Friday, May 31, 2013

A gang truce in Honduras, with a Canadian connection

Gang members, Adam Blackwell, in El Salvador jail
The big news in Honduras this week is a gang truce, with a Canadian connection. The deal was brokered by the Catholic archbishop and a Canadian diplomat who works with the Organization of American States and played a similar role in El Salvador.
It’s a bit surreal. The gang leaders have issued press releases, just like any political leaders. (Except from prison, and with bandanas over their faces.)
It’s also a positive step, despite lots of questions. The two main gangs - Mara Salvatrucha, or MS-13, and Mara 18, or M18, - have signed on. They pledged to stop recruiting new members and committing acts of violence.
The truce in El Salvador, also brokered by the church and Adam Blackwell, the Canadian who is the OAS “Secretary of Multidimensional Security,” has made a huge difference in the murder rate. The rate in El Salvador fell by 52 per cent after the truce, the government says. (The murder rate fell to 38 murders per hundred thousand people. The Honduran rate in 2012 was 87; Canada’s was 1.7.)
The El Salvador truce was hardly a panacea. Gang members are still criminals, and - as in Honduras - extortion is still central to their business model. If you have a business, or drive a taxi or bus, or sell fruits and vegetables, gang members collect a weekly ‘tax.’ 
And truce or not, extortion only works when the victims fear violence and death if they don’t pay. 
The numbers - in either country - are staggering. An El Salvador business group did an informal survey of members, asking if they or their business had been affected by crime in the previous 12 months - extortion, kidnapping, thefts, assault. 
More than 70 per cent said yes; 55 per cent said they had been affected by crime more than once in the previous 12 months.
La Prensa reported last month that extortion is worth $63 million a year to the gangs, and that some 17,000 small businesses had just given up and shut down in the past year because of the gang’s demands.
And there are doubts that the impact will be as great in Honduras. Observers say the gangs are less well-organized, and the truce might be ignored on the street. And gangs here are claimed to be a smaller cause of violence than in El Salvador. A 2010 UN report found gangs were responsible for about 30 per cent of murders.
But people said much the same thing about the El Salvador truce.
Any reduction in the murder rate would be great news. The daily toll of some 20 dead bodies is terrible for families.
And the fact that Honduras has the highest murder rate in the world has become the only thing people know about the country. The news reports are grisly. Potential tourists don’t know that most murders are related to gangs, drugs or feuds, and crime is focused in poor urban neighbourhoods. Or that tourists are not targeted.
So perhaps only half the gang members will accept the truce. Based on the UN estimates, that would mean a 15-per-cent drop in the murder rate - almost 1,100 fewer murders in a year.
There are all sorts of issues still to be sorted. Gang members are worried about continuing police violence. Some Hondurans reject the idea that gangs might not face responsibility for past crimes as part of the deal.
And the government’s role and the future of gang members is unclear. Estimates vary wildly, but assume about 7,000 people are currently active gang members. They might stop killing each other, but without alternatives they aren’t likely to give up crime.
Still, even with all the caveats and unanswered questions, the truce is a good thing for Honduras.
Footnote: The two main gangs - Mara Salvatrucha, or MS-13, and Mara 18, or M18 - have their roots in Los Angeles, started by the children of a wave of Central American immigrants in the 1980s. They've grown into full-scale multinationals, in part because of a U.S. policy of deporting non-citizen offenders instead of dealing with them in the justice system. That's helped the gangs spread rapidly throughout this region.

For more information
Insight Crime has an excellent briefing on the truce here.

Wednesday, May 29, 2013

For-profit health care: When surgical complications are good for business

I believe market forces and the pursuit of profits often bring creativity and innovation.
But not so much for health care. The problem was nicely crystallized in a Business Week article I read years ago, profiling the star CEO of a hospital chain. He was lauded for increasing revenue per patient, a key indicator. A few more tests, an extra day in hospital, fees for every aspririn dispensed, and the corporation does well and the CEO gets a bonus.
The problem was set out more starkly in a Wall Street Journal I snagged in one of the airports on the way back to Copan Ruinas from Victoria. 
It reported on a study that found U.S. hospitals make more money when a surgical patient has complications after surgery. A lot more money.
Thus there was no economic incentive to reduce avoidable medical complications that cause thousands of deaths and add billions to health care costs.
In fact, market forces worked against reducing surgical complications.
The study was legit. It was reported in the Journal of the American Medical Association and done by researchers from the Harvard Medical School, Boston Consulting Group and Texas Health Resources.
They looked at more than 34,000 surgical patients in 12 hospitals owned by Texas Health Resources.
And they found surgical complications - many avoidable - were good for business. Infections, complications, strokes, they all boosted the hospitals’ bottom line. The study found hospitals made an average $56,000 in profit from each privately insured patient who suffered complications, compared with an average $17,000 when the surgery went well. There were complications in about six per cent of surgeries, a fairly typical rate.
I’m not suggesting corporate execs, wringing their hands like Montgomery Burns, are plotting to have surgeons leave instruments inside patients or skimp on handwashing. (The latter surprisingly common.) The managers go home to their families too.
But proponents of private care can’t have it both ways. They argue market forces - the push for bigger profits - will ‘incentivize’ improvements in care.
So they have to acknowledge market forces now discourage efforts to reduce complications.  
No managers would say they like surgical complications because they are profitable. 
But they might say that spending on projects to address other problems is a higher priority. It’s not easy to explain the benefits of investing in programs that will reduce the companies’ profits.
Free-enterprise extremists likely have answers. The insurance companies, they might argue, should be pressing the hospitals to reduce surgical complications. The smart insurers would use the safest, lowest-cost hospitals, and cut premiums and attract more customers.
Except that isn’t happening. There are some 200,000 preventable deaths a year related to U.S. hospital stays. The rate of deaths from surgical complications has been declining, but slowly. 
The market isn’t working. Maybe the hospitals have too much power, or the insurers can charge what they like and have little incentive to push for better performance. It doesn’t really matter to the people who suffer as a result of avoidable complications, or everyone who pays higher health insurance premiums that flow to hospital shareholders.
There are still useful ways to encourage innovation through competition in a largely public system. (And we have an largely public system. Doctors are effectively Health Ministry employees with a great collective agreement.) 
Hospitals that find ways to deliver successful surgical outcomes could get extra funding, or financial incentives for participants. Why not? Everyone benefits if we can cut complications, or do four hip replacements for the cost of three. 
Meanwhile, proponents of private care face a problem. The current reality is that surgical complications are good for private hospitals in the U.S. And that is bad for patients.

Monday, May 27, 2013

'Research fishery' for Queen conch and the tragedy of the commons

Sometimes news stories just set off all kinds of alarm bells.
Honduras has apparently learned from Japan’s bogus scientific whaling program, which lets that country’s operators kill 900 whales a year - and sell the meat - in the name of science.
The Honduran government has announced a Queen conch fishery, justified as “a research and evaluation project for monitoring giant snail populations.”
It looks more like a way around restrictions on the fishery.
A lot of people have seen golden Queen conch shells, with their pink-tinged centres and classic spiral shape. They were a popular souvenir of Florida a generation ago, and thrived in waters from Florida to northern Brazil. 
They’re considered tasty, and are easy to harvest. Not good for them.
Queen conch aren’t on endangered lists yet, but CITES - the Convention on Trade in Endangered Species - has recommended an embargo on exports from Honduras, Haiti, and the Dominican Republic. CITES pitches the embargo as a way to support government conservation measures - if there is no market, there is no reason to grab the conch.
It’s loosely observed, and fishers still harvest both for export and local markets - conch soup, with coconut milk base, is a popular item on the Honduran coast. 
The government’s research fishery looks like a way to get around the export ban.
Honduras is going to let six ships capture 210 tonnes of Queen conch. About 100,000 conch. 
And 95 per cent of the catch is reserved for export, mostly to the U.S.
It’s hard not to be suspicious. If the government wanted to assess Queen conch stocks, it could co-operate with a university or look for grants for a survey. Grabbing 210 tonnes of a possibly endangered shellfish in the name of research seems dubious.
The whole tragedy of the commons theory is lived out vividly here. Serious poverty is a factor. So is the near-total absence of effectively enforced laws and regulations. Why should a small fisherman obey limits on Queen conch catches when people with influence can get access to a “research fishery”? (Or why should a campesino respect a forest reserve, or water source, when others are conducting illegal logging?)
Of course, North Americans shouldn’t be too judgmental of practices that evoke our relatively recent past. We moved to Copan Ruinas from British Columbia. That province built its current prosperity by logging old-growth forests. Wild salmon runs were sacrificed for quick profits for the fishing industry, developers and forest companies. It’s no different than grabbing the last of the Queen conches, except Hondurans are more legitimately desperate.
The theoretical argument for conservation is sound. Manage the resource and you will have sustainable economic activity long into the future. 
But the argument didn’t persuade British Columbians. Why should Hondurans, so much poorer, think it a good idea?
It’s great to talk about tourist potential and the economic value of preserving tropical jungles and deserted beaches and coral reefs and vast mangrove shorelines. The economic argument for conservation.
But not realistic. We were in La Moskitia, the vast biosphere in  southern Honduras, and it is spectacular - unspoiled nature, beaches, lagoons, fascinating cultures. But the roads are poor to nonexistent, there is no tourist infrastructure and travel is a challenge.
And the Honduran government’s total tourism promotion budget this year is $2.2 million. Destination BC has $49 million to promote one province.
Still, the alternative is grim. The newspaper reported last week that a company had cleared 50 acres of protected mangroves for a new shrimp farm. The story said nothing about investigations, or sanctions. The lesson is to join the gold rush, in conch or shrimp or logging or African palm plantations.
And La Moskitia includes the Rio Platano Biosphere Reserve, a UNESCO World Heritage Site. But since 2011, the reserve has been in UNESCO’s World Heritage in Danger list. Illegal logging and farming are factors, according to the UN agency. 
But so are the Honduran government’s lack of capacity and “general deterioration of law and order and the security situation in the region.” (It is a popular transit point for northbound cocaine shipments.)
Ultimately, for the Queen conch and La Moskitia and the mangroves and rain forest and so much more, that’s the greatest problem. There are solutions, and perhaps international partners to help. But only if the Honduran government can play a role..