Tuesday, September 27, 2016

The non-republicanism of Trump vs. the republicanism of Clinton, and Why That Should Matter to Republicans (and Democrats)

If one wanted to be appalled by Donald Trump's performance in the first (perhaps only) presidential debate, one would have had a virtual cornucopia of comments or mannerisms, each one a subtly different flavor from the next in terms of belligerence, complete lack of knowledge or understanding of public affairs, and just general indecency. But as is often the case with placing Trump in perspective, the truly meaningful moments--where the menace he represents to American democracy in a way heretofore never seen is laid bare--can get lost in the dust cloud of nattering about whether "stop & frisk" was unconstitutional, or whether he really did say that China invented the concept of global warning (he did), or why he hates Rosie O'Donnell so, or who on earth Sydney Blumenthal might be, and so forth. All that noise, in which people who sympathize with either Republican or Democratic views can disagree or at least emphasize different ways of looking at a contentious topic, can obscure the statements that should, to any sane individual, show that this is not a Republican running for president, but a man who has no apparent regard for the democratic process at all.

For Trump may be running as a Republican candidate, but there is no republicanism--small "r"--in his governing philosophy whatsoever. For over a year, his overt bullying indicated to tens of millions of Americans that this was probably true, but last night, in front of more than 80 million people, he stated in no uncertain terms what he really thinks about the purpose of the US government, and especially the US military: they're a moneymaking machine. Trump said that "we defend countries. They do not pay us what they should be paying us." There's very little need to reach for elaborate explanations to grasp the unsubtle nature of his view that the purpose of the US military should be an elaborate protection racket, in the words of the National Review (!). One pictures Trump envisioning small NATO countries the same way a mafioso might wander through a neighborhood of weak individuals, taking a casual stroll through, say, Estonia, as he drops a little hint to its leader, "Nice houses you got here. Pity if something bad should happen to them."

And what might have gotten missed in the literal he-said-she-said was that Hillary Clinton's reply was not the articulation of the philosophy of the Democratic party. Instead, it was the articulation of the philosophy of the United States of America--one shared, in almost absolute unanimity, by every member of both political parties, and is a philosophy that dates back to when Donald Trump was in swaddling clothes. The level of contempt that he has shown not simply for Hillary Clinton, or the Democratic party, or Jeb Bush, or Marco Rubio, or a former Miss Universe, or nearly anyone who speaks Spanish, or any number of people on a seemingly endless list--not these individuals, but the level of contempt for America as a democracy was undeniable in his NATO remarks, and this was not a spontaneous riff, for he has articulated this view before. It wasn't a mistake; it's the centerpiece of how he thinks.

I am aware of the difficulties that Trump's candidacy has created for lifelong Republicans who do believe in basic ideals of democracy and republicanism as part of the American project. But from where I stand, after today, now that he has gone before tens of millions of people and explained in clear terms what he really thinks about the meaning of US military force around the world, only someone who has taken complete leave of their senses could defend this man as being the standard bearer for what previously constituted Republican party philosophy. This undoubtedly leaves many Republicans having to deal with the unpleasant question of what, in fact, does currently constitute Republican party philosophy, since a clear majority of Republican primary voters prefer Trump to what has been peddled before. But either way, I think such voters will have to make the decision as to whether they are willing to throw their lot in with a man who thinks that, with respect to our military commitments, extremism in the defense of wealth is no vice.


Saturday, July 9, 2016

Today in Zika Hyperbole

In the aftermath of one of the more appalling weeks in our nation's history, Slate's lead headlines for July 9, 2016 include a news item about Zika to provide a further dollop of anxiety and dread. The headline notes that someone has actually died of Zika--right here, in the United States!--and then asks the question: now should we panic?

The answer is "no," but what's amazing about this is that the article itself makes clear the degree to which the headline is overblown. "The individual was elderly and 'had an underlying health condition,'" author Matt Miller notes in quoting a press release from the Utah Department of Public Health. Citing WHO statistics, Miller later reveals that the total number of Zika infections in 2015 was estimated to be between 400,000 and 1.3 million people, of which three can be supposed to have died from the virus (and five infants born with microcephaly--yes, that number is five, not five million, or even five thousand). "Zika is still a situation that warrants better public health communication, more extensive research, and certainly more funding. But this death is no reason to panic," the article concludes.

If that is so, then why run the article at all, unless the headline was to suggest precisely the opposite of what it did say?


Tuesday, March 29, 2016

Politics & Consistency: Presidential Primary Edition

I'm okay in general with people who feel the Bern. There's a lot of his critique that resonates with me, especially his sense of outrage about the injustice of a wildly inequitable system. But without getting too far into a debate about whether or candidate Bernie Sanders and his policy prescriptions are superior to that of Hillary Clinton--this post is not about advocating for one or the other--it is worth looking at one argument the Sanders' supporters consistently cite as evidence of the Fix that the Democratic Party and its mainstream media enablers have for Bernie and the Revolution: the undemocratic nature of the superdelegates.

As of March 29 following this weekend's contests, the current "pledged" delegate count stands at Clinton's 1243 to Sanders's 945 according to both RealClearPolitics and Bloomberg. The total number needed for the nomination is 2,382 delegates. So you say, aha! It's close! But then there are the superdelegates--effectively freelancers who are Party apparatchiks and, although still part of specific state delegations, can pledge themselves to whomever they see fit. Clinton is, at present, thumping the Vermont Senator in this category, 469 to 29. That means that Clinton has a sizeable advantage heading into the homestretch for the nomination.

Foul! Cry the Sanders people. This isn't democracy! This is a sham! 

Maybe yes, maybe no. I'm not sure how I come down on the question of superdelegates, and so this post isn't trying to defend that. What this post is trying to do, however, is point out that if you think democracy involves opening the doors to as many voters as possible, you can't trumpet big delegate pickups as evidence of the Will of the Voters if the process by which those delegates were earned is equally undemocratic. You can't have it both ways.

Sanders won the Alaska, Hawaii, and most importantly the Washington State caucuses this weekend. He won big, and that led to a haul of delegates, closing the gap by about 70. He crushed Clinton in Washington 73 to 27 percent. That's about as lopsided a win as you're going to get this cycle. And Sanders supporters have been reminding everyone of this huge win, saying it's every bit as important as all those Southern states that Clinton racked up, even though (the argument goes) the media plays up every Clinton victory, and downplays every Sanders victory.

But here's the thing: Clinton's southern victories really were bigger. Take a look at North Carolina: Clinton got about 55 percent of the vote to Sanders's 45. Less impressive than the Washington rout, right? Depends on how you count these things. In NC, 616,000 voted for Clinton to 460,000 for Sanders. In Washington, 19,159 caucused for Sanders, while 7,140 did so for Clinton.

Basically, Sanders has done exceptionally well in states that choose their delegates by holding caucuses--where the diehards have disproportionate impact on a contest. With the exception of Iowa, Nevada, and the American Samoa, Sanders has won every single caucus event (and Iowa was very close). By contrast, he has won the primaries in his own home state of VT and its neighbor in NH, the "Democrats Abroad" caucus, and the one big surprise, the close win in Michigan. But if you look at the total number of people who have actually cast their votes for the two, Clinton's lead is, as the Senator would say, yuge.

Effectively, caucuses are contests by which someone like Sanders with his dedicated following can win his own version of superdelegates. We can never know what would have happened in an open Washington primary, but I can only appeal to reason by saying that, even if Sanders had won the state, there was no way he would have won 73 to 27.

Just to be clear again: I am not saying that it's not fair that Sanders picked up his delegates that way. I don't have much of a dog in the fight for the Dem nomination one way or the other. But what I find off-putting about the righteous screeds that the Sanders supporters is their deep belief that everyone has stacked the cards against them...unless the cards happen to fall in their favor. If you say that superdelegates are undemocratic, well, then you're committed to saying that caucuses are as well.


Monday, February 29, 2016

Getting Back Into the Groove

It's been awhile since I've been in blogging mode owing to the completion of one manuscript and the simultaneous generation of another (stay tuned), to say nothing of fairly heavy clinical duties. I even let Zika pass along without any grumpy commentary, which is a shame, all things considered. And even though we are on the eve of Super Tuesday, which includes a primary in MA, I'm just going to throw out this little link to the Atlantic as a way to ease back in to the blog.

Who knows what kind of time I'll have in the months to come, but will try to squeeze something in.

Saturday, July 18, 2015

Late Night Thoughts on Pluto & Monrovia

I have been drinking a fair amount of alcohol tonight here in Monrovia, enjoying the company of some remarkable people at a dinner in the city center. We drove from there to our flat in Congo Town, about five miles away, where I sit and write this now.

The ride back along Tubman Boulevard was quiet as we listened to an extended BBC news report of the Pluto fly by of NASA's New Horizons spacecraft. I haven't actually seen many of the new pictures of Pluto given limited bandwidth here; mainly I check my email, and splurge on New York Times headlines every second or third day, but generally avoid the stories with high-resolution graphics as my internet access cuts out during the download.

Nevertheless, even listening to the radio program, it is hard not to feel a sense of wonderment at the magnificence of the event. This icy piece of rock, that circles the sun at an unimaginably long distance from our home, has become linked to us in a new and profound way; we are just a little more a part of a bigger and more amazing environment as a result of some electronic signals emanating from a piece of metal about to leave the Solar System. It is humbling. It is wonderful. It inspires awe.

Earlier today I stopped by the John F. Kennedy Hospital to check in on my resident. I didn't actually find him, but instead saw a 17 year-old who had been in terrible respiratory distress two days ago. She has an enlarged heart and had retained fluid around her lungs. I couldn't tell you the cause, though I have a few guesses--but without the resources to order the proper tests, they will remain only guesses. One of the residents--a true star, every bit as good and frankly better than many of even my high-quality residents back home--had taken the fluid off her lungs the previous two days, so that when I happened to wander in this afternoon, she had smiled for the first time I had seen her.

Her future remains tenuous, but for the moment, she thrives, and that has filled me with a certain hope, not merely for her, but somehow for Liberia, a country that has gone through much over the past year and yet moves ahead with hope and ambition. Along Tubman Boulevard, going from Congo Town to the JFK Hospital, there's a Coca-Cola billboard advertisement that wasn't there during the outbreak. It is simple. It merely shows a man, maybe my age, emerging from a car door, looking straight into the camera with a content appearance. "I'm confident of better days ahead," reads the caption.

I tend to brood, but perhaps tonight I am as well.


Friday, July 10, 2015


Thirty--that's the total number of Ebola cases in the three affected countries of Sierra Leone, Guinea, and Liberia, the latter country having been Ebola-free for months, with its first reported case on June 29th from some still entirely unknown means of transmission (the "dog hypothesis" I think is finally losing some steam since its remains tested negative, for which the dog population in Liberia is breathing one major sigh of relief).

Thirty cases--that's up from twenty last week. Hard to know, given an outbreak that is now longer than 18 months in duration, longer by far than anything previously known, whether that 20 to 30 is an uptick or just represents random statistical fluctuations at the end of the outbreak's tail. But given that the number has gone up and not down, and that we now have Liberia back in the mix (with cases not too far from where I sit typing this right now), it certainly isn't cause for celebration.

Thirty cases--a number of cases that hardly anyone except the hard-core international health junkies are paying much attention to these days. As this MSF doc laments, the news cycle moves on.

But thirty cases of Ebola is still an international emergency. Before January of 2014, the announcement of 30 cases of this disease would have dominated world headlines. This is especially true for a region the size of the current outbreak; thirty cases in a village would have gotten the world's attention only a few years ago. Now this news has to fight for coverage.

But make no mistake, as long as these cases simmer, it remains everyone's business.

Sunday, March 1, 2015

Ebola's Sword of Damocles

The mainstream American media loves a simple story, and with the West African Ebola outbreak--which is definitely not a simple story--the simple story goes like this:

Almost over!

Insert smiley face. This stands in marked contrast to the narrative from July through October, when everyone thought that Guinea, Sierra Leone, and especially Liberia might come apart at the seams. Now, however, there are confident pronouncements of Ebola's end. Ebola Treatment Units in Liberia sit almost completely vacant, and the number of cases even in Sierra Leone and Guinea is still dramatically lower than from the height of the epidemic, as can be seen here.

My quibble with such a feel-good pronouncement as I sit here in my final day in Monrovia before heading back to the States, leaving behind an unquestionably happier and healthier Liberia than the place I inhabited last October, comes from one fairly obtuse sentence in this week's WHO Situation Report. It almost sounds innocuous, a tumble of epidemiological words in the overview, a seemingly humdrum observation amidst the quiet huzzahs of fewer and fewer deaths.

This is from the first paragraph of the report, and I've emphasized the key phrases: "A total of 99 new confirmed cases of Ebola virus disease (EVD) were reported in the week to 22 February. Guinea reported 35 new confirmed cases. Cases continue to arise from unknown chains of transmission. Transmission remains widespread in Sierra Leone, with 63 new confirmed cases. A spike of 20 new confirmed cases in Bombali is linked to the previously reported cluster of cases in the Aberdeen fishing community of the capital, Freetown. There were 14 new confirmed cases in Freetown over the same period, with cases still arising from unknown chains of transmission in Freetown and elsewhere."

What that means is that, despite having an army of epidemiologists on the ground after several billion dollars of international aid has flooded the area to bring the outbreak under control, we still do not know where the virus is hiding in Sierra Leone and Guinea. This is now in marked contrast to Liberia, which not very long ago seemed the country in most dire circumstances; all current cases of Ebola in Liberia, which number only a few, have all had their chains of transmission identified. What that means is that for everyone who has developed infection, we know exactly where they got their infection from. This is not true for Sierra Leone, and it is not true for Guinea.

If you don't know the chains of transmission, then you can't do proper contact tracing. If you can't do proper contact tracing, you can't set up effective monitoring or quarantines. If you try to institute quarantines when you're shooting in the dark, you increase the chances (which are already significant) that all you're going to do is drive people who might be sick further underground, trying to outrun the quarantine and spreading the virus. This is at least partly the reason why we have seen the outbreak persist in Sierra Leone.

It's also worth noting that, while 99 new cases is a huge improvement over where we were at the height of the epidemic, by historical standards of Ebola outbreaks, 99 new cases in a week is a staggering number. The Kikwit outbreak of 1995, which lasted just under nine months and dominated news headlines for a time, had a total number of 315 cases.

I grant that the story has changed. My concern, however, is that the triumphant tone is premature. We still do not know where all of the cases are coming from. At this point, that is the news story, not the dramatic drop in cases. I find the phrase "unknown chains of transmission" almost as alarming as "Ebola outbreak" itself. We're not done just yet.


Wednesday, January 28, 2015

How Big a Deal is the Disneyland Measles Story?

In a word: big.

So far the Disneyland outbreak, as of the end of January, has tallied approximately 85 cases; about 50 of those cases have occurred in California residents. Of these, the California DPH knows the vaccination status of 34 of them. Overwhelmingly they are unvaccinated: 28 of the 34 received no vaccine, and a 29th only received one of the recommended two doses. It's generated a small amount of media splash, although the number of Americans who currently have opinions about the air pressure of footballs (including prominent physicists, for instance) vastly outnumber those who are aware of what took place at the Magic Kingdom. Many more people should know about it, however: in terms of health news, it's a big story.

But how to define "big"?

Before we get there, let's first understand some very basic facts about  measles. There are really only three concepts that are necessary to grasp measles in broad outline. First, it is incredibly contagious. Second, it is not particularly lethal. Third, there is a vaccine that is effective against it. (One should probably add a fourth: the vaccine is safe and does not cause autism.) From there, you can know what needs to be known about why this story is important.

How contagious is "incredibly contagious"? Simply put, it is either the most contagious virus known to man, or is among the top two. Epidemiologists use a variable known as R0 (pronounced "R nought") to describe a pathogen's transmissibility: the R0 tells you how many uninfected people a given person is likely to infect. Here is a graphic that compares some relative R0 values:

(Hang onto the bolded "Ebola" R0 value for a bit.)

It's important to understand that R0 is not a biologically fixed number: as the California measles data shows, the R0 for measles in unvaccinated people is much higher than it is for vaccinated people--especially since the total number of unvaccinated people at Disneyland was almost certainly much, much smaller than the total number of vaccinated people so the per capita infection rate of people who didn't have a Measles vaccination was much much higher. Measles, along with pertussis, are almost certainly the undisputed champs of microbes that cause human disease, with R0 values that range between 12 and 18. (Likewise, the R0 of Ebola has changed over the course of the epidemic, since people in West Africa changed their behaviors between June and October, dramatically decreasing the spread of the disease.)

So it's contagious--very contagious--yet it isn't especially deadly. About one or two children out of every 1000 who get measles will die. That's a small number, but isn't so small that it should simply be dismissed as a trivial threat. (Plus, some measles outbreaks have been significantly more deadly over history. Moreover, there are many more people living with compromised immune systems than ever before not only due to AIDS but also to the explosion of transplant medicine, and such patients are almost certainly at higher risk of complications from measles.)

But when you take a fairly small risk and combine it with a high transmission rate, you suddenly see large effects in aggregate. At the end of the last century, the World Health Organization surveyed measles mortality and didn't like what it saw: there were still nearly three quarters of a million people who died from measles in 2000 alone; it led to a massive worldwide vaccination campaign, such that the total mortality in 2013 was under 150,000 and the estimated number of lives saved over that time period is estimated at more than 15 million.

Which underscores, in very stark light, the third point, which is that the measles vaccine is safe and effective. A back-of-napkin calculation shows us what would happen in in the US if we took after places like rural Africa and Asia in the 1990s prior to the vaccination campaign (the 1990s being the time when anti-vaccination really began to gain traction in the West). If we could magically "de-vaccinate" every child in the US, and spread measles like wildfire--which, as noted, isn't that hard--here is what we would see: there are about 60 million kids under age 18, but let's be conservative and take the 40 million kids at greatest risk of measles and their complications, those under age 10. Measles has about a 90 percent infection rate, which means that it would be hard to avoid crossing its path. An absolute upper limit, then, would be 36 million infections, but again let's play this very conservatively and assume only half get infected. That's 20 million infections. If we take the more optimistic fatality rate of 0.1 rather than 0.2 percent, that would lead to a crisp two hundred thousand deaths. Based on the most recent available data, the actual number of deaths that occur in this age range is about six thousand.

So: measles is transmissible, it is deadly in populations even if not exceptionally dangerous to an individual, and people can dramatically reduce their risk of getting it by getting vaccinated (and, unfortunately, not going to Disneyland right now).

Another way to define the bigness of a story is to compare it to other stories. And there has been another virus that's been in the news of late. If you were unaware, there's an Ebola outbreak going on in West Africa. Ebola is, for the purposes of this discussion, a very convenient mirror image of measles: it is not especially transmissible, but it is very deadly (how deadly in the US, where there is better health care, is not fully clear). The R0 value of Ebola is generally estimated to be about two. When one thinks of Thomas Eric Duncan, the Liberian man who was infected there but developed disease in Dallas and ultimately died at Dallas Presbyterian Hospital, one sees a perfect display of this. Recall that Duncan was initially turned away from Presby and returned to his apartment, living in close quarters with his partner and five children, until he returned and was appropriately quarantined. During this time he not only exposed his family, he exposed people in the emergency room twice, he exposed laboratory personnel who didn't realize they were handling a lethal virus, and he exposed doctors and nurses. Then he exposed even more health care workers after he was correctly diagnosed. And the number of people he infected in the Dallas area after all of that was...two. Exactly the correct value, and a demonstration that it's hard to catch Ebola! (I would know!)

But when we compare the relative splash of the Disneyland story to Ebola, it's clear that there's a hugely misplaced anxiety in one area, and not quite enough understanding of how serious a story it is in another. Tallying Google searches is hardly precise science, but it does give some sort of general indicator of the level of buzz about a given topic. Obviously, Ebola is a really important story, so one can't just compare the total number of hits that a search for "Ebola" generates (~220 million) to that for the Disneyland story (~5 million). On the other hand, some searches show a much greater preoccupation with what are, in fact, minor threats to the public:

"Ebola doctor New York"--30.5 million hits
"measles"--23.4 million
"Ebola Dallas"--17.5 million
"measles Disneyland"--4.8 million
"Ebola subway New York"--3.6 million*
"risk of zombie attack"--600,000

What to take away from this? The overall Ebola story is big news, but millions of Americans are aware that Craig Spencer, the MSF physician who developed disease in New York City, took the subway and went bowling before becoming ill. In terms of risk, his subway travel and bowling adventures constituted as much a threat to the population of New York City as a zombie attack, yet this became a major source of Talmudic discussion among the chattering classes who seemed not to be aware that Spencer played everything by the book (which led to nobody being infected). The Google search on this non-story yielded only a little less than the number of hits of the Disneyland measles story.

The comparison is far from perfect, but it does I think broadly indicate the relative indifference the public has toward measles. The silver lining is that such ennui may be because most people really do have faith in vaccination and simply regard themselves as immune because of it (which is mostly true). On the other hand, this outbreak serves as an important moment to underscore what this virus is capable of doing, and just how big a lifesaver the measles vaccine really is. I don't think enough people are getting the message.


(*Searching using the Boolean operators "Ebola AND subway AND New York" yields a slightly more modest 2.7 million hits. It doesn't change the Disneyland number at all.)

Friday, October 17, 2014

Why I Go, uncut

It's been a rather big day here in Billy Rubinland, where against all odds there appeared this op-ed in the Paper of Record about my reasons for wanting to be in Liberia (where, as I type this, I am right now).

Needless to say, it has been a bit of a weird day.

At the risk of boring everyone to tears, I present the uncut version, which I knew was never going to make it into the Times based on length. But if you are interested in going into some greater depth, feel free to read on. Apologies for the redundant parts; they made very few changes from my original chopped version. But I did want some readers to know about Phil Ireland, and to remind everyone again about Sean Collier.

Why I Go

In nearly every medical school applicant interview, candidates are asked why they want to pursue medicine as a career. Invariably, the answer takes some form of a simple idea: I want to help other people. It is almost impossible to make this answer sound new or genuine or creative, and yet for most applicants it is an honest response. 

I’ve been thinking about this of late because, years after I had to answer that question, I’m being asked a similar kind of question from colleagues and friends. You see, I am going to be headed to Liberia shortly to participate in the efforts to control the Ebola outbreak, and—in addition to being asked whether or not I am insane—people want to know why I would willingly seek out such an assignment.

It is a legitimate question. Although I think many Americans have magnified the danger that a person like me faces heading into the current chaos of West Africa, it is nonetheless a risky thing to do, and there is the real possibility that something terrible will befall me while I am deployed. Becoming infected with Ebola is only one of a laundry list of hazards I will face. It is the rainy season in Liberia, which means that I am at risk of catching malaria (even though there are pills that can help prevent it, but it’s not 100 percent protective); I could acquire Typhoid fever, a common problem in sub-Saharan Africa; and there are a host of other infections, less well known but also capable of causing serious illness or even death, such as dengue and Lassa fever. 

But all of these hazards, even including Ebola, are a secondary concern to my primary fear, which is that of violence. As I type this, the media reports coming out of the region are abuzz with the news that eight health care workers trying to aid in Ebola education in a rural village in Guinea were murdered by locals and had their bodies hidden away. One cannot know precisely what was going through the minds of the locals as they committed this atrocity, but I am reasonably sure it was a mix of terror, rage, and helplessness that fueled the violence. Especially in the epicenter of the outbreak where the three most hard-hit countries of Guinea, Liberia, and Sierra Leone all border one another, whole communities are being decimated, and they do not trust anyone, to the point that they will act in ways that make matters only worse as they did in Nzedekore. There’s at least a 19th-century romantic gloriousness at the prospect of catching Ebola as an image of personal sacrifice, but there’s nothing appealing about having one’s body stuffed into a septic tank. I would really, really prefer that not happen to me.

So why do such a rash thing?

In trying to answer this question, a part of me wants to speak for all of the doctors and nurses and water sanitation engineers and all the other consultants who have been scrambling to get ourselves over there. So part of “why I go” is “why we go.” I cannot pretend to speak for everyone, but I am confident that it is this fundamental desire to alleviate human suffering that is driving us toward the Hot Zone. Many of the people on the ground or headed there soon are specialists in disaster relief: they are so committed to aiding people in the most dire circumstances that they have centered their careers around providing services in the most chaotic situations imaginable. They are experts at this sort of thing, and they endure great hardship to bring stability to these kinds of places, so that the people there can have something resembling a life that those of us in more comfortable circumstances would recognize: a chance to live, love and thrive in a reasonably safe environment. We go because we consider that a sacred obligation.

But I am not the kind of professional who made disaster relief my career path, and so while the suffering seen in, for instance, Iraq and Syria right now are no less troubling to me, I never thought to volunteer to go there, or any other number of places where human suffering can’t be quantified. But this outbreak, and the location of this outbreak, has a special resonance for me, and hopefully I can bring some particular skills to the situation.

I am an infectious disease physician. Our subspecialty is an odd lot, not generally highly pursued by ambitious internal medicine residents, who prefer the more lucrative and procedure-oriented specialties of cardiology, gastroenterology, or critical care. Many of those who join the ranks of infectious disease do so for the reason that I did, which is a passion for epidemics, and the awareness of the impact of human behavior and development on disease. Until we had adequate treatment for it, HIV was a disease that proved deadly not only because of the molecular mechanisms by which it chipped away at the immune system, but also because it was transmitted through sex, about which humans have both intense desire as well as deep ambivalence, and which led to policies and attitudes that only made the epidemic worse. 

An infectious disease doctor thinks about what occupations and exposures might cause a disease: where you’ve traveled, what kind of pets you have, what you just ate for lunch. Knowing the details of a disease’s “pathophysiology,” to use a fancy medical word, is only part of what makes infectologists good at their jobs: we simply have a habit of thinking about other factors that impact disease that other professions are less concerned with. I find that intellectual process continually fascinating, and is why I knew I wanted to pursue this specialty from my early days in medical school.

In particular, many infectious disease doctors are driven toward international health, and in particular settings where resources are most limited. Even before Ebola came, West Africa was a place where infections were still the leading cause of mortality, much like it was in the US and Europe 100 years ago. Global health groups often refer to the “big three” diseases that constitute the major causes of suffering: HIV, malaria, and tuberculosis. But that is only the beginning in West Africa. There is Yellow Fever, pneumococcal disease, meningitis, rickettsial infection, streptococcus, and a host of other maladies that can shorten lives and bring general misery to a place. 

Trying to provide long-term solutions to such places is why I became passionate about infectious disease. I read Laurie Garret’s book The Coming Plague (an exhaustive and thoroughly well-researched account of the many infections that threaten our lives) prior to medical school almost 20 years ago, and it changed my life. I agreed with her premise that the rapid technological changes to our world may create a host of unintended consequences that viruses and bacteria will be only too happy to exploit for their own purposes.

And this Ebola outbreak is the infection of my professional lifetime, as seminal an event as AIDS was in the 1980s when nobody knew how far the epidemic would spread or when there would be treatment and how effective it would be. This is as big an event as the Spanish Flu of 1918, which killed perhaps one percent of the entire world’s population in less than a year. And the particular dimensions of this outbreak—its ability to unleash paranoia and cause huge economic disruption on a regional scale—haven’t really been seen since 1665, the time of the last great episode of Plague in London. As an international calamity, the last episode of what we may be witnessing now happened in 1348, when the Black Death killed off about a third of Europe’s population and destabilized the entire structure of medieval European life.

As someone who chose this particular profession for the reasons why I did, how could I not want to help out? Why do the police put their lives on the line on a daily basis? To preserve order. Why do our soldiers don their gear and deploy all over the world, never questioning their orders even when they have personal reservations about their mission? To defend their country. Why do firefighters run headlong to the fire? To put it out, of course. Ebola is not really different, and it is my fire; along with many other colleagues, I go to put it out.

The vast majority of people who pursue these callings do not make the ultimate sacrifice, but they are willing to do so because they believe in something higher than their own lives. As I prepare for my deployment, I have been thinking a lot about Sean Collier, the young officer who served as cop at MIT as he began a career in law enforcement. Sean got a bullet through his heart because a few assholes thought they were making some kind of profound political statement by maiming a bunch of people with a bomb at the finish line of the Boston Marathon. His plans were to transition from his work at MIT to become an officer in a suburban town where he grew up north of Boston. Surely he must have thought that the most dicey moments of his work at MIT would consist of busting up a few frat parties or perhaps handling some rowdy people at a student protest. Yet he wore the uniform, prepared at least in theory to face more serious threats, and then the moment was upon him. His life—and more to the point, his death—serves as a reminder of the meaning of service. I go with a different agenda, but have similar notions.

I go also for more personal reasons. I am a medical educator: my professional joy is not only to care for my patients, but also to train the next generation of physicians. I love to teach and somebody pays me for it, and for that reason I ended up in Monrovia last year to help kick-start a residency program in Internal Medicine for the Liberian Ministry of Health. I was mainly based at John F. Kennedy Hospital, and gave lectures to a core of seven medicine residents, the first class of advanced trainees as Liberia tried to rebuild its medical infrastructure. I came to know these trainees and thought of them no differently than I think of my own residents where I work. 

Among those residents was a young man named Phil Ireland. He was the kind of resident that any faculty member would instantly recognize as a leader: he had a hunger to know more, a drive to take care of his patients, and a charming and warm personal manner. I was excited to see what would come of his career, and before I left Monrovia I asked him to think about whether or not he would consider coming to the US for further training, as Liberia would be able to benefit from his knowledge in the years to come upon his return. 

Then Ebola came, and Phil became infected in the course of his duties. The only good news about this is that Phil survived, although I do not know his condition as I write this. Surviving Ebola is not a matter of going back to work in a week, as survivors cope with a variety of ailments, some of which are quite debilitating. Moreover, they must cope with the psychological trauma of survivor’s guilt, and the post-traumatic stress of having lived through the nightmarish conditions they must have seen and experienced during the illness. I go with the hope that I will see Phil in Monrovia, as well as his classmates, and be able to resume my duties as their teacher. I have an obligation to them.

Finally, I go to honor the work of a colleague who was not as fortunate as Phil. My host in Liberia was the Chief of Internal Medicine at JFK Hospital, a man named Abraham Borbor. I liked him from the moment I met him. He was kind and intelligent and compassionate, and clearly had inspired fierce loyalty among his staff. But what drew me most to him was his sense of humor. We spent hours in conversation about the myriad challenges of living in a place like Liberia and the sorrows that his people have had to endure, and yet despite chewing on such weighty and depressing matters, he still was able to be amused at the world around him. He could joke about the fickleness of American and Liberian politicians as much as he found the idea of pouring some warm coke into his glass of warm beer a source of great amusement—“well, going the same place anyway,” he observed. He had a rich cackling laugh that had the effect of making you laugh along with him—a contagion of a different sort than what has befallen West Africa of late. 

Now, because of Ebola, the world will not hear that laugh again.

When Abraham Borbor saw this plague upon him, he did not flinch and he did not run. He did what he has always done, which is take care of patients. Putting himself in danger to do his job was not new to him. Liberia experienced a brutal civil war during the most productive years of his career. Nobody would have harshly judged his decision to flee the country with his skill set. He had done some training in Britain, and he could probably have managed to find a way to stay there and finish out his career. 

But he returned to JFK and, along with a handful of nurses, basically was the medical staff for years in Monrovia. He had few or no supplies, limited electricity if any, and the specter of real violence at his doorstep every day. Basically he had his wits, and what must have been a fierce determination to man his post. This was his life for years on end. The Liberia that I visited in 2013 must have seemed like a Garden of Eden compared to that. As he neared the end of his professional work, there must have been some satisfaction in that, along with the knowledge that he saw it through. 

Then Ebola came, and he met his end, along with his colleague Doctor Samuel Brisbane, who formed the internal medicine senior faculty at JFK. Not only has their loss been devastating to Liberian medicine in the present, as there are fewer doctors to direct medical care, but it will ripple into the future through the loss of their years of wisdom as a new generation of doctors and nurses learn medicine. There is a crisis upon us now, but after the storm, education will need to resume. I went there as an educator and was treated with kindness and deference. Now, especially with Borbor gone, I go to honor that commitment that he made to his profession and to the next generation. He took me into his world and placed a small part of Liberia in me; how could I not go after the disease felled him?

We live in a cynical age, where a term like brotherhood can only be uttered sardonically, tossed out as part of a joke making fun of Victorian idealism. But Dr. Borbor became—at least in some meaningful although small way—my brother when I went over there. I go because I owe him something.
In addition to thinking about the sacrifice of Sean Collier as I prepare to leave, I’ve also spent a lot of time calling up Beethoven’s Ninth Symphony in my mind. I am not the first to observe what a remarkable piece of music it is. But it is the lyrics that keep running through my head, for Beethoven set his music to a poem, the Ode to Joy, about brotherhood—pure, unadulterated and unironic. We have enshrined the Ode to Joy around the world: we play it as part of opening Olympic ceremonies, we sing it on New Year’s Eve, we listen to it in Symphony halls across the country on a perpetual basis.

Is the Ode to Joy just pretty music, or do we heed its message of a universal brotherhood? Do we find it a useful concept when all is going well but abandon it when chaos descends? Do we in the academic world, who hold graduation ceremonies bathed in lofty rhetoric, and allude to cultural touchstones like Beethoven’s Ninth as being the pinnacle of civilized achievement, really believe in the principles these words would imply? Or is it just cultural window-dressing, used for a carefully arranged photo op for the school’s website?

I go because I do believe in these words. I go because if I do not, after where I have been and the people I have met, those words would mean very little. I would very much prefer to return whole, but if I do not, it will be because I could not see any other way forward.


Tuesday, September 16, 2014

Obama's Response To Ebola Is Right

Front-page news: Obama is sending the US Military to West Africa to help "combat" the Ebola outbreak. 3000 troops & some other stuff is the gist.

He's right.

"This epidemic is going to get worse before it gets better," he said in a press conference at the CDC.

He's right. Only a month ago the World Health Organization was talking about 20,000 cases, and I went on record saying that was an underestimate by an order of magnitude. (Sort of, since in that article I was anonymous. I made my official stand here.) With each passing day, the WHO estimate seems like a best-case scenario that is increasingly unlikely to play out, and bigger numbers--much bigger numbers--are starting to be bandied about.

"We must take the dangerous, deadly threat of Ebola as seriously as we take ISIS," said Senator Lamar Alexander of Tennessee.

He's only half-right. ISIS is repugnant, but at worst will only cause some minor mayhem to Americans or other foreigners traveling in that part of the Mideast. They're unlikely to do real damage to the US. Ebola, by contrast, has the potential to bring world travel to a halt. That's rather worse.

The involvement of the US Military “could change the trajectory of the spread of the disease — if that response is fast,” said Steven Radelet, a "former development expert at both the Treasury and State Departments in the Clinton and Obama administrations who now advises the Liberian government on economic matters" according to the NY Times.

He's definitely right.

The question is: why the Army?

The key is this: we think of the Armed Forces of the US as being a monster with a lot of guns. That characterization is true, but it's not the whole story of what they do, either. What they also do--and they do better than any organization on earth--is figure out logistics and mobilization at short notice. Need to send 500,000 people somewhere in 3 months? Okay, fine. Where will you put them? How will you feed them? How will you set up fresh and clean water? Make sure waste is removed without turning a living site into a cesspool? Get electricity and telecommunications to a remote, off-the-grid location? Done. Anything else you need?

Nobody can do this like the US Military. A few others can come close: the Brits, the Germans, the French. I suppose the Russians could. The Chinese almost certainly could. More on them in a moment. But no matter what way you cut it, military organizations think about these kinds of issues all the time.

And what's needed right now is this kind of logistical expertise, especially in the chaos of West Africa. You want these aid organizations to send hundreds, maybe thousands of volunteers to help contain this epidemic? Okay, how are you going to build the facilities to care for the patients? Where will you house the volunteers? Who will clean their laundry without infecting them? How will they get in and out of the Hot Zone? How will you establish command and control? How will you organize your supply chain? And on and on.

The US Military is uniquely qualified to tackle this problem. Without them, the day may well be lost; with them, the tide may turn, although even then, some of the worst scenarios make me shudder.

The Ebola crisis is a national security threat, make no mistake. There is a good deal of ranting on right-wing websites carping about how 200,000 people from Ebola-stricken countries have visas to enter the US. Not surprisingly, it's the wrong preoccupation with the wrong aspect of this calamity. Those 200,000 people won't all get on a plane and come straight to the US, as those stories darkly (if only subconsciously) imply. Indeed, it's become almost impossible to leave Liberia right now by air as commercial carriers have stopped their routes and all but isolated the country.

But all it takes is a few infected people to get to Nigeria, the regional travel hub of Africa, and then the decision tree gets much more difficult. People from Nigeria go everywhere. Will we simply impose a travel ban on everyone from Africa? What would happen if we do, and Ebola travels to Europe or East Asia anyway? Then what would we do? Shutting down Transatlantic or Transpacific travel would cripple the world economy, and could lead to problems just as dire as the prospect of spreading infection itself. 

This is why a group like the US Military is needed. Whether or not they are the only solution is not yet clear. But it's not an overstatement to suggest they might be saving the world by ramping up in the region, which is not at all what their presence will do in Iraq.

As to the Chinese or the Russians being involved in the solution, perhaps they will soon come to recognize the threat of this problem. In the meantime, it is the US government that has drawn a line in the sand and committed itself in the name of world security. That is leadership, and why I am proud to be an American today.