The Attack on Assad and the TV News Media Response

President Trump, with his military advisers, and with the participation of France and England, carried through with his warning to President Assad that his use of poison gas would have serious consequences. A year ago a similar attack destroyed much of Assad's delivery capacity. This time it was the chemical weapon manufacturing and storage facilities. Apparently the attack was carried out with great precision and without involving civilian casualties or involving Russian assets which would have complicated the matter. 

President Trump was specific about his threat and followed through with it in an astute manner. This was in contradistinction to President Obama who issued the same warning to Assad but did not follow through. He and his surrogates explained at the time that the reason for this omission was that he had obtained the agreement of the Russians that they would see to it to remove chemical weapons from Assad's arsenal. Events have proven that President Obama's compliance with and trust in the Russians was misplaced. Unfortunately he allowed the Russians to become deeply embedded in the region. 

I have for some time now stopped paying much attention to TV news shows, including those on Fox News, finding them to be excessively focused on boring Washington political infighting. I tuned in this weekend to find out the details of this attack because of its potential importance. On the Jesse Watters show on Saturday, the night after the attack, I watched a Democrat commentator complain that while he had no disagreement with the attack, that President Trump was inconsistent because he had expressed his intent to get American forces out of Syria. This was a pretty far reach to be critical but not unexpected. It didn't tell me much. 

On Sunday morning I tuned into Fox News Sunday which I had always considered to be "straight news" as opposed to the obvious repetitive anti-Trump bias on the other networks. There I saw Chris Wallace repeatedly press the question as to why Trump responded to chemical weapons and not to Assad's use of conventional weapons. I watched as Jonah Goldberg, a long time conservative "never-Trumper" smugly accused Trump of responding mostly to things he saw on TV. 

The world was so revolted by the pervasive use of poison gas in WW1 that such weapons have been considered beyond the pale ever since. Every person with normal sensibilities understands the consequences of letting that cat out of the bag. Thus the negative reaction of both Presidents Obama and Trump to Assad's use of poison gas. On the other hand the Syrian civil war is a morass, with the anti-Assad forces being a very mixed bag. Trump's desire to extricate American troops from that situation as soon as is feasible is probably shared by the large majority of Americans. Chris Wallace's apparent misunderstanding of this basic distinction suggests to me that he is being provocative for the sake of provocation. Goldberg's misplaced attitude of superiority seemed ridiculous.

None of these people had to face the real decision about the event, the importance of it relative to overall national policy, what should be our response, how and with whom it should be carried out, what might be the collateral consequences of our actions, how would our friends and adversaries respond, how should it be announced to the world. To my mind the thing was carried out expertly all around. Good for Trump. Back to the waste basket for the TV news yappers. 

Guns and Sick Kids.

I am not a gun enthusiast. I never owned one and never fired one except while I was in the compulsory ROTC program in college. Even when I was in the Army, in the Medical Corps, I never used a gun. When we lived for years in an isolated wooded section of East Mountain where it sometimes felt a little scary it never occurred to me to get one for protection. It's not that I'm anti-gun; just not a gun person.

So I don't really have any skin in the game in the present gun argument after the school shooting. I know all the pro and con arguments and I don't want to get into that no-win situation. It just strikes me as sad that the immediate reaction is the usual angry debate over gun control which seems to take all the attention.

There are lots of ideas focused on the gun aspect of the problem floating around, and some of them even sound practical enough to get carried out this time, especially by some of the individual states, as opposed to the usual heated argument and do nothing result. We hear about raising the legal age to buy a rifle, banning "assault" weapons, limiting the number of bullets in gun magazines, arming some specially trained teachers, putting in metal detectors at school entrances.

I don't know. If this sick kid wanted to carry out destruction it seems to me he could have gotten a gun somewhere, or used a bomb, or a truck, or even waited a couple of years till he was 21. How much difference would it really make in the big picture if he killed 5 or 6 people instead of 17. And how pathetic is it that we would have to have armed teachers and metal detectors in the hundreds of thousands of schools around the country because of these rare incidents.

I was thinking about that the other day when we were flying from Florida and waiting in the long line to be inspected before going to our gate. I was around in the times when we just walked right in and so I guess this ritual that we've all gotten used to as being normal still jars me a bit. Think of all the waste of time and money being expended on millions of flights every day just because of lunatic fanatics.

Not much we can do about that I guess. But it seems to me the sick 19 year old in Florida is a different story, and while we're busy arguing about guns we're missing a big picture. Lots of people knew this young person was sick/violent and reported it but nothing was done about it except to expel him from school.

There are a lot of violent adults around but I'll bet most of them developed these traits when they were young. Pretty much everybody in our country goes through one school system or another when we're young. I'm sure it's not all that easy, but while we're arguing about guns, shouldn't we be paying at least as much attention to the idea of identifying sick kids and working with them. Parental loss seems to have been a major problem with this kid. Too bad there wasn't a guidance program supplying a surrogate adviser.

I had the good fortune to go to the old Scranton Prep. The physical facility at the time was bare bones and the tuition was very affordable for most families. Most of our teachers were Jesuits in training, not a heck of a lot older than we were. They took us on hikes and played football with us. We had to wear coats and ties and the teachers called us Mister. There was a lot of acting up as you would expect with teenage boys, but with only a couple of hundred students in the whole school it was pretty personal, unlike modern schools with thousands. So character building was part of the curriculum, not officially, but in actual practice. And those who had problems didn't get lost in the shuffle.

This treatise is getting too long as usual so I'll wind up. My point is that if all we do is make a few extra gun laws, or make every school child in the country go through metal detectors, and at the same time ignore problem kids we're fooling ourselves.

Trump's State of the Union

Trump's SOTU speech has been well received by the public who watched it. In the CNN poll public opinion turned out to be about the same as the reactions to Obama's and Bush's first try, about 3/4 favorable. Trump has a way different style from Obama but in his own way is an effective orator. His many years of being in the spotlight make him comfortable and confident in front of the cameras. His detractors will certainly disagree but his mannerisms bespoke a sincere personal belief in the words he spoke. He made extremely effective use of a large cast of sympathetic persons exemplifying the points he was making. 

It was booked ahead of time as being conciliatory but turned out to be a fairly full throated endorsement of conservative principles. The deal he offered on immigration was just that - a deal, and not a strategy of attempting to become friends with his opponents a la President Obama. The Democrats are opposing it and they showed their attitude in their behavior last night. It seems to me however that it's going to be difficult for them to hold the line and convince the so called Dreamers to turn down such generous terms. It would be a far better situation for them than the temporary reprieve they had under the Obama executive order which could be easily reversed and did not lead to full citizenship. 

It was largely an American pep talk, reminding me of the Reagan days. His supporters will love it overall, even those who don't like the idea of citizenship for the Dreamers. I think it will largely improve the Trump image with the apolitical independent group who will be swayed by appeals to economic improvement and patriotism. 

I disliked Obama and had a visceral negative reaction when I watched him speak despite a grudging admiration for his oratorical ability. However the Democrats, with a few exceptions,  have an almost pathological detestation of Mr. Trump and they showed it last night. I don't think that their inflexibly dour facial expressions will help them in public opinion except among their like-minded supporters. Minority leader Pelosi especially should have gotten some preliminary acting advice. To my mind she was almost for the first time showing her true age, perilously close to my own.

I found the image of the Congressional Black Caucus especially puzzling. The President's touting of the low black unemployment rate appeared to anger them. It is understood that they have a different opinion about the cause of the statistic but, knowing ahead of time that it was coming, they should have had a different response prepared. What really bothered me though is that in the Congress of the United States, a country that's supposed to be celebrating its diversity, especially among the Democrats, we have all the members of one race clustered as a bloc together, and all wearing symbolic African garb. These men and women are not Africans. In fact, despite all the despicable treatment their forebears received, they have more ancestral ties to this country than most others, and would do better I think to proudly display that reality. Isn't a special section for black people something those that preceded them fought so proudly to end? Just asking. 

Much of the Immigration Solution is Common Sense

The squabble over immigration policy is mystifying. Most of the basic principles seem like such common sense. 

The Democrats want something done about the DACA kids. Trump rescinded Obama's previous edict which allowed them to stay but allowed a 6 month grace period.  In essence he handed the decision to the legislature which was the constitutionally correct thing to do. This decision belongs to the legislature and not the executive. These individuals have been here most of their lives and are Americanized. So it makes sense to work out an arrangement to make them legal.

At the same time measures must be taken to end illegal immigration, really and truly. How can you disagree with that? Who can give a rational argument for allowing the free movement of individuals into our country whose identity, whereabouts and reasons for coming are unknown. There are some libertarians who believe in unrestricted migration but even if we concede that argument, which I think is craziness,  we still should know who's coming, where they are going and what brings them here.

I listened to a discussion of drug overdose deaths today. There were something like 65K in 2016 alone, more than the number of names on the Vietnam War Memorial. The overwhelming majority were not due to doctor's prescriptions but were from fentanyl and heroin brought into the country over the southern border.

So unless there is an argument which justifies allowing anyone who wishes to come over the southern border to do so unobstructed, and bring any contraband they'd like with them, then it seems pretty common sense that there should be an effective physical barrier to reinforce the thin line of the immigration officials, at least in those areas where there is no significant natural barrier. That would seem to me to be money well spent. 

And who can give an argument to justify allowing those with time restricted visas to ignore the restrictions and simply stay as long as they wish or for employers to hire those who they know are in the country illegally. If you have a visa and your time runs out either go back home or apply to have your time extended. If you have a business that could not exist with American workers then work to get a legal exemption. Allowing such obvious flaunting of the law makes no sense and it should be stopped. The laws should be enforced.

I am pro-immigrant. My father and all my grandparents were immigrants. I know all their stories well. They came, through legal channels, to seek a better life. They faced and overcame adversity. I saw personally what immigrants can contribute to our society. But what sense does it make to select immigrants based on a lottery, or solely based on what country they come from or what family members they happen to have here. We should want newcomers who admire the American ethos, who can contribute and who can make their own way regardless of their origin. So that should be our immigration policy, not some diversity quota or chain migration policy. 

These are all common sense things, not ideology. I am offended by those who try to confuse the issue by claiming that those who once and for all want to end illegal immigration are xenophobes and racists. Let the burden of explanation instead be on them to explain just why it is that they favor illegal immigration if that indeed is their opinion. 

Yes, beyond the DACA people we have the major issue of what to do with the millions of individuals who have come here illegally, have settled in and have done no wrong other than take advantage of many years of lax enforcement of the immigration law. That's a sticky problem. But let's first handle the issues that seem to the ordinary citizen like myself to be common sense. Come on congress - will you please for a change do your job. 

Government Controlled Medical Practice in the U.S.

The very first paragraph of the Medicare law states the following:

"Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, ... or to exercise any supervision or control over the administration or operation of any (medical) institution, agency, or person."

How pathetic a joke this statement has become. To be sure the Medicare bureaucrats and their academic health care planner allies do not actually enter the doctor's office to select the antibiotic, although I have no doubt they would like to if they could figure out a way to do it. But supervise and control doctors, hospitals and other medical entities they do in exquisite detail. Their invasion includes things like telling doctors what items to ask the patient, what body parts to examine, what categories of tests and treatments are preferred, and how and by what means these things must be written into medical records. They work their will by control of payments. Do it their way or you don't get paid.

They get the money to make the payments from us, from our payroll taxes and our income taxes. That's been a problem through the years because what they spend on us is always a lot more than what they collect from us even though the actual percentage of our paycheck that they take has multiplied many times over since the program began. Nowadays they put a lot of it on the tab, the national debt which is now 106% of GDP, up from 62% 10 years ago.

Ever worsening government interference bugged the hell out of me while I was in practice. I recently had occasion to meet some of my old colleagues and it's only gotten worse. They all tell the same sad story of the tremendous time and resources wasted on bureaucratic nonsense that does not add an iota of benefit to actual patient care. Well, you might think, that's the doctor's problem and none of my concern. Unfortunately that's far from true. All the billers and coders and IT personnel, etc, add greatly to the cost of medical care and bring no health benefit. And all the time wasted by your doctor in dealing with this nonsense translates to less time he or she can spend with you.

In the past few years CMS, the agency that runs Medicare and Medicaid, has come up with even more complicated regulations that went into full effect in 2017. A recent internal study announced that these new rules appear to be of no value in reducing cost or improving medical care. No study was needed. Any practicing doctor could have provided this information. The most depressing fact is that the ever increasing cost and complexity of government regulation is driving doctors rapidly our of private practice and into salaried positions with large medical conglomerates. It's the same with independent hospitals. That's not good folks - that is, not if you like being treated as an individual and not as a commodity.

Government has a legitimate function in making sure that acceptable health care is available to those who for one reason or another can't provide if for themselves. But for the rest of us government should bug off; it does nothing but screw things up.

Pearl Harbor Day. World War 2 and the American Spirit

Yesterday was Pearl Harbor Day. Mostly forgotten now, although we remembered it pretty well for many years. More than we remembered 9/11, really. I remember telling Emily after 9/11 how soon the horrible memory would fade from the American interest. It's how we are today, every hot event fading into the next news cycle.

I was only age 3 at the time so I don't remember the event, but the war went on for 4 more years so I do have memories of the times. In fact probably one of my earliest vague memories was of an air raid drill where my mother had to turn off the lights and pull the shades at our house in Pittston. I couldn't have been much more than 4 then.

That war was definitely different from those of today in that it wasn't fought by the military alone. Since then we've had "guns and butter", but not then. The whole population was intensely involved. Things back home were rationed since they were needed for the war effort. I can remember the gas ration stamps which entitled you to only so much unless you were needed for a critical job. Many other things were rationed, rubber, butter, nylon stockings and on and on. Auto plants were converted to manufacturing tanks and planes, so forget new cars. Sports were suspended since all the players went to war. The culture changed. Women went to work instead of staying home to replace the drafted men.

The whole country pulled together. There had been plenty of anti-war sentiment before Pearl Harbor, probably the majority. After the experience of WW1 nobody wanted to get involved in the crazy internecine feuds of the Europeans. But a deadly sneak attack in those days didn't sit well with the Americans. They didn't weep and wail and put up memorials. They got mad!  And FDR, regardless of what you may think of his social programs, was a superb wartime leader. As was his friend Churchill.

After Pearl Harbor, men didn't try to escape the draft, they enlisted. Even if you were afraid you would never admit it because it was  your duty. And for some there was even a certain feeling of excitement to get away from home, which for most at that time wouldn't have happened otherwise. It happened to my 2 uncles, who with both parents dead, enlisted as teenagers to see the world. One, my uncle Ross, came home with a Purple Heart and that meant something then. People proudly displayed their service. A blue star on your window meant you had a son in the military and a gold star was for a son who wasn't coming back. Such families grieved but with pride. The media and the entertainers didn't undermine the war, they promoted the effort. The movies mocked Hitler and Tojo, and esteemed military heros like Audie Murphy. They made movies like the Flying Tigers. And the entertainers volunteered like Jimmie Stewart; some never to come back like Glenn Miller. The government urged us to grow victory gardens and save tin cans.

We knew who was our enemy and put it right out there. I can remember in first grade making stick drawings of "Jap" planes being shot down by the red, white and blue. The war was fought with ferocity, all out and everybody contributed. And the industrial output of everybody working together overwhelmed 2 mighty enemies on 2 continents. It was fought to the finish in 4 years. It's a long time ago and I was little but I can remember the elation of VJ Day.

Today we're at each other's throats. War is some distant event, not even raising the interest of the TV cameras. 9/11 15 years later stirs up little fuss except for 1 day a year. It's pathetic really when you think about it as we should today.

Blood Glucose Testing, CGM and FreeStyle Libre

At our support group sessions we've talked about home blood glucose
testing. I encouraged almost all of my patients to do it, even those
with minimal problems. For the most part blood glucose cannot be
perceived and testing is necessary to know your levels and get
important feedback as to the influence of various factors. A1c is
useful as a guide to blood glucose control over the long term but does
not give information about daily fluctuations.

The timing of testing is important. Blood glucose fluctuates
throughout the day depending on food intake, activity level,
medication effects, and many other factors such as psychological
stress and the many hormones that the body manufactures and emits
intermittently. Key times to test are before and after meals. Diabetic
patients with type 1 and those with type 2 on complicated insulin
regimens should test several times daily.

The majority of type 2 patients taking less complicated treatment, and
particularly those with consistent meal and activity schedules, tend
to have a stable blood glucose pattern, rising and falling  in a
similar manner on a daily basis. For such patients I recommended a
less intense amount of testing, still testing at key times mentioned
above but limiting the number of days of testing to between 1 and 3
days weekly. The point with this approach is less to adjust things on
a daily basis and more to try to pick out a pattern, particularly of
high or low times during the day, which might be used for longer term
treatment changes. Doing this is much more useful than the common
practice of testing daily before breakfast which measures glucose at
one point in the day but misses all the rest of the fluctuation.

A more recent approach to blood glucose testing is with CGM
(continuous glucose monitoring), using a tiny glucose sensor which is
inserted under the skin and which measures and transmits blood glucose
information every few minutes to a remote monitoring device, such as
an insulin pump screen, a cell phone or even a wrist watch device.
Tremendous strides have been made in the development of these devices
in recent years, especially in accuracy and duration. In fact the most
recently available sensors work out of the box without calibration and
can be used as a substitute for finger sticks and give accurate
results for up to 7 days.

Continuous glucose monitoring is fast becoming the standard of care
for treatment of type 1 diabetes, primarily because one receives not
just a real time blood glucose reading, but more importantly because
trends are identified. It is more important when using insulin to
understand in which direction the blood glucose is heading and how
fast. Also because of this ability to show trends, CGM devices can
give out alarms that warn when the blood glucose is heading too low or
too high.

CGM devices hold great promise in the quest for automating insulin
treatment since their data can be linked wirelessly to insulin pumps,
thus advancing toward the promise of an "artificial pancreas". Many
innovators are working diligently toward this goal. However, as CGM
devices have become easier and simpler to use it seems to me that they
should be useful for monitoring of blood glucose in type 2 patients as
well, not constantly, but periodically, as a better way to do the
intermittant analysis which I mentioned above. For this purpose a less
expensive easier to use device with less high tech features would be
most desirable.

Today's newsletter was actually prompted by my happening upon news
about the soon to be marketed FreeStyle Libre. This is a somewhat
lower tech and lower cost CGM device that looks to me like it would be
good for most type 2 patients and would even make sense for those type
1 patients who wish to continue with insulin shots rather than a pump
and could reasonably take the place of most of their fingerstick
testing. The sensors are unobtrusive, about the size of 2 stacked
quarters and look like a cinch to apply. They can be kept on in the
shower and even be used under water for a short time. Instead of a
continuous display on a monitor as with most sensor systems,
information is transmitted to a small, low cost monitor when it is
passed over the sensor, like items at a checkout counter. Whenever
this is done, on the monitor screen appears your present glucose
reading, a graph depicting what's been happening over the last 8 hours
and an arrow indicating which direction and how rapidly your glucose
is changing. In addition various graphs useful to analyze the last 90
day's data can be called up on the screen or downloaded to a computer.
The rechargable monitor device is supposed to sell for $60 and the
sensors which last 10 days I'm told will sell for $40, far lower than
the other available CGM systems. These prices might be particularly
appealing for Medicare type 2 diabetic patients for whom CGM is not
covered and who might use the devices only periodically to analyze
their blood glucose responses. If I were still in practice I would
certainly be interested in using this system to analyze my patients.

More information can be found at https://www.freestylelibre.us/