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.
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.
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.
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?
Michael Lewis has in 219 pages outlined what is wrong with Trumpism.
 |
| Michael Lewis |
And what is Trumpism? At it's essence is the conviction we do not need government except for two things: Military might and defending our borders.
What Lewis shows, by telling stories of various admirable people who chose to work in the federal government, is how important the daily workings of the federal government really are: The Department of Commerce, which is really the department of Data, which collects weather data and transforms it into weather predictions. The Department of Agriculture, which is really the Department of Rural Development and the Department of Science and Technology.
Part of the problem is the names of the various Departments are misleading. We know what Defense and State do, even though those, too are misnomers: These are really the Department of War and the Department of Foreign Affairs. But most of us do not know or understand what Commerce or Agriculture do.
Growing up in the Washington suburbs, I went to school with the kids of Congressmen--this was back when Congressmen, especially Senators, moved their families to Washington and lived there--but most of the parent of kids I went to high school with worked for agencies like Standards and Measurement or NOAA or the National Institutes of Health, or NASA.
They did things like figuring out how much stuff had to be in building materials so skyscrapers wouldn't collapse, or figuring out how to predict tornadoes in time to warn people to take cover. They were involved in collecting huge troves of data which allowed airplanes to fly, buildings and bridges to remain functional. They did all the work which was too expensive or unprofitable for private enterprise to be interested in doing but which made private enterprise profitable--like developing something called "the world wide web" and the internet.
These are the people of what Trump's friends at Fox News call "the deep state." These are the men and women vilified by Steve Bannon: All those nefarious civil servants who Trump wants to root out.
People like the folks at the Department of Agriculture who, with astonishing speed, developed a lab test for bird flu so only a few million chickens had to be culled rather than hundreds of millions, and who protect us from Mad Cow Disease getting into McDonald's burgers across the land, or Toni Fauci, who heads the institute at the NIH which oversaw the identification and treatment of HIV/AIDS.
 |
| Toni Fauci |
But as Lewis demonstrates, the men President Trump has appointed to run these departments have either been actively hostile to the idea of what they might be doing-- without actually knowing--like Rick Perry who thought the Department of Energy was all about funding solar energy, killing "clean coal" and proving climate change was man made, and was clueless about it's more important mission, which is to track loose nukes (stolen nuclear war heads) to insure our own nuclear arsenal is maintained safely and to clean up vast areas contaminated by previous nuclear bomb building factories which currently are moving in subterranean drift toward the Columbia River.
 |
| Rick Perry |
Wilbur Ross, who heads Commerce, thought the business of Commerce was business and tariffs and had no idea it is actually the main data collection center of the federal government, which does the census, tracks water temperatures, weather patterns and most of the data on the planet's natural phenomenon which control fisheries, airplane and ship travel, and when he was told about these other, more important functions said he was not interested in any of that.
 |
| Wilbur Ross |
And there is Barry Myers, who founded a commercial weather prediction company which predicted a tornado would hit a town in Oklahoma but informed only his subscribers so the rest of the population of that town was struck without warning, whose company, Accu Weather, functions completely dependent on weather data collected by the federal government's National Weather Service (part of NOAA) but who considers the government a competitor and sought to become Secretary of Commerce so he could strip the Weather Service of its capacity to offer its services to any company but his own.
 |
| Barry Meyers |
All of this is the devil in the details.
We think we know the venality and avarice and sheer depravity of Trump and those who sail with him from the Trump tweets and from CNN, but the details of these banal creeps who have swarmed in to eat out our government from the inside is only apparent when you dig into it with someone like Lewis.
Daniel Patrick Moynihan was a Democratic United States Senator from New York, an academic, an ambassador to the United Nations, but he is best remembered as an adviser to Richard Nixon.
Like many academics, he seemed happiest when he didn't have to do anything to accomplish change but could simply write a paper and watch the person or people in power execute his advice.
Nixon, like Trump, was not a deep thinker, a policy wonk.
It is said there are 3 types of Congressmen: pot hole fillers, politicians, policy wonks, which is to say people who do constituent services, people who only care about getting re elected and people who like the idea of manipulating rules and systems to achieve big goals.
This applies to Presidents as well. Nixon and Trump clearly had no real interest in anything but staying in power and getting re elected.
So, it is natural that the President would put in place some people to tell him what to think and what to do.
In 1968 Moynihan was writing memos about the problem of global warming and CO2 emissions and burning fossil fuels.
He also wrote the famous memo, promptly leaked to the press, about "benign neglect" in the case of racial relations. What he actually was saying is there had already been too much said about race, that it began and ended every discussion and enough already!
Reading his memos to Nixon one sees the gauche pandering to a damaged ego, a friendly therapist who knows he is dealing with a fragile psyche he is being careful to bring along.
But the big take home is how very much more volatile and tumultuous the 1960's and 1970's were than what we have now with the Trumpling. American soldiers were coming home in body bags, or limbless, and were murdering Vietnamese villagers, women and babies at Mylai; demonstrations were drawing hundreds of thousands; National Guardsmen murdered 4 students on a college campus; large parts of the inner cities were being burned down; white racist Southerners were murdering white Freedom Riders and black people; women were still not advancing in the workplace.
Compared to all that, the Trumpling is merely a malodorous cloud of gas emanating from the hind parts of a dyspeptic and flatulent nation.
Mad Dog has been trying to come up with a moniker for the Trumpling, in an effort to respond to his joyous playground practice of hitting his targets with mud pies like, "Adam Schitt" and "Little Marco" and "Pocahontas" and "Low Energy Jeb," and "Da Nang Dick Blumenthal."
Oh, we've all heard "When they go low, we go high."
And we've heard the advice you can't out Trump Trump.
But the fact is, you do not stand up to bullies by smiling in a superior adult way.
But the fact is, there is a certain potency in these jibes. He really does identify the most vulnerable thing about a person and goes for that. Elizabeth Warren, that Waspy blue eyed blonde, claiming to be a Native American on an Harvard application, Richard Blumenthal caught in the lie of claiming to have seen combat in Viet Nam-- those speak to real flaws, disqualifying flaws of character because they are grounded in truth, however distorted or over played.
So what is the undeniable vulnerability in Mr. Trump?
Joe Biden roused some spirit among dispirited Democrats by saying he'd take Trump out in the alley and beat the shit out of him, but Biden faded from the scene.
After Nancy Pelosi walked out of the White House, she joined fellow Democrats back on Capital Hill and she reportedly said,
“It’s like a manhood thing with him — as if manhood can be associated with him,” Pelosi deadpanned. “This wall thing.”
And that is exactly what we need.
The appellation is now obvious. Listen to Trump talking about the wall. He quakes and quails about the nasty, dangerous, scary dark skinned people on the other side of the border, and he wants to build a wall to keep them out.
He is terrified. Dark people scare him. Violent people scare him. He will not visit the troops because he's afraid of being shot.
He is, in fact, a Big Sissy, which would make it B.S. "Big Sissy" Trump.
All this time we have been searching for alliteration.
And all along the truth was right in front of us.
