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Posts published in “Day: May 23, 2019”

Getting better


Maybe you’ve heard the statistic quoted that Idaho is last (or near) among states in doctors per capita. If medicine was a simple business that ratio might mean the dearth of physicians would ensure doctors in Idaho are among the best paid, supply and demand being what it is. But in fact, Idaho doctor salaries are about average to below average. Medicine may be a business but the economics are complicated.

Former Governor Otter’s commitment to boosting medical education in Idaho was supported in the legislature when I was there. In that tenure, the Idaho WWAMI program grew from 20 seats to 40. WWAMI is a medical education consortium of 5 states: Washington, Wyoming, Alaska, Montana and IDAHO. Those 40 seats are reserved for Idaho resident applicants. Idaho students now spend their first year and a half of the four years of medical school in Idaho. Many are based in small towns and rural communities, learning from the local physicians and patients about managing disease and chronic illness.

Medical training takes many steps. After receiving a bachelor’s degree (usually a four-year process) the next step is four years of Medical School. Then there is the residency step that takes 3-10 years, depending on the specialty one chooses. After residency docs go hang a shingle and see what they will be paid. Most doctors in Idaho make over $150K, so it’s not a shabby income. But many could do better elsewhere; market forces are real.

But for most doctors it’s not just the money that motivates. Most want to serve; their patients, serve their communities, serve their profession, serve their families. Unfortunately, many doctors put their service in that order. Families can suffer. If you are a small community in need of a doctor, think about what you can do to make a family thrive in your community. Could the schools be better? Do you have a good library? Do you have opportunities for a spouse, a family to thrive? Doctors will like such opportunities; so should you.

But getting a doctor is just part of the process. Keeping one and keeping them good is another. The Idaho WWAMI program is not just about running students through the four years, they are also committed to supporting doctors in small communities stay strong, stay informed, practicing good medicine.

Two of the toughest fields of practice for rural family physicians is behavioral health (the new term for psychiatric-emotional-personality-addiction problems) and chronic pain. The explosion Idaho and our nation have seen in overdose deaths from narcotics is just one indicator. Docs haven’t been doing the best managing pain. And most psychiatric care in Idaho is provided by primary care providers; we are last in the country for psychiatrists and behavioral health specialists. WWAMI saw this need and responded.

Two years ago, WWAMI set up the ECHO program. Providers (physicians and nurse practitioners, physician assistants, social workers or counselors) participate remotely in an interactive online session to discuss the difficult problems they face. The sessions focus on how to prescribe narcotics appropriately and managing behavioral health. Such support will go a long way to keeping providers at the top of their game in this rural and frontier state.

We hear about the cost of care, Medicaid and Medicare, who pays and who doesn’t. There is no doubt that the medical industrial complex has a strong presence in “the swamp” as our president refers to the business-political morass. And I’m sure there’s plenty of ideas about how to get out of this mud hole. Payment affects behavior; sometimes. But we, in our communities can make health care about being healthy. I would hope our dear state of Idaho has such a vision.



One of the older print books in my household collection - old enough that I bought the paperback new for 75 cents - is called Coup d’Etat: A Practical Handbook, a Brilliant Guide for Taking Over a Nation (Fawcett Premier, 1969). It delivers on the title, being a manual for a do-it-yourselfer: Here’s how to forcibly take over a country, preferably a less-technically developed one.

The author, Edward Luttwak, is a serious researcher on military and other history, and has written among other things a highly-regarded study of the strategy the Roman Empire used to grow itself, as well as a guide to military strategy used in armed forces training. Coup d’Etat was an unusual case. Opinion writer David Frum called it “that astounding thing: a great work of political science that is also a hilarious satire.” And it sort of is: Serious, factual and well-researched (he includes detailed lists of recent coups, successful and failed, referenced in the body of the book).

If on the surface it seems almost like an invitation to anarchy, the introduction (written by another writer) makes the case that “this book is as much a matter for the prevention of the coup as for initiating one.” (It was not, by the way, the first book on the subject. There was at least one predecessor, Technique of the Coup d’Etat, by Curzio Malaparte.)

Overthrows along the lines of what we might consider a coup go back to the days of ancient empires, but the modern form of the coup, in Luttwak’s telling, is made possible in the last couple hundred years or so by modern governmental bureaucracy and communications and transportation systems. He comes up with this definition: “A coup consists of the infiltration of a small but critical segment of the state apparatus, which is then used to displace the government from its control of the remainder.” The full term coup d'etat means in English a blow against the state. It does not have to be violent (though it might be), and it need not rely on support from the constituency (though it might obtain that).

That gives the sense that a coup is a long shot, that a number of elements have to fall into place to make it work, and Luttwak seems to make that case; his basic list of coups and attempted coups from 1945 to 1967 includes about as many failures as successes. He suggests that coups are much more likely to succeed when a set of preconditions are in place, such as “economic backwardness,” political independence (no close entangling alliances) of the target country, and a basic unity of the country (it’s not likely to break into pieces under pressure). It also depends on the standing, non-political, parts of the government not being strong enough to push back against an illegal change in leadership. Coups work best, then, in developing countries where institutions and economies are not large and stable. They also may be on the decline; 2018 was only the second year a century - 2007 was the first - to report no coup attempts internationally. See also the Coup d'etat Project.

A coup is an abrupt, generally unexpected, wrenching of the power of a state from whoever was legitimately installed to lead it. Luttwak refers to using the tools of the state to aggressively change its leadership, but that’s not the same as changing leadership using legitimate procedures. The rise of Adolf Hitler in Germany, for example, wasn’t a coup despite all of the activities of Brownshirts and others in the street; he was handed high office in that country according to constitutional procedures, at least at first.

The charge of one side or another fomenting a “coup” turns up periodically in recent American politics. On unusual occasions there were rumblings to effect from the left, about Republican efforts to kick out President Barack Obama (or, before that, Bill Clinton). As determined as some of those efforts were, none rose to the level of a coup; even the impeachment effort against Clinton was undertaken

Former television personality Bill O’Reilly wrote, for example, about what he described as a coup attempt targeting President Donald Trump: “The story of our time is the coup d’état that is being planned in this country. Sounds pretty bad, doesn’t it? In most countries, coup d’états happen when the military tries to overthrow the government. The United States military would never do that… but the national media certainly would.” News organizations, in other words, were trying to engineer a coup.

But even if you assume they were trying that, the description misuses the word “coup.” There is no forcible overthrow here; the governmental system of elections and succession remained in place, and O’Reilly wasn’t really trying to contend that it hadn’t. He was comparing criticism by news organizations to a violent military overthrow of the government, but the two things are wholly different; the most news organizations could do would be to influence the opinions of various sectors of the public.

A coup is not criticism or opposition. It is an illegitimate seizure of political power.

On that basis, it might be worth reviewing what the Russian government was trying to accomplish in the American elections of 2016. That did not involve direct seizure of the governmental levers of power. But, as a quiet, well-placed attempt to grab power, it comes close to meeting the definition of coup; whether successful or not, being a subject for further review.