Saturday, April 22, 2017

Why It's Not OK for Docs to Participate in Executions

Sandeep Jauhar's op-ed in the New York Times today poses precisely the opposite formulation, theoretically offering his musing on ethics as the State of Arkansas rushes to execute as many death-row inmates as possible prior to having their stockpiles of lethal injection drugs expire, for which there have been a flurry of legal challenges, although they have succeeded with one thus far. Given the topicality, Jauhar decided to wedge in some thoughts about how this policy interfaces with the practice of medicine, deciding in the end that it's copacetic.

It isn't, and from the moment the article appeared, a whole lotta people--including a whole lotta doctors--pointed this out, noting the intellectual contortions required to suppose that setting up the killing of an otherwise healthy human being doesn't violate the dictum, "do no harm." (Often dressed up in the fancier Latin phrase primum non nocere, the injunction against doing harm is taught to precisely every medical student, everywhere, on day #1 of school.) Jauhar's main argument revolves around the idea that only physicians have the required expertise to mix a batch of lethal drugs correctly, and therefore they are, in fact, relieving the patient's suffering. It is hard to write this with a straight face.

When I woke up at six and happened upon the article, there were perhaps a dozen replies; within an hour, there were two hundred. As of now, there are more than 500 comments. Most aren't impressed: the vast majority were outraged, and those that defended Jauhar often missed the point as they seemed to think the debate was about the death penalty itself, not the medical ethics of doctors participating in the process.

"As a correctional physician, it is chilling to wake to this. From his tone, it is doubtful to me that he has entered a correctional facility," wrote Matt from Boston in a comment. "The Times' decision to publish this comes as a shock. I entreat the author to refrain from more writing on the topic until he spends time in the correctional setting, meets our patients, and educates himself further on the ethical grounding of medical-correctional standards." Boom.

I had once thought myself a fan of Jauhar as I like to root for physicians who write for the public and help unravel medical complexities, but I'm less enthusiastic than I used to be, that's for sure. A few years ago, he had used similarly questionable logic while he advocated for the return of the old model of Doctor Knows Best, which led me to harrumph about it at the time. I haven't read his writing systematically or exhaustively, and now I'm beginning to worry what I might find if I do.

--Billy

Monday, January 30, 2017

Quick Take on Trump Ban, MD Training Edition

I receive daily updates from a discussion board for faculty members involved in residency programs that train internal medicine physicians. Usually it's a sedate series of discussions about how best to achieve throughput from the ER to the floors, or how best to schedule swing shifts in the ICUs, and so on. There's usually two or three such posts each day, and mostly I flick through them just to see the kinds of technical matters that affect residency training.


Today, however, only 48 hours after Donald Trump's travel ban on people from Syria, Sudan, Libya, Somalia, Yemen, Iraq, and Iran, there is practically an explosion of posts about what this means for programs across the country and their International Medical Graduates (or "IMGs"). And there's a fair amount of hand-wringing about what comes next. "All of our alarm bells should be going off," wrote one physician--and it's worth noting that in physicianspeak this comment is the rhetorical equivalent of going bonkers, for while I may tend toward hyperbole in political analysis, my colleagues on the whole do not. Trump's order, along with a host of other actions he has taken in his first week in office, is changing this to a degree heretofore unprecedented for this generally nonpartisan, apolitical profession.


The cause of the alarm is that a lot of resident trainees are going to be affected by this--see here for what may be the first of many examples of much-beloved doctors in the middle of training being put on a plane and sent packing without any warning whatsoever. This not only affects the residents, but will probably include a fair number of licensed physicians currently in practice, as visa waivers are granted to physicians from abroad who are willing to work in underserved areas--including many areas of the rural Midwest, ie the kinds of places that have embraced Trump and may soon feel the impact of this policy. In my home of internal medicine, there are about 7000 positions filled each year, of which half are filled by visa-holding immigrant physicians. Of course, only a small portion come from these seven nations, although I have known many a Syrian and Iranian physician in my time.


But the ban's impact is going to affect much more than the physicians coming just from these countries for training. Any Muslim physician, particularly those from majority Muslim countries, would be wise to consider whether their country will soon be on this list as well. And this order comes just as residency programs across the United States sit down and decide whom to rank for offers of residency training--not just internal medicine programs, but all of them. There are about 28,000 first-year spots open, of which nearly a quarter are filled by IMGs. Again, the ban won't affect all IMG physicians, but a substantial majority of programs devoted to primary care--internal medicine, pediatrics, family medicine, as well as psychiatry--are going to have to decide whether they want to roll the dice on highly-qualified Muslim applicants they may ultimately never be able to train, or take less promising applicants from elsewhere, or simply not fill the positions--which increases the work burden for trainees and faculty alike.


Since we aren't by any means experts on the subject, physicians shouldn't be in the business of wading into policies about immigration, but the thoughtlessness that has thus far characterized the first eight days of the Trump administration has forced this on the profession. We not only have only the faintest notion of what consequences this single action will bring, and there is no reason to suspect that we aren't in store for more policies with even greater impacts. In one week, Trump has shown himself to be utterly incapable of governing in a way that does nothing but wreak havoc, and one doesn't need to be a policy expert to see this. Nevertheless, the vast majority of Republican politicians and Washington insiders, who are the only people who have any shot at restraining this man, have been feckless enablers even as they must surely know deep down that if he is not stopped, genuine ruin awaits.


--Billy

Saturday, January 21, 2017

Inauguration Special: Flags & Hypocrisy

This weekend in Billy Rubinland we observe the passing of the torch from one president to another with the same level of dread that tens of millions are experiencing, and as such there isn't much to say, for certainly the words of the new President himself could not be a clearer elucidation of a philosophy of mendacity and unscrupulousness that Donald Trump has not in any way concealed since the very first moment he descended the escalator from his office tower to announce his intentions to supersize his medium-level business practice, which has always sordidly combined corruption and legal intimidation, into levels not previously witnessed in the American political landscape. His candidacy was a long shot, one that involved playing to the basest and most disgusting of the American--that is to say, the white American--id as part of a campaign to satiate an ego that can brook no criticism, and whose philosophy was really only that of self-adulation and worship of the little people because, well...him. He didn't adopt the Republican talking points of the past generation so much as exposed them for the galling hypocrisies that they were, channeling the white rage that Nixon kindled with his "Southern strategy" and Lee Atwater torched with Willie Horton and Rupert Murdoch poured gasoline on with Bill O'Reilly and Sean Hannity, dispensing with the code language that allowed so-called "conservative" politicians to maintain with a straight face that their unhinged hatred of a very mild-mannered, compromise-oriented centrist in Barack Obama was really all about ideology and had nothing, nothing whatsoever to do with race. After the 2016 presidential campaign, anyone who voted for such a scalawag was either an unapologetically virulent racist, a totally uninformed voter who did not bother to listen to his message, or was in absolute denial that somehow this man rejected the putative values of what heretofore had been the official ideology of the Republican party. To those who can't see the man for what he really is, there's not much point in having a discussion.

As I said, there isn't much to say. Basically, I would say this, if I could.

Instead, as we prepare for the Trump administration coming to power and the high likelihood that it will deliver justice on the national and international stage in a thoroughly arbitrary matter, I only wish to talk, ever so briefly, about one small piece of the vast edifice of hatred and hypocrisy that defines at least some of his supporters, and has been validated by the results of the election: the subject of free speech, treason, and the meaning of national flags.

Unsurprisingly, the US flag has become an object of scorn not only outside the United States, but from within as well. (Anyone from beyond the borders who didn't have a favorable opinion of the US prior to today's inaugural address just got a fresh & tasty justification that they were right to hold such views based on words issuing directly from the mouth of the new President himself.) Note here, for instance: US protesters engaged in the burning of the American flag in one of many demonstrations across the country. There were tens of thousands of people expressing their opinions in such marches without resorting to burning the flag, but the right-wing organs of media, along with Trump himself in the run up to the inauguration, immediately turned the actions of perhaps twelve justifiably angry people exercising their right to free speech into a matter of grave importance worthy of ignoring the unprecedented ethical conflicts of interest that--far from draining it--are about to make Washington DC a swamp that will be the envy of third-world tinpot dictators. After all, when uninformed billionaires who think poor people got that way because they are stupid and lazy are handed the keys to government power by a political movement that somehow thought it was--one tries in desperation to stifle a laugh--sticking it to elites....then it's of much, much greater importance to decide whether we should incarcerate some pissed-off millennial for years on the charge that he's somehow damaged the integrity of the country by setting flame to one US Flag.

It's one in a series of Three-card Monte games that will continue for the next four years--or, quite possibly as a result of some truly outrageous voter suppression shenanigans to which Jeff Sessions will minister, much longer. Today, marchers are marching as part of what is thus far not fully coordinated resistance to the Trump administration, and I am with them in spirit, but frankly I'm too depressed to head to the streets. If we live in a democracy that chooses a man such as Donald Trump to run our Government, then there's something very wrong with our democracy, and I'm not sure if marches or voting registration drives or legal filings by smart lawyers who actually fight for the small guys against the real elites will make any difference.

I know this is a hopeless and not especially helpful view of the matter. I would have been appalled by the presidency of a Ted Cruz or a Marco Rubio, and I would have at least have grumbled in disgust at the presidency of a Jeb Bush or a John Kasich or a Rick Perry, but I could at least feel like the combination of venality and shortsightedness was what I was used to. Trump, however, is in a class all by himself. He combines the bullying instincts of Chris Christie, the vengefulness of Rudy Giuliani, and the cluelessness of Ben Carson into one perfect package of American ignoramical anger. What makes him so unlike the other sixteen men who vied for the Republican nomination is that he never tried to hide it; even Christie, who at the start of 2016 I considered the most dangerous candidate, mouthed various pieties on the campaign trail about the value of democracy, and tried to distance himself from the most overtly racist rhetoric of the right-wing rallies. Trump by contrast brought the most deplorable elements--yes, Hillary Clinton was one hundred percent correct when she used the term--front and center into his traveling show of hate and resentment, shocking the Republican establishment which thought that you could only win if you used racism via the means of code words.

Now there's no more code words, and a monster sits in the White House, surrounding himself with people who on the whole are to the "establishment" what street thugs are to poor neighborhoods, with what seems to be only one well-informed and intelligent cabinet member not in possession of reams of conflicts of interest, and he happens to go by the nickname of "Mad Dog." Which is to say, not encouraging. If 60 million people can be presented this kind of a man and want to support him, we're no better off than Berlin was in 1933.

So I'm not going to try to engage in some sort of earnest appeal to anyone about which of the dozens of fubar elements of the Donald Trump presidency are worthy of shock and outrage, as there's not much point. The one quality I find so fresh and appealing about him is that one can't hide behind the veil of being uninformed when opting to support him. He doesn't trouble himself with the details of policy, and doesn't think you should bother, either. His brand, which he made exceedingly clear in his inaugural address, is hate, and you don't need a PhD in government studies or be familiar with the company Blackwater or understand the importance of the Iran-Contra affair or remember who Spiro Agnew was to know what Trump is about. Which is precisely why I see no point in any dialogue with any of his supporters.

But I am perfectly fine, on this first day of the new administration, to point out the standard asymmetric commentary--which is to say, frank hypocrisy--that's been part of the right-wing playbook for the last 40 years on one small matter. The flag-burning issue is, on the one hand, tedious: it forces centrists and liberals into legally defending an action that is, at the very least, aesthetically unpleasant, turning the dialogue into how to keep the mob quiet. (Not, of course, that the right-wing mob has a corner on the market: For left-wing hypocrisies, see "defending the good work that most cops do" or "supporting Israel's right to self-determination" during discussions about either systemic police violence against African-Americans or the Israeli-Palestinian conflict. But the left-wing mob isn't bankrolled by billions of dollars of organized Pravda-like media whipping them up into an ignorant frenzy on a daily basis.)

Anyway, it's a classic dumb issue intended to distract attention from the true outrages, but regardless it's still rank hypocrisy, for the free speech that Trump and his merry band of Republican lawmakers are prepared to punish in the most severe terms possible--treason is a crime that can carry the penalty of death, of course**--they're perfectly happy to endorse in the form of the waving of the Confederate flag. Since we have become so culturally inured to seeing the rebel flag, it's worth noting that this represents a political entity that was a mortal enemy of the United States of America. Our country has gone to war with many nations, demanding surrender of some of them, signing peace treaties with others. But the United States of America dissolved the Confederate States as an enemy nation, and while there has never been a federal law banning its display or use, it's clear that one who finds the burning of the US flag a crime should be moved in equal measure to criminalize the display of an enemy nation as part of political speech.

Personally I don't care about flag burning, but I'd be perfectly happy if we were willing to categorize traitors consistently across the board. Will our prisons be enough to hold so many? Of course, the penalty for treason includes death, so perhaps we can move things along at a quick clip.

--Billy

(**Not long after the election, I had a long and unpleasant exchange with an acquaintance on Facebook, someone with whom I went to high school and an ardent Trump supporter, about the penalty for treason, since she had joined the chorus that Trump started by posting something vapid about punishing flag-burners. It became a painfully drawn-out conversation because I merely wished for her to acknowledge the simple fact that she was stating her belief that one of her fellow Americans should be shot to death because they burned a flag in a protest. Faced with the unassailable conclusion of her belief, she eventually agreed, at which point I was called an asshole.)

Sunday, October 30, 2016

Billy Rubin Storage Vault: 1995 Edition, Cleveland Indians Chief Wahoo Special

Long before blogging came along, I was busy tilting at windmills by shooting off essays to various periodicals, if I can mix my metaphors there. Either way, they never got published, but I did get a certain satisfaction in trying to craft an argument carefully, which is pretty much what I use this blog for.

My proto-blogging has been on my mind of late as I watch the Cleveland Indians on the cusp of finally winning a World Series. Apologies, Cubs fans, I know you've waited longer. I became an Indians fan as a kid growing up in Ohio in the 70s, when they were a perennially terrible team in the midst of a three-decade slump (affectionately known by fans wanting to imitate a Red Sox tradition by referring to it as the "Curse of Rocky Colavito" even though such a wildly overblown comparison to Babe Ruth's departure from Boston only underscored the hopelessness of being an Indians fan in those days). Anyway, they got better--a lot better--in the mid-1990s, and finally got a crack at winning a World Series, but lost to a great Braves team in 1995. (They lost again, to the Marlins, in 1997, but that tragedy is a story for another day.)

The following is a letter I sent to the editor of the Cleveland Plain Dealer that year, taking a look at the team name and its logo. Given the current political climate, it seemed appropriate to dust off a piece I wrote half a lifetime ago, and as I look at it for the first time in decades, I think that young Billy and old Billy aren't so different, as it is largely the same argument I would make today. Thus, I give you thoughts on racism and Chief Wahoo. I made only one small edit; my language was a little more charged back in the day and I've elided some racial examples that strike me now as in very poor taste. Otherwise, it's a voice from the past.

One small point of explanation: the greed of the players and owners mentioned below is in reference to the baseball strike of 1994 and 1995, which led for the first cancellation of a World Series since 1904 and significantly depressed fan interest when the playing resumed.


Cleveland Plain Dealer
July 10, 1995

To the Editor,
As I near the end of my 25th year of life here in Boston, I find that I may have, perhaps, a surprising birthday present in store for me on September 10. My Cleveland Indians, whom I followed religiously throughout my youth in Mansfield, Ohio (and in my college years and beyond here in Boston), are currently not only in first place in their division, are not only first in the American League, but are the best team in baseball by five or so games. It seems plausible, from the vantage of the all-star break, that by the time I turn 26 they will be well on their way to their first pennant in a very long time. I’m told it last happened somewhere in the mid-fifties, but I’ve never been too concerned about the specific year, since the general drift for me as a fan is that they’ve never come close in my lifetime. Unless they choke only in as grand a manner as the baseball team that plays where I now reside, the Indians are assured of the playoffs, and are the favorite to take the Series.
The success of the Tribe this particular year is at once unfortunate and appropriate. Major League Baseball has insisted on demonstrating what fans have been trying heroically to ignore over the past ten years: that the players and owners alike are selfish, venal, and shortsighted. Finally, the fans, having gotten the message, have given up on the game. Overall attendance is down 20 percent, and except for the first-place teams, the fans do not appear to be returning anytime soon. How apropos that Cleveland, whose burning river became a symbol for the myopic greed of Big Industry and earned it a reputation as the national laughingstock, is in this year baseball’s glory team.
The metaphor of Cleveland’s success (an ugly city winning in an ugly year) brings to my mind, as a lifelong fan of the Indians, another, less talked about wart on the face of the team. Literally on the face—for the face is the embarrassment itself. Cleveland’s team name, obviously, symbolizes the Native American tribes from the Cuyahoga area. The icon of the team, Chief Wahoo, is a grinning, wide-eyed character with a lone feather poking up from behind his head. Apparently the team name of “Indians,” along with Chief Wahoo, instill in the fan a feeling that the actual players possess heroic qualities of the Natives: savage, fierce, uncompromising.
Although the sports media has never been known for its sophistication or talent in thinking in the abstract, one would figure that a serious debate about the potential offensiveness of Chief Wahoo could be had. After all, sports commentators—at least the ones that I have read over the past few years here in Boston and in Cleveland—simply love the concept of the symbol, understand its power, and use it all too often in their articles. Anyone who plunks down $150 for a pair of Nike shoes is willing to pay that price in part because of the outline of a certain basketball player’s body that appears on the shoe. That player and his awesome abilities symbolize excellence, beauty, and the illusion of flight—a seductive symbol, and the NBA (and a host of other businesses) nets hundreds of millions of dollars on it. But Air Jordan is the exception (the man symbolizing his own mythical status); team mascots serve just as much a purpose.
The suggestion that Cleveland’s mascot might be regarded as racist, however, has never been taken seriously, at least in the Cleveland media (and I have seen no other media market even mention it—except in Atlanta, whose Braves made the pennant race in recent years, drawing attention to a similar protest). I remember while I lived in northern Ohio during the past two years, watching the eleven o’clock news on Opening Day, where there would be a story on the small group of protesters who each year ask the fans to boycott games so that the team symbol can be changed. I also remember the anchor snorting derisively about the trivial nature of the protest. “Why don’t they do something better with their time?” would be the quip, and then the news would continue with the homicides of the day.
The challenge the protesters issued, apparently, seemed as esoteric as left-wing academic parlor talk. I find that a simple name change, however, highlights the simplicity and beauty of the protesters’ contention. We would blanch, for instance, were the front office to decide to start calling the team the Cleveland Dagos or the Cleveland Wops in honor of its Eastern European immigrants. Immediately our ears would send a message to our brains to go on high alert, not because these names are any worse in nature than a Native American slur, but instead because we are tuned into that brand of racism. Why then do we ignore this slight on Native American culture?
One simple reason is that there aren’t many Native Americans left to raise much of a fuss, and the vast majority of citizens do not have to face an insulted Native in their day-to-day lives. The reason why this has happened is because of the dirty little American secret of genocide. Perhaps, just perhaps, what is unnerving about the debate over Chief Wahoo is that we must be put face-to-face with an ugly history for which our generation is not responsible (though we reap the benefits of our forebears’ actions) and cannot possibly rectify. Perhaps we like to think of “Indians” as that mythical animal, described with the above cardboard cutout adjectives, who roamed the American wilderness and then somehow mysteriously disappeared, instead of realizing that they were simply a group of nations—more than one—that got crushed under a society hell bent on conquering the land on which we live today, and committed to systematically marginalizing (i.e., killing) anyone who opposed that goal.
All of this debate has nothing, so far as I can discern, with my being a fan. Nor does this have anything to do with Eddie Murray’s 3,000th hit, and hopefully his eventual 500th home run, or the pennant that is within their reach. The debate has to do with understanding that symbols sometimes do represent things, and that they can be used to perpetuate stereotypes that are inaccurate and harmful. Surely we as a citizenry must take the protesters and their argument seriously. In a year when baseball’s ugliness is in the fan’s full view, the Indians have it in their power to right a wrong, if only as a symbolic gesture, in the brightest moment of their organization and at the height of the city’s pride in them.

--Billy

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.

--Billy

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?

--Billy

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.

--Billy

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.
--Billy

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.

--Billy

Friday, July 10, 2015

Thirty

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.
--Billy