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December 14, 2008

Decriminalize, Crush, or Appease: You Choose

Filed under: Defense/Military, General, Latin AmericaJason Lakin @ 6:32 pm

Last week, Mexico’s Department of Defense estimated that, of the half million Mexicans involved in narco-trafficking in Mexico, at least one third are ex-military officers. While these new figures are shocking, the trend (soldiers deserting the military and joining the cartels) is not new. In the 1990s, the U.S. helped to train an elite force of Mexican soldiers to take on the cartels. Not long afterward, the cartels offered to hike their salaries, and most defected. They became Los Zetas, one of the most formidable mafia organizations in the country.

Violence in Mexico has metastasized, affecting people and places that were once largely immune.  For example, the media has increasingly become a target. According to the Committee to Protect Journalists, twenty four reporters have been killed in Mexico in the last eight years. Not all journalists attacked by the cartels are squeaky clean.  Some are targeted because they are on the cartel payroll, but do not follow their instructions. While it is easy to condemn journalists who are paid off by the cartels, the drug lords often threaten journalists or their families, leaving reporters feeling that they have no choice but to cooperate.

So what is to be done? To be sure, the Mexican government is not standing idly by. The Senate passed a constitutional amendment last week which will allow for improved national coordination in investigating and punishing organized crime. A national registry of cell phones will also be created to help investigate “express kidnappings” carried out by phone. The government recently received the first installment of in-kind support from the U.S. government under the Merida Initiative to upgrade Mexico’s security forces. There is talk of possibly introducing the death penalty in Mexico for certain crimes, although doing so would be very controversial and has been attacked by the country’s top human rights commissioner. Attempts are being made to clean up local police forces and purge corrupt elements.

Will any of this matter? At the margins, each of these things may reduce the level of crime, impunity, or both. But it is hard to believe that they will fundamentally alter the nature of the conflict. It would appear at this point that there are only a handful of realistic options for dealing with Mexico’s cartels, none of which are particularly attractive. The first would be decriminalization. Decriminalizing drug use would transform the nature of the drug trade overnight, but it is sure to meet determined opposition from the United States, and possibly also from Mexico. An alternative would be the complete militarization of Mexican society, including a draft to increase the size of the army, and support from the United States for aggressive military assaults on the cartels. By this, I mean something much bigger than the $1.4 billion Merida Initiative, and which would potentially involve American troops on the ground. This option is probably the least attractive of all, as it would likely result in substantial civilian casualties and human rights abuses, and there is no guarantee that it would be successful.

The final option is to negotiate with the cartels, just as the U.S. has considered negotiating with the Taliban. Negotiating a “live and let live” accord with the drug lords would allow the cartels access to what they want (secure drug routes) and reduce the need for violent confrontation. The government would, however, be in the unenviable position of possibly having to defend one cartel from another, and explicitly acknowledging its inability to enforce its own laws.

Making peace with drug lords sounds awful.  But the cartels are not going anywhere, and there is no reason to think that American-supported bluster will be any more effective now than it was in the 1990s.  The ebb and flow of conflict all around the world with despicable, violent organizations is driven by how accommodating societies are of illegal activity at different points in time. When they are more accommodating, there is less violence. When they get fed up, there is more.

Right now, the Mexican government is trying to play hard ball. If the government cannot defeat the drug lords, however, it will find a convenient moment to strike a private deal, declare victory, and let things return to the status quo ante: an uneasy accommodation.  The result will essentially be a less transparent version of what I am suggesting here. However ignoble, it will resemble successful pacts around the world. As Spencer Ackerman notes in a piece about the conflict in Afghanistan, “insurgencies rarely end with complete victory by one or the other side. They end by co-optation, integration and — yes — appeasement. Give your enemy a positive reason to stop fighting you that meets his core needs and you can probably get him to, you know, stop.”

It’s not a pretty picture. But neither is continuing to lose an endless war.

Sole Survivor

Filed under: GeneralKiran Bhat @ 4:30 pm

President Bush ducked two shoes that were thrown at him by a journalist during a news conference in Iraq today. This blogger is not sure if he is more impressed by the journalist’s considerable boldness or by the President’s cat-like reflexes.

Either way, the event speaks volumes about the way America’s president is currently perceived in Iraq and the Arab world in general – being touched by a shoe is quite the dishonor in most parts of the world. Bush shrugged the incident off, but he may lose a bit of sleep over it. Legacy matters to this president just as much as it has for all of them.

December 3, 2008

Health Corps

Filed under: HealthJason Lakin @ 4:07 pm

President-Elect Barack Obama’s transition webpage has a new video up featuring the nominee for Secretary of Health and Human Services, Tom Daschle, discussing health care. The transition team opened up the website last week to comments by ordinary Americans about what they would like to see in a health care reform. In the video, Daschle and an associate (Lauren Aronson) read through a few of the comments they received that they found particularly “interesting.” One of the citizen ideas that the pair latch on to is a national “health corps,” analogous to the Peace Corps. The skeletal concept is that doctors finishing their training would be encouraged to do a year or two of domestic service in communities with uneven access to health care professionals.

The attention given to this idea (one of only three mentioned, and the only concrete suggestion alongside “cost control” and “prevention”) is politically savvy: it is the kind of policy that no one is likely to disagree with, unlike the nitty-gritty details of an actual health reform. A systemic reform isn’t going to happen on http://change.gov. It is going to happen in Congress (it is already happening), and there is going to be serious horse-trading. The public won’t be welcome, although a President Obama may try to use the internet to rally supporters if the going gets tough.

That doesn’t mean the video, or the idea of a health corps, are irrelevant. In fact, a health corps should be part of a wider strategy to deal with one of the biggest problems in the American health system: the shortage of primary care physicians. Any reform of American health care is going to rely heavily on primary care physicians to manage care and keep costs under control. Yet, as a recent White Paper from the American College of Physicians argued, primary care physicians are a dying breed. The Journal of the American Medical Association reported that, in one 2007 study, only 2 percent of fourth-year medical students intended to study general medicine. A 2008 Health Affairs study predicts a shortfall of around 40,000 primary care physicians in the United States by 2025.

Primary care physicians do not get either the respect or the salaries necessary to keep the field attractive. Previous efforts to reduce the salary gap between primary care physicians and specialists have generally failed because they involve redistributing money from powerful specialists groups to PCPs, a result that is unacceptable to specialists. Senator Max Baucus’s health plan, which is currently making the rounds in Congress, would call for just this kind of redistribution, and has already been criticized on these grounds. Boosting PCP salaries without cutting specialist salaries may require some upfront costs that politicians find distasteful, particularly given the current economic climate. But if PCPs help to manage care appropriately and encourage preventive measures, the overall cost of providing care should come down, meaning that enhanced salaries are an investment that would at least partially pay for itself. It would also be easier to redistribute over time by allowing inflation to erode the salary gap rather than making a direct assault on specialists’ current salaries.

But increasing the flow of doctors into primary care is not just about salaries, it is also about respect. Medicine is no different from other fields, in which specialists doing cutting edge work that is intellectually interesting tend to have higher status than those who make the more hum-drum but essential contributions upon which the poor depend. This is where the Health Corps comes in. If the President were to authorize a Health Corps that helped doctors who dedicated themselves to primary care not only receive enhanced salaries, but also enhanced status, primary care would become a more attractive field. The American College of Physicians has already called for debt reduction for doctors that go into primary care. PCPs want more autonomy and less paperwork, too. A series of presidential honors for service, starting with recognition in the Health Corps, but moving on to mid and late-career recognition (monetary and non-monetary alike) could also enhance the profile of primary care physicians. PCPs could be preferentially called on to serve on governmental panels to guide the health system, and receive Master status as teachers and mentors through a system that would parallel the academy, but be based on experience, service to the disadvantaged, and mentoring, rather than academic publications.

The program would need some fleshing out, but a Health Corps shouldn’t just be a temporary foray into service for doctors who are willing to sacrifice a couple of years of high salaries. That should be part of what a Health Corps does, but it should also be a way to encourage doctors to remain in primary care, and to become experienced providers who receive salaries and status commensurate with the vital services they provide.