What the Working Class Is Still Trying to Tell Us

David Brooks in The New York Times



Republican supporters waited to enter a rally in Indiana where President Trump was campaigning days before the midterm elections. Credit Leah Klafczynski for The New York Times


I was ready for massive Democratic turnout for the election on Tuesday. But I was surprised how massive the Republican turnout was in response.

The Republicans who flooded to the polls weren’t college-educated suburbanites. Those people voted for Democrats this year.

They weren’t tax-cut fanatics. Half of the Republican members of the House Ways and Means Committee either left Congress, ran for other offices or were defeated.

They weren’t even small-government Republicans. The same red states that elected conservatives to office also — in Nebraska, Idaho and Utah — approved ballot initiatives to expand Medicaid. The same red states that elected conservatives also approved initiatives — in Arkansas and Missouri — to raise the minimum wage.

These were high-school-educated, working-class Republicans.

A lot of us pundits said Donald Trump should run a positive campaign bragging about all the economic growth. But Trump ran another American carnage campaign. That’s because American life still feels like carnage to many.

This is still a country in which nearly 20 percent of prime-age American men are not working full time. This is still a country in which only 37 percent of adults expect children to be better off financially than they are. This is still a country in which millions of new jobs are through “alternative work arrangements” like contracting or consulting — meaning no steady salary, no predictable hours and no security.

Working-class voters tried to send a message in 2016, and they are still trying to send it. The crucial question is whether America’s leaders will listen and respond.

One way to start doing that is to read Oren Cass’s absolutely brilliant new book, “The Once and Future Worker.” The first part of the book is about how we in the educated class have screwed up labor markets in ways that devalued work and made it harder for people in the working class to find a satisfying job.

Part of the problem is misplaced priorities. For the last several decades, American economic policy has been pinioned on one goal: expanding G.D.P. We measure G.D.P. We talk incessantly about economic growth. Between 1975 and 2015, American G.D.P. increased threefold. But what good is that growth if it means that a thick slice of America is discarded for efficiency reasons? 

Similarly, for the last several decades American, welfare policy has focused on consumption — giving money to the poor so they can consume more. Yet we have not successfully helped poor people produce more so that they can take control of their own lives. We now spend more than $20,000 a year in means-tested government spending per person in poverty. And yet the average poverty rate for 2000 to 2015 was higher than it was for 1970 to 1985.

“What if people’s ability to produce matters more than how much they can consume?” Cass asks.

The bulk of his book is a series of ideas for how we can reform labor markets.

For example, Cass supports academic tracking. Right now, we have a one-size-fits-all education system. Everybody should go to college. The problem is that roughly one-fifth of our students fail to graduate high school in four years; roughly one-fifth take no further schooling after high school; roughly one-fifth drop out of college; roughly one-fifth get a job that doesn’t require the degree they just earned; and roughly one-fifth actually navigate the path the system is built around — from school to career.

We build a broken system and then ask people to try to fit into the system instead of tailoring a system around people’s actual needs.

Cass suggests that we instead do what nearly every other affluent nation does: Let students, starting in high school, decide whether they want to be on an apprenticeship track or an academic track. Vocational and technical schools are ubiquitous across the developed world, and yet that model is mostly rejected here.

Cass also supports worker co-ops. Today, we have an old, adversarial labor union model that is inappropriate for the gig economy and uninteresting to most private-sector workers. But co-ops, drawing on more successful models used in several European nations, could represent workers in negotiations, train and retrain workers as they moved from firm to firm and build a safety net for periods of unemployment. Shopping for a worker co-op would be more like buying a gym membership. Each co-op would be a community and service provider to address a range of each worker’s needs.

Cass has many other proposals — wage subsidies, immigration reforms. But he’s really trying to put work, and the dignity of work, at the center of our culture and concern. In the 1970s and 1980s, he points out, the Emmy Award-winning TV shows were about blue-collar families: “All in the Family,” “Taxi,” “Cheers,” “The Wonder Years.” Now the Emmy-winning shows are mostly about white-collar adults working in Los Angeles, Seattle, Boston, New York and Washington. 

We in the college-educated sliver have built a culture, an economy and a political system that are all about ourselves. It’s time to pass labor market reforms that will make life decent for everybody.

Congress - The party of Hinduism?

Liberals hoping that Rahul Gandhi’s Congress would rescue them from Hindutva may be in for a rude awakening writes G Sampath in The Hindu


The stage is all set for Assembly elections in five States — Madhya Pradesh, Rajasthan, Chhattisgarh, Mizoram and Telangana. Described as a ‘semi-final’ for the 2019 Lok Sabha polls, they offer a foretaste of the electoral strategies likely to be on view next year. Though State and national elections often have their own specific dynamic, some useful inferences may be drawn from the campaigns of the national parties, especially the Congress.

An important conundrum is whether the Congress can emerge as a meaningful alternative to the Bharatiya Janata Party (BJP) and its Hindu majoritarian politics. On the evidence of its campaign so far, especially in Madhya Pradesh and Rajasthan, the party appears to have chosen the path of least resistance. Given that these two States also happen to be among those where the BJP’s Hindutva dimension is in full bloom, they presented the Congress with a good opportunity to test its political counter to the divisive agenda of its adversary. The combination of high anti-incumbency and a two-way contest with the BJP meant that the Congress could have taken the ideological battle to the Sangh Parivar.

Wooing the upper castes

But the Congress did nothing of the sort. It steered clear of the BJP’s majoritarian depredations, and opted to woo the same upper castes that constitute the BJP’s core vote base. It has embraced what has come to be known as ‘soft Hindutva’. In Madhya Pradesh, for instance, the Congress has promised to build cow shelters in every village if voted to power — this in a State where desperate farmers were fired upon by the administration. In Kerala, its State unit has played along with so-called religious sentiment, opposing the entry of women (between the ages of 10-50) in Sabarimala instead of standing by the constitutional principle of equality.

In Rajasthan, too, the Congress’s game plan is to retrieve the upper caste vote from the BJP. Hindutva politics has queered the pitch in such a way that today no party can specifically woo the savarna voter without pandering to communal sentiment. In effect, this means not confronting the infusion of religion into the heart of democratic politics. Conversely, challenging it would require two things from a party: certain ideological non-negotiables, among which, in the case of the Congress, would be the Nehruvian legacy of secularism and a politics of caste rooted in the principle of social justice.

Given the cynicism that has become commonplace in public discourse, it is fashionable to scoff at any expectation of principles in politics. But it is delusional to imagine that the very realpolitik that unleashed the genie of communal hatred on national politics will also be able — now that its disruptions are coming home to roost — to put that genie back into the constitutional bottle. In fact, the most troubling takeaway from the Congress’s approach to these Assembly polls is that even an outright victory for a Congress-led alliance in 2019, however improbable it may seem at present, may not really signify a defeat of communal forces.

The clearest indication yet that the Congress cannot be expected to counter the normalisation of Hindu majoritarianism came during party president Rahul Gandhi’s campaign tour in Madhya Pradesh, where he stated that the “Congress was a party of Hinduism”. He prefaced it by saying that it was “not a party of Hindutva” but the fact that he felt compelled to paint the Congress in Hindu colours marks a clear shift in the party’s overt political line.

For some time now, there has been a debate on the Congress’s use of ‘soft Hindutva’ as a counter to the BJP’s presumably ‘hard’ Hindutva. Mr. Gandhi’s supporters have argued that what has been labelled as ‘soft Hindutva’ is nothing but a free and open expression of his personal faith as a devout Hindu. Even if this were true, his temple visits, which rarely seem to take place without a photo-op, the recent emergence of vermilion on his forehead, his pilgrimage to Kailash Mansarovar, and his coming out as a Shiv bhakt, are all gestures saturated with political significance.

Smart politics?

They could either be read as a smart political response to the widespread ‘Hinduisation’ of the socio-political sphere, or as an admission of defeat to Hindutva forces, for this is exactly what they seek — an India where Hindu identity would be the starting point of any mobilisation for political power.

Last month, a Rajasthan Minister was booked for violating the Representation of the People Act after he gave a speech asking all Hindus to vote for the BJP. Mr. Gandhi has never verbalised such a plea with regard to his own party. But can we truly characterise his description of the Congress as a “party of Hinduism”, or his embodiment of Hindu symbolism on the campaign trail, as actions in keeping with either the spirit of the Representation of the People Act or the secularism the Constitution speaks of?

There are other aspects of this symbolism-driven ‘soft Hindutva’ that are as troubling: an overriding anxiety not to be seen as sympathetic to Muslims; and a low key yet consistent messaging that underscores Mr. Gandhi’s position at the apex of the caste hierarchy as a “janeu-wearing Hindu”. The phrase, used by a Congress spokesperson after Mr. Gandhi’s visit to the Somnath temple last year, was invoked by a BJP leader recently in the context of yet another temple visit by Mr. Gandhi, when he asked, “What kind of janeu-dhari are you? What is your gotra?” The focus on Mr. Gandhi’s caste pedigree once again reveals how temple politics is never without its attendant caste politics.

Put simply, it gives the lie to Mr. Gandhi’s self-serving distinction between Hindutva and Hinduism, a distinction that is also becoming increasingly popular among an influential section of Indian liberals who, much like Mr. Gandhi, seem to have suddenly woken up to their Hindu identity in the last four years. For these ‘proud Hindus’, one of whom has recently penned a bestselling book on why he is one, the classical secularist position that one’s religion is a private matter and not an instrument to garner social or political capital is, of course, past its sell-by date.

The distinction between Hinduism and Hindutva — which only matters because of the political uses of religion —rests on two premises. First, that Hinduism is inclusive and progressive, while Hindutva is exclusionary and regressive; second, that Hinduism is individualistic and preaches tolerance, whereas Hindutva is a supremacist ideology that deploys angry mobs to subjugate other religious communities.

On Sangh Parivar’s page

While this is, no doubt, an interesting distinction, it is even more interesting that no Hindutva ideologue has ever expressed any discomfort with this definition of Hinduism that categorically rejects Hindutva. If anything, representatives of the Sangh Parivar have been pleased with the transformation of the Congress president into a tilak-wearing, temple-hopping ‘Hindu politician’.

The Congress becoming more ‘Hindu’ is but another sign of savarna consolidation, a movement of which Hindutva is the flag-bearer. Mr. Gandhi’s version of non-threatening Hinduism and the Parivar’s aggressive Hindutva are in complete agreement on one issue: caste. They both want to be the party of choice for the upper castes, and so long as this remains the case, the Congress cannot be expected to operationalise in its politics the principle of equality. In other words, liberals and other good-hearted people hoping that Mr. Gandhi and the Congress would rescue them from Hindutva may be in for a rude awakening. As is well known, god doesn’t help those who don’t help themselves.

The making of an opioid epidemic

When high doses of painkillers led to widespread addiction, it was called one of the biggest mistakes in modern medicine. But this was no accident. By Chris McGreal in The Guardian 

Jane Ballantyne was, at one time, a true believer. The British-born doctor, who trained as an anaesthetist on the NHS before her appointment to head the pain department at Harvard and its associated hospital, drank up the promise of opioid painkillers – drugs such as morphine and methadone – in the late 1990s. Ballantyne listened to the evangelists among her colleagues who painted the drugs as magic bullets against the scourge of chronic pain blighting millions of American lives. Doctors such as Russell Portenoy at the Memorial Sloan Kettering Cancer Center in New York saw how effective morphine was in easing the pain of dying cancer patients thanks to the hospice movement that came out of the UK in the 1970s.

Why, the new thinking went, could the same opioids not be made to work for people grappling with the physical and mental toll of debilitating pain from arthritis, wrecked knees and bodies worn out by physically demanding jobs? As Portenoy saw it, opiates were effective painkillers through most of recorded history and it was only outdated fears about addiction that prevented the drugs still playing that role.

Opioids were languishing from the legacy of an earlier epidemic that prompted President Theodore Roosevelt to appoint the US’s first opium commissioner, Dr Hamilton Wright, in 1908. Portenoy wanted to liberate them from this taint. Wright described Americans as “the greatest drug fiends in the world”, and opium and morphine as a “national curse”. After that the medical profession treated opioid pain relief with what Portenoy and his colleagues regarded as unwarranted fear, stigmatising a valuable medicine.

These new evangelists painted a picture of a nation awash in chronic pain that could be relieved if only the medical profession would overcome its prejudices. They constructed a web of claims they said were rooted in science to back their case, including an assertion that the risk of addiction from narcotic painkillers was “less than 1%” and that dosages could be increased without limit until the pain was overcome. But the evidence was, at best, thin and in time would not stand up to detailed scrutiny. One theory, promoted by Dr David Haddox, was that patients genuinely experiencing pain could not become addicted to opioids because the pain neutralised the euphoria caused by the narcotic. He said that what looked to prescribing doctors like a patient hooked on the drug was “pseudo-addiction”.
Portenoy toured the country, describing opioids as a gift from nature and promoting access to narcotics as a moral argument. Being pain-free was a human right, he said. In 1993, he told the New York Times of a “growing literature showing that these drugs can be used for a long time, with few side-effects, and that addiction and abuse are not a problem”.

Long after the epidemic took hold, and the death toll rose into the hundreds of thousands in the US, Portenoy admitted that there was little basis for this claim and that he had been more interested in changing attitudes to opioids among doctors than in scientific rigour.

“In essence, this was education to destigmatise and because the primary goal was to destigmatise, we often left evidence behind,” he admitted years later as the scale of the epidemic unfolded.

Likewise, Haddox’s theory of pseudo-addiction was based on the study of a single cancer patient. At the time, though, the new thinking was a liberation for primary care doctors frustrated at the limited help they could offer patients begging to get a few hours’ sleep. Ballantyne was as enthusiastic as anyone and began teaching the gospel of pain relief at Harvard, and embracing opioids to treat her patients.

“Our message was a message of hope,” she said. “We were teaching that we shouldn’t withhold opiates from people suffering from chronic pain and that the risks of addiction were pretty low because that was the teaching we’d received.”

But then Ballantyne began to see signs in her patients that experience wasn’t matching theory. Doctors were told they could repeatedly ratchet up the dosage of narcotics and switch to a new and powerful drug, OxyContin, without endangering the patient, because the pain, in effect, cancelled out the risk of addiction. To her dismay, Ballantyne saw that many of her patients were not better off when taking the drugs and were showing signs of dependence.

Among those patients on high doses over months and years, Ballantyne heard from one after another that the more drugs they took, the worse their pain became. But if they tried to stop or cut back on the pills, their pain also worsened. They were trapped.

“You had never seen people in such agony as these people on high doses of opiates,” she told me. “And we thought it’s not just because of the underlying pain; it’s to do with the medication.”

As Ballantyne listened to relatives of her patients talk about how much the drugs had changed their loved ones, her misgivings grew. Husbands spoke of wives as if a part of them were lost. Mothers complained that children had become sullen and distant, their judgment gone, their personality warped, their character altered. None of this should have been happening. Pain relief was supposed to free the patients, not imprison them. It was all very far from the promise of a magic bullet.

As the evidence that opioids were not delivering as promised piled up, the Harvard specialist began to record her findings. By then, though, there were other powerful forces with a big financial stake in the wider prescribing of painkilling drugs. Pharmaceutical companies are not slow to spot an opportunity and the push for wider prescribing of opioids had not gone unnoticed by the drug-makers, including the manufacturer of OxyContin, Purdue Pharma, which rapidly came to play a central role in the epidemic.

As the influence of the opioid evangelists grew, and restraints on prescribing loosened, the pharmaceutical industry moved to the fore with a push to make opioids the default treatment for pain, and to take advantage of the huge profits to be made from mass prescribing of a drug that was cheap to produce.

 

Bottles of painkiller OxyContin, made by Purdue Pharma. Photograph: Reuters

The American Pain Society, a body partially funded by pharmaceutical companies, was pushing the concept of pain as the “fifth vital sign”, alongside other measures of health such as heart rate and blood pressure. “Vital signs are taken seriously,” said its president, James Campbell, in a 1996 speech to the society. “If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign.”

The APS wanted the practice of checking pain as a vital sign as a matter of routine adopted in American hospitals. The key was to win over the Joint Commission for Accreditation of Healthcare Organizations, which certifies about 20,000 hospitals and clinics in the US. Its stamp of approval is the gateway for medical facilities to tap into the huge pot of federal money paying for healthcare for older, disabled and poor people. Hospitals are careful not to get on the wrong side of the joint commission’s “best practices” or to fail its regular performance reviews.

In response to what it called “the national outcry about the widespread problem of under-treatment” – an outcry in good part generated by drug manufacturers – the commission issued new standards for pain care in 2001. Hospital administrators picked over the document to ensure they understood exactly what was required.

Every patient was to be asked about their pain levels, no matter what the reason they were seeing a doctor. Hospitals adopted a system of colour-coded smiley faces, to represent a rising scale of pain from 0-10. The commission ruled that anybody identifying as a five – a yellow neutral face described as “very distressing” – or above was to be was to be referred for a pain consultation.

The commission told hospitals they would be expected to meet the new standards for pain management at their next accreditation survey. Purdue Pharma was ready. The company offered to distribute materials to educate doctors in pain management for free. This amounted to exclusive rights to indoctrinate medical staff. A training video asserted that there is “no evidence that addiction is a significant issue when persons are given opioids for pain control”, and claimed that some clinicians had “inaccurate and exaggerated concerns about addiction, tolerance and risk of death”. Neither claim was true.

Some doctors questioned the value of patient self-assessment, but the commission’s regulations soon came to be viewed as a rigid standard. In time, pain as the fifth vital sign worked its way into hospital culture. New generations of nurses, steeped in the opioid orthodoxy, sometimes came to see pain as more important than other health indicators.

Dr Roger Chou, a pain specialist at Oregon Health and Science University who has made long-term studies of the effectiveness of opioid painkillers and helped shape the Centers for Disease Control and Prevention’s policy on the epidemic, said the focus on pain caused patients to give it greater weight than made sense.

“When you start asking people: ‘How much pain are you having?’ every time they come into the hospital, then people start thinking: ‘Well, maybe I shouldn’t be having this little ache I’ve been having. Maybe there’s something wrong.’ You’re medicalising what’s a normal part of life,” he said.

One consequence was that people with relatively minor pain were increasingly directed toward medicinal treatment while consideration of safer or more effective alternatives, such as physiotherapy, were marginalised. Another, said Chou, was the increased expectation that pain can be eliminated. Chasing the lowest score on the pain chart often came at the expense of quality of life as opioid doses increased. “It’s better to have a little bit of pain and be functional than to have no pain and be completely unfunctional,” said Chou.

Health insurance companies piled yet more pressure on doctors to follow the path of least resistance. This meant cutting consultation times and payments for more costly forms of pain treatment in favour of the direct approach: drugs.

The joint commission needed a way to judge whether its 2001 edict on pain was being adhered to and latched on to patient satisfaction surveys. It took a determined doctor to resist the pressure to prescribe. Physicians could spend half an hour pressing a person to take more responsibility for their own health – eat better, exercise more, drink less, find ways to deal with stress – only to watch an unhappy patient make their views known on the satisfaction survey and face a dressing down from hospital management. Or they could quickly do what the patient came in for: give them a pill and get full marks.

In Detroit, Dr Charles Lucas’s three decades of experience as a surgeon told him it was possible to what was easy and sign the prescription, or to do what was hard. Lucas grew up in the city and had been instrumental in establishing Detroit’s publicly owned hospital as the highest-level trauma centre in Michigan and one of the first top-tier centres in the country.

 

Activists in New York, during a protest denouncing the city’s ‘inadequate and wrongheaded response’ to the opioid overdose crisis. Photograph: Getty
Emergency departments became beacons for the opioid dependent, who quickly learned to game the system to get drugs on top of their prescriptions. They turned up feigning pain, knowing harassed medical staff under pressure of time and the commission’s standards were likely to prescribe narcotics and move on without too many questions.

“Some of the old-time nurses, they have that jaundiced look in their eye and say ‘So-and-so’s complaining of pain’. You can tell by the look in their eye that they don’t think it’s justified that they get any more medicine,” said Lucas. “The younger nurses, they say we have to treat this pain – because they’ve been indoctrinated – they’ve got to get rid of the pain. God forbid you don’t get rid of the pain. That would be like a mortal sin.”

But there was a price for resisting the pressure to prescribe ever higher doses of pain relief.

Lucas was knocked back in surprise, and then infuriated, to be summoned to appear before his hospital’s ethics committee after a nurse reported him for failing to provide adequate pain treatment.

The surgeon’s longstanding patients included Gail Purton, the wife of a well-known Michigan radio personality. Lucas operated on Purton a few times, and she was back for surgery after her ovarian cancer spread. “It was a big operation. Cut off all sorts of cancer.” The next day, a nurse asked Purton if she was in pain. Purton said she was. The nurse reported Lucas for failing to properly address a patient’s pain. “I got reported because I wasn’t giving her enough pain medicine. She had a big cut from here to here,” Lucas said, running his finger across the front of his shirt and scoffing at the idea that she could be pain-free after an operation like that.

The surgeon responded with a five-page letter to the ethics committee chairman, whom he happened to have trained, challenging the questioning of his professional judgment. Purton wrote her own letter, praising Lucas’s care and saying that she never expected not to have pain after a major operation.

The case was dropped, but it was not an isolated incident. Lucas has worked closely with another surgeon, Anna Ledgerwood, since 1972. She too was hauled before the ethics committee on more than one occasion, on the same charge. It cleared Ledgerwood, but Lucas said more junior surgeons buckled to the pressure to administer opioids just to stay out of trouble.

Lucas regarded the new pain orthodoxy as a growing tyranny. He also thought it was killing patients. He began to collect his own data.

As the joint commission was pushing out its new standards for pain treatment in the early 2000s, the industry was driving a parallel effort to influence the prescribing habits of doctors in small clinics and private practices across the country. Many were still hesitant to prescribe narcotics, in part because of fear of legal liability for overdose or addiction.

The American Pain Society and Haddox, who was by then working for Purdue Pharma, were instrumental in writing a policy document reassuring doctors they would not face disciplinary action for prescribing narcotics, even in large quantities. The industry latched on to the Federation of State Medical Boards because of its influence over health policy individual US states which regulate how doctors practise medicine.

In 2001, Purdue Pharma funded the distribution of new pain treatment guidelines drawn up by the FSMB that sounded many of the same themes as the standards written by the joint commission.

The document picked up on Haddox’s pseudo-addiction theory. “Physicians should recognise that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction,” it said.

The FSMB pressed state medical boards to adopt the guidelines and to reassure doctors that adhering to them would diminish the likelihood of disciplinary action.

Over the following decade, the FSMB took close to $2m (£1.52m) from the drug industry, which mostly went to promote the guidelines and to finance a book, Responsible Opioid Prescribing, written with the oversight and advice of a clutch of doctors who were strong advocates of wider use of prescription narcotics. The book was sold to state medical boards and health departments for distribution to physicians, clinics and hospitals. The drug industry paid for the publication but the FSMB kept the $270,000 profits from sales.

Within a few years, the model guidelines were adopted in full or in part by 35 states, and the floodgates were open to mass prescribing of what Drug Enforcement Administration agents came to call “heroin in a pill”. Opioids were soon the default treatment even for relatively minor pain. Dentists gave them to teenagers after pulling their wisdom teeth. Not just one or two days’ worth of pills, but a fortnight or a month’s worth, which, if they did not draw the intended recipient in, frequently sat in the medicine cabinet waiting to be discovered by someone else in the family. The lack of caution in prescribing left an impression among the users that the drugs were harmless, and some people shared them with others as easily as they might an aspirin. Prescribing escalated year on year. So did profits. OxyContin sales passed $1bn a year in 2000. Three years later they were twice that. Other opioid makers were pulling in huge profits too.

By the time the FSMB guidelines were landing in doctors’ inboxes in the early 2000s, Ballantyne had reached her own conclusions about the impact of escalating opioid prescribing. In 2003, she co-authored an article in the New England Journal of Medicine highlighting the dearth of comprehensive trials and saying that two important questions remained unanswered even as mass prescribing of opioids took off. Do they work long term? Are higher doses safe to take year after year? The drug industry and opioid evangelists said yes, but where was the evidence for it?

Ballantyne wrote that there was evidence that putting some patients on serial prescriptions of strong opioids has the opposite of the intended effect. High doses not only build up a tolerance to the drug, but cause increased sensitivity to pain. The drugs were defeating themselves.

Her assessment seemed to warn that if there was an epidemic of pain, it was partly driven by the cure. On top of that, there was evidence that the drugs were toxic. Then came the conclusion that stuck a dagger into the heart of the campaign for wider opioid prescribing. “Whereas it was previously thought that unlimited dose escalation was at least safe, evidence now suggests that prolonged, high-dose opioid therapy may be neither safe nor effective,” she wrote.

Ballantyne was also increasingly aware that the claim that pain neutralised the risk of addiction was false. Quantifying addiction, and who may be vulnerable, is notoriously difficult. Ballantyne, like a lot of doctors, estimated that between 10 and 15% of the population is vulnerable, but that it depends on the substance and circumstances. What she was certain of was that Purdue’s high-strength pill, OxyContin, had been a game changer. “The long-acting opiates suddenly put much higher doses into people’s hands and much more of it, and taking it around the clock made them dependent on it.”

From her research, Ballantyne concluded that OxyContin supercharged what was already widespread dependence on weaker opioid pills by drawing a new group of people into the category at risk of addiction and death. The danger was compounded by OxyContin’s failure to live up to its promise of holding pain at bay for 12 hours. For some patients, it wore off after eight, causing them to take three pills a day instead of two, greatly increasing their overall dose of narcotic and with it the risk of addiction.

Ballantyne thought the article would at least cause her profession and the drug industry to take stock of the impact of mass prescribing. By the time the article appeared, the documented death toll from prescription opioids was running at around 8,000 a year.

“When the 2003 New England journal article came out, I thought it was going to make the medical community sit up and say: ‘Wow. These drugs that we’ve been thinking are helping people are not. We have a real problem.’ But the medical community didn’t at all say: ‘Wow,’” Ballantyne said with half a laugh, 15 years later.

“People in my field who had been, like me, taught we have to do this – people who’d been lobbying to try and increase opiate use, like the palliative care physicians – said: ‘What are you doing? We worked so hard to get to this point, and now you’re going to turn it all around. They become so rattled when you suggest you shouldn’t give the opiates – it’s partly people in the pain field and especially people in pharma – because it’s big business.”

Lucas and Ledgerwood had their own study on the impact of opioids in the works. They came to believe the tyranny of the colour-coded smiley faces was costing lives. Years of surgery have given Lucas a healthy respect for pain as a tool for recovery. To suppress it was dangerous. But as large doses of opioids became the norm, the surgeon noted an increasing number of incidents of patients struggling to breathe after routine operations and being moved to intensive care.

Lucas and Ledgerwood visited trauma centres to collect data on deaths before and after the joint commission standards on pain treatment. In 2007, the two doctors published their findings. Before the commission’s dictum, 0.7% of trauma centre patients died from “excess administration of pain medicines”. The death toll rose to 3.6% after the commission’s policies kicked in.

“In each case, administration of sedation led to a change in vital signs or a deterioration in the respiratory status requiring some type of intervention which, in turn, led to a cascade of events resulting in death,” the paper said. Those were only the deaths in which there was little doubt opioids were responsible, and the real toll was almost certainly higher. “Overmedication with sedatives/narcotics … clearly contributed to deaths,” the study concluded.

A memorial in Washington DC, consisting of 22,000 engraved white pills representing the face of someone lost to a prescription opioid overdose in 2015. Photograph: Mark Wilson/Getty

“I’m convinced that because of the pressures brought to bear by the joint commission, we are killing people,” Lucas told me. The study said the medical staff lived in fear of the joint commission standards which created “great psychological pressure on caregivers” to use narcotics.

In a damning critique, the paper said that the commission’s reliance on pain scales to guide treatment had created an “excessive emphasis on undermedication at the same time ignoring overmedication”. The obsession with ensuring people were not in pain came at the expense of ignoring the dangers of giving large amounts of opioids to people recovering from surgery or serious injury. The drugs may kill the pain but they also risked killing the patient.

The two doctors made no secret of who they blamed for “this preventable cause of death and disability”. “It’s about money. Money has influence, and it influenced the joint commission,” said Lucas.

The surgeon presented the paper to a meeting of the Central Surgical Association and saw it published by the Journal of the American College of Surgeons under the headline “Kindness Kills: The Negative Impact of Pain as the Fifth Vital Sign.”

Afterwards, Lucas got a stream of letters and emails from doctors who recognised the problem. But, unlike Ballantyne, he wasn’t surprised when the policy remained the same. “Did I expect a change? No. It is too ingrained into the medical profession. It’s become financial just like the drug industry is financial. It’s nothing to do with right or wrong. It’s about how the money flows,” he said. “When you write a paper you want there to be unemotional data out there. You want that unemotional data to be analysed and interpreted in one way or the other, but you don’t expect the Renaissance.”

In 2012, nine years after Ballantyne’s cautioning against the mass prescribing of opioids as a quick fix for pain was published in the New England Journal of Medicine, a renowned British pain specialist, Cathy Stannard, called the doctor’s paper “a distant warning bell”, challenging the opening of the floodgates to strong opioids.

Ballantyne continued to collect data and publish ever more detailed insights into the impact of painkillers. A less rapacious drug industry might have paused in its headlong charge to sell opioids, and less blinkered and compliant regulators might have determined that this was the moment to weigh the claims made in favour of permitting such widespread prescribing.

Instead the pharmaceutical companies took the warnings as a challenge to their business interests. Through the 2000s, industry poured money into a political strategy to keep the drugs flowing. It funded front groups and studies to claim that there was indeed an epidemic – but it was of untreated pain. The millions coping with chronic pain were the real victims, the industry said, not the “abusers” hooked on opioids they often bought on the black market or obtained from crooked doctors. That one frequently became the other was conveniently overlooked.

Pharma’s lobbyists worked to persuade Congress and the regulators that to curb opioid prescribing would be to punish the real victims because of the sins of the “abusers”, and it worked. As a result, the devastation ran unchecked for another decade and more. By 2010, doctors in the US were writing more than 200m opioid prescriptions a year. As the prescribing rose, so did the death toll. Last year, more than 72,000 Americans died of drug overdoses, the vast majority from opioids, nearly 10 times the number at the time Ballantyne published her warning.

The head of the FDA at the time OxyContin was approved for distribution two decades ago, Dr David Kessler, later described the opioid crisis as an “epidemic we failed to foresee”. “It has proved to be one of the biggest mistakes in modern medicine,” he said.

Kessler was wrong. It wasn’t a mistake. It was a betrayal.

David Attenborough has betrayed the living world he loves

George Monbiot in The Guardian


By downplaying our environmental crisis, the presenter’s BBC films have generated complacency, confusion and ignorance

 

David Attenborough filming the BBC series Africa in the Suguta Valley, northern Kenya. Photograph: David Chancellor/BBC


Knowingly creating a false impression of the world: this is a serious matter. It is more serious still when the BBC does it, and yet worse when the presenter is “the most trusted man in Britain”. But, as his latest interview with the Observer reveals, David Attenborough sticks to his line that fully representing environmental issues is a “turn-off”.

His new series, Dynasties, will mention the pressures affecting wildlife, but Attenborough makes it clear that it will play them down. To do otherwise, he suggests, would be “proselytising” and “alarmist”. His series will be “a great relief from the political landscape which otherwise dominates our thoughts”. In light of the astonishing rate of collapse of the animal populations he features, alongside most of the rest of the world’s living systems – and when broadcasting as a whole has disgracefully failed to represent such truths – I don’t think such escapism is appropriate or justifiable.

It is not proselytising or alarmist to tell us the raw truth about what is happening to the world, however much it might discomfit us. Nor do I believe that revealing the marvels of nature automatically translates into environmental action, as the executive producer of Dynasties claims. I’ve come to believe it can have the opposite effect.

For many years, wildlife film-making has presented a pristine living world. It has created an impression of security and abundance, even in places afflicted by cascading ecological collapse. The cameras reassure us that there are vast tracts of wilderness in which wildlife continues to thrive. They cultivate complacency, not action.

You cannot do such a thing passively. Wildlife film-makers I know tell me that the effort to portray what looks like an untouched ecosystem becomes harder every year. They have to choose their camera angles ever more carefully to exclude the evidence of destruction, travel further to find the Edens they depict. They know – and many feel deeply uncomfortable about it – that they are telling a false story, creating a fairytale world that persuades us all is well, in the midst of an existential crisis. While many people, thanks in large part to David Attenborough, are now quite well informed about wildlife, we remain astonishingly ignorant about what is happening to it.

What makes Attenborough’s comments particularly odd is that they come just a year after the final episode of his Blue Planet II series triggered a massive effort to reduce plastic pollution. Though the programme made a complete dog’s breakfast of the issue, the response demonstrated a vast public appetite for information about the environmental crisis, and an urgent desire to act on it.

Since 1985, when I worked in the department that has made most of his programmes, I have pressed the BBC to reveal environmental realities, often with dismal results. In 1995 I spent several months with a producer, developing a novel and imaginative proposal for an environmental series. The producer returned from his meeting with the channel controller in a state of shock. “He just looked at the title and asked ‘Is this environment?’ I said yes. He said, ‘I’ve spent two years trying to get environment off this fucking channel. Why the fuck are you bringing me environment?’” 

I later discovered that this response was typical. The controllers weren’t indifferent. They were actively hostile. If you ask me whether the BBC or ExxonMobil has done more to frustrate environmental action in this country, I would say the BBC.

We all knew that only one person had the power to break this dam. For decades David Attenborough, a former channel controller widely seen as the living embodiment of the BBC, has been able to make any programme he wants. So where, we kept asking, was he? At last, in 2000, he presented an environmental series: State of the Planet.

It was an interesting and watchable series, but it left us with nowhere to go and nothing to do. Only in the last few seconds of the final episode was there a hint that structural forces might be at play: “Real success can only come if there’s a change in our societies, in our economics and in our politics.” But what change? What economics? What politics? He had given us no clues.

To make matters worse, it was sandwiched between further programmes of his about the wonders of nature, which created a strong impression of robust planetary health. He might have been describing two different worlds. Six years later he made another environmental series, The Truth About Climate Change. And this, in my view, was a total disaster.

It told us nothing about the driving forces behind climate breakdown. The only mention of fossil fuel companies was as part of the solution: “The people who extract fossil fuels like oil and gas have now come up with a way to put carbon dioxide back underground.” Apart from the general “we”, the only distinct force identified as responsible was the “1.3 billion Chinese”. That a large proportion of Chinese emissions are caused by manufacturing goods the west buys was not mentioned. The series immediately triggered a new form of climate denial: I was bombarded with people telling me there was no point in taking action in Britain because the Chinese were killing the planet.

If Attenborough’s environmentalism has a coherent theme, it is shifting the blame from powerful forces on to either society in general or the poor and weak. Sometimes it becomes pretty dark. In 2013 he told the Telegraph“What are all these famines in Ethiopia? What are they about? They’re about too many people for too little land … We say, get the United Nations to send them bags of flour. That’s barmy.”

There had not been a famine in Ethiopia for 28 years, and the last one was caused not by an absolute food shortage but by civil war and government policies. His suggestion that food relief is counter-productive suggests he has read nothing on the subject since Thomas Malthus’s essay in 1798. But, cruel and ignorant as these comments were, they were more or less cost-free. By contrast, you do not remain a national treasure by upsetting powerful vested interests: look at the flak the outspoken wildlife and environmental presenter Chris Packham attracts for standing up to the hunting lobby.

I have always been entranced by Attenborough’s wildlife programmes, but astonished by his consistent failure to mount a coherent, truthful and effective defence of the living world he loves. His revelation of the wonders of nature has been a great public service. But withholding the knowledge we need to defend it is, I believe, a grave disservice.

Cricket - This business called Elite Honesty

Osman Samiuddin in Cricinfo

Here is some elite honesty, a very elite example of it. Australia 238 for 5 against Pakistan in Hobart, needing another 131 for the win. Justin Langer, on 76, edges behind to Moin Khan but is not given by the umpire Peter Parker. Doesn't walk. Fine. That's the difference between elite honesty and regular honesty, understanding that it's the umpire's job to make a batsman walk.

---Also read

On Walking - Advice for a Fifteen Year Old

---

Langer's dad asks him about the edge. Nah, no edge, just a clicky bat handle. He tells his partner on the field and good mate Adam Gilchrist the same thing. Even his captain, elite honesty manifest as human, his mentor and idol, he tells him it was the clicky bat handle that dunnit.

These are elite mates and elite family, who deserve a bit of elite honesty and that's what Langer gives them. For the next decade and a half, this elite honesty is maintained. Then one day he downgrades it to mere honesty and reveals that he had smashed the hell out of the ball. He couldn't help it. He'd copped a bad one in the first innings. He was under the pump for his place. But while it lasted, the honesty was really elite.

If that was the only time you were elitely honest, then how elitely honest could you really be? Not very. So here's another quality bit of elite honesty. Notice how upright Langer is as he walks up to the stumps while fielding. The ball is dead and Hashan Tillakaratne in his crease. Langer deliberately tips a bail off the stumps and then watches his elite team-mates appeal for hit-wicket.

That we can identify this as elite honesty is only thanks to the ICC and their match referee Chris Broad. "Justin was disappointed that the charge was brought and explained his position in a very honest and succinct way," said Broad, following a hearing. You might call Broad's decision elite stupidity but I certainly won't. It's elite judgement.

Some say there is also elite honesty in how Langer ran Western Australia and Perth Scorchers, but I think the most elite example of elite honesty comes from Langer's idol, the true father of the modern Australian way. In a recent interview with Steve Waugh, our very own Melinda Farrell broached this idea of elite honesty (though we called it culture then). She asked Waugh about a couple of catches from his career that he dropped but claimed.

How do you look back at them now?

"Well, I don't really," Waugh responded, which is absolutely rule No. 1 in maintaining elite honesty. About the catch ("catch" used here in a way that also indicates drops) to dismiss Brian Lara, he continued: "It's just part of the game. I mean, at the time I still remember the catch. I still believe I caught it. It was inconclusive but in my mind it bounced off my wrist, but you know, that's all life. You don't want to look back at stuff. I try to look forward. You know, people have their own opinions on what happened there but I'm not going to change my opinion. My opinion was I caught it on the day."

You see why this is more elite? You understand? It's because from his response we end up learning something. We learn that catches are opinions, not facts. If your opinion is that the catch was good, then what business does the fact that it was a drop have anything to do with it? If you're asking yourself how you've managed life so far not abiding by these rules, console yourself that you're not alone. As the great man says, that's all life.

***

Us mortals alas, we aspire to mere honesty. Non-elite stuff. Proletariat. So here, humbly and hopefully, is some of it. 

This business of elite honesty - and Langer's elite mateship and elite humility - this is all elite BS. So is the Players' Pact. And the "hard but fair" act. It's classic corporate-speak - high-sounding words put together to sound and look pretty but that end up meaning nothing.

We're not talking about airplane seats where even economy can now be premium. Honesty is honesty. You either are or you aren't. There is no elite level to which you and I are not welcome and only Australian cricketers are. The truth is, and if it is not, then it is a lie; no number of demagogue leaders, politicians or cricket captains are going to change this fact (not opinion). In today's world, more and more people might not be accepting the truth, but that says something about a changing people and society, not the truth.

All that these words do is maintain the pretence that Australian cricketers operate - or should operate - on a higher moral plane than non-Australian cricketers; that the Australian line is the line, never mind that nobody's ever been told where that line is. It is what has got them into this mess in the first place.

It is what the extreme punishments to Steven Smith, David Warner and Cameron Bancroft were so much about. The rest of the cricket world was made to look like a collective of tree-hugging liberal halfwits for having - fairly maturely, actually - come to terms with what is an on-field code violation and not a sign of moral decay. Sides tampered with the ball, sometimes they got caught and were punished and yes, sometimes they got away with it. That's all life.

Cricket, though, reactionary and conservative cricket, fell for it, responding by increasing the seriousness and stigma of tampering as an offence. Instead of doubling down, cooling the atmosphere, and insisting that tampering wasn't an existential threat to the game, it went the other way, aspiring to this elite Australian way.

It was a depressing reminder of the way cricket is still unable to drag itself out of the streak of puritanism that has marked its operations for so long, where it believes it is not just a morally superior game but that it produces morally superior humans. That's the subtext of the Spirit of Cricket, which, lately Australia seem to have clung to tighter than others. But here's a truth bomb for all of us: cricket isn't morally superior to anything. If it ever was, maybe it was nearly two centuries ago. It's a great sport, no doubt, but that is all it is - a sport. If it expanded globally in reality, rather than just in an ICC mission paper, it may well loosen up and understand this.

What Langer's words and the set of associated ideas among which they float - about the exceptionalism of Australian cricketers - do is set Australia up, at some point down the line, for another fall and greater unpopularity. Look at the sniggering already - magnificently played, by the way, Graeme Smith. Imagine now the next time one of them stuffs up, delivers a nasty sledge, or bullies an umpire, or tampers, or surreptitiously tips over a bail, or claims a dropped catch, or doesn't walk when he's out.

Of course it'll happen. They may be Australian cricketers but - and here's the big reveal - they are also human. They are humans like the rest of the cricketers they play with and against, ones who also do all of these things occasionally, ones they used to always beat and now ones they don't beat so often. They are humans like the rest of us who watch them, envy them, criticise them and worship them; humans who are fallible; humans who are striving for some regular honesty, sometimes succeeding but other times failing.

To this eye, and perhaps many others, all Australian cricket should stand for is Australian cricket, because that has always been more than enough. The way their openers and one-downs come at you, the way they don't stop producing super-fast fast bowlers, the way their keepers yap and catch, the way their slips stand chewing gum like they're a street gang, the way they think leggies are the normal ones and offies the ones to be suspicious of, the way their grounds can feel simultaneously so big and so small, and the way no game is over for them until the very last of them has physically sat on the bus and left the stadium. It has never needed any buzzwords or catchphrases beyond that.

The Sarkari Mussalman - Interview with Gen. Zameeruddin Shah

The Rafale Mystery Deepens : Why did Dassault Invest in An Obscure Anil Ambani Company?

Interview with Ravi Nair - the person behind this story.

Exclusive: Post-Rafale, Dassault Investment in Inactive Anil Ambani Company Gave Reliance Rs 284 Crore Profit

Without any of the publicity which accompanied its smaller investment in a joint venture with Anil Ambani as part of the Rafale deal, the French firm has paid nearly 40 million euros for a 35% stake in an obscure Reliance company.

By Rohini Singh and Ravi Nair in The Wire

New Delhi: Even as Dassault Aviation and Anil Ambani’s Reliance group battle allegations that extra-commercial considerations drove their joint venture on Rafale, regulatory filings in France and India reveal that the French defence major followed its JV with an investment in 2017 of approximately 40 million euros in another Anil Ambani venture that is loss making and has almost zero revenues. The investment translated into a Rs 284 crore profit for the Ambani group company, Reliance Infrastructure, which sold shares in a subsidiary, Reliance Airport Developers Limited (RADL) at a premium.
It is unclear how the valuation for the RADL stake was reached between the two groups or why Dassault would buy a substantial share in an unlisted company that has little to no revenues and has nothing to do with Dassault’s core business.

Public filings by Reliance Infrastructure, a Reliance ADAG group company, show that it sold a 34.7% stake in RADL, a wholly owned subsidiary, to Dassault Aviation in FY 2017-18. The terms of the sale are not known but Reliance said it made a profit of Rs 284.19 crore on the sale of 24,83,923 shares which had a face value of Rs 10 each.

Reliance Airport Developers posted losses of Rs 10.35 lakh for the financial year ending March 2017 and earned revenues of Rs 6 lakh. In the year ending March 2016, the firm had no revenues and posted losses of Rs 9 lakh.

The company has stakes in a clutch of subsidiaries owned by the group. Most of them are loss making and are airport projects that were awarded by the Maharashtra government in 2009 for Rs 63 crore. A Business Standard report dated October 2015 quoted government officials and ministers saying that due to lack of progress in developing these projects by the company a decision was reached to take back the airports. The company also reportedly wanted to get rid of its stakes in these airports but a news report from January 2017 indicated it had changed its mind.

Ironically, while the Maharashtra Airport Development Council (MADC) was prepping to take back charge of the airports due to dissatisfaction with RADL’s progress on the projects, it speedily allotted 289 acres of its land to another group company the same year.

Dassault Aviation’s annual report for 2017 mentions the firm’s acquisition of ‘non listed securities’ including a 34.7% equity participation in Reliance Airport Developers. “In 2017, we also strengthened our presence in India through an acquisition of a 35% stake in Reliance Airport Developers Limited, which operates in the management and development of airport infrastructures,” its report said.

Oddly, the annual report of Reliance Airports posted on the Reliance Infrastructure site notes that Dassault Aviation now holds 34.79% of ordinary shares but when it comes to describing the terms and rights attached to the equity shares, the details have been blanked out.


Screenshot of RADL annual report.

The transaction finds an indirect mention in the Reliance Infrastructure annual report, buried in Note 43 under the exceptional items head, as “profit on sale of investment in Reliance Airport Developers Ltd” of Rs 284.19 crore.

In the Dassault report, the net book value of securities in RADL is stated as 39,962,000 euros. By contrast, the net book value of its securities in DRAL – the joint venture with Reliance for the Rafale – is just 962,000 euros, though presumably it will grow.


Reliance Infrastructure, Annual report for FY 2017

In a recent interview to the Economic Times, Dassault CEO Eric Trappier said Rs 70 crore had been invested in Dassault Reliance Aerospace Limited, Dassault’s JV with the the Anil Ambani group. Of this only 49% is Dassault’s stake.

Filings by Dassault Aviation in France show that besides the Rs 22 crore that Dassault pumped in as equity, it has also given a 4 million euro loan to the JV which roughly converts to Rs 32 crore in Indian rupees. This money, a source in the Anil Ambani group told The Wire off the record, was used by DRAL to pay for its hangar at Mihan. In his interview, Trappier did not mention the money spent for the purchase of a 35% stake in RADL.

How the land was acquired

Prime Minister Narendra Modi announced the Rafale deal on April 10, 2015. In July 2015, Reliance Aerostructure applied to the Maharashtra Airport Development Council for land in its Mihan SEZ in Nagpur. It was allotted 289 acres in August 2015 for Rs 63 crore.

The company later said it would take only 104 acres. While the allotment was done in August 2015, Reliance Aerostructure only paid the dues it owed on July 13, 2017, after missing several payment deadlines.

Reliance Aerostructure was incorporated on April 24, 2015, days after Modi announced the Rafale deal. It was also given a license to manufacture fighter aircraft by the defence ministry in 2016, which opposition parties allege is in violation of government guidelines.

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Filings for financial year 2017 show that Reliance Aerostructure received an inter-corporate deposit of Rs 89.45 crore from Reliance Infrastructure, the same year that Dassault aviation bought 34.79% of Reliance Infrastructure’s stake in Reliance Airport Developers.

From the sequence, it would appear that Reliance Aerostructure used the money received from Reliance Infrastructure to settle its outstanding Rs 38 crore payment with MADC for the land allotted. The dues had been outstanding for more than a year. Filings by Reliance Aerostructure state that the company’s “net worth has been eroded” but was kept as a going concern because of adequate financial support from its promoters. In FY 2017, Reliance Aerostructure posted a loss of Rs 13 crore. The year before that, it posted a loss of Rs 27 crore.

In a recent interview to CNBC, Dassault CEO Eric Trappier had claimed his company chose Reliance ADAG as its offsets partner because it had land available next to an airport. However, the land was only given to Reliance by the state government after it had reached an understanding with Dassault to collaborate on the Rafale.

According to a Dassault press release, Reliance Aerostructure’s joint venture with Dassault Aviation – Dassault Reliance Aerospace Limited (DRAL) – was formally incorporated in 2017 but goes all the way back to April 2015.

The land contribution agreement filed by DRAL with the Registrar of Companies dated July 12, 2018 talks of a sub-lease agreement between Reliance Aerostructure, DRAL and Dassault Aviation. According to this agreement, DRAL, the joint venture partner, would pay Rs 22.8 crore to Reliance as premium for 31 acres of leased property to the joint venture. This debt was converted into “non cash consideration” for 22.8 lakh equity shares of the company. Therefore, the land allotted by the Maharashtra government was used to pay for Reliance’s equity stake in the joint venture company. Dassault aviation gave Rs 21.09 crore cash for its equity stake in the firm.

The Wire has contacted Dassault and Reliance ADAG seeking greater clarity about the land transaction and Dassault’s wider dealings with the Reliance ADAG group, including the valuation of its investment in Reliance Airport Developers Ltd. The story will be be updated with their responses when received.

Note: In an initial version of this article, the euro figure corresponding to RADL’s stated profit of Rs 284 crore was mistakenly stated as 4 million at the prevailing exchange rates in 2017. It is actually 40 million.