The MacNeil/Lehrer NewsHour

MR. MacNeil: Good evening, and Happy Thanksgiving. I'm Robert MacNeil. After tonight's News Summary, we'll take another look at one of the key parts of the Clinton health care plan, coverage for the poor. Then Correspondent Charles Krause reports on a rare defection from Castro's Cuba and what it means for the Communist regime. Elizabeth Brackett has the story of one Midwest family's fight to reclaim its home after the flood, and essayist Roger Rosenblatt has some final words on this day of thanks.NEWS SUMMARY

MR. MacNeil: A big winter-like storm made Thanksgiving Day travel a struggle today for many across the Central United States. Up to a foot of snow fell in parts of Minnesota, stranding many motorists short of their destinations. The story was the same in the Dakotas and the other plains states. Freezing rain iced roads as far south as Dallas. Many people who did travel had trouble keeping their cars on the road, but most of the accidents reported were not serious. While millions of Americans enjoyed the holiday with family and friends, many turned out to serve meals to those less fortunate. The Community for Creative Non-violence served about 2,000 meals on the East Lawn of the Capitol. The Salvation Army and countless other groups held similar dinners in cities and towns across the country. For most American troops in Somalia, Thanksgiving meant the first meal not out of a package in months. The U.S. still has 16,000 troops in the African nation. All are due to come home by March 31st of next year. This was a violent day in the Middle East. At least 20 Palestinians were wounded in clashes with Israeli troops in the occupied Gaza Strip, and in Egypt, a Muslim militant group claimed a car bombing aimed at the country's prime minister. Vera Frankl of Worldwide Television News reports.

MS. FRANKL: The prime minister was on his way to a cabinet meeting when the car bomb exploded. He was just 500 yards from his home in the northern suburb of Haliopolis. His armored motorcade passed on with only a minor amount of damage. Sedkey was unhurt. But the piles of wrecked cars and shattered windows at a nearby primary school demonstrated the intensity of the blast. An 11-year- old student at the school was killed when a door was blown onto her. Four other pupils were cut down by shards of glass. As police investigators combed through the debris, the militant Muslim group, Jihad, claimed responsibility for the attack, the third against a cabinet minister in the past seven months. It took only a spark to rekindle unrest in the Gaza strip. Once again Palestinians and Israeli troops face each other in violent confrontation. On Wednesday, Israeli soldiers gunned down a Palestinian militant who was top of their wanted list. The incident has sent shockwaves throughout the occupied territories. Angry Palestinians took to the streets of Gaza. Their violence was met with gunfire by the Israelis. More than 30 wounded Palestinians were taken to hospital, two in a serious condition. The Israeli killing of Imadafo has also hardened opposition to the Israeli-PLO peace agreement. Palestinian militants want revenge, and a member of the Palestinian peace talks delegation says Israel must act quickly to protect the fragile peace accord.

MAHDI ABDUL HADI, Palestinian Delegate: If the Israelis and Mr. Rabin is interested to see Mr. Arafat deliver a peaceful, comprehensive settlement in the region, starting with the Palestinians, I think it's you, to the Israeli government of today to withdraw.

MS. FRANKL: Israel is due to begin withdrawing from the occupied territory in December, but if the violence continues, a smooth hand-over of power will be increasingly hard to achieve.

MR. MacNeil: British author Anthony Burgess died in London today after a long battle with cancer. He was 76. Burgess published at 15 non-fiction works and more than 50 novels, the best known of which was A Clockwork Orange, his vision of a violent, totalitarian state was filmed in 1971 by Stanley Kubric. Burgess was unhappy about the controversy caused by the film. Critics claimed it might incite young people to violence, and it remains banned in Britain. Burgess said A Clockwork Orange was never a favorite book of his, and he wished people would think of him in relation to something else. That's it for the News Summary. Now it's on to a medical plan for the poor, a flight to freedom, a journey home, and a special word of thanks. SERIES - HELPING HAND

MR. MacNeil: We lead this Thanksgiving with efforts to meet a special need of the neediest among us, health care for the poor. In the coming months, Congress will take up President Clinton's reform proposal. As that debate takes shape, we'll continue to examine the plan from different perspectives. Yesterday Jim Lehrer spoke to three people about providing coverage for those who can least afford it.

MR. LEHRER: How the Clinton health plan would affect the poor depends on who you talk to. we'll prove that right after a backgrounder on how it works now. Our medical correspondent, Fred De Sam Lazaro, reports from Detroit.

MR. LAZARO: Detroit Receiving Hospital is a place for heroic medicine, where highly skilled teams fight a daily battle to keep death at bay. It's also one of the most expensive places to get health care. Doctors from several specialties are on the premise 24 hours a day, prepared for any emergency. The problem is a substantial number of the hospital's cases are not emergencies.

LINDA JOST, Detroit Receiving Hospital: Now this is our emergency walk-in clinic.

MR. LAZARO: That's where Linda Jost fits in. She was hired a few months ago to deal with the inappropriate use of the emergency room.

LINDA JOST: Originally when my position was developed, we found that there was approximately 40 percent of our patients that used this clinic with considered inappropriate diagnoses to be in the emergency room. We get things like urinary tract infections, upper respiratory infections, sprains, strains.

MR. LAZARO: It's a problem that's become common in urban areas. Many patients use emergency facilities for primary care. Most have no means to pay for their visits here. Linda Jost's job is to send them elsewhere for follow-up care like a clinic run by Detroit's Health Department, for example.

LINDA JOST: [talking to patient] Detroit Public Health they're very busy so the thing is, is that you need to, if you want to be seen fairly soon, I would call and make an appointment because it may take a while to get in because, of course, there's a lot of patients that are in your predicament.

MR. LAZARO: Just how many patients become evident at the East side clinic run by the city's health department.

DIANE RESPERT, Clinic Administrator: Of course, we're talking about six weeks for people that are already patients of ours, and then when a patient calls in back here in pediatrics, it's the same situation. They call and the next available appointment is February if they're brand news, so ask us where they're supposed to go, and the answer is nowhere. You know, the Health Department is the only agency that will take them without insurance and do all these services for them on a sliding scale.

MR. LAZARO: Administrator Diane Respert says twenty to thirty thousand patients come through this clinic each year. Overall, they are in far worse health than the general population. Besides infectious diseases and cases related to drug abuse and violence, there's a large caseload of chronic diabetes and hypertension, all overseen by the single doctor in the adult medicine department.

DIANE RESPERT: About two thousand hypertensives, a thousand diabetics. That's just that diagnosis.

MR. LAZARO: And that's one doctor handling all these patients?

DIANE RESPERT: Right.

DR. MICHAEL WHITE, Public Health Physician: [talking to patient] Blood pressure is doing fine.

PATIENT: okay.

DR. MICHAEL WHITE: I'm concerned about this though.

PATIENT: I know.

MR. LAZARO: That doctor is Michael White. He's working here under a federal program that forgives medical school loans in exchange for serving in physician shortage areas. He says there's little else to recommend the job.

DR. MICHAEL WHITE: The money is low to be realistic. The risks are very high. There is really hardly -- once you find a disease, the only thing you probably can do is look at it and say hi to it, and expand on early treatments that will be needed. Typical example is someone who has diabetes. Basically what you do is treat the diabetes, try to control the blood sugar, but you can't treat the complications of diabetes, you know, cardiac disease processes, you know, you can't refer them. You can't have any support group behind them.

MR. LAZARO: Patients from here are difficult to refer to specialists in the private sector because they are uninsured. Even those with the federal and state government-funded Medicaid coverage are increasingly unwelcome in many doctors' offices.

DIANE RESPERT: Many of them have dropped the Medicaid clients because of their low reimbursement, the slow reimbursement. You know, it may be six months before they get their moneys back, and some physicians don't like that particular type client, so their idea is that this is a non-paying client who has multiple problems, and I don't want to be bothered.

MR. LAZARO: Doctors in Detroit's Public Health Service often personally plead for charity there in extreme cases and in cases that could become extreme.

DR. ERNEST CHIODO, Detroit Public Health Department: Joan and I basically get on the telephone, we beg a surgeon until one takes the patient and does a necessary operation.

DR. JOAN MORTON, Detroit Public Health Department: It's hard to get those little intermediate studies before a person is actually to the point that they have a stroke or they have a heart attack to get a stress test or to get these other things. Sometimes it's very difficult.

DR. ERNEST CHIODO: Without universal insurance, it is very difficult for us to get these people into, into the proper place to, to take care of it. If they're a charity case, there's only going to be so much charity going around.

MR. LAZARO: Insurance may help older patients, but it's no panacea at the other end of the clinic's demographics. Like many large cities, Detroit has a high pregnancy rate among young, single women. Until recently, Benita Harris had private insurance under her mother's policy. Even then the 20-year-old new mother says she skipped visits.

BENITA HARRIS: It was like I had to pay 20 to 30 dollars for an office visit, co-payments, which wasn't really bad but I couldn't really afford it.

MR. LAZARO: Harris says the lack of money, transportation, and sheer inexperience are other barriers for young women.

BENITA HARRIS: I have a friend now that's like eight months pregnant, and she misses a lot of her visits because she can't -- she don't have transportation -- she can't afford transportation. Either she's just -- she's scared. Actually she's scared they're - - she's gonna tell me something that she can't handle, you know, because she's had complications with her pregnancy.

MR. LAZARO: For those who cannot for whatever reason come in, public health nurse Valerie Watkins brings the clinic to the home. But like her colleagues at headquarters, Watkins too is spread thin, working in a team of two where once there were seven people.

VALERIE WATKINS, Public Health Nurse: Even when we had a full team, I was only actually making it out to see one-fourth of my cases.

MR. LAZARO: That's not counting about 10 percent of her clients who must be referred to special treatment for substance abuse complications.

VALERIE WATKINS: So at this point I'm only really seeing people that are at high risk for some reason, like this client today is a good visit because she's gestational diabetic, and she's also having problems with her blood pressure.

VALERIE WATKINS: [talking to patient] I've got 108 over 58.

MR. LAZARO: In visits like this, Watkins checks for any medical complications and passes on advice about everything from diet to transportation to the hospital.

VALERIE WATKINS: We're going to have one more class the Thursday after Thanksgiving.

DEBORAH: [patient] Mm hm.

VALERIE WATKINS: And we're going to go through the breathing and relaxation technique.

DEBORAH: Mm hm.

MR. LAZARO: Twenty-five-year old Deborah says she's grateful for the clinic's services. After her second child arrives, she plans to return to her first year of nursing school. She dropped out after getting pregnant. A nursing career will also mean the end of what she says is second-class treatment as a Medicaid patient.

DEBORAH: You get treated differently from other people, so like if you were somebody that had Blue Cross and Blue Shield or something like that, and with Medicaid they try to rush you out. And I don't really like that too much either.

MR. LAZARO: Under the Clinton health plan there would no longer be a separate program like Medicaid for poor people. All citizens, including the poor and unemployed, would be covered. Employers would pay most of the health insurance premiums for their workers. Government would pay the premiums for the unemployed. Most low income Americans would be required to make some co-payment for their health care. Preventive care would be emphasized, so routine services like physicals, prenatal care, and pap smears would be covered without any co-payment. Federal public health programs to combat infectious diseases like tuberculosis and AIDS would continue.

MR. LEHRER: Now our discussion on the Clinton way of fixing things. It is among three doctors, Risa Lavizzo-Mourey, an internist, and Jerry Attrition from Philadelphia, who served on the President's Health Reform Task Force, Neal Calman, a family physician in New York City who's president of the Institute for Family Urban Health, a group that brings doctors to poor neighborhoods, and Leroy Schwartz, a retired New York pediatrician who is president of Health Policy International, a research and education organization based in Princeton, New Jersey. Dr. Lavizzo-Mourey, what is the most important of these changes that the Clinton plan would bring to care for the poor?

DR. LAVIZZO-MOUREY: Well, I think as the story on Detroit pointed out, the most important part is that everyone will be covered and they'll have the same comprehensive benefits and access to coverage as everyone else. Medicaid patients will have payment that's comparable to other private, to private insurance. Now, we know that that's not going to be enough, because many people who have coverage don't get access, and some of the reasons were, again, brought out in your, in your film there. One is that there are not enough providers in inner city areas, and so there are provisions of this plan to increase the number of providers, to have loan forgiveness, to have tax incentives, to increase the number of providers in inner city areas.

MR. LEHRER: Meaning to try to bring more doctors, more medical facilities into where the poor people live?

DR. LAVIZZO-MOUREY: Exactly right, exactly right.

MR. LEHRER: And then they would be paid the same way that they would be paid, or the same rate that they would be paid if they were practicing medicine somewhere else in the suburbs?

DR. LAVIZZO-MOUREY: Exactly, so that you are not going to have a disincentive for taking care of a Medicaid patient or a low income person. So that the real key here is to not only take away the financial disincentives but to provide some additional services that we know will help people get the care that they need, such as transportation and child care. And there's one other critical piece to that, and that is to make sure that those providers that have been in inner city and other underserved areas providing care in times when no one else was doing it, that they are protected and encouraged to stay there and develop new networks, so that people that are -- we refer to as essential community providers, those clinics and solo practitioners and federally-funded clinics that are there now, are encouraged to not only do what they've always done very well but to actually improve what they're doing.

MR. LEHRER: Sounds expensive. Is it?

DR. LAVIZZO-MOUREY: Well, what's expensive is relative. It's very expensive --

MR. LEHRER: Compared to what it costs now to provide the care to the poor like we just saw in Detroit how does the new plan measure up?

DR. LAVIZZO-MOUREY: Well, if you're an individual going to an expensive emergency room to get care for a urinary tract infection or some other simple problem that can be handled in the office and paying hundreds of dollars to get that care in an emergency room as compared to a simple office visit, it's very much more expensive to get it in an emergency room than to get it in the office. So I think that we have to look at that. We have to look at the fact that many people who don't get primary care services end up hospitalized for procedures and for conditions that could have been cared for in the office like asthma or pneumonia or diabetes that's out of control. And those are the things that really will drive costs up, and we have to think about that when we talk about what an office visit might cost. It's far cheaper to do simple things than to do the more expensive, complicated ones.

MR. LEHRER: Now, Dr. Schwartz, you have some concerns about the Clinton plan. What are they?

DR. SCHWARTZ: Well, first of all, I think that America has a special dilemma. We happen to have a very large poverty population, larger than other countries, and they cost an awful lot of money because they're very sick. They require expensive care, extensive care, and intensive care. We also have a population that is involved very much in behavioral risk factors much more than any other country. We have more drug addicts. We have more injuries do to assault and violence. We have more problems with AIDS. We have more premature babies. We have more sickly transmitted diseases, and all of those illnesses require expensive and intensive care. And --

MR. LEHRER: And are found on a percentage basis more among the poor population than the middle income and upper income groups, is that what you're suggesting?

DR. SCHWARTZ: Well, I would say those problems are probably --

MR. LEHRER: The ones you just went through?

DR. SCHWARTZ: Yes. Those problems are found in the inner city to a large extent. They're also found in other populations.

MR. LEHRER: All right, but how does the Clinton plan address these things and doesn't do it adequately, in your opinion?

DR. SCHWARTZ: I don't, I don't believe the Clinton plan addresses the, the costs of care for these people because I don't think we know how many there are. Right now we have Medicaid. Half of the money being spent for Medicaid goes to the elderly. So we don't know how many people are going to sign up for this new program, and how sick they are, how much care they're going to need. So the whole idea of having a budget or a cap until we know that, I think that's going to be very difficult for the poor. In addition, the poor --

MR. LEHRER: Excuse me, let's -- meaning you're not sure just off the top that there's enough resources that are going to be made available under the Clinton plan to solve these -- this particular problem. Is that what you're saying?

DR. SCHWARTZ: Yes. We have a large number of people who can't pay for care. That's the nature of the country.

MR. LEHRER: Doctor, how did you all -- how has the, the cap and how have the costs been calculated in terms of the need, No. 1, based on Dr. Schwartz's objections?

DR. LAVIZZO-MOUREY: Well, we modeled how various populations use health services. We have had studies for a number of years looking at a cross-section of the population and knowing and seeing what kinds of expenditures they have for health care, what kinds of services they utilize, and we know from those studies the differences in many instances between those that are currently insured, those that are poor, those that are of various ethnic groups, and how they adjust their, their services.

MR. LEHRER: So you think you're on top of this.

DR. LAVIZZO-MOUREY: And I think that we don't know everything but we have looked very carefully at the projections of how people will use the services.

MR. LEHRER: What makes you think otherwise, Dr. Schwartz?

DR. SCHWARTZ: I think it's very difficult to know now the extent of the poverty in America and therefore to project our needs.

MR. LEHRER: You mean, it's not that they've done a poor job, it's not possible to do what you're saying?

DR. SCHWARTZ: We haven't taken care of large numbers of poor, and I'm afraid that when they come into the health care system, we're going to be overwhelmed. They need care. They have to catch up, and I would say that probably when they do catch up, the politicians are going to look at how much it costs, and they're going to say well, we can do one of two things, we can give them the care and raise the taxes, or we can ration the care. And I'm afraid that that's what's going to happen, the latter.

MR. LEHRER: Dr. Calman, you have a different set of concerns about the Clinton plan. What are they, sir?

DR. CALMAN: Well, some of them are similar to what you've already heard, but I think that we really have a tremendous problem in building access, and there are initiatives within the plan to build access, but this is a problem that's been present for years. We need more primary care physicians out in the community. The whole plan and the money savings that we're projecting really revolve around a managed care kind of orientation. What that means is that we're looking at plans where primary care physicians, nurse practitioners are out in the community serving as a point of first access for people who have health problems, and we don't have that system in place right now. You've seen that even with the limited access that the Medicaid population has right now -- and your tape, I think, showed it beautifully, and the large uninsured population that's really had no access, all of our current clinics and all of the systems that we've struggled years to put in place are totally overwhelmed by the need the way it exists. Now we're going to give everybody a red, white, and blue access card, and we're going to hope that this solves the problem. Now the Clinton plan does not pretend to think that that solves the problem. They have put a lot of resources into trying to develop this point of access, but I think that we have to really, really focus in tremendously on this particular piece. We can't just level the playing field. It's not enough to just pay doctors the same in poor communities as what we pay them in wealthy communities. We have to pay them more. We have to reverse all of the incentives that have been in place for years because we have a whole health care delivery system out there that largely functions for the middle class and for the upper class that has really not provided adequate access to primary care for the people that we're most concerned about, which are the poor.

MR. LEHRER: So specifically, what are you -- what needs to be done? You're talking about setting up -- government coming in and setting up clinics and bringing doctors in and just going full blast on it and not depend on a private system?

DR. CALMAN: Well, we're talking about -- I think we need to depend upon every single system that we have, and that means this is a multi-phasic approach. You need to build community health centers and continue to expand the ones that exist. We need to support hospitals in developing their ambulatory care networks. You have to increase the reimbursement rates for private physicians so that private physicians will go out and practice in areas, in poor urban and rural areas. No one solution is going to solve this problem. Even if we work in all of these fronts together, we're still going to have a problem for many years to come. To answer your question specifically, what we need to do, I think we've just grossly underestimated the amount of money that needs to go into this kind of a development. I mean, there needs to be a pre -- a whole system of development of primary care networks that need to take place at the same time that we're developing the primary care access through health insurance. And my fear is that we're spending a lot of time dealing with the insurance issue, and that what we're going to end up with is a huge population of people whose expectations will have been raised by the point that they have an access card but who really won't have a point of access.

MR. LEHRER: Dr. Lavizzo-Mourey, what about that? We're going to have a lot of people with cards and no place to go.

DR. LAVIZZO-MOUREY: Well, let me address both points that Dr. Schwartz made as well. We have factored in, I think, a fudge factor, a cushion, of about 15 percent to make sure that even if our estimates of utilization and expenditure are off, there's some additional cushion built in, and I think that's importantfor people to understand. This is not something that we have not been conservative about in estimating the figures. Now as far as how we go about correcting the problem in forming networks, there are strong incentives in the plan to encourage providers, physicians, nurse practitioners, and others to form those networks.

MR. LEHRER: Are you going to pay 'em more money? Are you going to pay 'em more money to practice --

DR. LAVIZZO-MOUREY: Exactly right, absolutely.

MR. LEHRER: -- to practice in the inner city?

DR. LAVIZZO-MOUREY: Exactly right. The way that this works is that although the premium is capitated and it's a community-rated premium so that everyone pays in the same amount, there's no underwriting associated with it, when the payment goes out from the alliance to the plan, it's risk-adjusted, which means that those who have more -- populations that are more severely ill, that are poor, that are very elderly, will get a higher payment, and so the incentive will be to take care of people in a way that is fairly compensated.

MR. LEHRER: In other words, the bottom line from your point of view is that what these two gentlemen are saying is not news to you and, and to the President?

DR. LAVIZZO-MOUREY: No, it's absolutely not news. Now we may not have gotten it exactly right, but there's been a lot of consideration on these, these points.

MR. LEHRER: Dr. Schwartz, much has been said since this health care reform thing got on the table that it is, it is -- much has been said -- this was obvious -- has drawn the attention of a lot of special interests, a lot of interests are brought to bear in a pressure way, in a lobbying way. Is there anybody lobbying in Washington for the interests of these folks you are talking about? Is that a concern?

DR. SCHWARTZ: I am. I would like to say parenthetically that what we've discussed is one side of the equation, what doctors and the system provide. The other side of the equation is what to the public provide in reducing the need for expensive care. We haven't spoken about that at all. The other thing is --

MR. LEHRER: You're talking about --

DR. SCHWARTZ: Cutting down.

MR. LEHRER: -- cultural things.

DR. SCHWARTZ: Exactly. Well, I mean, if we're going to continue to expand, indeed, through behavioral risk factors, if we're not going to help the people out of poverty so they can pay for themselves, it's going to continue the way it is. The other item is access. For example, poor people don't take care, don't take advantage of access the way middle class people do. It's not simply the doctor or the nurse that gets them to the doctor. They have to come themselves for the vaccinations, for the preventive care, and they don't do it. And that's what we need.

MR. LEHRER: Dr. Calman, how do you tackle that problem?

DR. CALMAN: Well, you know, we've known for years that it's much harder to take care of people who are poor. For one thing, they have a lot of other issues going on in their lives that make it sometimes just impossible for them to put the kind of priorities on health care that we in the health care business like to think. You know, all of us that are in the health care business like to think that health care is first and foremost on everybody's mind, you know, from the minute they wake up in the morning till they go to sleep at night. And that may be true if you have no other things to worry about. But if you're worried about whether your child's going to be able to walk out the door of your apartment and make it to school three blocks away safely and you're worried about whether or not you have enough food on the table and you're worried about whether or not you're going to have a job ever in your life or ever sort of be able to get out of this multi- generational cycle of poverty that your family has been in, if you're worried about those things, sometimes, you know, things like showing up for your annual checkup or your annual mammography or other things like that are just not that important. And so I, I quite agree with Dr. Schwartz that we're in a situation and I don't want to discredit the Clinton plan for this, because the Clinton plan is not a plan to socially transform America, it's a plan to deal with the health care crisis, and so I think that we all agree, and I'm sure that President Clinton would agree that we have many, many other conditions in our cities that need to be addressed. Maybe that will be the next thing on the agenda. And I think until we start to address some of those things, health care is going to become a priority for people who are poor, mostly when they're sick and when it gets raised to a level of consciousness in their mind, it has to be dealt with. And I think it's hard to get people to worry about preventive care when there are so many other troubling and disturbing things going on in their life.

MR. LEHRER: What do you anticipate doing about the preventative care? I mean, a lot of these things, if you agree with Dr. Schwartz and Dr. Calman, that a lot of these things are cultural things, have to do with a way of life that these folks live. How do you touch, how do you tackle that?

DR. LAVIZZO-MOUREY: Well, I think they've raised some very important points. Certainly, we all have behaviors that are perhaps detrimental to our health, and in -- among all people, particularly among poor people, one of the biggest predictors is whether or not they use preventive services, for example, is whether they've used them before. So by breaking the cycle we can make a lot of progress. We know that health education classes, nutrition classes, smoking cessation classes are effective, and those are covered as part of the comprehensive benefits package. We also know school education --

MR. LEHRER: This plan would pay for somebody to, to go to a class and learn to quit smoking cigarettes?

DR. LAVIZZO-MOUREY: Yes, and since smoking underlies many of the diseases that cause chronic illness and death, that's vitally important from a public health perspective. But the other part of this is that often these behaviors and approach to health care is learned at a very early age and is solidified often during adolescence. And for that reason, school-based clinics and health education as part of this is a critical part of the public health initiative in the reform package.

MR. LEHRER: All right. Well, doctors, all three, thank you very much.

MR. MacNeil: Now it's on to a Cuban top gun, surviving the flood, and some words of thanks. FOCUS - FLIGHT TO FREEDOM

MR. MacNeil: Next tonight, a rare perspective on the fate o the embattled Cuban regime of Fidel Castro. Defections from his authoritarian rule are nothing new. Just yesterday, eight athletes deserted the Cuban team during international competition in Puerto Rico. Last week, 13 Cubans were granted political asylum after commandeering a government crop duster and flying it to Miami. But to some observers, the most unusual and significant defections recently involve two of Castro's top guns, elite fighter pilots in the Cuban air force. Correspondent Charles Krause recently spoke to one of them and has our report.

MR. KRAUSE: Almost from the day Fidel Castro came to power 34 years ago, Cuban exiles have predicted that Cuba's communist revolution would fail. But as long as Castro had support from the old Soviet Union, and as long as he could count on the loyalty of Cuba's well armed and well-trained military, Castro's hold over power was never in any real jeopardy. Clearly, that has now begun to change. In mid-September, Captain E. Ravelo Rodriguez, a 12-year veteran of the Cuban air force, landed his MiG-21 jet fighter in Key West. Ravelo complained that his monthly salary couldn't feed his family even for two days. Then less than a week later, there was another defection. This time a Cuban MiG-23 touched down without warning at the U.S. Naval Base in Guantanamo Bay. Piloted by Captain Leonides Basulto Serano, it was the clearest sign yet of growing unrest within Cuba's armed forces. In Washington, a few days later, Basulto explained why he fled Cuba, because of his fears that the military would soon be ordered to turn its guns on Cuba's civilian population.

INTERPRETER: He says there is a risk that the may, indeed,fire upon the Cuban people.

MR. KRAUSE: Specifically, Basulto revealed for the first time the existence of an audio cassette circulated to military bases through Cuba in early September. On the cassette, Gen. Ulysses Rosalis Deltoro, Cuba's chief staff, ordered Basulto and his fellow officers to prepare to use force against Cuba's 11 million people.

LEONIDES BASULTO, Cuban Air Force Defector: [speaking through interpreter] I really didn't want to be involved in having to participate in this, in these combats against the people. That was the ultimate reason why I decided to leave Cuba.

MR. KRAUSE: Do you believe that the last cassette indicates that the government is planning to repress a popular uprising?

MR. KRAUSE: [speaking through interpreter] I believe that the general command is preparing for whatever might come. A popular insurrection, a general rebellion, it's preparing for whatever might come to pass in Cuba, using force in order to, because it would be important to do so to annihilate it.

MR. KRAUSE: Much of the growing opposition to Castro results from the virtual collapse of Cuba's economy. Food and fuel have been severely rationed since economic subsidies from the Soviet Union ended four years ago. That much was generally known. But Basulto was the first to confirm that Castro is seriously worried that the shortages could lead to a civilian uprising. And Basulto is an especially credible source, described as a pure product of the Cuban revolution, he was trained as a fighter pilot in Russia and was one of only three pilots that was based in South Central Cuba trusted enough to fly MiG-23's solo. Like all fighter pilots, he was pampered and privileged, an elite member of the most elite branch of the Cuban armed forces. And as recently as July, Basulto was selected to provide security for Castro, himself. Clearly, he was the kind of officer Cuba's communist leader thought he could count on until the bitter end. But Basulto said he is not alone, that many of his fellow air force and army officers would leave Cuba if they had the chance.

MR. KRAUSE: What impact will your defection and Capt. Ravelo's defection have on the military in Cuba?

LEONIDES BASULTO: [speaking through interpreter] I think that in the armed forces, not so much the armed forces in general, but in the air force, it's caused a very major impact because two planes in such a short period of time and in the current conditions, they're expecting complete support from the air force, complete support for the regime from the air force, and if these events come to pass, it would be a hard blow in general.

MR. KRAUSE: Do you see any leadership in the armed forces in Cuba that is forming to get rid of Castro?

LEONIDES BASULTO: [speaking through interpreter] For the time being, as far as I know, no. But I think that in the future, if things stay the same, things that I just mentioned, I think that a leader might come about who would make a definitive decision to go against Castro, cost him what it may.

MR. KRAUSE: Do you see any likelihood of a military move against Castro in the next year or two?

LEONIDES BASULTO: [speaking through interpreter] I think that in the next two years, within a year, year and a half, and maybe two, something might happen in the armed forces. I won't say it will occur any sooner because the high command has kept the armed forces very de-centralized. There's no single military chief who has control over a large part of the armament. The army is a part, the navy is a part, and the air force is a part. There is no general who has a large amount of material at his end. The general command dominates the entire armed forces.

MR. KRAUSE: Tell me about the base at Odeed. How many planes are based there?

LEONIDES BASULTO: [speaking through interpreter] Four MiGs.

MR. KRAUSE: A year ago, how many were operational?

LEONIDES BASULTO: [speaking through interpreter] A year ago about thirty or thirty-five planes were in service.

MR. KRAUSE: In other words, a year ago, you had almost ten times as many MiG's operational as you have today.

LEONIDES BASULTO: [speaking through interpreter] Correct.

MR. KRAUSE: What's happened? Why are these planes no longer operational?

LEONIDES BASULTO: [speaking through interpreter] What's happened is that with an end to the aid from the Soviet Union to Cuba, there is no way to keep such a powerful air force. I don't think that any developed country would be able to keep up an air force like ours, 150 or 200 airplanes in the entire country. Not even Venezuela, which is an oil-producing country, has that number of planes. Cuba, which has no oil, has no resources, has such a powerful air force, it's impossible to maintain it.

MR. KRAUSE: Based on what you know, has the readiness of the Cuban air force deteriorated over the past year?

LEONIDES BASULTO: [speaking through interpreter] It's declined a great deal in both quantity and quality. Before, approximately 22 planes would fly, now just two or three, so it has diminished significantly, and those that are operational, are a part of this active air force, they don't comply with their complete schedule of 50 hours because of technical problems, lack of spare parts and so forth. They don't carry out the entire plan.

MR. KRAUSE: How does this affect the morale of your fellow pilots? How do they blame?

LEONIDES BASULTO: [speaking through interpreter] That has affected the pilots' morale a great deal. Practically all of the pilots don't joke around anymore. They say there's no flights, there is no fuel, and in the next cutbacks, I'll be cut. And generally there is a mood of uncertainty as to what might become of the air force in the future.

MR. KRAUSE: Would there be reprisals if you were critical of the government on the base?

LEONIDES BASULTO: [speaking through interpreter] There would be reprisals and big reprisals on the base, off the base against any member of the military who made a statement, were to make a statement against thegovernment. If it were found out, even if it were a lie, reprisals would be taken and strong ones. Indeed, if it's found out that there were demonstrations by other people in the line or in any particular place, and there was a member of the military there who did not ask against that and adopt a strong position against that, then it was declared in that cassette that was sent that drastic measures would be taken with members of the military that allow such things to happen in front of them without reacting in an aggressive manner against demonstrators.

MR. KRAUSE: Do soldiers, do pilots receive special rations?

LEONIDES BASULTO: [speaking through interpreter] Military men like me, or the air force pilots. The flight personnel's diet has been kept pretty much what it was before. Where there's been a big change has been food for the land-based personnel, technical personnel, and soldiers. Officers had their dinner and breakfast suspended. They have only the right to lunch once a day. The standards in terms of the number of grams of rations for the soldiers were diminished by some 60 percent. Apart from that, supplies, including the 60 percent, isn't even complied with. And so there was practically very little.

MR. KRAUSE: What do you think the majority of your fellow officers want? Are they willing to accept Castro with some improvement in the economic situation, or do they see this as a dead end, want change?

LEONIDES BASULTO: [speaking through interpreter] I think that the armed forces still don't see Castro as a dead end. Everywhere, all the political information from the political personnel, they tell the officers that the only hope of saving the revolution is trusting in Fidel, that the only one who can get the country out of chaos is Fidel, and that we're lost without Fidel. And though some officers think otherwise, a few, I think that most still think that without Fidel there's no solution for Cuba.

MR. KRAUSE: Do you hope to go back to Cuba one day?

LEONIDES BASULTO: [speaking through interpreter] I think and I'm sure that I'll go back to Cuba and in the not-to-distant future, two years, a year and a half at the most.

MR. KRAUSE: Why do you say that?

LEONIDES BASULTO: [speaking through interpreter] Because of the current situation and the information that people have in recent years, I don't think that they're going to put up with the socialist system anymore, and I think they'll get rid of the fear they have and the people will rise up and bring an end to the system as happened in the Soviet Union.

MR. KRAUSE: Thank you. FOCUS - DOWN BY THE RIVER

MR. MacNeil: For so many of us, much of this day is about going home again to a familiar and secure place that only a true home can offer, but for one family this holiday is very different from Thanksgivings past. Correspondent Elizabeth Brackett has their story.

MS. BRACKETT: There were no preparations being made for the Thanksgiving Holiday in West Alton, Missouri. Instead, battered houses stood empty along bleak streets. Once pretty yards were filled with mud and trash, the aftermath of 12 feet of floodwaters that buried the town for six weeks last summer. West Alton resident Elizabeth Machens misses the farm that three generations of Machens had called home.

ELIZABETH MACHENS: Some days I really want to come back. I miss our friends. I miss the area. We have a really nice house that we're staying in in St. Louis, but I don't feel like I'm at home. I still feel like I'm misplaced or homeless or whatever you want to say.

MS. BRACKETT: What are you going to do over the holidays?

ELIZABETH MACHENS: It's going to be really rough. It already is rough. Every time we see a commercial about Christmas or I hear a certain song, it really bothers me, and it'll be, it'll be really hard. But we have a lot of family so we'll get through it.

MS. BRACKETT: Things started changing for the Machens last July 7th. That's when floodwaters forced them to pack up and leave home. By the next day, the water was already lapping at the back steps. Two weeks later, floodwaters were nearly up to the roof. It wasn't until August that the Machens could return to their home to assess the damage.

ELIZABETH MACHENS: Oh, that's disgusting. I don't even know how we're going to get it cleaned out. I just can't even imagine. Ooh. Oh, my God.

MS. BRACKETT: Elizabeth Machens found 10 inches of stinky, slimy, sticky mud.

ELIZABETH MACHENS: I cannot believe the mud that's just on my countertop. I just can't believe it. You know, and you think to yourself, oh, well, we got everything out, it won't be that bad to clean up, and then you look at this. I mean, I got sinks full of mud. That sink is completely full of mud. And now I'm walking around. I forgot to get my tapestry thing out that I bought, and my pants. Oh, there's no way we can move back into this house. There's no way.

MS. BRACKETT: The next though her husband, Gary, his father and stepfather started trying to make the house livable once again. By the end of the day, the once white carpet was at least visible. Three months later the changes were obvious.

MS. BRACKETT: So here's the kitchen. You've done a lot of work.

ELIZABETH MACHENS: Yeah. We've taken everything out of it and you don't realize how much it takes to take down a house. I think it would have been much easier just to build a brand new house, but, you know, you take the walls out, and you've got to get in there in all the corners, and you have to take the floor up, and the sub- floor, and pound the nails down and disinfect everything, and it's been a lot of work. We've done it throughout the whole house. We've just gutted the whole thing, and that was probably -- well, we've had a lot of hard days, but that was a hard day to see them -- we had a group from the university that came in to help us take down the walls, and to see them throw your kitchen sink out the front window and we had old cabinets and to rip them out, that was really hard to see them destroy my kitchen, but it's better now.

MS. BRACKETT: You had a nice kitchen. It was a lovely kitchen.

ELIZABETH MACHENS: It was home. It was homey, and that was like the center of the farm. We always had business meetings and people stop by and everybody kind of sits at the kitchen, you know, the hart of the farm, I guess, I don't know.

MS. BRACKETT: The Machens have also spent backbreaking hours removing dead bushes and shrubs and planting new grass seed, but the mud remains. Just ask the kids. Now, the Machens are moving on to tackle the farm buildings.

MS. BRACKETT: And these are your grain storage elevators?

ELIZABETH MACHENS: Right. We cleaned those out yesterday, and that was a big job.

MS. BRACKETT: You mean the old, the wet grain that was inside of them?

ELIZABETH MACHENS: No. There really wasn't grain. It was all mud. We just had, you know, eight inches of mud throughout every bin. It's like cleaning another house, you know, and then all -- everything was covered with mud. You had to get it all cleaned out.

MS. BRACKETT: The Machens' fields are still covered with mud and much too wet to plant with their usual winter wheat crop. The mud will help enrich the soil for next year's crop, but the Machens say that the levees, the earth dams built to contain the waters of the rivers, must be repaired before they can consider planting in the spring.

GARY MACHENS: If we don't have bigger levees, it's gonna be heard for anybody to farm these areas with the size of levees now, and these levees are some of the first to break. We're not asking for a hundred year levee in this area, but we need something we can live with.

MS. BRACKETT: Levee repairs have begun in the area but not in the levee district that once protected the Machens' home and field. Only Army Corps of Engineer federal levees presently are being rebuilt. This half-mile break not far from West Alton will cost $3 million to repair. The cost to repair federal levees just in the St. Louis district will be 12 to 13 million dollars. And that doesn't include the 2/3 of the levees in the area that are non- federal, levees like the Machens' that are maintained by local tax dollars. No repairs have begun on those levees yet. Col. James Craig heads up the Army Corps of Engineers in the St. Louis district. He says he knows the levee repairs are critical before the rivers rise again next spring.

COL. JAMES CRAIG, Army Corps of Engineers: Historically, it has flooded in multiple years. It flooded here in 1951. It flooded in '52. It flooded in 1973. It flooded in 1974. Now the following floods were not of a significance of the original one, but historically there have been multiple year floods. And the grounds on the Missouri Basin and the Upper Mississippi Basin remain saturated now. If those go into winter, when it freezes in a saturated condition, they'll be saturated when it thaws out in the spring. That provides no storage capacity in the ground. So that would certainly increase the chances of flooding next spring.

MS. BRACKETT: So this does not sound like a lot of good news for this area?

COL. JAMES CRAIG: No, not a lot of good news.

MS. BRACKETT: Since last summer, Col. Craig has been calling for a total re-evaluation of flood management, including re-thinking the building of levees.

COL. JAMES CRAIG: I think there still needs to be a look at flood plain management as an entirety on the upper Mississippi and Missouri Rivers.

MS. BRACKETT: Is anyone taking that look?

COL. JAMES CRAIG: No one's taking that look right now. But there is a discussion at the national level of how to go about doing that.

MS. BRACKETT: The federal, state, and county governments have discouraged people from rebuilding on flood plains. At least 3/4 of the homes in West Alton have been condemned, so their owners will not return. The Machens' house was damaged but not condemned, but the decision to return was not made easily.

ELIZABETH MACHENS: We've gone back and forth. One week we're coming back and the next week we're not coming back, but I think we are definitely coming back now.

MS. BRACKETT: And what's pushing you in that direction?

ELIZABETH MACHENS: Umm, when you own a farm, it's just easier on everybody if someone's living at the farm and it's, it's easier on me.

MS. BRACKETT: But the Machens will take some extra precautions this time. They have decided to build a second floor onto their home, so that all their main living space, their heat and utilities, will be above the 100-year flood level. Their flood insurance only covered half the value of their home. The money for the improvements came from a $100,000 low-interest loan that the Small Business Administration made available for flood victims, but they still have no idea when they will be able to come home again.

ELIZABETH MACHENS: When this whole thing started, I wanted to be home by December, by Christmas. Then I said, well, February. Then I went spring, and now I think maybe by next summer.

MS. BRACKETT: The waiting has not been easy.

ELIZABETH MACHENS: The other day my youngest had pictures out, family pictures out, and, you know, you see your house the way it used to look, and we had videotapes out, and you just get really homesick, you know, for things the way that they were, and they're not going to be that way anymore.

MS. BRACKETT: It's not going to be the way it once was for many Midwestern families this holiday season. The rivers have receded, but it will take many seasons to heal what the floodwaters left behind. ESSAY - AMAZING GRACE

MR. MacNeil: Finally on this day of thanks some special words of appreciation by essayist Roger Rosenblatt.

ROGER ROSENBLATT: Thank you for the achievements of children, remarkable to see. From the moment they first notice something in the world like a shadow or a leaf, to the moment they first stand up on their own as bipeds, to the first step they take, the first word they speak, the first word they read, that day they learned to swim or to ride a two-wheeler; that time they figured out a logic riddle, or an equation, or analyzed a problem or a point of ethics; that time they acted on a point of ethics. There was the ball he caught or the poem he wrote or the playwright or the doctor she became. There was the time one looked them over and discovered full-fledged, thoroughly likeable people one wanted to keep around forever. Thank you for that. Thank you for the intelligence of friends, the loyalty and attentiveness of friends we tend to take for granted, but the intelligence of friends, someone one has known all one's life suddenly saying something astonishing, enlightening, friendship that started out on the basis of admiration is regenerated on the spot, a friend who instructs and improves continually, a friend for life, thank you for that. Thank you for the constancy of beauty. Beautiful things never go away, though one forgets how extraordinary a flower is a or sea gull or a field. Beauty remains as constant as Penelope, waiting for the one who forgets to remember to look. And there it is, breathtaking as ever; that tree, that river, that sky. Thank you for the exacting nature of work. If work did not demand more of us, how would we ever know how good we can get? Trains stuffed with tired commuters at the end of a day, avenues paraded by the terrified, that raise, that promotion, the boss who never understands, all one ever needs to focus on is the work, the product to make, the crop to grow, the patient to save, the words to write. The work demands to be done better. Its voice drowns out all others. Thank you for that. Thank you for the impulse to lend a hand to people who need it. Hard to know where that impulse comes from in a mostly self- interested body, yet, it rises. Need some help? Thank you for the bright idea, no matter how stupid it may turn out. Thanks for the remembered good moment, especially with those long gone. Thank you for memories of the dead which give them life. Thank you for the sense of fair plan, for the high road, for the generous thought, the generous thought, an invaluable gift. Thank you for the company of a mate -- wife, husband, companions, one person with whom to share the pleasures of the achievements of children, the intelligence of friends, the constancy of beauty, the exacting nature of work, the generous thought. Thank you for the future with that person and for the past, and for this holiday which centuries ago someone was thoughtful enough to hallow and set aside so that we might survey the world we have and the world we are with appropriate gratitude. Thank you for that. I'm Roger Rosenblatt. RECAP

MR. MacNeil: Again, the main story of this Thanksgiving Day was the big pre-winter storm that caused travel troubles in the central part of the country. Snow and high winds stranded many motorists short of their destinations in the plains states and freezing rain made getting home for the holiday treacherous for travelers as far south as Texas. That's the NewsHour for tonight. We'll see you tomorrow night with political analysis from Mark Shields and a look at the situation in Bosnia as it faces a second winter under civil war. I'm Robert MacNeil. Good night.