King John is an oddity among Shakespeare’s plays in being almost wholly about politics. No one comes off well. The promises and acts of the powerful, we are told, are actuated by self-interest, not principle. Unlike in Richard III, the bad do not meet their comeuppance. The verse is poised between striking rhetoric (as the Greeks and Romans defined it) and Shakespeare’s uncanny ability to cut to the heart of the matter. The plot is resolved by a skillful modulation into diffident patriotism, mixing foreboding with hope. Confronted with disaster—the death of a child, civil dissension, invasion—the bastard Philip muses upon the future:
vast confusion waits,
As doth a raven on a sick fall’n beast,
The imminent decay of wrested pomp.
Now happy he whose cloak and cincture can
Hold out this tempest. . . .
I’ll to the king:
A thousand businesses are brief in hand,
And heaven itself doth frown upon the land.
Not usurpation but the failure of politics; not heaven but nature. A few changes are enough to fit these forebodings to our times.
Nearly one year on, the coronavirus pandemic shows few signs of slackening. Forecasts of its demise are still being reworked to fit new data and research results, but the basic contours of expert advice remain substantially unchanged: to shut down schools, workplaces, markets, etc. when necessary; to trace and identify carriers of the virus (and isolate their contacts); to test as many people as possible; and to practice social distancing, the use of masks, and so on. In addition, some countries closed their borders and sealed affected regions (such as Wuhan and Lombardy) for varying periods at the beginning of the pandemic. All these measures are designed to slow its spread, buying time to reinforce health care systems that exist, in theory at least, to treat everyone who falls ill.
The World Health Organization dispenses much the same advice to nations as diverse as Papua New Guinea and Germany, South Africa and Japan, India and Thailand, Uganda and France, Suriname and the United States. Up until now, only a few countries (mostly in Europe and East Asia) have proved willing and able to carry it through; for the most part, they saw a gradual decline in infections during the late spring and summer. The toll is uneven, with Germany and the Netherlands doing much better than Spain, Italy, or the United Kingdom. A considerable margin of uncertainty remains—including about the probable effects of a second wave—but, even so, it’s hard to believe that they will ever be as badly affected as the United States, Brazil, or India.
Strikingly, this advice rests upon an assumption that is hardly ever discussed. Its economic consequences in terms of lost jobs and livelihoods are clear enough—they vary, not just by the usual parameters of class, race, and caste but also by GDP: rich countries can spend much more to cushion the shock to their economies. But this does not affect the assumption, which holds that every country possesses a health system capable of dealing with the pandemic. In other words, one that provides affordable health care to all residents through public provision or insurance, or (more usually) a mix of the two.
In fact, health policies vary widely across nations, ranging from little or threadbare public provision to universal health care. Generally speaking, the most effective systems are to be found in the countries that invented social democracy or adopted it, with some variations, after the Second World War. Other nations were also constructing their own versions of the welfare state around this time: from one party dictatorships of varying Marxist persuasions—the countries of Eastern Europe, China, and Cuba (where increased social spending predated Castro’s assumption of power in 1959)—to authoritarian regimes wedded to managed capitalism (South Korea, Taiwan, and Singapore). In each case, the state undertook to provide schooling and health care to all citizens; despite considerable alterations in political systems and economic management, this compact still holds.
At the other end of the spectrum are countries where the state assumes little to no responsibility for health care: much of Africa, and some parts of Asia and Latin America. Between these two extremes lie a range of systems combining public and private provision. American exceptionalism extends to its health care system, which is structurally unique: very large, advanced, and expensive, with insurance assuming critical importance. By now it seems clear that countries with universal health systems, despite some struggles, have managed the pandemic much better than those where health care is privatized. In the United States, infections and deaths remain consistently higher than its share of global population. India, with its weak public health infrastructure and low rates of insurance cover, has experienced an unbroken rise in cases. Brazil’s public health system fares better in comparison but suffers from chronic underfunding—one reason for the severity of its travails.
The WHO’s advice may be homogeneous, but health systems are not. If anything, the pandemic reveals their striking diversity. The global history of health care and its relationship to nation-building is a complex one, with many distinctive features. This seems as good a time as any to revisit it, for the unequal landscape of suffering created by the pandemic can only be understood in historical context.
During the nineteenth century, as the Industrial Revolution gathered pace, state investments in education and public health became much larger and more systematic. For the most part, they were confined to a handful of states seeking to industrialize aggressively in order to reach some kind of parity with Great Britain (or Western powers in the case of Japan). Paradoxically, Britain, the most advanced economy of the time, lagged behind Germany, France, and Japan in this respect: by the late nineteenth century, all of them had centralized their education systems, made schooling compulsory for very many children, and were spending much more on public health.
This goal took shape in diverse political contexts—national unification in Germany; a growing sense of inferiority in France (magnified by the disastrous Franco-Prussian War of 1870); and, in Japan, the dissolution of feudalism, the titular restoration of the emperor, and the capture of power by an oligarchic group determined to modernize the country. In each case, it provided a strong impetus for reimagining the state and its contribution to economic development.
Widening political participation also drove social spending. In Western Europe, the nineteenth century was marked by waves of working-class agitation—for shorter working days, better pay, extension of the franchise, and other reforms. In response, ruling elites (buttressed with a strong middle-class element) usually made concessions on spending and political representation to shore up popular legitimacy. Britain was no exception to this even though the slow diffusion of education and health care owed more to local authorities, philanthropy, and church organizations than spending from London.
Japan remained a special case. Most countries in Asia and Africa were unable to make these investments even if they had wanted to, for the simple reason that they were colonies. China retained its independence only at the cost of surrendering much of its fiscal and political autonomy. The major colonial powers—Great Britain, France, the Netherlands, the United States (in the Philippines)—built schools and hospitals to appease a small fraction of their subjects (chiefly landed elites whose support they needed) and to train administrative personnel for the lower rungs of government. To spread these services more widely was inconceivable, for it risked the specter of rebellion; the “educated” native was also a political threat. In any case, such investment ran counter to the very logic of colonialism. Colonies were maintained for profit or glory (and preferably both): social spending provided neither. Besides, their inhabitants—as subjects, not citizens—deserved only what the metropole was disposed to grant.
Interestingly, the most progressive colonial power of the twentieth century was Japan, whose rule in Korea and Taiwan, although brutal enough—including the active proscription of Korean (and Taiwanese) culture and much sexual slavery—laid a solid basis for later progress. In Taiwan, it carried out a limited land reform by removing absentee landlords, encouraged peasants to grow more rice and sugar, and, starting in the 1930s, opened many light and heavy industries. In Korea, it swept away feudalism by abolishing slavery, codifying civil law, and creating property rights in land. Once this was done, Japanese companies moved factories there to take advantage of cheap labor. Japan also promoted education: in Asia’s Next Giant: South Korea and Late Industrialization, her comparative study of South Korea’s economic development, Alice Amsden notes that “investments in education, even at the university level, were unusually high by colonial standards, but they were motivated by policies designed to assimilate Koreans into Japanese society as the lower elements.”
By now it seems clear that countries with universal health systems, despite some struggles, have managed the pandemic much better than those where health care is privatized.
State expenditures on education were tied to the growing complexity of industrial production that conferred an advantage upon literacy. Spending on health care, by contrast, was driven by a new calculus of the state’s duties. This developed more slowly and is the reason why its real expansion had to wait until after the Second World War, when governments in Britain, Germany, and Japan were forced to assume control of the economy in hitherto unprecedented ways—through rationing, the distribution of scarce commodities, and active intervention in production and investment decisions. These policies were exported to colonies and conquered countries as part of the war effort. The sheer scale of the war’s destruction had a leveling effect on social structures; new ideas of the state’s role took root in its aftermath. The result was a wave of social spending: Britain, usually the laggard, went furthest by nationalizing its health care system.
Increased spending laid the foundations for unprecedented economic growth in Western Europe and East Asia. Whether it would have occurred with a different set of policies, as Thomas Piketty argues in Capital in the Twenty-First Century, is debatable. In retrospect, the period appears remarkably short—roughly thirty years, from the mid-forties to the early seventies—but its consequences were far-reaching. In East Asia, growth continued well beyond this point, fueled by the unstoppable rise of China, which began its takeoff even before growth rates in developed countries were flattening out.
With the war’s end, decolonization became imminent: a stream of new nations emerged on the world’s stage during the 1950s and 1960s. Some of them adopted economic policies modeled on the Soviet Union or the United States; others took their cue from the nineteenth century German experience. While many development economists laid stress on the benefits of equalizing landownership (by redistributing land), education and health care were taken for granted. Some countries invested in them, but most did not; regardless, the effect on economic performance aroused little interest. By the 1970s, as theorists of the free market captured the commanding heights of the discipline, it dropped out of discussion altogether. This has changed substantially in recent years, to the point where even The Economist stresses the integral role of health care and education in increasing workers’ productivity and stimulating growth. In Capital, Piketty takes the relation for granted: the training and productivity of a country’s workforce are assumed to determine its economic prospects.
India remains the only economy of significant size that has consistently failed to make these investments. For more than seventy years, its economic policies have been formulated with the explicit goal of catching up with the West. In this, of course, it’s far from unique: China, South Korea and Taiwan set out (from roughly comparable economic baselines) with much the same objective. But, unlike them, India failed to universalize health care and education. This is the chief reason why its industrial capacity remains so restricted. Economic management altered a good deal during this period: state intervention and planning gave way to a wave of market-friendly reforms, commencing in 1991, to full-scale deregulation and privatization from the turn of the century. From the 1980s, the centrist administrations of the Indian National Congress were challenged, then replaced, by the growing hegemony of the Hindu right. But the ultimate goal remains as far off as ever.
This failure becomes more explicable when placed in the context of the history of health care in India, for it reveals the relationship between social provision, economic growth, and industrialization in its starkest form.
The Fog of Cant
To provide health care or education, governments must first raise money to pay for it. If taxation is to be at all equitable or efficient, it must be progressive, with large corporations and wealthy individuals paying more than the rest. The trouble with achieving this is that they are able to buy enough influence to circumvent the rules. As some corruption is built into all political systems (though the degree varies), the limits to evasion are generally set by public opinion, the efficacy of institutional mechanisms, and international agreements. The problem is not confined to the developing world, although it does the most damage there. Many developed countries allow the rich to evade taxes by using perfectly legal loopholes.
In most developing countries, the inherent difficulty of levying taxes on the powerful (whether foreign corporations or local grandees) constitutes the first stumbling block. It’s exacerbated by multilateral agencies that advise (or compel) governments to spend less in order to balance their books, tax less in the name of stimulating private enterprise, and eliminate barriers to foreign investment and trade. For all their high-minded talk of reducing poverty, this has been the substance of the World Bank’s prescriptions and the International Monetary Fund’s structural adjustment programs for decades now. A form of shock therapy, intended to restore ailing economies to fiscal health, these programs have the usual effect of slashing social services to the bone. There is some irony, therefore, in the WHO’s facile assumption that poor countries have suddenly become capable of treating everyone infected by the virus.
Colonies were maintained for profit or glory (and preferably both): social spending provided neither.
Equitable access to health care and education opens the door to upward mobility. It creates a porous border between classes and lifts living standards by blunting the worst effects of inequality. In colonial India, a thin scattering of public hospitals provided medical treatment to Europeans and Indians (with services segregated by race and class). Over much of the countryside, they served villages that might be fifty to a hundred kilometers distant as the crow flies: if only for this reason, most people continued to frequent healers or practitioners of traditional medicine when they fell ill rather than doctors or hospitals.
In 1943, the colonial government appointed an official committee to make recommendations on health care in India. In its report, released in 1946, health was defined as a public good, to be promoted by public investment. However, the committee carefully refrained from suggesting any regulation of work practices or standards for consulting doctors. In 1947, the new republic inherited a health care system sharply restricted in scope, but largely under public ownership: by the end of the decade, private doctors in modern medicine accounted for only 5 to 10 percent of total patient care even though 73 percent of all qualified doctors were in private practice.
The political institutions of the new nation were dominated by upper and middle castes. Equality of opportunity threatened to destabilize the social order they sought to preserve while modernizing the country. The fear of popular unrest went hand in hand with an unspoken determination to preserve their hegemony. This was achieved by refusing to universalize education and health care.
The 1946 report had been formally accepted even before India became independent, but only at the cost of watering down its chief recommendations with respect to health coverage, hospital beds, doctors, etc. The slow and halting expansion of the public health system in subsequent decades lagged far behind the demand for medical services. The growing gap was filled by doctors in private practice. A large proportion of state funding went into programs to control diseases like malaria and tuberculosis instead of building primary and tertiary care facilities on anything like the required scale. Over time, these were systematically starved of resources, driving down quality. The ultimate effect was to restrict social mobility while stunting the economy as a whole.
India’s experience is noteworthy in revealing the fog of cant and false suppositions that bedevils economic analysis, even in hindsight. Its policies until the 1980s are usually described as socialist even though the right to property was written into the constitution until 1978. This ensured that the rich were well compensated for any confiscation of assets (for the simple reason that they could go to court to get rates of compensation raised) while peasants who lost their holdings to dams, mines, etc. never obtained fair compensation (because they could not).
A crippling reliance on indirect taxation was forged during these decades. India charges no tax on agricultural incomes on the mendacious assumption that all farmers are poor: in actual fact, prosperous landowners control politics over much of the countryside. Inherited wealth is not taxed. Property and wealth taxes, set by state and municipal administrations, are relatively low. Income tax was set high until the mid 1980s, but direct taxes as a percentage of GDP remain much lower than any of the member states of the OECD.
The failure is Janus-faced. The Indian state has never raised enough money from the rich; meanwhile, a very small proportion of its actual revenues are spent on social services. During the decades after independence, there was never any shortage of public money to put into dams, mines, and heavy industries, even airlines and hotels (many of these state-owned enterprises were pruned back or sold off from the 1990s). After the turn of the century, India became one of the largest buyers of military equipment in the world. Subsidies comprise another substantial outlay: these are distributed ecumenically to corporations, groups and whole occupational categories, “farmers” being especially favored. In addition, many states began setting up welfare programs to provide an array of grants and goods to poor families from the 1970s on.
Spending on education and health care remains strikingly low in relation to all these expenditures. Each state runs its own network of schools, hospitals and health centers, but their quality (with some notable exceptions) is so bad that only the poor use them. India’s industrial workforce is recruited from this pool: the result is a general stagnation of skills and productivity. In 2006, fewer than half of all students finished eight years of schooling; many of those who do get through school emerge with only a rudimentary knowledge of reading and writing. This has obvious consequences for morale, motivation, and productivity at work.
Many of India’s social indicators—malnutrition, maternal deaths, stunting, the toll from diseases like tuberculosis—bear comparison to sub-Saharan Africa. The effects of poverty are magnified by the absence of facilities to treat a range of preventable diseases, with the inevitable result that the average worker falls ill more often, takes more days off, is able to work less and produce much less than his or her East Asian counterparts.
Equitable access to health care and education opens the door to upward mobility. It creates a porous border between classes and lifts living standards by blunting the worst effects of inequality.
The public health system teeters on the brink of collapse at the best of times. The bare statistics reveal the scale of the problem. India spends between 1.02 to 1.28 percent of its GDP on health—no one knows the exact figure, but it is lower than Sri Lanka, Bhutan or Thailand. In private spending, it figured amongst the top twenty countries worldwide in 2005. No surprise then that more than 40 percent of hospital patients were forced to borrow money or sell assets to pay their bills. In 2017, twenty five percent of rural households and twenty percent of urban households were still going into debt or selling assets to cover costs of hospitalization. Close to two thousand primary health centers across the country lack doctors—the inevitable consequence of decades of underfunding. In 2017, the private sector accounted for 80 percent of all outpatient care and 60 percent of inpatient care. By 2019, it was estimated that India was facing a shortage of 2 million nurses (the WHO recommends a nurse to patient ratio of 1:483) and six hundred thousand doctors: it can safely be assumed that most of the doctors and nurses that it does have work in the private sector. Private companies enjoy a virtual monopoly in drug and vaccine manufacture; roughly half of medical education has also been privatized.
How does the Indian middle class view education and health care? The answer is not in any doubt—over the decades, it has constructed an exclusive system of private schooling and health care for itself on grounds of quality. Starting in the 1950s, middle-class families flocked to consulting doctors, whose numbers grew rapidly: the practice of medicine (unlike nursing) became both profitable and prestigious. Many of these doctors set up small hospitals or found work in quasi-charitable institutions. From the 1980s on, private health care received increasing support from politicians and policymakers as an antidote against the failures of a public system starved of resources. Entrepreneurs incorporated companies to provide hospital care; politically connected businessmen set up medical colleges; multinational companies entered drug manufacture.
During the following decade, state governments began setting up insurance programs to pay for treatment in private hospitals. This idea is now being taken to its logical conclusion—instead of reforming the public system, it seems easier (and much more profitable) to privatize it. A proposal to lease hospitals to the private sector was circulated in 2017. In return, they’re expected provide treatment at controlled prices to patients covered by state insurance programs; others will pay at market rates. Inevitably, the proposal was created from a template supplied by the World Bank and reworked by advisors from the private health industry.
The pandemic shines a harsh light on the crumbling foundations of health care in India. Its first effect was a steep fall in capacity as the private sector wound down. Most private clinics and small hospitals closed of their own volition; bigger ones set up barriers to exclude potential carriers, driving up costs for everyone. Patients arriving for other treatments were forced to pay for recurring tests. A large proportion of the middle class, for whom the system had been built, suddenly found itself excluded from it.
Private hospitals were briefly forbidden to treat infected patients in the interests of contact tracing (to obviate any risk that they might escape being registered with municipal authorities); however, these regulations were overturned in a matter of weeks as public facilities overflowed. By the end of May, ordinances to sequester hospital beds were being passed. Testing, by contrast, was thrown open to the private sector from early on. State facilities simply did not have the requisite capacity (so the argument ran), but the scale of potential profits to be made from tests was never in any doubt.
The problem of regulating test prices was allowed to fester—to be left, in the end, to state governments. Some went on to announce price caps for hospital care. The reluctance to treat the virus persisted; despite a slew of ordinances, private hospitals continued to refuse patients who failed to produce a negative test. This added to the growing pressure on public hospitals; by June, they had passed the point of collapse in some cities.
In June, over three hundred doctors in Delhi complained of not being paid for three months. There were other protests about delayed pay, lack of protective equipment, and high rates of infection and overwork from different places, usually squelched by intimidating the participants into silence: not difficult to do in a country where state jobs are so highly prized. Meanwhile, footage of patients waiting outside hospitals circulated; emergency cases were turned away for want of beds. Interviews with relatives painted a dire picture: deliberate callousness; the inability, in some cases, to provide food and water; patients left without nursing care; photos of the living lying cheek by jowl with the dead.
The Indian state has never raised enough money from the rich; meanwhile, a very small proportion of its actual revenues are spent on social services.
The manifold problems of the public health system can be reduced, in the main, to two elements. The first is a crippling shortage of personnel. This reflects a long-standing reluctance to hire them. Inadequate taxation and bad services have a reciprocal effect on each other: people are unwilling to pay more taxes because services are bad, but services cannot be improved without increasing revenues. The refusal to raise taxes on the middle class rests upon the assumption that they stand in no need of public services. The pandemic shows that this is not always the case.
The second concerns mechanisms of accountability: for the most part, they do not exist. More than seventy years after independence, there exists no overarching legal framework to regulate health care in India. Doctors form a strong and vocal interest group in favor of loose regulation. In 1948, they won the first of many victories when the government of Madras province exempted nursing homes and hospitals from the Madras Shops and Establishments Act (to regulate working hours and holidays). There is no legislation to register or regulate medical establishments in fifteen out of twenty-eight Indian states—a license from the relevant municipal authority suffices to open a clinic or hospital.
Proponents of self-regulation defend this system with the familiar argument that open markets improve standards. At the prices they charge, it would be astonishing if corporate hospitals did not provide efficient treatment. But these prices are beyond the reach of many middle-class families. Meanwhile, most Indians are forced to rely upon inadequate, overburdened state facilities or nursing homes with few beds and no enforceable standards.
Yet attempts to reform health care remain conspicuous by their absence. Instead, state governments have been trying, with varying degrees of desperation, to increase short term capacity by buying equipment, pressing in medical students, creating temporary facilities, and hiring contract workers. After admitting an alarming shortage of doctors and nurses in Mumbai’s hospitals, the government of Maharashtra asked Kerala to lend it some. Tamil Nadu chose to recruit health workers on short-term contracts; once the pandemic is over, they will be let go.
In all this, of course, India is far from unique: roughly similar scenes occurred (and are probably still occurring) in other parts of the world, from Brazil to South Africa and Bolivia to Kenya. Within the country, there is no shortage of disagreement over the economic and humanitarian aspects of the pandemic—the size of the stimulus, support for small businesses, migrant workers, the unorganized sector, and so on. Yet the crisis of a collapsing health system, fractured into two tiers, is barely discussed. Debates over development conducted by policymakers, politicians, and scholars pay virtually no attention to the obvious benefits of improving education and health care where the poor are concerned. Caste continues to shape political debates, government policies and life choices in India in the much the same way as institutional racism does in the United States.
Coping with Calamity
The heroine of Penelope Fitzgerald’s The Gate of Angels is a nurse, a young girl from early twentieth century south London, “where Stockwell turns into Brixton”: a solid and squalid working-class district. Overflowing with life and energy, Daisy has a vocation for giving. Inevitably, she finds her way to Blackfriars Hospital to train as a nurse. She is taken on not just because she is cheerful and intelligent but because she is fit. Nursing is a serious business, involving back-breaking work: “A sickly nurse is of no use to the profession. One might call her an enemy of the profession.”
Daisy loves her job and loses it because she tries to help a delusional patient, not too little but too much. The Gate of Angels brilliantly evokes the nature of nursing in a particular place and time: its practices are different, but the basic ideas have already been developed. The “care” in health care forms the operative part of the term. In some cultures, it was used to signify care of the soul as much as the body. Ever since the nineteenth century, when the complex structures of modern medicine began to assume recognizable shape, it has been about profit, yes, but also something more—that intangible quality summed up in care.
In 1918, after the Bolshevik Revolution, Russia became one of the first countries in the world to universalize education and health care—the context was admittedly unusual in that the state assumed complete control of the economy. The invention of the welfare state produced another model. In it, the notion of care expands significantly—if education and health care play a fundamental role in shaping life experiences and skills, it becomes the obligation of the state to provide them to all citizens without exception.
The WHO’s advice on tackling the pandemic reflects this association. Since most rich countries (with the striking exception of the United States) have universal health care, its framework is taken for granted: the ability to trace, to test, and, above all, to treat everyone who falls ill, rich or poor. But this is far from being the case—universal provision is the exception, not the rule. If the exceptions include a few developing countries like Thailand, Cuba and Uruguay, many more resemble India, where health care is not and never has been a public good.
The difficult problem of converting health care (or education) from a luxury to a right is analogous to that of tackling climate change. The relationship is reflected in the historical connection between universal provision and industrialization and industrialization and climate change. The economic trajectories of Western Europe, North America, and East Asia converge during the decades after the Second World War. The effect is unprecedented economic growth, fueled by soaring rates of production and consumption. Its corollary is an unstoppable rise in greenhouse gas emissions; fifty percent of carbon dioxide released into the atmosphere since the Industrial Revolution was added after 1990.
We’ve reached the point where some degree of ecological and ethical sanity can only be achieved by decoupling these ideas—by separating universal provision from economic growth; production and consumption from well-being. Education and health care are public goods: their value is independent of any contribution to GDP. It is, or should be, the fundamental duty of every government to provide them. Meanwhile, an economic system that makes well-being contingent upon growth and growth upon consumption has succeeded in destabilizing the ecological mechanisms on which our survival depends. Without setting some limits to production and consumption (and therefore to growth), no long-term solution is possible. But this can only be done by recasting basic ideas of comfort, convenience, and progress that we have long since learned to take for granted.
Penelope Fitzgerald’s father, E.V. Knox, editor of Punch from 1932 to 1949, was a notable exponent of light verse. In an essay from 1992, reprinted in her posthumous collection, A House of Air, she points out that this often served as
The last resort for subjects that have got beyond rational comment. It struck my father, as it struck a good many others, that the world was increasingly ruled by misguided people, in that they no longer seemed able to create a system that benefited even themselves. They could only be appropriately described in light verse.
The problems of public health, in India and elsewhere, grow out of preexisting structures of inequality. These coexist with a generalized indifference to all other forms of life, an unshakable belief in “our” unfettered freedom to pursue “well-being,” however we choose to define it. The result is a system that no one, apart from the truly rich, much likes, but whose insecurity and crippling burdens they feel obliged to ignore when they cannot justify them.
Meanwhile, the pandemic tells us that even suffering has a sliding scale: some individuals, groups, and nations find themselves better fitted by history to cope with calamity than others. But this offers little comfort in the long run—our common humanity cannot be infinitely divided if it is to retain any meaning. Its patched and threadbare cloak is already full of holes. Satire may not be the only consolation we’re left with—not yet—but there seems little doubt that the time remaining to turn things around is short and growing shorter.