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

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.

--Billy

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.

--Billy

(*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.)