Kevin Drum - May 2011

Return to Kurdistan - Part 1

| Tue May. 31, 2011 10:37 PM PDT

Several years ago I published a series of blog posts from Jonathan Dworkin, a medical student at Mount Sinai School of Medicine in New York. He spent a year organizing a collaboration between Kurdish and American doctors in order to assess the long-term consequences of Baathist chemical attacks on the Kurdish civilian population of Halabja, and in 2006 he spent several months travelling in Iraqi Kurdistan and sending occasional dispatches about his travels. You can find them here (scroll to the bottom for a complete list).

Jonathan is now an infectious diseases fellow at Brown, and has spent the past few weeks in Kurdistan working to develop the public health infrastructure. He's back now, and has written a series of three posts on how things have changed since his first visit, hitting on themes of transparency in the economic system, willingness of the government to peacefully transfer power, freedom of journalists, independence of public institutions (like the university), and relations between Kurds and Arabs. Kurdistan has pretty much fallen off the radar of the U.S. media, so this is stuff you won't find anywhere else.

Part 1 is below. The next two parts will follow on Thursday and Friday.


“Basis of life is sleep, sex, nutrition. I am nutrition.” That’s what the cook said, and then he handed me a meatball. Kurdistan has changed a lot in five years, but the cook at the dar is an example of how it hasn’t changed, and hopefully never will change. After spending two days in a hotel I moved to the residence for medical house officers, which everyone here calls the dar. This is one of Kurdistan’s primary mechanisms for alleviating the economic hardship of prolonged training and the social hardship of deferred marriage. The dar is a place for young doctors to live together, study together, and tease one another. And in a characteristically class levelling way, the teaser in chief of this dar is the cook. “Doctor is survivor of electro-shock therapy,” he explained while puffing on a cigarette and indicating the young psychiatrist sitting to my right. “He is very crazy man. He will sleep next to you tonight.”

The ostensible reason I’m in this situation is to conduct public health research for Brown University. The research is part of my training as an infectious diseases doctor. During my previous visit to the Kurdish autonomous region of Northern Iraq in 2006 I saw several cases of typhoid fever, but our small team wasn’t equipped to characterize them in any systematic way. This time we are armed with data collection tools and grant funding. Burden of disease studies — a simple form of public health work — are often precursors to interventions such as vaccine programs or infrastructure investments. But all of this is largely beside the point. The real reason I’m back, doing this typhoid project in this province, as opposed to another, is because I love Kurdistan. In medicine it’s the people that draw you in, and the work is an expression of solidarity.

The dark side of this trip begins with the fact that it almost didn’t happen. In February, during the beginning of the Arab spring, protests erupted in Kurdish Sulaimania. The reasons for the opposition were varied, but at its core the protests were against the patronage system established by the ruling Kurdish parties. For two months the opposition occupied Sara Square, in the center of the city, and the protests ended when the authorities deployed Kurdish units of the Iraqi Army. Hundreds were wounded and several people died in the worst internal violence since the 1990s.

The original plan for my trip was to come with my family and live for a month in an apartment my friends had picked for me. The apartment was in a comfortable neighbourhood called German Village. After the protests erupted unidentified gunmen stormed the area and burned down an opposition television station. Nothing will ruin the reputation of a nice neighbourhood faster than a secretive militia affiliated with a political party. The German Village becoming more like Beirut, I changed my plans and arrived alone.

Now the streets are quiet. German Village is well-kept and calm, deceptively German. There is no heavy security presence in Sara Square, though party buildings are well defended. The economic and cultural life of the town appears uninterrupted, at least on the surface. In fact the city is larger and more vibrant than five years ago. Electricity is better. Water quality, though imperfect, is better. Construction projects and new businesses are everywhere. The hospital is functioning on a much higher level. Not only are routine diagnostic tests available 24 hours per day, but advanced interventions such as cardiac bypass surgery and kidney transplantation are now offered. One of the ironies of recent history here is that the government’s moment of crisis ought to be a moment of triumph. The Kurdish region never descended into violence, despite what happened in the rest of Iraq. There was a contested election, opposition parties, and a critical press. All of that success is threatened by the recent violence.

Spending a weekend with my friends before beginning data collection, it’s easy to pretend this is the Sulaimania of five years ago. You can still walk the streets safely and encounter friendly smiles as an American. You can still go to a cafe and talk politics over rice, vegetables, and grilled meat. There’s an openness one feels around Kurdish people, particularly in Sulaimania, that reminds me of why I fell in love with this town in the first place. But probe deeper and you find a poisonous pessimism that is taking root. It is that despair, and the realization that a bold attempt to build a new Kurdish civic society may end in failure, that is the real story this spring in Sulaimania.

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Time to Get Off the Bus

| Tue May. 31, 2011 3:18 PM PDT

I think I've now read at least half a dozen mainstream media figures lamenting the absurd level of coverage that the mainstream media is giving to Sarah Palin's bus tour cum summer vacation cum presidential campaign tryout. Note to the nation's editors: your own reporters think that chasing her around like a starstruck junior high school kid is nuts. Isn't it time to pull the plug and let her tour the United States with the privacy she allegedly wants?

What's Your Problem?

| Tue May. 31, 2011 11:52 AM PDT

Gallup says today that doctor-assisted suicide is the "most controversial cultural issue" in its recent poll. Why? Because it's the issue where opinion is divided most closely. I'm not sure that's really much of a proxy for "most controversial," but I guess it's their poll, not mine.

What struck me about their list, though, was how few of these things I object to. Out of 17 issues, there were only four I objected to, and even there my objections depend on circumstances. There really wasn't a single one that I just flatly, always think is morally unacceptable. I'm not sure what this says about me.

Anyway, here's the list. See if you can guess the four I found kinda-sorta unacceptable. (Hint: I don't really have a problem with human cloning, though I suppose I might change my mind if a cloned race of superhumans takes over the world and enslaves the rest of us.)

Building Better Teachers

| Tue May. 31, 2011 9:35 AM PDT

Dana Goldstein, writing about our need for better teachers, sums up my skepticism over the entire ed reform agenda in one sentence:

But what if the United States is doing teacher reform all wrong?

Well, yes. What if we are? Unfortunately, this is a question that hangs over practically every initiative to improve our schools. We just don't know for sure if they work, and studies to prove things one way or the other are almost impossible to conduct properly.

So what's the problem with our efforts to build better teachers, anyway? Are we doing it all wrong?

That’s the suggestion of a new report from the National Center on Education and the Economy, a think tank funded mostly by large corporations and their affiliated foundations. The report takes a close look at how the countries that are kicking our academic butts — Finland, China and Canada — recruit, prepare and evaluate teachers. What it finds are policy agendas vastly different from our own, in which prospective educators are expected to spend a long time preparing for the classroom and are then given significant autonomy in how to teach, with many fewer incentives and punishments tied to standardized tests.

OK, fine. Here's some anecdotal evidence that this might be true. It comes from my mother, who was talking to one of her old teacher buddies, who recently got a job teaching teachers how to teach students to write critically about literature. Apparently it's to improve the performance of kids in AP English classes, who have been immersed in the wretched five-paragraph format their entire lives and don't know how to write coherently about abstract subjects.

And that's fine. But my reaction was the same as my mother's: aren't AP English teachers supposed to know how to do this already? Why do they need a coach? What have they been doing their entire teaching careers if they haven't been teaching their kids how to write about literature?

So that's that. But of course, the plural of anecdote is claptrap, so this doesn't mean anything. The real question is whether better trained teachers in the Finnish mode are really what we need to get better schools. Considering the almost universal contempt that teachers and everyone else have for ed schools, that's either hard to believe or else self-evidently true. I can't quite tell which. But there are a lot of other reasons that Finnish and Chinese schools might produce better test scores than ours, and adopting their models of teacher training would be fantastically expensive. So we had better figure it out before we commit to some massive nationwide program to train better teachers.

But how do we figure it out? Good question. See the beginning of this post for my non-answer.

Healthcare Reform and Political Coalitions

| Tue May. 31, 2011 8:18 AM PDT

Robert Pear reports that hospitals are unhappy over new federal regulations that pay them based on the cost of care they provide to Medicare patients compared to other hospitals:

For the first time in its history, Medicare will soon track spending on millions of individual beneficiaries, reward hospitals that hold down costs and penalize those whose patients prove most expensive....Hospitals could be held accountable not only for the cost of the care they provide, but also for the cost of services performed by doctors and other health care providers in the 90 days after a Medicare patient leaves the hospital.

....Under the new health law, Medicare will reduce payments to hospitals if too many patients are readmitted after treatment for heart attacks, heart failure or pneumonia. In addition, Medicare will cut payments to hospitals if they do not replace paper files with electronic health records, and it will further reduce payments to hospitals with high rates of preventable errors, injuries and infections.

In related news, Aaron Carroll reports that physicians, who used to be rabidly opposed to national healthcare, are now substantially in favor of it:

Remember, this was support for federal legislation to establish National Health Insurance. That’s far more radical than the PPACA. And 59 percent of physicians supported it. That was an increase of 10 percent from what we found five years earlier, and it was statistically significant. More than half the respondents from every medical specialty supported it, with the exception of surgical subspecialties, anesthesiologists and radiologists. That means support included a majority of general surgeons, medical subspecialists and obstetricians/gynecologists.

Aaron calls this a problem for the AMA, and I suppose it is. But I think it's also a problem for hospitals: to a large extent, the interests of hospitals and physicians are not only diverging, but becoming actively opposed. In the past, physicians probably would have been as opposed to these new Medicare regs as hospital administrators, but I'll bet that's largely not the case anymore.

As an analogy, this strikes me as having mirror-image similarities to No Child Left Behind, another piece of legislation designed to force efficiency on a particular sector of the economy. At first, parents were largely in favor of NCLB while teachers and school administrators were largely opposed. But as time has passed and suburban schools have started to suffer from the law (either because they're given failing grades or because inner city schools start competing effectively for the best teachers), the ground has shifted: parents and teachers now find themselves frequently in agreement that NCLB has gone further than they like. This provides a growing political coalition to change or water down the law.

In healthcare, it's the same dynamic in the opposite direction: a political coalition is breaking up. Doctors and patients are starting to align one way, while hospitals and insurance companies are aligning in another way. The good news is that this makes it less likely that healthcare reform will be repealed. There just isn't a united political coalition in favor of it.

Chart of the Day: The Death of Small Businesses

| Mon May. 30, 2011 6:37 PM PDT

Like me, you've probably been hearing for years that small businesses are the engine of job creation in the United States. But that's an outdated view. The number of new startup businesses has declined sharply since the beginning of the recession, while the number of jobs created by startup businesses has been declining for over a decade. As this chart from the BLS shows, the number of jobs created by new businesses peaked in 2000, began declining at the start of the Bush administration, and has been plummeting ever since:

The number of new establishments for the year ending in March 2010 was lower than any other year since the series began....The number of jobs created by establishments less than 1 year old has decreased from 4.1 million in 1994, when this series began, to 2.5 million in 2010. This trend combined with that of fewer new establishments overall indicates that the number of new jobs in each new establishment is declining.

....The number of jobs created from establishment births peaked in the late 1990s and has experienced an overall decline since then. The decrease in birth-related employment during the latest recession is the largest in the history of the series, followed closely by the period of “jobless recovery” after the 2001 recession.

Since the recession began in 2008, the biggest net generator of jobs has been neither small businesses nor large businesses. It's been medium-sized businesses.

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New York, New York

| Mon May. 30, 2011 8:45 AM PDT

It's vacation time again! Soon, anyway. I'll be in New York for a few days at the end of June, and I'm looking for suggestions for things to do. Last time I did this I was accompanied by Marian and some friends who had never been to New York before, so lots of standard tourist stuff was on the agenda. This time I'm on my own, so I'd be interested in ideas that are a little off the beaten path. This worked pretty well last time, so I thought I'd ask readers for suggestions again.

Not that the usual stuff is off limits. I'm definitely going to spend a few hours at MOMA. I haven't been there in ages and my hotel is right nearby. And I've never been to the Bronx Zoo. Is it worth a visit if the weather isn't too bad? Or maybe a Yankees game at the new stadium if I can find someone who wants to go with me. Beyond that, though, I have no plans. What should I do and what should I eat while I'm there?

Letting the Dead Pay for Medicare, Part 2

| Sun May. 29, 2011 10:47 AM PDT

Nobody's reading the blog today, right? So that makes it a good time to revisit a topic at great length that's politically out of the question and will never happen.

I've always been open to the idea of means testing Medicare, and a few days ago I suggested a different way of doing it: after death instead of before. For each Medicare recipient, keep a running tally of the cost of their care, and when they die deduct the premiums and copays they've been responsible for. What's left over gets taken out of their estate, the same way back taxes would. Rich people would end up paying their entire bill, poor people with no estates would end up paying nothing, and those in the middle would pay a portion that depends on how big their estate is. Will Wilkinson wasn't impressed:

I've got a better idea. Don't give the elderly rich any government money for health care. Let them pay for it, because they're rich! And give other seniors just the assistance they need—no more, no less—to buy a health plan of a certain minimum level of coverage. Now, I know this is a fantastical idea for crazed, science-hating, Rand-thumping Jacobins, amounts to destroying Medicare as we know it, and is good for nothing but losing elections. But for all that it seems at least as practical as picking over dead peoples' estates.

That phrase — "picking over dead peoples' estates" — is, of course, the Achilles' heel of my proposal, since that seems to be the instinctive reaction of just about everyone to the idea of allowing the government first crack at estates. Still, let's put that aside for the moment. Is means testing of living people really as practical as means testing dead people, as Will suggests? I don't think it is.

First off, let's review Welfare Economics 101. The problem with means testing — any means testing — is that it acts like a gigantic tax on earnings. Suppose, for example, that you receive $5,000 from the government if your income is below a certain level. If you start earning more, your benefits go down. Maybe the income threshold is $10,000, and for every $1,000 above that you lose $500 in benefits. Do you see the problem? It's like a 50% tax on everything you earn over $10,000, and that reduces the incentive to work hard and earn more.

This is a well-known problem with all means-tested programs, and there's no ideal solution to it. You just have to muddle through. The Medicare version of this is that means testing would reduce the incentive to work and save while you're young. Why bother if it's just going to get eaten up by Medicare expenses later in life? Why not live for the moment, keep your income below the means-testing threshold, and then take advantage of free Medicare when you're old?

Beyond that, there's the problem of how to means test and what the threshold should be. Will says that we should give people "just the assistance they need," but that's not as easy as it sounds. Should means testing be done on income or wealth? If it's income, then you're giving away benefits to people who might have modest retirement incomes but lots of assets. Why should they be allowed to keep their expensive homes and cars and boats and stock portfolios while Uncle Sam pays for their hip replacement? But if you means test on wealth, then you force people to impoverish themselves before they qualify for care. Do you want to be the one to tell granny that she has to sell her house and all her belongings before she gets a dime from the government? I didn't think so.

Well, how about just limiting means testing to the genuinely rich? If you have a retirement income of $200,000 and $10 million in assets, then you can certainly pay for your own medical care. No argument there. The problem is that the genuinely rich only account for about 2% of the population. Maybe 5% tops. Sure, you can make them pay for their own care, but it's not going to make much of a dent in Medicare spending. So why bother?

So now consider my idea. You can earn and save money in your youth and know that you'll still have it in your old age. You can spend it as you like. We don't need any complicated formulas for figuring out who qualifies for free Medicare and who doesn't. We don't need to impoverish granny and take away her house.

Instead, we just keep track of what you spend and then take it out of your estate when you don't need it anymore. Will people try to hide assets or give them away in order to avoid Uncle Sam's bite? Sure. But think about this for a moment. The average cumulative Medicare bill after you've died will be on the order of $100-200,000. The really rich, who have the means and the legal talent to do fancy estate planning, aren't going to run down their estates below that amount. It's just too piddling, and they want to have at least a few millions unencumbered by legal chicanery throughout their lives. Conversely, the working and middle classes mostly don't have the ability (i.e., money for expensive lawyers and estate planners) to cheat their way out of this. That leaves the upper middle classes, and they'll probably try to evade some of their Medicare expenses. But that's a relatively small number of people — and without minimizing the problem here, it really is possible to regulate a lot of it away. If Medicare had first claim on estates the same way the IRS does, it would mostly get all the money owed to it. Just giving them first claim on homes would go a long way toward keeping things kosher.

This doesn't completely get rid of the Welfare 101 problem, of course. There's still a certain amount of disincentive to earn and work while you're young, knowing that you can't bequeath every last dime of your money to whoever you want to. But the disincentive is a lot less. Your parents love you and all that, but guess what: they mostly love themselves even more. They'll do a lot more to protect their own access to their wealth than they will to protect yours.

To some extent, of course, all I've done is shift the problem: there's now an incentive to spend all your money not during your working years but during retirement. Why not, if it's all just going to Uncle Sam after you die anyway? There's no question this will happen, but my guess is that it will happen less you might think. I don't know if there's any empirical evidence on this score (how would you get it?), but there's a limit to how much people want to spend down their wealth. Mostly they don't want to sell their houses while they're still alive, for example, and if they're the saving types they probably want to keep a certain amount of their savings around no matter what. Besides, if you means test Medicare, this incentive to spend down your savings during retirement exists regardless of whether the bill comes due before or after death.

So, roughly speaking, that's my case. Charging for Medicare expenses after death solves the problem of trying to figure who deserves what and how much you can afford. We just don't bother. We simply tot up the charges and then take it out of your estate. If there's no estate, that probably means you were poor and couldn't have afforded to pay for it in the first place. If there's a big estate, it means you were rich and can pay for 100% of your Medicare costs. And for the middle classes, which are by far the trickiest for any means testing policy, it allows effective means testing that, almost by definition, takes from you only money that you can truly afford to pay.

There is, of course, no reason this has to be a standalone policy. We still need to rein in the growing costs of Medicare no matter what. You might also want some pretty strict rules about what you can do with your money if you're currently in a nursing home being paid for by Medicare or Medicaid. (Though the rules on this are already pretty strict in a lot of states, which really do require you to impoverish yourself before you qualify for aid.)

But still: this would almost certainly raise a huge amount of money. It would raise it not based on what you might use in the future, but on what you've actually used during your life. And it would raise that money from people who don't need it anymore.

Let me repeat that: It would raise the money from people who don't need it anymore. If you want to think of this in ghoulish "picking over dead peoples' estates" terms, you can. But it's not. What it is is charging people for a service based on whether they can afford it; it's allowing them to live their actual lives free of fear and impoverishment; and it's settling an account the same way that anyone else would who has a claim on an estate. Do you think of a supermarket as ghoulish if they insist that granny's estate pay for the grocery bill she ran up during her final year of life?

There might be technical reasons that make this unworkable (though I suspect most of them could be resolved tolerably well), but philosophically I just don't see the objection. It's fair, it's efficient, it raises a lot of revenue, and it lets people live their lives decently for as long as they're alive. What's not to like?

Lead, Prisons, and Crack: Why Violent Crime is Down

| Sat May. 28, 2011 2:31 PM PDT

Crime guru James Q. Wilson surveys the evidence for why violent crime rates have dropped so dramatically over the past two decades. The state of the economy, he says, seems to have little to do with it:

One obvious answer is that many more people are in prison than in the past. Experts differ on the size of the effect, but I think that William Spelman and Steven Levitt have it about right in believing that greater incarceration can explain about one-quarter or more of the crime decline.

....There may also be a medical reason for the decline in crime. For decades, doctors have known that children with lots of lead in their blood are much more likely to be aggressive, violent and delinquent. In 1974, the Environmental Protection Agency required oil companies to stop putting lead in gasoline....A 2007 study by the economist Jessica Wolpaw Reyes contended that the reduction in gasoline lead produced more than half of the decline in violent crime during the 1990s in the U.S. and might bring about greater declines in the future.

....Another shift that has probably helped to bring down crime is the decrease in heavy cocaine use in many states....Drug use among blacks has changed even more dramatically than it has among the population as a whole....Among 13,000 people arrested in Manhattan between 1987 and 1997, a disproportionate number of whom were black, those born between 1948 and 1969 were heavily involved with crack cocaine, but those born after 1969 used very little crack and instead smoked marijuana.

So if I can put words into Wilson's mouth, the decline in crime is perhaps one-quarter due to increased incarceration, one-quarter due to reduced cocaine use, and one half due to reductions in blood lead levels in children. Better policing might be part of it too, though the evidence is spotty. Oddly, though, Wilson's own summary is different: "At the deepest level, many of these shifts, taken together, suggest that crime in the United States is falling [...] because of a big improvement in the culture." Aside from the reductions in cocaine and crack use, however, none of this sounds all that cultural to me. It sounds like we cleaned up the environment and built a lot of new prisons. It's hard to see an awful lot of room for cultural explanations here.

Friday Cat Blogging - 27 May 2011

| Fri May. 27, 2011 12:00 PM PDT

My sister headed off to England for a vacation yesterday, and before she left she insisted that I post some extra special catblogging today so that she'd have something good to look at while staving off jet lag on her first evening in town. We always do our best on that front, but it really all depends on the cats, doesn't it?

So how's this? On the left, Inkblot is camped out on our new sofa, which Karen hasn't yet been over to see. So this is her first look at it. Inkblot's bright-eyed expression is due to timing: I took this picture last night just as Marian was shuttling food around for dinnertime, and that perked him up. On the right, Domino is basking (as usual) in the sun this morning. However, this picture's extra specialness was probably dimmed a bit because she kept batting the camera strap around instead of holding still in some kind of extra specially cute pose. Still, I hope this does the job.

Have a good Memorial Day weekend, everyone. There will probably be a light bit of posting this weekend, but normal blogging will resume on Tuesday.