It's Not My Fault: An Ode to Morpheus

Pardon me for jolting you out of the Third Millennium, where today journalists are vacillating between wall-to-wall coverage of Donald Trump's presidential candidacy and blaming doctors for the opioid addiction epidemic, but I want to take you back to the early 1800s, when Thomas Jefferson was president of the United States and Friedrich Wilhelm Adam Sertürner was a pharmacist's apprentice in Paderborn (then part of Prussia).

Sertürner purified one of the active alkaloids from the opium poppy and named it morphine, after the Greek god of sleep and dreams, Morpheus.  Morphine was given that name because of its propensity for inducing drowsiness.  It also stimulates receptors in the human central nervous system involved in perception of pain, and so it has analgesic effects.  And it can elevate mood  - produce euphoria.  Thus morphine - and later its many derivatives and congeners - was added to the list of things we now called "mood-altering substances."

Morphine was brought to market by Merck, the German chemical company, in 1827.  Then in 1874 Charles Romley Alder Wright, a British chemist and physicist, was tinkering with morphine and added two acetyl groups to the molecule, creating diacetylmorphine.

When injected intravenously diacetylmorphine has a more rapid onset of action than morphine and is more potent (a smaller dose is required to produce an effect of the same magnitude).

Heinrich Dreser, a chemist working for Bayer (another German chemical company) continued testing diacetylmorphine, and Bayer brought the drug to market in 1888 as a cough suppressant and pain reliever under the trade name Heroin.  Twenty-five years later, recognizing its potential for causing addiction, Bayer withdrew it from the market.

Most Americans think of heroin as an illegal drug because it has that status in the United States.  By contrast it is used medicinally in the United Kingdom and is superior to some other agents because of its rapidity of onset of action and its more favorable side effect profile.

In the U.S. it is on Schedule I of the Drug Enforcement Administration's list of controlled substances.  Schedule I is supposed to be reserved for drugs that are considered dangerous and have no recognized, legitimate medical use.  As heroin does not meet the second criterion (except by arbitrary and unscientific edict), it does not belong on Schedule I.

Since the 19th Century we have developed many synthetic derivatives of the substances isolated from the opium poppy, and we call them, collectively, opioids.  Although at one time such substances could be purchased without prescription in the US, at present only codeine (the other active alkaloid from the opium poppy) can be obtained without prescription, and only in certain formulations, from some pharmacies, in about a dozen states.

Given that people have been cultivating opium for at least 5,000 years, it is interesting to contemplate the fact that some mood-altering substances humans have derived from plants (opium, coca) are considered to have such high potential for abuse and addiction that they are very strictly controlled, while others (alcohol by fermentation of the sugars in plants, and tobacco) are regulated but easy to purchase legally.  Addiction to opioids and cocaine and addiction to alcohol and nicotine have many similarities, and all of these substances can be damaging to health and lethal in overdose.

We experimented with prohibition of ethanol in the US, and that is viewed by most as having been a spectacularly unsuccessful experiment.

And that brings us into the 20th Century, when we decided that opioids should be available only by prescription.  This means that if you have need of the most effective of the pain relievers, you must consult a physician.  That is obviously rather arbitrary.  Stressful day at work?  If you go home and have a glass or two of wine to relax and unwind, that is considered no problem, and meets a common definition of moderate drinking.  If instead you wanted to have 5 or 10 mg of oxycodone, that is considered a very serious problem.  You can, I suppose, guess that I don't see a substantive difference.  But I can order wine by the case and have it delivered to my house.  If I tried to order oxycodone by the case for personal use, my medical license and controlled substances permit would be gone in a flash. 

Sociologists and criminologists use the term "social problems" to describe a vast array of societal ills, and misuse of opioids is, in my view, a social problem. Many things that are social problems cross the very blurred lines and are also viewed as medical problems, and of course misuse of mood-altering substances can be regarded as a medical problem.  But in its strictest sense, it is only the complications of the misuse that are medical problems: overdose, infectious complications of injection drug use, etc.

In my specialty (emergency medicine) we find ourselves addressing social problems a great deal of the time, both because the profession has "medicalized" many social and behavioral problems and because the emergency department is often the place to which people turn for help when they have no idea what to do.

The truly vexing thing about opioid abuse as a social problem is that doctors are getting blamed for creating it.

Dude!  Seriously?  Abuse of, and addiction to, opium has been around for millennia.  This is not our fault.  Blame it on something that, in pharmacology, is called the "fallacy of the specific."

The fallacy of the specific means that one should never assume - because the assumption will usually be wrong - that a drug will do one thing, its intended effect.  In this case, opioids relieve pain, but they also have effects on mood. Those latter effects get some people into trouble, because they like that feeling, and they may start using a drug for relief of pain and then use it partly to relieve pain and partly to feel good more generally, and before you know it they are using it as much for mood elevation as for pain relief, or even entirely for mood elevation, without even realizing that is happening.  And then they may find themselves using it to keep from getting symptoms of withdrawal from the drug. A person may find anything from a general unease to restlessness, cramps, vomiting, diarrhea, and sweats occurring because the nervous system has gotten used to the drug, and now it's not being provided.  Then the addict is using the drug not to feel good but to keep from feeling terrible.

Legal acquisition of opioids requires consultation with a physician, and a prescription, and many addicts start with prescribed opioids and end up using far too much of them and engaging in all sorts of deceptive behaviors to get them from insufficiently wary (or blatantly unethical) doctors, or they switch to illicit sources and start snorting, smoking, or injecting heroin.  So ... let's blame the doctors for this social problem.

That's right.  The problem of abuse of and addiction to mood-altering substances has been part of the human condition for thousands of years, and modern medicine has been around for about a century, but it's doctors' fault.

Believe it or not, I have no problem understanding this.  You see, I have been married for more than 30 years, so I have grown quite accustomed to accepting blame for problems that are not my fault, apologizing for them, and doing my best to fix them.

And I am willing to do the same thing here.  But not without pointing out the obvious: it really isn't my fault.  And no, I'm not even going to lay the blame at the doorstep of all the well-meaning but seriously misguided regulators who have been telling us how to practice medicine all the years I have been a doctor, first telling us we under-treat pain and then telling us we have turned America into a nation of addicts.  And I'm not going to blame the ridiculous, single-minded focus on patient satisfaction, which has led so many doctors to have, at the center of every encounter with a patient, the goal of finding out what the patient wants or expects and giving it to him whether it's a good idea or not.

Nope.  It's not the regulators and administrators, and it's not the weak-willed tendency of doctors just to give patients whatever it takes to make them happy.

What is it, then?

Human existence is miserable.  Not for everyone, but for a sizable minority of us.  And that's what mood-altering substances are all about.  We smoke tobacco; we drink beer, wine, and liquor; and we use opioids and other potentially dangerous drugs like cocaine - all to find a temporary escape from the misery, or at least drudgery, of human existence.

Are opioids really more dangerous than alcohol?  Spend a few hours searching for good statistics, and you will find plenty about the number of lives ruined and deaths caused by alcohol abuse.  Alcohol and opioids have much in common and many differences.  In the emergency department I see dozens of people who've died or been snatched from the jaws of death after an opioid overdose for every one person who dies suddenly from consuming too much alcohol in a single episode.  So the opioid-related deaths really get our attention, especially as they often involve young people who had previously been healthy.

Here's what's unique about opioids: they have a legitimate medical use - relief of severe pain - coupled with effects that lead to misuse, and we have given authority over their legal availability to physicians.

With authority comes responsibility.  But there's a catch.  I have authority over the decision about who needs strong pain medicine.  I do not have authority - or control - over what is done with the opioid after the patient gets it from the pharmacy.  Can I peer deep into a patient's psyche and tell who might abuse the drug?  I think I'm pretty good at that, but that is part of the art of medicine and not the science, at least for now.

I like to think that, as a practitioner of medicine as an art, I'm much closer to Renoir than to the kindergartner trying to color inside the lines.  But I will not always be right.  And if you expect doctors always to be right in the decisions they make about prescribing these drugs, you have wildly unrealistic expectations.

At its foundation this is more a social problem than a medical problem.  My colleagues and I will do all we can to help to solve it.  But we didn't create the problem, and we cannot solve it alone.  I am pleased to report that my patients are catching on.  More and more often when I ask someone with an illness or injury that is painful, "Do you think you will need something stronger than acetaminophen or ibuprofen for pain relief?" the patient's answer is no.

We all need a lot more insight.  I'll do my part.  You do yours.
    

Trump in Chicago: Wrong Again

A campaign rally for Donald Trump was scheduled to be held last week on the campus of the University of Illinois at Chicago.

Rewind nearly 40 years.  In 1977 the modern American version of the Nazi party sought to hold a political rally in Marquette Park in Chicago.  Permission was denied when the city authorities banned political demonstrations at the park.  The organization's leadership then decided they would conduct a march through Skokie, Illinois, a town with a large Jewish population that included many Holocaust survivors. The subsequent legal battle focused on the wearing of the swastika, the Nazi symbol, and whether doing so was protected by the First Amendment and therefore could not be prohibited.

Local and state courts enjoined the political demonstration and the march, and the case went to the US Supreme Court.  The Supreme Court ordered the state courts to hold a hearing focused on the First Amendment issues.  Those proceedings initially prohibited the use of the swastika, but the Illinois Supreme Court subsequently ruled that the wearing of the symbol was protected and did not constitute "fighting words."

The Skokie case became famous for its protection of provocative expression.  It illustrates just how far we are willing to go, in the United States, to support the principle that the First Amendment was intended to protect political expression, even when it is exceptionally unpopular or despicable.

Fast forward once more to 2016, when Donald Trump is a candidate for president.  His candidacy attracts supporters with whom some of his darkest rhetoric resonates powerfully.  His detractors observe that he repeatedly expresses ideas that are nativistic, xenophobic, jingoistic, misogynistic, homophobic, and racist.  Immigrants, racial and ethnic minorities, women, and the LGBT community find his appeal to a segment of the American public to be a shocking reflection of a broad and deep streak of intolerance that remains in American society despite decades of effort to enhance tolerance and acceptance of groups that constitute the "other" in our culture.

The United States has one of the most heterogeneous societies on earth, and this has long been a source of pride, as people have come here seeking not only economic opportunity but religious freedom and the tolerance for people of varied backgrounds for which this nation has been greatly admired.

At any rally by supporters of the Trump candidacy for the nation's highest office, speech and conduct displaying intolerance of all sorts, the antithesis of our spirit of inclusiveness, have been very much in evidence.  People attending the rallies who have differing views, even if they are quiet and their differing views are suggested only by something they are wearing (such as an article of clothing bearing the name or symbol of another candidate) or even by the color of their skin (non-white) have sometimes been heckled or threatened by Trump's supporters and escorted from the premises by law enforcement officers, ostensibly for the purpose of preventing trouble.  Trump himself has repeatedly endorsed such conduct: "Get him out!" he demands, referring to any detractor who might be in attendance at one of his rallies.

One could predict that in a city with the racial and ethnic diversity of Chicago, a Trump rally might draw a sizable number of protestors.  Thus, the selection of a site for the rally should be made with some consideration of that possibility.

On the other hand, perhaps there is an intent to be provocative.  If so, one might choose a location full of people most likely to find Trump's views and the sentiments and inclinations of his supporters to be especially disagreeable.

Among the possibilities suggesting themselves as most likely to fit that bill is the University of Illinois at Chicago.  This is an institution of higher learning noted for diversity and inclusiveness in the selection of students for admission.  Here is a college campus on which the diversity of color of skin, ancestry and national origin, ethnic background, and gender and sexual orientation is perhaps greater than just about any other in the country.  Aside from its educational mission, this is a university that exists to welcome students of diverse backgrounds.  Thus, this is a university whose community is most likely to find the prospect of Trump as a political leader for this nation truly appalling and the views and behavior of his supporters a shocking representation of the deep-rooted intolerance that persists among a segment of the populace.

So how might one view the selection of the University of Illinois at Chicago as a site for a Trump campaign rally?

"Asking for trouble" comes to mind.

And trouble, not surprisingly, ensued.  Protestors recruited or encouraged by various groups that promote diversity and inclusiveness and that are, in their philosophy, reactionary against the reactionary in American political life, turned out by the thousands.

There was much disturbance of the peace.  The rally was cancelled.  The protestors cheered.  Trump's supporters cried foul and strenuously objected to intolerance of their intolerance.  Irony abounded as protestors who believe passionately in First Amendment rights of all sorts - speech, press, assembly, religious belief, practice and expression - clearly felt that a Trump rally on this site simply went too far and was intended to be provocative in the most disruptive and potentially dangerous manner.

Among the protestors were many supporters of another presidential candidate, a man whose history has been one of championing the civil rights and seeking to better the economic lot of minorities of all sorts.  The supporters of Bernie Sanders made no secret of their political preference in this election year.  While the Sanders campaign had nothing to do with his supporters' decisions to protest the holding of the Trump rally on the UIC campus, Sanders himself found no reason to criticize or apologize for their participation.

Trump personally responded to the participation by Sanders' supporters, calling on Sanders to condemn their participation.  In doing so, rather than maintaining any sort of decorum that might have made it possible to take seriously his expression of dismay over the intolerance of those who preach tolerance, Trump ridiculed Sanders as a "communist" and mocked him by saying "Bernie" with the drawn-out, sing-song intonation of a schoolyard bully.

Condemnation of Trump and his pronouncements on what it will take to "make America great again" has come from all corners.  Rather than softening any of his rhetoric, Trump has mostly doubled down on his expressions of antipathy for all who are not part of white Christian America.  He has been marginalized by most of the leadership of the party whose presidential nomination he seeks, despite his standing in the polls and his garnering of votes on primary election days.  This has led many party leaders to look, as an alternative, to Ted Cruz - a candidate who, as a member of the United States Senate, is liked by virtually none of his colleagues in that body.  What could be a more powerful indication of the contempt in which Trump is held by the GOP establishment?

Many apparently believe Trump's unpopularity with the political establishment is evidence of his merit as an outsider who can go to Washington, DC and shake things up.

It is very clear that Trump wants to shake things up, and that he is very good at that, and that he doesn't care how many people he offends, or how deeply, in so doing.  Trump has succeeded in marginalizing himself more than any of his opponents could ever succeed in marginalizing him.  One might even think he is intent upon proving that he has no place in a civil society - certainly not in the one we have striven to build in the United States.

The publication founded by that intellectual luminary of the modern American conservative movement, William F. Buckley - the magazine National Review - devoted an entire issue recently to making the case "Against Trump."

The decision to hold a campaign rally on the campus of the University of Illinois at Chicago, with the full knowledge that it would be provocative to the point of being incendiary - and apparently seeking that outcome - is further evidence that all thinking Americans who believe in the broad social values this great nation represents should, together, stand Against Trump.

I Am a Banker

Not really.  This is a thought experiment.
I run a bank in an average American community.


My customers save money.  They have passbook savings accounts, certificates of deposit, and individual retirement accounts.

My customers borrow money.  They have personal loans, car loans, home mortgages, and credit cards.

I make plenty of money as a banker.  I take the money my customers are saving and lend it to others at interest rates higher than what I am paying the savers.

I also charge fees for some of the services I provide.

Some of customers are not very well off.  They are struggling.  They live paycheck to paycheck.  That means that by the time they get a paycheck, they have run out of money from the last one.

Sometimes it is hard for them to pay their bills on time.  Sometimes they miss due dates.

This is an opportunity for me to make more money.

You see, if they are afraid of missing a due date, because being late with a payment will result in late charges and may harm their credit rating, they may write a check for a payment and hope it doesn't hit before their next paycheck goes into their account.  But they don't want the check to bounce.  So they have authorized me to pay the check with money that's not in the account yet, even though that means I will charge them an overdraft fee.  Their account may be overdrawn by only a few dollars, for only a day - or maybe only a few hours.  No matter.  I will still charge them an overdraft fee of $37.50.  And if two checks come in before the paycheck, it will be $75.00.  I know it's $75.00 they don't have, and the record keeping didn't actually cost me a penny, but the $75.00 is pure profit, and I'll take that any time I can get it.

I can also make big bucks on the credit card account they have with me.  The federal government lets me charge 20% interest.  This is a gold mine when I'm dealing with people who often cannot pay off the balance every month.  I charge my best customers much lower rates, because they are credit-worthy.  I charge the highest rates to the people whose credit ratings are lower.  Yes, I know, that takes money from them they cannot afford, makes it more likely they'll make a late payment, keeping their credit rating low and their interest rates high, but that's the way this business works (because I like it that way), and I am going to keep charging them high rates to make up for the fact that every once in a while someone declares bankruptcy and I may take a loss.

What's that, you say?  It isn't right for me to charge the highest rates and fees to the people who can least afford it?  You cannot be serious.  I am not running this bank as a charity.  I'm here to make money.  I can't be worried about these customers as people.  What kind of businessman would I be if I did that?

The socialists say the way I run my business contributes to the plight of the working poor, making the problem of little upward mobility for them worse.  Cry me a river.  I am in business to make money.  If I try to make money from customers who have plenty of money, they will take their business elsewhere. They know their business is valuable, and they act accordingly.  The folks who are scraping by have no idea if the bank down the street will give them a credit account or a car loan, and they are afraid to find out.  So they'll stay put.  That's the way I like it.

How do I sleep at night?  Very well, thank you.  I'm one of the 1%, you see.  If you think I lie awake at night worrying about the well-being of the 99%, you have another think coming.  They aren't even smart enough to go to the polls and vote in their own economic interest.  A lot of these working class folks vote Republican!  Can you believe that?  They should vote for democratic socialists, but they believe what they are told about class warfare and the politics of envy, so they keep voting for politicians who promise them a rising tide that will lift all boats, even if mine is a luxury yacht and theirs is a canoe.  And never you mind that sometimes their canoe is foundering while it's full steam ahead for my yacht.  Let me know if you hear them yell for help when their canoe overturns, and I'll see if I can find something buoyant to toss in their direction.  Maybe their church can help.

Socialism will never take hold here in the good old US of A, as long as the masses remain convinced they are not an exploited proletariat but merely temporarily embarrassed millionaires.  They'll never be millionaires.  Certainly not with any help from me.  After all, I have to make a profit.

I love America: the country that allows me to buy politicians who will keep the rules the way I like them.

Spreading the Wealth?

It brought back memories of Joe the Plumber.  That was the fellow who had a campaign-stop conversation with presidential candidate Barack Obama in Ohio in 2008 about tax policy.  Joe, a Republican, didn't like the idea that Obama thought it was a good idea to "spread the wealth around."

This time it wasn't Joe, and the candidate wasn't Obama. Two friends of mine, both in EMS, were commenting (on Facebook) about the idea that Bernie Sanders is a "socialist."  One of them, Ken, said Sanders "wants to share my money with people who work less."  I promised Ken I'd write back later to explain why that isn't really so.

A little more than a century ago (February 1913) we amended the US Constitution to allow for a federal income tax.  Many Americans look at their paychecks or their tax returns every year and wish we had never done that.  But there are a lot of things we expect the government to do, and they all cost money.  The consequence of that is that we have enacted a dizzying array of taxes.  It seems as though any time money changes hands the government wants a cut.

When people are asked about taxes, most say they don't have a problem with paying money into the federal treasury so long as they can be confident that it is being spent wisely.  And there's the rub, to borrow an expression from Hamlet. The late Senator William Proxmire of Wisconsin created the Golden Fleece Award, presented monthly from 1975-1988, to call attention to examples of what the senator considered wasteful public spending.  In the 1820s and '30s famous frontiersman Davy Crockett served two terms in Congress and was noted for his belief that members of the House - where bills related to raising revenue and spending it are supposed to originate, according to the Constitution - should be as careful with the people's money as they were with their own.

We do not, in general, believe that our elected representatives are careful with our money.  English Prime Minister Margaret Thatcher said, "The trouble with socialism is that eventually you run out of other people's money."  As a matter of fiscal policy, of course, that's complete nonsense, because the stream of revenue flowing from the people into the treasury is continuous.  But Thatcher's quotation does make the point that if public officials don't spend public dollars wisely, the money does run out, and that leads to deficit spending and ever-growing public debt.

But we don't have socialism in the United States, so this isn't a problem, right?

The idea that socialists are spendthrifts and capitalists are frugal is, to be charitable, comical.  Dwight Eisenhower warned us about the "military-industrial complex," and if you look back over the last century, we have done an astonishing amount of deficit spending and creation of debt to engage in wars of dubious merit (to say the least), and capitalists running companies with fat defense contracts have vigorously promoted all of that.

That brings us back to Ken's worry that Bernie Sanders wants to share some of his money with people who work less.  What Ken should understand is that his money is not being funneled directly to some lazy bum sitting at home collecting a welfare check and other benefits of social programs.  No, if you take one of the dollars Ken sends to the federal treasury and divide it up according to the federal budget, that's a pretty small fraction.

But Ken's remark does highlight something that is a striking feature of the national conversation, to the extent that we have one, about spending on social programs.  People with moderate incomes are having their opinions shaped by the very successful efforts of the wealthy to focus our attention on how our tax dollars are spent to help the poor - specifically the undeserving poor.

Traditionally, for many centuries, there has been "class warfare" that has pitted the poor against the rich, from the peasants of Europe versus the noble aristocracy before democratic governments began to replace monarchies, to the working classes of the modern industrial age against the capitalist robber barons.

The wealthy are keenly aware that this kind of class warfare is bad for them. And they have succeeded in using the corporate media to help them mold public opinion, so that now class warfare is between the struggling working-class folks - who often live paycheck to paycheck but get by without any help from government social welfare programs - and those who have it even rougher and rely on some of those programs for subsistence.

How do they do this?  After all, while we are in many ways a nation of rugged individualists, we also believe in helping the less fortunate.  So they do it by finding examples of the undeserving poor, the small fraction of people getting stuff from social programs by working the system, people whose problems stem more from being lazy and shiftless than from misfortune or disability.

Remember the California surfer dude using his SNAP card (what used to be called food stamps) to buy sushi and lobster?  It doesn't take many stories like that to make the working class feel as though the poor are the enemy, at least economically.

The trouble with those stories is that there is just a little bit of truth to them - after all, no "entitlement" program is going to be completely successful in screening out the people who really aren't entitled to any help - but they fail to mention that the percentage of the dollars going to people who don't deserve them is very small.

So what about Bernie?  What is he going to try to do if he gets elected?

For one thing, he would like to see far less money spent on an astonishingly bloated defense budget that often has far more dollars in it than our military leaders ever requested.  While I am no expert on defense policy, I am skeptical of the need for the American taxpayer to spend more on defense than all of the other First World nations combined.

More directly to Ken's point, though, is where the money will come from (besides a shrinking military budget) to pay for the things Bernie believes are worthwhile, like rebuilding our crumbling infrastructure and funding education so the US can reclaim its position as having the world's best-educated workforce. (We were once #1, and we are now #12.)

That income tax I mentioned earlier is supposed to be "progressive."  That means that, as you earn more money, and the amount you earn rises ever higher above what one needs to live on, the percentage you pay in federal income tax rises, too.  As a high-income-earning professional (a physician), I am in the top marginal tax bracket.  What does that mean?  Well, on the calendar, before we've gone too far past the midpoint of the year, about 40¢ of every dollar I earn is going to the US Treasury.  The top marginal tax rate used to be much higher.  I'm old enough to remember when it was 70%.

What about Social Security?  That is a very different situation.  The tax on that stops - that's right, stops - before I reach the midpoint of the year, because there is a cap on the amount of my income that is subject to the tax.  What that means is that the more I earn, the smaller the percentage of the total goes to pay that tax.  That is what an economist would call a regressive tax.

So, does Bernie want me to pay higher taxes?  Yes, he does.  He wants to lift the cap on my Social Security tax.  Am I happy about that?  No, of course not. But in another ten years I may start to collect Social Security, and I might actually need the money to avoid a dramatic decline in my standard of living, so the adequacy of the revenue stream that funds the system is important to me.

What about Ken's taxes?  Would they go up?  I'm not Ken's accountant, so it's hard to be sure.  But look at the overall picture.  Ken is not a front-line medic. He's a small businessman - like Joe the Plumber.  If Bernie gets the single payer health care financing system he wants, Ken and his employees, in the aggregate, might pay a little more in taxes, but that would be far more than offset by the fact that they wouldn't be paying eye-popping health insurance premiums.  If Ken and his employees have kids, and Bernie gets the funding he wants for higher education, the parents won't be struggling to pay for college, and their kids won't be graduating with educational debt the size of a mortgage on the house that they might then actually be able to buy.

So is that enough money?  Savings on a bloated defense budget and taxes a little higher on average folks but way more than offset by what they'll get back?

Nope.  It's not.  It will also take higher taxes on what Al Gore called - in his sing-song, whiney drone that made me want to find the mute button as quickly as possible - the wealthiest one percent.

Who are they?  Well, the bottom half of that top one percent includes some high-income-earning professionals.  Not emergency physicians, but probably some surgical specialists - who get paid a lot because of the high value of their work.  But the top half of that one percent is where the real money is.  The folks up there make most of their money in capital gains: interest, dividends, proceeds from investments.  And that money is taxed at a lower rate!  Does that make sense to you?  The rationale for taxing capital gains at a lower rate, as it might be explained to the working class, is to encourage savings and investment.  But tell me, does someone making over a million dollars a year really need an incentive to save and invest?  For Pete's sake, many of these folks don't even want to pay the capital gains tax as it is, and move their assets overseas to try to avoid it.

This is the kind of outrage that must stop.  The wealthiest people in this country, the ones who can most afford to pay higher taxes, are paying a lower percentage of their income in taxes than anybody else.  And large corporations are getting all manner of subsidies, from the oil industry to agribusiness, and we - the regular folks - are paying for all that.

So before we have a conversation about whether it makes sense to give the single mom more money if she has yet another child out of wedlock to a father who will take no responsibility, let's have a conversation about how Walmart has $75 billion in assets overseas, in countries where the company doesn't even operate any stores, just to avoid US taxes.  I'm pretty sure the taxes that we should be collecting on that would pay for daycare, K-12, and college for every one of those children of deadbeat dads in the entire country, with plenty of money left over.

So, Ken, the answer is no.  Bernie doesn't want your money to give to people who work less.  He wants the wealthy and powerful to start participating the way they should be, in the American society that has been so good to them, by paying taxes instead of using every imaginable dodge to avoid them.  Oh, and one more thing.  Yeah, those tax dodges (loopholes) are legal.  How did they get there?  They were enacted into law by politicians bought and paid for by the wealthy.

Look at Bernie's campaign financing.  His money comes from folks like you and me.  No big corporations.  No fat cats.  No super-PACS.  He wants to give the government of this nation back to you and me.  I don't know about you, but I think that's a great idea, and it's high time.

Time to Ban Guns?

Last week the New Republic published a piece by Phoebe Maltz Bovy, a regular columnist for that publication, that makes the argument for banning all guns from American society. Interestingly, the writer isn't talking only about civilian gun ownership, as she advocates disarming the police as well.

It's been a while since I last saw something in print that staked out this position, and so I found myself thinking that it might be time to ban guns, or it might be time to review the reasons why we should not do so.  Further, the columnist sets forth her reasons for making the argument, explaining that she believes it is necessary to make the case for elimination of guns from our society in order to bring the possibility into the public mind.  And that got me to thinking about the other side of the coin: reasons why, instead, it might actually be counterproductive to do this.

First, a little background for those who may not be familiar with the publication. The New Republic is a "progressive/liberal" magazine with a focus on politics and public policy.  It has been around for over a century, and its founders included that luminary of American journalism named Walter Lippmann.  (For those with an interest in the history of American journalism, I highly recommend Ronald Steel's book Walter Lippmann and the American Century, a superb biography that was published in 1981 and won the Bancroft Prize.)  So this is not some millennial left-wing blog site.

Let us first consider the case for banning guns.  In its most elemental form, it is starkly simple.  Guns are used for things other than killing people, to be sure, but Maltz Bovy does not address that, so I will set that aside for the moment and focus on this particular use.  Guns are used to kill people.  Yes, we know that "guns don't kill people; people kill people."  And we know there are other ways of killing people, as people killed each other, sometimes in large numbers, for millennia before the invention of the firearm, which historians place in the 12th or 13th Century.  So the gun is simply a tool, an inanimate object without autonomy.  Thus, as a careful user of English, I am constantly irritated by news accounts that someone was killed by (rather than with) a gun, just as I am when there is a report that someone was "killed by an SUV."  But guns are used to kill people, and it is argued that they afford more of what the New York Times called "brutal speed and efficiency" in a recent editorial advocating a new ban on semiautomatic rifles.

So let us imagine 21st-Century American society without guns.  To be sure, that does require some imagination.  We cannot assume it will be like more primitive societies that didn't have guns because they hadn't been invented yet, because at the same time they didn't have guns, they also didn't have modern social institutions that provide stability and make violent behavior generally unacceptable.  In other words, we have made much progress toward creating a "civil society" in the last half millennium, so if we could just eliminate guns, that would be a great leap forward, with apologies to Chairman Mao for appropriating the phrase.  Of course we also cannot assume an American society from which we magically removed all guns would be suddenly transformed into a North American version of Japan, where guns in the hands of civilians are rare.  There are vast sociocultural differences between Japan and the US.  To offer just one example, many of the shootings occurring in the US each year are related to the urban subculture involved in illegal drugs and gang activities, and Japan doesn't have anything quite analogous to that.

But let us imagine that we could eliminate all guns, and thus all shootings, from American society.  Would that eliminate all crime?  Well, no, obviously not.  It would not eliminate crime, it would not eliminate violent crime, and it would not end homicide.  It would reduce the number of killings - both homicides and suicides (the latter of which typically outnumber the former) in which guns are used, necessarily to zero, because this is an absolutist hypothetical.  But there are other ways of killing; they simply tend to be more difficult and may require more skill or planning.

In general violent crime, to be successful, requires the same things that are required for success in war: careful planning or some other approach that results in the victim being surprised or unprepared to put up a defense; disparity of force; or both.  Firearms are not required.

Now let's look at things from the intended victim's viewpoint.  How does one avoid becoming a victim?  Well, take the elements required to make you a victim and hold them up to a mirror, and you see that you must be prepared to put up a defense and must be able to avoid being on the wrong end of disparity of force. So the keys are education and training, mental preparation, and possession of a tool that can serve as an equalizer if the person(s) intent on victimizing you are bigger, stronger, faster.  This is the rationale for the possession of a gun for personal defense.  Note the importance of education, training, mental preparation, and practice.  Without these, the gun is unlikely to serve its purpose.  It is not a talisman.

At this point it is tempting to go off on a tangent about whether private ownership of guns increases or decreases the risk to one's personal safety. The published literature is replete with "evidence" pointing in opposite directions.  If there is a gun in the household it is more likely to be used to injure or kill a member of the household than against a criminal intruder, says one side.  Oh, no, says the other side, the number of times guns are successfully used for self defense is greater by an order of magnitude, if you look at data collected and reported by criminologists.

So, rather than going off on that tangent, I'll just opine that the private citizen who does the "right things" mentioned above (education, training, mental preparation, practice) along with other "right things" such as safe storage, is going to be one for whom the risks of ownership are low and the value of possession for personal protection has obvious appeal.  In a household with children or other irresponsible people and adults lacking the good sense to secure firearms effectively; or a history of domestic violence; or people who are depressed and think the world would be better off without them ... yes, clearly, there are households where guns don't belong.

But when the advocate for a total ban is talking to a gun rights advocate and it gets down to brass tacks, one believes in the right to armed self defense and the use of lethal force in defense of life, and the other does not.  Once the discussion arrives at that point, there isn't really anything more to talk about.

So now let us imagine that we would like to see fewer guns in American society. Maybe our idea of "fewer" is zero, but let's leave it imprecise for the moment. We could say we'd like to keep guns out of "the wrong hands."  We could say we'd like to ban "weapons of war" (even though we mean the AR-15, when it's actually the M-16 that is a weapon of war).

So we press for universal background checks, and we say no one "needs" an AR-15, and we can find millions of gun owners to agree with us.  After all, the number of gun owners is about ten times as large as the number of owners of the AR-15 and similar rifles, and it's easy to compromise on what the other fellow has.  The large majority of members of the NRA are OK with universal background checks, although the percentage might drop a little if you remind them that if Uncle John is going to buy a new hunting rifle and decides he'll give his old .30-06 to Bobby, who is ready for his first deer season, that transfer has to go through a dealer.

Now, hold on, say the hardliners to their brethren inclined toward a softer position.  This is only the beginning.  This is a slippery slope.  Give 'em an inch and they'll take a mile.  Every time they say "common sense gun control" remember it's always the first step toward something you won't like.

And that brings us to the question raised by Maltz Bovy's essay.  Not the first one: is it time to ban guns?  The rationales for and against could fill a book (and they have, many books), and I've given you the highlights.  No, the second one: is it time to make the case for this and try to bring it front and center in the public mind?

On the pro side, Maltz Bovy is right, if you tacitly accept that something is not possible, then it is not possible.  If you start talking about it like it is not only possible but clearly the right thing to do, then you can work on shifting public opinion your way.

On the con side, if you make a forceful public argument that unequivocally states your endgame, the very first move of the very first pawn will be resisted.

If you are a gun control advocate, Maltz Bovy is not helping your cause.  If you are a gun rights advocate urging the compromisers to take a harder line, Maltz Bovy has just made your case for you.

Muting the "Trump-Et?"

The other day Donald J. Trump, who is seeking the Republican nomination in the 2016 presidential contest, issued a public statement in the aftermath of a shooting in San Bernardino, California.

Tafsheen Malik and Syed Farook, a Pakistani immigrant and her husband, the Illinois-born son of Pakistani immigrants, attacked a large holiday gathering of Farook's coworkers, reportedly using semiautomatic rifles to kill 14 people and injure 21 more.  The pair were married, and early details of an ongoing investigation suggested both were "radicalized" Muslims who had embraced the concept of jihad as an Islamic fundamentalist war with Western society.

This mass shooting occurred as the federal government is grappling with decisions about admitting to the United States thousands of refugees from strife-ridden Syria, where the Islamic extremist group ISIS controls large areas of the country, now engulfed in civil war.

Mr. Trump called for a ban on any further immigration of Muslims into the United States until the federal government can "figure out what the hell is going on."

This was just the latest in a series of provocative statements from the candidate during a months-long campaign in which he has distinguished himself from others seeking the office in many ways, perhaps most notably a complete rejection of any notions of political correctness.  Trump has shown that he is ready, willing, and able to offend absolutely everyone.

In other parts of cyberspace, although not yet in the blogosphere, I have characterized Trump as jingoistic, xenophobic, nativistic, racist, and homophobic.  I have said he appeals to the basest impulses and the ugliest prejudices to be found in the American psyche.  His attractiveness as a candidate, I believe, relates to the fact that there is a segment of the electorate that is incoherently angry about many changes going on in the world around them.

[No, I am not a fan.]

His demand for a suspension, as he later qualified his call for a ban, of immigration by any and all Muslims until our government figures out "what the hell is going on" stems, I believe, from the simple fact that Mr. Trump himself does not know what the hell is going on.  Geopolitics and foreign policy are, and will likely remain, well beyond his ken.  What he sees is that there are Islamic extremists whose intentions toward Western society in general and the US in particular are malevolent.  Therefore, he insists, until some foolproof test is devised whereby it can be determined whether an individual Muslim who wishes to come to the US is, and will remain, no threat to Americans, we should allow absolutely no Muslims to enter the country.

Anti-immigrant sentiment has been with us for a very long time.  Before the Civil War, these tendencies were already very much with us.  American society went from 1.6% foreign born in 1830 to 9.7% in 1850, and the us-versus-them view of immigrants by the native-born was sufficient to provide the foundation for a strong nativist current in US politics in the second quarter of the 19th century.

That this phenomenon is not new, however, makes it no less repulsive. America has always been a beacon of freedom - political, religious, economic, social - to the rest of the world, and that necessarily attracts immigrants.  That is a fact of which we are justifiably proud.  We are inspired by "The New Colossus," the famous poem by Emma Lazarus that is inscribed in a place of honor at the base of the Statue of Liberty, a poem that concludes with the words

Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door! 

Mr. Trump has declared that ISIS, and Islamic extremists like Malik and Farook, along with the terrorists who killed over 120 people in Paris last month and others who have carried out attacks around the globe, have proven that all of the world's billion or so Muslims are suspect and must be viewed through a prism of presumptive guilt.

Words such as repugnant, appalling, reprehensible, and disgraceful can only begin to describe this kind of public pronouncement and the rationale that underlies it.

So what? you may be asking.  We live in a country in which freedom of expression is guaranteed.  People can think and say whatever they want, with few exceptions: no shouting "Fire!" in a crowded theatre or making other utterances that could pose an immediate danger to the public safety, for example.

Yes, freedom of expression is guaranteed - against abridgment by government. If someone who finds Trump's public utterances opprobrious punches him in the nose, that person has not violated the candidate's First Amendment rights, although he will likely be charged with battery.

This also means that the press has no obligation to report Mr. Trump's declarations.  They may do so if they think what he has to say is newsworthy. They are equally free to choose not to report, although they risk losing audience share if they don't report a story that is sure to interest the public.

What would Trump have to say to get the news media to decide it doesn't bear repeating?  Can we assume that no matter what he might say, no matter how outrageous, they will tell us, because it's news?  Probably so.

Then, at what point is there an obligation on the part of the press to say, here is what this fellow said, and these are the ravings of a madman?

Oh, no, they can't do that.  That would be interpreting.  They mustn't do that. They can only report the interpretations of others.  So they can tell us other Republican candidates have condemned what Trump said.

Let me tell what I think of that: Baloney!

The news media have a great deal of control over what and how much we learn about candidates.

Here is an example.  You've all seen how news organizations commission polls because of the public interest in the "horse race" aspect of the presidential campaign.  Within the last week, three polls were commissioned by news organizations: CNN, MSNBC, and USAToday.  All three looked at how Hillary Clinton matched up against Republican candidates in hypothetical general-election pairings, Clinton versus Trump, or Cruz, or Rubio, or Carson.  (MSNBC included Bush; the others did not.)

Missing from these polls, as reported by the superb political website realclearpolitics.com, was any match-up between the Republican candidates and Bernie Sanders.  Oh, well, that must be because Sanders doesn't match up anywhere nearly as well as Clinton.  After all, the conventional wisdom is that he's unelectable because his image is that of a crazy left-wing socialist.

Not so fast.  A poll conducted last week by Quinnipiac University (not on behalf of a news organization) looked at exactly those Sanders-versus-Republican-candidate match-ups, and ... well, waddya know?  Bernie does even better than Hillary, leading against Trump, Carson, Rubio, or Cruz.

The media have reported this campaign season's news as if Bernie Sanders is barely worth a mention.

Well, let me tell you something.  There is a candidate in this race who is barely worth a mention, and his name is Donald Trump.  Trump is a disgrace to this great nation.  Remember Ronald Reagan, who famously said Republicans should never speak ill of each other?  This was known as Reagan's "Eleventh Commandment."  Now consider this: Senator Lindsay Graham and former Governor Jeb Bush, two other Republican candidates, described Trump as "dangerous" (Graham) and "unhinged" (Bush) in the wake of The Donald's call for a "total and complete shutdown" of Muslim immigration.

The news media do not have an obligation to report, breathlessly, the ravings of a madman who has been characterized by his fellow Republicans as "dangerous" and "unhinged."

Not when they have clearly made a deliberate decision to minimize their coverage of the campaign of Bernie Sanders, whose career and whose candidacy have been the most positive and principled this pundit has ever seen in American politics.

Is it newsworthy that we have a candidate who taps into deep-rooted American prejudices and ugly, base, xenophobic instincts?  Perhaps.  Should that be reported?  Before we can answer that question, we must ask another.  Does Trump merely tap into those ugly features of the American psyche?  Or does he encourage, ignite, inflame them?

I think you know my answer.

Shame on you, Donald Trump.  And shame on you, complicit journalists.
  

Research on Gun Violence Banned? Not Exactly.

Churchill, Thompson submachine gun, 1940

As a physician specializing in emergency medicine, I have a keen interest in areas of research that are related to my practice.  This includes public health and injury prevention.

Much medical research is funded with public dollars.  In fact, most medical research is funded either with public dollars or by industry, meaning the pharmaceutical industry and the manufacturers of medical devices. Among folks in academic medicine, it is considered a truism that publicly funded research is much more likely to be of high quality, whereas industry-funded research is much more likely to be biased, with problems ranging from study design intended to produce certain results, through dubious statistical methods, to spinning results to draw conclusions that aren't really justified.

Many years ago my colleagues in public health came up with the idea that violence is a public health problem.  This led to an interest in all sorts of research into the nature and causes of interpersonal violence.  One area of this research involves violent acts committed with firearms.

Early on some of the researchers adopted a metaphor from the discipline of infection control in which guns are viewed as "vectors" of "disease," rather like the way in which the female anopheles mosquito is a vector for malaria.

And here you can see where some trouble might begin.  You see, there are people - many Americans among them - who like guns.  And so, if you adopt a viewpoint that guns are a vector of disease, you will inevitably find yourself in conflict with those people.  If you want to control malaria, you are likely to decide an effective approach is to wipe out the population of mosquitos that transmit the parasite that causes the disease.  If you view guns as a vector, according to this metaphor, you are likely to think that eliminating guns from human societies may be the solution to the problem.

The reaction from gun rights advocates was predictable.  Maybe violence is a public health problem, they said, but guns are not a vector of disease, and this is an essentially flawed metaphor - a metaphor that biases the research done by the medical scientists working in this field, nearly all of which seems to begin with some sort of hypothesis that guns are bad and that wherever you look at the role of guns in human societies you will find trouble that would go away if we just took guns out of the picture.

At the same time that public health researchers were publishing one study after another that concluded guns are a problem (if not the problem), social scientists (especially criminologists) were doing research that seemed to reach very different conclusions, often finding that guns are used at least as much - maybe much more, according to some - to deter or stop crime than to injure or kill innocents.

It would be easy to conclude that researchers examining the same questions and reaching essentially opposite conclusions probably are all biased, and their opposite conclusions reflect opposite biases.  And that may be the case.  If you are reading this essay, that suggests you are interested in my opinion, so I'll tell you I have read most of this research, and it is pretty clear to me that there is plenty of bias to go around, and it is quite difficult to tell how much the results are influenced by it.  This much, however, I can tell you: the truth is not entirely on one side of this question.

One cannot reach any other conclusion than this: more research would be a good thing, and the less biased that research is by preconceived ideas on the part of researchers, the better.

Where should the funding for that research come from?

Well, public dollars seem a sensible choice, given that gun violence is a public health problem (in the view of medical scientists) or a social problem (in the view of social scientists).  (It is obviously both.)  Besides, what sort of private funding might there be?  You can imagine the potential source of bias if the money came from the firearm manufacturing industry, on one side, or billionaires (such as Michael Bloomberg or George Soros) who ardently support pro-gun-control advocacy groups, on the other.

And that takes us back to 1996, when the National Rifle Association was fed up with the public health research that pretty uniformly concluded guns are bad and we should get rid of them.  The NRA lobbied Congress, with the result that an omnibus appropriations bill prohibited the flow through the CDC of research funding that would "advocate or promote gun control."  (Those are the actual words in the legislation.)  Notice that this is not a prohibition on federal funding for research into the problem of gun violence.  But an article in the New York Times explains how it effectively became that, mostly because the CDC became "squeamish" about funding research in this area.

This puts a little bit different spin on the subject than what we have repeatedly been reading and hearing in the news lately, which is that the NRA succeeded in putting an end to research into this problem.  Two quotations from the Times article offer insight into two quite different perspectives on what the NRA asked the Congress to do:

 “We’ve been stopped from answering the basic questions,” said Mark Rosenberg, former director of the National Center for Injury Control and Prevention, part of the CDC-P, which was for about a decade the leading source of financing for firearms research.

 and

Chris Cox, the NRA’s chief lobbyist, said his group had not tried to squelch genuine scientific inquiries, just politically slanted ones.  “Our concern is not with legitimate medical science,” Mr. Cox said. “Our concern is they were promoting the idea that gun ownership was a disease that needed to be eradicated.”

In 2011 further congressional action extended this restriction on the flow of research dollars so that it affected all other agencies funded through the Department of Health and Human Services.

It seems clear that more research is needed.  It is not clear that congressional action is needed to reverse the actions taken in 1996 and 2011.  I may be extremely naive, but if were in charge of these dollars at the CDC, I would look for opportunities to fund research on gun violence that appeared to lack obvious bias in either direction, and consider the burden of proof to rest upon anyone who objected to convince my congressional overseers that the research was intended "to advocate or promote gun control."

And what sort of research might be funded?  Perhaps you've heard of the National Academy of Sciences.  One of the institutes under its umbrella is the Institute of Medicine (IOM).  The IOM's Division of Behavioral and Social Sciences and Education has a Committee on Law and Justice that published an excellent report addressing this question two years ago: Priorities for Research to Reduce the Threat of Firearm-Related Violence.  (If you follow the link you will see that you can buy a paperback copy of the report, but you can also read it online or download it as a pdf, free of charge.)  If you wonder about bias in this IOM report, I would draw to your attention that two of the reviewers of the report were Paul Blackman, a criminologist and political scientist who is regarded by his detractors as a shill for the NRA, and Arthur Kellermann, a distinguished medical professor and public health researcher whose work is harshly criticized by gun rights advocates.  The IOM does an excellent job of pulling in diverse viewpoints on controversial subjects.

When we see and hear in the news that more than 30,000 people are killed with firearms each year, and many more injured, a small fraction of these in horrific mass shootings that grab the headlines, we all want somebody to do something about it.  The question is what.

And the answer is not whatever seems to you or me to make sense.  I can tell you from my experience of 37 years studying medicine (beginning with medical school) that what makes sense often turns out to be completely wrong when subjected to scientific study.  We need more research.

Thanks to the IOM, we have an agenda.  It is possible to approach this research with an open mind and without bias.  That kind of research has not been prohibited by Congress.  So let's get moving!