Transplantation: progress and continued shortcomings

 Here's a guest essay from the NYT that focuses on a different set of shortcomings of organ transplantation than organ availability. The author writes about how her long history of immunosuppression, to keep her transplanted organ(s) alive, has left her vulnerable to cancer.

My Transplanted Heart and I Will Die Soon.  By Marine Buffard

"My 35 years living with two different donor hearts (I was 25 at the time of the first transplant) — finishing law school, getting married, becoming a mother and writing two books — has felt like a quest to outlast a limited life expectancy. 

...

"Organ transplantation is mired in stagnant science and antiquated, imprecise medicine that fails patients and organ donors. And I understand the irony of an incredibly successful and fortunate two-time heart transplant recipient making this case, but my longevity also provides me with a unique vantage point. Standing on the edge of death now, I feel compelled to use my experience in the transplant trenches to illuminate and challenge the status quo.

"Over the last almost four decades a toxic triad of immunosuppressive medicines — calcineurin inhibitors, antimetabolites, steroids — has remained essentially the same with limited exceptions. These transplant drugs (which must be taken once or twice daily for life, since rejection is an ongoing risk and the immune system will always regard a donor organ as a foreign invader) cause secondary diseases and dangerous conditions, including diabetes, uncontrollable high blood pressure, kidney damage and failure, serious infections and cancers. The negative impact on recipients is not offset by effectiveness: the current transplant medicine regimen does not work well over time to protect donor organs from immune attack and destruction.

"My first donor heart died of transplant medicines’ inadequate protection of the donor heart from rejection; my second will die most likely from their stymied immune effects that give free rein to cancer.

...

"Without vigorous pushback, hospitals and physicians have been allowed to set an embarrassingly low bar for achievement. Indeed, the prevailing metric for success as codified by the Health Resources and Services Administration is only one year of post-transplant survival, which relieves pressure for improvement."

*************

That one year of measured graft survival is both too short, as the author points out, and too long.  By penalizing transplant centers for transplants that fail to survive a year, the current regulations make transplant centers too risk averse, so that kidney transplants that would have only, say, an 85% chance of working well are often not conducted, leaving patients to remain on dialysis, often til death,  for that 85% chance of life.

Transplantation is, still, a modern miracle. But until we can do without it, we'll have to keep trying to do it better.

The World Health Organization (WHO) at 75

 An editorial in Nature considers the complicated history of  the World Health Organization. 

The WHO at 75: what doesn’t kill you makes you stronger. The World Health Organization is emerging from the peak of the pandemic bruised. Its member states must get back to prioritizing universal health care.

"When thinking about the WHO’s 75 years, it’s worth remembering the time and circumstances of its creation. In the aftermath of the Second World War, the newly established United Nations and its specialized agencies, including the WHO, were designed to future-proof the world from another global conflict. Around 80 million people died during the two world wars, many from famine or disease.

"The WHO deserves more money for its core mission — and more respect

"The WHO’s founding constitution states unequivocally: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”

"And yet, the agency’s creators chose not to prioritize robust systems of universal health care that would meet these goals. This absent focus is one factor in why infectious diseases continue to impact populations in low- and middle-income countries. The eradication of smallpox in 1980 was a big win. But for other diseases, the agency and its donors have been unable to reach targets, including in the elimination of HIV and AIDS, malaria and tuberculosis.

"The WHO does, however, have a consistent record for establishing itself as the go-to organization for setting global standards for the efficacy, safety and quality of vaccines and medicines. As we have seen during the pandemic, the agency is central to alerting the world to new infectious diseases, helped in no small measure by the revolution in biomedicine and health data, especially genomics."

In general I think the WHO does important work reasonably well, but I have reservations about their policies concerning blood and transplants, which seem to me to reflect some now outdated repugnance to the complexities of “Substances of Human Origin (SoHO)." (Not that these issues don't remain complex.)

Discriminatory quotas in admissions to universities and graduate schools (and some black humor from my father's generation)

 History doesn't exactly repeat itself, but it rhymes. (Mark Twain apparently missed the opportunity often attributed to him of saying that.) Here's a story about the history of ethnic quotas for Jews, as it played out in medicine in the 20th Century. (And at the bottom, some old jokes about coping with it...)

The History of Discriminatory Jewish Quotas in American Medical Education and Orthopaedic Training, by Solasz, Sara J. BA1; Zuckerman, Joseph D. MD1; Egol, Kenneth A. MD1,a, The Journal of Bone and Joint Surgery 105(4):p 325-329, February 15, 2023. | DOI: 10.2106/JBJS.22.00466

"By the early 1920s, formal quota systems were put in place to limit the number of Jewish applicants admitted to many American medical schools. This quota was partly a result of the second wave of Jewish immigration and the subsequent rise in antisemitism in the country. As a sign of the growing antisemitism in America, in 1920, Henry Ford published a weekly series called “The International Jew: The World’s Problem” on the front page of his newspaper, The Dearborn Independent. In this series, which continued for years, Ford fueled antisemitism both at home and abroad. The effect at the time was enormous: the feeling was that if an American icon as rich and powerful as Ford could hold this conviction so strongly, then it must be credible5,6. In addition to the effect on medical school admissions, measures were taken to deny Jewish people access to social institutions, neighborhoods, swimming pools and beaches, and employment.

...

"Harvard was known to have quotas restricting the number of Jewish students admitted to the college under the leadership of Lowell. In a letter to a philosophy professor, Lowell wrote that admitting Jewish students would ruin Harvard, “not because Jews of bad character have come; but the result follows from the coming in large numbers of Jews of any kind, save those few who mingle readily with the rest of the undergraduate body.”8

"It is within this social and political climate that the Jewish quota system appeared in medical schools throughout the U.S. Although medical school officials have always denied the existence of Jewish quotas, records from schools across the country reveal a systematic and intentional anti-Jewish prejudice. The medical historian Henry Sigerist wrote that Jewish students were subject to a “tacit, but nevertheless highly effective, quota system and in most schools the number of Jewish students rarely exceeds 10 per cent.”9 Many mainstream thinkers in higher education argued for further reductions in the acceptance rate for Jewish students, advocating for discrimination against Jews under the guise of keeping the “national ratio correct,” which would bring down the number of accepted students to represent only 3% to 4% of the total class.

...

"The most significant decrease in the number of admitted students occurred at Columbia University, which asked for the applicant’s religion, parents’ birthplaces, racial origin, and mother’s maiden name11. At the Columbia College of Physicians and Surgeons, the rate of enrollment of Jewish students between 1920 and 1940 dropped from 47% to 6%; during the same period, the rate dropped from 40% to 5% at Cornell University Medical College3. Throughout the Northeast, where the concentration of Jewish applicants was the highest, quotas appeared at schools such as Harvard Medical School, Yale School of Medicine, and the Woman’s Medical College of Pennsylvania3.

...

Facing this widespread sentiment, Jewish students hoping to gain admission to medical school were forced to take action—with some even changing their last names to avoid discrimination. Medical schools identified “Jewish names” on applications, especially when the applicants were from areas with large Jewish populations, to indirectly discriminate against Jewish students. Soon, schools expanded applications to require completion of a “change of name” section. *

...

"Prior to the establishment of the current U.S. residency “match” system, each residency position was sought individually with an application and interview and was typically followed by a near-immediate offer of a position. This system certainly provided a biased and unfair method for filling training programs.

...

"In New York State, the Education Practices Act (1948) set a precedent for other states to pass legislation to eliminate discriminatory admissions practices. As the wave of antisemitism began to fade and the need for physicians grew, medical schools and graduate medical education programs started to remove the quota systems, which came to a complete end in the 1970s."

##############

*Black humor was common in my dad's generation, including jokes about name changing (sometimes told in Yiddish). Here are two, approximately remembered.

1. Shmuel and Moshe, friends from Odessa, meet in New York after both have immigrated to America.  Moshe spots him from a distance and rushes over, calling out "Shmuel!"  They embrace, and Shmuel says, "I'm called Sam now, in America.  How about you?"

Moshe says "my American name is Sean Ferguson."  Sam is astonished, and asks "how come?"  "Well," says Moshe/Sean, I had picked out a good American name, but I was so nervous when I got to Ellis Island that I couldn't remember it. So when the immigration officer asked me my name, all I could think of to say was "I've already forgotten/ ikh hab shoyn fargesn, which is what he wrote down."  (איך האב שוין פארגעסן)

2. A few years later, Sean Ferguson goes to court to change his name again, to John McMillan. The judge asks him why he wants to do that.  He says "When I apply for positions, people ask what my name used to be..."

The (American) market for assault rifles

There was a time when Americans thought that rifles were for hunting game, and assault weapons were banned.  That has changed.

The Washington Post has the story:

The gun that divides a nation. The AR-15 thrives in times of tension and tragedy. This is how it came to dominate the marketplace – and loom so large in the American psyche. By Todd C. Frankel, Shawn Boburg, Josh Dawsey, Ashley Parker and Alex Horton 

"The AR-15 wasn’t supposed to be a bestseller.

"The rugged, powerful weapon was originally designed as a soldiers’ rifle in the late 1950s. “An outstanding weapon with phenomenal lethality,” an internal Pentagon report raved. It soon became standard issue for U.S. troops in the Vietnam War, where the weapon earned a new name: the M16.

...

"Today, the AR-15 is the best-selling rifle in the United States, industry figures indicate. About 1 in 20 U.S. adults — or roughly 16 million people — own at least one AR-15, according to polling data from The Washington Post and Ipsos.

...

"One Republican lawmaker, Rep. Barry Moore of Alabama, introduced a bill in February to declare the AR-15 the “National Gun of America.”

"It also has become a stark symbol of the nation’s gun violence epidemic. Ten of the 17 deadliest U.S. mass shootings since 2012 have involved AR-15s.

...

"the U.S. firearms industry came to embrace the gun’s political and cultural significance as a marketing advantage as it grasped for new revenue.

"The shift began after the 2004 expiration of a federal assault weapons ban that had blocked the sales of many semiautomatic rifles. 

...

"Today, the industry estimates that at least 20 million AR-15s are stored and stashed across the country.

"More than 13.7 million of those have been manufactured by U.S. gunmakers just since the Newtown massacre in late 2012"

*************

NPR puts some history into perspective:

The Nashville school shooting highlights the partisan divide over gun legislation , by Ron Elving, April 1, 2023

"The Stockton schoolyard shooting in 1989

...

"The Stockton story was national news, featured on the cover of Time magazine with the headline "Armed America." Public alarm at Stockton pushed the legislature to be the first to prohibit the sale of assault weapons that year.

"Stockton was still reverberating three years later when California, the home of Republican presidents Richard Nixon and Ronald Reagan, sent two liberal Democrats, both women, to the U.S. Senate It also stocked its legislature and congressional delegation with big Democratic majorities and gave its Electoral College vote to Bill Clinton.

"One of the two women senators elected that year was former San Francisco Mayor Dianne Feinstein, who had first become mayor when her predecessor was shot to death in his office in the 1970s. She had long been outspoken on gun control and brought that commitment to Washington, D.C., becoming one of the principal sponsors of a bill banning assault weapons ban in her first year.

"The Assault Weapons Ban of 1994

"Feinstein and her cosponsors wanted to end the sale or manufacture of 14 categories of semi-automatic assault weapons. They also wanted to go beyond the California ban by outlawing copycat versions of earlier models and high-volume detachable magazines that held more than 10 rounds.

"But the bill did not address the status of an estimated one million assault weapons nationwide. "Essentially what this legislation does is create a freeze," she said. She lamented the resistance that rarely produced actual arguments among her colleagues. She said had never realized "the power of the NRA in this town."

...

"There were literally hundreds of exceptions included in the final version, distressing many of the bill's supporters. But getting the ban into the crime package to be passed in that Congress (with billions in new police funding) required many compromises. Ultimately, to get to a majority, Feinstein would have to accept a sunset provision by which her restrictions would need reenactment after 10 years.

...

"So when the 10-year expiration date on Feinstein's bill arrived in 2004, Democrats were no longer the majority party in Congress and all attempts to extend the 1994 ban were unavailing.

...

"The Sandy Hook Test in 2012

The next time serious energy developed behind renewing the ban was in the winter of 2012-2013. Barack Obama had just been reelected president, and the Senate was still in Democratic hands.

"Just as important, the effort to address the gun issue had been given an enormous boost by a new and more horrific tragedy.

"On Dec. 12, 2012, Adam Lanza, 20 — described by counselors as fascinated with mass shootings — killed his mother and took guns she had legally purchased to a Sandy Hook Elementary School in Newtown, Conn.

"There he shot dead 20 children, ages 6 and 7. He also killed six adults on the school staff. Then he killed himself.

"The national shock at the time is hard to appreciate a decade later, as there have been so many like it. 

...

"But the 113th Congress came and went in 2013 and 2014 without passing notable gun legislation. A compromise measure on background checks, offered by West Virginia Democrat Joe Manchin and Pennsylvania Republican Pat Toomey, got 54 votes in the Senate but needed 60.

"As for prospects for reviving gun legislation in the current Congress, the situation looks much as it did a decade ago. The 118th Congress has a Senate where Democrats have a nominal majority that depends on the cooperation of several independents. Feinstein is still in the Senate, the longest-serving incumbent Democrat, but planning to retire next year.

"The current House, like that of a decade ago, has a Republican majority led by a speaker whose power depends on placating a hardcore group known as the House Freedom Caucus."

Jobs at risk from AI chatbots

 The WSJ has the alarming news:

The Fortune Cookie Industry Is in Upheaval. ‘Expect Big Changes Ahead.’ Factories split over whether to use software, instead of humans, to write the random bits of wisdom inside the wafers. ‘Society is moving too fast.’  By Angus Loten

"Over the past two decades, Charles Li, the owner and chief executive of Chicago-based fortune-cookie factory Winfar Foods Inc., has drawn on Chinese proverbs and popular sayings to write thousands of messages that go into the wafers. Mr. Li says he and his 80-year-old father-in-law spend long hours coming up with lines that are clever but still brief enough to fit on a ribbon of paper.

...

"OpenFortune Inc., a New York-based company that supplies printed messages to well over a dozen fortune-cookie factories around the world, says it has started using ChatGPT technology to potentially generate a near-limitless inventory of new messages.

"Making up the sayings in the cookies is a vigorous line of work. By some estimates, three billion fortune cookies are made by factories around the world every year. Nearly all are written by a handful of fortune-cookie factory owners, their families or small teams of copywriters."

Kidney transplants from donors who died from illegal drug use

 There was a time when the modal deceased kidney donor had suffered a head injury in an auto accident, but that time is long gone, due to increased auto safety and to the rise in drug overdose deaths.  Those latter deaths now constitute a large proportion of deceased donors, and here's a report from Canada confirming that those kidneys work well in their new owners.

Xie, Max Wenheng, Sean Patrick Kennan, Amanda Slaunwhite, and Caren Rose. "Observational Study Examining Kidney Transplantation Outcomes Following Donation From Individuals That Died of Drug Toxicity in British Columbia, Canada." Canadian Journal of Kidney Health and Disease 10 (2023): 20543581231156853.

"Abstract:

"Background: The illicit drug toxicity (overdose) crisis has worsened across Canada, between 2016 and 2021 more than 28 000 individuals have died of drug toxicity. Organ donation from persons who experience drug toxicity death has increased in recent years. 

"Objective: This study examines whether graft loss after kidney transplantation differed by donor cause of death. 

Design: Retrospective cohort. 

"Setting: Provincial transplant program of British Columbia, Canada. 

"Patients: Transplant recipients who received kidney transplantation from deceased donors aged 12 to 70 years between 2013 and 2019 (N = 1012). 

"Measurements: Transplant recipient all cause graft loss (graft loss due to any cause including death) was compared by donor cause of death from drug toxicity or other. 

"Methods: Five-year Kaplan-Meier estimates of all-cause graft survival, and 3-year complete as well as stratified inverse probability of treatment weighted Cox proportional hazards models were conducted. 

"Results: Drug toxicity death donors donated to 25% (252/1012) of kidney transplantations. Drug toxicity death donors were more likely to be young, white, males, with fewer comorbidities such as diabetes or hypertension but were more likely to have a terminal serum creatinine ≥1.5 mg/dL or be hepatitis C virus (HCV) positive. Unadjusted 5-year estimate of all cause graft survival was 97% for recipients of drug toxicity donor kidneys and 83% for recipients of non-drug toxicity donor kidneys (P < .001). Recipients of drug toxicity death donor kidneys had decreased risk of all cause graft loss compared to recipients of non-drug toxicity death donor kidneys (hazard ratio [HR]: 0.30, 95% confidence interval [CI]: 0.12-0.77, P = .012). This is primarily due to the reduced risk of all-cause graft loss for recipients of younger (≤35 years) drug toxicity death donor kidneys (HR: 0.05, 95% CI: 0.00-0.55, P = .015). 

"Limitations: Potential selection bias, potential unmeasured confounding. 

"Conclusions: Donation after drug toxicity death is safe and should be considered more broadly to increase deceased donor kidney donation."

...

"illicit drug toxicity remains the leading unnatural cause of death in BC accounting for more deaths than homicides, suicides, and motor vehicle incidents combined.

...

"The United States is also undergoing an opioid epidemic which began earlier than Canada and has recorded similar increases in organ donation from individuals that died of illicit drug toxicity.9-11 Studies in the United States have found that recipient survival after kidney transplantation from individuals who died from drug toxicity was similar for recipients of kidneys from donors that died of any other cause of death."

Brain Death

 Before there was the possibility of organ transplantation, determining that someone was dead could be a relatively leisurely affair. But transplants depend on organs remaining alive after the potential organ donor has died.  If the death is due to irreversible absence of circulation and respiration (Donation after Circulatory Death – DCD), it has to be declared quickly, so that preparation for organ recovery can begin promptly. If the declaration of death is based on brain death, i.e. on irreversible absence of whole brain function (Donation after Death declared by Neurologic Criteria - DDNC), then it must occur while the potential donor is on a ventilator, so that his/her organs continue to be oxygenated.  This means that the declaration of death occurs while the ventilator is still maintaining many of the signs (respiration, heartbeat) that are usually evidence of a living person.  So deciding when someone is brain dead requires both expertise and consensus.

Here's a recent discussion of all this, including some controversy, in JAMA: 

The Uncertain Future of the Determination of Brain Death, by Robert D. Truog, JAMA. 2023;   329(12): 971-972. doi:10.1001/jama.2023.1472

"In 1980, the US Uniform Law Commission (ULC) established the Uniform Determination of Death Act (UDDA), which was subsequently adopted (with some modifications) by all 50 states.1 The law states that death is defined as either (1) the irreversible cessation of circulatory and respiratory functions or (2) the irreversible cessation of all functions of the entire brain, including the brainstem.

...

"The framers of the UDDA rejected the claim that this was a new way of defining death.2 Instead, they pointed to evidence at the time suggesting that the brain is necessary for maintaining biological functioning and that when this brain regulation is absent, homeostatic mechanisms fail, with cardiac arrest invariably occurring within 1 to 2 weeks at most. In other words, brain death and cardiopulmonary arrest were seen as equivalent and equally valid criteria for diagnosing the biological death of a patient.

"However, with improvements in critical care medicine, this equivalency has been called into question. With modern intensive care unit support, some patients can be stabilized and, if provided with mechanical ventilation and tube feedings, their bodies may survive for many years.

...

"In fact, patients with brain death may retain most of the capacities of living people, including the ability to absorb nutrition, excrete waste, heal wounds, grow, undergo puberty, and even gestate. This has led many families to reject the diagnosis and insist on the continuation of medical support for their loved ones.

"In addition, a second issue has been that, although the UDDA requires “the irreversible absence of all functions of the entire brain,” the current guidelines from the American Academy of Neurology (AAN) test for only a select number of functions and most notably do not test for hypothalamic functions, which are sometimes present in patients who are diagnosed with brain death

"In the wake of an increasing number of legal challenges related to the determination of brain death, ULC began a process in 2021 to assess whether the UDDA should be revised.1 At least 3 distinct proposals have been considered.

"Proposal 1: Revise the Guidelines to Align With the Current Definition

"One option would be to leave the UDDA intact, but revise the AAN guidelines to include testing for the absence of hypothalamic function.

...

"Proposal 2: Revise the Definition to Align With the Current Guidelines

"A second proposal has been to change the definition of brain death to be in alignment with the guidelines.

...

"Revising the UDDA so that it required not the irreversible loss of all brain functions, but rather only those functions that support consciousness and spontaneous respiration, would bring the UDDA into alignment with the AAN guidelines. This approach also has precedent, in that it is the definition that was adopted by the United Kingdom in 2008.

...

"Proposal 3: Maintain the Status Quo

"If the position endorsed by commissioner Bopp were to prevail, some states could choose to entirely eliminate the determination of death by neurologic criteria. The impact would be 2-fold: in those states it would no longer be permissible to procure transplantable organs from patients diagnosed with brain death and physicians could be required to continue to provide intensive care unit beds and life support to patients who will never regain consciousness. Such an outcome could have disastrous consequences for our existing systems of organ procurement and transplantation, leading to thousands of otherwise avoidable deaths.

"This has led some commissioners to lean in favor of not making any major revisions to the UDDA, leaving well enough alone."

Mega-Journals and scientific publishing

 Academic publishing is getting more varied. A recent article in JAMA focuses on the rise of 'mega-journals,' which seek to publish papers that are correct, without filtering for (referees' opinions about) novelty or importance.

The Rapid Growth of Mega-Journals: Threats and Opportunities  by John P. A. Ioannidis, MD, DSc1,2; Angelo Maria Pezzullo, MD, MSc3; Stefania Boccia, MSc, DSc, PhD3,4, JAMA. Published online March 20, 2023. doi:10.1001/jama.2023.3212

"Mega-journals, those that publish large numbers of articles per year,1 are growing rapidly across science and especially in biomedicine. Although 11 Scopus-indexed journals published more than 2000 biomedical full papers (articles or reviews) in 2015 and accounted for 6% of that year’s literature, in 2022 there were 55 journals publishing more than 2000 full articles, totaling more than 300 000 articles (almost a quarter of the biomedical literature that year). In 2015, 2 biomedical research journals (PLoS One and Scientific Reports) published more than 3500 full articles. In 2022, there were 26 such prolific journals (Table). The accelerating growth of mega-journals creates both threats and opportunities for biomedical science.

...

"we define mega-journals as open-access peer-reviewed journals that charge article processing fees and publish more than 2000 full articles in a calendar year. The 2 early-launched mega-journals, PLoS One and Scientific Reports, were also characterized by very broad publishing scope, covering scientific topics in general. 

...

"Mega-journals typically claim to publish articles based on whether they are scientifically sound rather than important and novel. Accordingly, their acceptance rates, when disclosed, are 20% to 70%

...

"It would be unfair, nevertheless, to dismiss mega-journals as simply a negative development. Several of their characteristics could be aligned also with desirable scientific practices. First, open access is a good starting point, and it can be coupled with greater transparency. If these journals routinely adopt transparent research practices, such as sharing of data, code, protocols, and statistical analysis plans, they can have a transformative effect, given their large output. Several older, broad-scope mega-journals (eg, PLoS One, Royal Society Open Science) have already championed such efforts. It is crucial that disciplinary-focused mega-journals do the same. Second, publishing technically sound scientific work regardless of the nature of the results is highly commendable. It offers opportunities to curb publication and selective reporting bias. Empirical studies are needed to investigate whether mega-journals do achieve this goal or still have selective reporting biases and variants thereof (eg, “spin”). Third, mega-journals may allow publication of results deemed undesirable in traditional specialty journals with entrenched, inbred publishing practices. Enhanced diversity of perspectives and opportunities to challenge orthodoxy are welcome, provided the journals publish rigorous data and safeguard against conflicts of interest. Securing editorial independence and maximizing transparency about conflicts for editors, reviewers, and authors will be key in reaping such benefits.

...

"At the publisher level, competition may have major indirect effects on medicine and science at large. Scientific publishing has an annual work cycle exceeding $30 billion and very large profit margins, which are possible in part because approximately 100 million hours of peer reviewers’ time is offered free yearly.8 The publishers behind the new generation of specialized mega-journals (Table) are taking this money-making recipe to new heights. Science and scientists may feel thwarted, if not entirely powerless, while big publishing corporations fight for field domination. However, it would be to the benefit of all if scientists, medical and research institutions, and funders gave credit to and rewarded journals (and publishers) that promote more transparent research and more rigorous research practices."

Experiments and market design, video (I'm interviewed by Chiara Spina from INSEAD)

Professor Chiara Spina interviewed me about the use of experiments in market design (20 minute video). (We spoke about a number of experiments I collaborated on with Judd Kessler, among others.)

Comstockery and abortifacients, on the way to the Supreme Court

 The Comstock Act of 1873 made it a Federal crime to distribute information or medicines for contraception or abortion, and more generally on material judged to be for "any indecent or immoral purpose."  The 1965 ruling in Griswold vs. Connecticut found the bans on contraception to be unconstitutional, and the bans on pornography were strictly limited the year before in the case Jacobellis v. Ohio.  But the Act reared its head again when it was cited by a Federal judge in Texas, Matthew J. Kacsmaryk, in his ruling that the abortion inducing drug mifepristone was illegal to distribute anywhere in the U.S., including in states where abortion is legal.

Michelle Goldberg in the NYT writes about "The Hideous Resurrection of the Comstock Act"

"suddenly, the prurient sanctimony that George Bernard Shaw called “Comstockery” is running rampant in America. As if inspired by Comstock’s horror of “literary poison” and “evil reading,” states are outdoing one another in draconian censorship. In March, Oklahoma’s Senate passed a bill that, among other things, bans from public libraries all content with a “predominant tendency to appeal to a prurient interest in sex.” Amy Werbel, the author of “Lust on Trial: Censorship and the Rise of American Obscenity in the Age of Anthony Comstock,” described how Comstock tried to suppress photographs of cross-dressing women. More than a century later, Tennessee has banned drag performances on public property, with more states likely to follow.

"And now, thanks to a rogue judge in Texas, the Comstock Act itself could be partly reimposed on America. Though the act had been dormant for decades and Congress did away with its prohibitions on birth control in 1971, it was never fully repealed. And with Roe v. Wade gone, the Christian right has sought to make use of it. The Comstock Act was central to the case brought by a coalition of anti-abortion groups in Texas seeking to have Food and Drug Administration approval of mifepristone, part of the regimen used in medication abortion, invalidated. And it is central to the anti-abortion screed of an opinion by Matthew J. Kacsmaryk, the judge, appointed by Donald Trump, who on Friday ruled in their favor.

...

"On Friday a Washington State judge issued an opinion directly contradicting Kacsmaryk’s and ordering the F.D.A. to continue to make mifepristone available. The dispute now is likely headed to the Supreme Court."

Alcoholic beverage distributors

 The FCC investigates and regulates not just the industries we all know about, but also industries that quietly do a lot of the heavy lifting in ordinary lines of business.  Here's report of a (possible) FTC probe that sheds light on distributors of alcoholic beverages, in which big businesses I hadn't previously heard of operate in a much more concentrated fashion than I would have guessed.

Politico has the story:

Feds target alcohol pricing in new antitrust probe. The FTC has a similar investigation involving the soft drink market.

"The Federal Trade Commission has opened an investigation into the largest U.S. alcohol distributor, Southern Glazer’s Wine and Spirits, over practices related to how wine and liquor are priced and sold around the country, according to three people with knowledge of the probe.

"The FTC is investigating Southern Glazer’s Wine and Spirits for possible violations of the Robinson-Patman Act, a 1936 law prohibiting suppliers from offering better prices to large retailers at the expense of their smaller competitors, according to the people.

...

"According to a December 2022 Forbes report, Southern Glazer is the 11th largest privately held company in the U.S., with around $25 billion in revenue and distributing over 7,000 different brands of alcohol, wine, beer and other beverages. Republic National Distributing Company, the second largest alcohol distributor, which is not known to be a target in the probe, had 2022 revenues of around $12 billion, according to Forbes. Combined, the two companies account for the bulk of U.S. alcoholic beverage distribution.

Markets in human milk, placenta, and feces

I've blogged earlier about markets for breast milk, but here is an article that considers them also in connection with placenta and feces: 

The Law of Self-Eating—Milk, Placenta, and Feces Consumption by Mathilde Cohen, Law, Technology and Humans, 3(1), pp.109-122.

"Milk, Placenta, and Feces 

"Since antiquity at least, there have been markets in human milk. Until the twentieth century, they relied primarily on wet nurses hired (or forced) to nurse infants directly on the breast.14Ancient Egyptian, Greek, and Roman pharmacopeias called for human milk as a therapeutic substance to treat burns as well as ailments affecting the ears, eyes, and genitals.15Traditional Chinese medicine  employed  human  milk  in  a  variety  of  preparations  to  cure  diseases,  such  as  debilitation,  arthritis,  rheumatism, voicelessness, amenorrhea, eye infections, and poisoning.16

"Today, markets in human milk continue to thrive.17Such markets assume two main forms: 1) informal markets through which people give or sell their milk peer-to-peer via their social circles or online; and 2) formal markets whereby profit or non-profit organizations, such as milk banks and commercial human milk companies, collect, process, and distribute milk to hospitals and a few outpatients for a fee. Human milk is sought after by three main categories of consumers: infants, adults, and researchers.

...

"Placenta

"Human placentas are used for spiritual, nutritional, medical, pharmaceutical, and cosmetic purposes. Placentophagy, or the act of eating one’s placenta after childbirth, has been practiced in the Global North since the beginningof the home-and natural-birth movement in the 1970s.22It is not an unprecedented phenomenon. Indeed, historian Jacques Gélis reported that:

    "Placentophagy, the custom of eating the newly expelled placenta,     has existed at various times amongst people of very different         cultures. From the sixteenth century onwards, European travellers to     the new world were much struck by this custom, which they         unfailingly reported.23

"According to Gélis, placentophagy was also practiced in Europe; however, “doctors and churchmen  were  more  and  more repelled, from the end of the seventeenth century onwards, by this custom . . . so ‘repugnant to humanity."  In the past decade, placentophagy has reemerged as a mainstream practice in the U.S., where it has been described as “anew  American  birth ritual.25

"Few randomized controlled trials have corroborated the benefits of placentophagy. However, placenta eaters are motivated by the hope of obtaining nourishment, hastening post-birth recovery, warding off postpartum depression, facilitating lactation, as well as spiritual motives, such as connecting with the baby and the environment. Placentas can be eaten raw or cooked."

...

"Minimally processed placental membranes have significant commercial and medical potential to treat, among other indications, eye diseases and acute and chronic wounds. The for-profit American company MiMedx also “grinds up amniotic tissue from placenta into an injectable product to treat tendinitis, strains, and other ailments.”29Much  like  human  milk,placentas  are increasingly seen as reservoirs of stem cells and thus are attractive to the field of regenerative and tissue engineering, and, more recently, as potential sources for treating coronavirus patients."

...

"Feces

"Excrement is typically regarded as disgusting; however, the medical use of human and animal feces has a long record. Heinrichvon Staden notes that:

"Most prominent among the ingredients in the Hippocratic pharmacological ‘dirt’ arsenal is the excrement of various animals. ..  .  the  belief  in  the  therapeutic  usefulness  of  excrement  was  shared  by  ancient  Mesopotamian,  Egyptian,  Greek,  Chinese, Talmudic, and Indian healers. . . . There is, therefore, abundant evidence that . . . ‘excrement therapy’—was a cross-cultural phenomenon extant already in the ancient world.32

"In Chinese medicine, human feces were used 1,700 years ago as a “suspension by mouth for patients who had food poisoning or severe diarrhea.”33

"Fast forward to the twentieth century, the community of microorganisms that dwell in the human gut has been shown to play a crucial role in human health. Fecal microbiota transplantation (“FMT”) was first identified in the modern scientific literature in 195834and has rapidly grown in popularity since the early 2010s. FMT consists in the delivery of processed stool from a healthy donor into the intestinal tract of a sick person via an enema, colonoscopy, naso-duodenal tube, capsules, or other means. As microbiologist Mark Smith and his colleagues noted, “the goal is to displace pathogenic microbes from the intestine by re-establishing a healthy microbial community.”35FMT  has  proven  strikingly  effective  in  treating Clostridium  difficile, a potentially lethal infection that most commonly affects older adults in hospitals or in long-term care facilities, typically after the  use  of  antibiotics."

...

"Despite these differences, milk, placenta, and feces share two sets of core similarities that justify their grouping in this analysis. First, milk, placenta, and feces are tissues that can be severed from the body without harm or risk of harm. Notably, milk and feces  are  replenishable  bodily  substances,  while  the  placenta  is  a  transient  organ  expelled  from  the  body  during  childbirth. Thus, far from constituting “corpse medicine”42(i.e., medicine that uses human materials obtained from dead bodies), the use of such substances can be characterized as living food or medicine. There are also no adverse health effects associated with the act of donation. Quite the opposite, good health requires that people eject the milk, placenta, and feces they produce from their bodies.  

...

"Second, these three products have similar channels of circulation, including via private, domestic consumption, peer-to-peer markets, medical and research institutions, and global markets in foods, drugs, and cosmetics. This wide scope for circulation is possible due to the potential for DIY treatments alongside higher tech uses involving special processing and expertise. Milk, placenta, and feces are collected, processed, and distributed by banks similar to other tissue banks; however, aspiring consumers can  also  obtain  milk,  placenta,  and  feces  and  use  them  on  their  own.  Unlike  blood  transfusion  or  organ  transplantation,  no professional expertise or complicated equipment is necessary to achieve basic forms of consumption. Milk, placenta, and fecescan be obtained directly from their producersafter some screening (or not) and consumed as is or minimally processed at home. Conversely, bio-banks systematically screen donors, subjecting them and their samples to a battery of tests, before processing their  products  in  various  ways;  for  example,  by freezing,  thawing,  pooling,  enriching,  freeze-drying  (in  the  case  of  milk), irradiating (in the  case of placenta), encapsulating (in the  case of stool). This is a fast-evolving field.

...

"No uniform perspective  has emerged on the  legal  classification of the  various body materials consumed by humans. In this respect, milk, placenta, and feces provide a case in point, as they do not fit neatly within the standard legal classifications for comparable products, such as foods, drugs, tissues, cosmetic ingredients, or waste products. Different countries have adopted contrasting legal regimes—or no regimes at all—to regulate these substances.

...

"In  the  so-called  post-colonial  era,  the  law  of  self-consumption  illustrates  the broader phenomenon of a “jurisprudence of disgust,” to use an expression that Alison Young developed to describe the legal censorship of provocative or “obscene” artwork.71A  significant  dimension  of  contemporary  law  making  can  be  characterized  as  a  response  to  what  is  considered disgusting around or among us, which reflects an endeavor to confine and tame what repulses us. This is particularly obvious in the context of what legal scholar Kim Krawiec calls “taboo trades” (and economist Alvin Roth dubs “repugnant markets”); that is, the exchanges and transactions of products that are considered culturally immoral and uncaring, such as those involving organs, babies, sex, drugs, and corruption."

Surrogacy in Spain is hard to suppress

 In a widely reported story, a Spanish celebrity has become the surrogate mother of her grandchild, with the help of sperm from her deceased son, and an American surrogate.  This has raised controversy in Spain, where surrogacy is illegal.

Here's the Guardian on the story:

Spanish TV star says surrogate baby is actually her grandchild. Ana Obregón, 68, says her son, Aless Lequio García, expressed desire to have a child before death in 2020

"A heated debate in Spain triggered by a 68-year-old celebrity who was reported to have used a surrogate mother in Miami to have a baby took a twist on Wednesday when the woman announced in the socialite magazine ¡Hola! that the baby was actually the daughter of her son who died of cancer in 2020.

...

"Surrogate pregnancies are banned in Spain, although children from such pregnancies in other countries can be registered.

...

"Initial reports about the baby grabbed the attention of the Spanish media and the country’s political parties, sparking criticism from the leftist coalition government. Many leading politicians and outlets of Spanish media refer to surrogacy as “womb renting”.

"The equality minister, Irene Montero of the leftist United We Can coalition partner, said surrogate pregnancies were “a form of violence against women”. The coalition’s Socialist party said legislation should be tweaked to prevent Spaniards using surrogates in other countries.

...

"The main opposition conservative People’s party has said it is open to debating legalising such pregnancies if there is no payment involved."

********

Recent related post:

Wednesday, April 5, 2023

Surrogacy under siege in Italy

Introductory workshops to the Mathematics and Computer Science of Market and Mechanism Design semester at Berkeley MSRI

 The semester of Mathematics and Computer Science of Market and Mechanism Design August 21, 2023 to December 20, 2023 at Berkeley will lead off with two introductory sessions:

Connections Workshop: Mathematics and Computer Science of Market and Mechanism Design  September 07, 2023 - September 08, 2023

REGISTRATION DEADLINE: AUGUST 18, 2023

TO APPLY FOR FUNDING YOU MUST REGISTER BY: MAY 17, 2023

Organizers Michal Feldman (Tel-Aviv University), LEAD Nicole Immorlica (Microsoft Research)

"The Connections Workshop will consist of invited talks from leading researchers at all career stages in the field of market design.  Particular attention will be paid to real-world applications.  There will also be an AMA focused on career paths with highly visible individuals in the field, and a social event intended to help workshop attendees network with each other."

and

Introductory Workshop: Mathematics and Computer Science of Market and Mechanism Design  September 11, 2023 - September 15, 2023

REGISTRATION DEADLINE: AUGUST 25, 2023  TO APPLY FOR FUNDING YOU MUST REGISTER BY: MAY 21, 2023  

Organizers Scott Kominers (Harvard Business School), Paul Milgrom (Stanford University), Alvin Roth (Stanford University), Eva Tardos (Cornell University)

"The workshop  will  open  with  overview/perspective  talks  on  algorithmic  game  theory  and  the theory and practice of market design; the afternoon will feature a panel on active research areas in the field (again, at the overview level). The next 2 days will consist of introductory mini-course and tutorials, on topics such as game theory, matching, auctions, and mechanism design. The following day will focus on applicable tools and technology, such as lattice theory, limit methods, continuous optimization, and extremal graph theory. The workshop will conclude with a panel discussion on major open problems."

Earlier announcement:

Tuesday, November 8, 2022

Mathematics and Computer Science of Market and Mechanism Design, at Berkeley MSRI, August 21-December 20, 2023 (applications open)

Surrogacy under siege in Italy

 Opposition to surrogacy in Italy has taken aim at the babies of same sex couples.

The NYT has the story:

Surrogacy Emerges as the Wedge Issue for Italy’s Hard Right. Prime Minister Giorgia Meloni has ordered municipalities to stop certifying foreign birth certificates for same-sex couples who used surrogacy, leaving some babies in a legal limbo.  By Jason Horowitz

"the government of Prime Minister Giorgia Meloni ordered municipalities to obey a court ruling made in December and stop certifying foreign birth certificates of children born to Italian same-sex couples through surrogacy, which is illegal in Italy.

"The decision has left Martino Libero and several other children suspended in a legal limbo, depriving them of automatic Italian citizenship and residency rights like access to the country’s free health care system and nursery school.

...

"Milan, a city that has long served as a cosmopolitan haven for same-sex couples in Italy, has for now complied with the Meloni government order and suspended issuing Italian birth certificates.

"Without official recognition, Libero Martino, 2 months old this month, will have to leave and re-enter the country every few months to remain legal. A court could eventually recognize one of the men as the biological father — they decline to say which one is the sperm donor — and then they could start a separate adoption process for the other.

...

"Ms. Meloni’s government has sought to shift the issue away from the status of the children to the practice of surrogacy, which, while legal in the United States and Canada, is illegal or restricted in much of Europe outside of Greece, Ukraine and a few other countries. In Italy, home of the Vatican, it is not only illegal, but it is also widely opposed, including among Catholic corners of the center-left opposition.

...

"Prominent members of Ms. Meloni’s Brothers of Italy party have called surrogacy a crime “even worse than pedophilia,” in which gay couples, one of whom is usually the biological father, seek to “pass off” children as their own and mistake “children for Smurfs,” saying gay couples can uniquely afford surrogacy, even though it is overwhelmingly used more by heterosexual couples.

"The party is floating a proposal, made by Ms. Meloni when she was a member of Parliament, to make Italians’ seeking of surrogate births abroad — what she had called “procreative tourism” — illegal and “punishable with three months to two years of prison and a fine of 600,000 to a million euros.”

...

"In an interview shortly before her election, as her young daughter ran around her in a Sardinia courtyard, Ms. Meloni said she opposed gay marriage, not because she was homophobic — “I’ve got many, many homosexual friends” — but because she saw it as a step to same-sex adoption, which she opposed, and which the Roman Catholic Church successfully lobbied to exclude from a civil unions law passed in 2016.

********

Earlier:

Monday, February 20, 2023

Will Italy criminalize foreign surrogacy?

The Robert Rosenthal Memorial Lecture for 2023 at BU, by Parag Pathak

 Parag Pathak gave this year's Robert Rosenthal Memorial Lecture at Boston University. The title of his talk is “Still Worth the Trip? The Evolution of School Busing in Boston” 

(The video below may undergo some further editing, but right now it starts with introductions at minute 3.) 

You can also find the Rosenthal lectures from previous years at the link.

(I had the honor of giving the 2007 lecture... Bob Rosenthal and I are academic siblings, we were both advised by Bob Wilson.)

Test of Time Award 2023 to Immorlica & Mahdian, and Ashlagi, Kanoria & Leshno

 Matching theory is recognized this year for bringing theory and observation into harmony...

The SigEcom Test of Time Award for 2023, "… for explaining an apparent gap between the theory and practice of matching markets and helping us understand why small cores are so common." goes to two papers, by five authors.

The first of the two papers is

Marriage, honesty, and stability by Nicole Immorlica and Mohammad Mahdian, Proceedings of the 16th Annual ACM-SIAM Symposium on Discrete Algorithms (SODA), 2005, pp. 53–62.

ABSTRACT: Many centralized two-sided markets form a matching between participants by running a stable marriage algorithm. It is a well-known fact that no matching mechanism based on a stable marriage algorithm can guarantee truthfulness as a dominant strategy for participants. However, as we will show in this paper, in a probabilistic setting where the preference lists of one side of the market are composed of only a constant (independent of the the size of the market) number of entries, each drawn from an arbitrary distribution, the number of participants that have more than one stable partner is vanishingly small. This proves (and generalizes) a conjecture of Roth and Peranson [23]. As a corollary of this result, we show that, with high probability, the truthful strategy is the best response for a given player when the other players are truthful. We also analyze equilibria of the deferred acceptance stable marriage game. We show that the game with complete information has an equilibrium in which a (1 - o(1)) fraction of the strategies are truthful in expectation. In the more realistic setting of a game of incomplete information, we will show that the set of truthful strategies form a (1 + o(1))-approximate Bayesian-Nash equilibrium. Our results have implications in many practical settings and were inspired by the work of Roth and Peranson [23] on the National Residency Matching Program.

**

And the second of the two papers is

Unbalanced random matching markets, by Itai Ashlagi, Yashodhan Kanoria, Jacob D. Leshno, Proceedings of the 14th ACM Conference on Electronic Commerce (EC), 2013, pp. 27–28.

ABSTRACT: We analyze large random matching markets with unequal numbers of men and women. Agents have complete preference lists that are uniformly random and independent, and we consider stable matchings under the realized preferences. We find that being on the short side of the market confers a large advantage.

"We characterize the men's average rank of their wives. For each agent, assign a rank of 1 to the agent's most preferred partner, a rank of 2 to the next most preferred partner and so forth. If there are n men and n+1 women then, we show that with high probability, in any stable matching, the men's average rank of their wives is no more than 3 log n, whereas the women's average rank of their husbands is at least n(3 log n). If there are n men and (1+λ)n women for λ0 then, with high probability, in any stable matching the men's average rank of wives is O(1), whereas the women's average rank of husbands is λ (n).

"Moreover, we find that in each case, whp, the number of agents who have multiple stable partners is o(n). Thus our results imply a limited scope for manipulation in unbalanced random matching markets for mechanisms that implement a stable match.

"These results are in stark contrast with previously known results for random matching markets with an equal number of men and women. In such balanced random matching markets, the lattice of stable matches is large, with the two extreme points of the lattice, the men optimal stable match (MOSM) and the women optimal stable match (WOSM) possessing contrasting properties. The men's average rank of their wives is just log n under the MOSM, but as large as n/log n under the WOSM, and the opposite holds for the women's average rank of their husbands. Thus, the proposing side in the Gale-Shapley deferred acceptance algorithm is greatly advantaged in a balanced market, whereas we prove that in markets with even a slight imbalance, the MOSM and WOSM are almost identical. This reveals the balanced case to be a knife edge.

"Our proof uses an algorithm which calculates the WOSM from the MOSM through a sequence of proposals by men. A woman improves if, by divorcing her husband, she triggers a rejection chain that results in a proposal back to her from a more preferred man. The algorithm lends itself to a stochastic analysis, in which we show that most rejection chains are likely to end in a proposal to an unmatched woman. Simulations show that our results hold even for small markets."

***

see also the longer version of Ashlagi, Kanoria and Leshno (with shorter abstract) in the JPE in 2017 (too recent for the test of time award itself:)

Ashlagi, Itai, Yash Kanoria, and Jacob D. Leshno. "Unbalanced random matching markets: The stark effect of competition." Journal of Political Economy 125, no. 1 (2017): 69-98.

Abstract: We study competition in matching markets with random heterogeneous preferences and an unequal number of agents on either side. First, we show that even the slightest imbalance yields an essentially unique stable matching. Second, we give a tight description of stable outcomes, showing that matching markets are extremely competitive. Each agent on the short side of the market is matched with one of his top choices, and each agent on the long side either is unmatched or does almost no better than being matched with a random partner. Our results suggest that any matching market is likely to have a small core, explaining why small cores are empirically ubiquitous.

Blue water, green water and climate change

 Much of the discussion of redesigning the markets for water focus on "blue water," i.e. surface water in rivers and lakes, and runoff from rain, and resulting accumulation in reservoirs, snowpacks, and ground water.

Here's a paper in Nature pointing out that, particularly as climates change, we also have to think of "green water," namely water from evaporation and rain, and how to manage that.

Rockström, Johan, Mariana Mazzucato, Lauren Seaby Andersen, Simon Felix Fahrländer, and Dieter Gerten. "Why we need a new economics of water as a common good." Nature (2023).

"Water managers have always had to deal with natural variability, building larger reservoirs and tapping aquifers to fight scarcity, for example. But current challenges and trends in the rest of this century demand a completely different approach: a radical shake-up in how water is governed, managed and valued, from local to global scales, including a re-evaluation of human water needs (see Supplementary information, Box S1).

"Today, the sector concentrates on flows of ‘blue’ fresh water — liquid that runs off the land and is stored in rivers, lakes, reservoirs and underground aquifers. Utilities capture and extract this water locally for drinking and sanitation, agricultural irrigation and industry.

...

"Managing fresh water on a global scale means going beyond our current fixation on capturing blue water, which constitutes 35% of all fresh water on land, to also encompass green water, which makes up the remaining 65% (see Supplementary information, Fig. S1). Flows of moisture and vapour from land and vegetation are essential for regulating the water cycle and securing future rainfall, as well enabling carbon sequestration in soils and forests.

"Globally, up to half of terrestrial precipitation originates from green water evaporated over land, with the rest from evaporation over the ocean3. Thus, landscape changes can alter water supplies in regions downwind, as well as changing local climates and streamflows. For example, deforestation in the Congo Basin lowers rainfall in neighbouring countries, and even across the Atlantic in the Amazon. Heavy irrigation of crops in India can boost the streamflow of the Yangtze River in China, through moisture transported downwind4.

"By analogy with watersheds on land, researchers refer to ‘precipitationsheds’ and ‘evaporationsheds’ in the atmosphere. Simply put, a precipitationshed is where rain comes from and an evaporationshed is where evaporation goes to. (Here, evaporation refers to total evaporation from the ocean and green water flows from land, including from soil and water bodies, as well as transpiration from vegetation.)"

Headlines that could have appeared on April 1

 Grim news largely crowded out funny news this past 12 months, but not completely (and some grim news is also funny).

National Park Service Asks Visitors to Please Stop Licking Toads (NYT, Nov, 2022)

Wyoming lawmakers propose ban on electric vehicle sales (The Hill, 01/16/23) "A group of GOP Wyoming state lawmakers want to end electric vehicle sales there by 2035, saying the move will help safeguard the oil and gas industries."

Sex on the beach: pressures of extreme polygamy may be driving southern elephant seals to early death (Guardian, March 2023)

Idaho governor signs firing squad execution bill into law, AP, March 25, 2023. "... making Idaho the latest state to turn to older methods of capital punishment amid a nationwide shortage of lethal-injection drugs. ...firing squads will be used only if the state cannot obtain the drugs needed for lethal injections.

Opioids and Appalachia by Sally Satel

 Sally Satel, who has treated patients in Appalachia, writes movingly of the drug addiction problem there. Here's a paragraph that sets the stage.

"The history of opioid pain relievers in Appalachia is a prime illustration of the fact that drug epidemics rarely burst onto the scene out of nowhere. Instead, they find their place in regions that are already home to an established base of individuals who abuse similar drugs. Thus illicit OxyContin, a more potent opioid, efficiently gained popularity over Percocet and Vicodin in the same way heroin would substitute for prescription opioids as the latter grew scarce after 2010."

That's from Opioids and Appalachia by Sally Satel, in the current issue of National Affairs.

The whole thing is well worth reading; here are a few more paragraphs that caught my eye.

"The churn of pills — diverting, using, and selling them — soon had eastern Kentucky, southeastern Ohio, and West Virginia pulsing with crime. Realtors routinely told home sellers not to leave pills in their medicine chests during open houses. Funeral directors and hospice nurses cautioned the bereaved not to mention in obituaries that their loved ones had succumbed to cancer — a red flag signaling that huge bottles of pills were likely on the premises. In eastern Kentucky, local law enforcement was often stymied by close ties between people within communities. Loyalty within large families and fear of retaliation by neighbors made it hard to cultivate informants and to impanel neutral juries that would convict when prosecutors proved their case.

...

"Appalachians seemed to take the corruption in grudging stride. In one survey, 90% of over 100 Kentuckians working in law enforcement, health, and community governance said the rural OxyContin problem in the early 2000s was "fueled by a cultural acceptance of drug misuse." Indeed, many residents tolerated unlawful activity, since it generated revenue for the community from sales of pills to outsiders. This happened in places like Williamson, West Virginia — dubbed "Pilliamson" — where the local Wellness Center was a hub of reckless prescribing. Cash-laden out-of-staters flocked there to buy painkillers and, in a small area near the center, trade and sell those pills.

"Pablo Escobar and El Chapo couldn't have set things up any better," wrote Eyre. "The coal barons no longer ruled Appalachia. Now it was the painkiller profiteers."

...

"Today, opioid pills are no longer pouring into Appalachia as they once did; highly lethal products like fentanyl-laced heroin, methamphetamine, and counterfeit fentanyl pills are what people are selling."