Sunday, May 21, 2017

Sunday Poem


So many smiles are gaping wounds
Deftly slashed into faces.
The spaces between what we mean
And how it may seem
Are the distances between parted lips.
Our false visages belie skittishness
And those shameful resistances
That compel us to embellish
With garish grins and rictal expressions.
Curtains will drop, facades like a solar eclipse

Your eyes have never lied.
A glinting of light
That breaks through the crinkled cracks in the corners of your eyes,
Lingers, then slowly fades without a fight
Skin smoothing to stillness like uncrumpling snack wrappers tossed to the ground
A smile is an absence of flesh,
An aperture always in flux.
It is a wound, it is not a wound.
It is a mask of obfuscation, it is a life force that erupts

Wounds can reveal
And wounds can be used to conceal.
A smile can be real
A smile ought to be real



A few weeks ago I was awakened by a 2 a.m. call from the ED regarding a case of pneumoperitoneum.  I barely recall the specifics of the conversation, but I vaguely remember snippets of phrases, words that light the fires and compel immediate action: "free air, tender all over, hypotension".  I donned some old scrubs and quickly drove in to the hospital.

The patient wasn't much older than me.  He looked healthy, had a robust build.  No other medical problems.  But his vitals were perilously unstable.  Heart rate 120's.  Blood pressure 70 systolic despite several liters of fluid.  The CT showed air under the diaphragm and inflammatory changes in the pelvis consistent with acute perforated diverticulitis.  And he certainly had peritonitis on exam.  I didn't have much of a choice.  He needed an emergency operation.

An hour later I had washed him out, resected the colon with the gaping hole, and fashioned an end colostomy.  Primary anastomosis was not a consideration given the degree of contamination and pressor sustained systolics in the 80's.  We call it the Hartmann's procedure; an old school operation that is not used as often as it once was.  We found that it isn't always so easy to reverse a colostomy (70% success rate) and the procedure itself can result in significant morbidity.  Nowadays we find we can treat many cases of perforated diverticulitis medically with antibiotics alone.  Primary anastomosis is performed even on unprepped bowel in cases of mild contamination and hemodynamic stability.  Sometimes you can even get away with just laparoscopically washing out the pelvis, placing some drains, and bringing the patient back later on, for definitive one stage surgery, once the sepsis clears.  Lots of options.  But there is still a role for the Hartmann's procedure.  Four or five times a year I find myself resorting to it, even still.

The guy did well.  Got better, cleared the sepsis, started eating.  Right before discharge, I received a call from the case manager.  She told me she would not be able to arrange for a wound vac or home health care assistance, as I had requested, because the patient lacked any health insurance.

I must say, I have received far fewer phone calls of this nature since 2008.  Obamacare (in all its iterations, not just the exchanges but the Medicaid expansion as well) has certainly reduced the number of "self pay" cases I have seen.   And this simply makes statistical sense.  The number of uninsured since the passage of the ACA has fallen from 50 million to around 20 million (which is still embarrassingly too high!)

I told them to discharge the guy home with wound care and colostomy instructions and some bags of extra dressing supplies and to see me in the office in a week.  There isn't much else you can do in this situation.

The first thing he asked me in the office was, as expected: "doc, when can you put me back together again?"  Well, it's complicated, I told him.  I had been dreading this moment because it inevitably casts me in the role of villain--- the predatory quid pro quo shyster who financializes the doctor/patient relationship.  You gotta get some insurance, man, I told him.  I do plenty of uncompensated emergency surgery.  I'll be damned if I willingly perform complex elective surgeries without the guarantee I will be remunerated for my services.  In addition, it isn't just about me--- there is an anesthesiologist and the hospital facility that will want to bill for services.  I could do the procedure gratis, but he would still get a bill for 20 grand or more.

And the guy was not some street urchin or derelict.  He owned his own landscaping business.  He worked 60 or so hours a week.  He was married and had children.  By all metrics, he was an upstanding, contributory member of his community.  But he didn't have any health insurance.  And the reason is because he was able to choose not to have health insurance.

There is a mandate built into Obamacare, but it is a fairly weak one.  The cost of not having insurance often was cheaper than the cost of purchasing a plan on the open market.  Furthermore, the Trump administration, via executive orders, has enacted changes at the IRS that make it easier for people to get away with not paying anything at all.

Outside of government-run, single payer health care systems like the NHS in the UK (i.e., the rest of Western Europe and many countries in Asia), everything hinges on universal participation.  Universal coverage directly correlates with universal participation.  If the pool of patients buying health insurance are only the sick, the critically ill, and those with chronic illnesses, a health care fund will need to pump up premiums in order to ensure financial viability.  You need the young and the healthy on those health care roles in order to justify enforcement of "community rating".

Sadly, I see us starting to slip back into old ways.  AHCA probably has no chance of passing in the Senate.  But there are other ways of eroding the incremental reform brought to Americans under the imperfect auspices of Obamacare.  Executive orders to "decrease regulations" are one such seemingly anodyne way of accomplishing this.  Simple administrative incompetence and mismanagement is another way to sow doubt in the minds of private insurance companies and impel them to withdraw from markets.

So yeah, we can go back to those "good old days" when 50 million Americans lacked health insurance, when medical bills were the number cause of personal bankruptcy, when a person could be denied reasonably priced insurance due to pre-existing conditions.  It would be just as shameful and inexplicable in the future as it has always been.  The wealthiest, most hegemonic nation in the history of the world, unable to muster the means to care for its own citizens when illness strikes.

Wednesday, May 10, 2017

Wednesday Poem


For Easter dinner I sat next to a Buddhist who claimed to have no thoughts
What do you mean “no thoughts”? I asked him
Where did they go?
What happens instead
On the inside and what fills your head?
He only smiled at me.  
He smiled and nodded his slab of a head

But I was serious.  How is that done?
He looked at me like I was dumb

Later on, I watched him blankly chewing a piece of cake
An urge to smash his face into the plate
How do you fill the time---the space---between the bites?
How do you imbue a mind with pure silence?
It seemed an act of violence----
A forfeiture, at best a bluff.
Not even a whisper or a cough
Like church when we were asked to bow our heads and pray
And instead of a higher communion I could hear
Only the creaking of pews and the scuffling of shoes
The birds twittering outside, the wail of a passing siren.
Instead of warm peace I felt only cold fear.
The whirling tumult of my inside world gone speechless, silent.
Nothing to say, haltingly austere
When I most wanted to speak, when I most wanted to hear.


Sunday, May 7, 2017

Sunday Poem

Count to Ten

There are things I could do
But none of them will help you
I could excise that tumor with my knife
But it will not save your life.
It’s spread; you’re infested,
Surgery should not have been suggested.

I was called because they always call.
It is up to me to say things like “infested”
To tell you what the others cannot.
They defer to my judgment
Someone must do what cannot be said:
Snatch the terminus of an unwinding thread.

Now let us close the door
And dim the lights.
I’m going to take a seat right here.
Close our eyes and count to ten
And then count again

That was twenty from ten
Shall we carve out another block of time
Like initials into an old oak, a forgotten forest from youth?
Will we get closer to the truth?
What was her last name again?

The IV alarms
Tubing occluded
Sir, you must straighten your arm
Let us count one more time
I know it is hard
You need not speak, just listen to my voice:
One, two, three…
When I get to ten
You can open your eyes
Will I still be here?
Will the lights be on?
Will you still be trapped between dusk and dawn?


Tuesday, May 2, 2017

Noble Hearts Crack

Deep in the trenches of childhood memories I recall always being told I would be a doctor.  Birthday cards addressed to "Dr J", surgical scrubs as pajamas, a heavy dose of science-themed gifts (microscopes, insect dissection kits and the like).  The message was undeniably clear.  You will be a doctor.  You, child with the good grades, the quicksilver Jeopardy answers shall become a physician, the highest of the high, the one true and noble landing point for a child of your talents and gifts.  When you are a child you don't even think to question it.  I was a typical first born boy who aimed to please, to make my family proud.  At all the Easter, Thanksgiving, Christmas family gatherings I'd be peppered with questions (what kind of doctor? kids or adults?  surgery or medicine?) I couldn't even begin to try to answer.

 In retrospect it probably wasn't fair.  To thrust that sort of expectation and pressure upon a young boy.  But none of it was of malicious intent.  I know they were all proud of me.  My mom was a Child Life specialist in a hospital and my aunt worked as an ICU nurse.  For them, the all-powerful doctor represented the pinnacle of achievement.   I understand it all, of course.  I may not have chosen my path, it may have been thrust upon me, but no matter.  After my parents divorced, my dad moved to Arizona and started a new family.  We grew up in relative poverty.  We were on welfare for a time.  I was a latch key kid until I could drive.  Absent the realm of hunger and true squalor, you never realize relative paucity of material well being until you get older.  I may have represented something for the older women of my family, something beyond the hum-drum mediocrity they had known.  (What they didn't realize was that life can be hum-drum and drab and mediocre no matter your station, but that's another topic...)

A couple weeks ago I saw Hamlet again on stage.  It is a work I have always returned to over the years.  I'm a dork about Hamlet.  I memorized the famous "To be or not to be" soliloquy when I was 17 and haven't forgotten it since.  (From time to time, usually in the car, I'll randomly spout it out to no one, and usually, for some strange reason, end up veering into a bizarro Australo-Irish brogue by mid-speech)  Hamlet speaks to me, as the wise asses say.  The melancholic, brooding youth paralyzed by fear and time and inaction.  Knowing there is but one chance along the path of time, that every decision we make is fraught with loss, life as a series of paths untread.

The older I get the more Hamlet stops "speaking to me" and simply informs me of who I am.  It isn't a conversation, it's "here you are, take it or leave it".  And that's fine.  I keep coming back to it so there must be some good to be had.

Hamlet, as per Harold Bloom, is the only character in Shakespeare we can conceive writing any of the actual plays of Shakespeare.  He is human in a way that most flesh and blood, most of the quick can only hope to aspire to.  He speaks and acts his way into existence.  He is the sort of character that, as Holden Caulfield says, we wish were a friend of ours, someone we could call up on the phone and talk when we wanted or needed to.  He has been my friend for an awful long time.   Sad as that is to say.  (I never "mixed" well).

The transformation that occurs in Hamlet from the time he sees his father's ghost to the final duel with Laertes at Elsinore is really quite astounding.  I never noticed it in younger days.  We too easily deposit Hamlet into the bin of "moody adolescent anti-heroes" without paying attention to what happens to the young Dane, the maturation that erupts forth, the flesh and blood human who rises from the pages by Act 5.  Too often we over-focus on the woe-is-me ninny in the first couple of acts who yearns that his "too, too solid flesh would thaw and melt itself into a dew" without recognizing the new man emerging at the end who stoically accepts the dictum of "let it all be".

In the beginning Hamlet is wracked by indecision and guilt and rage.  His father, the noble warrior King Hamlet, has been murdered, it is revealed, by the jealous scheming Uncle Claudius, who then seduces the grieving widow Gertrude; she, "with such dexterity to incestuous sheets", brings the mourning son of a king shame beyond description.  The ghost appears to Hamlet, reveals all and demands vengeance.  It is incumbent upon Hamlet alone to right the wrongs of a foul, foul murder.  None of these events are caused by any act or idea of Hamlet himself.  He is appropriated by filial duty, obligation, social and cultural pressure and urged into action.  He must exact revenge for his murder, but in doing so, risk losing his soul.  His manhood hangs in the balance.  Hamlet swears in writing "adieu, adieu, remember me!" as his ghost father passes into oblivion.  And then we get 3 acts of  equivocation.  To be or not to be.  The anguish that an actor could weep over fictional Hecuba with such volcanic emotional range while Hamlet himself is frozen despite having the "motive and cue for passion" to carry out his dead father's final plea.

In the end he never initiates, just reacts to events as they occur.  He forces Claudius to ignite the fuse with endless schemes and walks into traps willingly.  He stops giving a damn about what others might expect.  He stops trying to manifest the ideal foisted upon him by the Other.   He finds himself in predicaments of the moment and begins to face them with a newfound dignity.  The transformation is completed when he holds the skull of Yorick aloft:
Alas, poor Yorick! I knew him, Horatio: a fellow 
of infinite jest, of most excellent fancy: he hath 
borne me on his back a thousand times; and now, how 
abhorred in my imagination it is! my gorge rims at 
it. Here hung those lips that I have kissed I know 
not how oft. Where be your gibes now? your 
gambols? your songs? your flashes of merriment, 
that were wont to set the table on a roar? Not one 
now, to mock your own grinning? quite chap-fallen?

Memento mori.  All shall pass into dust.  The clay of the remains of even Alexander the Great could be used to plug up a hole in a beer barrel.  All pass into nothingness.  The cat will mew and dog will have his day.  Death becomes a tangible inevitability for the young Dane, not something abstract to theatrically fret and shed tears over.  Life will go on until it stops; whether we act or abstain, whether we lash out or hide behind ramparts, the end will come, far into the future or prematurely.  Life will end.  The path we have trod cannot be retraced and we find that the reasons for our steps assume less and less importance as the years elapse.  All reasons are forgotten in time.  There is only the moment of the eternally recurrent present in which you reside, briefly, before you die.

We find ourselves in places chosen by others.  We never had a chance to weigh in.  But a moment arrives and we make the best of it.  We choose to be, we embrace our fate with indifference, with what Harold Bloom calls a "noble disinterestedness".  By the time Hamlet kills Claudius, he has forgotten all about the ghost of his father.  The events that have driven him to the precipice no longer matter.  He has transcended the boy, become a man, by turning away from filial and social expectation.  His duty is to himself.  Once his fate has been sealed by the sharp tip of Laertes' rapier, he acts, fully in control of himself, for himself.

I still have those envelopes addressed to "Dr J" from years ago.  I keep them in a chest in the attic.  They remain a part of who I was but no longer impact the choices I make, no longer feel woven into my being.  I make my rounds not for those lost whispered promises from my youth, but for the sick, for mine own ends.  I have become the compilation of the days I have lived.  No longer am I an animated projection of the dreams of others.  And each dawn will bring the opportunity to add fresh material to the narrative of a life.

Hamlet walks knowingly into the final trap, despite Horatio's protestations:
We defy augury. There’s a special providence in the fall of a sparrow. If it be now, ’tis not to come. If it be not to come, it will be now. If it be not now, yet it will come—the readiness is all. Since no man of aught he leaves knows, what is ’t to leave betimes? Let be.
Yes, let be.  We shall be ready.  Hamlet learns that the question of "to be or not to be" is no longer a question about living versus dying; at some point along a lifespan it becomes about taking ownership of your own being.  Let it all come rumbling down from the mountain tops and let us rejoice in our transient freedom of the now, to choose to be our own best version of ourselves. Doctor, husband, father, citizen, son....

Sunday, April 30, 2017

Sunday Poem

"Minor Excision"

You’ll feel a pinch and a burn
Like the time she broke your heart.
At first the needle feels sharp
You won't forget, but you don't ever learn

My injection numbs the flesh, her
Touch warmed, ignited desire.
I’ll make an island of ice, a frozen slab
In the middle of your roiling magma of fire.
You won’t feel any pain, what you feel is just pressure

I’ll have it out before you know it:
The memories, pain, joy.  The sound of rain
On Saturday morning when you pulled her head to your chest,
When you closed your eyes, felt quiet and blessed.

That wetness you feel is your own blood dripping.
Almost finished, you can stop gripping
The edge of the table---
Your wound is not fatal.
Won’t take long to close it up.
Now it’s gone, a wedge of you floating in a cup.
It won’t grow back, I had the final say
The wound will heal, your scar may fade


Sunday, April 23, 2017


There was a very bad op-ed published in the NY Times Saturday by the writer/cardiologist, Dr. Sandeep Jauhar.  It's called "Why It's OK for Doctors to Participate in Executions" and that pretty much tells you all you need know.  If you were to  read something online entitled "Why It's OK for Rapists to Babysit Your Child" you would feel the same filthy layer of scum descend upon your skin as I felt when I read Dr Jauhar's inexplicable ode to Doctors of Death.

The piece comes on the heels of a recent decision by the good ol' state of Arkansas to execute 8 men on death row over the next 11 days--- not because their crimes were particularly heinous or irrefutable, or just from sheer coincidence, or some other fluke of timing in the sentencing--- but rather because the state's supply of IV drugs used in executions is due to expire by the end of the month.  There's enough in that last batch, apparently, to knock off 8 inmates.  So...while the iron is hot....

Dr Jauhar makes the error of assuming that capital punishment will never go away, that all we can do as a society is to figure out ways of rendering it in a less mendacious, less barbaric, more telegenic fashion.  And who better to assure that a lethal drug cocktail will be administered with elan and efficacy than a practicing physician?  After all, medical errors are the 3rd leading cause of death in our great country! Allegedly.

I need to break Dr Jauhar's piece down paragraph by excruciating paragraph.  It's the only way to do this with any justice.  Here's one paragraph:
The three drugs in Arkansas’s execution protocol — midazolam; vecuronium bromide, a paralytic used during surgery that halts breathing; and potassium chloride, which stops the heart — are administered intravenously. The execution procedure therefore requires the insertion of catheters, controlled injection of lethal drugs and monitoring of a prisoner’s vital signs to confirm death. This makes it important that a doctor be present to assist in some capacity with the killing.
What is it about "insertion of catheters, controlled injection of lethal drugs, and monitoring of a prisoner's vital signs" unequivocally necessitate the presence of a physician?  The next time I witness an actual real live doctor place a peripheral IV in a patient, inject a medication all by himself, and then check a set of vital signs will be the first in at least a decade of practice.  There is nothing about the act of lethal injection that is inseparable from physician presence.  The idea that basic procedures performed every day by nurses and EMT personnel cannot be duly done without a physician watching over their shoulders is both condescending and ill-informed.

Here's another paragraph:
 The American Medical Association, however, strongly opposes physician participation in executions on ethical grounds. Selecting injection sites, starting intravenous lines and supervising administration of lethal drugs, the association says, violate a doctor’s oath to heal or at least to do no harm. Doctors who defy the association’s guidelines face censure and the threat that a state medical board might revoke their license, though it is doubtful such punishment has ever been carried out. I disagree with this view. Though I oppose capital punishment as a matter of principle, as a doctor I believe physician presence at executions is consistent with our mandate to alleviate suffering.
Who edited this piece? Here we have a physician outlining the American Medical Association's firm stance opposing any physician participation in lethal injection executions and then, blithely, distancing himself from that view while still claiming to hold a higher moral ground---- he only wants to alleviate suffering!  That's obnoxious, man.  You want to stick a doctor in a death chamber with vials full of instant death and call yourself a hero because you are allowing for the state to eradicate a human in a way that seems quiet and unobtrusive and clean.  Even the kids can come out to watch.  Watch the bad man go to sleep, Johnny.  See?  See how peaceful he looks?  Is that a smile on his lips?  He's happier now!  His sin has been purified! Christ has smited him!.  Satan has him now!

I have to go to another paragraph before I start writing 3000 words in the voice of a Evangelical Christian from Little Rock talking to his kid at a state sanctioned execution:
A lot can go wrong during lethal injections. In 2014 in Oklahoma, to cite just one gruesome example, a 38-year-old convicted murderer named Clayton Lockett writhed in pain at his execution, clenching his teeth and straining to lift his head off the pillow, according to witnesses, after a botched injection into a vein in his groin.
A lot can go wrong?  Even with lethal injection?  State sanctioned murder for more civilized and  sophisticated tastes?  You don't say!   You mean that when dangerous drugs are given off label for purposes they weren't meant for that sometimes things can "get a little hairy"?  That's some wild and wacky shit.  Short side tangent here: Do you know why vecuronium is always included in lethal injection cocktails?  Because it is a strong paralyzing agent.  My anesthesiologist colleagues often use it to render a patient completely still when I perform abdominal surgery.  The purpose of the drug in a death chamber is pure optics.  The third drug administered, the actual killer, is generally a lethal dose of potassium chloride.  Once injected it causes a massive myocardial infarction--- which is excruciating.  Even the injection of KCL into the veins itself will make it feel like your arm has been lit on fire.  So to spare us the "theatrics" of a condemned man writhing and groaning in agony while strapped to a gurney, we give the paralyzing agent as cloak; to hide the unsavory awfulness of what an execution actually entails.

Here's 2 paragraphs in a row:

Sunday, April 9, 2017

Sunday Poem

Baked In

There is a sadness baked into existence.
Without it there’s no flavor.
You’d never know what to savor
Or how to wait for joy’s recrudescence

Your cupboard is a cage
Where it sits in darkness
Next to the cinnamon, pepper and sage.
Take what you need, cook your own catharsis

A pinch here, a dash there
Taste it as you stir the mixture
You always add more as time goes along
There’s no limit, you can’t do it wrong.
Some gets added when you turn your head---
It’s serendipity!
Never was a written recipe
Try to recall what mother once said

Put it in the oven and let it bake.
There’s no timer, it’s imprecise.
No way to know when the swirl of sadness coalesces
With the rest and then rises.
A taste you can only imagine will have to suffice

Look outside in the early pre-dawn, dark as sable,
Rows of homes with kitchen lights on.
All of us awake, anxiously waiting at tables
For our cakes to get done



From Erich Fromm's The Art of Listening:

  1. The basic rule for practicing this art is the complete concentration of the listener.
  2. Nothing of importance must be on his mind, he must be optimally free from anxiety as well as from greed.
  3. He must possess a freely-working imagination which is sufficiently concrete to be expressed in words.
  4. He must be endowed with a capacity for empathy with another person and strong enough to feel the experience of the other as if it were his own.
  5. The condition for such empathy is a crucial facet of the capacity for love. To understand another means to love him — not in the erotic sense but in the sense of reaching out to him and of overcoming the fear of losing oneself.
  6. Understanding and loving are inseparable. If they are separate, it is a cerebral process and the door to essential understanding remains closed.
 Some useful advice in there for the working physician.  It may not improve your patient satisfaction scores.  Press-Ganey is unlikely to have a metric that measures one's adherence to the above.  But a concentrated effort to focus on your patient's narrative with open mindedness, imagination, empathy and love sure seems like a good way to be a better doctor.

It's the best part of the job, really.  Once the OR lights go off, the post op orders are written, you finally sign out of the EMR for the night, what you will remember most are all those moments in time when you sat in a room alone with other human beings and listened to them tell you not only what hurt but what things were like before the pain started. Past and current lives and loves.  What the future might hold.  Expressions of gratitude and disappointment.  You will hear special and unique kinds of humor and anger and fear.  In a minute of side wise glances between spouses you will see the theretofore hidden dynamics of an entire relationship.  In short, you will experience the transformation of the human into the Human.  Real known people will emerge from the great mass of anonymity that we mindlessly push through every day like prairie grasses.  And all you have to do is sit there with patience and an open heart, ask a few questions, and just.... listen.

Sunday, April 2, 2017

A Nation in Pain

This past week, Governor John Kasich of Ohio issued an executive order limiting the amount of opioids doctors and dentists can prescribe to no more than a 7 day supply.  Failure to comply could result in disciplinary action, including loss of license.  Exceptions exist only for patients with cancer or those enrolled in hospice programs.  For all the rest, it represents a hard full stop.  No longer will the chronic pain sufferer, the woman status post lumbar back fusion x 3, be able to get a prescription for a month's supply of oxycodone with 3 refills.

On the surface this appears to be a reasonable initiative.  We are undoubtedly in the midst of a true crisis in terms of opiate/opioid abuse in this country.  It is a crisis that disproportionately affects the poor, the downtrodden, across large swaths of flyover rural America.  Something must be done, any reasonable elected official would say.  Over 50,000 Americans died last year as a result of an overdose.  Overall life expectancy declined last year for the first time in nearly 30 years, a decline mainly attributable to middle aged males and females from lower economic and educational attainment strata dying sooner.  Suicide and overdose have been targeted as culprits in this real "American carnage".

But what I am uncomfortable with is the evolving narrative that the entire crisis was fomented by evil "pill mill" doctors lining their pockets with cash as their patients spiraled into despair and degradation .  Certainly, bad apples are out there.  But anecdotal stories about physician malfeasance fail to adequately explain the opioid epidemic.  Why does it exist?  Why are so many Americans turning to escapist options to dull their pain?  What is this constant throbbing ache, this intermittent sharp twinge, that afflicts so many?  Why are so many from very specific geographic areas, from very specific socioeconomic stations seeking relief from a great contagion of pain?

It's easy to say: those damn doctors.  Bad doctors can be fixed.  They can be demonized as scourges upon society.  All stories flow easier with an identifiable villain.  But it's much harder to say: the structural/cultural/economic foundations of our country have been slowly eroding over the past 35 years and as the ramparts come tumbling down, those left exposed, vulnerable to the ravages of life's uncertainties will then turn to something, anything to assuage pain, numb anxiety.  A life lived in a state of constant uncertainty and despair breeds hopelessness.  And for many, escape becomes the only reasonable solution.

Since we embarked upon a path of free market globalization, our nation has seen a rise in income inequality that puts the Gilded Age to shame.  As the following graphs show:

Source: Emmanuel Saez, Center for Equitable Growth, June 2015
Source: Striking it Richer: The Evolution of Top Incomes in the United States, Emmanuel Saez, June 2015
Source: Institute for Policy Studies and AFL-CIO analysis of Bureau of Labor Statistics average hourly earnings data and corporate proxy statements, 2016

And how did this occur?  How is it that, in the richest, most wealthy nation in recorded history, so much of the fruits have gone to so few of its citizens? The answers of course, reside outside of what this blog post can elucidate, but the common theme revolves around wealth concentration and restricted distribution.  We have all driven by the shuttered factories in the heartland.  Those jobs shipped off to third world countries in the 80's and 90's will never return.  No longer can a male of mediocre intellectual talents just sign up for a job out of high school at the local Ford plant or the rubber tire factory and plan to settle in for 25-30 years of solid pay with good benefits and be able to raise a family, send his kids to college, retire at 65 with a 7 figure pension.  Those days experienced by the baby boomer generation, are almost mythically unattainable by the bulk of Americans in the heartland today.

And so what happens?  What happens when a man or a woman cannot honorably earn a living?  When the costs of higher education go up 400% over 25 years?  When health care expenses skyrocket beyond affordability and, in the absence of employer based insurance, become the driving etiology of bankruptcy and financial catastrophe?  What happens?  Is it simply of case of legions of evil doctors descending upon these wracked plains of a nation and unleashing their addictive and destructive medicines?  Is that the narrative we ought to go with, in the face of so much contrary evidence of systematic instability?

Governor Kasich and Senator Portman in my home state, have made the opioid epidemic a priority in terms of legislation and executive orders.  I am not so cynical as to doubt their motivations.  They see the pain and suffering in so many of their constituents and want to alleviate it, to the extent they are able.  But these measures are akin to the crackdown during the War of Drugs.  We ended up incarcerating millions of Americans (mostly minorities, mind you) without having any impact on drug use, especially in the areas where the crackdown was most targeted, i.e. the inner cities.  Prohibitionary measures simply don't work.  The evidence from the 1920's and then from the 1970-2015 War on Drugs era is irrefutable.  You cannot simply criminalize or police your way to complete abstinence.  The black market will always step in to fill the gaps in supply.  And the greater you restrict access, the more the black market will place its foot upon the throats of those clamoring for a fix.  The vicious cycle will continue.  The drugs will be less regulated, stronger, more dangerous.  More will die.  More will go to jail and be forever stained with a felony tag.  It would be a tragedy to repeat the same mistakes we've made in the past for this new scourge.

The real issue, the potentially fixable issue, is one of demand.  Why are all these Americans turning to the escapism offered in the form of heroin or prescription opioids?  And how can that demand be addressed?

We know that 20% of Vietnam veterans were addicted to heroin during the war.  But only a small percentage continued to use heroin once they returned home to America, back to jobs and wives and existential stability.  We know that in Portugal and Switzerland, opiate addicts can go to "clinics" for heroin injections early in the morning on their way to work.  That many of them eventually simply stop using the drugs as they become more and more integrated back into stable and meaningful life routines.  In America opt to do things differently.  Marijuana is categorized as a  Schedule I substance (no accepted medical use).  Addicts are treated as derelicts, scum of the earth.  We continue to incarcerate more people for drug related offenses than the rest of the world combined.  And nothing has changed, nothing has improved, despite the trillions of dollars spent on this ill-advised "war" over the past 35 years.

A nation writhes in pain.  No one can avert their eyes from it.  Our ER's fill up nightly with overdoses.  The young and middle aged are dying in unprecedented numbers.  A plague is upon us.  You can regulate doctors a little more, I guess.  You can repudiate the idea that "pain is the fifth vital sign", as the American Medical Association has done.  But you can not simply tell people that they are not hurting.  You cannot erase the pain of dislocation, uncertainty, economic catastrophe.  You cannot tell a man with three kids, a drug habit, trapped in rural middle America, that the pain he feels every morning in his back, his joints, his heart and soul is somehow not real.  That he ought to feel shame.  That it is somehow all his fault.  

You can threaten doctors.  You can cut off the legal flow of a few bottles of prescriptions drugs.  But it won't stop the pain of the millions with no prospects and no hope.  Kasich's order is a band-aid applied to a gaping hemorrhaging wound.  It's something, I guess.  But it isn't nearly enough.