Later On

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Archive for the ‘Healthcare’ Category

1 Son, 4 Overdoses, 6 Hours

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Katherine Q. Seelye reports in the NY Times:

The first time Patrick Griffin overdosed one afternoon in May, he was still breathing when his father and sister found him on the floor around 1:30. When he came to, he was in a foul mood and began arguing with his father, who was fed up with his son’s heroin and fentanyl habit.

Patrick, 34, feeling morose and nauseous, lashed out. He sliced a love seat with a knife, smashed a glass bowl, kicked and broke a side table and threatened to kill himself. Shortly after 3, he darted into the bathroom, where he shot up and overdosed again. He fell limp, turned blue and lost consciousness. His family called 911. Emergency medical workers revived him with Narcan, the antidote that reverses opioid overdoses.

Throughout the afternoon his parents, who are divorced, tried to persuade Patrick to go into treatment. His father told him he could not live with him anymore, setting off another shouting match. Around 4, Patrick slipped away and shot up a third time. He overdosed again, and emergency workers came back and revived him again. They took him to a hospital, but Patrick checked himself out.

Back at his mother’s house and anxious to stave off withdrawal, he shot up again around 7:30, overdosing a fourth time in just six hours. His mother, frantic, tried pumping his chest, to no avail, and feared he was dead. Rescue workers returned and administered three doses of Narcan to bring him back. At that point, an ambulance took him to the hospital under a police escort and his parents — terrified, angry and wrung out — had him involuntarily admitted.

The torrent of people who have died in the opioid crisis has transfixed and horrified the nation, with overdose now the leading cause of death for Americans under 50.

But most drug users do not die. Far more, like Patrick, are snared for years in a consuming, grinding, unending cycle of addiction.

In the 20 years that Patrick has been using drugs, he has lost track of how many times he has overdosed. He guesses 30, a number experts say would not be surprising for someone taking drugs off and on for that long.

Patrick and his family allowed The New York Times to follow them for much of the past year because they said they wanted people to understand the realities of living with drug addiction. Over the months, their lives played out in an almost constant state of emergency or dread, their days dictated by whether Patrick would shoot up or not. For an entire family, many of the arguments, the decisions, the plans came back to him and that single question. Even in the cheeriest moments, when Patrick was clean, everyone — including him — seemed to be bracing for the inevitable moment when he would turn back to drugs.

“We are your neighbors,” his mother, Sandy Griffin, said of the many families living with addiction, “and this is the B.S. going on in the house.”

In Patrick’s home state of New Hampshire, which leads the country in deaths per capita from fentanyl, almost 500 people died of overdoses in 2016. The government estimates that 10 percent of New Hampshire residents — about 130,000 people — are addicted to drugs or alcohol. The overall burden to the state, including health care and criminal justice costs and lost worker productivity, has ballooned into the billions of dollars. Some people do recover, usually after multiple relapses. But the opioid scourge, here and elsewhere, has overwhelmed police and fire departments, hospitals, prosecutors, public defenders, courts, jails and the foster care system.

Most of all, though, it has upended families.

All of the Griffins speak of nonstop stress. They have lived through chaotic days: When the parents called the police on their children (both Patrick and his sister, Betsy, have been addicted to drugs); when Dennis, the father, a recovering alcoholic, worried that every thud on the floor was Patrick passing out; and when Sandy was, by turns, paralyzed with a common parental fear — that she had somehow caused her children’s problems — or was out driving around looking for them on the streets. . .

Continue reading.

Trump refuses to make the opioid crisis a national emergency, though he promised that he would. His promises turn out to be worthless.

Written by LeisureGuy

21 January 2018 at 7:27 am

Using marijuana to fight the opioid crisis

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Margery Eagan writes in the Boston Globe:

IN WASHINGTON, Attorney General Jeff Sessions has reversed Obama administration policies and freed US attorneys to prosecute the marijuana business, even where it’s legal.

In Boston, US Attorney Andrew Lelling has given no assurances that he won’t.

Meanwhile, in a nondescript Natick strip mall, in a physician’s office above a pizza joint and dance school, and down the hall from the Ebenezer Assembly of God ministry, Dr. Uma Dhanabalan helps patients use marijuana to wean themselves from an actual drug menace. That would be opioids, legally prescribed, government approved, a drug that’s made billions for the politically wired pharmaceutical industry and now kills nearly 100 Americans every day.

“I hated them,” said Beth, one of Dhanabalan’s patients, a 52-year-old wife and mother, about the Hydromorphone and Oxycodone she was prescribed for pain from a herniated disc and osteoarthritis.

On opioids, she couldn’t work. Her job involves money. She couldn’t misplace a decimal point. The drugs made her “cotton-ball headed, like a hangover mixed with a cold. I couldn’t think.”

On opioids, she couldn’t work. Her job involves money. She couldn’t misplace a decimal point. The drugs made her “cotton-ball headed, like a hangover mixed with a cold. I couldn’t think.”

She also endured the indignities of another notorious opioid side effect: constipation. For that, physicians routinely prescribe yet another drug with side effects almost as horrifying as those of opioids. Opiod side effects include not just dizziness, drowsiness, mood swings, and confusion, but also addiction, accidental overdose, and death.

“The nerve pain used to be unrelenting, like pushing out at the front of your consciousness,” she said. But the marijuana “put a barrier between conscious awareness and the pain. It’s still there, but like a shadow. It’s not banging. And I am clear-headed.

“I used to drink two glasses of wine a day. Now I’ve stopped drinking almost entirely. Now I do errands and walk the dog.” She stood up and showed me her loose pants. “And I’ve lost 30 pounds.”

Beth did not want her last name used. She has a teenage son. Stigma and unease remain. And both became worse when prosecutor Lelling called marijuana a “dangerous” drug he may, or may not, crack down on.

The irony, said Dr. Dhanabalan, is that “nobody in the world has ever died from a cannabis overdose.” She calls cannabis “the exit drug” from opioid addiction, a controversial claim but one that is fast gaining traction.

Sitting in blue scrubs, pictures of a marijuana plant on one wall and her medical degrees and a plaque from the Veterans of Foreign Wars on another, the former family physician said it’s hard to fathom the continued hostility toward, and ignorance about, cannabis. She said it’s helped not only patients kicking opioids but also those with cancer, PTSD, or common maladies like insomnia. “It changes lives,” she said.

Surely it changed Daniel Snyder’s. A 64-year-old Stoneham mechanic badly injured in a tractor rollover, he said opioids helped his pain tremendously — at first.

“The reason people get addicted is this stuff makes them feel so good, it’s like you could have a good time watching paint dry,” he says. “Then you want more, and you end up in a deep dark hole.” . . .

Continue reading.

Written by LeisureGuy

15 January 2018 at 11:40 am

A family of doctors helps reinvent medical marijuana

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Justin Moyer reports in the Washington Post:

The Knoxes are a clan of four doctors living in Oregon and California who specialize in medical marijuana. They seem to be doing quite well selling something that is illegal in many states, working with those they know best.

“We’re all fighting the same fight,” said Janice Knox, the founding doctor behind American Cannabinoid Clinics in Portland, Ore. — and the mother of two fellow physicians and the wife of the other. “I think when they do see us they’re surprised at who we are,” she said of her patients. The family aims for something not always associated with medical marijuana: professionalism.

Knox led the family’s move into medical marijuana in 2012, when she retired from a decades-long career in anesthesiology. One of 15 children, she grew up in the San Francisco Bay area and went north for medical school in the 1970s.

“There were not very many black women or men, at least not at the University of Washington,” she said. “It felt like a cultural shock when I went there.”

Knox stuck it out, choosing a career as an anesthesiologist because she thought — wrongly — it would give her more time to raise children. (A lot more on them in a minute.) After 35 years, however, she got tired of working up to seven days a week. And she got tired of being mistaken for a nurse. “Patients would say, ‘I want a white male doctor,’ ” Knox said.

After she stepped away from the job, she got a call from a “card mill” — a practice known more for writing prescriptions for medical marijuana quickly than for close attention to patients’ needs. One of the doctors couldn’t be found. Could she fill in?

Knox wasn’t sure. One of her colleagues, a marijuana enthusiast, had been sent to rehab. And despite attending the University of California at Berkeley, she was a square — Knox had never seen or smelled marijuana “at a time when drugs were everywhere,” she said.

But she had always been interested in natural treatments, and she agreed to fill in — and was pleasantly surprised to see that the patients were not a bunch of a reprobates. . .

Continue reading.

Written by LeisureGuy

14 January 2018 at 3:25 pm

“Best healthcare system in the world”: Social media fury follows video of dazed woman put out in cold by Baltimore hospital

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I am always surprised when someone opines that the US healthcare system is the best in the world. It’s not even close. Watch the videos in this Facebook post.

John Woodrow Cox, Theresa Vargas, and Justin Wm. Moyer report in the Washington Post:

The man hurried up the Baltimore sidewalk with a camera in his hand as four black-clad hospital security guards walked toward him, then past him. One of them was pushing an empty wheelchair.

“So wait, y’all just going to leave this lady out here with no clothes on?” said Imamu Baraka, referring to a dazed woman wearing only a thin hospital gown who they had left alone at a bus stop Tuesday night in mid-30s temperatures. Her face appeared bloody, her eyes empty.

It was the latest incident of “patient dumping” that has sparked outrage around the country — one that, according to an expert, probably violated a 1986 federal law that mandates hospitals release those in their care into a safe environment.

“This kind of behavior is, I think, both illegal and I’m sure immoral,” said Arthur L. Caplan, founding head of the division of medical ethics at the New York University School of Medicine. “You don’t just throw someone out into the street who is impaired and may have injuries. You try to get them to the best place possible, and that’s not the bench in front of the hospital.”

The phenomenon was pervasive two decades ago, when the law was largely unenforced, Caplan said, but remains a problem from California to Virginia.

On Tuesday, the woman left outside the University of Maryland Medical Center Midtown Campus could barely walk and seemed unable to speak.

Still filming, Baraka turned and followed the guards back to an entrance.

“That is not okay,” he shouted.

“Due to the circumstances of what it was,” one of them said.

“Then you all need to call the police,” replied Baraka, a licensed counselor.

At the doorway, Baraka asked for a supervisor, demanding to know why they were leaving her outside.

“She was . . . medically discharged,” one of the guards said, before the camera captured them walking into the hospital, their backs turned.

What Baraka filmed next — the woman, staggering and screaming into a night so cold that the sidewalk remained speckled with salt and bits of unmelted snow — has been viewed more than 1.4 million times on Facebook, triggering a cascade of online fury and an apology from the hospital.

At a news conference Thursday afternoon, the hospital’s chief pledged to investigate what he described as “a failure of basic compassion and empathy.” . . .

Continue reading.

Do read the whole  thing. The other examples are even worse.

Profits before patients.

Written by LeisureGuy

11 January 2018 at 6:43 pm

Posted in Business, Healthcare

The Irrationality of Alcoholics Anonymous

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Gabrielle Glaser writes in the Atlantic:

J.G. is a lawyer in his early 30s. He’s a fast talker and has the lean, sinewy build of a distance runner. His choice of profession seems preordained, as he speaks in fully formed paragraphs, his thoughts organized by topic sentences. He’s also a worrier—a big one—who for years used alcohol to soothe his anxiety.

J.G. started drinking at 15, when he and a friend experimented in his parents’ liquor cabinet. He favored gin and whiskey but drank whatever he thought his parents would miss the least. He discovered beer, too, and loved the earthy, bitter taste on his tongue when he took his first cold sip.

His drinking increased through college and into law school. He could, and occasionally did, pull back, going cold turkey for weeks at a time. But nothing quieted his anxious mind like booze, and when he didn’t drink, he didn’t sleep. After four or six weeks dry, he’d be back at the liquor store.

By the time he was a practicing defense attorney, J.G. (who asked to be identified only by his initials) sometimes drank almost a liter of Jameson in a day. He often started drinking after his first morning court appearance, and he says he would have loved to drink even more, had his schedule allowed it. He defended clients who had been charged with driving while intoxicated, and he bought his own Breathalyzer to avoid landing in court on drunk-driving charges himself.

In the spring of 2012, J.G. decided to seek help. He lived in Minnesota—the Land of 10,000 Rehabs, people there like to say—and he knew what to do: check himself into a facility. He spent a month at a center where the treatment consisted of little more than attending Alcoholics Anonymous meetings. He tried to dedicate himself to the program even though, as an atheist, he was put off by the faith-based approach of the 12 steps, five of which mention God. Everyone there warned him that he had a chronic, progressive disease and that if he listened to the cunning internal whisper promising that he could have just one drink, he would be off on a bender.

J.G. says it was this message—that there were no small missteps, and one drink might as well be 100—that set him on a cycle of bingeing and abstinence. He went back to rehab once more and later sought help at an outpatient center. Each time he got sober, he’d spend months white-knuckling his days in court and his nights at home. Evening would fall and his heart would race as he thought ahead to another sleepless night. “So I’d have one drink,” he says, “and the first thing on my mind was: I feel better now, but I’m screwed. I’m going right back to where I was. I might as well drink as much as I possibly can for the next three days.”

He felt utterly defeated. And according to AA doctrine, the failure was his alone. When the 12 steps don’t work for someone like J.G., Alcoholics Anonymous says that person must be deeply flawed. The Big Book, AA’s bible, states:

Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way.

J.G.’s despair was only heightened by his seeming lack of options. “Every person I spoke with told me there was no other way,” he says.

The 12 steps are so deeply ingrained in the United States that many people, including doctors and therapists, believe attending meetings, earning one’s sobriety chips, and never taking another sip of alcohol is the only way to get better. Hospitals, outpatient clinics, and rehab centers use the 12 steps as the basis for treatment. But although few people seem to realize it, there are alternatives, including prescription drugs and therapies that aim to help patients learn to drink in moderation. Unlike Alcoholics Anonymous, these methods are based on modern science and have been proved, in randomized, controlled studies, to work.

For J.G., it took years of trying to “work the program,” pulling himself back onto the wagon only to fall off again, before he finally realized that Alcoholics Anonymous was not his only, or even his best, hope for recovery. But in a sense, he was lucky: many others never make that discovery at all.

The debate over the efficacy of 12-step programs has been quietly bubbling for decades among addiction specialists. But it has taken on new urgency with the passage of the Affordable Care Act, which requires all insurers and state Medicaid programs to pay for alcohol- and substance-abuse treatment, extending coverage to 32 million Americans who did not previously have it and providing a higher level of coverage for an additional 30 million.

Nowhere in the field of medicine is treatment less grounded in modern science. A 2012 report by the National Center on Addiction and Substance Abuse at Columbia University compared the current state of addiction medicine to general medicine in the early 1900s, when quacks worked alongside graduates of leading medical schools. The American Medical Association estimates that out of nearly 1 million doctors in the United States, only 582 identify themselves as addiction specialists. (The Columbia report notes that there may be additional doctors who have a subspecialty in addiction.) Most treatment providers carry the credential of addiction counselor or substance-abuse counselor, for which many states require little more than a high-school diploma or a GED. Many counselors are in recovery themselves. The report stated: “The vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.”

Alcoholics Anonymous was established in 1935, when knowledge of the brain was in its infancy. It offers a single path to recovery: lifelong abstinence from alcohol. The program instructs members to surrender their ego, accept that they are “powerless” over booze, make amends to those they’ve wronged, and pray.

Alcoholics Anonymous is famously difficult to study. By necessity, it keeps no records of who attends meetings; members come and go and are, of course, anonymous. No conclusive data exist on how well it works. In 2006, the Cochrane Collaboration, a health-care research group, reviewed studies going back to the 1960s and found that “no experimental studies unequivocally demonstrated the effectiveness of AA or [12-step] approaches for reducing alcohol dependence or problems.”

The Big Book includes an assertion first made in the second edition, which was published in 1955: that AA has worked for 75 percent of people who have gone to meetings and “really tried.” It says that 50 percent got sober right away, and another 25 percent struggled for a while but eventually recovered. According to AA, these figures are based on members’ experiences.

In his recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, a retired psychiatry professor from Harvard Medical School, looked at Alcoholics Anonymous’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on these data, he put AA’s actual success rate somewhere between 5 and 8 percent. That is just a rough estimate, but it’s the most precise one I’ve been able to find.

I spent three years researching a book about women and alcohol, Her Best-Kept Secret: Why Women Drink—And How They Can Regain Control, which was published in 2013. During that time, I encountered disbelief from doctors and psychiatrists every time I mentioned that the Alcoholics Anonymous success rate appears to hover in the single digits. We’ve grown so accustomed to testimonials from those who say AA saved their life that we take the program’s efficacy as an article of faith. Rarely do we hear from those for whom 12-step treatment doesn’t work. But think about it: How many celebrities can you name who bounced in and out of rehab without ever getting better? Why do we assume they failed the program, rather than that the program failed them?

When my book came out, dozens of Alcoholics Anonymous members said that because I had challenged AA’s claim of a 75 percent success rate, I would hurt or even kill people by discouraging attendance at meetings. A few insisted that I must be an “alcoholic in denial.” But most of the people I heard from were desperate to tell me about their experiences in the American treatment industry. Amy Lee Coy, the author of the memoir From Death Do I Part: How I Freed Myself From Addiction, told me about her eight trips to rehab, starting at age 13. “It’s like getting the same antibiotic for a resistant infection—eight times,” she told me. “Does that make sense?”

She and countless others had put their faith in a system they had been led to believe was effective—even though finding treatment centers’ success rates is next to impossible: facilities rarely publish their data or even track their patients after discharging them. “Many will tell you that those who complete the program have a ‘great success rate,’ meaning that most are abstaining from drugs and alcohol while enrolled there,” says Bankole Johnson, an alcohol researcher and the chair of the psychiatry department at the University of Maryland School of Medicine. “Well, no kidding.”

Alcoholics Anonymous has more than 2 million members worldwide, and the structure and support it offers have helped many people. But it is not enough for everyone. The history of AA is the story of how one approach to treatment took root before other options existed, inscribing itself on the national consciousness and crowding out dozens of newer methods that have since been shown to work better.

A meticulous analysis of treatments, published more than a decade ago in The Handbook of Alcoholism Treatment Approaches but still considered one of the most comprehensive comparisons, ranks AA 38th out of 48 methods. At the top of the list are  . . .

Continue reading.

Written by LeisureGuy

11 January 2018 at 11:17 am

Why American doctors keep doing expensive procedures that don’t work

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The procedures are ineffective and expensive, but doctors keep doing them, in part because doctors get their income (for the most part) from their fees: no procedure, no fee. The same applies to hospitals: if you’re not hospitalized, the hospital doesn’t make money.

Eric Patashnik reports in Vox:

The recent news that stents inserted in patients with heart disease to keep arteries open work no better than a placebo ought to be shocking. Each year, hundreds of thousands of American patients receive stents for the relief of chest pain, and the cost of the procedure ranges from $11,000 to $41,000 in US hospitals.

But in fact, American doctors routinely prescribe medical treatments that are not based on sound science.

The stent controversy serves as a reminder that the United States struggles when it comes to winnowing evidence-based treatments from the ineffective chaff. As surgeon and health care researcher Atul Gawande observes, “Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.”

Of course, many Americans receive too little medicine, not too much. But the delivery of useless or low-value services should concern anyone who cares about improving the quality, safety and cost-effectiveness of medical care. Estimates vary about what fraction of the treatments provided to patients is supported by adequate evidence, but some reviewsplace the figure at under half.

Naturally that carries a heavy cost: One study found that overtreatment — one type of wasteful spending — added between $158 billion and $226 billion to US health care spending in 2011.

The stunning news about stents came in a landmark study published in November, in The Lancet. It found that patients who got stents to treat nonemergency chest pain improved no more in their treadmill stress tests (which measure how long exercise can be tolerated) than did patients who received a “sham” procedure that mimicked the real operation but actually involved no insertion of a stent.

There were also no clinically important differences between the two groups in other outcomes, such as chest pain. (Before being randomized to receive the operation or the sham, all patients received six weeks of optimal medical therapy for angina, like beta blockers). Cardiologists are still debating the study’s implications, and more research needs to be done, but it appears that patients are benefitting from the placebo effect rather than from the procedure itself.

Once a treatment becomes popular, it’s hard to dislodge

Earlier cases in which researchers have called into question a common treatment suggest surgeons may push back against the stent findings. In 2002, The New England Journal of Medicine published a study demonstrating that a common knee operation, performed on millions of Americans who have osteoarthritis — an operation in which the surgeon removes damaged cartilage or bone (“arthroscopic debridement”) and then washes out any debris (“arthroscopic lavage”) — worked no better at relieving pain or improving function than a sham procedure. Those operations can go for $5,000 a shot.

Many orthopedic surgeons and medical societies disputed the study and pressed insurance companies to maintain coverage of the procedure. Subsequent research on a related procedure cast further doubt on the value of knee surgeries for many patients with arthritis or meniscal tears, yet the procedures remain in wide use.

Other operations that have continued to be performed despite negative research findings include spinal fusion (to ease pain caused by worn disks), and subacromial decompression, which in theory reduces shoulder pain.

There have been fitful efforts to improve the uptake of empirical studies of medical practices by doctors — one seemingly promising initiative being the “Choosing Wisely”campaign, launched in 2012 by the American Board of Internal Medicine Foundation in partnership with Consumer Reports. Its goal is to get medical societies to develop lists of treatments of minimal clinical benefit to patients.

But Choosing Wisely seems to have had little impact so far. One study of that campaign’s results examined seven procedures that have widely been shown to be ineffective, including imaging tests for “uncomplicated” headaches, cardiac imaging for patients without a history of heart problems, and routine imaging for patients with low-back pain. In the two-to-three-year period leading up to 2013, only two of the seven practices targeted for reduction showed any decrease at all in the US. (And the declines were tiny: The use of scans for those uncomplicated headaches decreased from 14.9 percent to 13.4 percent, for instance.) . . .

Continue reading.

Written by LeisureGuy

2 January 2018 at 9:39 am

Life expectancy in US down for second year in a row as opioid crisis deepens

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Update: See also Kevin Drum’s post “What’s Really Causing the Decline in US Life Expectancy? It’s Not Opioid Overdoses.”

Jessica Glenza reports in the Guardian:

Life expectancy in the US has declined for the second year in a row as the opioid crisis continues to ravage the nation.

It is the first time in half a century that there have been two consecutive years of declining life expectancy.

Drug overdoses killed 63,600 Americans in 2016, an increase of 21% over the previous year, researchers at the National Center for Health Statistics found.

Americans can now expect to live 78.6 years, a decrease of 0.1 years. The US last experienced two years’ decline in a row in 1963, during the height of the tobacco epidemic and amid a wave of flu.

“We do occasionally see a one-year dip, even that doesn’t happen that often, but two years in a row is quite striking,” said Robert Anderson, chief of the mortality statistics branch with the National Center for Health Statistics. “And the key driver of that is the increase in drug overdose mortality.”

Especially disconcerting, said Anderson, was preliminary data researchers received about overdoses in 2017: “It doesn’t look any better.” Together, the drug overdose epidemic and a plateau in improved mortality rates from cardiovascular disease are “affecting the entire national picture”.

“We haven’t seen more than two years in a row in declining life expectancy since the Spanish flu – 100 years ago,” said Anderson. “We would be entering that sort of territory, which is extremely concerning.”

Widely available prescription painkillers . . .

Continue reading.

Trump has tried to get some PR mileage from doing things that garner publicity but do nothing whatsoever to address the problem. So it’s getting worse. Big surprise.

Not a great time to try to take healthcare insurance away from millions.

Again, an obvious and glaring sign of the decline of the United States: It can’t even take care of its own citizens—or, more accurately, it won’t take care of its own citizens. I would guess that’s because of severe inequality: the ruling class of the very wealthiest Americans now feel totally separate from the rest of the country and really don’t care what happens to it so long as they can drain even more money from the public treasury. Avaricious greed knows no bounds (cf. Donald J. Trump).

Update: Another sign of decline: “FDA lacks “efficient and effective” food recall process, inspector general finds.”

Written by LeisureGuy

28 December 2017 at 1:25 pm

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