Dander Still Up. Drowning in Great Dismal Swamp. Film at Eleven.

Maybe this is the last in my series of dander-raising essays, as recent national and world events have most definitely left so many of us with a raging case of TDS. (Trump Derangement Syndrome, look it up it's a thing).

So many damned browser tabs sitting there open. So little time.

Or maybe not. Who knows. Where are all these suicides coming from?

My editor keeps telling me, "don't let it make you paralytic." Hey, I'm trying.

Just sensing a kind of coalescence in all the corruption our bloggers keep writing about. How do we even differentiate these activities across so many sectors of society. We were going to see our swamp drained. He promised. But instead there's just this big brand new bodacious cesspool. There it is in all the revolving-door sectors. Federal government. Private sector. Health care non-profits and even academia.

Just read back over recent weeks and months of this, your favorite blog.

The coalescence of corruption is certainly made easier by our enjoyment of a remarkable and possibly quite barmy Confabulator-in-Chief. He's just sort of paved the way for what one pundit recently characterized as a sort of race-to-the-bottom. No corruption is too small (cone of silence? nifty office furniture? wipe out environmental health? give Big Pharma another bye?). Or, of course, too large.

None of this is terribly new, just the way it's all melded into what the cancer biologists call a syncytium. There are no winners and losers in all this. Just a lot of organelles swimming around and causing havoc at our expense. Just a bunch of top-level narcissists and then, under them, a phalanx of careerist stronzi streaming out of academic backwaters and think tanks to grab their fifteen minutes of ... what?

Surely not fame, unless you're looking for a spot on an SNL cold open. Microphone time maybe? Let's call out a few of them.

The careerist gets fifteen minutes, max, by the way. The turn-over in government, especially, in the federal executive, is many-fold that of any previous administration. If this were tennis we'd all have whiplash. Everybody seems to be trying to find their own inner Scaramucci.

Just now, in fact, it seems to've gelled intoone great big scandal. Adam Serwer in The Atlantic: "there is only one scandal." While the Chest Thumper-in-Chief runs around doing what he does best--sullying the western world and laying down cover for his army of swampy miscreants--the careerists continue to run up a debt whose bill will surely come due. Of course by then, so many will have cashed out. Guess who'll be left to pay the tab. You, me, our sickest, our poorest. Mother Earth.

In the private sector it may take years for the ins and the outs to get in and then back out. But of late in both Big Pharma and in Health IT, both the revolving door and the Invasion of the Body Snatchers (aka baleful effect of activist investors and hedge funds) have taken their toll and we pick up the pace. Most recent casualty: Bush family scion and alleged wife-beater Jonathan B, thrown out of possibly the most innovative, but not quite profitable enough, athenahealth EHR company he once founded. Offed just now by the Elliott organization, which is headed up in turn by ultra-right political donor Peter Singer. (Here and here and pretty much everywhere--don't get stuck in his cross-hairs.)

Ah, yes, these are the glory days for the Big Families. Donorship gets you a whole party of your own. The Prince-DeVos family, the Koch family, the Uihlein family, the Mercer family. And Las Vegas Gambling Tycoon Sheldon Adelson, who almost single-handedly handed Binyamin Netanyahu an unearned win in Jerusalem.

Their common goal: effacement of government, Ron Reagan's great "problem child," in favor of its replacement the Great Dismal Swamp.  (In fact much of the real GDS, out of North Carolina, was actually bought up by Betsy DeVos's brother Erik to train Blackwater mercenaries.)  So now, on to the Great Dismal Swamp of outsourced everything. Outsourcing, along with the revolving door and the Anechoic Effect, these form the inner dynamic, the secret history of what's happening now. Outsource security. Outsource VA health care. (See my earlier blog on a secretary's attempt to resist that.) Outsource public education. Outsource, or at least deregulate, clinical trials of unproven drugs. Privatize, don't shade your eyes (apologies to Tom Lehrer).

(Note that in the course of all this privatizing the common weal, these Big Dogs not infrequently can turn on each other. Singer turns on Bush. Koch the Elder turns on Koch the Younger. The dollar is king and the beat goes on and Throw Momma From the Train.)

Other major features of this secret history:

• The Scorching of the Earth. Both literally (health consequences of climate change), and figuratively: the flaming rhetoric of the careerists. The most glaring recent example, albeit outside of our health purview, White House National Trade Council Director and temporary-in-from-the-cold academic Peter Navarro, awarding "a special place in hell" to Canada.  (Wait, what?!? Canada?) Why? Because it dared to cross his new boss. Cross the boss, thump the chest. Ten points for the thumper, zero points for the country--either one. We'll learn later this year, and again in 2020, whether there's enough of the vaunted "base" left to be snookered by all this guff. The chest-thumpers may discover a special place in hell meted out to folks closer to home. The charlatans. The quislings. Pretty clear now who they all are.
• The Swamp-Ooze of the Careerists. Navarro's one high placed example. Another newly high-placed with a more direct impact on health care, and also flaming the air waves, is National Economic Council Director and former CNBC correspondent Larry Kudlow. In the recent presidential travels Kudlow did not speak cosmologically of heaven and hell, but only politically. He called Canada's measured response "betrayal." On health insurance, he's agin it. It kills jobs, per Mr. Kudlow. And he ought to know how things really work, right? In 2007 he famously predicted the continued success of an earlier deregulatory GOP economic policy suite in that once-great organ National Review. William Buckley turned over in his grave. The headline read: "Bush Boom Continues." The following tag line: "you can't call it a recession." (Emphasis his.) The date: December 10, 2007. (Despite which, get well quick Larry. Maybe find a less stressful job would help.)
• Health and the Environment. Ah, yes, and in environmental health we have Scott Pruitt heeding HMV while lining his own pockets and lobbying for his wife's Chick-fil-A franchise (honest I can't make this stuff up), all the while dumbing down any expertise on health. This dumbing down and anti-science motif pervades the Great Dismal Swamp. Never before has there been such a dearth of scientific, pedagogical, or health expertise in any of the departments that so direly need those capabilities. Interestingly, the small-bore corruption of these characters seems more prominent in the upper, Pruitt-like, echelons than in the Small Fry. Or are we just not hearing about the little guys?
• Lesser Careerists. You can't have a syncytium without both big and little organelles. The little guys are actually among the more damaging, as they tend to be true believers with claimed expertise that goes poof when examined closely. Among the most famously wrong-minded recent ones we have the Press Secretary herself, Ms. Sanders, who from the depths of her health policy experience pronounced last fall that “I can’t think of anything worse than having the government be more involved in your health care instead of less involved.” Oh, Miss Sarah, I can. Even more peculiar is the role of the rather more obscure Ms. Katy Talento, of the White House Domestic Policy Council. She gets to act as conduit and house pundit for the new HHS secretary Alex Azar. It's fascinating. In several easily-reached venues she's described, by self or others, as "an epidemiologist." Harvard's master of science (not MPH) degree in epidemiology and public health can be obtained, as she did, in something between three and twelve months. Not exactly a board certification. Then she went on to build her career in ideological rightist causes and organizations, including anti-abortion campaigns and one notable set of pronouncements on the supposed link of birth control to miscarriage.
  
  Came the time for Azar to prep his new boss on last month's Big Speech on reducing drug costs, Talento broadcast the news that "no ox would be gored." Said she, "This is a fearless president and he doesn't know or care why things have always been done. It's not like your typical Republican authorizing committee that protects this model that they helped write for decades...." Wait, one little thing. It didn't happen. The big play available, as I said in a previous post, would've been having Medicare bargain for prices. Instead--and clearly Azar could've tried and failed to get this--the Caregiver-in-Chief declared that drug prices in the US should come down by having other countries pay more. What so strange about this is not merely the absurdity of such a statement, coming from a former Pfizer top exec. It's the fact that here's a lower-level careerist who went straight into RNC speech writing and working for a right wing southern Republican (Tillis, NC), then became the "epidemiologist" for Mr. Azar.
  
  Hold the phone. Among all the young staffers willing to sell their souls to get the Big Show on their CVs--don't they know it's a shabby little show?--what about the wonderful lady who dissed the ailing John McCain as inessential (just now he's incredibly essential), because, after all, he's going to die soon? Out the door she went, but of course her Republican friends got her a soft landing. Her name is Kelly Sadler, a real comer. Or goner.
• The Rise of the Druggists. Last but not least, part of the secret history that, now I see it, has really got the dander way up, is how in health care and health policy, Pharma's now fully the tail-that-wagged-the-dog. CVS is moving into health care--see Dr. Poses's recent posting on just how well that organization understands their responsibilities. Actually having pharmaceutical and pharmacy folks elbowing out health care professionals who understand professionalism, it's not a new thing. Philadelphia Big Donor Leonard Abramson founded U.S. Healthcare and made a mint when he discovered how easy it was to make Managed Care actually Denied Care, then, with this proof-of-concept, cashing out and selling to Aetna. That goes way back. More recently, though, the pace of They Come at Night has picked up, viz. the firing of David Shulkin MD at the VA and the hiring of Alex Azar at HHS. These clearly result from both the privatization motive and the Pharma tail wagging the dog. At least two of the three branches of the federal government understand the business model of Pharma. They don't come anywhere near understanding the professional ethics of doctors--even while relying on their personal physicians to exercise such ethics.
• Business ethics in medicine, as practiced by Pharma, have been laid out in many, many places in this blog. I and others have laid the blame for a big chunk of the opiate crisis at the door of Purdue pharma and the Sackler family. I regret to remind that the early Sacklers were physicians. But they were first and foremost business folk, possessed of a truly novel business model, which may be called outright dissimulation. (For a fascinating and harrowing description of one high-functioning Ivy-League opiate addict's experiences at Yale, with all its Sackler money and Oxy pills traded on the New Haven Green, see this Guardian piece.)
  
  Actually, I've talked to a lot of pharma execs and they're often quite ethical and responsible. They have their hands full fighting off the PBM companies. They get singled out for their K Street spending, but many of them actually have rather low budgets for that, the recent Novartis scandal notwithstanding. Other execs blush at this Novartis nonsense and want nothing to do with it. I say all this mainly to point out some dreadful outliers. It's not just the brand name drug makers, either. Teva, the Israeli generics giant, is allegedly a real problem. As I write this, good old Ron Wilson, the Wisconsin Republican who just keeps on giving his gifts, is blocking his Ranking Member Claire McCaskill from obtaining information Teva's contributions to the opioid crsis. He's saying leave it to the courts.

OK, as I just hinted, I agree with you. None of this recent stuff is really secret. Not even really novel. It's just coalesced like never before into into a dismal swamp. (Orwellian doublespeak: yes, we've seen the swamp drained. Of what? What was he promising to drain? Yes, drained, if that meant getting rid of people ("Deep State"?) who know stuff. So people who don't know stuff can get on with the business of ripping us off.)

Hence in my current rant I just wanted to point to those commonalities that are, right about now, more egregious than ever. Honestly, they are. When the history is written, it will prove me right. Oh, wait, Alexander Hamilton wrote it already, hundreds of years ago.

When a man unprincipled in private life desperate in his fortune, bold in his temper, possessed of considerable talents, having the advantage of military habits—despotic in his ordinary demeanour—known to have scoffed in private at the principles of liberty—when such a man is seen to mount the hobby horse of popularity—to join in the cry of danger to liberty—to take every opportunity of embarrassing the General Government & bringing it under suspicion—to flatter and fall in with all the non sense of the zealots of the day—It may justly be suspected that his object is to throw things into confusion that he may “ride the storm and direct the whirlwind.”