There is no justification whatsoever for running expensive advertisements on television that end with the line “Ask your doctor whether…is right for you. ” There is no need to make the patient into a sales representative for a product that the ...
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Still pushing drugs American style and more...

Still pushing drugs American style

There is no justification whatsoever for running expensive advertisements on television that end with the line “Ask your doctor whether…is right for you.” There is no need to make the patient into a sales representative for a product that the patient may end up buying. If someone has, say, osteoporosis, then it should be sufficient for the physician to suggest a range of possible treatments, and to tell the patient the desired effects and the likely side effects of each of the possible treatments. And that information should be given directly to the physician in the form of the results of clinical trials, not in the form of slick presentations delivered in the context of work-vacations at expensive resorts. The cost of disseminating objective information is relatively low, whereas the cost of trying to persuade a physician to prescribe product A rather than the almost-identical product B is much higher.
Pushing drugs, American style

Still as concerned about the high cost of healthcare in the United States as I was when I wrote those words in February 2017, during the past week I made a note of prescription drugs that were advertised   on television programs I happened to be watching—mostly network or cable news programs. I then looked up the advertised products on the Internet to discover more about them, including pricing information. I then calculated approximately how much it would cost to take each of these products for a month, bearing in mind that a patient carrying insurance would probably not pay the full price out of pocket. Nevertheless, the prices listed do reflect the amount of money the pharmaceutical company marketing the products aspires to get from some combination of an insurance plan and a patient's co-pay. Here is a list of the prescription drugs I saw advertised in alphabetical order.

  • Austedo (deutetrabenazine). This drug is used to treat involuntary movements (chorea) caused by Huntington's disease. The initial dose is 6 mg orally once a day. Tho dosage may be increased in increments of 6 mg/day at weekly intervals up to a maximum dose of 48 mg/day. The cost for Austedo oral tablet 6 mg is around $4,286 for a supply of 60 tablets.
  • Biktarvy This drug is used to treat HIV, the virus that can cause acquired immunodeficiency syndrome (AIDS). Dosage is 1 tablet orally once a day. The cost for Biktarvy oral tablet (50 mg-200 mg-25 mg) is around $3,553 for a supply of 30 tablets.
  • Cabenuva (cabotegravir and rilpivirine). Cabotegravir and rilpivirine are antiviral medicines used to treat HIV. The cost for Cabenuva intramuscular suspension, extended release (200 mg-300 mg/mL) is around $4,144 for a supply of 4 milliliters.
  • Caplyta capsules contain lumateperone, an antipsychotic medicine. Caplyta is a once-daily capsule used to control the symptoms of schizophrenia in adults. The cost for Caplyta oral capsule 42 mg is around $1,470 for a supply of 30.
  • Cosentyx (secukinumab) is an immunosuppressant that reduces the effects of a chemical substance in the body that can cause inflammation. The dosage is 150 mg subcutaneously every 4 weeks. The cost for Cosentyx subcutaneous solution (150 mg/mL) is around $6,200.
  • Dupixent (dupilumab) is used to treat moderate-to-severe eczema that cannot be controlled with topical medicines applied to the skin. A maintenance dose is usually 300 mg subcutaneously every other week. The cost for Dupixent subcutaneous solution (200 mg/1.14 mL) is around $3,354 for a supply of 2.28 milliliters.
  • Gardasil 9  is used to prevent  human papillomavirus (HPV), a sexually transmitted disease. The cost for Gardasil intramuscular suspension quadrivalent is around $175 for a supply of 0.5 milliliters. The typical dosage is two or three 0.5 ml injections, making the cost of full vaccination around $525.
  • Humira (adalimumab) is used to treat psoriatic arthritis. The usual adult dose of Humira is 40 mg taken subcutaneously every other week. The cost for Humira subcutaneous kit (40 mg/0.8 mL) is around $6,240 for a supply of 2 kits.
  • Imbruvica (ibrutinib) is a cancer medicine that interferes with the growth and spread of cancer cells in the body. The typical dosage is 560 mg orally once a day until disease progression or unacceptable toxicity. Imbruvica costs $484 per capsule/tablet regardless of the strength (70mg, 140mg, 280mg, 420mg, 560mg). This works out to $13,546 for a supply of 28 tablets/capsules.
  • Ingrezza (valbenazine) is used to treat symptoms of tardive dyskinesia, a nervous system disorder that causes repetitive uncontrolled muscle movements, usually in the face. The initial dose is 40 mg orally once a day, which is increased to 80 mg orally once a day after one week at the initial dose. The cost for Ingrezza oral capsule (40 mg-80 mg) is around $7,362 for a supply of 28 capsules.
  • Jardiance (empagliflozin) is an oral diabetes medicine that helps control blood sugar levels. The recommended dose is 10 mg once daily. The cost of 10 mg oral tablets is around $582 for a supply of 30 tablets.
  • Keytruda (pembrolizumab) is a cancer medicine that interferes with the growth and spread of cancer cells in the body. According to the Keytruda website, “The list price for each indicated dose of Keytruda when given every 3 weeks is $10,268.72. The list price for each indicated dose of Keytruda when given every 6 weeks is $20,537.44.”
  • Opdivo (nivolumab) is a medicine that is used alone or in combination with other medicines to interfere with the growth and spread of cancer cells in the body. According to its website, “For patients receiving Opdivo 240 mg every 2 weeks, the list price is $6,779 per infusion. For patients receiving Opdivo 480 mg every 4 weeks, the list price is $13,559.”
  • Otezla (apremilast) is used to treat active psoriatic arthritis in adults. A typical maintenance dose is 30 mg orally twice a day. The cost for Otezla oral tablet (10 mg-20 mg-30 mg) is around $890 for a supply of 27 tablets, so a month's supply would be around $1780.
  • Rybelsus (semaglutide) is used treat type 2 diabetes mellitus. The maintenance dose is 7 to 14 mg orally once a day. The cost for Rybelsus oral tablet 3 mg is around $899 for a supply of 30, so if one were taking 14 mg daily the monthly cost would come to around $2687.
  • Toujeo (insulin glargine) is a man-made form of a insulin that is used to treat diabetes. The cost for Toujeo SoloStar subcutaneous solution (300 units/mL) is around $415 for a supply of 4.5 milliliters.
  • Vraylar (cariprazine) is an antipsychotic medication used to treat schizophrenia or bipolar disorder type I in adults. The recommended dosage range is 1.5 mg to 6 mg once daily. The starting dosage is 1.5 mg daily. The dosage can be increased to 3 mg on Day 2. The cost for Vraylar oral capsule 1.5 mg is around $892 for a supply of 20. Taking two pills a day would come to a monthly cost of around $2676.
  • Xiaflex (collagenase clostridium histolyticum) is used to treat Dupuytren's contracture in adults. This condition causes an abnormal thickening of the tissue in the palm of the hand. Xiaflex is also used to treat a related condition called Peyronie's disease in adult men, a condition resulting in an abnormal curving of the penis during erection. The dosage is 0.58 mg as a single injection and up to two follow-up injections at 4 week intervals, if necessary. The cost for Xiaflex injectable powder for injection 0.9 mg is around $5,687 for a supply of 1 powder for injection.

No doubt people who are suffering from the afflictions that these pharmaceutical products are designed to treat are grateful when their conditions are ameliorated, but seeing slick television advertisement for those products is not what provides the relief. Relief comes when a qualified physician makes a diagnosis and prescribes a medication. Being asked by patients whether a given product is right for them is not likely to help the doctor make an accurate diagnosis or prognosis or prescription of treatment. It is the physician's job, not the patient's, to know which treatments are most likely to be effective in curing or at least bringing some relief from an affliction. It is the physician's job, not an advertising company's, to inform a patient about what the possible treatments are. Costly television commercials serve to do little but add unnecessary expense to pharmaceutical products.

If legislators are serious about finding ways to make medical care more affordable and less likely to drive patients into bankruptcy, one of the many legislative tools to consider is a ban on the advertising of medications.


Are nations obsolete?

“A nation without borders is not a nation at all.”
— Donald Trump (September 16, 2016)

People who are in favor of building a physical barrier, such as a wall, along the border between Mexico and the United States sometimes echo the claim that without borders there is no nation, and without strictly enforced immigration policies there is no border. The purpose of this posting is to examine both of those claims and then to examine a presupposition on which both of those claims depend.

Can there nations without borders?

The question of whether there can be a nation without any borders can probably be answered in the negative. A nation is, among other things, a clearly demarcated territory with boundaries that differentiate it from a neighboring territory. The more interesting question is whether there can be a nation without strong borders, a strong border being one that keeps people from neighboring nations or territories out. The answer to that question is clearly affirmative. One need look only at the many nations within the European Union, all of which have borders, but none of which have tight restrictions on who may cross those borders. One can bord a train in the Netherlands and travel to France, passing through Belgium, without passing through a checkpoint. I recall taking a train from Leiden, Netherlands to Gent, Belgium, and the only way I knew I had crossed the border was that my cell phone received a text message from my Dutch carrier informing me that I was now in Belgium and that the rates for a mobile telephone call in Belgium were different from the rates for a call in the Netherlands. (I found it a little spooky that my mobile phone was tracking my whereabouts so precisely that it informed me of all this within seconds of the train crossing the border, but that is another matter.) Passing between two countries in the European Union is now easier than passing from the state of New Mexico into the state of Arizona; sometimes, but not always, I have had to stop at a checkpoint in Arizona to insure the authorities that I have no fruit in the car that might carry diseases that could endanger Arizona fruit orchards. Despite the ease with which anyone can pass between one European nation and another, each nation maintains its own distinctive government, passes its own legislation and enforces that legislation with its own agencies. France is still unmistakably France, and Spain is Spain and Belgium is Belgium. Whatever factors go into making them nations are still intact, and strongly defended borders is not one of those factors.

It is not at all obvious that the United States would cease to be a nation if it belonged to an American Union similar to the European Union, a union in which people could freely cross from Canada into the United States or from the United States into Canada, or from either of those countries into Mexico, either for a short visit or to take up residence and take up gainful employment. Indeed, if there were a union including every nation in North America, Central America and South America, a union in which people and goods could cross borders with a minimum of difficulty, it is difficult to make the case that the situation would have any more of a negative impact on any of the American nations than the open-border policies in the European Union has on the nations of Europe.

Can there be borders without strictly enforced immigration policies?

Once gain, the European Union provides a hint as to how this question can be answered. The members of the European Union do have immigration polices, and they are enforced. A key to the successful enforcement of any law or policy is that the law or policy be enforceable. It should be obvious to most lawmakers that the current numbers of immigrants who have entered the United States to live and work illegally proves that the current laws are not enforceable. If millions of people do not follow a law, the law is probably not enforceable.

The most reasonable response to this situation is not to have a “zero tolerance” policy whereby every person who crosses the border is detained, charged with a crime and deported, but rather to have laws that are a better reflection of the social and economic realities behind the migration of peoples from one place to another. Current immigration laws and policies in the United States fail to take into full consideration why people migrate. Most people do not move from one place to another simply because they like to be in motion. Rather, they go to live in another place because life where they have been living has become untenable or unsustainable. Policymakers in the United States would do far better to look into ways that they might help improve the living circumstances of neighboring countries than to look into ways to keep people from neighboring countries out. Trying to keep desperate people out of an an area that has better opportunities for a fulfilling life that the area where they have been living is a task that only a fool would undertake. The task is not only foolish but heartless.

The question to ask is not “Can there be borders without strictly enforced immigration policies?”, but rather “Can there be enforcement of unrealistically strict laws?” and the answer to that question is obviously No. The United States does not need a wall along its borders. What the United States does need is to wake up the the complex economic and social realities that have led to its borders being crossed by millions of people.

Is there really a need for nations any more?

All of this discussion of whether there can be a nation without strong borders presupposes that nations are desirable in the first place. Are they? The answer to that question requires having a clear idea of what a nation is in the first place. An online dictionary defines a nation as “a large aggregate of people united by common descent, history, culture, or language, inhabiting a particular country or territory.” Given that understanding, one might ask in what sense the United States has ever been a nation. It has never been the case that the inhabitants of the country have had a common descent, history, culture or language, although there have been attempts at various times either to impose a common culture and language on everyone or to marginalize those who do not speak the same language or share cultural values with those who happen to be in power. Given the ease of travel on the planet, and the networks of communication in most parts of the planet, especially where economic power is concentrated, it is increasingly unlikely that there will ever be a place in the modernized world where all the people in that region have a common descent, history, culture or language. The nation, if it ever had a place in the world, certainly no longer has a place or a function. It is at most an abstract fiction. The human race may well have come to the point where it no longer needs to think in terms of people living in nations. It is arguably the time to begin thinking in terms of people simply living in the world, a world without artificial boundaries, a world in which there are thousands of living languages and cultures and particular histories, a world in which anyone can live and work wherever life and work are possible.

Maintaining the fiction of the artificial construct of a nation entails a waste of resources that the planet can ill afford. The defense of borders (against whom, aside from fellow human beings?) has come to involve the maintenance of armies and navies (and in the fantasy world in which some politicians live, even military units designed to dominate outer space) and immigrations and customs enforcement agencies and departments of homeland security and countless other entities that have no clear function other than to maintain an illusion that everyone on one side of an imaginary line has a common culture and history that differentiates them from those living on the other side of that imaginary line. The very idea of a nation has become a costly and wasteful fiction, one that is entirely out of line with the realities of human life on this planet.

I would suggest that rather than laboring under such pointless nationalistic slogans as “Make [plug in the name of an artificial construct here of your choice] Great Again,” we should consider a far more meaningful and easily achieved slogan such as “Make Humanity Nationless Again.”


Memories of being alarmed

“The alarm in the morning? Well, I have an old tape of Carlo Maria Giulini conducting the Vienna Philharmonic Orchestra in a perfectly transcendent version in Shubert’s seventh symphony. And I’ve rigged it up so that at exactly 7:30 every morning it falls from the ceiling onto my face.” ― Stephen Fry

When I was a child, I was rudely awaked every morning by a device that was aptly named an alarm clock, so-called, I suppose, because it was alarming to be awakened by the raucous sound of a clapper feverishly striking two little bells on top of the clock.

By the time I was an adolescent and unable to go for more than a few minutes at a time without listening to what I, but not my parents, called music, I had a clock radio, which could be set to turn itself off after a given number of minutes at bedtime and then turn back on at a specified time in the morning. The clock radio made it possible to go to sleep listening to music and to wake up listening to music. For those who needed to be alarmed, an obnoxious buzzer could be set to go off a few minutes after the music began to play, just in case the music was insufficiently jarring to bring sleep to an end. For those who were prone to fall back to sleep after the alarm went off, there was a feature called a snooze alarm, which sounded at intervals until the alarm was deactivated. When I was living with my parents and had a bedroom to myself, I relied on my clock radio to help me achieve the transitions between wakefulness and sleep. When I went to college and had to be considerate of roommates, I tried without much success to learn to go to sleep and wake up without external aids; I slept through many morning classes. (Much later, I atoned for that sin by teaching early morning classes that many of my students slept through.)

In early adulthood I completely outgrew my need for alarm clocks, having replaced them with babies who woke up crying just before the sun came up. From that point in my life onwards, I have nearly always awakened at just about the time the sun comes up and have had to set an alarm only on days when circumstances called for getting an early start. As a result of having a fairly reliable internal clock, my relationship with external wake-up mechanisms has deteriorated somewhat. While that is generally true, there have been a few memorable devices along the way that have yanked me out of slumber when the need arose.

When I was living in Japan in the late 1970s I was introduced to a number of electronic gadgets that did not become commonplace in North America until several years later. One of them was a slab of plastic small enough to fit into a shirt pocket that kept track of time and had an alarm that emitted high-pitched beeping noises. When I returned to North America, I bought one for my father, who loved new gadgetry. For a few years he enjoyed being on the cutting edge of chronometric technology, but it was not long before small battery-powered clocks and timers were available everywhere at much lower prices than the cost of a round-trip ticket to Japan.

A few years before I retired from teaching, I was with a student and had occasion to look at my wristwatch to see what the date was; even though wristwatches that showed the date had been around for decades, I still marveled at the clever convenience of a machine that could indicate both time of day and calendrical date. My student, seeing me glance at my timepiece and datepiece, remarked that people of his generation would never settle for a device that did only one thing. I asked him what he consulted when he wanted to know the time, and he pulled out a cellphone—not even a smartphone, but a flip phone of the sort that hardly anyone but old fogeys like me still carry. He demonstrated that his cellphone told the time and date, could be used to make telephone calls, had a calculator and several kinds of timer and alarm clock and a digital agenda book and a few simple games. He then pointed out, unkindly I thought, that his multifunction device cost less than half what my cumbersome two-function wristwatch cost. I realized then and there that I had outlived my usefulness.

Even though I still have a cellphone that is more simple and minimalistic than the mobile telephones that people were carrying ten or fifteen years ago (which, incidentally, I use mostly as a clock, since I hate both making and receiving telephone calls and am much too old to learn how to send or receive SMS), I do now have a multifunction device that fits on my wrist. It serves as a pedometer, heart-rate monitor, clock, calendar and stopwatch. It calculates an estimate of how many kilocalories of energy my body has consumed. If I wear it to bed, it logs an estimate of how many hours of deep sleep I have had, and if I set the alarm, it gently and noiselessly vibrates on my wrist to wake me up (although in performing the task of waking me up, it usually loses a race with my bladder). While I confess to finding it a bit silly to have a device that monitors my life as thoroughly as that wristband, I do find it an improvement on the clanging of the windup alarm clocks that woke me up as a child.


Pushing drugs, American style

Watching the news makes people sick

At the outset I must confess to being addicted to watching the news on television. Although my favorite televised news sources are on PBS, on most nights I supplement the PBS News Hour with the news on one of the traditional network stations or a cable news channel. Something that has repeatedly struck me in watching the evening news on traditional network stations is that advertisers have obviously learned that the vast majority of people who watch the evening news are suffering from indigestion, irritable bowel syndrome, erectile dysfunction, atrial fibrillation not caused by a heart-valve problem, moderate to severe psoriasis, rheumatoid arthritis, osteoporosis, depression, insomnia, restless leg syndrome or dry eye disease. If not afflicted by one of those conditions, they are being assaulted by meatballs or chicken wings.

Not all the commercials are pushing drugs, of course. Interspersed with all the pharmaceutical products are commercials featuring lawyers who are prepared to sue pharmaceutical companies for offering products that have life-changing side effects, and health insurance plans that complement Medicare to provide coverage to pay for all those pharmaceuticals that TV viewers are urged to ask their doctors about. Given the evidence of television commercials, remarkably few of the people who watch the televised news are under the age of sixty-five and have sound minds in sound bodies. 

An often-heard claim of those who are convinced that the Affordable Care and Patient Protection Act has all but destroyed the health-care system in the United States is that the ACA (which they persist in calling Obamacare) has driven insurance premiums through the ceiling, thus bringing financial ruin to small businesses and confronting hard-working Americans with having to choose between health insurance and sending their children to overpriced universities. What is missed in this analysis, of course, is that health insurance is expensive because medical care and pharmaceuticals are expensive. Also left out of consideration is that almost every pharmaceutical product sold in the United States is available in Canada for a fraction of the cost.

Why don’t Canadians pay their share of the cost of drugs?

A claim I have heard many Americans make, clearly a claim that they have learned from the pharmaceutical companies themselves, is that the prices of pharmaceutical products are so high in the United States because it costs pharmaceutical companies a great deal of money to do the research necessary to develop new products. Some American friends have even shown indignation that Americans are subsidizing Canadians, who derive all the benefits of expensive medical research but pay none of the cost. Once, when I was still living in Canada, I received an email from a (former) friend in the United States who accused me, in language unsuitable for anyone not in either the navy or a motorcycle gang, of being a freeloader who was enjoying good health at the expense of poor Americans. That claim was false for two reasons. First, I have almost never been prescribed a pharmaceutical product and tend to avoid over-the-counter medical products. Second, there are better explanations for why pharmaceutical prices are outrageously high in the United States. So the answer to the question “Why don’t Canadians pay their share of the cost of drugs?” is that they in fact do pay their fair share. Americans pay more, not because they are subsidizing freeloading Canadians, but because Americans pay far more for products than it costs to develop and manufacture those products.

Why do Americans pay for overpriced pharmaceuticals?

The pharmaceutical companies typically claim that they must charge high prices for their products because of the high cost of developing them. It cannot be denied that running controlled tests on new products and making sure the products meet safety standards is costly. It should also be pointed out, however, that advertising the products once they are developed is also costly. To that can be added that pharmaceutical companies also tend to pay shareholders rather high dividends. When health care products are manufactured by for-profit corporations that have investors to reward with high dividends, then costs naturally rise. While the claim of many advocates of free-market capitalism is that competition keeps costs down, the opposite is often the case. If two companies are competing for a share of the market, the cost of the competition—the advertising of products to potential consumers of the products and to potential prescribers of those products—can be quite high. 

Neither of those kinds of advertising is necessary. There is no justification whatsoever for running expensive advertisements on television that end with the line “Ask your doctor whether…is right for you.” There is no need to make the patient into a sales representative for a product that the patient may end up buying. If someone has, say, osteoporosis, then it should be sufficient for the physician to suggest a range of possible treatments, and to tell the patient the desired effects and the likely side effects of each of the possible treatments. And that information should be given directly to the physician in the form of the results of clinical trials, not in the form of slick presentations delivered in the context of work-vacations at expensive resorts. The cost of disseminating objective information is relatively low, whereas the cost of trying to persuade a physician to prescribe product A rather than the almost-identical product B is much higher. 

One way to bring medical costs down is to make advertising of medical products illegal, as it is in some countries that have lower costs for pharmaceuticals and hands-on medical care. Another way is to have government-imposed limits on the amount of profit a company can make on a product, as is also the case in some countries that have reasonable consumer-costs for health-related products. A third way is to have a government-run insurance plan that negotiates prices with pharmaceutical companies and imposes a cap on how much a pharmaceutical company can receive for its products. There is no need for a government-run plan to be managed by the central government. In Canada each province has its own plan, and no two provinces have exactly the same setup.

Health care is far too important to be left to the vagaries of markets in a for-profit corporate scheme. The good health of the entire citizenry is far more important than the bank accounts of capitalist shareholders. There are plenty of other markets in which investors can make or lose their money. Pharmaceutical companies, manufacturers of medical devices, clinics, hospitals and retirement homes for the elderly should not be in the private investment sector of the economy. (Neither should correctional facilities, but that is a matter for another day.)

Americans desiring affordable health insurance should first advocate for more affordable treatments, and that is best achieved by a not-for-profit health-care system. They should be asking for, in fact demanding, more government involvement and less private-sector investment in products designed for health. Such a change in outlook would, however, require that Americans first seek a cure for their addiction to free-market capitalism and the delusion that the best way to keep costs down is to let the market determine prices. That strategy has been tried again and again, and it has failed again and again. It is time for Americans to considered an alternative system (not to be confused with “alternative facts”).

Next time you see a television commercial for an expensive treatment that you have seen a hundred times before, instead of simply reaching for the mute button on the remote control, ask your doctor whether socialized medicine is right for you. If you doctor says No, then consider seeking a second opinion. 

Eve of Destruction

Yeah, my blood’s so mad, feels like coagulatin‘,
I’m sittin’ here, just contemplatin‘,
I can’t twist the truth, it knows no regulation,
Handful of Senators don’t pass legislation,
And marches alone can’t bring integration,
When human respect is disintegratin’,
This whole crazy world is just too frustratin’,
And you tell me over and over and over again my friend,
Ah, you don’t believe we’re on the eve of destruction.
   —P. F. Sloan. “Eve of Destruction” (1964)

On Tuesday, November 6, 1860, Abraham Lincoln became the first Republican to be elected President of the United States. His running mate was Senator Hannibal Hamlin of Maine, an active opponent of slavery who had begun his political life as a Democrat but switched to the Republican Party in 1856, convinced that party was more in line with his staunch anti-slavery views.

Reaction to the election of Lincoln and Hamlin was swift. On Thursday, December 20, 1860, the State of South Carolina seceded from the union. A document entitled South Carolina Declaration of Causes of Secession began with this paragraph:

The People of the State of South Carolina, in Convention assembled, on the 26th day of April, A.D. 1852, declared that the frequent violations of the Constitution of the United States, by the Federal Government, and its encroachments upon the reserved rights of the States, fully justified this State in then withdrawing from the Federal Union; but in deference to the opinions and wishes of the other slaveholding States, she forbore at that time to exercise this right. Since that time, these encroachments have continued to increase, and further forbearance ceases to be a virtue.

Among the specific articles of the Constitution of the United States that the Convention of South Carolina stated was Article 4, Clause 3:

No person held to service or labor in one State, under the laws thereof, escaping into another, shall, in consequence of any law or regulation therein, be discharged from such service or labor, but shall be delivered up, on claim of the party to whom such service or labor may be due.

One of the stated causes for South Carolina’s leaving the union was that there were Northern states that were not honoring this clause but were harboring fugitive slaves. The constitutional obligation of states to return fugitive slaves to their rightful owners was, the document goes on to say, “so material to the compact, that without it that compact would not have been made.” The States that allowed slavery would never have agreed to sign the Constitution of the United States or to be part of the Union unless their rights to own slaves, and to have that ownership honored by all the other States, was ensured.

The document drawn up by the Convention of South Carolina served as a model for similar documents in other slaveholding states. By the time Abraham Lincoln and Hannibal Hamlin were sworn into office on March 4, 1861, six more states (Mississippi, Florida, Alabama, Georgia, Louisiana and Texas) had already declared themselves to be sovereign nations no longer part of the United States of America. During the first four months of Lincoln’s presidency, four more states (Arkansas, North Carolina, Virginia and Tennessee) seceded from the Union. When the Lincoln-Hamlin ticket was elected in November 1860, there were thirty-three states. By the time they had been in office for ninety-five days, eleven states had declared independence from the United States, and one state (Kansas) had been added. Elected to be President of thirty-three United States, by June 1861 Lincoln was President of twenty-three United States, a nation that had been at war with the Confederate States of America since April 12, 1861. By the time the war—generally called “The War of the Rebellion” in the United States and “The War for Southern Independence” in the Confederate States of America—came to an end, there were an estimated 750,000 American military deaths (in contrast to 405,399 in World War I; 116,516 in World War II; and 58,209 in the war in Vietnam), or nearly 2.4% of the total American population at that time. About a month before the war was declared fully ended in May 1865, President Lincoln had been assassinated and succeeded by his second Vice President, Andrew Johnson, formerly a Democrat from the State of Tennessee, who had run with Lincoln in 1864 on the National Union ticket. President Johnson favored a quick restoration to the Union of all the states that had seceded, but his plans made no provision for the protection of former slaves. The failure to provide this protection enraged the Congress, dominated by Republicans, and the House of Representatives impeached him. The Senate, however, voted by a margin of a single vote to acquit him, allowing him to finish his single term as seventeenth President of the United States.

Although the thirty-six states—West Virginia had been admitted to the Union in 1863 and Nevada in 1864—of the United States were officially united again, it could be argued that the deep conflicts that had divided them have never been resolved. Nearly every politically charged issue in the politics of the early twenty-first century has some dimension of the unresolved controversy of whether there should be national policy or fifty different state policies. Should there be a national Environmental Protection Agency, or should each state have its own policies, or lack thereof, on protecting the environment from human enterprises? Should there be a national Department of Education, or should each state fund its own schools, set its own curriculum, and have its own criteria of whether the educational system is meeting its goals? Should there be a national Bureau of Land Management, or should each state determine how the lands within its borders are used and by whom? Should it be decided by the Supreme Court of the United States that all women in the nation have access to birth control and abortion, or should each state have its own policies? Should there be a national policy on who can have access to which kinds of firearms, or should each state be left to decide its own policies? Should there be a national schedule of which substances people can use for medicinal or recreational purposes, or should each state have its own food and drug policies? Generally speaking, should the central government be subordinate to regional governments, or vice versa? These issues were hotly debated as the United States Constitution was being drawn up, they came to a boiling point during the American Civil War, and they have been simmering ever since. Ever since the Constitution of the United States was written in 1787, there have been heated disputes about the balance of jurisdictions between the central government and state governments, and in many states disputes about the balance of jurisdictions between state and county and municipal governments.

One could be forgiven for thinking that 230 years of failure to arrive at a smoothly working federalism—that is, a mixture of central and regional governments—may stem from the fact that the very idea of federalism is fundamentally flawed. Two possible remedies to this failure are both such a radical departure from what has been in place for twenty-three decades that neither is likely to be adopted, for either one would mean an end to the States of America that are United in name only. One remedy would be to abolish the states altogether and simply have a national government with a unicameral legislature, a single House of Representatives with no Senate (and no electoral college). The other remedy would be to abolish the central government altogether and to have a number of sovereign nations—ideally, far fewer than fifty, since many of the current states have arbitrary borders that were drawn with a straightedge and a compass in Washington, D.C. without any regard to the geographical, economic and cultural integrity of the regions enclosed in those borders.

I personally would be more inclined to favor the first of those two radical solutions; indeed, I would be in favor of abolishing every sovereign nation and replacing them all with a single planetary government with jurisdiction over the entire planet Earth. I do not expect to live long enough to see that solution put into place. It seems more likely that I may live long enough to see at least the beginnings of the opposite radical solution, a dramatically weakened central government with correspondingly strengthened state governments, the result being a very weak union of nearly sovereign states held together only by the glue of the vested interests of major corporations that have no regard for anything but material profits and the foolish pride and dangerous over-confidence of a delusional figurehead with autocratic pretensions.


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