U.S. health care: paying more, getting less

Gershom Gorenberg calls attention to a recent report on the performance of our national healthcare system by the Commonwealth Fund.

The report shows that Americans pay a lot more but receive a lot less for health care compared to other countries. Gorenberg quotes the report as scoring the U.S. an overall 65 out of a possible 100 on 37 core indicators of performance well behind other Western nations. Additionally, access to health care declined from 2006 to 2008.

According to Gorenberg:

In what may be the most striking measure, the U.S. had the highest number of deaths that could have been prevented by care - 110 per 100,000. Portugal did better, and so did Greece. In “healthy life expectancy at age 60″ - meaning the number of healthy years you can still expect to live at that age - the U.S. was also close to the bottom. Infant mortality? In the U.S., the rate is 6.8 per 1,000 births, compared to 5.3 in Canada and 3.3 in Finland. The 10 healthiest states in the U.S. came had more infant deaths than Denmark, slightly less than Canada as a whole.

The Commonwealth Fund, alas, didn’t include Israel in its charts. So I emailed my friend Gary Ginsberg, health economist to the world, and asked him for some comparisons. His answers: The infant mortality rate in Israel is 3.9 per 1,000 - better than Denmark, worse than Finland. Sadly, health in Israel shows inequality - the picture is significantly worse for non-Jews. So the infant mortality rate for non-Jews is 6.7 - still better than the U.S. national average.

In Israel in 2002, a man had a healthy life expectancy 16.8 more years, a woman of 18.2 more years. In America, the matching figures were 15.3 years for men, 18.1 for women.

The reason for these differences is pretty obvious: The United States, an underdeveloped country, lacks universal, socialized medical care. The free market flunks at health care. The invisible hand marks up the cost and provides shoddy goods.

Ah, but some well-off Americans might protest: Those pesky figures are for everyone in a country. If you are insured and well-off in America you will live longer and better because of the fabulous hospitals, the incredible techniques.

The incidental evidence is poor on that as well. Check this from the New York Times today: American doctors put in artificial joints that have already proven flawed and that wouldn’t be used in other countries - because the other countries have a national registry that reveals problems quickly, and the U.S. doesn’t. Skip all the arguments about exactly why the U.S. doesn’t. They boil down to: no national health care system. The free market is good at giving you expensive care, not necessarily good care.

You can read Gorenberg’s entire piece here. You can read the report here.

Johnny Griffin: “My Little Suede Shoes”

Johnny Griffin died today at age 80. He was a bop and hard bop tenor saxophonist. Griffin was known as the "fastest tenor in the west", for the ease with which he could execute fast note runs with excellent intonation. He played with many of the big names in jazz since he starting performing in the 1940’s. His last concert, July 21, 2008 was played in Hyères, France.

The Johnny Griffin & Art Taylor Quintet performs “My Little Suede Shoes” above.

Europe witnesses the 44th president of the United States

U.S. Presidential candidate Barack Obama spoke before a cheering crowd of over 200,000 in Berlin, Germany yesterday. "The walls between old allies on either side of the Atlantic cannot stand," Obama said, speaking not far from where the Berlin Wall once divided the city. As Gerhard Spörl in Der Spiegel puts it, Europe is witnessing the 44th president of the United States:

… Barack Obama is a passionate politician who is fixated on -- and takes very seriously -- his desire for a better world. That he is an impressive speaker who knows how to casually draw his audience into his image of the world -- one who doesn't have any need to resort to the kind of cheap effects that tend to prompt the uproarious applause of an audience. That he is a typical American -- an idealist in the true spirit of the American success story who is now very casually making his claim to becoming something akin to the president of the world.

He also could have said: We are a world power, the only one on the planet at the moment, and I intend to act as if this were the case. But you're also allowed to participate in the attempt to try to save the world -- at least a bit of it. In that sense I am different from George W. Bush, very different. Indeed, Barack Obama has his own sound -- it's more utopian, he speaks of the general human desire for better conditions for all of humanity; and he speaks of the longing for strong and dynamic presidents and chancellors who are capable of acting on a global scale. With this drive and this radiance, he managed to drive Hillary Clinton out of the campaign. It is also the way he will outpace John McCain by November 4. It is the way he took the hearts of Americans by storm, and it is the way he is now taking Europe by storm.

***
Europe is witnessing the 44th president of the United States during this trip….

Hopefully, President Obama can repair the image of the United States, which has plummeted around the world since the beginning of the 21st Century.

Oscar Peterson Trio: “A Gal In Gallico” (1958)

Oscar Peterson Trio (Peterson on piano with Ray Brown on bass and Herb Ellis on guitar) performing “A Gal In Gallico” in 1958.

How much does John McCain really know about foreign policy?

There seems to be an assumption among the media that Senator John McCain has substantial experience in foreign policy and that somehow automatically translates into wise leadership internationally. But is that a fair assumption?

There are his multiple gaffes such as his referral to "the Iraq-Pakistan border," or calling the Czech Republic "Czechoslovakia" (three times), or confusing Sunnis with Shiites, or saying that the U.S. troop surge preceded (and therefore caused) the Sunni Awakening in Anbar province. Fred Kaplan wonders, “Were they gaffes—slips of the tongue, blips of momentary fatigue? Or did they reflect lazy thinking, conceptual confusion, a mind frame clouded by clichéd abstractions?” Of course, McCain gets a pass by the press whereas if Obama said anything like this he would have been declared too inexperienced to qualify for the presidency.

However, what is disturbing about McCain is less the not-well-thought-out comments he makes to the press off the top of his head but some of his supposedly well-thought-out foreign policy proposals.

Fred Kaplan examines a few of those proposals:

… Quite apart from the gaffes, in formal prepared speeches, McCain has proposed certain actions and policies that raise serious questions about his suitability for the highest office. As president, he has said, he would boot Russia out of the G-8 on the grounds that its leaders don't share the West's values. He would form an international "League of Democracy" as a united front against the forces of autocracy and terror. And though it's not exactly a stated policy, he continues to employ as his foreign-policy adviser an outspoken, second-tier neoconservative named Randy Scheunemann, who coined the term "rogue-state rollback" and still prescribes it as sound policy.

Evicting Russia from the group of eight leading industrial nations may have some visceral appeal, but it has at least two drawbacks. First, all the G-8's other members are opposed to the notion. Second, the main issues that concern the G-8—for instance, climate change, energy policy, nuclear nonproliferation, and counterterrorism—cannot be fully addressed without Russia's participation.

The idea of a League of Democracy has a nice ring, especially given the United Nations' frequent obstructionism in the face of human misery and common danger. The obstructionism stems in part from vetoes by Russia or China, which, of course, would not be members of this league. But there are a few problems here as well. First, democratic nations often differ on high-profile issues (e.g., the invasion of Iraq, the rules of engagement in Afghanistan, the Kyoto Treaty, etc.). Second, very few of the world's pressing problems break down along the lines of democracies vs. nondemocracies, either by topic or constituency. Third, creating such an overtly ideological bloc as a central tool of foreign policy would only alienate the excluded nations—and possibly incite them to form an opposing bloc. The challenge is to find common solutions to global problems, not to encumber them in a new Cold War.

As for rolling back rogue states, one would hope that McCain has learned some lessons from George W. Bush's failures as even Bush himself has done, albeit belatedly—for instance, in deciding to negotiate with the North Koreans (though not until after they tested an atomic bomb). Someone should ask McCain: Would he cut off those talks? Does he value Scheunemann's advice? If so, which rogues does he hope to topple next, and with whose army does he plan to do it? (Ours is overbooked at the moment.)

In other words, how much does John McCain really know about foreign policy after all? It's a question to be asked and answered, not brushed away as impertinent.

George Benson & McCoy Tyner: “Alligator Boogaloo”

Guitarist George Benson and pianist McCoy Tyner perform “Alligator Boogaloo”. They are backed up by Avery Sharpe on bass and Aaron Scott on drums.

Catholic Church condemns birth control in the Philippines

Despite the fact 1.4 million unplanned pregnancies contribute to an annual population growth of 2.34 percent in the Philippines while its ranking on the Human Development Index declines, the Roman Catholic Church still condemns the use of the pill and other forms of contraception. One couple reported below they were counseled to use the natural method of having sexual intercourse when the woman is not fertile and if they desired sex at other times to simply watch a movie or look at one another.

Here is the story by Stella Gonzales:

As World Population Day was being marked on Jul. 11, Tess and Andy were attending a family planning seminar as a requirement for their forthcoming wedding. It turned out to be window into one of the major problems besetting the Philippine population programme.

Because their seminar was conducted by a doctor-volunteer in a Catholic church in Manila, Tess and Andy (surname suppressed) were expecting the facilitator to toe the church’s line against artificial contraception. But they did not anticipate the kind of information that was given them and several other couples.

They said the doctor told seminar participants that the pill was an abortifacient (a device that acts after human life has begun) and that condoms do not protect against HIV (the virus that causes AIDS). "Yet she did not present any scientific evidence to back her claims," Tess told IPS.

Tess was stunned when the doctor, again with no proof, said some babies had been born with an intrauterine device (IUD) stuck in their heads.

Andy, a Scandinavian who has travelled to various parts of the world, said the seminar was "one of the weirdest" experiences he has ever had. As he listened to the doctor, Andy said he was thinking to himself: "This can’t be happening. It’s something that happens only in the movies."

He said that while he was aware that people in some African countries were being told that condoms do not work against HIV, further aggravating the AIDS problem there, he never expected to hear the same line being disseminated in a country such as the Philippines.

Tess said the doctor promoted only natural family planning methods, where couples who do not wish to bear children are supposed to have sex only when the woman is not fertile. "I asked what couples were supposed to do when they wanted to have sex during an ‘unsafe’ period. She said we should go watch a movie or just look at each other," Tess recounted.

***

The country’s population, with an annual growth rate of 2.34 percent, is projected to hit 90 million this year. Last year, the Philippines’ human development index (HDI) ranking fell seven places, to number 90. In comparison, its South-east Asian neighbours Vietnam and Indonesia saw significant improvements in their HDI.

President Gloria Arroyo, despite clamour from various sectors, has refused to lay down a comprehensive national population policy. Arroyo, a devout Catholic, has instead left it to local governments to come up with their own programmes.

Former President Fidel Ramos said Arroyo’s "ambiguousness" towards her population policy "has put mothers’ lives and health, together with their babies, at risk for the sake of political expediency and religious traditionalism."

During his presidency, Ramos implemented a population programme that resulted in bigger funding for reproductive health, more family planning workers, and -- at the end of his term in 1998 -- a lower population growth rate.

The Catholic church, which is seen to be politically influential because 85 percent of the population is Roman Catholic, vehemently opposed the programme. But Ramos, a Protestant, stood his ground. The next president, Joseph Estrada, also had a strong population programme but was ousted after only three years in power.

Arroyo, who took over in 2001, hewed close to the church’s stand and has not changed her position on the issue. …

***

In nearby Quezon City, Joseph Juico, a local councillor, said he was moving his scheduled wedding from a Catholic church in the city to another venue after a priest allegedly threatened not to give him communion on his wedding day because of a population management ordinance he had introduced. That measure, approved earlier this year, provides access to artificial contraceptives and free sterilisation.

Adding fuel to the fire was a pastoral letter issued a few weeks ago by a Catholic bishop saying that politicians who push for "abortion" should not be given communion in parishes. In the eyes of the Catholic church, contraceptives such as the pill induce "abortion."

The pastoral letter was apparently in reaction to reports that several members of Congress were going pushing for a bill that would provide for a national policy on reproductive health and population development. That measure includes "sexuality education" for elementary and high school students and the allocation of a "gender and development" budget for the Commission on Population.

***

Studies have shown that there are about 1.4 million unplanned pregnancies in the country each year, of which one-third ends in abortion, a criminal act in the Philippines.

You can read the entire article here.

Karadzic finally arrested for war crimes

Radovan Karadzic has been arrested on an international warrant for war crimes. He was a fugitive from justice from 1996 until this week. Karadzic was a proponent of Serb nationalism during the breakup of Yugoslavia and under his military leadership of Serb forces in Bosnia during the early 1990’s many atrocities were committed against non-Serb civilians.

Russ Baker’s 2004 article reminds us of the scale of Karadzic’s crimes:

One really shouldn't engage in atrocity one-upmanship, but it's arguable that compared with such more famous current and recent fugitives as Osama bin Laden and Saddam Hussein, Karadzic, wins the odiousness sweepstakes. A remarkably public front man for genocide in the former Yugoslavia, the disarmingly avuncular Bosnian Serb leader dispensed lies to packed press conferences while his soldiers laid siege to Sarajevo (where he previously worked at the main hospital) and went village to village, locking families inside houses and setting them afire, bringing women to detention camps where they could be mass-raped. Along with his general and fellow fugitive Ratko Mladic, Karadzic is accused of responsibility for all manner of atrocity, most notably the 1995 massacre of about 8,000 Muslim men and boys in the U.N. safe area of Srebrenica, the single worst crime committed in Europe since World War II.

Heather Hurlburt notices the trend towards international accountability for crimes against humanity:

For an institution that has been ridiculed, assaulted and accused of non-existence in recent years, international law -- and more important, international accountability for crimes committed against one's own citizens -- is having a pretty darn good run right now.

Today comes the news that, in response to yet another round of European Union pressure, the Serbian government itself arrested indicted war criminal Radovan Karadzic -- a far cry from the days of NATO troops chasing him futilely around the Bosnian countryside seven years ago. Looks as if the Hague is his next stop. (Karadzic, in case you've forgotten, ordered the killings of 7500 Bosnian Muslim men and boys at Srebrenica in 1995, shelled Sarajevo, and used UN peacekeepers as human shields. ….)

And last week we had the International Criminal Court indictment of Sudanese President Omar Bashir for his leadership in the mass killings in Darfur. To be reminded of what he has done, check out the ENOUGH Project's list of his misdeeds here. …

Human Rights Watch's Richard Dicker has a sober, net positive appraisal of the ICC's first five years here. Suspects indicted in four countries but no one brought to trial; a first trial stopped because of problematic evidence rules; financial and law enforcement support from member governments that is not what it should be.

Speaking of member governments, you will notice something interesting about this trend -- from the EU in the Balkans to the states parties to the ICC, progress toward a small-bore, excruciatingly slow but nonetheless forward-moving mechanism of international justice has taken place pretty much without the United States or even, in the case of the ICC, against the will of our government. That business about being the sole superpower and nothing of importance being decided without us? Maybe think again.

We can only hope this trend picks up steam.

Maliki: Tenure of U.S. troops in Iraq should be limited

On the eve of a visit to Iraq by Senator Barak Obama, Der Spiegel published an interview with Iraq’s Prime Minister Nuri Kamal al-Maliki. In that interview Maliki stated his government’s position that U.S. armed forces should leave Iraq as soon as possible and basically endorses Senator Obama’s 16-month timetable for withdrawal. Here is a portion of the Der Spiegel interview:

SPIEGEL: Germany, after World War II, was also liberated from a tyrant by a US-led coalition. That was 63 years ago, and today there are still American military bases and soldiers in Germany. How do you feel about this model?

Maliki: Iraq can learn from Germany's experiences, but the situation is not truly comparable. Back then Germany waged a war that changed the world. Today, we in Iraq want to establish a timeframe for the withdrawal of international troops -- and it should be short. At the same time, we would like to see the establishment of a long-term strategic treaty with the United States, which would govern the basic aspects of our economic and cultural relations. However, I wish to re-emphasize that our security agreement should remain in effect in the short term.

SPIEGEL: How short-term? Are you hoping for a new agreement before the end of the Bush administration?

Maliki: So far the Americans have had trouble agreeing to a concrete timetable for withdrawal, because they feel it would appear tantamount to an admission of defeat. But that isn't the case at all. If we come to an agreement, it is not evidence of a defeat, but of a victory, of a severe blow we have inflicted on al-Qaida and the militias. The American lead negotiators realize this now, and that's why I expect to see an agreement taking shape even before the end of President Bush's term in office. With these negotiations, we will start the whole thing over again, on a clearer, better basis, because the first proposals were unacceptable to us.

SPIEGEL: Immunity for the US troops is apparently the central issue.

Maliki: It is a fundamental problem for us that it should not be possible, in my country, to prosecute offences or crimes committed by US soldiers against our population. But other issues are no less important: How much longer will these soldiers remain in our country? How much authority do they have? Who controls how many, soldiers enter and leave the country and where they do so?

SPIEGEL: Would you hazard a prediction as to when most of the US troops will finally leave Iraq?

Maliki: As soon as possible, as far as we're concerned. U.S. presidential candidate Barack Obama talks about 16 months. That, we think, would be the right timeframe for a withdrawal, with the possibility of slight changes.

SPIEGEL: Is this an endorsement for the US presidential election in November? Does Obama, who has no military background, ultimately have a better understanding of Iraq than war hero John McCain?

Maliki: Those who operate on the premise of short time periods in Iraq today are being more realistic. Artificially prolonging the tenure of US troops in Iraq would cause problems. Of course, this is by no means an election endorsement. Who they choose as their president is the Americans' business. But it's the business of Iraqis to say what they want. And that's where the people and the government are in general agreement: The tenure of the coalition troops in Iraq should be limited.

White House attempting to redefine abortion to include many types of contraception

The Bush administration is attempting to re-define abortion so broadly as to include many types of contraception. This is part of a larger proposal by the Department of Health and Human Services to cut off federal aid or grants to individuals or institutions that, according to the administration, discriminate against nurses and other health care providers or researchers who object to abortion.

Common usage and understanding of the term “abortion” generally refers to the surgical procedure for the removal of an embryo or fetus from the uterus and not to oral contraceptives or emergency contraception as would be included in this proposal.

This is from Tuesday’s New York Times:

The Bush administration wants to require all recipients of aid under federal health programs to certify that they will not refuse to hire nurses and other providers who object to abortion and even certain types of birth control.

Under the draft of a proposed rule, hospitals, clinics, researchers and medical schools would have to sign “written certifications” as a prerequisite to getting money under any program run by the Department of Health and Human Services.

Such certification would also be required of state and local governments, forbidden to discriminate, in areas like grant-making, against hospitals and other institutions that have policies against providing abortion.

The proposal, which circulated in the department on Monday, says the new requirement is needed to ensure that federal money does not “support morally coercive or discriminatory practices or policies in violation of federal law.” The administration said Congress had passed a number of laws to ensure that doctors, hospitals and health plans would not be forced to perform abortions.

In the proposal, obtained by The New York Times, the administration says it could cut off federal aid to individuals or entities that discriminate against people who object to abortion on the basis of “religious beliefs or moral convictions.”

The proposal defines abortion as follows: “any of the various procedures — including the prescription, dispensing and administration of any drug or the performance of any procedure or any other action — that results in the termination of the life of a human being in utero between conception and natural birth, whether before or after implantation.”

Mary Jane Gallagher, president of the National Family Planning and Reproductive Health Association, which represents providers, said, “The proposed definition of abortion is so broad that it would cover many types of birth control, including oral contraceptives and emergency contraception.”

“We worry that under the proposal, contraceptive services would become less available to low-income and uninsured women,” Ms. Gallagher said.

Indeed, among other things the proposal expresses concern about state laws that require hospitals to provide emergency contraception to rape victims who request it.

Nancy Keenan, president of Naral Pro-Choice America, said, “Why on earth is the Bush administration trying to discourage doctors and clinics from providing contraception to women who need it?”

Christina Pearson, a spokeswoman for the department, declined to discuss the draft. “We don’t normally comment on whether we are considering changes in regulations,” she said.

The (real) price of cheap oil

Many or all of us complain about the high prices we pay as the gas pump these days. But the few extra dollars out of our pockets is nothing compared to what many people in oil producing countries pay in the devastation of their communities and lives to subsidize our dependence upon this limited natural resource. Johann Hari takes a look at Nigeria:

When you cry for cheaper oil, do you know what you are really asking for? …

To understand, you need to know the story of the Niger Delta, a once lush land of mangrove swamps at the base of Nigeria. In the late 1950s, in the final days of British imperial rule, Shell's local subsidiary discovered it lay on top of vast pools of oil. Britain immediately became its number one user, with the US close behind. In the long decades since, more than $200bn worth of oil and gas has been pumped from beneath the Delta people's feet.

So you would imagine the Niger Delta must now be an oasis of riches, with its 30m people bathing in wealth. But no: they live with nothing and die by the age of 40. While the lifeblood of twenty-first century techno-life is pumped from their land, they live in the Stone Age, with no schools, no hospitals and barely any electricity. They have felt three effects from the petrol. Their land has been poisoned by oil spills; the fish they lived off have been turned into stunted, toxic rarities; and when they ask for compensation, they are shot at.

Here's just one everyday story about how that feels, unusually well documented because some journalists happened to be there. In October 1998, there was a leak of raw petroleum near one Delta village. Somehow – a stray cigarette, perhaps – a spark hit it, and a huge fireball whooshed up to incinerate over 700 people.

Three years later, the journalist Greg Campbell went back to see some of the victims. They had received no medical treatment. Christiana Akpode, a 24-year-old mother, could barely walk; her legs were forced into a permanent kneel. Campbell explained: "Her legs are hard to look at: from the shin to the knee, her legs are little more than red and purple scabs bleeding white pus. She scratches this section incessantly. Her days are spent warding away flies from the open wounds." As the journalist left, she pleaded: "You should kill me."

The people of the Niger Delta have not watched this destruction of their homeland – for us – passively. They signed petitions, went to the oil barges to ask for a fair share of the proceeds, and refused to co-operate with the oil companies. The response? According to Human Rights Watch, the Nigerian military – hungry for its own hefty cut of the cash – beat, tortured or killed them, sometimes with the active help of some of the oil companies.

For example, in 1998, more than 100 ordinary villagers went to one of Chevron's barges to ask peacefully to speak to the company's managing director. They were told to wait.

They saw helicopters approaching, and assumed they were Chevron spokespeople – until the gunfire began. Two of them were shot dead. Others were taken away and tortured. The rest managed to flee. A Chevron spokesman admitted the corporation flew in the Nigerian soldiers who did the shooting – and that the protestors they murdered were unarmed.

Peaceful protests had been swelling in popularity since the early 1990s – so the movement's leaders were seized. The head of the local Internal Security Task Force, Lieutenant-Colonel Paul Okuntimo, made clear why, in a 1994 memo that was later leaked: "Shell operations are still impossible unless ruthless military operations are undertaken," he wrote, including "wasting targets ... especially vocal individuals." (Shell claims the memo is fake, and if it is real they find it "abhorrent".) One of the arrested leaders, the playwright Ken Saro-Wiwa, said: "This is it – they are going to execute us. For Shell." In his final plea before he was hanged, he asked: "Why should the people on oil-bearing land be tortured?"

After that, silence. The people were too terrified to act. But two years ago they tried a new tactic. Non-violent resistance got them massacred, so some turned to violent resistance. The Movement for the Emancipation of the Niger Delta (Mend) emerged from the mangrove swamps to vandalise oil pipelines and kidnap oil industry workers. "We are not communists or even revolutionaries," their spokesman explained. "We are just extremely bitter ... We are people who would rather be with our families raising our children, sending them to school. We want all this to be over, but what future do our children have?"

Mend has issued three simple demands. It wants $1.5bn in compensation already awarded to it by the courts for damage to the environment; a 50 per cent claim on all oil pumped out of their land; and the release of their captured leaders. That's it. A former oil worker hostage of Mend told Vanity Fair: "Their grievances are legitimate ... To be out in the swamp with no water or electricity, of course they're upset. They are looking through our fence at golf courses and tennis courts where the floodlights are on at midnight [when] they are without electricity for days."

Mend has so much support in the Deltas that it has now been able to disrupt oil pumping by 30 percent. This shooting up of the pipelines is one of the main reasons why oil prices have shot up across the world. There are two possible responses now. The first is to meet Mend and the Delta's demands: let the people have a fair share of their own oil profits. The second is to violently suppress the population with a renewed mass terror.

***
An old woman from the Delta tries, in the new American documentary Sweet Crude, to talk directly to you. She says: "I'd like people all over the world to realise there's a segment of humanity suffering as a result of oil production – ordinary men, women, children. They should think about them and not think simply of energy. Think of us as people. That's more important than anything."

But while we are unrepentant junkies, howling for cheap petrol, will we be able to hear her?

You can read the entire piece here.

The challenge of a national security that is fundamentally flawed

Andrew J. Bacevich graduated from West Point in 1969 and served in Vietnam in 1970 and 1971. He continued in the military retiring as a Colonel in the early 1990’s. He earned his Ph.D from Princeton University in the history of American Diplomacy and has taught at West Point, John Hopkins University and Boston University. His son followed his career path into the military and was killed by a roadside bomb in Baghdad in May of 2007.

Bacevich has been a conservative critic of Bush foreign policy and presents this assessment of the Bush presidency in yesterday’s Boston Globe:

FEW AMERICANS, whatever their political persuasion, will mourn George W. Bush's departure from office. Democrats and Republicans alike are counting the days until the inauguration of a new president will wipe the slate clean.

Yet in crucial respects, the Bush era will not end Jan. 20, 2009. The administration's many failures, especially those related to Iraq, mask a considerable legacy. Among other things, the Bush team has accomplished the following:

· Defined the contemporary era as an "age of terror" with an open-ended "global war" as the necessary, indeed the only logical, response;

· Promulgated and implemented a doctrine of preventive war, thereby creating a far more permissive rationale for employing armed force;

· Affirmed - despite the catastrophe of Sept. 11, 2001 - that the primary role of the Department of Defense is not defense, but power projection;

· Removed constraints on military spending so that once more, as Ronald Reagan used to declare, "defense is not a budget item";

· Enhanced the prerogatives of the imperial presidency on all matters pertaining to national security, effectively eviscerating the system of checks and balances;

· Preserved and even expanded the national security state, despite the manifest shortcomings of institutions such as the CIA and the Joint Chiefs of Staff;

· Preempted any inclination to question the wisdom of the post-Cold War foreign policy consensus, founded on expectations of a sole superpower exercising "global leadership";

· Completed the shift of US strategic priorities away from Europe and toward the Greater Middle East, the defense of Israel having now supplanted the defense of Berlin as the cause to which presidents and would-be presidents ritually declare their fealty.

By almost any measure, this constitutes a record of substantial, if almost entirely malignant, achievement.

Bush's harshest critics, left liberals as well as traditional conservatives, have repeatedly called attention to this record. That criticism has yet to garner mainstream political traction. Throughout the long primary season, even as various contenders in both parties argued endlessly about Iraq, they seemed oblivious to the more fundamental questions raised by the Bush years: whether global war makes sense as an antidote to terror, whether preventive war works, whether the costs of "global leadership" are sustainable, and whether events in Asia rather than the Middle East just might determine the course of the 21st century.

Now only two candidates remain standing. Senators John McCain and Barack Obama both insist that the presidential contest will mark a historic turning point. Yet, absent a willingness to assess in full all that Bush has wrought, the general election won't signify a real break from the past.

The burden of identifying and confronting the Bush legacy necessarily falls on Obama. Although for tactical reasons McCain will distance himself from the president's record, he largely subscribes to the principles informing Bush's post-9/11 policies. McCain's determination to stay the course in Iraq expresses his commitment not simply to the ongoing conflict there, but to the ideas that gave rise to that war in the first place. While McCain may differ with the president on certain particulars, his election will affirm the main thrust of Bush's approach to national security.

The challenge facing Obama is clear: he must go beyond merely pointing out the folly of the Iraq war; he must demonstrate that Iraq represents the truest manifestation of an approach to national security that is fundamentally flawed, thereby helping Americans discern the correct lessons of that misbegotten conflict.

By showing that Bush has put the country on a path pointing to permanent war, ever increasing debt and dependency, and further abuses of executive authority, Obama can transform the election into a referendum on the current administration's entire national security legacy. By articulating a set of principles that will safeguard the country's vital interests, both today and in the long run, at a price we can afford while preserving rather than distorting the Constitution, Obama can persuade Americans to repudiate the Bush legacy and to choose another course.

This is a stiff test, not the work of a speech or two, but of an entire campaign. Whether or not Obama passes the test will determine his fitness for the presidency.