same concerns...
...They looked at two truck engine and two electrical equipment factories in the Ukraine and Great Russia...
...Hourly employees have only limited say outside their prescribed duties...
...This economist has something approaching a social conscience (always refreshing to discover in a Bush administration apparatchik) and several ideas that don't fit the doctrinaire supply-side mold...
...But after a decade in which the richest fifth of the population saw its share of national income increase much faster than its share of the tax burden, economic disparity isn't a question that should be swept under the rug...
...For Americans the objective of the Vietnam war, and hence its value, was never made clear...
...Basic Books, $21.95...
...McNamara, they write, was an early backer of "finite deterrence" but slowly shifted his views after learning what the think-tank people and their allies were really saying...
...And during his 1989 return, Safer again hit on the truth...
...He notes, for example, that between 1970 and 1986, America's physician-topeople ratio increased from 146 to 220 per 100,000...
...What do you do with it...
...Such disillusionment was mirrored in Safer's conversation with Pham Xuan An, an erstwhile correspondent for Reuters and for Time magazine in Saigon who turned out to be a Viet Cong colonel who had been working for the communists since 1944...
...Throughout this century, Ginzberg notes, fierce debates have raged within the medical community about the supply of doctors...
...Yet there were important people in Washington who grew to understand the risks entailed in ever using the weapons, men like Robert McNamara and Henry Kissinger...
...An SDI scientist can sincerely deny he is working on a "weapon of death," and workers at nuclear plants can reject as nonsense any suggestion that they are doing anything wicked, as A.G...
...The Americans had to be driven out of Vietnam one way or another...
...Morley Safer did not lose the Vietnam war...
...Quality circles" and "gain sharing"—two invogue management concepts—tend to be add-ons, not integral parts, of the traditional American chain-of-command structure...
...Enterprises...
...If his analysis proves anything, however, it's mostly that tax shelters and loopholes are as culpable as high tax rates...
...Work groups reduce overhead costs by assuming responsibility for scheduling, machine maintenance, even at times training and discipline within the group...
...It is the objective of the war, Carl von Clausewitz wrote in 1832, that determines its value, and it is that value that determines the sacrifices to be made for it both in magnitude and duration...
...In this age of dying ideologies and heightened global competition, that's an accomplishment that deserves notice...
...This in turn intensifies the trend towards lucrative —and over-subscribed—specialties...
...The German physicians whom Lifton once interviewed and wrote about committed awful crimes...
...In America the same goals of teamwork and cooperation are constantly espoused, but with less satisfactory results...
...and their kindnesses undermined the very purpose they were in Vietnam to achieve...
...Random House, $18.95...
...Even so, the authors are on to something...
...In 1932, the AMA-financed Commission on Medical Education noted that the United States still had more physicians per capita than any other country in the world...
...Two chapters, "The Politics of Physician Supply" and "The Reform of Medical Education," are particularly good...
...And vivid combat television coverage of "the horrors of war" was also a rarity...
...You must remember the kind of bravery those young men had," Colonel Tin told Safer...
...That compares to just $13.5 billion, or 4.7 percent of the GNP in 1950, when Dr...
...In one of the many contradictions he encountered, Safer was surprised to learn that Tin, a 37-year NVA veteran, has a sister living in Los Angeles...
...Phil Keisling Behind the Factory Walls: Decision Making in Soviet and U.S...
...My own experience suggests these difficult questions are already hard upon us...
...But for the Vietnamese communists it was a different story, as Safer found during his return visit to Vietnam...
...Of course it was neither...
...Duong Quynh Hoa, one of the 16 founders of the National Liberation Front, the Vietcong...
...the people were immediately forgotten...
...An early supporter of cautious deterrence, he became increasingly bellicose after moving into Nixon's White House, going so far as to draft a memo in 1972 about "strategic sufficiency" and how it could "ensure the U.S...
...David P. Hamilton The Genocidal Mentality: Nazi Holocaust and Nuclear Threat...
...They then studied four comparable plants in this country...
...Most of them, he notes, spend three years in medical school, and then at least two more in specialized medical education...
...the "crimes" the lunatics and Strangeloves among us may one day commit haven't happened yet, though Lifton and Markusen believe—perhaps correctly, who knows?—that our nuclear weapons system "creates a threshold waiting to be crossed...
...Such standard management tools as inventory control, cost accounting, and marketing were in primitive stages of development...
...Lawrence Lindsey has actually written two books under one cover...
...Your soldiers fought very well," said North Vietnamese General Vo Nguyen Giap (whose reputation, Safer notes, was based "on the bones of perhaps two million of 'the sacrificed' "), "but they did not know why they were here...
...More shocking still is what we're not getting for this money: Half our citizens who live in poverty are not covered by Medicaid...
...I thought I was making a revolution for the people," she said...
...The Cam Ne story was broadcast over and over again in the United States and overseas," Safer remarks in Flashbacks, his retrospective on his time as a Vietnam war correspondent and account of his 1989 visit there to make a CBS documentary...
...He sacrifices consideration of everything— from interest rates to global economic factors to plain old common sense—in pursuit of the proof that low tax rates are the single most important element of economic efficiency...
...America's health care system seems to be coming apart at the seams...
...Intentional American cruelty toward the Vietnamese was far outweighed by the thousands upon thousands of acts of help and generosity resulting in a reservoir of good will toward Americans (as Safer discovered) that continues until this day...
...Hence, eliminating shelters and taxing fringe benefits are equally viable alternatives to cutting taxes for the rich...
...Elsewhere, a workers' council blocked an attempt by the local party functionary to fire a supervisor—a situation unthinkable a few years ago...
...Why did your revolution fail so miserably...
...Mark Relater The Growth Experiment: How the New Tax Policy Is Transforming the U.S...
...Like Ginzberg, all of us would rather do both, but too often that's difficult...
...Strengthening the Saigon government was supposedly the primary reason we were in Vietnam...
...capitalism...
...Marine company putting the torch to Cam Ne hamlet while women screamed and cried in the foreground and their wailing children clung to their skirts in terror...
...The infamous Flexner Report of 1910 is known to students of health care policy as a watershed in the "professionalization" of American medicine...
...And people will eventually bring it down in East Asia as well...
...Safer got the same story from retired Colonel Bui Tin of the North Vietnamese Army (NVA...
...Lawrence B. Lindsey...
...Lindsey ends up recommending that old Republican standby, the flat tax...
...For example, the fear of malpractice lawsuits has also encouraged the "Call me if you don't feel better" style of practice to give way to the "Come back next week for a check up" approach...
...Their findings go beyond the current round of self-congratulation about the superiority of U.S...
...It called for much higher standards, to be accomplished by closing a number of substandard medical schools and reducing the number of doctors...
...In the four factories, newly elected workers councils and team leaders were not only in place, but were emerging as effective players in decision making...
...He would also tax corporations on their cash flows (revenue minus production expenses and reinvestment), a move that would not only simplify a needlessly complicated section of the tax code but would also eliminate the tax-based bias in favor of debt financing over equity...
...As Ginzberg suggests, the oversupply of physicians cannot help but affect health care costs...
...Moreover, the subject is sexy and rewarding, often transforming these desk warriors into celebrities, while the existence of a vast technological capacity and commitment to the weapons invites and helps sustain the "genocidal mentality...
...Safer has a way of illuminating the truth, even to a degree that he himself does not understand...
...How sad...
...Robert Jay Lifton, Eric Markusen...
...An replied, "They called it a people's revolution...
...But after hanging around the war games theorists he finally uttered his nowfamous complaint: "What in the name of God is strategic superiority...
...Management meets on a daily basis with group leaders and takes pains to build a consensus rather than hand down orders...
...One of the persistent myths of that conflict is that television, by bringing the horrors of war into American living rooms, fatally undermined American public support for the war...
...That they both require the collaboration of doctors, psychiatrists, engineers, physicists, social scientists, businessmen and political ideologists, as the authors argue, is no doubt true...
...by 1922, there were just 81 schools producing 2,529...
Vol. 22 • April 1990 • No. 3
