Cvr/Back Cvr Winter98-99 - Creighton

WINDOWCREIGHTON

Spring 1995

UNIVERSITY

Managed Health Care:

Pluses and Minuses

Medical School in the New Age

Pilgrim’s Progress: Fr. Linn on the Road

Can DemocracyThrive in Africa

This Time?

The New Way of Medicine:Managed Health CareWriter Mary Kenny hopscotches the United States toquery Creighton doctors about the new age of medicine:managed health care. Add up the pluses and minusesstarting on Page 4.

What Do New Health Plans Mean forC.U. Med School?

Medical School Dean Dr. Thomas Cinque isinterviewed by Cynthia Reynolds. What is on the horizon for the school as changes in the health care system evolve?Page 10.

Pilgrim’s Progress:On the Road With Fr. LinnBob Reilly’s portrait of Fr. Henry Linn, S.J., as apresident and a fund-raiser is based on intimate

knowledge gained from Reilly’sdays “on the road” with the

short-of-stature, tenaciousFr. Linn. Page 14.

Democracy Has Another Chance InAfrica; Will It Succeed This Time?Dr. James Wunsch, a professor whose interest in Africais a consuming one, profiles the continent’s new chanceat democracy. Can it succeed this time? 0.

Alumnews......................................................................................................Page 26University News...........................................................................................Page 27

Generates PrideThe Winter 1994-95 issue of WINDOW isabsolutely outstanding!

All four feature articles were superblywritten, and so beautifully illustrated.They covered such varied subjects —Bob Reilly’s well researched look at JesuitFormation in the Nineties; the well-deserved recognition of the Ph.D. nurs-ing personnel and their areas of research;and Eileen Wirth’s two articles, the onean analytical look at the new dean of theCollege of Business Administration,Bernard Reznicek, and the other her owninsightful discovery of the value of“Cura Personalis.”

As always, each issue of WINDOWgenerates feelings of nostalgia and pridein me. I could not help but feel deservedpride in Creighton while reading thoseexcellent articles because in my 18 yearsof education on the corner at 25th andCalifornia, from kindergarten throughgraduation from the university, I had theopportunity to truly live “the Jesuit expe-rience” through close association as analtar boy and student with “The LongBlack Line,” as Bob Reilly so succinctlyput it.

Fr. Doll’s marvelous photographsgave me a sense of truly being there,especially those of the Liturgy being cele-brated in St. John’s Church, in the Jesuitchapel in the Administration building,and on the north grounds. His overheadshot during a concelebrated Mass isspectacular, to say the least. I servedMass at the main altar and six side altarsdaily for many years. I recall being in theJesuit Chapel once or twice but the recollection is hazy for I don’t rememberif it was to serve Mass in the summerwhen all the Scholastics were away, or ifit was to take something over there fromthe church.

I hope those who yearn for the “goodold days” when the training of a Jesuit

Volume 11/Number 3 ■ Creighton University ■ Spring 1995

Publisher: Creighton University; Rev. Michael G. Morrison, S.J., President; Michael E. Leighton, Vice President forUniversity Relations. WINDOW staff: Jana M. Martin, Executive Editor; Robert U. Guthrie, Editor; Pamela A. Vaughn,Associate Editor. Editorial Advisors: Rev. Donald A. Doll, S.J.; Charles J. Dougherty, Ph.D., Richard L. O’Brien, M.D.; AllenB. Schlesinger, Ph.D. and David G. Schultenover, S.J.Creighton University WINDOW (USPS728-070) is published quarterly in January, April, July, and October by CreightonUniversity, 2500 California Plaza, Omaha, NE 68178-0001. Second class postage paid at Omaha, Nebraska, and additionalentry points. Address all mail to Public Relations and Information, Omaha, NE 68178. Postmaster: Send change of addressto Creighton University WINDOW, P.O. Box 3266, Omaha, NE 68103-0078.

COPYRIGHT © 1995 BY CREIGHTON UNIVERSITY

Pursuant to our educational obligation to search for truth and to expand knowledge, WINDOW Magazine promotes thediscussion of a variety of issues. Although published by a Catholic, Jesuit university, the opinions expressed in WINDOW

are not intended to be construed as the official teaching or position of Creighton University or of the Catholic Church.

2 Creighton University WINDOW

LETTERSWINDOW WINDOW Magazine edits Letters tothe Editor, primarily to conform to

space limitations. Personally signedletters are given preference for

publication. Our FAX telephonenumber is: (402) 280-2549. E-mailaddress: [email protected].

followed strict regulations, compared tothe more relaxed but still disciplinedapproach of today, will read the end ofBob Reilly’s lead-off article which con-cludes with the words of St. Ignatius,founder of the Jesuits, to one of his priestleaders. When that priest felt existingregulations hampered his presiding overa new community, St. Ignatius replied, asBob relates: “Adapt the rules to the placeas best you can...I want you, for the rest,to act without any scruple, as you judgefrom the circumstances ought to be done,notwithstanding rules and ordinances.”

The goal of Jesuit training and teach-ing then, as now, was to take the “wholeperson” approach, to aid each person todevelop his or her own spirituality to thefullest so as to walk with Jesus each dayin our quest for the eternal salvation hepromises. The Jesuits remain committedto their mission today. What we gainedfrom them helps us work in concert withour own parish and Diocese for buildingup the kingdom. Wouldn’t it be a betterworld if we could all be as committeddisciples as our Jesuit teaching atCreighton called us to be? Nothing elsereally matters.

Ben Haller Jr., PhBJrn’42West Des Moines, Iowa

Seeking OthersBoth as an alumnus and as the vocationdirector for the Jesuits of a seven stateregion that includes Creighton, I con-gratulate WINDOW for its cover story,Jesuit Formation in the Nineties. It successfully balanced nostalgia with the dynamic orientation toward thefuture which must characterize Ignatian spirituality.

My only regret is that it did not indi-cate how one might go about enteringJesuit formation today. I did not enter theSociety until six years after graduatingfrom Creighton. I would like to thinkthere are others like me “in the nineties”as well.

You have my permission to print myname, address and phone number.

Richard C. Burbach, S.J. (BA’72),Director of Vocations,

Wisconsin ProvinceSociety of Jesus

1035 Summit Ave.St. Paul, MN 55105-3034

(612) 224-5593FAX (612) 224-4734

Email: [email protected]

Cathedral, TooYour January issue of WINDOW is excel-lent, as is each issue.

The two articles by Eileen Wirth,Ph.D. interested me especially. In the arti-cle about Bernard Reznicek Electric ExecTakes Charge of Business College I wishEileen had mentioned that Bernard andhis wife Mary (Gallagher) Reznicek areboth graduates of Cathedral HighSchool, Omaha: Bernard in 1954 andMary in 1955. Cathedral Alumni and for-mer faculties, as well as CreightonUniversity, are proud of BernardReznicek.

Sister Pauline Wisdom, O.P.,MS’67Omaha

Losing Relevancy?I enjoyed your article, Jesuit Formation inthe Nineties. Losing a third of your man-power may have slimmed you down butI am sure that much talent you couldhave used has left. It isn’t like the down-sizing of a big, overbureaucratized company. They have left or not joinedbecause you have lost a lot of relevancy.You are tied to the larger bureaucraticstructure of the Catholic Church that hasmostly become unresponsive to thechanging times. So let us see how thosetimes are changing. I want first to look atthe idea of God.

We come from a deductive past whereabsolutist-type thinking gave rise to ourideologies. Our thinking now is induc-tive and the forward thinking is non-ide-ologic. Reflecting this, our old idea ofGod was a deductive God, who was allgood, all knowing, all creative. An induc-tive God would be different — more likea God in process. A God of this descrip-tion would fit better with the presentnotion that we are in the process ofbuilding something of transcendent val-ue right here on earth. This fits better ourpresent notion of being co-creators withGod rather than merely being passivereceptors of God’s beneficence.

Another thing the hierarchical churchis ignoring, largely, is evolution. Thechurch wants to fix doctrine and fix itsown structure in a situation of constancythat an adequate concept of evolutionwon’t allow. So evolution in society’sstructures and thinking has relegatedchurch thinking to irrelevancy. And as Istated before, the new thinking is induc-tive, leading us to explore where we aregoing, making life an adventure. Giventhis thinking we must base our positions

on working hypotheses rather than onbeliefs. The old absolutes that have guided the church in its positions onbirth control, abortion, ideals of socialstructure, valid avenues of research mayno longer apply.

The new man for the Jesuits will notwant to be bound by the rules of poverty,chastity and obedience. These are rulesfollowed by the underdeveloped, not bymature men. You want men of the worldwho understand all of the vicissitudes oflife. Only when they have the freedom tochoose will they truly reach their ownpersonal maturity.

I would like to see an article withpriests on both sides of these points. Ifyou are going to move to a church that is beyond ideology in order to becomerelevant in the modern world, you aregoing to need to open yourselves to this discussion.

Ward R. Anthony, MD’54Lakewood, Colo.

Helping Get a JobI really enjoyed Eileen Wirth’s articleabout Bernard Reznicek, new dean of theCollege of Business Administration. Iapplaud his efforts to help his studentsfind employment after graduation, espe-cially his plan to expand internships.

I hope other deans will follow suit.Non-business majors and their parentsare also concerned about life afterCreighton. Internships give young peo-ple a leg up on their competition.

Thomas H. CecilBellevue, Neb.

Vise, Not ViceI have a bone to pick with the proofread-er of the Letters section. In my originalmissive I referred to “a small nation(Hungary) of Jews, Catholics, Protestantsand unbelievers ... caught in the VISE(not vice) of rapacious great powers, bothwestern and eastern.”

Undoubtedly, “vice,” i.e., depravity,corruption, etc., could be considered afactor, but the “vise,” the relentless pres-sure of political and economic hybris ofthe great powers, their lack of under-standing and ignorance of millennia oftradition, contribute to suffering.

Such a misprint turned me into thecynosure of friendly ribbing by col-leagues and friends. May I ask that youfind a way for a suitable rectification inthe next issue.

G. J. SzemlerLake Bluff, Ill.

3Spring Issue 1995

4

PHYSICIANS WORKIN A NEW AGE

Managed Care

PHYSICIANS WORKIN A NEW AGE

By Mary Kenny

When Omaha pediatricianJanie Fitzgibbons Mikuls,

BA’83, MD’87, began her prac-tice in 1990, she and her part-ner maintained a busy sched-ule despite the fact that theyhad few patients enrolled inmanaged care programs.“Every year we’d say, ‘Well,another year without HMOs(Health Maintenance Organ-izations) — it won’t last forever,’” she said.

This year it ended.“In mid-1994, we saw that

we were losing patients — westarted to see the numbersgoing down,” she says. “Threeor four of the major employers

in Omahachangedtheir em-ployeeinsuranceplans and allof a suddenthese won-derfully loy-al patientswere out the

door. It doesn’t matter whatyou do for the patient; if theiremployer changes plans,they’re gone.”

Dr. Mikuls and her partnerrecently signed on with threeHMO plans.

Sixteen-hundred miles awayin Upland, Calif., internistVince Carollo, MD’62, also hasseen his share of changes withthe advent of managed care.Like Dr. Mikuls, he has seen adisruption in patient care.

“The saddest change onesees is losing patients whodon’t want to leave your prac-tice but are forced to because ofthe insurance situation,” hesays. “That’s the number-onesaddest event for both the doc-tor and the patient. When theycome in and they are in tears

and you’ve taken care of themfor 10, 15, 25 years, it’s liketearing your arm off or tearingyour heart out.”

Still, Dr. Carollo has notjoined an HMO.

And in a state where 35 percent of the population —nearly 11 million people — areenrolled in HMOs, he says it isa hardship for a medical prac-tice not to sign on. “The sys-tem, at least here in SouthernCalifornia, is a steamroller,” he says.

◆◆◆◆◆

Though the tide of healthcare reform has temporarilyebbed, the wave of managedhealth care plans continues itssweep across the country. Some physicians are goingwith the flow, and others aretreading water.

Managed care plans — networks of physicians, hospi-tals and financing bodies thatdeliver and pay for health care — will almost inevitablyform the foundation of anynational health reform planthat is adopted.And they aregrowing.

An estimat-ed 100 millionAmericans arenow membersof managedcare programs.By the end ofthe decade, 75million moreAmericans areexpected to join them.

Managedcare, typicallyin the form ofHMOs andpreferred provider organiza-tions (PPOs), has become thestandard method of health care

delivery. Traditional indemnityinsurance plans, once theindustry heavyweights,claimed 71 percent of thehealth care market in 1988. By1993, that figure had dipped to 45 percent.

Most agree that reform ofU.S. health care delivery islong overdue. In 1970, thenation’s health care bill was$215 billion, 6 percent of thegross national product (GNP).By 1993, health care costs hadrisen to $900 billion, more than14 percent of the GNP. In contrast, health care in otherindustrialized nations averages8 to 10 percent annually. Anddespite the high cost, 34 mil-lion Americans lack healthinsurance.

Managed care, in the form ofHMOs, began on a small scalein the 1930s, when groups ofdoctors and hospitals begancontracting with employers toprovide medical care for a flatannual fee. But HMOs took offduring the early 1980s, with thenumber of enrolled members

more than quadrupling between1983 and 1993, from 10.8 mil-lion to more than 45 million.

Spring Issue 1995 5

Dr. Mikuls

W

Kathryn Graham, a customer representative, works at one of Creighton’sFamily Practice clinics, tackling the paperwork. Photo by Kent Sievers

The move toward managedcare has signaled a turn awayfrom the traditional fee-for-ser-vice payment method in whichpatients or their insurancecompanies pay health careproviders on the basis of ser-vices rendered. The methodhas been blamed, in part, for driving up the cost ofhealth care.

In contrast, the prototypicalHMO is a prepaid plan inwhich consumers can choosetheir health care providersfrom a list of primary carephysicians and hospitals. Theprimary care physician over-sees the care of the patient andserves as a “gatekeeper,” mak-ing referrals for services andappropriate specialists withinthe HMO network as neces-sary. (The more loosely struc-tured PPO allows members togo outside the network for anadditional out-of-pocket fee.)

In the HMO, the physician is paid a fixed amount perpatient per year — a capitatedfee. The physician receives thefixed amount regardless of thenumber of times the patient isseen and is responsible for anycosts incurred by the patientabove the yearly capitation fee.

The reasoning suggests that,using a capitated fee, doctorswill be more prudent in ordering tests and referrals tospecialists to avoid exceedingthe capitation rate, thus keeping health care costs“manageable.”

Managed care plans monitorboth patients’ and physicians’use of services through utiliza-tion review services, whichalso track the outcomes ofpatient treatment.

But despite the growingpresence of managed care pro-grams, this method of health

care delivery remains the sub-ject of debate. Proponents ofmanaged care argue that boththe gatekeeping and capitationfeatures of HMOs help prima-ry care physicians focus onpreventive medicine and earlydetection, and in general, helpcontain health care costs.Opponents contend that thefeatures compromise both thequality of care and the physi-

cian-patient relationship bystressing cost control over care.

In some areas of the country,the proponents seem to be hav-ing their way. According to theGroup Health Association ofAmerica (GHAA), the threelargest regions of HMO pene-tration are the Pacific, with 31.6 percent of the populationenrolled in HMOs; NewEngland, with 25.6 percentenrollment; and the Mountain

region, with 19.8 percent.The Mid-Atlantic region,

which includes New Jersey,New York and Pennsylvania,enrolls 18.9 percent of the population, followed by theMidwest with slightly morethan 15 percent.

HMOs have been slowest topenetrate the South Atlanticregion with 12.7 percent enroll-ment and the South Centralregion at 7.4 percent.

A sampling of Creightonalumni throughout the UnitedStates reveals a number ofcommon concerns about thepractice of medicine in a man-aged care environment. Theirconcerns and experiences mir-ror the issues that have been atthe center of the nationalhealth care reform debate —patient access to care, qualityof care, integration of services,capitation and gatekeeping,among them.

For many physicians likeOmaha pediatrician Dr.Mikuls, joining an HMOmeans the difference betweensinking or swimming.

Dr. Mikuls said that about 50percent of her patients pay forservices through private insur-ance, compared with about 80percent three years ago.

Creighton University WINDOW6

The primary care physicianoversees the care of thepatient and serves as a“gatekeeper,” making

referrals ... within the HMOnetwork as necessary

Dr. Donald Frey examines patient Terry Shevchenko at one of Creighton’s FamilyPractice clinics, which are scattered throughout Omaha. Photo by Kent Sievers

Since Dr. Mikuls joined threeHMOs in January, she alreadyhas seen changes. “The patientbase has gone up and many ofour patients who had to leaveare back, lots of families, andthat’s great,” she says.

On the other hand, “it’smore headaches for our billingpeople and for our office man-ager in terms of paperwork —that’s all they do right now,”Dr. Mikuls says.

And, Dr. Mikuls says, withcapitation comes a new strate-gy and new control towardpatient care:

“In the old days, we mayhave had a new mom who wasnervous about her child’s earinfection, and we’d talk to herfor about 20 minutes about thethings she could do for thechild without going to an ear,nose and throat (ENT) special-ist. Still, two days later, we’dget a call from the ENT’s officeletting us know that the momhad gone ahead and scheduledan appointment anyway. Now,with capitation, I will have a little more control overwhether or not she goes to theENT — I’ll be more the manag-er of the health care.

“I really think that if you dothings right, if you’re efficientand you manage things well,and you try to promote thehealth of your patients, you’lldo OK,” she says.

But Dr. Carollo sees man-aged care in a different light. A1962 School of Medicine gradu-ate who has been in privatepractice since 1969, Dr. Carollosays 25 percent of his patientsbelong to PPOs. However, “Idon’t participate in HMOs,which in Southern Californiameans capitated medicine,” hesays. “PPOs are wonderful intoday’s world. I accept a dis-

counted fee and I am allowedto practice medicine the way I should.”

And, in Dr. Carollo’s opin-ion, the overall quality ofpatient care is declining, withmedicine being taken over bybusiness managers.

“What I see in the communi-ty with HMO capitated care isthat it’s hard for patients to getthe care they really should begetting. If doctors are gettinginto capitation and get X num-ber of dollars each month perpatient regardless of whetheror not they see the patient, thenthe motivation for physicians isnot to see people. I’ve stayedout of capitation for that reason— I don’t want to be part ofthat,” he says.

“I don’t know how long Ican persist. But I’ve been here25 years and I’ve built up apractice and a reputation, andmany people still want theirdoctor and still want theirchoice and are willing to dowhatever it takes to do that.But for some patients, whentheir employers tell them thatthey have to belong to a partic-ular HMO and that’s it, thoseare the people who are tornaway from your practice. Inmy community right now thereare only a handful of physi-cians who are able to do whatI’m doing.”

Dr. Carollo predicts that, inthe future, most physicians willbe employed by a large man-aged care network of somekind, a situation he considersunfortunate.

“I think patient care will becompromised,” he says. “Inthat situation, the doctors willhave to answer to theiremployers instead of theirpatients. I think doctors shouldbe their patients’ advocates,

not their adversaries.”But, in some regions, main-

taining a private practice

is becoming increasingly difficult.

Dr. John Hussey, a 1976 fam-ily practice graduate, lives inthe small town of Gardiner,Maine, population 5,000. Thecensus is closer to 60,000 whennearby feeder communities areincluded.

“All my life, I wanted to be afamily doctor. That was mydream, even when I was 5

years old,”Dr. Husseysays.

“I achiev-ed mydream. Butthen thesolo prac-tice, as I seeit in the wayof third-par-

ty payers, went the way of thesteam locomotive. The third-party payers want the physi-cian at some point to becomepart of their business structure,and (the payers) are motivatedby profit,” he says.

Dr. Hussey says that,

Spring Issue 1995 7

Dr. Joanne Schaefer (foreground) and medical assistant Laurie Borrink go over apatient X-ray at one of Creighton’s FamilyPractice clinics. Photo by Kent Sievers

Dr. Hussey

increasingly, the role of thefamily practitioner in a man-aged care environment has“turned away from the caring,hands-on, sit-and-listen personto one who is more removedfrom the patient, spends lesstime with the patient and isexpected to crank patientsthrough.”

Dr. Hussey spent eight yearsin private practice in Gardiner,from 1982 until 1990, “when itbecame impossible to make itas a solo practitioner. I saw thehandwriting on the wall. I waslosing money and still working60 hours every week.”

Dr. Hussey closed his pri-vate practice and began work-ing as a staff physician for thestate mental health hospital, apractice he enjoyed for nearlyfive years until state budgetcuts began trimming the hospi-tal staff. Dr. Hussey now has a new position lined up at the Veteran’s Hospital in near-by Togas.

According to Dr. Hussey, hissituation is not unusual.

“Everyone I know in familypractice in the area, about 10 ofus, now work for someoneelse,” he says. “There are abso-lutely no family practitioners

in private practice — theyeither work in the hospital orat the community health cen-ter. And this has just comeabout over the last few years.”

Back in the Midwest, familypractitioner Robert Cure hasmanaged to find a happymedium as an employee of an HMO. A 1983 School ofMedicine graduate, Dr. Curehas been practicing in theMinneapolis/St. Paul areasince 1989. Minnesota, a pio-neer in managed care, has been

referred to as an HMO “labora-tory,” with 46 percent of theTwin Cities’ populationenrolled in HMOs.

Dr. Cure has practicedmedicine in a managed caresetting from two distinct van-tage points. After finishing hisfamily practice residency inMinneapolis in 1987, he beganhis practice with a multi-spe-cialty group in Spokane, Wash.When he joined the group,there were 30 physicians; whenhe left 18 months later, (thegroup) had grown to 70. “I wasone of the first family practicephysicians they hired. Theywere trying to get in on the bigflow of primary care and buildup their referral base,” he says.

According to Dr. Cure, thegroup belonged to a number of

managedcare plans:

“One ofthe things Ididn’t likeabout it wasthe wholeidea of capi-tation. You’dhope yourpractice

wouldn’t depend on the finan-cial arrangements, but in allpracticality it comes down tothat. There was always some-one looking at what you weredoing and they’d suggest,‘Maybe you ought to changeyour referral pattern.’ Therewas always this subtle, ‘Hey,we’re capitated; we have towatch this population.’”

And the group was “work-ing on production,” Dr. Curesays. The physicians who hadbought into the group (Dr.Cure was salaried) were paidon a complicated fee schedule.

“Part of it was based on basesalary and part of it was pro-


Dr. Cure

Dr. Frey (in background) works on papers at one of Creighton’s Family Practiceclinics. A reminder of his patient connection is the sculpture on his desk that depictsa doctor examing a child. Photo by Kent Sievers

“Everyone I know in familypractice in the area, about

10 of us, now work forsomeone else. There are ...no family practitioners in

private practice.”

duction — how many patientsthey saw, how many tests theyordered,” Dr. Cure says. “Theywere then paid a percentage ofthat. In that situation, even themost pure-hearted peoplewould be a little swayed onhow they manage their prac-tice. Some of the doctorsaccused me of stealing theirpatients — it was the wholeidea of production, where theyfelt if you were getting a partof the pie, it was less a part ofthe pie for them. It wasn’t alarge percentage of the doctors,but a few were always lookingover their shoulders and overyour shoulder.”

When Dr. Cure moved backto Minneapolis in 1989, hejoined a family practice clinicoperated by a large HMO.

“When I was doing my fami-ly practice residency,” he says,“I was impressed with thenumber of good doctors in this‘big system.’

“Usually, the big systems aremore rigid. But I was im-pressed with their philosophyand their morals, and in gener-al, the way they do things.” Forexample, the HMO provides “a lot of indigent care to manyyoung mothers and youngfamilies. That says a lot for theethical side of the system,” he says. And there is no pres-sure in terms of capitation or production.

Dr. Cure is paid an annualsalary and benefits, and “if Iwant to make extra money, Ican work extended hours. If Iwant to cut back my hours, Ican. There’s a lot of flexibility.”

Dr. Cure says being part of alarge managed care system hasnot compromised his ability toprovide quality care or his rela-tionship with his patients:“When I was in Spokane, I was

feeling an uncomfortable senseabout the capitated patients. Ihad to really think about whatI was ordering — not justwhether it was necessary ornot, but how expensive was it?If I order it now, will I be ableto order it later? I definitelyprefer (the Minneapolis) system.

“Of all the places to be andof all the subspecialties to be(in) at this time and with all thethings in health care that arechanging, I can’t think of amore stable place to be than in the Midwest, in family practice. I’d hate to be a sub-specialist on either one of the coasts.”

In the Southeast, 1960 Schoolof Medicine graduate Jim Millsalso thinks managed care hasthe potential to compromisequality of care. Dr. Mills, anobstetrician/gynecologist,practices in a large multi-spe-cialty group in Fort WaltonBeach, Fla. And though Floridahas a large number of HMOs(35 according to GHAA fig-ures), Dr. Mills’ practice iscomprised of less than 5 per-cent of managed care patients.

“We are still primarily fee-for-service and third-partypayer, though we expect bigchanges in the next three yearsor so,” he says. “Our locationin the panhandle of the state is somewhat isolated, so we’vebeen able to maintain our independence.”

The primary disadvantage tomany managed care plans isthe capitation feature, Dr. Millssays. “If you think you aregoing to lose money, you’re notgoing to order tests. No matterhow much you care aboutpatients, you are not going toorder tests or do certain proce-dures, even though (managedcare proponents) stress thatthey are also in the business of quality.”

In Dr. Mills’ opinion, theproblems with managed care

boil down tothe businessof managedcare.

“In themanagedcare system,you nowhave peoplewho 10 yearsago had

nothing to do with the healthcare of the nation, and they areall now third-party intermedi-aries. And all they are doing istaking more of the health caredollar,” he says.

Eventually, Dr. Mills says heknows his multi-specialtygroup will see more and moremanaged care patients. “If wedon’t, we’ll be dead in thewater. We’re at the point nowwhere we don’t have an optionbecause all the patients will becontrolled by some kind ofmanaged care program. Ifyou’re not involved, you’re notgoing to have any patients.” W

Spring Issue 1995 9

Dr. Mills

“All the patients will be controlled by somekind of managed care program. If you’re not involved, you’re not going to have anypatients.” — Dr. Mills. Photo by Kent Sievers

Back in 1959, when Thomas J. Cinqueearned his medical degree at

Creighton, neither he nor his fellowgraduates had an inkling of what thefuture would hold for medical practi-tioners in their lifetime: the startling newtrends in health care, the astoundingtechnological breakthroughs, and theresearch projects that would change thecourse of disease control.

When Dr. Cinque returned toCreighton two and a half years ago asdean of the School of Medicine, his wifeasked him, “What will you do all day?They are 100 years old and your workhas always been to build anew.”

“I don’t think I’ve come up for breathsince I moved into this office,” he sayswith a grin late one winter afternoon ashe leans back in his desk chair, ignoresthe blinking computer screen and thetelephone for an hour or so and discuss-es his perception of the American healthcare system, how it is changing and howit is causing Creighton to change.

Health care has become one of thehottest topics in America.

Every day, newspapers and televisionnews shows broadcast stories of spiral-

ing health care costs, tales of personaltragedies in the lives of uninsuredAmericans, unethical practices by physi-cians and new ethical dilemmas arising

from new medical procedures.The health care issue was instrumen-

tal in putting Bill Clinton in the WhiteHouse and Hillary Clinton in the lime-light. Health care issues have consumedcountless hours of debate in Congressand spurred many more hours of debatein medical schools around the country.

“Let’s see...There’s so much going on in the American health care systemthese days that it’s hard to know whereto begin,” the dean says. “Let me giveyou a vision of how I see the future ofmedicine, what the impact is on medicalschools, and how medical schools canpossibly address the changes that are occurring.

“This vision includes multiplechanges from the way medicine waspracticed as recently as 10 years ago.”

Dean Cinque credits the states andinsurance carriers, not the federal gov-ernment or medical schools, with initiat-ing the reform movement in health carethat is propelling America toward


WHAT’S HAPPENINGWITH CREIGHTON’SMEDICAL SCHOOL?

Dr. Cinque credits the

states and insurance

carriers, not federal

government or medical

schools, with initiating

managed care reform in

the health field

The Health Care System’s Effect

WHAT’S HAPPENINGWITH CREIGHTON’SMEDICAL SCHOOL?

By Cynthia Reynolds

a system of managed care.Until very recently, patients asked for

referrals, interviewed doctors and chosetheir own physicians. Now, the deanpoints out, it’s not the patient, but others— particularly insurance carriers — whoare instrumental in determining whowill manage a patient’s treatment.

“That means that the patient has lesschoice and the employer has less cost,”Dr. Cinque says.

The system of managed health carethrives on competition. Health careproviders know that they must do somestrong recruiting of insured employeegroups if they are going to survive in thenew system. Area hospitals—includingmedical schools and their affiliated hos-pitals — now are vying with each otherfor patients. Creighton realizes that withits teaching hospital, St. Joseph, it mustnow compete with other delivery sys-tems for patient contracts, its dean says.

“Why is the medical school in com-petition?” he asks rhetorically. “Our primary purpose is education and animportant corollary to that is research,the uncovering of new knowledge. Weneed patients to bring new diseases toour medical school in order to teach newphysicians. And we need patients inorder to do research in the pursuit ofnew knowledge.”

There is also a strong financial incen-tive to patient recruitment. In recentyears, medical schools have increasinglyrelied on patient care to supplementtheir funding. Between 40 and 50 percentof Creighton’s Medical School budgetnow stems from patient care—up from a “very low percentage” 15 years ago,the dean says.

But while Creighton relies heavily on its income from patients, the competi-tive atmosphere among local hospitalsleads to price discounts that affectincome levels.

“Insurance companies have put ussmack in the center of competition forproviding quality care at the most effi-cient price,” without being sensitive toour educational and research mission,Dean Cinque says, adding, “Unfortu-nately, however, the consumer won’t seemuch of a discount. It’s a shifting of the

dollar. The greaterprofit seems to be indelivery plans.”

The managedhealth care systemnot only affects amedical school’sbudget, but it alsoaffects its academicprograms.

“In a managedhealth care system,patients must firstsee a gatekeeper, aprimary care physi-cian, who deter-mines whether theywill be sent to otherdiagnosis facilitiesor to specialists,”the dean explains.“The need for moreprimary care spe-cialists is growingrapidly. So is theneed for moreambulatory care centers.”

Creighton isworking overtimeto design new programs to trainprimary care physi-cians and to design ambulatory care programs.

“Both of these situations require newmodalities of teaching, and no one has agreat deal of expertise in how thisshould be done,” Dr. Cinque says. “Wewill have to develop new sites, whichwill cost the medical school more money— an added strain on the medicalschool’s budget.”

So, Creighton, like other medicalschools, finds its income from patientsshrinking at a time when it has to spendin order to institute new programs andsites. And, to make matters worse, fund-ing for research — which has bolsteredmedical school reputations and budgetsfor generations — has dropped dramatically.

“The golden age for research grantsbegan in the 1950s and ran through the‘70s,” Dr. Cinque says. “Across the

board, there was a technological surge, amindset that science could cure every-thing. I think that’s changing.

“So, as we head into the 21st century,we’re looking at shrinking dollarsbrought in from patient practice, a needfor new programs and sites, and dimin-ishing research dollars. Not an easyprospect.”

One way to handle these challenges isto offer multi-faceted delivery systems,where hospitals form consortiums tocoordinate health care programs. “Thishas happened with varying success else-where,” Dr. Cinque says. “We’re in theinfancy stages of developing this type ofprogramming.”

In response to all these changes andchallenges, medical schools are begin-ning to restructure away from depart-ments toward institutes and centers,such as the Institute of Neurosurgery, the

Spring Issue 1995 11

“Why is the medical school in competition (for patients)? Ourprimary purpose is education and ... research, the uncoveringof new knowledge. We need patients to bring new diseases ... to teach new physicians ...” — Dr. Cinque Photo by Monte Kruse

Cancer Center and the Cardiac Center,all of which cluster professionals in relat-ed fields from nutritionists to psycholo-gists, social workers, radiologists,oncologists, surgeons and gene therapists.

“These centers will focus on preven-tive care as well as treatment,” Dr.Cinque says, predicting that the movefrom department orientation to a sys-tems orientation could take as long as 25 years to complete.

Meanwhile, however, in two shortyears the medical school’s faculty haschanged from a loose federation of indi-viduals to a “collegial group that speakswith one voice in order to work togetherto get things done,” the dean says.

“Before, each department was on itsown,” he explains. “Now we have onepractice plan. We have received our first contract with state Medicaid andsigned on with one insurance medicalplan. That means we’re competitors inthe market.

“In a very short time, we’ve tried tochange a lot of things, to prepareCreighton for the future.”

And what will the future hold?

“Across the nation, I think we’ll seemore and more reforms at the state lev-el,” Dr. Cinque predicts. “The insurancecompanies seem to be the predominantplayers. Reform will come in spite of the lack of a Washington drive. I don’t

think that we’re going to see a veryactive approach to global delivery systems yet, however.”

He predicts that three areas of con-cern will capture research dollars and

public attention in theupcoming years: gene ther-apy, preventive care, andthe issue of violence.

“Gene therapy holds somuch promise for thefuture, if it is used correct-ly,” he says. “A concern forpreventive care is alreadyevident in the movetoward better nutritionalstandards, exercise andfocused routine medicalvisits. And right now, peo-ple are very, very con-cerned and anxious aboutviolence and why itappears to be rising.Studies will try to deter-mine whether a tendencytoward violence is genetic,environmental or biochem-ical or some combinationof each.”

As research fundingdrops, Creighton has

turned increasingly to industry for back-ing on research projects, particularly inthe area of drug studies.

“The only research projects thathaven’t been affected by a drop in dol-lars are those focusing on AIDS and can-cer research,” the dean says. Creightonhas earned international recognition forone aspect of cancer research, thanks tothe hereditary cancer research programheaded by Dr. Henry Lynch.

“Right now we’re developing a premier Hereditary Cancer Center at the school and we’re working withONCORE, a company whose primaryfocus is developing a package to allowconsultations for people who are gene-positive,” Dr. Cinque says.

The proliferation of gene therapy programs and testing may cause earth-shaking changes in the practice ofmedicine, he adds.

“Very soon, every physician maybecome capable of doing gene testing.That pushes the boundaries of med-ical practice to new horizons, and, with it, new ethical and educational challenges.”

Creighton is working to develop an


Dr. Cinque predicts

three areas will capture

research dollars and

attention: gene therapy,

preventive care, and the

issue of violence and its

ties to genetics

and/or biochemistry

Discussing patient care at a Creighton Family Practice clinic. From left: Drs. Pierre Lavedan,Margarita Rodriguez, Donald Frey, Michael Kavan, and Abdulrahman Davis. Photo by Kent Sievers

information system to help determinethe most effective gene therapy. With theaid of Dr. Lynch’s vast supply of casehistories, physicians soon may be able tocounsel patients on the probable progno-sis for various treatments.

“How will we affect the genes? Whatwill be put into patients that mightchange their DNA or RNA?” he specu-lates. “We’ll have to confront a wholenew set of ethical questions very soon.”

For instance, should someone who isgenetically predisposed to colon cancerundergo surgical therapy before canceris ever detected?

What about the question of replacinggenes? If a patient contracts a certain dis-ease, what do you do with the gene?Change it?

Then there is the limitation issue. Ifmedical science comes up with a particu-lar mode of therapy and it doesn’t havea favorable cost/benefit ratio, how do practitioners denytherapy?

These debates don’t even cover thetip of the proverbialiceberg when it comesto new ethical questions.

And even morequestions face aCatholic, Jesuit medicalschool. For instance,what are the ends of life?

“Where do we stopmedical therapy at thebeginning and at theend of life? We’ll bestruggling with thatissue,” the dean pre-dicts. “We’ll deal withthe question of repro-duction and the newmethods that developmultiple embryos.What should be donewith those?”

Right nowOB/GYN residentsaren’t required to takea class in abortion foraccreditation, and

Creighton refuses to teach abortion.What will that mean?

“The ethical questions that medicalscience will confront seem almost over-

whelming,” Dr. Cinque says. “We’ll bestruggling with these—and many more

questions with ethical import—for years to come.”

When he looks back over the yearssince 1959, he sees significant differencesnot just in the cosmic concerns, but alsoin the everyday outlook of doctors.

“I see more concerns about the quali-ty of life these days,” he observes.“Among our alumni, there is a generalanxiety because no one knows for surewhat the future holds — it seems farmore nebulous than it did 10 years ago.

“But,” he adds, “I see a collegiality inthe profession that some of us might nothave anticipated. And what makes memost optimistic is that Creighton has9,100 applications for 112 spots (last yearwe had 9,300). These are outstandingstudents, quality people who have doneimpressive things with their lives.

“It’s hard not to be optimistic whenyou see this type of person still wantingto go into medicine.” W


Dr. Cinque chats with third-year student Peter Leonovicz. “Very soon,” Dr. Cinque says, “every physicianmay become capable of doing gene testing. That pushes the boundaries of medical practice to new horizons,and, with it, new ethical and educational challenges.” Photo by Monte Kruse

“What makes me most

optimistic is that

Creighton has 9,100

applications for 112

spots. These are

outstanding students,

quality people ...”


n March 5, 1962, I’m summoned to Fr.Henry Linn’s office. He asks me toclose the door. I notice he’s distraught

and that the trademark cigar is absent.“Something terrible has happened,” he

says to me.I make a quick examination of conscience,

reviewing potential public relations blunders Imay have initiated, and slowly sit down.

“I’m president of Creighton University,” Fr. Linn intones. “I have been for two days.”

I don’t rememberresponding.

“I didn’t ask for this, didn’twant it,” he continues, “but ithappened. Only two people oncampus know, Fr. Reinert and I.Now I’m telling you because youhave to write the news release. For tonight, after dinner. Youunderstand?”

I did. An old Jesuit ritual calls forthis administrative change to beannounced at the evening meal, almostas part of the routine readings, signify-ing, I suppose, that anyone may be called to serve.

We talk about the wording of therelease. Both of us understand that it’snecessary to allay concerns about thefuture role of Fr. Carl Reinert, Creighton’sleader for the past dozen years. Half of the three-page releasewill deal with Reinert’s new post as vice president of universityrelations, the job previously held by Fr. Linn. They will, ineffect, switch assignments.

“There’s another thing,” adds Fr. Linn. “We have to tell the Regents at this afternoon’s meeting. I’m not looking forward to that.”

The Regents gather in the Union Pacific room, greet eachother as peers, the most powerful group of men in Omaha. Withthem Fr. Reinert covers the scheduled agenda, then asks themto remain a few minutes.

“Gentlemen,” he says firmly, “there’s been a change. I’m no longer president of Creighton University. Fr. Linn is our new president.”

Stunned. That’s the word I’d use. They were stunned. Andangry, too. They hadn’t been consulted on this most importantof issues. Then came the flood of questions. How? When? Why?

“Why?” responds Reinert. “It’s routine. I’ve been presidentfar beyond the normal six-year term.”

“Who makes a decision like this? Who do we have to contactto change things? What about the campaign?”

Fr. Reinert says it will be fruitless. It is over.They won’t accept that. They would see the Provincial.

They will write to Rome. One Regent weeps openly and leavesthe room.

I look at Fr. Linn at the end of that long, dark table. He seemsdiminished, lonely, like a child being discussed at a parent-teacher meeting. No one congratulates him.

The Regents depart, still arguing, still plotting to reverse thedecision. A few manage an apologetic salute to Fr. Linn, who

shyly acknowledges their confusion.I ask him about this later, about how he

felt at what should have been his happiestmoment, but one that had turned into anembarrassing confrontation.

“Bob,” he remarked, with simple can-dor, “I realized when I accepted thisoffice that I would be replacing the mostpopular president we’ve ever had. Ihave no illusions about the situation. Ijust have to do the best I can.”

On paper, the transition lookedgood. Fr. Reinert declared Fr. Linnwould have been his first choice assuccessor. Fr. Linn said he was look-ing forward to continuing his closeassociation with his former superior.The team remained intact.

“I just have to do the best I can.”Fr. Linn always makes me think

of Harry Truman, not solelybecause of physical appearance orMissouri roots, but because both

replaced near legends and had to perform thesame duties with a less obvious set of gifts. But Fr. Henry W.Linn had forged his own identity over a lifetime of hard knocksand frustrations.

He was born in the Kerry Patch district of St. Louis, the sonof a bookbinder whose paycheck was never sufficient to meetthe needs of his family — himself, his wife, and their five chil-dren. Further complications arose when the elder Linn contract-ed tuberculosis, and both a sister and brother of Henry wereinvalided with rheumatic fever. By the sixth grade, Henry washelping out with a part-time job.

The future Creighton president wanted to attend a localJesuit high school, but the tuition was beyond reach. So Henryshowed up at the school’s reception desk, asking to see theJesuit president. He was told this was not possible, that thepresident was a busy man. The boy persisted. A black-robedpriest came over, asked what was wrong.

“I want to go to school here,” insisted the young Linn, “butI’m a poor boy and I’ve got to have a scholarship.”

Fr. Linn logged more than 800,000 miles from

1946 to 1962, many of them in a car such as

this, once surviving a crash that broke all

but one of his ribs.

O

Pilgrim’s Progress:Pilgrim’s Progress:

By Bob ReillyBy Bob Reilly

“If you gotta have a scholarship,” said Fr. Bernard Otting,S.J., the president Linn was trying to see, “then you gotta have ascholarship.” He wrote out instructions on the spot, providingHenry with the means to attend school.

In Henry’s sophomore year, his father died, so the youngman left the classroom and assumed the support of the family.He labored for a year at a print shop, then spent three yearsmaking inner tubes for Model-T Ford tires. It was here helearned to chew tobacco, convinced it would prevent tuberculo-sis, and here, turning the heavy rubber cylinders, he overdevel-oped the muscles in his right shoulder. Here, too, he perma-nently injured an index finger.

“When he’d point at you,” recalls Fr. Neil Cahill, S.J., once astudent of Fr. Linn’s, “it was hard to tell if he was singling youout or the fellow next to you.”

Sympathetic educators provided Henry — or maybe he wasalready calling himself “Harry” by this time — with out-of-school tutoring in Latin and Greek. So, despite hislifelong lack of a high schooldiploma, his proficiency inclassical languages enabledhim to join the Society of Jesus.Later, of course, he would earnhis bachelor’s and master’sdegrees, a doctorate, and hislicentiate in sacred theology.

At the seminary in Florissant,Mo., Fr. Linn was not shy aboutcriticizing programs and individ-uals he found wanting. He washard on himself and on others.When he completed his tertian-ship, schools weren’t clamoring forthe services of this outspokenyoungster. He contemplated leavingthe Society and seeking a diocesanassignment. His superior had a longtalk with him, reviewing the notesclassmates had made about him, then urging him to stay and tochange. With that remarkable deter-mination which was always part of his makeup, Fr. Henry Linn redesignedhis personality.

Fr. Cahill, who credits Fr. linn withinfluencing his own vocation, remem-bers commenting to the older man on his even disposition.

“You’re meeting the post-tertianship Linn,” he was told.After teaching classical languages at Xavier of Cincinnati

and St. Louis University, Fr. Linn appeared at Creighton in 1938to pursue the same teaching regimen. This was the beginning ofa 31-year career that provided him with multiple hats: teacher;spiritual advisor; liaison between Creighton and various mili-tary units during WW II; chaplain; dean of University College,the School of Journalism and the Graduate School; founder and

director of the Institute of Industrial Relations. To meet awartime need, he even taught physics to men in the military,including myself.

In 1946, Fr. Linn was named Executive Secretary to thePresident (then Fr. William H. McCabe, S.J.) and Director of theCreighton University Development Program. With the adventof Fr. Reinert, his title eventually changed to Vice President forUniversity Relations, embracing development, public relations,and alumni affairs. In reporting this latter change, The CreightonAlumnus magazine added this paragraph:

“In making the announcement, Fr. Reinert said that Fr.Linn would not be traveling as much as he had in the pastseveral years and will therefore have more time to give towork in Omaha and at the University.”Someone forgot to convey this news to Fr. Linn, who logged

over 800,000 miles from 1946 to 1962, visiting alumni and rais-ing funds. The late Hollis Limprecht, writ-ing about Fr. Linn in a Magazine of theMidlands piece, calculated that distancematched 32 trips around the world. Everyyear Fr. Linn would visit the 53 largestalumni chapters, along with individualstops in hundreds of smaller towns. Hemet, personally, nearly 10,000 alumni intheir home areas.

He could call them all by name.Everyone who knew Fr. Linn commentson this remarkable recall. I experiencedit myself, shortly after I came toCreighton in 1950, combining duties inpublic relations, alumni relations, jobplacement, recruiting and develop-ment. Fr. Linn and I drove to Denver,leaving at an hour when even themost restless Jesuits were still abed,and arriving in the Mile-High City intime for a pre-party cocktail hour atthe home of an alumnus. Fr. Linn circled the room, introducing me to each person, often addingdetails about their relatives or classmates, people I might recall.He stopped before one man,momentarily puzzled.

“You don’t remember me, do you?”challenged this alumnus.

Fr. linn paused, not ready to surrender.“I’ll give you a hint,” said the man, supplying his college

nickname.Fr. Linn reacted immediately, providing the full name, but

adding that this man was supposed to be in Cheyenne, Wyo.The alumnus confessed he was passing through town, heardabout the party, and just decided to show up.

We got to bed late that night and had to return to Omahaearly the next morning. I was asleep when my head hit the


(Photo: Fr. Reinert, left, and Fr. Linn) “I real-

ized when I accepted this office that I would be

replacing the most popular president we’ve

ever had. I just have to do the best I can.” — Fr.

Linn, after being named president of Creighton.

pillow. A knock on the door brought me upright. It was Fr. Linnin the adjoining room, poring over the list of Colorado alumni.He wanted to know if I had spoken to this person, if anotherindividual had mentioned his son planning on med school, if Icould come up with the name of this man’s wife. That was hissystem. Constant, dogged repetition and rote.

Before every trip, recalls Rosemary Reeves, Fr. Linn’s secre-tary for 19 years, he would go to the vault to extract records andinformation on those he planned to meet. His maps were allmarked in colored pencils.

“We worked hard every time he went on the road,” sheremembers, “and he would phone frequently withrequests for more data.”

In his glove compartment would be a supplyof those terrible stogies which Rosie ordered firstfrom Italy, and later from “somewhere in theSouth.” His well-worn cassock might sport sev-eral holes where ashes had taken their toll.

“I see him seated at some banquet table,”says Fr. William Kelley, S.J., vice president of the university foundation,” next to a beauti-fully-coifed woman, clad in an exquisiteevening dress, and completely engulfed incigar smoke.”

Harry Dolphin, former director of public relations at Creighton, remembers stealing one of those dark ropes one time and tryingto smoke it.

“My head nearly came off,” he says.Sometimes Fr. linn would wrap toilet

paper around the end of these cigars, thebetter to fit his holder. And he’d use thestogie to punctuate sentences, to drivehome a point, to calm his own nerves.

For a man with so much on-the-road experience, he wasn’t what you’d call a relaxing driver. Here, too, he and Fr. Reinert made a team. Fr. Reinert drove faster, often inthe middle of secondary roads, certain no one was coming overthe approaching hill. Fr. Linn’s equally chilling habit was to cutright back into the lane after passing a car. We’d watch strangersin the passenger seat instinctively retract their elbows.

His vehicles were equipped with extra weights, to keep themclose to the road. I remember driving Fr. Linn’s car once andbraking for a passing train. I was standing up and nose-to-nosewith the barrier arm before I came to a stop. Fr. Linn moved meout of the driver’s position.

In those early years he often had a dentist or physician withhim on his treks, notably Dr. Louis McGuire and his wife, whospent as much as three months a year traversing the countrywith Fr. Linn.

But he was alone in mid-July, 1952, driving his two-year-oldDodge along rain-soaked Highway 20 in Nebraska, headed forthe Dakotas and Colorado. Not far from Valentine, he missed acurve, crashed, and was thrown from the car. On his hands andknees in the center of the wet road, still gripping his cigar

holder, he found he couldn’t rise. No wonder. All but one of his24 ribs were broken, along with a single vertebra. His lung wasalso punctured.

His guardian angel was certainly aware of the situation,since two cars came down this lonely road while the wheels ofFr. Linn’s car were still spinning. One of the arrivals was anurse. They bundled him into a car, took him to a Valentine hospital, then, the next day, transferred him by ambulance to St. Joseph’s Hospital in Omaha. Fr. Linn was in shock, his condition very serious.

Fr. Reinert was quoted as “ordering him to live, because weneed him so badly.”

They gave him the Last Rites, however, and many ofus wondered if Fr. Harry Linnwould ever again get behind thewheel of a car. Two months later,he was back in his office. In pain,on medication, but back at work.

His friend Dr. McGuire, whoheaded the surgical team, said, “Iknow it’s a miracle ... but I’m tak-ing some of the credit, too.”

Soon Fr. Linn was back onAmerica’s highways, most of his mileage ahead of him. He’dcruise into a community, head for an office or a home, present theCreighton message. Sometimes the alumni were not anxious to see him. Some ducked out the back door.

“How do you handle that kind ofrejection?” I asked him.

“There are three levels of obedience,”he replied. “The first is when you dosomething because you’re told to do it.

The second level finds you doing something because you’regood at it, because it’s your job. You may even like it. The thirdlevel is when you believe this is your special mission in life,when you convince yourself God put you here to do just thisone thing. I’ve psyched myself into this third level, so occasion-al frustration doesn’t bother me.”

That doesn’t mean he didn’t get nervous. In many ways hewas a basket case, never sitting for more than a few minutes,always pacing, thinking of a hundred different things.

“Very fidgety,” horticulturist John Mulhall, once Creighton’sfull-time landscape gardener, assessed him. “He hadn’t enoughtongues to express all the emotions in him. He thought thewhole world depended on the existence of Creighton, and hisjob was to see that Creighton succeeded. Even when he got acheck for $50, it was like a million.”

But he also raised millions. I’ll wager no one individual onthe fund-raising circuit ever matched him in volume. When thenew development era arrived, with its computerized lists andmulti-produced personal letters and expanded staffs, some of


Fund raising in Fr. Linn’s day mighthave had lower goals, but he drovehimself to meet them. Note the cigar.

the modern fund-raisers would scoff at Fr. Linn’s antiquatedmethods, driving around the nation, buttonholing one alumnusat a time.

Maybe so, but in their early stages, all their fancy tacticsfailed to duplicate the results of this one priest in one car on onemission. He was a development dinosaur, but he set a lot of records.

At home he was a peacemaker, diffusing controversy,avoiding conflict. He was sometimestoo easy on his employees, givingthem second and third and fourth andfifth chances. He’d often talk around areprimand rather than hurt an individu-al. He could also be blunt, but honest.

“He was always straight with me,”avers Dolphin. “He could read me like abook, and had a way of instilling confi-dence with a few words.”

Former television news director SteveMurphy, who worked part time forCreighton in the ’50s, agrees.

“I served Mass for him at St. John’swhen I was a kid, and he was the first per-son I dealt with after getting out of the Army. I was always comfortable with him.”

Rosie Reeves knew him best, of course.“He was a very fair man, concerned about his employees. He

might tell us to keep the noise down once in a while if we wereworking in a group, but he was kind to everyone. He remindedus constantly that we were doing God’s work. I never saw himget real upset.”

On one subject he had tunnel vision: Creighton. There wasno other school like it, no other students or alumni to match thisuniversity’s. If you talked about Wilt Chamberlain, he’d counterwith Paul Silas. The Harvard school of Business must necessari-ly rank behind Eppley College of Business Administration. Ifyou cited an alumnus of Cal Tech, he’d provide a list of Bluejaygraduates who were superior. It was a unique chauvinism.

“He was so inebriated with his own exuberance,” declaresFr. Cahill, “especially about Creighton, that he’d even begin tobelieve it all himself.”

For recreation, he played some bridge, read mysteries, hungout at the Jesuit villa (read “cabin”) on the Platte. I’ve never metanother person who could, like Fr. Linn, get most of his plea-sure vicariously. We all want the ball, the spotlight, a chance toplay. Fr. Linn would shrink into a corner, totally happy, watch-ing others enjoy themselves. He would encourage Fr. Reinert to sing, or the late Leo Pieper, once Creighton’s placementdirector, to play the accordion. Over the Rainbow was one of his favorites.

Sometimes he would visit friends’ homes. Rosie’s, theMcGuire’s and dozens of others. Each Christmas we invitedseveral Jesuits and assorted lay people to our house to decoratethe tree, eat, and sing carols. Fr. Reinert was in charge. Fr. Linn

would remain outside the circle, perhaps with one of our chil-dren on his lap. He was especially fond of our eldest daughter,Kathy, who was deaf. For years he heard her confession. Andevery Yuletide he’d remain slightly detached, smiling encour-agement, but never asking for a role.

Although he professed to enjoy a good meal, he seldom atemuch and couldn’t sit long at a table. Or at a desk.

“He inhaled his food,” declares Fr. Cahill.The late Bernie Conway, who shared many

cross country tours with Fr. Linn, used to tell ofone trip to Texas. En route, Fr. linn asked Bernieif he liked prime rib, and the alumni secretaryacknowledged that he did. Fr. Linn promisedhim they would dine in a restaurant that nightwhich featured the best prime rib he’d evertasted. He described the meal like an adver-tising copywriter. They checked into theirmotel, then headed for the restaurant. Whilethey sipped a drink in the adjacent lounge,Fr. Linn and Conway ordered from themenu. Summoned to their table, Bernie set-tled in for a relaxing repast.

Fr. Linn took a few bites, looked at hiswatch, looked at Bernie, sat back impa-tiently in his chair. After several minutes

of uneasy association, Fr. Linn excused himselfand said he’d meet Bernie in the car. Conway finished the mealalone, and more rapidly than he preferred, while Fr. linn sat sto-ically in the parking lot. Then they tooled back to their roomsand watched television.

Fr. Linn liked basketball, but rarely attended a game.“I get too excited,” he confessed. “I listen on the radio so I

can turn it off at tense moments.” Any Creighton loss was a personal defeat.

Not an effective orator, he was persuasive one-on-one, anexceptional salesman, like Fr. Reinert. They were a matched set.Fr. Carl was the visionary, the extrovert, the charismatic frontman. Fr. Linn mastered the details, content to be second banana. They were Arthur and Bedivere during Creighton’sCamelot years.

That narrative was recast in 1962, when Fr. Henry Linn tookover the Hilltop reins. His 88-year-old mother heard the newswith joy, but Fr. Linn was troubled, uncertain how this newarrangement would function.

“He had to walk a tightrope,” admits Fr. Kelley, “but I neversaw any real tension between them. Still, it must have been dif-ficult, because there is nothing as past as a past president.”

These presidential years were hard on him. His back hurt,the occasional drink he enjoyed didn’t mix well with his medi-cation, the demands of his office were constant, the perceivedslights were silently absorbed. And the Linn/Reinert tandemdidn’t work quite as smoothly as before. There were minor dis-agreements between the two old friends, always muted, andwith Fr. Linn succumbing most easily. Some people in Omahatreated Fr. Reinert as if he were still CEO, sometimes circum-


A rare moment without a cigar.


venting his successor. No serious rift evolved, but I felt thestrain myself before leaving campus.

Fr. Linn, typically, took my departure personally.Disappointed at my failure to sign on forever, he spoke at myfinal bowling banquet dinner, wishing me well, but predictingI’d be back “since I just wasn’t cut out for the business world.”

A week later, at one of architect Leo Daly’s memorable cock-tail parties, Daly, a Regent, inquired how Fr. Linn took the newsof my leaving. I repeated that bowling banquet sentence. Helaughed, and then we spoke about Daly’s possible expansioninto Ireland. I asked him to remember me if he needed someonethere in public relations. Leo shook his head and said, “Fr. Linnwas right.”

People tend to underestimate the seven years of the Linnadministration. It was an era of great change, in the country and on campus. The Cuban Missile Crisis, the deaths of theKennedys and Martin Luther King, the Second Vatican Council,John Glenn’s orbit of the earth, racial violence in Los Angeles,Detroit and elsewhere, and the divisive struggle in Vietnam.

As Fr. Linn dealt with the echoes of these events, he man-aged to keep a lid on student protests, defend faculty whodemonstrated against injustice, and come down hard on signsof bigotry. In an open letter to students andfaculty written a month before he died, Fr.linn decreed:

“During the past few weeks there havebeen some incidents of an abusive andinflammatory nature on the part of somestudents and even on the part of a fewteachers in the classroom. This points tothe existence of an intolerable whiteracism at Creighton. As president of aCatholic university, I will not tolerateracist behavior on campus.”

The poor boy from Kerry Patchmade his meaning clear.

Fr. linn also promoted urban renew-al, restructured the University’s Boardof Regents, raised faculty salaries, wit-nessed the continued campus facelift,encouraged dialogue, and watchedthe interstate system snake up to theschool’s doorstep.

He tried his best to implement the dictates of Vatican II.“Harry read part of the Vatican II documents every day,”

recalls Fr. Robert Shanahan, S.J., now working in pastoral careat St. Joseph’s Hospital. “The pages would be all marked up,with notes scribbled in, emphasizing things which struck him.”

It all came to an end on a November weekend in 1969. I wasdriving back from St. Louis with my wife, intending to have herdrop me off in Lincoln to attend my first Big Red football game.Somewhere in Missouri I heard the news that Creighton’s 20thpresident had died. We drove straight to Omaha, to join the other mourners.

There was a meeting of Province consultors that Saturday.

Because he would be tied up for a few days, Fr. Linn had said tohis secretary on Friday, “Rosie, do you have any letters to sign?I probably won’t see you anymore.”

When he failed to show for the opening session the follow-ing day, Frs. Shanahan and Flavin went to his room. They foundhim dead, still in his bed. Fr. Shanahan sat beside him, took hishand, and, as if indicting all of the crosses Fr. Linn bore, said,“Well, they can’t hurt you anymore.”

Fr. Cahill, who would be a pallbearer, went to Fr. Linn’sroom to help organize his belongings. Weeks earlier, Fr. Cahillhad urged the Jesuit minister to buy Fr. Linn half a dozen shirtswith French cuffs so he would look more presidential. Five ofthese shirts were in his drawer, still wrapped. The sixth was onhis small body. He’d never bought cuff links.

“He was a peasant until the day he died,” reflects Fr. Cahill,with obvious affection for this man with few pretensions.

Letters of condolence poured in to Creighton. FormerCreighton student and employee, Dr. Joseph Soshnik, then pres-ident of Nebraska University, declared Fr. Linn “always stoodfor what was solid and right, even at times when his positionwas not the popular one.” History professor Ross Horningpraised his lack of rigidity, his deep consciousness of human

relations, and the fact that “he never let up on himself.” A former student, Maureen PolkingMiller, wrote that Fr. Linn taught herabout courage and commitment whenher husband died, that he would alwaysbe around.

The celebrant of the funeral Mass, theVery Rev. Joseph Sheehan, S.J., provincialof the Wisconsin Province, called Fr. Linnone of the most honest men he ever met,and cited his love for the openness ofyoung people.

“I never found the least bit of devious-ness or the least amount of self-seeking inhim,” he stated in his eulogy. “He genuinelyquestioned his own ability to lead this uni-versity, because he always felt it deservedthe best in effort and talent.”

He looked over the standing-room-onlycrowd in St. John’s campus church and con-tended, “Today we bury a happy pilgrim, aman who has traveled thousands and thou-

sands of miles for other people, all the while seeking to helpand do his part to provide a place where young people whomhe loved could find truth and could find their God.”

I guess, in the end, he was happy. What others saw aspenance, he embraced as mission. He had no unfulfilled aspirations because he figured everything he did was part of a larger plan.

And those 800,000 miles? Perhaps he viewed them as anoverlong rosary, to be said and savored, decade by decade,because wherever he drove, whatever he did, was sort of dutiful prayer. W

Fr. Linn and his Fifties fedora.

(Dr. Wunsch, who gained an interest in Africa while a student at Duke Uni-versity, majored in political science andAfrican studies at Indiana University,where he earned his doctorate. He held aFulbright-Hays Fellowship in Ghana in1971-72. Dr. Wunsch has lectured widely in Africa and has held researchawards from the National ScienceFoundation, the National Endowmentfor the Humanities and the U.S. Agencyfor International Development. Heserved two years with the latter agencyas a social science analyst. Dr. Wunschhas been at Creighton since 1973.)

Hopes werehigh whenindependencedawned in SubSaharan Africain the 1950s and1960s.

Most of Africa’s new states had expe-rienced a gradual decolonization processwhich included steadily increasingresponsibilities for self-government.

Generally they reached independencewith remarkably low levels of blood-shed, in what has often been a traumatic and violent process. Most states, as well,

had a sophisti-cated and educat-

ed (even if small) cadre to staff theirgovernment, had significant hard cur-

rency reserves, and had internationaldonors ready to support the enterprise.While they were underdeveloped, theywere agriculturally self-sufficient andoften had rich mineral deposits to build on.

Thus, the prospects for democracyseemed bright, and most of the formercolonies began independence withdemocratic institutions and democraticelections.

MALI

MOROCCO

WESTERNSAHARA

GUINEA-BISSAU

MAURITANIA

GUINEA

SENEGALGAMBIA

ALGERIA

NIGERCHAD

LIBYA

TUNISIA

EGYPT

SUDAN

ZAIREBURUNDI

RWANDA

UGANDAKENYA

SOMALIA

DJIBOUTI

CONGO

GABON

CAMEROON

NIGERIABENINTOGO

IVORYCOAST GHANA

LIBERIA

SIERRALEONE

BURKINA FASO

CENTRAL AFRICANREPUBLIC

EQUATGUINEA

ETHIOPIA

TANZANIA

MOZAMBIQUE MADAGASCAR

BOTSWANANAMIBIA

ZIMBABWE

MALAWIZAMBIA

ANGOLA

SOUTH AFRICASWAZILAND

LESOTHO

MALI

MOROCCO

WESTERNSAHARA

GUINEA-BISSAU

MAURITANIA

GUINEA

SENEGALGAMBIA

ALGERIA

NIGERCHAD

LIBYA

TUNISIA

EGYPT

SUDAN

ZAIREBURUNDI

RWANDA

UGANDAKENYA

SOMALIA

DJIBOUTI

ERITREAERITREA

CONGO

GABON

CAMEROON

NIGERIABENINTOGO

IVORYCOAST GHANA

LIBERIA

SIERRALEONE

BURKINA FASO

CENTRAL AFRICANREPUBLIC

EQUATGUINEA

ETHIOPIA

TANZANIA

MOZAMBIQUE MADAGASCAR

BOTSWANANAMIBIA

ZIMBABWE

MALAWIZAMBIA

ANGOLA

SOUTH AFRICASWAZILAND

LESOTHO


AfricaAfrica

Will DemocracyThrive in Africa This Time?By Dr. James S. WunschProfessor of Political Scienceand International Studies

Photos by the Author, except where noted

Within a decade all this had gone terribly wrong.

Virtually every democratic govern-ment had fallen: some to military coupsand strong man governments; some tosingle-party, “life-president” systems;and some to personalistic and corruptdictatorships. The quality of these gov-ernments varied. Some offered relativelyhonest and effective management ofpublic affairs, but others descended intocorruption, abuse of human rights, andeventual disintegration.

1995 marked a remarkable turn-around. The last remnants of Western

colonization — Namibia and SouthAfrica — had held democratic electionsand begun responsible, constitutionalgovernance. Many other African stateshad returned to democratic elections andgovernments as well, including Zambia,Congo, Mali, Malawi, Benin,Madagascar, Senegal, the Central AfricanRepublic, and Ghana. Others, includingIvory Coast, Tanzania, the newly inde-pendent Eritrea, Zimbabwe and even theonce savagely torn Uganda were movingin a democratic direction. The civil warsof Mozambique and Angola showedpromise of ending. Even with the disap-


THE AUTHOR’SJOURNEY AND HOPE

Democratic reforms in Africahave generally occurred in anextended, two-stage process.

■ ■ ■

THE FIRST STAGE encom-passed the surrender of the oldregime to the necessity of change. In

some areas, Tanzania for example, thisappears to have come largely via internalforces and domestic processes. In most,however, elements of the internationalcommunity have played a role. At timesthis has been primarily facilitative, provid-ing aid in holding elections and observing ballot-tallies. Ghana generally fits this pat-tern. In other cases, a more aggressive rolehas been taken by outsiders. In Kenya thegovernment was brought to electionsbecause of intense domestic discontent, aid-ed by pressure from a substantially U.S.-leddevelopment assistance boycott, as well assignificant international criticism, also U.S.-led. In Zambia, after the single-party gov-ernment was stunned by its electoraldefeats in 1991, retired foreign leadershelped persuade the leader, PresidentKaunda, to step down. Later on, Zambianleaders helped play a similar role inMalawi’s reforms.

Certainly the international economicboycott and other sanctions played a largerole in the end of apartheid in South Africa.While each of these democratic reforms/revolutions had their own unique internaldynamics, and were won by battles theirpeoples waged, international actors, including the United States, have playedimportant roles.

■ ■ ■

THE SECOND STAGE of democraticreform is an even bigger one than gainingfree and fair elections. This is the buildingof sustainable democracy. Governmentsmust manage public affairs well: respon-sively, efficiently, effectively and transpar-ently if democracy is to survive. While thisis once again primarily a domestic chal-lenge, international donors are playing amajor role as well.

Dr. Wunsch (larger photo above) shows the work of the African artisan (inset) hecommissioned to weave the brightly colored cloth, which hangs in his office.

Pho

to b

y M

onte

Kru

se

Continued Next Page

pointing return of military authoritarian-ism in Nigeria, the continued kleptocra-cy of Zaire, and the tragedies of Rwanda,Somalia, Liberia and Sudan as conspicu-ous reminders of the limits of thesechanges, Africa had come a long way.

But will these changes last? Toanswer that, one must first understandwhy these fledgling democracies failed.

Most close observers of Africa’s firstdecades of independence believe thatfour interrelated factors contributed tothe democratic failures of the immediatepost-independence era:

— ethnic pluralism, — economic underdevelopment, — the international environment, — and the experiences and world

views of the “independence” generationof African leaders.

Ethnic PluralismPerhaps the paramount fact anyone

must know to understand Africa is thatits states are virtually all composed of

multiple nations. Westerners, particularly journalists,

often obscure this by use of the term“tribe.” Tribe connotes a small, unso-phisticated, isolated and “primitive”

group of people, one that few wouldhardly expect to be able to manage amodern state, nor to get along rationallyor peacefully with members of other“tribes.” Outsiders caught in this lan-guage trap would hardly expect “tribal”peoples to succeed in democracy, muchless peaceful civil relationships, econom-ic progress or the like.

In fact, Africa is composed of manynations, just as Europe, Asia and LatinAmerica are. We hardly consider the fivemillion Danes to be a “tribe:” They areseen as one of the constituent nationalgroups of Europe.

Similarly the millions of Ibos,Yorubas, and Hausas are also nations.However, because of the accidents ofcolonial history, they, along with manyother nations in Africa, live mixed in single states. Just as Western Europe’s“tribes” at different times and in differ-ent contexts have gotten along better andworse, so have Africa’s.

Multi-ethnic states are problematic.The Canadians, the Belgians, the Russianfederation, India and the formerYugoslavia have wrestled with this withvarying levels of success.

Ethnic pluralism does not ensure hostility: The substantial majority ofAfrican states that have maintained civilpeace demonstrates that. But it compli-


This is a “lorry park” in Kumasi, Ghana. Private entrepreneurs provide transporta-tion to almost anywhere from this location. It is also a marketplace for goods.

■ ■ ■DR. JAMES WUNSCH, of Creighton,

has journeyed to Africa seven times since 1992to participate in this second process. InZambia, in 1992, he led a U.S. Agency forInternational Development team which evalu-ated Zambia’s governmental reorganizationneeds, designed a reformed cabinet secretariatto strengthen policy-making and coordination,and helped establish a legislative research support capacity for their newly elected parliament.

In South Africa he participated in confer-ences and seminars, lectured to numerousaudiences (civic, business, academic and parti-san) on the rest of Africa’s experience withdemocracy, and on federalism, local govern-ment, and rural development policy. One 15-minute “courtesy call” with an ANC officialinvolved in the constitutional negotiations,turned into a four-hour, two-person seminaron the U.S. experience with local government!

During 1993-94, Dr. Wunsch journeyed toNigeria five times to work on local govern-ment reforms. Focusing on the delivery of primary health care, Dr. Wunsch led a four-

person team (he and three Nigerians) in evaluating Nigeria’s primary health care sys-tem: both to redesign and strengthen it, and asa case study to identify needed reforms in theentire local government system. The work,funded by the USAID, was prematurely endedby the November 1993 military coup.

Far from being discouraged, Dr. Wunschobserved, “I have long believed democracy inAfrica will be built from the grass-roots up, notfrom the center down. Nigeria’s local-leveldemocratization went too far for the center tokill it. One day the military will return to theirbarracks, and local government will providethe foundation for an enduring democracy.”

Applying his field experience to U.S. foreign policy, Dr. Wunsch spent much of fall,1994, preparing the strategic planning back-ground paper for USAID’s world-wide demo-cratic-governance program. He also is servingon a panel working to develop an analyticalframework to evaluate democratic reforms inindividual African countries. The latter taskwould set a research agenda to guideAmerican policy experts in determining howthe U.S. government might assist fledglingdemocratic governments in Africa.

Continued From Page 21

cates governance in several ways, and insome circumstances it may make democracy difficult:

■ Multiple languages can slow com-munications and focus citizen attentionon sub-state identities and loyalties tothe exclusion of others.

■ Multiple ethnic groups exist asready-made and potentially divisiveblocs that ambitious political leaders canintensify in pursuit of office and power.

■ Ethnicity usually coincides withregion, intensifying regional competitionfor political power and spoils; the samepattern applies at times to religion.

■ When significant cultural differ-ences (in values, in understandings ofmoral imperatives) exist among ethnicgroups, developing and implementingeffective public policy is difficult.

■ Historical legacies: Past militaryconflict, inequalities in education or economic development, can heightenethnic suspicion.

■ States grafted on multiple nationstend to command less identification withand commitment by the citizens.

All these factors are as applicable toCanada as to Africa. And each area hashad difficulty in dealing with multi-ethnicity.

Briefly put, multi-ethnic states arepolities built on divided citizenries who

share few cultural norms, may feel a lim-ited moral obligation to the state, andfeel more trust in their own ethnic/national leaders than state leaders. As aresult, the stakes of political competitioncan be very high: Each group fears what the others might do if they capture the state.

Restraints on political tactics areweak: When the ballot-box fails, fearfulpeople take to the streets. There are few,if any, wide-spread and deeply heldnorms which undergird constitutionalprovisions, which makes their subver-sion more likely. Also, state leaders areaware of the tenuousness of their consti-tutional claim on office, and tend to seekadditional ways to strengthen their hold:single-party systems, life-time tenure in office, co-optation of opponents, andthe like.

When these dynamics began to getout of control, as they did in Ghana andNigeria, the military has taken power. Inother countries, more astute (and per-haps more lucky!) leaders succeeded inestablishing a stable patron-clientagesystem where the benefits of politicalpower were shared-out much like theclassic American urban machine. Aslong as the money held out, ethnicfragmentation could be contained thisway. Ivory Coast, Kenya, Zambia,

Senegal and Cameroon more closely fitthis model.

Either way, democracy was the casualty.

Economic UnderdevelopmentA second problem for African

democracy has been the poverty andunderdevelopment of the continent.

For the most part, this is not the utterpoverty one may see in some Asiancities: Most Africans have land or a routeback to the land. Except for periods offamine and warfare, hunger is rare inmodern (and traditional) Africa. Theproblem economic underdevelopment in Africa poses for democracy thus is not impoverishment and great class differences.

Instead it is manifested in four areas:weak civil societies to check and chal-lenge government; limited commercialand industrial enterprises with a stronginterest in the rule of law and constitu-tional government; a disproportionateamount of the economy controlled bythe state and available to it to consoli-date political control; and vulnerabilityto a world economy where commodityprice instability, rising interest rates and“oil-shocks” have weakened the state’sability to pursue policy effectively.

Underdeveloped economies spawnfew of the intermediary organizationswhich elsewhere criticize, harass, correct,invigorate, renew and check the state.Unions, professional associations, themedia, private universities, foundations,business and trade associations, andbenevolent organizations, are in substan-tial measure a result of a developedeconomy where there are multiple pro-fessional roles, specialization of enter-prises, and some excess wealth to investin and sustain groupings between theindividual and the state. Throughoutmost of Africa, these are underdevel-oped if they exist at all.

Secondly, as an economy develops,persons, corporations and international


This castle, erected — probably in the 1600s — on the coast of Ghana by one of theEuropean powers, was used to hold captured slaves for transport to America.

entities develop an interest in stable andpredictable law to regulate their busi-nesses and guarantee their investments.

As these grow to encompass a largershare of the economy, their interest inconstitutional government becomes apolitically powerful factor governmentsmust heed, or face serious economic con-sequences. In simpler, agrarianeconomies, on the other hand, individualfarmers and small-scale commercialinterests are vulnerable to the power ofthe state: to fragment an already geo-graphically dispersed and weak categoryof people and selectively to buy off themost dangerous among them via thenational budget.

Barrington Moore, the noted political-sociologist, summarized all this in aphrase: “no bourgeoisie, no democracy.”He was not referring to any supposedvirtue among the bourgeoisie, but to itseconomic interest in constitutional gov-ernance, to its political interest in assuring its control over the state ratherthan vice versa, and to its potential for economic and therefore politicalautonomy from the state’s control of the national budget.

The International EnvironmentThe world economy has not been

kind to Africa. Since independence, commodity

prices have slid,African productshave faced tradebarriers in thedeveloped world,and energy costs inthe 1970s devastat-ed Africa. Mean-while interest ratesand debt burdenssqueezed itseconomies still further.

Interestinglyenough, thesetrends generally

hit African states after the democracieswere largely gone. In fact, if anything,these crises probably helped end theauthoritarian regimes, as their perfor-mance deteriorated during the 1980s.However, other international factors,specifically the Cold War and French foreign policy, worked earlier to erodedemocracy. The Cold War was a factorbecause of the oft-noted tendency ofboth the United States and the SovietUnion to shore up and support non-democratic regimes and rulers whenthey fit the respective superpower’sgeopolitical interests.

France contributed to this because of its cozy relationships with and exten-sive economic and military support formany authoritarian regimes. In the IvoryCoast, Gabon, Cameroon, Senegal,Congo and elsewhere the French sup-ported non-democratic leaders. Thoseleaders welcomed extensive Frenchinvestment, military presence and influ-ence in their governments. Indeed, it wasonly in the last year that the French government ceased supporting the currency of most of its former colonies,30 years after independence. While theFrench usually (but not always) did notdirectly attack democracy, their steadfastsupport for authoritarian regimes cer-tainly helped sustain them and easepressures for reforms.

African LeadersAfrican leaders themselves began the

independence era with a strongly pater-nalistic, elite-oriented, rationalistic, andtop-down approach to governance.

While democracy had been a tool tohelp drive away the colonial powers,these leaders’ actions (and sometimestheir words as well) reflected little sup-port for democracy once independencewas won. They moved early and quicklyto consolidate the dominance of singleparty systems, muzzle the press, controlthe economy, weaken local governmentand co-opt their opponents. Disagree-ment was to be contained within a gov-erning coalition; public dissent they sawas disloyalty.

Unity behind a single leader or anintegrating revolutionary ideology wasseen as the prerequisite for developmentand national unity. Economic develop-ment could not be left to the vagaries ofthe market, but must be planned fromthe center, one far removed from anypublic accountability.

These policies reduced the space fordemocratic discourse, as they graduallyshrank the political arena from the entirepopulation to small cliques within theleadership. The impetus behind themmay have been well intended, as paternalism often is. The result was thepreemption of democracy and govern-ments that progressively grew out oftouch, ill informed, and prone to pursueat times disastrous policies and pro-grams. While it is a subject beyond thescope of this article, few in the develop-ment community regard African domes-tic development policies as a recipe foranything other than economic decline.

Crashing in the 1970sBeginning in the late 1970s, Africa

began to crash. A darkening world economy, ineffi-

cient and wasteful governments, domes-tic policies that caused economicshrinkage, growing unpopularity, and


Because there is no killing frost of winter, Ghanians burn offstubble after harvest to cleanse the soil of bacteria and pests.

the like worked to topple regime afterregime. Ghana was one of the first; SouthAfrica (with differences, but still remark-ably consistent with this model) was oneof the last.

The Cold War ended, and internation-al support for authoritarian regimes faded. The collapse of the Soviet Unionand the liberation of Eastern Europeremoved a legitimizing model, and theold rhetoric of benevolent or ideologicalstatism lost its luster. Finally the old gen-eration retired, died or was occasionallyremoved from power.

But will these changes last, or willAfrica return once again to authoritariangovernment?

The prospects for Africa are unclear.On the plus side are several importantchanges.

The international environment is farmore supportive of democracy and

human rights than it was 30 years ago.Beginning with the Carter administra-tion, carried through after some initialhesitation by the Reagan and Bushadministrations, and now supported bythe Clinton administration, Americanforeign policy and development assis-tance in Africa have, for the most part,placed democracy and human rights atthe center of its agenda. The Roman

Catholic Church and a plethora of inter-national non-governmental organiza-tions also have strongly supporteddemocratic reform. The cessation ofCold-War maneuvering to strengthen thefavored “strong-man” has largely ended,and no one of importance in the interna-tional community speaks for dictator-ship or authoritarian government.

Second, Africa’s leaders and peopleshave developed a healthy skepticism forrevolutionary, statist, strong-man andother non-democratic solutions to theirdual challenges of economic develop-ment and governance. Decades of disap-pointment with various top-downsolutions have left many receptive todemocracy at the center, pluralism incivil society, market forces in theireconomies, and even to local govern-ments where grass-roots people actuallyhave some control over their lives. While

institutions remain to be built, the gener-al direction is, for now, generally clear.

Third, while Africa remains a conti-nent of multi-nation states, the diminish-ment of the scope and power of the statehas reduced the greatest single cause of ethnic conflict: competition for theprize that political power can be.Decentralization, marketization, civicpluralism all reduce the costs of

political loss. Ethnic conflict may beexpected to shrink.

On the negative side, certain prob-lems remain.

With the exception perhaps of SouthAfrica and Eritrea, no African state has asocial covenant or normative agreementthat exists “behind” and undergirds thelegal constitution. Absent that, regimesremain vulnerable to both overt attackand gradual erosion. And while theAfrica of 1995 remembers the failedpromises of performance by the authori-tarian leaders and has turned to thelegitimacy of democratic process instead,its commitment to process will likelyfade without some performance. Andthe international economic arenaremains a bleak one.

Also, Africa’s economy, except forSouth Africa and in some measureZimbabwe, remains highly underdevel-oped. Therefore, the healthy civil societyand role of bourgeois interests that mostscholars see as essential for democracy’ssurvival, are absent.

Finally, the reach and will of theUnited States and other internationalactors who might support democracy inAfrica remains to be seen. Those who dohave influence there, for example, theFrench, have not been conspicuousactors behind democracy. Perhaps ademocratic South Africa can begin toplay this role.

Thus the jury on African democracyin 1995 is still out. Still, by most criteria,African democracy is in a far better position than it was in 1960.

Some states will probably slip back,given the performance challenges andthe contextual weaknesses they face.Nonetheless, there is nothing in African culture as a whole that says itcannot attain and practice responsibleand accountable governance. Thedetailed form and institutional expres-sion will certainly vary from theAmerican or European experience.

But the human aspiration for dignityand the rejection of arbitrary and poorgovernance are shared in by all.

Ultimately, Africa will succeed. W


Africa is seldom remembered for its developed coastline, attention often beingfocused on the underdeveloped interior. This is Takoradi, a major Ghanian seaport.

BILL FITZGERALD’S GIFTFOR GIVING TOOK ROOTEARLY IN LIFE

Bill Fitzgerald recalls one of his first fund-raising projectswhen he was an aspiring businessman.

At age 22, “the new kid on the block”, he was assigned by hisemployer to collect for a community charity from neighborhoodmerchants. Bill believed securing donations would be easy. “To my surprise, a lot of people said ‘no’. Two days later, mydad asked how I was doing and I told him, ‘People just aren’t giving.’”

“Dad said, ‘Giving’s got to be taught. If you learn to give as a young person, you’ll have alifetime of giving.’”

Now Chairman of Commercial Federal Bank, the 1959 graduate of Creighton’s College ofBusiness Administration took his dad’s words to heart: He’s made it his business to give —by building a model business in Omaha and serving on countless boards and communityprojects — from United Way to the Boy Scouts to Ak-Sar-Ben.

Remembering Creighton has also been second nature to Bill. A long-time member of theUniversity’s Board of Directors, he recently led the Creighton 2000 Campaign’s LeadershipGifts Committee in Omaha — a group that secured more than $21 million of the $57 millionraised to date in the $100 million Campaign.

Bill’s reason for supporting Creighton is simple. “When you ‘give back’ to society, youthink of the cause of your success. When I was growing up, Creighton and the Jesuits had thebiggest impact on my life.

“We need universities like Creighton . . . which offers not only quality education but some-thing more — teaching that caring aspect, educating a person for others.”

“The Degree of Difference”®

Fitzgerald

PROFILE OF ACHIEVEMENT

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