Current Events

Leftism = Victim blaming

Bruno Gonçalves Rosi Current Events, Law , , , ,

Trying his best to become a martyr, former President Lula didn’t surrender to the police as it was stipulated by judge Sergio Moro.

Lula and his gang stole billions of dollars from the Brazilians. Now, all of a sudden, the left is worried about the rule of law.

Lula wanted to surrender Brazil to the interests of Foro de São Paulo, a supranational organization whose aim is to transform Latin America into a new USSR. Now, all of sudden, the left blames judge Sergio Moro for destabilizing Brazil’s democracy.

The only faction responsible for Brazil’s predicament is Lula and his gang. Thanks, judge Sergio Moro and his team for giving Brazilians a glimpse of hope.

A glorious day in Brazil

Bruno Gonçalves Rosi Current Events, Politics , , , , , ,

A glorious day in Brazil: former president Lula da Silva expected to be sent to jail soon.

Contrary to what the Washington Post says, there is no “political chaos” in Brazil. Former president Lula was ordered to jail, plunging Brazil into cosmos ahead of a presidential election.

Contrary to the Guardian, most Brazilians don’t hold any affection for Lula. Lula had support while he was able to feed the poor. Many poor people are already migrating their votes to Jair Bolsonaro.

Also contrary to the Guardian, Brazilian democracy is not connected to Lula. The country’s democracy will be alive and well without him. As for the “parliamentarians, academics and others” who say “Lula should be allowed to stand in the presidential elections,” please, be my guest: take him to run in your country.

A good day for Brazil, Latin America, and the world!

From the Comments: More trade, more states?

Brandon Christensen Comments, Current Events , , , , , , , , ,

Nguyen Ha left this thoughtful comment about my post on protectionism in Africa that I am embarrassed I missed:

Would you care to explain how “stronger economic ties will hasten the demise of current African states’ superficial institutions”?

What a tough question! First, though, I stated that it was my hope that deeper trading ties would lead to more states, not my prediction. My hope is based on current trends around the world: stronger economic ties have led to more states (and more aspirations for statehood within existing states).

The best academic treatment on this topic comes from Giacomo Ponzetto, an economist currently at CREI in Barcelona (he’s been mentioned at NOL on more than one occasion, too), and especially the Introduction and Section 5 of his working paper titled “Globalization and Political Structure.” Here:

As globalization proceeds, localities remove borders by increasing the size of countries. The number of countries declines and the mismatch between each locality is ideal and actual provision of public services grows. Eventually, this mismatch is large enough to justify a move to a two-level governance structure. The world political structure shifts from a few large countries to many small countries within a world economic union. The two-level structure is more expensive, but it is nonetheless desirable because it facilitates trade and improves preference-matching in the provision of public services.

By “two-level governance structure” Ponzetto means one level, a locality, that’s focused on delivering public goods to that specific locality, and another level, a world economic union, that’s focused on protecting property rights and eliminating border costs.

You can see this concept play out in a few different federative structures, especially the EU, the US, India, and China. In the European Union, multiple localities have tried to separate from countries (Catalonia from Spain, Scotland from UK) while still remaining part of the international economic union in place. Deeper trade ties, more states.

Three new states were created in India in 2000, and China is currently grappling with federalism as a way to keep up with its predictable economic success. The US hasn’t seen any new states added since 1959, but that’s because its system does a good enough job overall to keep all its member states content (happy, even).

The free trade zone in Africa will be interesting to watch because there are so many different variables at play than in China, the EU, India, or the US. India was governed by one overseas empire; the EU has been able to maintain stability because of American military power and the security umbrella it provides; China has been unified on and off again for centuries; and the US is, for all intents and purposes, a polity underscored by British cultural, economic, and political mores. Africa has none of these traits, yet its various leaders recognize that free trade leads to prosperity and often (not always) to better diplomatic ties.

If all goes well, and current trends elsewhere are any indication, Africa would see more states come into being to go along with its deeper economic ties. (This might be a major factor why Nigeria refused to join; Abuja fought a vicious civil war in the 1970s against separatists in Biafra and its leaders are probably tacitly aware of current global trends.) If all doesn’t go well, then violence and poverty will be just around the corner.

Can Elizabeth Warren help turn the populist tide?

Tridivesh Singh Maini Current Events, Politics , , , , , , , , ,

During her recent visit to China, a Democratic Senator from Massachusetts, Elizabeth Warren (perceived by many as a potential Presidential Candidate of the Democratic Party in 2020), came down heavily on US President Donald Trump’s approach towards foreign policy, arguing that it lacks substance, is unpredictable, and does not pay much attention to liberal values and human rights, which according to her has been the cornerstone of US foreign policy for a long time.

Trump’s unpredictability

Commenting on Trump’s unpredictable approach towards Asia, Warren stated:

This has been a chaotic foreign policy in the region, and that makes it hard to keep the allies that we need to accomplish our objectives closely stitched-in.

Critical of US approach towards China

Warren met with senior Chinese officials including Liu He, vice-premier for economic policy, Yang Jiechi, a top diplomat, and the minister of defense, Wei Fenghe, and discussed a number of important issues including trade and the North Korea issue.

Warren criticised China for being relatively closed, and stated that the US needed to have a more realistic approach towards Beijing. She also spoke of the need for the US to remain committed to raising Human Rights issues, and not skirt the issue, while dealing with China.

Said the Democratic Senator: Continue reading →

Lunchtime Links

Brandon Christensen Current Events, Links , , , , , , , , , , ,
  1. David Reich’s essay in the New York Times on genetics, race, and IQ
  2. Henry Farrell’s essay at Crooked Timber on genetics, race, and IQ
  3. Ezra Klein’s essay at Vox on genetics, race, and IQ
  4. Chris Dillow’s essay at Stumbling and Mumbling on genetics, race, and IQ
  5. Andrew Sullivan’s essay at Daily Intelligencer on genetics, race, and IQ

Andrew’s essay is a must read. It’s careful, well thought out, and bolder than the other ones. All are well-worth reading, though.

Reich’s essay has sparked an important dialogue in the Anglo-American world (props to the NY Times). Globally, I think conceptions of race, genetics, and IQ in the non-Anglo world are based on pseudoscience (at best), so it’s nice to see this debate unfold the way it has (so far).

I don’t think any of them have done a good job grappling with Charles Murray’s argument. (More on that later.)

Thanks to Uncle Terry for bringing this to light in the first place.

An update on the federalist debate in India

Tridivesh Singh Maini Current Events, Politics , , , ,

In recent days, numerous leaders in India’s South have spoken in one voice against the 15th Finance Commission — arguing that it is unfair to South Indian states. The bone of contention is a directive in the terms of reference given to the Finance Commission, which states that the distribution of revenues amongst states should be based on the 2011 census, as opposed to the 1971 census. During this period, South Indian states have fared well in controlling their population, while Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan, and Uttar Pradesh – all northern states – have been unsuccessful. South Indian states have put forth the argument that they have been penalized for controlling their population, while states which have not fared particularly well have been rewarded.

Some leaders have also objected to the commission dubbing important welfare schemes as ‘populist’ without understanding the economic and social dynamics of different states.

Non-Economic Issues Continue reading →

The President’s commission on opioids (2/2)

Bill Rein Culture, Current Events, Law , , , , , , , , ,

Here’s the second half of an abridged essay I wrote for a public policy course. First half is here, and next week I’ll write about the FDA’s new enemy, kratom.

 

Epidemic status

The DEA’s 2015 declaration of an opioid epidemic was the first sign of large-scale federal attention to prescription analgesics, to my knowledge. On the CDC’s official glossary, “outbreak” and “epidemic” are interchangeable: “the occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time.”

The classification of addiction as a disease is sometimes controversial. (See also Adam Alter’s Irresistible for a popularized form of the psychological takes on addiction.) For the opioid problem to be an epidemic, the focus must be the addition rate, and not the overdose or death rate alone. The federal government usually refers to the opioid situation as an epidemic or emergency (which presupposes a value judgment), and when media has covered it (as with the deaths of Philip Seymour Hoffman, Heath Ledger and Prince) they use the same language. One definitive media moment might have been last year, when John Oliver announced for a young progressive crowd that “America is facing an epidemic of addiction to opioids.”

Oliver was referring specifically to addiction — criticizing companies like Purdue Pharma (creator of OxyContin) for misleading or misinformative advertising about addictiveness. But usually it does not seem like the focus is on addiction. As stated, nonmedical usage of opioids is generally down or stabilized from the last couple years, and the problem is mostly overdoses. (True, these are intimately connected.) This might indicate that cutting the pills with other drugs or general inexperienced use are greater problems than general addiction. So, there is an epidemic in the colloquial usage — extensive usage of something which can be harmful — but only questionably in the CDC’s medical definition, as the usage rates are expected to be up as synthesized morphine-, codeine- or thebaine-based pain relievers diversified, and these have mostly stabilized except for heroin (thought as often beyond opioid status) and fully synthetic derivatives which get less attention (fentanyl, tramadol).

Why the standard of abuse fails

John Oliver — worthy to talk about because much of the public plausibly started paying attention after his episode — noted that the pills are assigned to patients and then, even if the patient doesn’t develop an addiction, they end up in the “wrong hands.” What happens at this point? The Commission recommends that companies design their prescription drugs for “abuse-deterrent” formulations (ADF). After spikes in opioid abuse, Purdue Pharma and other companies began researching mechanisms to prevent abusers from easily obtaining a recreational high by tampering with the pill or capsule. In a public statement, FDA commissioner Scott Gottlieb asserted that the administration’s focus is on “decreasing unnecessary exposure to opioids,” but, recognizing the real role that prescription opioids play in pain relief, Gottlieb continues that “until we’re able to find new nonopioid forms of pain management … it’s critical that that we also continue to promote the development of opioids that are harder to manipulate and abuse, and take steps to encourage their use over opioids that don’t offer any form of deterrence.” Some of these abuse-deterrent options are crush resistance or wax coating to make dissolving more difficult.

However, opioid abuse comes in two forms which are conflated by the legal language. The first is when a patient takes more than their recommended allocation or takes it in the wrong way. The second is when someone with or without a prescription consumes them purely for recreation. Many drug savvy abusers of the second variety have adapted methods to get a recreational high but avoid potential health risks, the most popular method being “cold water extraction” (CWE). Most opioid pills contain both a synthesized opium alkaloid (from morphine, codeine or thebaine) and acetaminophen: Percocet contains oxycodone and paracetamol; Vicodin contains hydrocodone and paracetamol. The acetaminophen or APAP has no recreational benefits (a pure pain reliever/fever reducer) and can cause severe liver problems in large quantities, so recreational users will extract the opium alkaloid by crushing the pill, dissolving it in distilled water, chilling it to just above freezing, and filtering out the uncrystallized APAP from the synthesized opium. This way a greater quantity of the opioid can be ingested without needlessly consuming acetaminophen. Other recreational users that want less of the opium derivative can proceed without CWE and insufflate or orally ingest the particular pills.

ADFs might be able to dent the amount of abusers of the second variety. If the pills are harder to crush (the route of Purdue’s 2010 OxyContin release) or, for capsules, the interior balls are harder to dissolve (the route of Collegium Pharmaceutical’s Xtampza), amateur or moderately determined oxycodone enthusiasts may find the buzz is not worth the labor. As the Commission observes, more than 50% of prescription analgesic misusers get them from friends and family (p. 41) — these are not hardcore aficionados, but opportunists who might be dissuaded by simple anti-abuse mechanisms. Abusers of the first variety, though, are unaffected: at least in the short term, their abuse rests on slightly-over-the-recommended doses or a natural tendency to develop an addiction or non-medical physical dependency. And, if the political core of the opioid emergency is patients that develop an addiction accidentally (those that stay addicted to pharmaceuticals and those that graduate to heroin), abuse-deterrent focuses are unlikely to create real change in addiction rates. It could even have the unintended consequence of higher overdose deaths for amateur narcotics recreationalists, who aren’t skilled enough to perform extractions and opt to consume more pills in one sitting instead.

And furthermore, ADFs can be incorporated into the naturals and synthetics that are usually bonded with APAP like codeine, oxycodone, hydrocodone and tramadol, but cannot for the drugs that come in pure form like heroin or fentanyl. And those are the problem drugs. The NIDA research on drugs involved in overdose deaths across the board, for one, shows that overdose deaths are on the rise as a whole (except for methadone), and also that the synthetic opioids are much more deadly than the naturals and semi-synthetics: fentanyl is the biggest prescription analgesic killer (it’s much more potent than morphine, and tramadol is not very good for recreation).

drugoverdosedeaths

(This graph also shows, however, that the natural/semi-synthetic usage rate was possibly leveling out but resuscitated in 2015.) So ADFs are useless for the drugs most massively causing the “opioid epidemic.” Making them harder to abuse only dents the second category of abuser, and does not limit their addictiveness for those prescribed them for postsurgical pain or otherwise.

Moreover, from a libertarian standpoint, the second category of abuser does not really belong in the “public health crisis” discussion. Those who knowingly consume opioids for recreation are not a problem, they are participants in a pleasure-seeking activity that doesn’t tread on others. So long as their costs are not imposed on other people, it might be better to separate them from the “epidemic” status. Blurring the lines between the groups that fall under “abusive” means that those with a side-interest in OxyContin on Friday nights are lumped in with addicts suffering from physical dependency. Someone who has a glass of wine each night is not “abusing” alcohol, but we can recognize someone who is an alcoholic; the same distinction should be applied medically to opioid users. By painting all consumers outside of direct medical usage as “abusers,” there can be no standard for misuse, and thus no way for a recreationalist to know how much is too much, when health problems might set in, if they are really trapped in their recreation, etc. Research and knowledge are threatened by the legal treatment and classification.

Conclusion

To summarize, the government terminology of “abuse” obscures a legitimate distinction that is justified on both medical-political and civil liberty grounds. Some of the approaches in the Commission report, like the market-based CMS package recommendation, will likely succeed at quelling opioid exposure (and thus addiction and overdoses), while other maneuvers like an education campaign or ADFs should be treated with cautious skepticism. The trends show that heroin and fentanyl are actually the biggest contributors to the opioid epidemic, although semi-synthetics are climbing again in overdose deaths after leaning toward stabilization two years ago. Evidence that prescription abuse and street use are linked, as well as testimony from former addicts, indicates that drug users easily swing between the legal and black market.

The President’s commission on opioids (1/2)

Bill Rein Current Events, History, Law , , , , , , , , ,

Given Zachary’s post on the drug war and opioid crisis, I thought I would share parts of an essay I wrote for a class last semester about Trump’s commission on opioids, which is the first policy step the new administration took in dealing with the issue. It’s edited for links and language and whatnot.

 

One of the more recent executive steps to combat the opioid crisis — the “abuse” of prescription and illegal opioid-based painkillers — was the creation of The President’s Commission on Combating Drug Addiction and the Opioid Crisis (hereafter, the Commission) two years ago by the Trump administration. The commission, led by Chris Christie, was instituted to investigate the issue further and produce recommendations for the government and pharmaceutical industry. It released its final report in November and seems set to work on opioid use with the same sort of strategies the federal government always treats drugs, except maybe a little more progressive in its consideration of medicinal users. Looking at the Commission’s report, I argue that a refusal to treat unlike cases dissimilarly will lead to less than effective policy.

The President’s Commission

The DEA first asserted that overdose deaths from opioids had reached an epidemic in 2015. In March of last year, Donald Trump signed an executive order establishing the policy of the executive branch to “combat the scourge of drug abuse” and creating The President’s Commission. The Commission is designed to produce recommendations for federal funding, addiction prevention, overdose reversal, recovery, and R&D. Governor Chris Christie of New Jersey served as Chairman alongside Gov. Charlie Baker (R-MA), Gov. Roy Cooper (D-NC), representative Patrick J. Kennedy (D-RI), former deputy director of the Office of National Drug Policy and Harvard professor of psychobiology Bertha Madras, and Florida Attorney General Pam Bondi.

Included in the final report is a short history of opioid use in the United States, characterized by a first crisis in the mid- to late-19th century of “unrestrained … prescriptions,” eventually reversed by medical professionals “combined with federal regulations and law enforcement.” A public distrust of opioids developed afterward, but this was “eroded,” and now the new crisis, traceable to 1999, has become more perilous by innovations since the 19th century: large production firms for prescription drugs, a profitable pharmaceutical industry, cheaper and purer heroin, new fentanyl imports from China.

Since the Commission’s report, several bills have been introduced in the House or Senate currently awaiting judgment (e.g., H.R.4408, H.R.4275, S.2125). Declaring widespread addiction and overdoses to be a national emergency in August, Trump fulfilled one of the interim steps proposed by Christie in an early draft of the report; since, the President has met with drug company executives to discuss nonopiate alternatives for pain relief. Within the next few months we should start to see large scale moves.

Through all of this, the treatment of opioids by the Commission and the US government uses a traditional framing. The National Institute on Drug Abuse (NIDA) defines drug abuse in the following way:

[Use of substances] becomes drug abuse when people use illegal drugs or use legal drugs inappropriately. This includes the repeated use of drugs to produce pleasure, alleviate stress, and/or alter or avoid reality. It also includes using prescription drugs in ways other than prescribed or using someone else’s prescription. Addiction occurs when a person cannot control the impulse to use drugs even when there are negative consequences—the defining characteristic of addiction.

This definition by the federal government does not discriminate between various levels of damaging consumption behavior. The weakness of this definition is that, because all illicit drug consumption is categorized as abuse, there can be no standard for misuse of a black market drug for recreation. An entry-level dose of heroin qualifies as equally “abusive” as a lethal dose because of the binary character of the definition. Other federal agencies give similar definitions; in its report on recommendations for abuse-deterrent generic opioids (see below), the HHS and FDA use a definition of abuse characterized by the “intentional, nontherapeutic use of a drug product or substance, even once, to achieve a desired psychological or physiological effect.” This terminology still characterizes any and all recreational consumption of opioid analgesics as abuse, and not misuse, regardless of dosage or long-term dependency. It will be seen that this is a problem for the success of any sort of policy aimed at quelling usage, and particularly hazardous for the opioid problem.

Legal Background

First, the legal background and a more extensive history. The category “opioid” covers much drug terrain both prescription and illegal. Opioids in the most expansive sense are synthetic derivatives of alkaloids in the opium of the West Asian poppy species Papaver somniferum. Opium resin contains the chemicals morphine, codeine and thebaine. Morphine is the basis for powerful pain relievers like heroin and fentanyl. Codeine is considered less powerful for pain relief but can be used to produce hydrocodone; it also doubles as a cough suppressant. Lastly, thebaine is similar to morphine and is used for oxycodone. 90% of the world’s opium production is in Afghanistan.

All opioids are criminalized under federal Drug Scheduling. Heroin is a Schedule I drug as part of the Controlled Substances Act. Several synthetic opioid drugs that contain hydro- or oxycodone are Schedule II (Vicodin, Dilaudid, OxyContin). Fentanyl is also a Schedule II drug. Heroin is just a brand name for the chemical diacetylmorphine (invented by Bayer), still used as treatment in plenty of developed nations like the United Kingdom and Canada; after heroin was completely criminalized in the United States (“no medical benefits”), synthesized opiate drugs became more popular for prescriptions.

The Pure Food and Drug Act of 1906 introduced labels on medicine containing codeine and opium in general after Chinese immigrant workers introduced the drug to the states. Through 1914, various federal laws restricted opium further until the Harrison Narcotics Tax Act on opium and coca products (which are not narcotics, and the colloquial language has been messed up ever since) effectively criminalized the prescription of opioid products to addicted patients. Shortly afterward, the amount of heroin in the U.S. skyrocketed. Only in recent decades have synthesized opiates occupied the public mind, however. Between 1999 and the present, deaths from overdoses of opioids and opioid-based painkillers like OxyContin, Vicodin, morphine and street heroin have risen almost fourfold.

The data on overdoses and deaths does not paint a straightforward picture, and the group “opioid” obscures the different trends between drugs. The CDC classifies data according to four varieties of opioids: natural/semi-synthetic opioid analgesics like morphine, codeine, oxy- or hydrocodone, and oxy- or hydromorphone; synthetic opioid analgesics like tramadol and fentanyl; methadone; and heroin. The last is the only completely illegal opioid. Overdose deaths that have included heroin and completely synthetic opioids have increased exponentially from 2010 and 2013, respectively, while deaths from natural/semi-synthetic opioids and methadone have roughly stabilized or gone down over the last decade. Taken altogether, the deaths from opioid overdoses per 100,000 from 2000 to 2015 have increased from three to eleven people. (As of 2016, natural/semi-synthetic opioid deaths have actually started to go up again, but its still recent in the trend.)

OpioidDeathsByTypeUS

In 2016, the CDC issued guidelines for treating chronic pain that warned physicians against prescribing high dose opioids and suggested talking about health risks. It also advised to “start low and go slow” — a slogan later mocked by John Oliver in a segment on opioids. And, according to a CDC analysis, prescriptions for the most dangerous opioids have dropped 41% from 2010 to 2015, and so have opioid prescriptions in general dropped. This has resulted in patients with physical dependency suffering withdrawal, often without programs to ease the transition to nonopioid pain relievers. Opioid dependants with withdrawal, or average citizens in need of pain relief, often turn to stronger street narcotics, since heroin is the cheaper and stronger alternative to oxycodone. For example, with the drop in first-time OxyContin abuse since 2010, heroin use has spiked. In Maine, a 15% decrease in opioid analgesic overdoses came with a 41% increase in heroin overdoses in 2012. The use of prescribed opioids, then, looks like it might be strongly connected to the use of street narcotics. The Commission, for its credit, notes that “the removal of one substance conceivably will be replaced with another.”

One fact lost in the discussion is that the use of nonmedical opioids has decreased but the amount of overdose deaths has increased. And “opioid epidemic” when discussing overdoses highly obscures that heroin is the major contributor alongside fentanyl — not merely prescription analgesics. We hear a lot about OxyContin and Vicodin, which are actually leveling out (or were until 2015), and less about the drugs which are already policed more, have been policed longer, and cause more physical problems.

What the Commission proposes

In its report, the Commission concludes the goals of its recommendations are “to promote prevention of all drug use with effective education campaigns and restrictions in the supply of illicit and misused drugs.” The President’s Commission doesn’t want to interfere too strongly, despite all of Trump’s suggestions of a revamped drug war. The report notes that coming down hard on opioids will hurt patients with real needs, as has already happened, and, in a way, has happened since 1924. Much of the Commission’s recommendations come from a market approach, e.g. the suggestion (Rec. 19) to reimburse nonopioid pain treatments. The current Centers for Medicare and Medicaid Services (CMS) policy for reimbursement for healthcare providers treats nonopioid, postsurgical pain relief treatments the same as opioid prescriptions, issuing one inclusive payment for all “supplies” at a fixed fee. Nonopioid medications and treatments cost more, and so hospitals opt for dispensing opioids instead. The Commission recommends “adequate reimbursement [for] a broader range of pain management” services, changing the bundle payment policy to accommodate behavioral health treatment, educational programs, “tapering off opioids” and other nonopioid options.

Trump himself suggested an educational approach in a public announcement, which triggered critical comparisons to the failed D.A.R.E. program and “your brain on drugs” commercials. Educational programs are a less coercive option than direct regulation of opioids, but their effectiveness seems to be hit and miss. The Commission cites the Idaho Meth Project from 2007 (ongoing), conducted by a private nonprofit to inform young adults on the health problems associated with methamphetamine use, as a success story: “The Meth Project reports that 94% of teens that are aware of the anti-meth campaign ads say they make them less likely to try or use meth, and that Idaho has experienced a 56% decline in teen meth use since the campaign began.” This meth project is one success story out of many failures. For instance, the Montana Meth Project from 2005, on which the Idaho project was modelled, “accounting for a preexisting downward trend in meth use,” was determined to have “effects on meth use [that] are statistically indistinguishable from zero,” according to an analysis by the National Library of Medicine. Then again, one large scale anti-drug educational campaign, truth, which encourages youth to avoid tobacco, might be having success. Their modern guerrilla tactics are a major improvement on the old model of Partnership for a Drug-Free America. 

In another market approach to help recovering addicts reenter society, the Commission recommends decoupling felony convictions and eligibility for certain occupations (Rec. 50). The report cites Section 1128 of the Social Security Act, which prohibits employers that receive funding from federal health programs from hiring past convicts charged with unlawfully manufacturing, distributing or dispensing controlled substances. Any confrontation with law enforcement is a barrier to landing a job — a protected area of discrimination — and government laws that specifically ban their hiring make it worse on ex-users and -dealers trying to get clean. Recommendations like these lessen the role that the state has in keeping ex-convicts out of work. 

Much of the funding requested by the President’s Commission is authorized by the Obama administration’s major contribution to combating opioid usage, the Comprehensive Addiction and Recovery Act (CARA), signed into law July 2016 and credited as the “first major federal addiction legislation in 40 years.” CARA helped implement naloxone (an opioid overdose-reversal nail spray) in firefighting departments and strengthen drug monitoring programs. 

 

I’ll post the second half soon, and then a bonus post on my personal favorite solution.

Midweek Reader: The Drug War, the Opioid Crisis, and the Moral Hazard of Overdose Treatment

Zachary Woodman Current Events, Links , , , , ,

Today, I’m reviving an old series I attempted to start last year that never came to fruition: The midweek reader. A micro-blogging series in which I try to link to stories that are related to each other to provide deeper insight into an issue. This week, we’re looking at the relationship between the Opioid Crisis and the drug war, and the academic debate around a controversial paper finding moral hazard in policies that try to increase access to Naloxone.

  • At Harpers Magazine, Brian Gladstone has a fantastic long-form piece looking into how attempts to crack down on opioid addiction by targeting the prescription pain meds have left many patients behind and questioning the mainstream narrative that the rise of opioids was driven primarily by pain prescriptions. A slice:

    Yet even the most basic elements of this disaster remain unclear. For while it’s true that the past three decades saw a staggering upsurge in the prescribing of opioid medication, this trend peaked in 2010 and has been declining since: high-dose prescriptions fell by 41 percent between 2010 and 2015. The question, then, is why overdose deaths continue to skyrocket, rising 37 percent over the same period — and whether restricting access to regulated drugs is actually pushing people toward more lethal, unregulated ones, such as fentanyl, heroin, and carfentanil, a synthetic opioid 10,000 times stronger than morphine.

  • Similarly, at the Cato Institute, Jeffery A. Singer has a good piece exploring the relationship between America’s War on Drugs and the rise of opioid addictions. He concludes:

    Meanwhile, President Trump and most state and local policymakers remain stuck on the misguided notion that the way to stem the overdose rate is to clamp down on the number and dose of opioids that doctors can prescribe to their patients in pain, and to curtail opioid production by the nation’s pharmaceutical manufacturers. And while patients are made to suffer needlessly as doctors, fearing a visit from a DEA agent, are cutting them off from relief, the overdose rate continues to climb.

  • At Vox, philosopher Brendan de Kenessey of Harvard has a piece exploring the philosophy of the self and of rational choice to argue that it’s wrong to treat drug addiction as a moral failure. A slice:

    We tend to view addiction as a moral failure because we are in the grip of a simple but misleading answer to one of the oldest questions of philosophy: Do people always do what they think is best? In other words, do our actions always reflect our beliefs and values? When someone with addiction chooses to take drugs, does this show us what she truly cares about — or might something more complicated be going on?

  • An econometrics working paper by Jennifer L. Doleac of University of Virginia and Anita Mukherjee of the University of Wisconsin released earlier this month, which sparked spirited discussion, investigated the link between opioids and laws increasing access to Naloxone. They found the laws increased measurements of opioid use but did reduce mortality, which they theorize is because Naloxone increases moral hazard for addicts by reducing potential costs of an overdose. However, they conclude:

    Our findings do not necessarily imply that we should stop making Naloxone available to individuals suffering from opioid addiction, or those who are at risk of overdose. They do imply that the public health community should acknowledge and prepare for the behavioral effects we find here. Our results show that broad Naloxone access may be limited in its ability to reduce the epidemic’s death toll because not only does it not address the root causes of addiction, but it may exacerbate them. Looking forward, our results suggest that Naloxone’s effects may depend on the availability of local drug treatment: when treatment is available to people who need help overcoming their addiction, broad Naloxone access results in more beneficial effects. Increasing access to drug treatment, then, might be a necessary complement to Naloxone access in curbing the opioid overdose epidemic.

  •  Alex Gertner, a PhD candidate at UNC-Chaple Hill, published a criticism of Doleac Murkhejee at Vox pointing out that their data linking Naloxone and opioid-related hospital visits are not necessarily due to a casual story involving moral hazard:

    The authors find that naloxone access laws lead to more opioid-related emergency department visits, the premise being that naloxone access laws increase opioid overdoses. But there’s a far more likely explanation: People are generally instructed to seek medical care for overdose after receiving naloxone.

    Overdose is a general term to describe experiencing the toxic effects of drugs. People can overdose, and often do, without either dying or seeking medical attention. If people who would otherwise overdose without medical attention are instead using naloxone and going to emergency rooms, that’s a good thing.

  • The widest-ranging and most thorough critique of Doleac-Murkhejee comes from Frank, Pollack, and Humphries at the Journal of Health Affairs. They argue that the original authors (1) assume too much immediacy in effect of changes in Naloxone laws than is probably warranted (2) ignore a variety of exogenous variables like Medicare expansion. They conclude:

    We believe the best interpretation of Doleac and Mukherjee’s findings is that their main treatment variable—naloxone laws—thus far have had little impact on naloxone use or nonmedical opioid use during the period studied. This disappointing pattern commands attention and follow-up from both public health practitioners and public health researchers.

John Bolton: the view from India

Tridivesh Singh Maini Current Events , , , , , ,

On March 23, 2018, US President Donald Trump tweeted that he was removing H.R. Mcmaster as his National Security Advisor, and that John Bolton would take over on April 9, 2018.

Bolton, the US Ambassador to the UN during George W Bush’s Presidency, has evoked strong domestic reactions in the US, with both Democrats and certain Republicans being skeptical of him because of his mercurial nature and outlandish views on complex foreign policy issues. Bob Menendez, a top Democrat on the Senate Foreign Relations Committee, publicly commented on his appointment:

While the President may see in Mr Bolton a sympathetic sycophant, I would remind him that Mr Bolton has a reckless approach to advancing the safety and security of Americans – far outside any political party.

One significant point, which is being made by a number of analysts who have watched Bolton closely, is that while Trump is a pure isolationist, Bolton, according to conservatives, believes in ‘preventive war.’ While the US President was a critic of the Iraq war, Bolton has defended it. In a tweet in 2013, Trump had stated:

All former Bush administration officials should have zero standing on Syria. Iraq was a waste of blood & treasure.

How is Bolton’s appointment viewed in South Asia Continue reading →

Who are the protectionists in Africa?

Brandon Christensen Current Events, Politics , , ,

Rwanda, a country that thankfully avoided “humanitarian” military intervention by Western powers during a nasty killing spree in the 90s, is leading the charge on free trade in Africa. Of the 54 countries on the African continent, 44 have signed the agreement, but the traditional economic giants of the continent – Nigeria and South Africa – have not. Surprisingly, Botswana, an example often cited by economists as an African success story, has not signed it either.

CNBC reports on why Nigeria has so far refused to join the agreement, citing a consultant who specializes in global trade:

There is a general sentiment among (labor unions and industry bodies) that Nigeria’s export capacity in non-oil sectors isn’t sufficiently robust yet to expose itself to external competition.

Unions and “buy local” capitalists: The scourge of prosperity and progress worldwide, but also not much of a surprise.

What will be interesting to see is where this bold experiment leads. How can 44 countries with poor institutions come together to form a free trade pact? I am hoping this will lead to more states in Africa. My logic goes something like this: stronger economic ties will hasten the demise of current African states’ superficial institutions, while allowing informal institutions to flourish. Because these informal institutions are better at solving coordination problems, they’ll eventually be recognized as states. Here’s how I put it back in 2012:

A better way of looking at it, and one that I have pointed out before, is to look at Europe realize that it shares roughly the same amount  of polities as does Africa (50-ish) despite being four times smaller. I bring up the comparison with Europe because in the Old World things like ethnicity still have a strong hold on how individuals identify themselves with their various social spheres. Rather than the 50-ish number of  polities in Africa that we have today, a better way of solving Africa’s problems would be to let the polities currently in place dissolve into 400 polities. Or 500. Then, I think, Africans would know peace and prosperity.

I’d add, today, that this would only be possible if the links built by this free trade pact endure. Economic integration is vital to the dissolution of Africa’s despotic states. (h/t Barry)

Brazil top court delays decision on blocking prison for ex-president Lula

Bruno Gonçalves Rosi Current Events, Law , , , , ,

Brazil’s Supreme Court decided that leftist former president Luiz Inacio Lula da Silva cannot be sent to prison for a corruption conviction until he exhausts all possible appeals. About that:

“It will be of little avail to the people, that the laws are made by men of their own choice, if the laws be so voluminous that they cannot be read, or so incoherent that they cannot be understood: if they be repealed or revised before they are promulg[at]ed, or undergo such incessant changes, that no man who knows what the law is to-day, can guess what it will be tomorrow.” – James Madison (16 March 1751 – 28 June 1836), fourth President of the United States (1809–1817), co-author, with John Jay and Alexander Hamilton, of the Federalist Papers, and traditionally regarded as the Father of the United States Constitution.

“Brazil is not for beginners.” – Antônio Carlos Jobim (January 25, 1927 – December 8, 1994), also known as Tom Jobim, Brazilian composer, pianist, songwriter, arranger, and singer. Widely considered as one of the great exponents of Brazilian music.

Trump’s personal game might work in China

Tridivesh Singh Maini Current Events, Politics , , , , , , ,

In spite of all the economic and strategic differences between the US and China, personal relationships play an important role in bilateral relations between Washington DC and Beijing.

Trump’s Ambassador to China 

One of the first appointments made by US President Donald Trump was that of Terry Branstad as US Ambassador to China. The key reason was Branstad’s personal rapport with Chinese President Xi Jinping. This began in 1985, when Branstad was Governor of Iowa, while Xi Jinping an official from Hebei was visiting Iowa. In 2011, Branstad visited Beijing, and met with Xi at the Great Hall of the People. In February 2012, when he was vice-president, Xi stopped in Muscatine, Iowa, where he met not just with Branstad but with big industrialists and farmers from the states.

The US President, commenting on the reason for appointing Branstad, stated:

Governor Branstad’s decades of experience in public service and long- time relationship with President Xi Jinping and other Chinese leaders make him the ideal choice to serve as America’s ambassador to China.

During US President’s China visit in November 2017, Branstad, who shares a good rapport with Trump, did the groundwork for the visit. While in recent weeks tensions between both countries have escalated, with Trump imposing tariffs on Chinese goods worth $60 billion, the American president was delighted with the welcome he had received during his trip and had even told the Chinese President: “My feeling towards you is incredibly warm.”

It would be pertinent to point out that Trump’s decision to appoint Branstad as Ambassador to China (December 2016) came as a relief to the Chinese, given the fact that the US President took Taiwanese President Tsai-Ing Wen’s phone call, much to the chagrin of Beijing (since this went against established US policy).

If one were to look beyond the role of personal relationships in the very complex but important Beijing-Washington relationship, China lays a lot of emphasis on experience (educational, professional) in the US. If one were to examine the credentials of some of the top officials in Xi Jinping’s administration, US education as well as experience in dealing with economic issues pertaining to the US, has played a key role in some of the Chinese President’s appointments.

For instance, Liu He, whom Xi Jinping has appointed as a Vice Premier for overseeing the economy and financial sector, is US educated. Liu, who speaks fluent English, obtained a master’s degree in public administration from the Kennedy School of Government (Harvard University) in 1995. Apart from his in-depth understanding of the Chinese economy, Liu has also been involved in important discussions with US leaders.

Another significant appointment by Xi Jinping is that of Yi Gang, who has been named as Governor of the People’s Bank of China (PBOC). Yi obtained a business degree from the Hamline University in St. Paul, Minnesota, and a Ph.D. in economics at the University of Illinois, before moving to Indiana University at Indianapolis as a professor in 1986. He taught later at the Peking University in Beijing, before moving to the PBOC in 1997.

While economic and strategic issues are too complex to be driven by personal relationships or chemistry (though Trump seems to be a keen believer in personal chemistry given the emphasis he lays on individual ties) alone, an in-depth  understanding of the culture, politics, and economics of one’s interloctutors is especially handy. Given the current tensions between both countries over tariffs, this dynamic may prove to be especially useful.

India’s near-abroad: Iran’s regional moves

Tridivesh Singh Maini Current Events , , , , , , ,

Close attention was paid by sections of India’s strategic community (and understandably so) to the statement of Iranian Minister of Foreign Affairs, Dr Javad Zarif, during his visit to Pakistan, in which he extended an invitation to Pakistan to join the ambitious Chabahar Project (about 70 kilometres from China’s ambitious Gwadar Project).

Zarif, while delivering a lecture at the Institute of Strategic Studies Islamabad (ISSI), stated:

We offered to participate in the China-Pakistan Economic Corridor (CPEC). We have also offered Pakistan and China to participate in Chahbahar

He further went on to state that Iran’s ties with India were not in any way targeted at Pakistan, just as Islamabad’s ties with Riyadh were not against Iran.

Surprise in India

This invitation surprised many in India, given the fact that it has provided financial assistance for Phase 1 of the project and will operate two berths. During Iranian President Hassan Rouhani’s visit in February 2018, one of the tangible outcomes was the lease contract signed by IPGL (Indian Port Global Limited) and Iran’s Port and Maritime Organization, for operating Phase 1 (Shahid Beheshti Port) over an 18-month period. The joint statement also made a clear reference to India’s unwavering commitment to the Chabahar-Zahedan Rail Line, which will enable transportation of goods all the way up to the Afghan border. The Indian side also stated that it would like to see Chabahar as part of the INSTC (International North South Transport Corridor). The INSTC will help in connecting India to Russia and Europe, via Iran.

Chabahar as India’s answer to Gwadar

Many in India have looked at Chabahar as India’s answer to the Gwadar Project, and of course its gateway to Afghanistan and Central Asia. The project is especially important to New Delhi because it enables India to bypass Pakistan, which has flatly refused to give India access to Afghanistan and Central Asia. In 2016, during Indian Prime Minister Narenda Modi’s visit to Iran, India, Iran, and Afghanistan had signed a three nation transport and transit corridor pact to enhance connecitivity. While leaders of all three countries spoke about the relevance of this agreement in the context of connectivity, the Iranian President had made it clear that it was not targeted at anyone. Said Rouhani:

[This pact is] not against any other country […] it is beneficial to the entire region.

India also sent a consignment of wheat (15,000 tonnes) to Afghanistan through the Chabahar Port in 2017. The shipment was dispatched from Kandla (Gujarat, India) and reached Chabahar in Iran. From Chabahar it was transported by road to Nimroz Province in Afghanistan.

India’s response

Replying to Zarif’s statements in a press briefing, India’s Spokesman Raveesh Kumar stated that:

[It is the] prerogative of the government of the Islamic Republic of Iran to choose its partners for the development of infrastructure facilities there.

Kumar also explained the strategic relevance of the project given its geo-political importance.

India-Iran ties beyond the Chabahar Port

Ever since the signing of the nuclear agreement in 2015 between Iran and the P5+1 countries, business linkages – and not just the Chabahar Project – between Iran and India have gotten a fillip. In 2017, India’s oil imports from Iran went up to 4.37 million barrel per day, even though there was a dip between April-December 2017 due to tensions between both countries on the Farzand B gas field. (Iran was supposed to award the gas field to India, but there have been differences on terms and conditions.) During Rouhani’s visit, both countries decided to address the obstacles related to banking and taxation, in order to bring about closer economic linkages.

Iran has thus emerged as an important strategic and trade partner for India.

What may have surprised sections of Indian government, along with its strategic thinkers, would be the Iranian invitation given to Pakistan, in spite of bilateral tensions between the two. In May 2017, for example, the Iranian Army Chief, Major General Mohammad Bagheri, had threatened to strike terror camps in Baluchistan (Pakistan) after the killing of ten Iranian guards by Jaish-Al-Adl in the Sistan-Baluchestan province. Said Baqeri:

[…] unless Pakistan control[s] the borders, arrest[s] the terrorist[s] and shut[s] down their bases […] we will hit their safe havens and cells wherever they are.

Since then tensions between the United States and Iran have also risen, and the latter has a close relationship with China. This has reshaped the Pakistan-Iran dynamic.

New Delhi’s real challenge

The real challenge for India in the near future is the hawkish stand of US President Donald Trump’s most recent appointee: Michael Pompeo (who was earlier head of the CIA, a main American intelligence agency). Trump is also likely to replace his current National Security Advisor, HR Mcmaster, and one possible replacement is John Bolton (former US Ambassador to the United Nations), a known hawk on Iran.

Pompeo would go along with Trump, and have no qualms in scrapping the Iran Nuclear Deal in May 2018, the next date when the issue comes up for consideration.

Pompeo’s predecessor, Rex Tillerson, had differed with Trump on this issue on more than one occasion. During the election campaign, Trump had criticized the Nuclear Agreement. He had dubbed the agreement a ‘disaster’ and ‘the worst deal ever negotiated’. In an address to a Pro-Israel Lobby group, AIPAC, the US President had gone to the extent of stating that dismantling the deal would be his first priority.

Tillerson, no dove on Iran by any stretch of imagination, had categorically stated that dismantling the deal was not in US interests, though the US President disagreed. Commenting on their disagreements about Iran, Trump had stated:

When you look at the Iran deal, I think it’s terrible […] it was okay. I wanted to either break it or do something, and he felt a little bit differently. So we were not really thinking the same.

Tillerson was closely working with European countries to rework the deal, and address some of the Trump administration’s concerns.

The Chair of the Senate Foreign Relations Committee, Bob Corker, has also predicted that Trump will walk out of the Deal: “The Iran deal will be another issue that’s coming up in May, and right now it doesn’t feel like it’s going to be extended.”

More aggressive Saudi Arabia

Saudi Arabia is likely to become more aggressive after the exit of Tillerson. In fact, on the eve of Saudi Crown Prince Mohammed Bin Salman’s arrival in the US, the Saudi Foreign Minister, Adel al-Jubeir, criticized the Iran Nuclear deal. Said the Saudi Foreign Minister:

Our view of the nuclear deal is that it’s a flawed agreement.

During the Saudi Prince’s visit, Trump too did not miss out on an opportunity to lambast the Iran nuclear agreement. While commenting on the future of the deal, the US President stated:

The Iran deal is coming up soon and you will see what will happen […] Iran hasn’t been treating that part of the world, or the world appropriately.

According to the Arab News it was also decided that the United Arab Emirates, Saudi Arabia, and the US would set up a trilateral security forum which would look not just at issues pertaining to Middle East and Iran, but also South Asia.

Conclusion

India would be advised to be cautious, and while some sections the Right have been ecstatic with Trump’s stance vis-à-vis Pakistan (not to mention China), New Delhi needs to be prepared for some turbulence as a consequence of the recent changes within the Trump Administration. New Delhi needs to articulate its strategic and economic interests in Iran, not just to the US, but also to Saudi Arabia. In the past, the US has not objected to Iran’s close ties with India, but it remains to be seen whether or not Trump and his team will exhibit flexibility and pragmatism vis-à-vis Iran.

New Delhi has a myriad of foreign policy challenges, and Trump’s rigidity towards Iran is likely to be a major one in the near future.

Are voting ages still democratic?

Bill Rein Culture, Current Events, Law , , , , , , , ,

Rather par for the course, our current gun debate, initiated after the school shooting in Parkland, has been dominated by children — only this time, literally.

I’m using “children” only in the sense that they are not legally adults, hovering just under the age of eighteen. They are not children in a sense of being necessarily mentally underdeveloped, or necessarily inexperienced, or even very young. They are, from a semantics standpoint, still teenagers, but they are not necessarily short-sighted or reckless or uneducated.

Our category “children” is somewhat fuzzy. And so are our judgments about their political participation. For instance, we consider ourselves, roughly, a democracy, but we do not let children vote. Is restricting children from voting still democratic?

With this new group of Marjory Stoneman Douglas high school students organizing for political change (rapidly accelerated to the upper echelons of media coverage and interviews), there has been widespread discussion about letting children vote. A lot of this is so much motivated reasoning: extending suffrage to the younger demographic would counter the current proliferation of older folks, who often vote on the opposite side of the aisle for different values. Young people tend to be more progressive; change the demographics, change the regime. Yet the conversation clearly need not be partisan, since there exist Republican- and Democrat-minded children, and suffrage doesn’t discriminate. (Moreover, conservative religious groups that favor large families, like Mormons, could simply start pumping out more kids to compete.)

A plethora of arguments exist that do propose pushing the voting age lower — 13, and quite a bit for 16 (ex. Jason Brennan) — and avoid partisanship. My gripe about these arguments is that, in acknowledging the logic or utility of a lowered voting age, they fail to validate a voting age at all. Which is not to say that there should not be a voting age in place (I am unconvinced in either direction); it’s just to say that we might want to start thinking of ourselves as rather undemocratic so long as we have one.

An interesting thing to observe when looking at suffrage for children is that Americans do not consider a voting age incompatible with democracy. If Americans do not think of America as a democracy, it is because our office of the President is not directly elected by majority vote (or they think of it as an oligarchy or something); it is not undemocratic just because children cannot vote. The fact that we deny under-eighteen year olds the vote does not even cross their minds when criticizing what many see as an unequal political playing field. For instance, in eminent political scientist Robert Dahl’s work How Democratic is the American Constitution? the loci of criticism are primarily on the electoral college and bicameral legislature. In popular parlance these are considered undemocratic, conflicting with the equal representation of voters.

Dahl notes that systems with unequal representation contrast to the principle of “one person, one vote.” Those with suffrage have one or more votes (as in nineteenth-century Prussia where voters were classified by their property taxes) while those without have less than one. Beginning his attack on the Senate, he states “As the American democratic credo continued episodically to exert its effects on political life, the most blatant forms of unequal representation were in due time rejected. Yet, one monumental though largely unnoticed form of unequal representation continues today and may well continue indefinitely. This results from the famous Connecticut Compromise that guarantees two senators from each state” (p. 48).

I quote Dahl because his book is zealously committed to majoritarian rule, rejecting Toqueville’s qualms about the tyranny of the majority. Indeed, Dahl says he believes “that the legitimacy of the Constitution ought to derive solely from its utility as an instrument of democratic government” (39). And yet, in the middle of criticizing undemocratic American federal law, the voting age and status of children are not once brought up. These factors appear to be invisible. In our ordinary life, when the voting age is brought up, it is nearly always in juxtaposition to other laws, e.g., “We let eighteen year olds vote and smoke, but they have to be 21 to buy a beer,” or, on the topic of gun control, “If you can serve in the military at 18, and you can vote at 18, then what is the problem, exactly, with buying a gun?”

What is the explanation for this? We include the march for democracy as one progressive aspect of modernity. We see ourselves as more democratic than our origin story, having extended suffrage to non-whites, women and people without property. We see America under the Constitution as a more developed rule-of-the-people than Athens under Cleisthenes. So, we admit to degrees of political democracy — have we really reached the end of the road? Isn’t it more accurate that we are but one law away from its full realization? And of course, even if we are more of a representative republic, this is still under the banner of democracy — we still think of ourselves as abiding by “one person, one vote” (Dahl, 179-183).

In response, it is said that children are not properly citizens. This allows us to consider ourselves democratic, even while restricting direct political power from a huge subset of the population while inflicting our laws on them.

This line of thought doesn’t cut it. The arguments for children as non- or only partial-citizens are riddled with imprecisely-targeted elitism. “Children can be brainwashed. Children do not understand their own best interests. Children are uninterested in politics. Children are not informed enough. Children are not rational. Children are not smart enough to make decisions that affect the entire planet.”

Although these all might apply, on the average, to some age group — one which is much younger than seventeen, I would think — they also apply to all sorts of individuals distributed throughout every age. A man gets into a car wreck and severely damages his frontal lobe. In most states there is no law prohibiting him from dropping a name in the ballot, even though his judgment is dramatically impaired, perhaps analogous to an infant. A nomad, who eschews modern industrial living for the happy life of travel and pleasure, is allowed to vote in his country of citizenship — even though his knowledge of political life may be no greater than someone from the 16th century. Similarly, adults can be brainwashed, adults can be stupid, adults can be totally clueless about which means will lead to the satisfaction of their preferred ends.

I venture that all Americans do not want uninformed, short-sighted, dumb, or brainwashable people voting, but they will not admit to it on their own. Children are a proxy group to try to limit the amount of these people that are allowed in on our political process. And is banning people based on any of these criteria compatible with democracy and equality?

Preventing “stupid” people from voting is subjective and elitist; preventing “brainwashable” people from voting is arbitrary; preventing “short-sighted” people from voting is subjective and elitist, and the same for “uninformed” people. We come to the category of persons with severe mental handicaps, be their brain underdeveloped from the normal process of youth, or injury, or various congenital neurodiversities. Regrettably, at first glance it seems reasonable to prevent people with severe mental defects from voting. Because, it is thought, they really can’t know their interests, and if they are to have a voting right, it should be placed in a benefactor who is familiar with their genuine interests. But now, this still feels like elitism, and it doesn’t even touch on the problem of how to gauge this mental defect — it seems all too easy for tests to impose a sort of subjective bias.

Indeed, there is evidence that this is what happens. Laws which assign voting rights to guardians are too crude to discriminate between mental disabilities which prevent voting and other miscellaneous mental problems, and make it overly burdensome to exercise voting rights even if one is competent. It is hard to see how disenfranchising populations can be done on objective grounds. If we extended suffrage from its initial minority group to all other human beings above the age of eighteen, the fact that we prolong extending it to children is only a function of elitism, and consequently it is undemocratic.

To clarify, I don’t think it is “ageist” to oppose extending the vote to children, in the way that it is sexist to restrict the vote for women. Just because the categories are blurry doesn’t mean there aren’t substantial differences, on average, between children and adults. But our reasoning is crude. We are not anti-children’s suffrage because of the category “children,” but because of the collective disjunction of characteristics we associate underneath this umbrella. It seems like Americans would just as easily disenfranchise even larger portions of the population, were we able to pass it off as democratic in the way that it has been normalized for children.

Further, it is not impossible to extend absolute suffrage. Children so young that they literally cannot vote — infants — could have their new voting rights bestowed upon their caretakers, since insofar as infants have interests, they almost certainly align with their daily providers. This results in parents having an additional vote per child which transfers to their children whenever they request them in court. (Again, I’m not endorsing this policy, just pointing out that it is possible.) The undemocratic and elitist nature of a voting age cannot be dismissed on the grounds that universal suffrage is “impossible.”

It is still perfectly fine to say “Well, I don’t want the boobgeoisie voting about what I can do anyway, so a fortiori I oppose children’s suffrage,” because this argument asserts some autocracy anyway (so long as we assume voting as an institutional background). The point is that the reason Americans oppose enfranchising children is because of elitism, and that the disenfranchising of children is undemocratic.

In How Democratic is the American Constitution? the closest Robert Dahl gets to discussing children is adding the Twenty-Six Amendment to the march for democratic progress, stating that lowering the voting age to eighteen made our electorate more inclusive (p. 28). I fail to see why lowering it even further would not also qualify as making us more inclusive.

In conclusion, our system is not democratic at all,
Because a person’s a person no matter how small.