Medical Journal: 8/22/18

Found a brave cardiologist willing to try an angiogram without starting me on dialysis first: Dr. Dmitri Feldman, the one recommended by Dr. Sanders. Apparently there’s a version of an angiogram that uses very little (<30cc.) contrast medium. Somewhat weirdly, it appears that the first time I’ll meet Dr. Feldman is Monday, when the procedure is scheduled. I’m going to check in with Dr. Bomback, the nephrologist, to follow up on Dr. Lew’s suggestion of taking 600mg of n-acetylcysteine twice a day the day before and the day of the procedure.

The plan is to have me in and out of the hospital within about five hours, suggesting that the procedure isn’t all that drastic. But I’ve been surprised before. Fingers crossed.

Illicit Tobacco and Nicotine Markets

Man who ran one of the largest cigarette smuggling operations in Virginia pleads guilty, will serve 3 1/2 years of 85-year sentence.

Philip Morris suspends social media campaign after Reuters exposes young influencers. Are heat-not-burn products a safer alternative to cigarettes? Reynolds Tobacco blames teen vaping crisis on Juul in fighting FDA plan to rein in e-cigarettes.

Opinion: Progressives blow smoke on sensible solutions.

435,000,000 illegal cigarettes smoked in Ireland last year.

How should Congressional Dems handle the debt ceiling?

Make a long list of demands, and choose a shorter list of “must-haves,” with an eye to electoral appeal as well as substantive advantage.

I had missed this Kevin Drum post from last month (Note to self: Never miss a Kevin Drum post!) and the WashPo article it refers to.

Tl;dr:

The Federal Government will hit the debt ceiling sometime this fall, and Democrats need to consider whether to pass a “clean” increase or instead to hold it hostage to various things we want. Kevin is (tentatively) on the side of adhering to the norm of not using the threat of national insolvency as a political lever.

I might agree, if such a norm existed. But Republicans smashed it all to pieces when Obama was President, so respecting it now looks too much like unilateral disarmament.

It seems to me the right question is: What should Democrats in the House demand as the price of passing a “must-pass” bill? My answer would be: Demand everything, including the kitchen sink, and negotiate from there, with a few “must-have” demands.

Possible demands can be roughly sorted into two bins; for each bin I’ve provided possible examples.

  • Procedural/rule-of-law/democracy items
  1. Compliance with all Congressional subpoenas
  2. Production of Trump’s tax returns
  3. A Special Counsel to inquire into violations of the Emoluments clauses
  4. Defensive measures against foreign interference in U.S. elections, including a stronger FARA
  5. A new Voting Rights Act, with a standard for the maximum waiting time at the polls and an explicit ban on using criminal justice financial obligations to deny the right to vote
  6. An explicit ban on partisan gerrymandering in Congressional elections (clearly within one of Congress’s enumerated powers and thus fairly bullet-proof in court)
  7. Taking the citizenship question off the 2020 Census
  • Substantive policy items
  1. Card check
  2. $15 minimum wage
  3. Banning family separation at the border
  4. Disaster relief including California and Puerto Rico
  5. More money for Head Start
  6. Fiscal incentives for states to adopt Medicaid expansion
  7. Reversal of the Trump tax breaks for returns with more than $1M in annual income
  8. A down payment on college debt relief
  9. Medicare buy-in
  10. More money for the opioid crisis
  11. A program to reverse the rise in maternal and infant mortality
  12. [Fill in the blank] about women’s pay equity
  13. [Fill in the blank] about global warming/climate change
  14. Ending support for Saudi Arabian warmaking in Yemen
  15. Rural broadband
  16. Postal banking in any county with more than x% of households unbanked
  17. Arbitration reforms to avoid people’s being required to sign their rights away

I don’t see any harm in making the list fairly comprehensive, with appeals to a variety of interests and opinions. Then the question is what to absolutely hold out for.

Trump’s tax returns are the obvious candidate from the RoL list, just because he’d have very limited public sympathy if he tanked the economy to protect himself from corruption charges. But forbidding the Executive from spending any money to challenge Congressional subpoenas in court, and providing stiff statutory penalties both on an individual level and via withholding appropriated funds for non-compliance, would certainly be high on the list. From the substantive-policy column, I’d be tempted to hold out for card check, since I agree with Kevin that union power is the key both to reversing the increase in income inequality and in deciding who wins elections. But that’s probably a bridge too far: the Republicans would almost certainly prefer to crash the country’s credit than give working people a fair break. So pick whichever two or three of the rest poll best.

This can’t be done overnight, so both the think tanks and the committees need to get to work ASAP on putting the list together and writing the necessary legislative language.

Cannabis News Round-Up

Oregon Senate puts temporary freeze on marijuana production. Oregon marijuana surplus spurs senators to block new grower licenses. As legal marijuana booms, Denver votes on decriminalizing hallucinogenic mushrooms. Colorado senators lead way on national legalization of marijuana. Colorado pot czar: Legal marijuana not a “cash windfall.” San Fransciso’s Haight Street gets a new, legal king of weed.

Massachusetts makes history as first legal marijuana shops on East Coast open. Uxbridge, Massachusetts entrepreneur dreams of selling legal marijuana at a drive-through pot shop. Vermont House committee approves legal marijuana market. Follow-up on the legalization of marijuana in Connecticut.

New York Senator says fate of marijuana legalization depends on Cuomo’s willingness to use political capital. Is New Jersey legal weed fight being hurt by governor’s squabble with top Democrats over corporate tax breaks? Prospects for New Jersey legal weed bill looking grim, insiders say. Want cannabis jobs? Advocate for legalization, says New Jersey panel.

D.C. mayor wants Council to make marijuana sales legal in nation’s capital.

Illinois Governor introduces bill to legalize recreational marijuana. Illinois Representative on recreational marijuana: Not so fast. Opposition to recreational marijuana in Illinois mounts. Illinois legal pot opponents reject Pritzker’s social equity arguments. Police oppose marijuana legalization in Illinois, but want a bigger cut of the proceeds if law passes. Illinois marijuana legalization efforts leave questions for employers. Would Illinois legal marijuana bring dispensaries to DeKalb and Sycamore? Mayors weigh in.

The arc of legal weed bends toward injustice. Merger madness reshapes marijuana business. Attorneys General from thirty-three states urge pot banking reform.Republican congressman tells Democrats to end Trump obsession and focus on marijuana. Why Cory Booker cares so much about legal weed. TSA: “We’re cool,” and we’re not looking for your weed. Breaking the news to mom and dad: I’m selling weed (legally).

New Zealand Cabinet set to consider cannabis referendum. New Zealand government releases details of marijuana legalization referendum. Legalizing cannabis in Australia could create $1 billion in tax revenue.

Illicit Tobacco and Nicotine Markets

Ashes to ashes: How British American Tobacco avoids taxes in low and middle income countries. New head of South African Revenue Service to investigate reports of $140 million in cigarette tax evasion.

Rome, New York police seize over 200 cartons of untaxed cigarettes. After a months-long investigation of the alleged possession, transportation and sale of unstamped cigarettes the Rome Police Department and state Department of Tax and Finance have arrested a local man.

Eight Chinese nationals denied entry to Australia after discovery of 177,000 undeclared cigarettes. Illegal cigs worth $160,000 seized in Malaysia.

Around sixteen percent of all cigarettes smoked in Islamabad, Pakistan are illicit. Tobacco companies play faulty with illegal smokes in Pakistan.

Castleford, UK booze store boss gives up license after 6,000 illicit cigarettes found in toilet.

Medical Journal: 8/20/18

Just heard back from Dr. Weiss, the internist. He’s all for medical management of the cardiac issue once we know what it is, but he’s pretty sure it will take an angiogram or the moral equivalent to make a definite diagnosis. “Looks like three-vessel disease. If you’re 80% restricted, medical management should work. If you’re 99% restricted, you need to be re-vascularized.” He will send the chart to the cardiologist Dr. Sanders recommended and ask him what ought to be done. That might mean a low-contrast angiogram that wouldn’t require putting me on dialysis first. Fingers crossed.

First radiation treatment today. Other than the fact that the mask shrunk a little bit as it dried and is now tight around my nose, no discomfort at all. That was the predicted result for the first couple of weeks. Then things might, or might not, get hairier; apparently there’s almost no risk of something really hairy.

I’ve been getting lots of notes from friends, and they’re greatly appreciated. Despite what I thought was a reasonably optimistic prognosis, a number of you were very distressed; that wasn’t my intention. Those of you who went through this with me last round know that these notes aren’t the least bit sugar-coated; when I’m actually suffering, or when the news is bad, you’ll know about it. So when I say I’m cheerful and that the outcome is likely to be that I come out of this in reasonably good health, you can take that to the bank. If I thought the country was as likely as I am to be in good shape five years from now, then I’d really be a happy camper.

Love Means Saying You Are Woman Sorry

Yesterday, a British journalist asked me how the supporting technology was at Washington Post since Jeff Bezos bought it. I replied “Quite good” and his expression told me I had been misunderstood. So I said “I meant American quite good not British quite good”.

This reminded me of a common problem of the heterosexual couples I counselled back in the day. The wildly popular 1970 film Love Story taught Americans that “Love means never having to say you are sorry.” No wonder the divorce rate was so high in what Garry Trudeau called a kidney stone of a decade. Of course you sometimes have to say you are sorry to keep an intimate relationship going. But what do you mean when you say it?

For most of the men I saw in counseling, saying sorry meant that you had done something wrong and were apologizing. For most of the women, sorry more often meant “I feel you”. A common resulting scenario for misunderstanding would be that the husband would complain about, say, his awful boss and his wife would say “I’m sorry about that”, leading the man to reject this expression of sympathy with “Why? It’s not your fault.” Even more painfully, when the wife would describe her own troubles she might feel hurt that her husband didn’t express any sorrow. Meanwhile, he would be thinking “I feel bad for it, but it’s not my fault, so I’m not going to say I’m sorry”.

A way past this that seemed to help was to teach the couples the difference and help them become comfortable in emotional exchanges to refer to “woman sorry” and “man sorry”, e.g., “I’m not saying it’s your fault, I’m asking you to be woman sorry for me” and “I’m man sorry that I didn’t understand until this moment what you needed from me”.

How to legalize cannabis: the case of Maine

There’s more to legalizing cannabis than setting up a market. The extent of post-prohibition public-health and public-safety problems depends on the details, and especially on price.

One reason I distrust the state-by-state process of legalizing cannabis and prefer a national approach is that the people drafting the laws and writing the regulations tend to reason more or less along these lines:

“Cannabis and alcohol are both intoxicants. We know how to regulate alcohol, so we should handle cannabis the same way.”

There are two things wrong with that.

First, cannabis is like alcohol in some ways but unlike it in others, so it needs a different control regime. (E.g., it’s not clear that we should criminalize cannabis use in public, use by minors, or stoned driving; doing so risks a kind of “backdoor re-criminalization.” In each case the link to aggression and violence that is so marked with alcohol is weaker, or may not even exist, with cannabis.)

Second, the current alcohol control regime leads to an estimated 88,000 excess deaths per year, and incredible amounts of disease and misery. That doesn’t look like a successful policy to me, and applying that policy to cannabis would be a clear case of “Doing the same thing and expecting a different result.” If you were to ask a state alcohol regulator about the prevalence of Alcohol Use Disorder among high-school students, or the number of alcohol-involved murders or suicides, you’d mostly get a blank look. A liquor board usually understands its job as making sure the taxes are paid, that the premises are orderly, and that licensees don’t sell directly to minors. The impact of alcohol on public health is the province of the health department, while its impact on public safety is a problem for the police and the prosecutors.

So with cannabis. Most state regulators are more interested in creating an orderly legal market that can displace the illicit market than in serving a broader policy vision that includes minimizing the predictable bad side-effects of commercial legalization.

BOTEC Analysis was hired by Maine’s Office of Marijuana Policy to review a draft set of regulations, which were pretty much as we expected. 

The introduction to our comments, explaining what we were trying to do, is pasted in below the fold.  While the comments are linked to specific sections of the Maine regulations, some of the ideas might be of interest to regulators elsewhere, and to legislators and advocates drafting new legalization statutes. 

Continue reading “How to legalize cannabis: the case of Maine”

Medical Journal: 8/12/18

Met with Dr. Sanders, the pulmonologist, who saw me way back when we thought my cough might be a mycobacterium avium intercellular infection and who figured out from a CAT scan of the chest that it wasn’t, then sending me to Dr. Sulica, the ENT, who finally diagnosed the carcinoma.

(I know, you can’t tell the players without a scorecard. I’ve been extremely impressed with the intelligence and energy of the physicians I’ve been seeing in New York; I got some excellent care in L.A., especially from my oncologist, Dr. Emmanuelides, but overall the docs I saw were a little bit too laid-back and not as decision-theory oriented as I would have liked; when Dr. Weiss told me that he wasn’t completely reassured by my first, negative stress test because that test is only 80-85% sensitive, I knew I was playing in a different league. It would be wrong to notice the high prevalence of (((a particular characteristic))) among the people treating me in New York, so I won’t mention that as a possible explanation.)

I brought him up to date; apparently my Columbia Presbyterian records (from my nephrologist and the radiocardiology folks) aren’t transparent to the Weill Cornell system. I’m hoping that won’t be a problem for the transplant team at NYU Langone. He thinks the cough will resolve once the tumor has been burned out. When I explained the difficulty of finding a cardiologist to do a cardiac catheterization without putting me on dialysis, he looked at the PET results and said “Are you considering a bypass? This looks as if it could be managed medically rather than surgically, but you’re not currently on any of those drugs.” He gave me the name of an interventional cardiologist, Dr. Dimitry Feldman. I’m going to pass that suggestion along to Dr. Weiss. If it’s right, that would be extremely good news under the circumstances.

Lab Report

In his dissent in New State Ice Co. v. Liebmann, 285 U.S. 262 (1932), Justice Brandeis wrote:

[T]he advances in the exact sciences and the achievements in invention remind us that the seemingly impossible sometimes happens. There are many men now living who were in the habit of using the age-old expression: ‘It is as impossible as flying.’ The discoveries in physical science, the triumphs in invention, attest the value of the process of trial and error. In large measure, these advances have been due to experimentation. In those fields experimentation has, for two centuries, been not only free but encouraged. Some people assert that our present plight is due, in part, to the limitations set by courts upon experimentation in the fields of social and economic science; and to the discouragement to which proposals for betterment there have been subjected otherwise. There must be power in the states and the nation to remould, through experimentation, our economic practices and institutions to meet changing social and economic needs. I cannot believe that the framers of the Fourteenth Amendment, or the states which ratified it, intended to deprive us of the power to correct the evils of technological unemployment and excess productive capacity which have attended progress in the useful arts.

To stay experimentation in things social and economic is a grave responsibility. Denial of the right to experiment may be fraught with serious consequences to the nation. It is one of the happy incidents of the federal system that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.

Id., 285 U.S. at 310-311.

The states either supported by their courts or, in some cases, lead by their courts, have been doing a good deal of experimentation.

For instance, in League of Women Voters v. Pennsylvania, __ Pa. __ (February 18, 2018), the Pennsylvania Supreme Court held that a Republican attempt to gerrymander congressional districts violated the Pennsylvania state constitution. The U.S. Supreme Court refused to block the Pennsylvania ruling. Thus, the Pennsylvania ruling is impervious to the sort of attack I recognized as a possibility with respect to the various federal cases holding gerrymandering unconstitutional under the federal constitution.

Earlier, I posted a report on a Kansas decision based on that state’s constitution, upholding, at least temporarily, a woman’s right to an abortion.

Finally, this week, the Maryland Court of Special Appeals, Maryland’s intermediate appellate court, in Montgomery County v. Complete Lawn Care, Inc., fended off an attack on a county ordinance restricting the use of certain pesticides for cosmetic purposes in the county. The attack was based upon a claim that the county enactment was preempted by state law. (Among the plaintiffs seeking to block the law was the misleadingly named “Responsible Industry for a Sound Environment, a Committee of Croplife America,” a pesticide trade organization.)

I suppose that it could be argued that the current round of cases differs from the situation presented in New State Ice Co. There, the courts were blocking progressive legislative actions. In the Pennsylvania and Kansas cases above, the courts were acting as bulwarks against legislative attacks on progressive positions. Of course, this gives a somewhat different take on the concept of states’ rights.