Chris Hayes: A Colony within a Nation

One of those Christmas books you finally get around to reading turns out to be very worthwhile: Chris Hayes, "A Colony in a Nation." 

Before he gets to the riots and revolt in Ferguson, Missouri, Chris Hayes tells a few tales about the American revolution, beginning with the Boston Tea Party which, he says, occurred because the King and Parliament lowered the tax on Tea arriving at the port of Boston making legal tea as inexpensive as black market tea imported by bootleggers from the Netherlands.

Destroying the village to save it

(One has to imagine if we made heroin, cocaine et al available at cost at local dispensaries in downtown Baltimore whether the local drug lords would set fire to these dispensaries.)

So the Boston Tea Party was not about Americans indignant because they could not afford their beloved tea, but it was a black marketeers' action to protect their markets, more Tony Soprano than freedom riders.

The king's agents, who enforced taxes, were much reviled in the colonies and often attacked for doing their jobs. Some were pretty benign, but others, particularly soldiers who were forced into the homes of locals, were seen as agents of oppression.

Land of the Free

Fast forward to Ferguson in the 21st century and tales of how police executed the policies of local (white) government officials to collect taxes and you see the analogy. Rather than raise property taxes on the white property owners who had a voice in Parliament, the government officials decided to extort money from the poor Black community in a travesty of police work where sitting in a car while black, walking while black and certainly driving while black were all crimes, and black citizens issued summons, fines and fines upon fines. As Hayes notes, the federal Department of Justice was a little taken aback when they investigated, to see how very open the white town officials were about how they intended to ramp up revenues by assessing fines and penalties in a spiraling vortex of never ending penalties where black "offenders" were not even allowed to pay their fines and thus accrued more and more penalties. Arriving at the court room door, a long line awaited and the court closed before half of the citizens had a chance to pay their fines and more penalties were added.

Response to "tyranny" 

Blacks were routinely stopped, humiliated by gun toting police who would demand identification from a black man, and when he asked why, charged him with failing to carry a driver's license, making a false statement (calling himself "Mike" rather than "Michael" which was on his birth certificate) and so brazenly and cynically building a mountain on top of not just a mole hill but a cavity.

No real freedom without Economic Justice

Simply reading of the indignations visited upon the black population of Ferguson the wonder is why they hadn't burned down City Hall years before. 

I was once on a jury in very white Montgomery County Maryland, where a Latino man, Cesar, was on trial for selling a 1 oz pack of marijuana and he was arrested by nine Montgomery County police, who charged a cross a parking, lot, a field, a playground and arrested, mistakenly, the man's brother who was working under the hood of his car, only arresting Cesar, when he emerged from the apartment building carrying what might have been the change for his customer. I sat in the jury box thinking, "The real threat to the community that morning was all those police, waving Glocks as children in the playground and their mothers, scrambled to get out of their way."

The blacks of Ferguson daily had their 4th Amendment rights against unreasonable search and seizure violated not to mention their 1st, 13th amendment rights, and likely a long list of other Constitutional rights violated daily. 

Which is to say, they were treated as a hostile enemy and the police thought of themselves as an occupying army. It was the "Fort Apache, the Bronx" scenario, the police being the victims hold up in a fort, surrounded by hostile and barbaric natives.

Of course, some of this is imagery and hyperbole to make the point, but the basic point--that the police were seen as angry, dangerous oppressors working for a corrupt, criminal white government--is strongly supported. 

Maintaining Order

The details Hayes lays out make his case.
Criticisms about his use of the analogy of a "colony" miss the point. The basic truth is persuasive: the police are illegitimate in this setting, not representative of the people, not there to serve and protect the population against actual criminals who rob and murder. The police are part of the robbery scheme, and in some cases, the police murder. 

Whenever I see that confrontation between "black lives matter" and "blue lives matter" I'll see it differently now.

Indians, Native Americans, and Politically Incorrect Thoughts

Better take my temperature. 
Do a spinal tap.
Check my blood sugar.
My brain is clearly not functioning.
And I know, this is a rant which is an indication I simply need to do more reading, to educate myself, but I saw the photo of "Native Americans" which accompanied an article in the NYT Book Review of "The Heartbeat of Wounded Knee"  and I thought, "I'm getting so tired of Indians."

Frederick Banting, MD, artist 

Which is another way of saying, I'm getting tired of people who insist on living in the past. 
And I know, I know, you can say the same about the Holocaust remembrances going on: Get over it. It's past. Move on. And the reply is, we must remember the past or we'll repeat it. We can see the neo Nazis today and we ought to remember where their kind of thinking leads.

Discoverers of Insulin, Banting and Best

But really. 
"Native Americans" are no more native than European Americans: They just got here first. They migrated from Asia. Europeans migrated from Europe, but later.
And then the Europeans annihilated their predecessors, ruthlessly, relentlessly, as so many invading conquerors had throughout human history before them.
They introduced small pox to kill native Americans. They slaughtered women and children. They made a virtue of killing Indians: as Phil Sheridan said: "The only good Indian is a dead Indian."
Some Indians had lived in log cabin villages and they were slaughtered.
Some Indians were nomadic people who roamed the Great Plains and they were slaughtered. 

White slave

Indians who were forced into signing "treaties" and moved onto reservations did so with the gun to their heads.
Slavery was an odious system, and it caused a destructive Civil War. It was one of those instances where the history of barbarity was close enough and vile enough and the institution it created was such a festering wound, it could not be allowed to go un remedied. And Lincoln, reflecting on how history had caught up with America speculated that this might be a just God's punishment for 240 years of cruelty, such that every drop of blood drawn by the lash had to be repaid by a drop of blood drawn by the sword. 
Extermination and genocide of the American Indians was ineffably cruel, in a different way.
But, looking at it from the 21st century, we have to say, we can never atone, and we can never compensate blood for blood. Human history is so drenched in blood and cruelty we can only say: This the savagery we came from, but this is not who we want to be now.
I cannot help that my great greats beat and raped slaves. I cannot change that my great greats committed genocide against American Indians.  But I can be different myself, and that is all I can do.
At what point do you have to say: Okay, we have a blood drenched past, a past that like so much of human history is the story of struggle, remorseless killing and deception, lies, sanctimonious hypocrisy. 
But this is where we are now. 
A German, a 20 year old woman who was born in 1975, once asked me, "Why am I seen as a loathsome demon seed? What have I done wrong? I was born 30 years after Hitler died. He was hideous. But because I'm German, speak his language, I'm guilty? Of what?"
She might have added: "You lived in the United States when your countrymen were killing babies, napalming villages, spreading Agent Orange over Vietnam. And you look at me and call me guilty?"
We can look at Indians living on reservations and say, "Let us distribute some money in a way to give you a chance to live in our society, be educated to our ways, benefit from our system (health care, university education, learning a trade) and we can all be one big family. 

American children getting educated

Or you can continue to "honor the past" speak of great spirits and live in a fantasy world which rejects science and new knowledge, i.e. you can cleave to a primitive past. 
We, all of us, ultimately come from a primitive past, whether our ancestors were Scots, Vikings, Visigoths, Nazis, Romans, Israelites, Zulus, Masai or Incas. 
We can be enriched by the past, but we should not try to cleave too much to it, because, truth be told, the past was bitter, nasty and lives were short, brutal and ended quickly.

Trump's "infestation"

The important thing is to embrace each other. That the great great great great grandaughter of a Viking should, today, be happily give birth to the great great great grandson of a Masai warrior and that kid should grow up learning to code, be guided through his journey by a GPS from a satellite and possibly do heart surgery to save the great great great great granddaughter of an Apache chieftain, should be something to celebrate.
But spare me the feather in the cap, the rain dances and the beating drums. 

And definitely, spare me the MAGA hats. 
We are so much greater today than we ever were.

Shattered Dreams: Boston Globe Valedictorians Project, Journalism at its Best

If ever you are challenged by someone who says the media are lost and worthless now, you have only to refer to the Boston Globe's "Valedictorian Project." 

Yes, there was the Spotlight and its revelations about Catholic priests, but this piece is far more widely applicable.

The jist of the report is that top students graduating from disadvantaged city schools in Boston, the valedictorians, did not rise above their humble origins through the alchemy of public education and enter the upper classes. 

They, most often, failed. 

The implications for affirmative action are obvious.
The implications for America as the land of opportunity are dismal.
The idea of selling aspiring young people on a dream which turns out to be a fraud is repellent, but important. 

And it is all so obvious to anyone who has worked among the folks this story follows.

Of the more than 100 valedictorians who said they wanted to to medical school after high school, followed over the years by the Globe, only two are in medical school, both at offshore, non American medical schools.

The take home is that without a family to help navigate, support and guide a young person, the rise from one class to the next is doomed. No Great Expectations story of Pip here. These kids sink beneath the waves, overwhelmed by all that they cannot see or understand. 

It is a sobering tale.

It is also such a relief to see real reporting, amid all the stories about what Trump is thinking, what Mueller might be up to, what impact the latest Tweet will have on public opinion polls, whether tariffs are helping or hurting the economy.

This is a story rooted in actual experience, and it must have been the product of hours upon hours of hard work, pursuing people, getting their stories, shaping it.

The implications are important. There are uncomfortable truths. 

Transgenders in the Military: It's not So Simple

Transgenders in the military pose a different problem from gays in the military. 

For one thing, gays have served in the military probably from the origins but certainly since WWII and with distinction, whereas the whole notion of transgender is a relatively recent thing, a creation of 20th century medicine and psychiatry.

Dr. Frederick Banting

Yes, women disguised themselves as men and served in the Civil War, but nobody knows if these were an early sort of "transgender." For the most part, the explanation we have is these women simply wanted to serve and as warriors not as nurses. 

Transgenders are different from homosexuals in many ways, but from the point of view  of the military, homosexuals need no medical support to be homosexuals; they simply are. Transgenders need ongoing hormone therapy and sometimes urologic care and always medical surveillance.

Next time you discuss this topic with someone who claims transgenders are no different than women on birth control pills, ask that person to describe the exact medications and the risks of those medications to you. 

Soldiers, sailors, airmen and certainly Coast Guard personnel who become diabetic are bounced out of their respective services quite ruthlessly. Not in every case. A West Point graduate I know served in Afghanistan with an insulin pump, but in most cases you cannot serve in combat or on a Coast Guard cutter on insulin. You are discharged, terminated, bid good bye from service. 

Transgenders have argued the hormones they need are no more complicated than the hormones in birth control pills or the pills. But that is not true. If it were true, transgenders could be taken care of by primary care providers, but just watch those PCP's run in droves from taking on that responsibility. Transgender care occurs in uncharted seas and is complicated enough that even most endocrinologists demur in their care. 

van Gogh

The suicide rates alone, among transgenders is daunting: It is indisputably somewhere between 25 and 40%, with most studies leaning to the higher number. 
Is this suicide burdern, which might later be laid at the feet of a PTSD claim what the military really wants to take on?

Obadiah Youngblood

Nobody should be made to feel badly because of their sexual preferences or because of their gender identity. But saying that is a far cry from saying transgenders should get everything they want in life. Diabetics, hypertensives, people with all sorts of medical conditions requiring prescriptions cannot serve. Transgenders deserve no special consideration in this regard. 

Insulin, Big Pharma and the Basic Flaw

Fred Rice, who once represented Hampton in the New Hampshire House of Representatives, recommended New Hampshire lower the cigarette tax, in hopes of luring Massachusetts smokers across the state line to buy their cigarettes in New Hampshire.

A doctor in the audience raised his hand, "Uh, Mr. Rice," the doctor said, "I thought one reason we tax cigarettes severely is to encourage people to stop smoking, or at least to cut down. You are talking about using a lower tax to encourage consumption."

"To encourage spending in New Hampshire," Mr. Rice replied, face open and suggesting he could not understand what the problem might be. "It IS a legal product.."
"So, what you are proposing, " the doctor persisted, "Is exporting our cancer to Massachusetts."
"I hardly think that's fair," sputtered Rice.
Facing a Senate Committee, Martin Shkreli a 20 something owner of a drug company faced Elizabeth Warren, across the hearing floor. She asked about his raising the price of anti anti parasitic drug from $3.50 to $75, overnight. 
"Well," Shkreli responded, "It was perfectly legal." 
"Uh, Mr. Shkreli," Warren replied, "In case you have not noticed, you are in the chambers of the United States Senate. We get to say what is legal."

But both Fred Rice and his soul mate, Martin Shkreli were correct about one thing, and that is in the American system, our big pharma, our entire system which includes insurance companies, work place human resources departments, and a whole variety of middle men and brokers, including pharmacy  benefit managers (PBM's) function to make sure our system is not about your health, or any patient's health, but about making profits for investors. 

In today's NYT, Danielle Ofri writes about insulin prices which have risen from $25 a bottle to $300 a bottle. Well, of course, that's not the price people with insurance pay. That price is paid only by those unfortunates who had no insurance or only minimal insurance. 

She notes there are only three companies who make insulin in the world. Actually, it's worse than that. There are only two companies who make the basic insulins but there are several others which make the "new" insulins, which are actually less effective but do have the virtue of being WAY more expensive and profitable.

We have come a long way from Banting and Best, who struggled for two years to bring insulin into the world and who sold their patents for $1, so insulin could be mass produced quickly and save lives world wide. We are eons since Alexandre Yersin, the man who identified the causative organism of The Black Plague, and who devised the first effective therapy for Bubonic plague, would say, "I could never practice medicine because I could never bring myself to say to a man, 'Your money or your life.'"

Neither Shkreli nor Fred Rice nor any of the faceless CEO's at the big pharma companies have any such qualms. 

Even President Trump has mentioned drug prices, but of course, he cannot follow through or even remember what he said yesterday, except for "The Wall."

Until we take profit out of medical care, we will not see any change here. 

Insulin and It's Discontents

NPR this morning ran a story on insulin pricing. Costs for patients have tripled over the past 10 years.
Of course, costs for all patients have not tripled, only costs in the United States and only for those patients who don't have some sharp advocate at a work HR dept or in a union to watch out for them.


The insulin story as it ran on Morning Edition was one of "human interest" sob stories about sympathetic people who are struggling to pay the $600 monthly for a medication they cannot live without. In some cases, the costs were $30,000 annually, for reasons which were unclear.

As heart rending as these stories may be, they are the "easy" story, the low hanging fruit for today's media--all you have to do is send out a reporter with a microphone and interview people taking insulin.


But the real stories here are not as easy to uncover:
1. Why are insulins so expensive?
2. Why are some insulins $600 a month and others $25 a month?
3. What are the decision drivers for the big Pharma companies, whose executives in their glass windowed corner offices are pricing these products?
4. Who are the "good guys" in this story, from the point of view of John Q. Public?


So there is a story here about journalism failing to do its job.
There is also  the story about how the commercialization of medicine drives costs without benefits.
There is the story about the failure of government, with some notable exceptions, to meaningfully address this scandal.
And there is the Trumpsky story: He has randomly tweeted the way he does, about drug prices, but then, as always, lost interest.

Insulin was discovered in Toronto by Banting and Best in 1921-1922,  one of the most important triumphs of 20th century science and medicine. (Who knew? Every school child learns about generals and Presidents: Can your kids tell you what Banting and Best did?)


From the time of its discovery, new insulins have been developed, new delivery systems have been invented but, truth be told, these are all just nibbling around the edges--insulin therapy has not progressed much since it was first discovered. Oh, it's been refined, but still you inject it, and wait for it to start working and when it stops, you give some more.


In the United States, there are only 2 companies which make the standard, basic insulins: Eli Lilly and Novo Nordisk. There are other companies which make "newer" insulins, which they claim are significantly better than the old ones, but which in fact, are not; they are only more expensive, not better.
All insulin, in the end, is the same when it arrives at the insulin receptor at the cell and fits into that receptor like a key fitting into a lock, where it opens the door to the cell and allows sugar, which is hanging out in the blood doing nobody any good, to be sucked inside the cell where it is used to generate energy.


All insulins, or almost all, are now packaged into more convenient, souped up delivery systems called "pens" or in insulin pumps. But it's the same insulin, just a different vehicle. The old insulins (N and R) are like the Chevy with the standard shift; the new insulins range from the Mercedes (insulin pump) to the BMW (insuln pens) with prices to match. The "new" insulins with different structures and huge price tags are really no different than the old insulins, although their manufacturers and marketers will shriek with indignation to deny that.


If you go for fancy delivery systems, you pay the premium for all that engineering, glass and plastic. A very large premium.


And yet, oddly, in some places, like the Commonwealth of Massachusetts, if you are on Mass Health (Medicaid), you can get the pens and the latest versions of insulin at no cost or very low cost.

How much does it cost to manufacture insulin? Professor Google says about $72 per patient per year. Presumably this is for the standard, basic insulins (NPH and Regular.) The drug companies which make the newer insulins (Novolog, Humalog, Lantus, Basilar etc) will argue there were research costs in developing these, but this would only justify their costs if they were somehow superior to the old, standard, basic insulins.


Just remember: all insulin looks the same to the insulin receptors on the cells. The only real difference among any of the insulin is in their different "kinetics" i.e., how fast or how slowly they begin working and how long they last. But in the end, all insulins are the same; we are just arguing about convenience and price.


If the government took over manufacture of insulin, the prices for the patients, for the American citizens, would drop from $30,000 a year (in some cases) to $75 a year.


Consider who would benefit and consider who would be hurt by this outcome.
You will understand the answer to the "why" question of why we have this current state of affairs insulin pricing.

"The People" and their Representatives

My father would respond to my diatribes about the structural problem with a representative democracy: I maintained the majority of people were too lame to actually know what they wanted or what was best for them.


"Oh," he said, "They may not know how to get what they want, but they know what they want, at least in general terms."

But yesterday, in my office, I was struck again by what's out there.
A woman whose bones were found to be thin and likely to fracture kept insisting this made no sense at all because she swallows four calcium pills a day. When I told her there is no evidence that oral calcium was effective in building bone density or strength or preventing fractures she said, "But I take my pills every day." It turned out she did not understand what "oral" meant, as in taking a pill by mouth.

And another woman who came in walking with a red and white cane: I asked her, "Do you have any vision at all?

She did not know what vision meant. And English is her native language. She also could not recall the name of the doctor who had operated on her brain aneurysm. It was "Chan." Not a complicated name. She was conversational, and would have struck nobody, from ordinary conversation as being demented. She is a lovely grandmother to her grandchildren. She just never got much of an education.
She does not watch "The PBS News Hour." She watches Fox.

As Ben Franklin emerged from the Constitutional Convention in Philadelphia, a woman asked him, "What kind of a government have you given us, Doctor Franklin?"
And he replied, "A Republic, madam. If you can keep it."


Watching Nancy Pelosi's investiture on CSPAN was one of those experiences when hope was ascendant over experience. Our hope is so high, but there among the House CSPAN panned over Jim Jordan chewing his gum like cud and Ted Yoho and Louie Gohmert, who really do represent people who, in the immortal words of Stringer Bell, from the Wire, are simply "too ignorant to have the floor."

(This occurred when Stringer tried to run his meetings of hoppers and touts and street thugs by Roberts' Rules of Order and a young tout challenged his plan for becoming less confrontational and more business like and Bell cut him off and one of the other touts reminded him, "Stringer, Poot do have the floor." And Stringer Bell dismissed all that with, "This nigger too ignorant to have the floor.")

Guerra

And so we wonder, as the American Experiment goes forth, are our people simply too ignorant to have the floor?