Sunday, February 21, 2010

Excisions


AUTHOR'S NOTE: This essay is probably too long to be a blog post.  If like me you prefer to print out long pieces and read them off-line, here is a PDF link.

The death was announced, with respectful irony, on the front page of The New York Times: “Henry Molaison, An Unforgettable Amnesiac, Dies at 82.”  Before that day he had been known to the annals of neuroscience, and to me, only by the identity-cloaking initials of H.M. I never met the man, but still, it felt like I had lost an unknown cousin.

Who was H.M.?  And who was he to me?

Henry Molaison was knocked over by a boy on a bicycle when he was nine, gashing his head badly.  The injury led to a series of debilitating seizures which continued and worsened until, at the age of 27, they were impeding his livelihood as a motor repairman.  In 1952, he went to the Hartford office of Dr. William Beecher Scoville, a patrician neurosurgeon related to the author of Uncle Tom’s Cabin.  After exhausting other treatment options, Scoville decided that some experimental surgery was in order.  Using only scalp-deep local anesthetic, he peeled the skin on H.M.’s forehead over his eyes, drilled two silver-dollar-sized holes through his skull and – with a spatula-like retractor – lifted the frontal lobe out of the way so that he could access the limbic area of the brain.  Then, with a silver straw, Scoville sucked about two-thirds of H.M.’s hippocampus out of his head.

Scoville’s surgery actually did reduce the frequency of the seizures – but it also created history’s most famous amnesiac.  The memory-formation processes in H.M.’s brain were permanently damaged.  For the rest of his life he would encounter every name, every face, every object, every event as if it were new and previously unknown to him. What the rest of us see as a vast landscape of time was, for him, just the thin 20-second slice his short-term memory could retain.  All that came before was a confusing void; all that came after (since mental plans would soon be forgotten) was a dark limbo too.  Till his death H.M. would need caretaking – first from relatives, and finally in an institution.

My first name is William.  I was named after the surgeon who crippled H.M.’s brain.  That obituary made some family history surface in my memory – and it prodded me to find out more about the man whose name I took.  Behind my investigation was a nagging wonder… was I named after a neurological cowboy?  Was William Beecher Scoville a gambler with a scalpel, willing to risk his patients’ faculties for his own surgical glory?

To answer that question, I must first do what H.M. couldn’t… remember how I got here.

*   *   *

The story begins in Lima, Peru – it is 1960, about a year and a half before I was born.  Jorge A. Gadea, a young father of four, is diagnosed with a herniated disk.  A respected local neurosurgeon, Dr. Fernando Cabieses, operates.  Within days the patient’s condition is deteriorating and he is soon paralyzed from the neck down.

Cabieses didn’t know it, but the problem wasn’t a disk.  A congenital cyst, present in the spinal column since before birth, had begun to grow and pressure the cord.  Cabieses’ surgery allowed the cyst room to grow and bloom, causing the paralysis.

Years later, my father would paint Cabieses as the bad guy in the episode:  “After I was paralyzed we went to Cabieses and asked – what can we do?  He says ‘look, there’s no hope.  Pretty soon your organs will fail and you’ll die.  If the spasms are so bad, maybe we should take out the muscles in your body so you can die peacefully.’  I said no, ¡basta!  Is there some other doctor we can consult?  He said the only one who might be able to cure you is my teacher in America, Dr. William Beecher Scoville.”

And that’s how it was that my father and mother (with financial help from my extended family, my father’s Masonic lodge, and a generous American church) flew to Hartford, Connecticut, to place themselves in the care of (the soon-to-be miraculous) Dr. Scoville.  I’ll let my father continue the story, as he told it to me many times:

“Once we got to Hartford things moved very fast.  We met Scoville – he did his tests.  He injected this liquid into my spine that showed up on x-rays, and he put me on a special table that tilted from one end to the other.  That way he could see, from the way the liquid flowed, where the obstruction was in my spine.  He operated and found the cyst.  It was about the size of a grape, he said.  This was a very rare condition, and this was one of his greatest operations.  There were three or four operations in his career he was most proud of, and this was one of them.

“The very first day after the operation I was walking again.  And except for my left arm being a little weaker than my right, I made a full recovery.  A few months after that, you were conceived.  And we called you William… en honor al doctor.

“Scoville asked me not to sue Cabieses, so I didn’t.  But some people we knew said they had seen him drinking out late the night before the operation.”

It loses something without my father’s performance, but that was the gist: a bad doctor/good doctor tale. In the process of writing this, I dug up a medical paper that Scoville and Cabieses jointly wrote about my father’s case.  The first thing that struck me was seeing my father referred to as J.G.; here he had attained the same initialed anonymity as H.M. The article puts the doctors on parity in one way: Scoville’s initial diagnosis was no different than the one Cabieses gave: a herniated disk. Scoville just had the wherewithal to fish around until he found the actual problem, the cyst.  The paper confirms what my father used to say, that Scoville was proud of his operation.  The article heralds a first-ever surgical recovery from a rare condition.  (A somewhat sheepish footnote, added months after the initial writing, reveals that neither the condition nor the recovery from it was quite so rare.) The story about the Cabieses’ drinking is, of course, just a rumor.  But if the rest of my father’s story is true, then Cabieses didn’t just miss the cyst, he gave my father a post-operative prognosis and palliative treatment option that, if heeded, would probably have killed him.

William Scoville, on the other hand, gave my father his life back, and for that he became something of a demi-God in my family.  The Doctor stayed in contact with us, even visiting us in Peru once in the mid-60s.

I was too young to remember the visit, but my father told this story about it:  “I took the doctor to the Inca museum.  He stood in front of one exhibit for a long time.  There were some Inca skulls with round cuts in them like they were made very carefully.  Scoville says that looks like brain surgery.  Not just that, but he is noticing that the bone got healed, meaning the patients survived the operation.  And – here’s where it gets interesting… ¿sabes lo que dijo?  Judging from the part of the brain they were working on, they were probably trying to affect personality.  Something even today’s surgeons haven’t achieved!”  My father loved that story because it incorporated two of his favorite themes: the genius of the Incas and the genius of Scoville.  With the information I received later about Scoville’s interest in psychosurgery, I wondered whether the doctor wasn’t a little envious of his Inca counterparts.

My mother liked a different story: “Scoville was visiting around the same time Granpa was with us.  Granpa had been having trouble with his legs.  Scoville is sitting in the living room, seeing my Dad’s leg twitch – and it’s bothering him, he can’t take his eyes of the leg.  Finally he can’t help himself anymore and he gets up, takes that glass ashtray” – and at this point, my mother would usually point to the actual ashtray that we still had – “and he tests my grandfather’s reflexes.  He asks a couple of quick questions, and he says: here’s your problem.  One of my father’s feet was swollen, and he had taken to wearing two different shoes… because one was looser and more comfortable for him.  Scoville says the trouble is that one sole is thicker than the other, and that causes a tilt in his carriage.  And the tilt is what puts pressure on the nerve… back here.”  She points to her lower back.  “And you know what – my father started using the same kind of shoe on each foot.  The problem went away.  He was right!” 

After the company this story was told to left, I would hold the glass ashtray that Scoville used like it was the artifact of a saint.  The ashtray had a chip off one of its edges… did the doctor use the sharp edge or the smooth edge to tap my grandfather’s knee?  I was too young to remember the Lima visit, but we still have photos of it.  One shows the surgeon with his young namesake by his side.

Allow me to pause and point out what might be obvious.  My family at this point knew nothing about H.M. or his operation. I didn’t find out until the mid-nineties.  I was leafing through my Sunday paper when Scoville’s name jumped off the page and ambushed me. It was a review of Philip Hilts’ Memory’s Ghost, a book about H.M. The review made Scoville seem craven, even joking to his wife about the mishap.  I remember so clearly thinking: ‘I wish Papi were alive so I could see what he thought of this!’  It’s only when I was writing this piece that I constructed a timeline and soon realized… that would have been impossible.  The book came out in 1995; my father did not die until three years later.  Why didn’t I tell him?  To protect him from being disillusioned?  To protect me from unpleasantness?

Which leads to the question: how does memory get bent?  It’s as if we have event dots in a mental graph of our life, and we draw a regression line through them.  This line is who we are, where we’ve been, what our strengths and weaknesses are: our character, our story.  We extend that line with a confident, dotted projection that leads to the glory or tragedy or oblivion we anticipate for ourselves.  And when no one’s looking – and we’re not looking – the event dots get shifted a little closer to the regression line so that our story is a little tidier, a little more dramatic.  It doesn’t matter why I failed to tell my father; I was embarrassed that I didn’t.  So I changed the memory.

But here is where I have to wonder: what must it have been like to be H.M.?  If you cannot produce memories any more, then how can you produce a narrative?  And is this “self” we have anything more than just a narrative?  They say that when he was uncertain of something H.M. would often remark, sometimes several times a day: “I’m having an argument with myself.” When his memory was removed by suction tube, did a unitary sense of his self go too?  Of course, he recognized the package of sensation bundled in his skin – but did he see a character?  Was there a Henry in Henry’s mind?

*   *   *

We moved to the Dominican Republic in 1976; Dr. Scoville had occasion to visit us there not long after we arrived.  Before I describe how I remember him, let me share some descriptions I’ve come upon of the younger man.  Everyone describes Bill Scoville as exceedingly handsome – and photographic evidence confirms it.  He was a high-spirited man who met his first wife by jumping onto the running board of the moving car she was in.  A colleague recounts other daredevil anecdotes: how he climbed a cable to the top of the George Washington Bridge at night, and how another time he jumped into a Spanish bullring with a live bull.  In his youth, Scoville wanted to be a mechanic instead of a doctor, but his father prevailed on him to choose a proper profession.  His mechanical proclivity led to his inventing and refining many neurosurgical instruments, but cars remained an enduring passion; he loved working on them and he loved driving them very fast.  He owned a string of Jaguars, which he kept shiny and in excellent condition.  And he applied his sense of adventure to his profession too: the same colleague describes him in a written tribute as “a free spirit, unfettered by rules and regulations…he is an innovator, never willing to accept the status quo… driven by an insatiable ego, seeking better ways of doing things and espousing new ideas with their frequent and often angry confrontations.”

The man I met was more mild-mannered – by the time you’re 70 years old, perhaps everyone is more mild-mannered.  He had a second wife by then – a handsome, French-speaking woman – and two young children.  We took their family to the then-best restaurant in Santo Domingo, Vesuvio – an Italian place on the Malecón.  I remember his son more than him. I was a precocious 15-year old and he was a just-a-bit-more-precocious 12-year-old.  Like me, he had been given Dr. Scoville’s first name.

For the most part, the Doctor seemed a little detached, a little distracted.  But there was a point after dinner when the tone on the adult side of the table firmed.  My father had lit up a cigarette after his meal and Scoville had admonished him, urging him to give up the habit.  He was a man not prone to being chastened, but my father smoked his last cigarette that night.  I’m sure he must have long known the insalutary effects of smoking, but the message gained force when it came from Scoville.  (Curiously, he was too proud to remember it that way.  In coming years, when he talked about giving up smoking he would say: “I woke up one morning and los cigarillos disgusted me.  Just like that I quit.”)

Knowing that Scoville was something of an adventurer, my father had talked a wealthy friend into taking us deep sea fishing.  It was threatening to rain, so our host wondered whether we should perhaps call it off.  Scoville would have none of it.  You could tell the prospect of wrestling with a marlin a la Papa Hemingway had captured his imagination.  I was pretty excited too, so I was glad he was game.  Unfortunately, we didn’t even get a nibble on the line, and had a rough ride on some choppy seas.  By the time we were back at the dock Scoville was disappointed and a little seasick.  I remember him bumping his head as he climbed out of the boat, and seeing him hold on to the part that hurt.  The image of him I was left with was of a fragile old man: discouraged, queasy… and now injured.

As we were saying goodbye on that visit, Scoville addressed me, the pimpled teenager who was named after him.  “If you decide on a medical career, I would be glad to write you a recommendation to Yale Medical School, where I teach,” he said.  This pleased my father immensely. “Yale Medical School is one of the best medical schools in the world, if not the best!” he gushed after the doctor left.  “And Scoville is willing to write you a recommendation!” He might have thought this was a sufficient condition for admission; my father had the Latin American view (which was proven correct often enough) that the world turned on an axis of personal connections. Of course, a medical career was the last thing on my mind.

The next time I saw Scoville was under a less happy circumstance.

I was 17 and very excited about going off to college at NYU.  I was literally counting down the days in my head.  Around the time I was down to single-digits, the Dominican Republic was hit by one of the worst tropical hurricanes of the century: Hurricane David.  Our ground floor apartment was flooded with a foot of water.  Looking out the taped windows it seemed like you were peering into contents of a blender.  Trees were uprooted within our view.  The next day we would learn that the eye of a category 5 hurricane had passed almost directly over us.  2,000 Dominicans had been killed.

My father was working for a non-profit at the time.  It was quickly decided that, in order to solicit funds for hurricane relief, he would take the trip to the U.S. with me.  While he was up north, he would take advantage of the opportunity to get a check-up with Scoville at Hartford Hospital.

We arrived in New York and took a hotel room in the east 20s.  Our first night in town we decided to go see a movie.  When we walked to the theater my father asked me to hold his arm while he negotiated the curbs.  His check-up with Scoville was not customary; there had been a marked deterioration in his condition over the last few months. That night we saw Woody Allen’s Manhattan, which was late in its initial run then.  It seemed to me like a preview of my new city’s secrets and sophistications.

The next day we took the bus to Hartford and a taxi to the hospital.  Dr. Scoville greeted us in a warm but brisk manner.  Here in his habitat, the Doctor no longer seemed as vulnerable as he did back on the Caribbean dock.  After running some tests, his verdict was curt: “I’d like to operate again.”  He explained that he would need exploratory surgery to see what was going wrong.  My father wasn’t expecting this.  “Do I have time to return to Santo Domingo and put my affairs in order?”
            “I’d prefer to do it sooner rather than later,” Scoville replied.

The operation went for longer than expected.  Being in the waiting room felt a little surreal… like I was in a too-melodramatic movie.  I remember a kind nurse asking if I needed anything.  And my memory of this is hazy but I think that after many hours Scoville came out and said something non-committal.

Scoville had only found adhesions, the scarring from previous operations, which he tried to remove as well as he could.  However, my father woke up largely paralyzed from the neck down and would remain so for the rest of his life.  He would retain limited use of his hands and a bit of feeling in his legs.

Years later, after Scoville’s death, my father would travel to Los Angeles to be examined again – this time with the benefit of an MRI, a diagnostic tool not commercially available at the time of Scoville’s operation.  The doctors would tell him that Scoville had operated in the wrong place.  The cyst had regenerated, but in a new location. Scoville had missed it altogether.  Perhaps the operation itself did damage to the spinal cord, or perhaps it aided the progression of the cyst, as Cabieses’ operation apparently did.  Either way, it seems likely that a better outcome was possible.

Looking back on those days since, I’ve often thought: if the boy that accompanied my father to Hartford Hospital had been a man, he might have had the presence and maturity to worry whether an operation that so depended on motor skills should be left to a septuagenarian.  He might have had the sense to suggest that they seek out a second opinion, even if Scoville was good.  Truthfully, I don’t feel guilty about the judgment I did not contribute to – the judgment to operate in Hartford with Scoville.  I find it highly unlikely that the 17-year old boy could have stood up to the family God.

My father used to say that he had never been prouder of me than the day he took me to kindergarten and I was the only kid in the class who didn’t cry.  The proudest he ever made me was in the days of his post-operative convalescence, when he arranged for some executives from a charity in Hartford to visit him in the hospital regarding hurricane relief.  I had seen these performances before.  When my father asked for money, he was never a beggar… he was a salesman.  He didn’t ask pity for a weather-torn nation; he offered opportunity! – a chance to do good, to help rebuild.  It was a great pitch.  Even flat on his back in a hospital bed – his limbs no longer under his command, his life to come under a dark shadow – he could still cast a spell over these stoic New Englanders.

*   *   *

So what is the verdict on Scoville?

It would be unfair to write of the H.M. operation without providing fuller context.  When he came to Scoville, Henry Molaison’s condition was dire.  Prior to the operation he was having around ten minor blackouts a week; the grand mal seizures came as often as once a week.  The disease was disrupting every facet of his life: work, family, social.  He was not allowed to rise to the stage for his high school graduation, for instance, because it was feared he would have a fit.  Drug therapy did not work for him.

Also, we must put the event in its period:  this was the heyday of psychosurgery.  Only four years earlier, António Egas Moniz had been awarded the Nobel Prize in medicine for his work in developing the prefrontal lobotomy.  And while nowadays the establishment might look askance at what Scoville himself called a “frankly experimental” procedure, the ethical protocols of current medicine had not been developed yet: no informed consent forms, no institutional review boards.

Having said that, Scoville performed an irreversible procedure on an organ even our current science understands poorly.  It is a medical doctor’s first principle: first, do no harm.  Scoville would argue that in his opinion the potential benefits outweighed the risks, but at least one of his contemporaries found the operation questionable; when Scoville shared the results over the phone with Dr. Wilder Penfield, an eminence gris in the field, his colleague is said to have exploded in anger.

Providing fuller context also forces fuller accounting.  Scoville was one of the pioneers in bringing the lobotomy to the U.S., one of the more dismal procedures of 20th century medicine.  It is true, he was more sensitive to the side effects of the operation than others were.  While the huckster Walter Freeman was streamlining the procedure into a 10-minute-long ice-pick-poke-through-the-eye-sockets that he even performed in hotel rooms (disabling patients that included JFK’s sister Rosemary,) Scoville was refining what he felt was a subtler, less damaging method called orbital undercutting.

Yet Scoville was complicit in the big problem with lobotomy: it was the lobotomists who decided how successful they were.  Even in our day of evidence-based medicine, clinical trials for new surgical techniques are a rarity.  That’s problematic, but less so when the results can at least be measured reliably; an orthopedic surgeon trying a new knee operation, for example, can measure the flexibility and strength of the post-operative joint to the degree and pound-of-pressure.  Measuring psychic pain is more difficult.  And crucially, weighing alleviation of pain against loss of intellect and higher functioning is exceedingly difficult.  That is as much a philosophical as a medical problem, and that is what psychosurgeons needed to decide.  Such a subjective call should not be left to doctors with a possible attachment to their handiwork.

There is evidence to question whether Scoville’s judgment was always sound in this regard. On H.M.’s chart prior to discharge, Scoville marked his patient’s condition after the operation as “Improved.”  And in a 1961 paper he writes that total lobotomy is more likely to be indicated in the case of patients with a “low cultural background.”  Presumably, this is because he believes that people with a lower educational level are less likely to miss the higher intellectual capacities that a lobotomy might damage, but really… isn’t that presumptuous?

Scoville didn’t just begin psychosurgery earlier than most, he held onto it longer too.  By 1973, lobotomies had almost disappeared, made obsolete by drug therapies and electro-shock treatment, but a New York Times article of the time introduces Scoville as having “possibly performed more lobotomies than any other surgeon alive today.”  Even at that late date Scoville is a proponent, claiming a 50% improvement rate, and admitting there is a price to pay: “the blunting of higher sensibilities, such as intelligence, abstract thinking, and the ability to fantasize.”

How should we judge Scoville?  I’m sure he was a man who tried to do good, and I’m sure that for many patients he succeeded.  Still, there is arrogance in his ambition.  I have to suspect that his dreams of beneficent glory sometimes overshadowed the frail specimens of humanity before him. I have to imagine there were times when his story told him, when the shadows cast their caster.  Scoville coveted the power to reshape the brain, the seat of the soul, the source of our suffering.  He sought the power of a God.  And like Icarus and Prometheus and all the other fellows who got too big for their britches, in the case of Henry Molaison he had a comeuppance – a very gentle one by mythological standards.

My father rebelled against greater authority too.  Soon after he returned to the Dominican Republic as a quadriplegic, it seemed like he engineered a rupture with his employer, an organization that had been remarkably caring about his condition and accommodating of his handicap.  His story would not be stymied by tragedy; indeed, he would send them to hell just to show them he was as capable and self-sufficient and fierce as ever. Underestimating his will was always dangerous: even after having lost that job, and even from a wheelchair, my father made substantial sacrifices and managed to put me through college – albeit with the help of a scholarship I was very lucky to receive.

That personal narrative which was forever quieted in H.M. – it must have been a raging, heroic symphony thundering in the minds of both Scoville and my father.  It must have made the wispy music of the world sometimes hard to hear. The best defense I can make for whatever hubris either man had is emotional: that I owe so much to it.  If my father had not recklessly disregarded obstacles, would I have received the education I did?  Would I be forming these same thoughts?  If William Beecher Scoville had not been too confident of his abilities, would he still have had the verve to cure my father?  Would I have even come onto this earth?

*   *   *

Scoville was killed in an automobile accident in 1984.  I wonder whether he was driving?  I wonder whether his love of fast cars finally did him in.

My father spent the last 19 years of his life in a wheelchair.  He died in 1998.  The cause was complications from bed sores, the bane of paralysis patients.

Henry Molaison – the famed H.M. – outlived them both.  He died on December 2, 2008, sparking many wonder-filled obituaries.

Ironically, today I find myself striving to achieve H.M.’s condition.  It’s not that I want to lose painful memories.  I want to discard burdening narratives: quiet the voices that grieve for loves lost and promise unfulfilled; quiet the whispers of sweetness to come, grandness to come.  I want to live my life – not a story of my life.  I spend a half-hour each morning sitting, watching my breath. It helps bring H.M. a little closer.  In the Zendo I frequent there is a statue of the Buddha holding a knife; I’m told he uses it to surgically remove attachments.

Of course, I don’t literally wish for H.M.’s loss of faculties.  Scoville took much of his life away from him: the ability to form relationships, to care for himself, to observe himself. Yet if we see him as just the victim of a horrible surgical mishap, we don’t do his life justice. They say that apart from his disability he was personable, humorous, intelligent.  And importantly, H.M. was a teacher to humanity.  The studies of him by Brenda Milner and Suzanne Corkin have opened up a new era in memory science. Henry was, at least intermittently, aware of this role.  In an audio recording from the 90s he is heard saying in an earnest, middle-aged voice: “The way I figure it is, what they find out about me helps them help others.”  It was a ravaged life, not a wasted one.

For H.M. and for me, Scoville was Shiva… a creator and a destroyer.  Rest in peace, Henry, known to the world as H.M. Rest in peace, William, who’s name I took.  Rest in peace, Jorge, whom I called Papi. 





Thursday, January 21, 2010

Clowns to the Left of Me, Jokers to the Right

It may be premature to write the obituary of health care reform today, but it’s hard to deny that it is bleeding, panting and prone. Who was responsible for what may be its mortal wounds?

It wasn’t Martha Coakley or Scott Brown. It isn’t her fault that she’s an awful candidate, or his fault that he’s a talented one. No, the bulk of the blame belongs to others. With deference to one of our honorees, let’s call these… the worst persons in the world!

This debacle wasn’t all these guys’ doing. But each of them represent in a perfect way the three groups that dimmed the dream of health care for (nearly) all. 

Republicans. Richard Nixon proposed a health care plan that was very similar to the current proposal. Mitt Romney signed a plan in Massachusetts that was also a close analogue, but failed to address costs. A proposal like this one has been well within the Republican mainstream before, yet still Republicans have maintained the fiction that this was a far-out government takeover of health care. It is hard to conceive of how a plan could do more to minimize government intervention and still broaden coverage significantly. 

The Republicans calculated that they had more to gain from a Democratic failure than from a bi-partisan success – and of course, they were right. But if they ever regain a Congressional majority, they will have to live with the culture they have created... drink the soup they've peed on, if you will. They’ve not only proven that obstruction is a winning formula, they have facilitated the means. 60 votes in the Senate, a super-majority that Republicans have not enjoyed since 1922, is now necessary for -- not just controversial -- but any significant bit of business. They might be able to lower taxes and drive us into penury through reconciliation, but anything needed and significant (like controlling Medicare costs) will be out of their reach. We are well on the way to Californiazation: a labyrinth of gridlock with Debt as the Minotaur.

Democratic Centrists. If Max Baucus had not dawdled for months in the foolish hope of getting a Republican to sign on and thus make it a little easier for his centrist buddies to cast a tough vote, this bill would already have been signed. If Lieberman had not killed Medicare expansion, a lot of support from the left would have been saved. If Nelson hadn’t held out for a Nebraska freebie, the Republicans’ best talking point would have been averted. All these guys, but particularly Baucus, share responsibility for the bill’s predicament.

Look, all sides face political pressure. And it is perfectly legitimate for legislators to fight for their interests. But politics is a team sport. It is better to score fewer points on a winning side than be the losing side’s big scorer. These guys thought they were covering their hide, but all of them will be in electoral trouble anyway; it’s impossible to defend a losing bill you voted for. When they get sent home, they won’t be able to say they saved many families from bankruptcy, or got medical care to those who needed it. They lacked circumspection and a sense of proportion about the stakes at play. They valued their place in office more than their place in history.  

Democratic Lefties. Let’s not pretend this bill’s death-knell came solely from the moderates. In fact, some timely reporting seems to indicate that it is the progressives who are setting up the roadblock in Congress. Who are these people led by? Olbermann in the media, Kucinich in Congress, Jane Hamsher in the blogosphere. They decided to draw their line in the sand at a bridge too far: the public option, a proposal that never came close to having 60 votes. Even after the public option was diluted beyond significance, they kept at it as a matter of pride. What was the effect of this? Here, why don’t I show you.
 
Given that so many are dissatisfied with the bill because it doesn’t go far enough, it’s safe to say that if the proposal had maintained the support from the left the bill would enjoy a comfortable plurality of approval in polls and the narrative that it is unpopular would never have taken root. Lefties were angry that centrists were using their leverage in full, and they wanted to have an equivalent amount of leverage. The only way to do this was to convince others (and themselves) that they were willing to walk away too. The natural effect of that was for people, on the left and in the middle, to say… “well, it must not be a very good bill then.”  

I’ve been flabbergasted at the epic ennui that so-called progressives have shown regarding the biggest progressive proposal in decades… the political dream of our lifetimes. They have placed the proposal in a murderous crossfire. Throughout, I’ve been stunned at how difficult it’s been to convince them that our most important priority should be extending coverage to the uninsured, something that I would think would be a basic assumption for them. Instead I’ve heard concern about cost controls being insufficient (as if the status quo were better), concern that the most effective form of cost control is included in the proposal, concern about the Democratic brand, concern about corporate profits, concern about ‘regressive’ taxation (on plans that cost what many would consider a healthy wage.) Really… does any of that stack up against the insuring 30 million people? Does it stack up against letting a whole lot of sick people get medical help? 

I’ll say it again… politics is a team sport. It does not help the progressive cause to destroy a Democratic Presidency that could have (and still might) launch a decades-long majority.

And how has Obama done? I think his strategy was sound, but he is on the verge of a big mistake, if we take his morning talk seriously. Kevin Drum is absolutely right: going back to the Senate would be very foolish. If Obama tries to negotiate a new bill with Snowe and the Republicans, they will do the exact thing they did in 2009. String him along for months but leave him stranded well before a roll call is called. The preferable option is for the House to pass the Senate bill with a reconciliation sidecar. If it can’t do that, then they should pass a (by necessity) more modest bill with reconciliation. Ezra Klein suggest Medicare buy-in, Medicaid expansion, and taxes on the rich to pay for it.

If Obama does choose to go back and grovel to the Republicans, he will have lost this faithful supporter. As the former President Bush once sagely said: "Fool me once, shame on me. Fool me twice… won’t get fooled again."

Tuesday, January 19, 2010

Fiscal Infantilism

My major beef against the GOP is that it is the major purveyor of fiscal infantilism in our country. What's the standard line?

"Obama has run up a $1.2 trillion deficit! We need to cut spending to bring down that deficit, and cut taxes to get our economy going again."

But won't cutting taxes hurt our deficit?

"No! Cutting taxes pays for itself by spurring the economy."

Even among conservative economists, the only ones who believe this last claim are hacks like Larry Kudlow who are willing to deceive themselves on the historical evidence. Look at this graph:



The Republican tax cuts of the early 80s and early aughts both raised the deficit, even as a percentage of GDP. Reputable conservative economists like Gregory Mankiw readily admit that tax cuts cost money.

But for the sake of argument, let's imagine unicorns exist and tax cuts pay for themselves. Can we balance the budget by spending cuts alone? Well, how much is the deficit projected to be next year again? $1.258 trillion. And how much is discretionary spending for next year, including defense? $1.250 trillion. You could literally cut ALL of government except for Medicare and Social Security and still not be able to balance the budget. (And of course, we know from the current health care debate that Republicans would NEVER cut Medicare spending.)

The smart conservatives all know that they can't make these promises and be fiscally responsible, but they wink at each other and say "hey, tax cuts have been pretty good for getting us elected in the last 30 years. Why change a winning formula?"

Because you can't govern responsibly by getting elected on this platform.

And why do the talking heads, who often profess to be intensely concerned with matters of fiscal rectitude, why are they unable to ask a Republican a tough follow-up when they propose mathematically impossible remedies for our country's problems?

Honest disagreements are possible in politics, but this is surely a question of character. The numbers are inescapable. If a politician is willing to run on the standard Republican platform, he is either a stone-cold idiot or someone who cares more about power than their country.

Sunday, December 27, 2009

The Case for Geo-engineering

Nathan Myhrvold appeared last week on Fareed Zakaria's GPS making a compelling argument for geo-engineering in general, and one scheme in particular. I encourage you all to hear him out.

The arguments against geo-engineering tend to fall into three categories. The first is that we don't know whether geo-engineering will work. The second is that it is harmful to even talk about geo-engineering because it might puncture the political will to reduce carbon emissions. Third and finally, geo-engineering is a bad idea because it might bring about unintended side-effects.

Like most advocates of geo-engineering, I would argue that it should be researched further and deployed in conjunction with emission controls, not replacing them. However, in the interest of a fuller examination of our options, I will note that all three arguments could be made just as convincingly against emission controls.

We certainly don't know that an emission control strategy will work -- politically, at least. The IPCC has said that developed nations should reduce carbon emissions by 25-40% come 2020 in order to have a 'reasonable chance' of averting catastrophic global warming. Many now say these targets are too lax, but the Waxman-Markey bill currently being considered in the Congress wouldn't meet them. The bill would reduce U.S. emissions by 17%, and and even that weak bill has little chance of becoming law. With China determined not to jeopardize its growth strategy with verifiable targets, the odds of a global treaty that might head off global warming have to be counted as tiny.

The second argument is easier to dispense with. As Myhrvold himself argues, blaming geo-engineering for reducing the will for carbon controls is like blaming a bypass surgeon for encouraging his patient's snacking. You might also blame carbon controls for discouraging people from taking geo-engineering seriously.

The final argument is more substantive. Many people instinctively recoil at Myhrvold's proposal to reduce solar radiation by pumping sulfur dioxide into the stratosphere via an 18-mile-long hose suspended by a trail of balloons. How could more pollution cure the effects of pollution? But the reason Myhrvold focused on sulfur dioxide is because a natural experiment of this stratagem has already occurred. When Mount Pinatubo erupted in 1991, 20 million tons of sulfur dioxide were injected into the air, lowering temperatures by half a degree. We know the climactic effects of this chemical, and we know its atmospheric effects as well because our power plants already eject it, albeit at far lower altitudes than Myhrvold is proposing. The overall amount of sulfur dioxide believed to be necessary to tame global warming is about one-twentieth of one percent of the amount ejected today by natural and man-made sources, but by expelling it near the arctic and at high altitudes we would be leveraging this chemical for the maximum of its reflective potential.

Are the risks zero? No. We need to research this idea further. But again, the unintended side effects argument could be made against emission controls too. Not even the most optimistic economists think the transition to a non-fossil-fuel future would be free in terms of GDP growth. Particularly in developing countries, GDP has a high corelation with all kinds of mortality data. Sacrificing growth could cost many, many lives.

If we are to be humble about what we don't know, then we should truly be humble about what we don't know. PBS recently had a valuable piece on the environmental effect of mining rare earth compounds in China. Rare earth, a collection of 17 rare elements in the periodic table, is indispensable for many green technologies from car batteries to wind turbines. At the dawn of the internal combustion engine in the 18th century, we had no idea what effect this technology would have on the environment. Can we say for sure that we know all the risks that renewable energy technologies might pose? These wouldn't be discrete acts like putting a hose into the stratosphere, but a million uncontrolled experiments scattered throughout the globe.

Of course, carbon dioxide has effects other than global warming. It also leads to the acidification of the oceans, for example. That is why geo-engineering cannot replace a saner energy policy, but it has to be at its side, preferably before the 'tipping point' effects such as methane release from permafrost and arctic ice melting take their worst toll. At its most basic, geo-engineering is something humble (and cost-effective) like painting your roof white to reflect more sunlight. More ambitious schemes include seeding oceans with iron to encourage plankton growth (the plankton captures CO2) and using solar-powered devices to create water vapor clouds over seas. The governments of developed countries, including our own, need to explore the safety, effectiveness and viability of these technologies.

Finally, I want to make a purposefully provocative comparison. The right-to-life movement tells us that abortion is murder. If they really think it's murder, shouldn't they be the biggest advocates of education about contraceptives? Usually they aren't, because they often believe that sex out of marriage is a sin too, and that education about contraceptives encourages this sin. Of course, education about contraceptives is not promiscuity. It is not even encouraging promiscuity, and might well include messages intended to discourage it. At its worst, education about contraceptives might be seen as encouraging promiscuity. So let's step back: is seeming like you might be encouraging promiscuity really worse than murder? Even if it were a sin, shouldn't you pick a lesser sin if it will diminish a far greater sin? The truth is that the right-to-life movement wants to use abortion as a trojan horse for its ethos. They say abortion is murder, and I'm sure they believe it, but they aren't willing to let go of their worldview in order to act rationally on their convictions.

I fear the same thing is true for not all but many environmentalists. They say the fate of the planet is in the balance, but if it truly is, shouldn't we be exploring every avenue to solve the problem? In the clip, Fareed Zakaria describes their attitude as Calvinist. I'd say they have developed a sort of secular spirituality. In their view, the only thing that will appease Mother Earth is not another sin, but the properly sanctioned sacrifice.

Monday, November 2, 2009

A Third Way in Afghanistan

President Obama is currently pondering the most difficult decision of his young administration: our country’s future direction in Afghanistan. His choice has often been portrayed in the media as binary: should he pursue the counterinsurgency strategy (COIN) proposed by General McChrystal, or should he follow the counter-terrorist strategy advocated by Vice-President Biden?

Media reports indicate that Obama is unsatisfied with the choices he has, and he should be. Both approaches are fatally flawed. Before I say why that is the case, and what a better strategy might be, let’s review why we’re in Afghanistan at all.

What are our interests in Afghanistan? If the Taliban returns to power, it would likely provide a haven for Al Qaeda to launch terrorist attacks against us. There is a legitimate controversy as to how important safe harbor is for an organization like Al Qaeda, with many pointing out that in the past attacks have usually originated in European cities, and that Al Qaeda is now functioning under a ‘cloud’ model that obviates central command. This is true, but it is undeniable that allowing them to reconstitute a sheltered and functioning command and control would be an operational and propaganda victory for them.

If this were the only risk, it would not be sufficient reason for us to stay. The more serious risk we run is that a Taliban victory in Afghanistan might provide moral encouragement, financial assistance and tactical support to an insurgency in Pakistan. Pakistan has a large and capable military, but it is badly infiltrated, and the Pakistani population is the most radicalized in the region. Given that Pakistan has around 50 nuclear weapons, a radical fundamentalist regime next door is simply an unacceptable risk. The claim that is sometimes made about the Iranian leadership – that they are so fanatical they are willing to take risks that threaten their existence – is probably not true about them, but has proved true of the Taliban. In 2001, they threw away power and risked their lives rather than give up their Al Qaeda cohorts; that is a symptom of fanatical – and undeterrable – ideological commitment.

Preventing a Taliban victory, however, is a daunting task. In his recent resignation letter, U.S. Diplomat Matthew Hoh spelled out the difficulties. One doesn’t have to agree with his prescriptions to admire how well he frames the challenge:
If the history of Afghanistan is one great stage play, the United States is no more than a supporting actor, among several previously, in a tragedy that not only pits tribes, valleys, clans, villages and families against one another, but, from at least the end of King Zahir Shah's reign, has violently and savagely pitted the urban, secular, educated and modern of Afghanistan against the rural, religious, illiterate and traditional. It is this latter group that composes and supports the Pashtun insurgency. The Pashtun insurgency, which is composed of multiple, seemingly infinite, local groups, is fed by what is perceived by the Pashtun people as a continued and sustained assault, going back centuries, on Pashtun land, culture, traditions and religion by internal and external enemies. The U.S. and NATO presence and operations in Pashtun valleys and villages, as well as Afghan army and police unites that are led and composed of non-Pashtun soldiers and police, provide an occupation force against which the insurgency is justified. In both RC East and South, I have observed that the bulk of the insurgency fights not for the white banner of the Taliban, but rather against the presence of foreign soldiers and taxes imposed by an unrepresentative government in Kabul.
So when General McChrystal, in his August 30 assessment, writes:
ISAF’s [International Security Assistance Force’s] center of gravity is the will and ability to provide for the needs of the population “by, with, and through” the Afghan government. A foreign army alone cannot beat an insurgency; the insurgency in Afghanistan requires an Afghan solution.
He is giving away the very Achilles heel of the operation. The Afghan forces are as much invaders to the Pashtun tribes as the Americans are. The tribes see them as a force they’ve been fighting for decades: a Kabul-centered government that takes much, imposes much, and gives back nothing. Even if Kabul were squeaky-clean instead corrupt, and duly-elected instead of illegitimate, it would still not command the allegiance of the Pashtun tribes that have resisted their rule for decades. The Pashtun do not like the Taliban either, and they resent their interference – but at least the Taliban is Pashtun. Hoh rightly calls this sentiment ‘Valley-ism.’ The Pashtuns value affiliations of family, tribe, and proximity far more than they feel the bonds of nationality. That at this stage, we do not understand the nature of the challenge ahead of us is uncomfortably reminiscent of Vietnam, where we mistook nationalism for ideological fervor.

Conversely, the problem with a counter-terrorist strategy is not that it is impractical, but that it doesn’t address our interests adequately. Aerial strikes on terrorist targets would make our presence unpopular to the local population, and might hasten a fall of the government. The U.S. might be able to prevent the building of training camps in Afghanistan, but that is all we would prevent. An ideological movement threatening our vital ally, Pakistan, would remain unchecked.

We need to take a step back and ask ourselves: Is the end state we are envisioning – a stable and democratic Afghan government with control over all its land – necessary for the achievements of our goals? The answer is no. We are trying to give Afghanistan something it has never had before, something we do not need in order to defeat the Taliban.

Our recent experience in Iraq might hold some lessons for us. The key to the dramatic turnaround in that country was not the small increase in troops called “the surge,” or the change in strategy to COIN (which since it depends on a change of attitude in the population, would certainly have taken far longer to show such dramatic results.) The reversal was due to the Anbar Awakening: smart U.S. officers on the ground recognized a rift between Al Qaeda and the Sunni insurgency and intelligently exploited it. They backed and coordinated with Sunni brigades called “Sons of Iraq” that employed disaffected former insurgents. This is a strategy that bubbled from the ground up, and it caught everyone by surprise. We didn’t need to defeat our enemies; we could, in effect, hire them.

Perhaps something similar is possible in Afghanistan. Major Jim Gant, a decorated Special Forces officer, was stationed in 2003-2004 with seven other U.S. troops in a small Pashtun village near the Pakistani border. He writes about this experience in a paper, and corroborates much of what Hoh wrote:
Afghan tribes always have and always will resist any type of foreign intervention in their affairs. This includes a central government located in Kabul, which to them is a million miles away from their problems, a million miles away from their security.
But Gant goes on to describe how he developed close relations with the village chieftain, whom he affectionately called "Sitting Bull." He was audacious enough to arm and supply the village's fighters, probably breaking many rules but winning their trust and allegiance and gaining access to valuable intelligence. It is this approach - a tribal engagement strategy - that he advocates for the country as a whole. He calls the fighters Arbakai, a tribal militia that would protect their neighbors from Taliban intimidation. These could be the Afghani equivalent of the “Sons of Iraq,” grass-roots warriors defending their own tribal interests, with the U.S. as their ally – not imposing a central government on them, but giving them what they want: security, their tribal traditions, and the right to be let alone.

I will go farther than Gant does. Instead of envisioning an end state where Kabul dominates all of Afghanistan, we should be striving for Kabul + Largely Autonomous Tribe Lands. The Karzai government would control the heavily populated areas in the east of the country, and as best they could the border areas with Pakistan. They would have nominal sovereignty over their country, as previous Afghani governments have. The Pashtuns would be empowered to defend themselves from the Taliban, but they would largely be free of Kabul too. Provincial government structures would have to be developed in order to resolve inter-tribal conflicts and law-and-order issues; largely, governance would come from nearby.

Obviously, bringing about this end state is an extraordinarily difficult task. We would need a lot of men like Gant: smart, highly trained, with a ravenous cross-cultural appetite and a keen emotional intelligence. These people would have to develop close relationships on the ground and would need to attain a granular view of local politics. It would be a war won not so much by force as by micro-diplomacy. Despite the complexity of the task, this might be the only way to achieve our objectives. It is foolish to fight a war that requires winning the allegiance of an inherently conservative people while also attempting to re-engineer their society. As Gant writes:
We will be totally unable to protect the “civilians” in the rural areas of Afghanistan until we partner with the tribes for the long haul. Their tribal systems have been there for centuries and will be there for many more. Why should we fight against not only what they have been accustomed to for centuries, but what works for them? They will not change their tribal ways. And why should they?

Friday, October 9, 2009

Beyond Theory

In this recent op-ed David Brooks contrasts Bentham, an arrogant central planner, with Hume, a humbler fellow who prefers decentralized, market-based solutions to problems.

I agree that there are two kinds of people in the world, but I don't divide them this way: my two groups are pragmatists and ideologues. One group works from the evidence to the solution; the other works from the solution to the evidence.

At this point in history, we can safely say that we know these things for sure: pure, unfettered markets do not work and central command economies do not work. The ideal is somewhere in the middle; we need to sort out when it is the right time to to intervene and regulate, and when we need to let the market do its magic. Who do we trust to do that? Who can look at the evidence dispassionately, and make decisions based on facts instead of predilections?

If I know nothing else about them, I'll go with the person who doesn't enter the room trumpeting his principles.

In Angels in America, Tony Kushner has the world's oldest living Bolshevik plaintively ask "how are we to proceed without theory?" That same question seems to be stirring in the hearts of many conservatives today.

Thursday, August 20, 2009

Pssst! My Negotiating Position Is Not My Real Position

I know I’m not supposed to say this. I’m supposed to say “the public option is non-negotiable! No public option, no health reform!”

I realize why I’m not supposed to say what I’m going to say. The people who are willing to walk away from a deal are the ones who have the negotiating leverage. I know this. But even though I really want to see the health care reform bill include the public option, I have this thing… I can’t help but blurt out the truth sometimes. And the truth is I wouldn’t dream of letting health care reform die just because public option wasn’t included. Why? Well, isn’t it obvious?

What would happen if health care reform failed?

  • Barack Obama’s presidency would be crippled. Any hopes of passing cap-and-trade, financial reform, or an immigration bill on our terms would be dimmed dramatically.

  • The Democrats would likely be punished in 2010. The last time a popular Democratic President failed to pass health care reform the Dems lost 54 seats in the House. A swing of that magnitude would give the Republicans the lower chamber again.

  • Health insurance companies would be able to continue to dump sick patients from their rosters.

  • Coverage would continue to be out of reach for those with prior conditions.

  • Lifetime caps and high out-of-pocket requirements would ensure that the endless march of healthcare bankruptcies continued.

  • We likely would not see another attempt to reform health care for a generation, if ever. 18,000 people die from lack of health coverage every year; extend that number over two or three decades and perhaps half a million people might die unnecessarily if we fail to gain universal coverage.

I’m not willing to pay this price. All these items could be avoided and reversed, even with a plan that did not contain a public option. Would a true progressive put an ideal bill above the pressing interests of 47 million uninsured? No, of course not. But we have to say we will!

Pretending that we are willing to kill health reform forces us to use unconvincing arguments sometimes. For instance, we say that if we don’t get the bill right this time, we’ll never get it right. This is baloney. Comprehensive health reform is extremely hard to pass: Truman, Johnson, Carter, and Clinton all failed at this challenge. There’s simply no evidence that tweaking health programs once they are law is nearly as difficult. S-CHIP has been repeatedly amplified and refocused, Medicare grew a prescription benefit, and Medicaid has been tweaked many times over the years, sometimes for the better and sometimes for the worse.

We also say that if we don’t pass the public option health care expenses will grow out of control and the Dems will be blamed for it, allowing the Republicans to roll back our reforms. Of course, the other side will try to blame us for growing expenses (and they will likely grow anyway, with or without the public option.) But what would happen with no bill at all? Many significant measures that would lower cost and improve quality – like comparative effectiveness research, more power to MedPAC, and health care IT expansion – would be lost. As for the idea that the Republicans would roll back universal coverage, I say this: Will. Never. Happen. No industrialized nation that has achieved universal coverage has ever gone back. Even Margaret Thatcher, a political giant who privatized every damn thing she touched, didn’t dare touch the British health service.

We have to over-sell the public option. CBO says it will save the government $150 billion over 10 years; a whole lot of money, but we have to pretend the fate of the trillion dollar plan depends on these savings. And we have to exaggerate the scope, even though it’s likely that only 10 million people will be covered by the public option.

Finally, in order to make sure that Obama puts maximum pressure on the Senate centrists, we have to pretend that he has the magical ability to buckle Senators from states where he lost by 15 points. Even though we’re a ways from getting even 50 votes in the Senate, we have to pretend that 60 is a cinch. As they say, the squeaky wheel gets the grease.

I know I sound like I’m being ironic. The thing is I’m not. Yes, the public option is an uphill battle, but it’s definitely not a lost cause. That’s why Steve Pearlstein is wrong in saying we should give it up. Intrade lists the public option’s odds at 35%. We are still in the game, and not letting on to our bottom line is a big part of the game.

So maybe someone in comments is going to “disagree” with me. You’re going to call me a sell-out and a weak-kneed accommodator. You’re going to say of course we should ditch the health care bill if it doesn’t have the public option… it would be worthless without it! That's exactly what you should say, thank you. Sorry we “disagree” (wink, wink.)

Others of you (not many I hope) are going to share my lack of discipline and surfeit of honesty and tell me you agree with me. All I can say is… shame on you.

Okay, maybe now I’m being ironic.