Friday, January 28, 2011

Democracy is a goal, not a starting point

Praveen Swami in the UK Telegraph expresses pessimism that the anti-authoritarian protest movements in the Middle East will result in a blossoming of democracy in the region:
I’d like to believe that the rising tide of popular protest will sweep aside the region’s authoritarian kleptocracies, bring about democratisation and address the problems of its peoples.

The first of these possibilities might just be realised. The second is less likely. The third, I fear, is fantasy.

Referring to the self-immolation of a Tunisian man that set off the revolt in that country, Swami points out that the demise of authoritarian regimes is a necessary but wholly insufficient condition to create freedom and democracy:
Even if the fire Mr Bouaziz lit razes authoritarian regimes in the Middle East, though, it is unlikely to make a huge amount of difference. That’s because the real problem isn’t authoritarian or Islamism or any other -ism, which are but symptoms of a far deeper malaise: the lack of a functional political culture.

Political life in the Middle East has been narcotised by two powerful drugs: oil money and western aid. The powerful patronage networks this cash has engendered, have undermined the integrity of the polity itself. Regimes have been able to defer badly needed reforms. More important, civil society itself has had little incentive to negotiate the condition we call modernity, which demands fundamental changes of attitudes on everything from gender to knowledge.

The one thing Tunisia does have in common with other countries in the Middle East and North Africa is what demographers call a “youth bulge”. Tunisians aged between 15 and 24 made up 21 percent of the population in 2005. Elsewhere in the Middle East and North Africa, the figures are even higher.

Each year, millions of young people seeking to build a life meet with frustration –the root of the rage we’re seeing on the streets. Youth unemployment ranges, across the region, at between 20 and 40 percent.

If the end of authoritarianism is necessary but insufficient, democratization in and of itself is not enough to make up the insufficiency:
The received wisdom is democracy will somehow solve the problem. This sounds good, but isn’t true. Democracy is a process, not an outcome in itself. Processes don’t guarantee outcomes.

Like people everywhere, residents of the Middle East seek peace and prosperity. But dealing with the problems confronting the region calls for cultural, political and economic transformation of an order that will dwarf Eastern Europe’s transition to a market economy. There there’s nothing to show the protest movements in the Middle East have a leadership with the vision to bring them about.

The democratic successors of today’s authoritarian regimes will find themselves hard-pressed to deliver change, for much the same reasons their predecessors did: the changes needed are too large, and the solutions too painful.

It's certainly true that processes don't guarantee outcomes. But where Swami says "democracy is a process, not an outcome in itself," I would characterize it a little differently:

The building of democracy is a process that leads ideally to the outcome of a stable and robust democracy. The process uses democracy as a tool, but it is not the most important tool nor the first tool that should be brought to bear.

Autocracies that allow the development of a middle class, a functioning economy with adequate employment opportunities, and a culture that values individual freedom can transition successfully to democracy: Taiwan, South Korea and Chile are examples. Most autocracies are prone to corruption, nepotism and suppression of individual freedom, and when they fall, they do not transition to stable democracies: they tend to fall to anarchy or to a replacement autocrat.

So I fully agree that stable democracies will not flourish in former autocracies unless and until they undergo cultural and economic transformations to match their political transformations.

President Prissy

We have finally learned who Barack Obama is.

During the campaign of 2007-2008, he assured us that he was the competent chief executive with a solid plan to rein in government spending even as he revived economic growth, grew employment and initiated a raft of new policies to stop the rise of the oceans and make cars run on sunshine. His ascension to the Presidency, he claimed, would in and of itself raise America's standing in world opinion so much that our enemies would become our friends and our allies would rush to put their blood and treasure into every one of our foreign policy endeavors.

And when the financial crisis of 2008 broke, and the American people asked, "Can you fix this," Barack Obama stepped up and said, "I know everything about fixing the economy."

Now, after two full years of his Presidency, the American people cry, "Our burden of debt has become far heavier, our economic prospects are as dim as ever, more people are out of work than when you took office, our enemies are still determined to kill us -- can you fix this?"

And in his second State of the Union address, he told us clearly: "I don't know nothin' about running no country!"

President Prissy.

Wednesday, January 19, 2011

Frankly, a coat hanger would have been a major step forward in medical care

The Grand Jury's report begins thusly:

This case is about a doctor who killed babies and endangered women. What we mean is that he regularly and illegally delivered live, viable, babies in the third trimester of pregnancy – and then murdered these newborns by severing their spinal cords with scissors. The medical practice by which he carried out this business was a filthy fraud in which he overdosed his patients with dangerous drugs, spread venereal disease among them with infected instruments, perforated their wombs and bowels – and, on at least two occasions, caused their deaths. Over the years, many people came to know that something was going on here. But no one put a stop to it.

In 1993, the State of Pennsylvania apparently decided that abortion clinics didn't need supervision or inspection. And one such clinic -- the Women's Medical Society -- found that being exempt from outside scrutiny was a license to mint money by exploiting poor women and murdering their babies.

From the Grand Jury report:

Because the real business of the “Women’s Medical Society” was not health; it was profit. There were two primary parts to the operation. By day it was a prescription mill; by night an abortion mill. A constant stream of “patients” came through during business hours and, for the proper payment, left with scripts for Oxycontin and other controlled substances, for themselves and their friends. Gosnell didn’t see these “patients”; he didn’t even show up at the office during the day. He just left behind blank, pre-signed prescription pads, and had his unskilled, unauthorized workers take care of the rest. The fake prescriptions brought in hundreds of thousands of dollars a year. But this drug-selling operation is the subject of separate investigation by federal authorities. Our focus was on the other side of the business.

Murder in plain sight

With abortion, as with prescriptions, Gosnell’s approach was simple: keep volume high, expenses low – and break the law. That was his competitive edge. Pennsylvania, like other states, permits legal abortion within a regulatory framework. Physicians must, for example, provide counseling about the nature of the procedure. Minors must have parental or judicial consent. All women must wait 24 hours after first visiting the facility, in order to fully consider their decision. But Gosnell’s compliance with such requirements was casual at best. At the Women’s Medical Society, the only question that really mattered was whether you had the cash. Too young? No problem. Didn’t want to wait? Gosnell provided same-day service.

The real key to the business model, though, was this: Gosnell catered to the women who couldn’t get abortions elsewhere – because they were too pregnant. Most doctors won’t perform late second-trimester abortions, from approximately the 20th week of pregnancy, because of the risks involved. And late-term abortions after the 24th week of pregnancy are flatly illegal. But for Dr. Gosnell, they were an opportunity. The bigger the baby, the more he charged.

There was one small problem. The law requires a measurement of gestational age, usually done by an ultrasound. The ultrasound film would leave documentary proof that the abortion was illegal. Gosnell’s solution was simply to fudge the measurement process. Instead of hiring proper ultrasound technicians, he “trained” the staff himself, showing them how to aim the ultrasound probe at an angle to make the fetus look smaller. If one of his workers nonetheless recorded an ultrasound measurement that was too big, it would just be redone. Invariably these second ultrasounds would come in lower. In fact, almost every time a second ultrasound was taken, the gestational age would be recorded as precisely 24.5 weeks – slightly past the statutory cutoff. Apparently Gosnell thought he would get away with abortions that were just a little illegal. In reality, of course, most of these pregnancies were considerably more advanced.

But the illegal abortion business also posed an additional dilemma. Babies that big are hard to get out. Gosnell’s approach, whenever possible, was to force full labor and delivery of premature infants on ill-informed women. The women would check in during the day, make payment, and take labor-inducing drugs. The doctor wouldn’t appear until evening, often 8:00, 9:00, or 10:00 p.m., and only then deal with any of the women who were ready to deliver. Many of them gave birth before he even got there. By maximizing the pain and danger for his patients, he minimized the work, and cost, for himself and his staff. The policy, in effect, was labor without labor.

There remained, however, a final difficulty. When you perform late-term “abortions” by inducing labor, you get babies. Live, breathing, squirming babies. By 24 weeks, most babies born prematurely will survive if they receive appropriate medical care. But that was not what the Women’s Medical Society was about. Gosnell had a simple solution for the unwanted babies he delivered: he killed them. He didn’t call it that. He called it “ensuring fetal demise.” The way he ensured fetal demise was by sticking scissors into the back of the baby’s neck and cutting the spinal cord. He called that “snipping.”

Over the years, there were hundreds of “snippings.” Sometimes, if Gosnell was unavailable, the “snipping” was done by one of his fake doctors, or even by one of the administrative staff. But all the employees of the Women’s Medical Society knew. Everyone there acted as if it wasn’t murder at all.

I am sure that people who defend the practice of partial-birth abortion will point out that Gosnell didn't actually engage in that practice: he instead favored complete-birth infanticide.

The State agencies charged with protecting Pennsylvanians against his horror, the Department of Health and the Department of State, seemed singularly uninterested in doing their duty -- but are now scrambling to find legal counsel:
The first line of defense was the Pennsylvania Department of Health. The department’s job is to audit hospitals and outpatient medical facilities, like Gosnell’s, to make sure that they follow the rules and provide safe care. The department had contact with the Women’s Medical Society dating back to 1979, when it first issued approval to open an abortion clinic. It did not conduct another site review until 1989, ten years later. Numerous violations were already apparent, but Gosnell got a pass when he promised to fix them. Site reviews in 1992 and 1993 also noted various violations, but again failed to ensure they were corrected.

But at least the department had been doing something up to that point, however ineffectual. After 1993, even that pro forma effort came to an end. Not because of administrative ennui, although there had been plenty. Instead, the Pennsylvania Department of Health abruptly decided, for political reasons, to stop inspecting abortion clinics at all. The politics in question were not anti-abortion, but pro. With the change of administration from Governor Casey to Governor Ridge, officials concluded that inspections would be “putting a barrier up to women” seeking abortions. Better to leave clinics to do as they pleased, even though, as Gosnell proved, that meant both women and babies would pay.

The only exception to this live-and-let-die policy was supposed to be for complaints dumped directly on the department’s doorstep. Those, at least, would be investigated. Except that there were complaints about Gosnell, repeatedly. Several different attorneys, representing women injured by Gosnell, contacted the department. A doctor from Children’s Hospital of Philadelphia hand-delivered a complaint, advising the department that numerous patients he had referred for abortions came back from Gosnell with the same venereal disease. The medical examiner of Delaware County informed the department that Gosnell had performed an illegal abortion on a 14-year-old girl carrying a 30-week-old baby. And the department received official notice that a woman named Karnamaya Mongar had died at Gosnell’s hands.

Yet not one of these alarm bells – not even Mrs. Mongar’s death – prompted the department to look at Gosnell or the Women’s Medical Society. Only after the raid occurred, and the story hit the press, did the department choose to act. Suddenly there were no administrative, legal, or policy barriers; within weeks an order was issued to close the clinic. And as this grand jury investigation widened, department officials “lawyered up,” hiring a high-priced law firm to represent them at taxpayer expense. Had they spent as much effort on inspection as they did on attorneys, none of this would have happened to begin with.

But even this total abdication by the Department of Health might not have been fatal. Another agency with authority in the health field, the Pennsylvania Department of State, could have stopped Gosnell single-handedly. While the Department of Health regulates facilities, the Department of State, through its Board of Medicine, licenses and oversees individual physicians. Like their colleagues at Health, however, Department of State officials were repeatedly confronted with evidence about Gosnell, and repeatedly chose to do nothing.

Indeed, in many ways State had more damning information than anyone else. Almost a decade ago, a former employee of Gosnell presented the Board of Medicine with a complaint that laid out the whole scope of his operation: the unclean, unsterile conditions; the unlicensed workers; the unsupervised sedation; the underage abortion patients; even the over-prescribing of pain pills with high resale value on the street. The department assigned an investigator, whose investigation consisted primarily of an offsite interview with Gosnell. The investigator never inspected the facility, questioned other employees, or reviewed any records. Department attorneys chose to accept this incomplete investigation, and dismissed the complaint as unconfirmed.

Shortly thereafter the department received an even more disturbing report – about a woman, years before Karnamaya Mongar, who died of sepsis after Gosnell perforated her uterus. The woman was 22 years old. A civil suit against Gosnell was settled for almost a million dollars, and the insurance company forwarded the information to the department. That report should have been all the confirmation needed for the complaint from the former employee that was already in the department’s possession. Instead, the department attorneys dismissed this complaint too. They concluded that death was just an “inherent” risk, not something that should jeopardize a doctor’s medical license.

Apparently the bureaucrats in Health and in State may have felt that after the departure of a pro-life Democrat Governor, a pro-choice Republican Governor would be sympathetic to their unilateral easing of restrictions on abortion clinics. There is a special circle of Hell reserved for those bureaucrats, and they seem to know it.

(Hat tip: Ace of Spades HQ.)