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"The Potemkin Moment"

(Playing off "The Minsky Moment.") I have a picture, perhaps wishful, of the political system as a painted canvas, like a stage set, and then some clumsy galoof puts a foot through the it, or a kid pokes a hole in it with a pencil, and then suddenly everybody realizes what they thought was real and permanent and everlasting isn't. For example:

ObamaWar demotivates the Democratic base. 2010, here we come? [The Week]. Interestingly, Ryan Coole shifts focus at the end to this conclusion:

But let’s face facts: expecting our jalopy institutions to successfully navigate the rapidly shifting tangle of alliances in Syria is ludicrous. America is a country where the Secret Service doesn’t notice the White House has been shot until four days after the fact, and is apparently unfamiliar with how door locks work.

It sounds like Cooper’s been reading Naked Capitalism, or Golem XIV, or the Archdruid, all of whom would concur on our “jalopy institutions” (“corruption” is far too narrow a frame). Will institutional rot and demented and sclerotic elites become an issue in 2014 or 2016? Seems unlikely, but then what Ryan Cooper wrote above would have seemed unlikely too, until quite recently. It was also unlikely that Emperor Cuomo would have been challenged, but you can see Teachout and Wu working these same issues in their interviews with Naked Capitalism (the PayPal button is to your right), and they came out of nowhere to take 30% of the vote. So you never know! And remember that the legacy parties are jalopies, too, despite their fearsome appearance and noisy operation.

So, the operation run by the political class is ripe for a "Potemkin Moment," right? Here's another:

Nonetheless, the hospital systems seems to have had trouble confronting the challenges of the change in environment due to Ebola.  Also, according to a very recent story in the Dallas Morning News, there have been performance issues at Texas Health Resource hospitals, and specifically at Texas Health Presbyterian,

Texas Health Presbyterian Hospital — under fire for releasing a Liberian man who later turned out to have the Ebola virus — has lagged behind its peers on emergency room care and lost some federal funds the past three years because it had high discharge rates of patients who later had to return for treatment.

The hospital scored significantly worse than the state and national averages in five of six emergency care indicators, with emergency room wait times twice as long as the averages, according to data from the U.S. Centers for Medicare & Medicaid Services.

The hospital also was the most penalized in Dallas under a three-year program designed to reduce the number of patients readmitted for care, according to the data.

The delays in patient treatment in the emergency room, in particular, raise important questions about Presbyterian’s emergency care, said Dr. Ashish Jha, a professor at Harvard University’s School of Public Health and a practicing general internist.

In 1988, Alain Enthoven advocated in Theory and Practice of Managed Competition in Health Care Finance, a book published in the Netherlands, that to decrease health care costs it would be necessary to break up the “physicians’ guild” and replace leadership by clinicians with leadership by managers (see 2006 post here).

Thus from 1983 to 2000, the number of managers working in the US health care system grew 726%, while the number of physicians grew 39%, so the manager/physician ratio went from roughly one to six to one to one (see 2005 post here). As we noted here, the growth continued, so there are now 10 managers for every US physician. 

We have frequently discussed how generic managers in charge of health care organizations may follow business-school dogma at the expense of patients’ and the public’s health.  In particular, they may also prioritize short-term revenue ahead of all other concerns, and hence may favor high-technology and procedural care, often performed electively, ahead of the the less glamorous and remunerative parts of health care, e.g., ED care of poor, uninsured, febrile patients.

Unfortunately, much of the country’s efforts to ward off Ebola are likely to be lead by generic managers who may have little understanding of epidemiology, public health or virology, and little understanding of the state of health care at the sharp end.  So unfortunately I expect continuing “glitches,” or worse.  Hopefully, the country, although not every single one of its inhabitants, will survive them.  Then we need to seriously reflect on the wisdom of handing control of health care over to generic managers, rather than health care professionals. 

The nurses ask:

If an Ebola patient becomes sick while being transported, ‘How do you clean the elevator?’

Basic, basic stuff! Another system ripe for a Potemkin moment.

* * *

I have heard that one reason the Soviet Union collapsed is that people ... just walked away from it. That was the Mother of All Potemkin moments. Does anyone have more knowledge on this point?

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Jay's picture
Submitted by Jay on

I have heard that one reason the Soviet Union collapsed is that people ... just walked away from it. That was the Mother of All Potemkin moments. Does anyone have more knowledge on this point?

Dimitry Orlov has written extensively on the collapse of the Soviet Union and how he sees parallels in that collapse with what he sees in the U.S. I bought his book, The Five Stages of Collapse, and highly recommend it as an entertaining, well-written, and (im?) -pertinent take on US society and institutions. To him, collapse is certain if not imminent, and I value his observations as I would a wise older neighbor with a background different from mine who has seen with his own eyes how these things go down.

Submitted by lambert on

I should have remembered. Thanks!

pmj6's picture
Submitted by pmj6 on

USSR collapsed mainly because of fragmentation within the elite, the apparently unbridgeable rift between the reformers and the reactionaries which was exploited by Yeltsin and a few others in the wake of the August Putsch. But the people, who clearly recognized that the system was failing, were not asked, though the separatist sentiment in some republics (or parts of republics) was indeed very strong for other reasons (history of nationalism, etc.). So the parallels to the US stop right there, because whatever can be said about the US elites, they are quite well consolidated, their public "spats" for the benefit of the masses notwithstanding.

Submitted by lambert on

You make the argument:

whatever can be said about the US elites, they are quite well consolidated, their public "spats" for the benefit of the masses notwithstanding.

I'm not so sure. How would we verify this? It is true that I would like this thesis not to be true, since splits in the elites would be useful... But I have a general sense of drift and angst, taking the war news as an example: They wanted their war, and now they have it, but now they have it they don't quite know what to do with it. And the August test marketing was quite clumsy. We are not dealing with an especially classy or competent elite this time round. Madison and Adams and Jefferson, or even Reagan and Baker they are not.

NOTE I hate the locution "the masses" with the hatred of a thousand burning suns. I think it denies them agency and impllies that "the masses" must be led to a better understanding by, say, the Bolsheviks. Bad track record there.

quixote's picture
Submitted by quixote on

I don't know about that. My take on it is that the elites had little to do with it except getting slightly out of the way.

I come from a Russian family, visited the USSR when it was still the USSR, in the mid-1960s. The people had already left at that point. I expect the great popular Potemkin moment was right around the time of the real Potemkin. During Stalin's day (long before my time) when almost every family knew what it was to get a knock on the door at 3AM. Very hard to feel much warm fuzzy illusion about your government under those circumstances.

What was keeping it going when I visited was a still-adequate degree of fear and entrapment. The one who took the lid off, fully knowing what he was doing, was Gorbachev. He deserves a lot of credit for that. But the US sure as hell didn't want a Russia with its act together and with a social democratic system similar to Europe's, which was Gorbachev's goal. So they worked hard to undermine him and get a corrupt and drunken Yeltsin in, and they succeeded.

Anyway, long story short: just because the people have their Potemkin moment doesn't guarantee any kind of good outcome.

Submitted by lambert on

But since you visited... What I'm looking for is very concrete details. Say your grandmother had a Potemkin Moment. What triggered it? Did others have the same at the same time? And so forth....

quixote's picture
Submitted by quixote on

Well, my specific Grannie is not a good example since she had to flee the Bolsheviks to avoid getting the chop. Not too hard to figure out the government is not on your side in that case. :wry face:

But I've watched people in different parts of the world come to the realization that it's all going hugely wrong for them personally. Some even in this country in the high and far off times when guys lit out for Canada to avoid the draft.

In my experience what triggers understanding is serious personal danger. Someone spends three hours bleeding in an emergency room before being seen. Tends to be an eyeopener about "the best health care in the world." Losing a job and not finding anything comparable before all one's savings are gone. Stalin sending your sister off to a gulag. Or having a draft that ends in Vietnam.

I mean, some people have enough vision to see the Potemkin moments without threat to life or limb. But the evidence I see suggests that for most people it takes a major personal disturbance. And we haven't had that yet on a huge scale in the US. The New Depression hit a lot of people, but not the *majority* to the extent that seems to be necessary. Likewise with the current forever wars. I think that's why there's such impenetrable complacency here, in spite of everything.

quixote's picture
Submitted by quixote on

As for the health system: Duncan (the Dallas Ebola patient) didn't have insurance. How many stories have we heard about the uninsured being told to go home with heart attacks, strokes, ruptured appendixes, and so on and on? The hospital is in an ignored part of town and makes a practice of that sort of thing. Hence their atrocious emergency room record. Their big mistake this time was sending somebody contagious and newsworthy away (/sarcasm).

The whole way insured medical care works in the US looks like the problem. Bean counters are just lumps in the mix.

Jay's picture
Submitted by Jay on

I don't think we'll ever get to the bottom of why he was sent home, but suspect this is true. Another reason they offer is that their records management system didn't show the physician everything in the nurse's report. Not only do I think that is utterly believable,* I'd go further and suggest that bureaucratic inertia prevented them from foreseeing, planning for, or implementing changes to their intake interview protocol, with Ebola in mind. I'll bet a lot of hospital administrators and electronic medical records people are crawling over that. Another tidbit of information was that he reportedly said he hadn't been around/handled sick people while in Liberia. Maybe a language problem, maybe a confused sick person problem, maybe a chaotic work environment, maybe a box checked in haste. It happens.

* a nationwide electronic medical records management program went down for several hours a few months ago. Surgeries were canceled, outpatient visits couldn't be conducted, the shit hit the fan. Imagine going into surgery and your anesthetist can't find out what allergies you have to certain medications. Major aspects of whole hospitals have been practically shut down.

McDee's picture
Submitted by McDee on

Some years ago I was stricken at work with chest pains. My boss called 911. The ambulance was there quickly and they took me to the nearest hospital.

I was on a gurney in the hallway with about a dozen others. A man in a white coat carrying a clipboard came right out. "Thank god, a doctor" I thought. No, the admitting clerk. First thing he says is " Do you have Insurance?" I told him I had Travelers, the long time railroad employees insurance plan (Thank You, Clerks Union!)

He snapped his fingers, an orderly came out of nowhere and I was wheeled into ER and attended to by a team of doctors/nurses etc. Those others on the gurneys in the hallway may have been sent home or may still be waiting to see a doctor.

It's all about insurance and/or ability to pay. Health Care is a commodity. If you can't afford it (like a Mercedes) you can't have it. Sad...

V. Arnold's picture
Submitted by V. Arnold on takes some kind of sick, greedy, fuck to figure out how to commodify every aspect of our lives. It seems most don't connect the commodification to loss of choices/freedoms that used to be so basic to our lives. Pity really...

Barmitt O'Bamney's picture
Submitted by Barmitt O'Bamney on

Unlike the Russkies, when the people of the United States of America have their wake up moment, and realize that their institutions are rotten, their leaders are corrupt, and their laws are written to keep them on their knees, IMO it will more likely signal the final slide into total barbarism, instead of heralding the dawn of some longed-for New Enlightenment, or some local Rebirth of Freedom. American institutions are corrupt and America's people are putting up with them because they are also corrupt. They (We) are the product of a bad education and sick environment. When everyone sees our ruling institutions no longer deliver the goods anymore, that they no longer lie persuasively about why the gravy train derailed or maintain the pretense that general prosperity will come again, what you will probably see is not an outraged, reinvigorated citizenry asserting their natural right to secure mutual defense and the common good, but more like something resembling the a zombie Apocalypse movie. There is no American People with shared American values & identity to come together and refashion some new, legitimate res publica. Our leaders and the people who own them have very carefully seen to that. It's poor manners, I know, to piss on people's optimism. Sorry, but my bladder is very full at this point and I just can't hold it in anymore.

V. Arnold's picture
Submitted by V. Arnold on

...your observations.
After thinking about the Potemkin Moment I have come to the conclusion there won't be any Potemkin Moments en masse; just individually. I had mine March 19th, 2003 and acted on it in April, 2003.
Over the past decade I've heard a lot of talk, but haven't seen any action.
People seem to mistake talking for action...