MASS MURDERS AND INSANITY

The NRA party line is that people who commit mass firearm homicides are simply insane. Therefore, the problem of firearm homicide is basically a public health issue; if we were sufficiently adept at identifying and treating mental illness, the problem of mass firearm homicide would go away. Not so, say experts in mental illness. Most mass murderers are not insane, and Americans are not more prone to mental illness than citizens of other countries in which mass firearm homicide is almost nonexistent. The explanation for the daily occurrence of mass firearm homicides in the United States is simply this: the easy availability of military grade weapons with high capacity magazines.

If what people do is any reflection of who they are, then Devin P. Kelley, who slaughtered 26 churchgoers recently in Texas, surely was a madman.

Before the atrocity, he had attempted to sneak weapons onto an Air Force base after making death threats to his superiors, according to a local police report. In 2012, he had escaped from a mental hospital in New Mexico to which he had been sent after assaulting his wife and fracturing his stepson’s skull. A video of the church killing reportedly shows Mr. Kelley working his way methodically through the aisles, shooting some parishioners, even children, at point-blank range.

“I think that mental health is your problem here,” President Trump told reporters after that particular killing spree.

It is true that severe mental illnesses are found more often among mass murderers. About one in five are likely psychotic or delusional, according to Dr. Michael Stone, a forensic psychiatrist at Columbia University who maintains a database of 350 mass killers going back more than a century. Although the figure for the general public is probably closer to 1 percent, many experts place that at a higher number.

Most of these murderers do not have any severe, diagnosable disorder. Though he was abusive to his wife, Omar Mateen, who killed 49 people in an Orlando nightclub, had no apparent serious mental illness. Neither did Stephen Paddock, who mowed down 58 concertgoers from a hotel window in Las Vegas.

Ditto for Dylan Roof, the racist who murdered nine African-American churchgoers in South Carolina in 2015, and Christopher Harper-Mercer, the angry young man who killed nine people at a community college in Oregon the same year.

Nor does anything in these criminals’ history — including domestic violence, like Mr. Kelley’s — serve to reliably predict their spectacularly cruel acts. Even if spree killers have committed domestic violence disproportionately more often — and this assertion is in dispute — the vast majority of men who are guilty of that crime never proceed to mass murder.

Most mass murderers instead belong to a rogue’s gallery of the disgruntled and aggrieved, whose anger and intentions wax and wane over time, eventually culminating in violence in the wake of some perceived humiliation.

“In almost all high-end mass killings, the perpetrator’s thinking evolves,” said Kevin Cameron, executive director of the Canadian Center for Threat Assessment and Trauma Response. “They have a passing thought. They think about it more, they fantasize, they slowly build a justification. They prepare, and then when the right set of circumstances comes along, it unleashes the rage.”

This evolution proceeds rationally and logically, at least in the murderer’s mind. The unthinkable becomes thinkable, then inevitable.

Researchers define mass killings as an event leaving four or more dead at the same place and time. These incidents occur at an average of about one a day across the United States; few make national headlines.

At least half of the perpetrators die in the act, either by committing suicide (Mr. Kelley is said to have shot himself in the head) or being felled by police.

Analyzing his database, Dr. Stone has concluded that about 65 percent of mass killers exhibited no evidence of a severe mental disorder; 22 percent likely had psychosis, the delusional thinking and hallucinations that characterize schizophrenia, or sometimes accompany mania and severe depression. (The remainder likely had depressive or antisocial traits.)

Adam Lanza, who in 2012 killed 26 people at Sandy Hook Elementary in Newtown, Conn., exhibited insanity characterized by extreme paranoia in the months leading up to his crime, isolating himself in his room.

But what to make of John Robert Neumann Jr., who in June shot and killed five former co-workers at a warehouse in Orlando before turning the gun on himself? Mr. Neumann was not overtly psychotic, as far as anyone knows, and this is far more typical of the men who commit mass killings generally.

“The majority of the killers were disgruntled workers or jilted lovers who were acting on a deep sense of injustice,” and not mentally ill, Dr. Stone said of his research.

In a 2016 analysis of 71 lone-actor terrorists and 115 mass killers, researchers convened by the Department of Justice found the rate of psychotic disorders to be about what Dr. Stone had discovered: roughly 20 percent.

The overall rate of any psychiatric history among mass killers — including such probable diagnoses as depression, learning disabilities or A.D.H.D. — was 48 percent. About two-thirds of this group had faced “long-term stress,” like trouble at school or keeping a job, failure in business, or disabling physical injuries from, say, a car accident.

Substance abuse was also common: More than 40 percent had problems with alcohol, marijuana or other drugs.

Looking at prior studies, and using data from his own work, J. Reid Meloy, a forensic psychologist who consults with the F.B.I., has identified what he believes is a common thread: a “paranoid spectrum,” he calls it.

At the extreme end is patent psychosis. But the majority of people on this spectrum are not deeply ill; rather, they are injustice collectors. They are prone to perceive insults and failures as cumulative, and often to blame them on one person or one group. “If you have this paranoid streak, this vigilance, this sense that others have been persecuting you for years, there’s an accumulation of maltreatment and an intense urge to stop that persecution,” Dr. Meloy said. “That may never happen. The person may never act on the urge. But when they do, typically there’s a triggering event. It’s a loss in love or work — something that starts a clock ticking, that starts the planning.” Mental health treatment might make a difference for the one in five murders who have severe mental disorders, experts say. Prevention is also possible in a few other cases — for instance, if the perpetrators make overt threats and those threats are reported.

But other factors must be weighed. “In my large file of mass murders, if you look decade by decade, the numbers of victims are fairly small up until the 1960s,” said Dr. Stone. “That’s when the deaths start going way up. When the AK-47s and the Kalashnikovs and the Uzis — all these semiautomatic weapons, when they became so easily accessible.”

               THE BOTTOM LINE?

Attempting to discover the vast numbers of people who possess mental disorders that might be potential murderers is clearly impossible. Even if we could detect those most likely to perform such acts, society’s rules usually preclude any attempts to force them to undergo treatment prior to any acts of violence. Thus the only possible countermeasures are—prior to all firearms purchases—careful background checks for past mental disorders or violent and/or other antisocial acts. This must also be coupled with rigorous general restrictions of assault weapens capable of rapid repetitive fire into multiple targets.

Perhaps the demented leaders of the N.R.A. should be brought in for mental evaluations prior to more mass shootings!

The ultimate irony? If one believes that insanity should disqualify all persons from gun ownership, then the opinions of 27 mental health experts (http://www.mortontavel.com/2017/10/09/) should be enough to prevent Trump himself from getting his hands on any lethal weapons, especially of the nuclear variety!

 

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THE REAL CAUSE OF OUR BROKEN HEALTHCARE SYSTEM

This nation spends 3 trillion dollars yearly on healthcare, representing 17% of our total economy, which is—per capita—about double that of other western nations. Of that total, 40-50% goes to hospital charges, 20-30%, to tests and other services, 20% to doctors, 15% to drugs and devices, and 5% to nursing homes.

Conventional wisdom teaches us that prices for healthcare should come down when subjected to “free-market” forces, i.e. supply and demand, like the pricing of automobiles, household goods, etc. But nothing could be further from the truth! When did we see hospitals advertise the lowest rates in town, or healthcare purveyors state that hip replacements or cataract surgery was going on sale next month—or any month? Or, when confronted by an emergency, the cost of an ambulance would be based upon a prearranged lowest competitive price to transport a stricken patient to a nearby hospital offering competitive daily occupancy rates? And this extends to virtually all of healthcare. If we are lucky enough to possess good insurance, we may not worry about these charges, but history shows that once a procedure is covered by insurance, its sticker price generally goes up because patients (and physicians) are largely insulated from the costs, and this further prevents a “free market.”

In the face of rising healthcare costs in the early 20th century, Medicare first entered the market and covered usual charges from 1965 until the 1990s, but because of rapidly increasing charges, Medicare began limiting payouts, which served as a partial restraint on some of the rising charges: For instance it applied a system to bundle and restrain allowable hospital charges for given diseases/and or treatments. Also Relative Value Units extended to physicians’ compensation. But such limits don’t extend to private insurance or to the uninsured, unless by negotiated agreement.

Working through private insurers, the ACA (Obamacare) has provided some financial support for people needing insurance, but it also provided no effective means to control healthcare charges, which are continuing to spiral even higher. Notwithstanding Medicare, there are no real limits on most charges, meaning that most healthcare facilities can charge what they wish, free of any governmental or outside interference.

For instance, hospitals can pad their bills through the use of inscrutable charges that include all sorts of add-ons such as “facility fees,” needles, pills, laundry, multiple doctors, various tests etc. Moreover, excessive hospital charges encompass administration that often rewards CEOs with millions of dollars yearly, includes billing and collection costs, extensive gardens and physical additions, etc. Despite their being called “non profit,” most hospitals are de facto private entities, calling profits “operational excesses” and reaping the benefits of the avoidance of local taxes, while, at the same time, encouraging tax deductible contributions.

With regard to drug prices, there are no effective restraints on pharmaceutical companies’ charges. Unlike other countries, our government-run Medicare program is prohibited by federal law from negotiating lower drug prices with manufacturers. Prices for newer patent protected drugs are often excessive, and overcharges for older, generic drugs are also commonplace. In the case of certain cheaper generic drugs whose interest and availability are waning, they may become subject to a single company’s seizure of exclusive control of limited supplies, and then becoming a de facto monopoly, allowing for prices to suddenly surge to stratospheric levels. Collusion between competitors has also been alleged as another means to raise these latter prices.

In contrast with all western countries save New Zealand, pharmaceutical companies in the U.S. are legally allowed to advertise prescription drugs on television, provided that they list various side effects and dangers as well. Predictably these products are regularly expensive and may or may not be superior to older generics. Advertising costs these drugs generally account for about 30% of the companies’ expenditures, whereas research in new drug development amounts to a paltry 15%.

In order to deal with our broken healthcare system, we can learn from other countries’ experiences. Although some pundits claim otherwise, our outcomes are clearly not better than those of other advanced countries, meaning that our profuse money outlay is largely wasted. Although there are several contrasting methods, they all contain governmental price controls and universal participation. The best examples are provided by Germany, Japan and Belgium, in which rates for all services are set that include upper caps. In Germany, for instance, most individuals must purchase state sponsored insurance, with premiums based upon one’s income. Private insurance is allowed and may supplant the base insurance for the few who can afford deluxe services. Canada, Australia, the United Kingdom and Denmark, use variants of a single payer system, all of which couple price limits for services together with a mandate that the entire population will be insured.

The U.S. could adopt any of these methods, but a single payer (“public option”, or Medicare for all) would seem to be the most cost-effective. Administrative costs for Medicare average about 2-3%, in comparison to about 20-30% of most private insurers.

Expanded Medicare would not preclude the addition of supplemental private insurance, as we now have in combination with its basic coverage. An overall plan directed by the single payer must be empowered to control prices for all methods and procedures, allowing us to approach costs of other western countries. A single payer system would also simplify record keeping and unify documents, reducing time required by physicians and office personnel. It could be phased in gradually by lowering age eligibility for Medicare.

Given these facts, the underlying problem becomes clear: We are overpaying for virtually all components of our health care system, and governmental restraints on charges are necessary. This must be coupled with universal participation.

 

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Price-fixing collusion: Another reason for drug price gouging

A large group of U.S. states accused key players in the generic drug industry of a broad price-fixing conspiracy, moving on Tuesday to widen an earlier lawsuit to add many more drug makers and medicines in an action that sent some company shares tumbling.

Mylan Labs CEO, Heather Bresch, was sworn in before a House Oversight and Government Reform Committee hearing on the Rising Price of EpiPens, at the Capitol in Washington September 21, 2016. The lawsuit, brought by the attorneys general of 45 states and the District of Columbia, accused 18 companies and subsidiaries and named 15 medicines. Shares of Pennsylvania-based Mylan, named as one of the defendants, closed down 6.6 percent.

The states said the drug makers and executives divided customers for their drugs among themselves, agreeing that each company would have a certain percentage of the market. The companies sometimes agreed on price increases in advance, the states added.

The states said company leaders had communicated directly to agree on their companies’ shares of the market for a delayed-release version of a common antibiotic, doxycycline.

“It is our belief that price-fixing is systematic, it is pervasive, and that a culture of collusion exists in the industry,” Connecticut Attorney General George Jepsen, who is leading the case, told a news conference in Hartford.

Mylan said in a statement it had found no evidence of price-fixing by the company or any of its employees, and vowed to defend itself vigorously. Mysteriously, the company’s second-ranking official, has received more than $50 million in compensation over the past three years, last year making more than its CEO Rajiv Malik.

“Mylan has deep faith in the integrity of its president Malik, and stands behind him fully,” the company said.

Emcure, also a defendant in the case, did not immediately respond to a request for comment.

Two former executives of Emcure’s subsidiary Heritage Pharmaceuticals pleaded guilty in January to federal charges of conspiring to fix prices and divide up the market for doxycycline and the diabetes drug glyburide. The two men, former Heritage president Jason Malek and former chairman and chief executive Jeffrey Glazer, reached a deal with 41 states and territories in which they each agreed to pay penalties of $25,000 and cooperate with the state probe.

Soaring drug prices from both branded and generic drug manufacturers have sparked outrage and investigations in the United States.

Executives like Mylan’s Bresch and former Turing Pharmaceuticals CEO Martin Shkreli have been called in front of Congress to defend the cost of their products.

MORE COMPANIES TARGETED

      The original complaint, filed in December, targeted Mylan, Heritage, Aurobindo Pharma USA Inc, Citron Pharma LLC, Mayne Pharma USA Inc and Teva Pharmaceuticals USA Inc.

The states are pressing a new complaint that would add Novartis AG’s unit Sandoz, India-based Sun Pharmaceutical Industries Ltd, Endo International PLC’s unit Par Pharmaceutical, Dr. Reddy’s Laboratories, Apotex Corp, Glenmark Generics Ltd, Lannett Company Inc, Alkem Laboratories Ltd’s unit Ascend Laboratories and Cadila Healthcare Ltd’s unit Zydus Pharmaceuticals Inc.

Jepsen said the investigation is continuing, and that claims would likely be brought against more companies, and possibly executives, in the future.

The news hurt shares of companies named in the expanded suit that are traded in the United States. In addition to Mylan’s drop, Lannett lost 13.7 percent. Shares of Endo were up 7 percent, but down from their 12 percent peak before the news of the amended lawsuit.

Teva spokeswoman Denise Bradley said the company denied the allegations. Endo spokeswoman Heather Lubeski said the company would vigorously defend itself against the claims. Other companies did not immediately respond to requests for comment.

The expansion of the suit requires the court’s permission.

The original lawsuit centered on just two medicines, delayed-release doxycycline and glyburide.

The price of doxycycline rose from $20 for 500 tablets to $1,849 between October 2013 and May 2014, according to U.S. Senator Amy Klobuchar, a Minnesota Democrat who had been pressing for action on high drug prices.

The amended complaint would expand the number of drugs to include glipizide-metformin and glyburide-metformin, which are among the most commonly used diabetes treatments.

Others include: acetazolamide, which is used to treat glaucoma and epilepsy, the blood pressure medicine fosinopril; the anti-anxiety medicine meprobamate; and the calcium channel blocking agent nimodipine.

The U.S. Justice Department is conducting a parallel criminal investigation. On Friday, the department asked the Pennsylvania court presiding over the lawsuit to put the lawsuit’s discovery process on hold, saying it could interfere with the criminal probe.

Connecticut Assistant Attorney General Joseph Nielsen said recently that states would likely oppose that request, which could slow the lawsuit.

     This should provide a sober reminder that, despite the profuse numbers of “free market,” enthusiasts, government vigilance and intervention are absolutely necessary to prevent the public from being robbed!

 

 

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