Tuesday, March 31, 2020

COVID: Ninety Five

A thoroughly scary, sobering piece in the Metro Section of the New York Times has the Billy Rubin blog staff wondering what will await us in just about fourteen days. If the article can be condensed into one word, that word would be: apocalyptic. Nurses and (to a more limited extent) doctors are being sent into battle without proper gear, and anyone who reads this piece can only conclude that, as the tide crests, the lack of protection will consign not only some health care workers, but also some patients, to a very unpleasant and undeserved future.

Yet it is the opening picture that's the subject here: a nurse holding a placard saying "Will Work For a New N95!" It's a clever protest--clever enough to earn its spot in the Paper of Record--and one that expresses enormous anxiety among the doctors and nurses who have moved forth to do battle. Without N95 masks, the reasoning goes, health care workers are as lambs to the COVID slaughter.



Except for one thing: that assumption is not, largely speaking, true.

What is an "N95"? The term derives from the National Institute for Occupational Safety and Health's categorization of face mask protectiveness. The "N" denotes that it isn't resistant to oils, but the 95 is the important bit, as it indicates that it filters out 95 percent of airborne particles. (There are 99 and 100-grade N masks, as well, in addition to "R" and "P" masks based on oil resistance, each with their own 95/99/100 gradations as well, for a total of nine different types of particulate protective masks. But the only one relevant for this discussion is the N95.)

The N95 mask is used in medicine for what is known as airborne precautions: when one is in the presence of a patient who may pass along an infection that can occur simply by breathing in local air. Two of the most well-known airborne pathogens are tuberculosis and measles. That is, someone with measles doesn't have to cough to infect another person, all they have to do is breathe and have someone in their vicinity. Once they breathe, the virus can remain in the air for hours. (Coughing, though, really throws infectious particles into the air.) The same is true for TB, although TB is not anywhere near as efficient at spreading. (Dr. Rubin has worked for years in TB-endemic places, with TB-positive patients, without the benefit of an N95 mask, and has yet to become infected with TB.)

N95s aren't cheap, and are generally only used in narrow circumstances like TB or measles. Most respiratory viruses do not spread by the airborne route, but instead by something infection control people call droplets. Droplet spread means that the virus or bacteria need to hitch a ride to something--usually phlegm, or the aerosols generated in a sneeze. Those loogies are governed by the laws of gravity, however, and so droplet spread means that, as long as you're not directly in the line of those aerosols or droplets (or, alternately, you're not touching the surfaces where such droplets dropped), they will quickly fall to whatever surface is closest, and as long as you're wearing a mask of some kind (like a surgical mask), you stand almost no chance of getting infected--and we'll get to the "almost" in a second.

The question then becomes: is COVID an airborne, or a droplet/contact-spread, virus?

Getting at this answer is less simple than it may seem, because there's different ways of answering the question. One way is to look at actual people who get infected--say, health care workers--and review whether they were wearing N95s or just surgical masks (which protect adequately against droplet-spread viruses and bacteria), and seeing whether there is a difference in workplace-acquired infections. But this isn't a perfect way of measuring the effect, since people can't be controlled the same way mice can be controlled in a careful experiment. Humans have a way of behaving in ways that confound the results. In the first 55,000 cases of COVID in Wuhan, the Chinese CDC in conjunction with the WHO found that many health care workers--some wearing N95s, others wearing surgical masks--became infected, which would suggest that this virus is mightily transmissible even with the most adequate protection. But then the epidemiologists in China looked at what was happening in the homes of the health care workers, and in a substantial number, they found that workers didn't get infected at work where they adhered to proper precautions, but they got the virus at home, when they reverted to less vigilant practices. (See page 11 of the report.) Thus, it wasn't at all clear whether N95 provided adequate protection or not.

Based on previous experience and study with coronaviruses, the World Health Organization felt that airborne precautions (that is, the use of N95 masks) were not necessary in caring for COVID patients unless they were generating aerosols. Thus, unless someone was doing something to a COVID patient that generated these aerosols, like intubating them, doing chest compressions, swabbing their throats, then a surgical mask would suffice. Which would mean that there should in theory be plenty of N95 masks in the world stockpile available for patient care. (Ventilators, unfortunately, are a different story.)

But a brief letter to the New England Journal of Medicine gave everyone pause when it noted that "aerosol transmission of [COVID]...is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days." Here's the pic that shows the scary data:



It's the middle, leftmost, red streak that suggests the ghastly conclusion: the decay of the virus when aerosolized--which is to say, the amount of virus in the air that can be picked up--was slow indeed, lasting for hours. You can see that its decline is much slower than seen in the other panels, which indicates the viability of the virus on various surfaces. The study immediately generated headlines suggesting that WHO had gotten it wrong (and, sort of by extension, the CDC, whose guidelines are subtly different but basically concur with WHO on the notion that there's no strong evidence for airborne spread).

But here's the relevant description from the article of how they designed the study. The authors state that "aerosols...were generated with the use of a three-jet Collison nebulizer and fed into a Goldberg drum to create an aerosolized environment" [my emphasis]. Moreover, the study didn't attempt to recover unambiguously intact coronavirus, but instead performed something called "PCR," which looks for the nucleic acid found inside the virus. It's an indirect, and strong, piece of evidence, but it's not, as it were, airtight, as broken up bits of virus can litter surfaces for hours and days long after intact virus can be recovered--thus getting a positive PCR test but being of little biological relevance.

Which is to say, this doesn't look anything like real life. It aerosolizes the virus, sure, but quite possibly in a way that no human larynx ever could, unless it was the Cough Heard Round The World. Thus, it's an interesting and intriguing piece of experimental science, but it's simply one piece of evidence in a quilt of information about how the virus is spread--and each individual piece of information does not have the ability to stand entirely on its own.

The experimental data adds a perspective, but the epidemiology gives real-life evidence of what happened, although that data too needs to be understood for its limitations. Even the lead author cautioned against over-interpretation of her work, noting in her Twitter feed the following: “Important: we experimentally generated [COVID-19] aerosols and kept them afloat in a drum. This is not evidence of aerosol transmission.”

But this nuance--this will come as a shock--has gotten completely ignored in the fevered rush to judgement and general freakout. And it's, you know, a kinda important nuance. Today's news brings another article even more extreme in its assertions--that an "MIT researcher" (they're smart!) is quoted in the New York Post as saying that COVID "can travel 27 feet and linger for hours." The "research" done to prove this? Turns out it's little more than a commentary, and describes no genuine new study designed to truly evaluate what happens when a COVID-infected patient is in a room with someone who is wearing a surgical mask but not an N95. In fact, it doesn't even deign to consider the strong epidemiologic data suggesting that N95s are unnecessary (with exceptions noted above). What it does show is...a video of someone sneezing. And what is its biggest citation? The very NEJM study described above. Which is to say, there's no there, there.

At the Billy Rubin Blog, we don't consider that to be the kind of science to merit headlines. We like articles like this, instead, that provide a whole lotta context about the question of airborne versus droplet spread. Good reading! And a lot less anxiety-provoking than the New York Post story.

Indeed, in this environment, when fingers are being angrily pointed, this seems to just pour kerosene on the flames. There are real outrages that have occurred as part of this epidemic, and for which many people are going to needlessly die. (See, for instance: Trump, Donald.) But based on what is currently known, there is not yet good reason to believe that there's anything shortsighted about public health officials suggesting that a surgical mask is, for the most part, safe for most situations involving COVID patient care.

The outbreak is moving fast, and that could change, but as of yet, the science isn't even close to being definitive that the N95 is required in all COVID situations.

--Billy

Monday, March 30, 2020

COVID: As Advertised

Scattered thoughts:

I. I am not truly in the trenches, but I'm close enough to the trenches, and I do a number of reconnaissance missions to the trenches each day, such that I can get a good enough view of this beast. Everything I have read on the professional discussion boards, from Washington State to Texas to Louisiana, and above all, to New York, all check out. No disease is pleasant to behold, but some are worse than others, and this one, for those who are most affected, is bad. In the words of a colleague, "there's nothing subtle about this virus." Of course, he was referring to those who are in our intensive care units--it is precisely its subtlety among most infected people that makes it so difficult to contain.

But his point with respect to the sickest is spot on. The Cat scans do not require years of radiology training to elicit a gasp; they don't even require attendance at medical school, as this week's New England Journal images so amply demonstrate:


I have now seen three or four such CTs on patients I'm following; I expect to see more in the days to come.

II. The notion that this was some piddling, trivial virus should have all but evaporated once Italy and Iran exploded at the end of February, although even as recently as two weeks ago a majority of Republicans still found it untroubling. Wuhan was a warning, and Italy and Iran should have led any sane individual who was paying attention to realize that Wuhan wasn't a fluke--that the virus was moving fast, and that with a one percent lethal virus, one percent of a lot of people equals a lot of people. The math behind this was evident two months ago. Quibbling over whether the mortality rate was one percent or two percent or even 0.5 percent missed the essential truth, which is that the absolute number is what's staggering in a virus that can infect with such ease.

There is a virus well known to humans that should have taught us this lesson. Its mortality rate is an order of magnitude less than COVID, but its threat can be found in its extremely high transmissibility, for it is probably the most transmissible virus known to humankind. It is measles, and prior to the measles vaccine, it leveled children: only one in a thousand, which seems laughable, except that a child with measles can infect between 12 and 18 unvaccinated people. Millions of kids died every year, and even now, after a massive campaign that has reduced the mortality rate of measles by almost 75 percent, there are still nearly 150,000 children who die from the disease each year.

COVID's not that good at transmission--an infected person probably infects somewhere between two and three people--but it's good enough in an age of transcontinental travel to light up the globe in only two months.

III. There are at present three countries left in the world that do not have documented cases of COVID, and last week I was on one of the last planes out from one of them. Sometimes I do question my own sanity.

IV. I wonder if we had been lulled into a kind of virus stupor with COVID because we had been so acclimated to the fearsome case fatality rate of Ebola. Get Ebola, and until recently, it was basically flip a coin as to whether you lived or died. Actually it was flipping a trick coin, since the mortality rate was a bit more than 50 percent until finally we established that two specific treatments definitively worked. A one percent case fatality sounds so pedestrian compared to Ebola's case fatality that I wonder if it even caught the epidemiologists by surprise. At any rate, some historian in the years to come may want to juxtapose the initial response to COVID in terms of the deadening of a stimulus-response brought on by Ebola preoccupation.

V. Irony: I worked with Ebola patients during the West African Outbreak five years ago. I was millimeters from that virus. I examined patients while they sweat on my PPE, held them while they vomited and while they cried. I gave one of them back rubs regularly. I held their hands and walked them from the suspect ward to the confirmed ward. On occasion I stuck needles into their arms in order to draw blood tests. And during my time working in the unit, I slept like a baby. I was never scared of what I was doing. It wasn't that I thought I was going to be okay--far from it--it's just that I was able to approach my work with a calm that never abandoned me.

This thing? It's not so much that I'm scared, but I am definitely tense, and in a way that I never was in the Ebola Treatment Unit. The whole damn hospital is Hot--indeed, the entire state is Hot. And there is something grim and menacing about that.

VI. More on books to read another day, but if anyone wants to step back from the daily COVID cacophony yet still learn something about this moment in history in which we find ourselves, there may not be a better book than John Barry's The Great Influenza. It is impossible to read this book now without feeling a sense of deja vu. If you really do have the time on your hands, this is a good place to start--but more on some other pandemic/plague books worth reading another time.

More soon.

--Billy

Wednesday, March 4, 2020

A COVID-19 Analogy: Snowstorm

Here at the Billy Rubin blog we're fond of medical analogies to blizzards, and as I see article after article breathlessly talking about coronavirus-this and coronavirus-that, and what still seems to be mass panic across the world, it may be helpful to think about the coming COVID-19 epidemic in terms of how those of us who live in snowy climates think of bad snowstorms. Which is to say, they can be bad and disruptive--and even deadly--but people have learned to cope with them. And with the proper approach, they can be weathered, but that doesn't mean they don't put a lot of strain on the system.

A massive snowstorm makes travel difficult at best; that drains the workforce of workers who make or do things. (Yes, there's telecommuting, but no, that won't work for, say, plumbers and electricians, who are, you know, important to making things run.) Schools shut down so even people who might be able to make it in are otherwise occupied. Overall, the economic impacts are real, but temporary, and mostly remain confined to cold-weather areas and don't ripple all the way through the economy.

People die in snowstorms, generally by power and heat loss, or through heart attacks of people with heart disease who head out to shovel snow (I saw this during my residency more than once). Do a lot of people die? No. But does a bad snowstorm strain the system if a bunch of frostbitten or collapsing snow shovelers require emergency medical care? Yep.

That's this coronavirus in a nutshell, though with some important differences. The first involves economic impact: the epidemic isn't just limited to a small part of one country, but will shut down the workforce everywhere. Supply chains of products are international, so the effects of China's aggressive containment policies will very likely have a negative impact on the global economy for months. And a snowstorm lasts days; this is already two months old, and it's hard to guess when the workforce brownouts will stop--though I don't think six months is an unreasonable estimate.

And people will die, just as they do in bad blizzards. Any given individual who gets infected is unlikely to die, just like your chance of dying in a snowstorm is fairly low. But that doesn't mean you can't attribute a number of deaths directly to the storm. And again, the storm will hit the entire country (indeed, nearly every country). In aggregate, it will add up to a lot of people.

Just as with snowstorms, there are protective measures that reduce risk, and the most important of these is handwashing.as well as "social distancing"--keeping yourself at arm's length (though the CDC says 6 feet) from people, particularly those with symptoms. It won't reduce the risk to zero, just as no intervention can prevent the hazards associated with a blizzard. But it isn't hopeless, and shouldn't cause mass panic.

Analogies are tricky, but hopefully this one helps give a little context to the numbers.

--Billy

Wednesday, February 26, 2020

COVID-19 *Is* Coming: Should You Panic?

In a word: no. Panicking is never good, gets you nowhere, and invariably makes things worse.

But COVID-19 is coming to the United States. And by that, I mean coming everywhere, as common as the cold or flu. Am I certain that it's going to be widespread? No, but I'm confident at this point that this is a virus that might have been contained at the very beginning, perhaps a week or two into infecting humans, but that opportunity was missed (perhaps squandered), and we are now in a place where the reality is that COVID-19 is going to infect a lot of people. Containing its spread is highly, highly unlikely.

One of the central problems of understanding COVID-19 in the early 21st century is the confusion surrounding public understanding. This reflects the confusion that people have in general with respect to news: there are simply too many sites, and not enough of those sites are reliable and provide responsible journalism that is, for lack of a better word, nutritious. It's mostly junk food for the brain. More on that another day.

Let's start with one of the most simple of aspects of the virus: its relationship to other respiratory seasonal virus illnesses, the cold and the flu. COVID is definitely more deadly than a typical influenza virus. Based on a study of the first ~72,000 cases in China, just over 1,000 people died from the infection, and it becomes a simple matter of dividing the fatalities by the total, and you get a case fatality rate of 2.3 percent. The typical influenza case fatality rate is a little less than one per one thousand, somewhere between ten and twenty times less deadly than COVID.

Now, a 2.3 percent lethal disease may seem trivial when placed against Ebola or Marburg, viruses with case fatality rates in excess of 50 percent (though now there is treatment for Ebola that may drop it to a pedestrian 30 percent). But COVID spreads efficiently. Really efficiently. Take a look just at the number of total cases in South Korea: as of today, the number stands at 1261; one week ago, that number was 51. That is breathtakingly fast. By comparison, the total number of Ebola cases in Liberia in late August 2014--when it was the number one story in the world--was about the same as Korea's total is today (1,378 confirmed and suspected cases). How long did it take to go from fifty cases to that number? Give or take, it took six months--a lumbering pace compared to COVID's lightning-fast spread.

So it is deadly but not Ebola-deadly, and it is efficient at spreading. Part of its efficiency is linked to that relatively low mortality rate: while a few suffer terrible consequences, many more have mild symptoms, some to the point where they do not seek medical care at all, such that they don't change their daily routine, continue to work, shop, and all the other activities that can expose other people. Others may be spreading the virus before they have symptoms, which makes procedures that isolate sick people useless at containment. (The CDC page linked is cautious about this information, noting that pre-symptomatic spread isn't the main way transmission occurs.)

Stopping a virus like Ebola turns out to be relatively easy in the sense that you can perform "contact tracing" by connecting the sick to the sick to the sick, and so on back to Patient Zero, the original source of the outbreak. But there have already been cases in the COVID outbreak that have no obvious source--no contact that would clearly link them in a chain going back to Hubei Province over the past two months. Indeed, one estimate is that for every known transmission outside China that could be traced back to a Chinese citizen, there were two transmissions to outsiders that have gone undetected. This is why the virus has popped up in unexpected places, and will continue to do so.

Which includes the United States--and as if to prove the point, just during the time I've been writing this, it appears a new case has arisen in California. This is breaking news as I type this, so it may require revision. But even if it turns out not to be a confirmed case, it highlights how this virus is already spreading in places we cannot yet know, and the US will be no exception.

So if it's coming anyway, and it's only got a measly two percent fatality rate, why be concerned at all? Instead of panicking, maybe we should just shrug it off, like Rush Limbaugh, that purveyor of well-reasoned political analysis, has opined recently, likening COVID to the common cold?

Similarly: no. Two percent of a lot of people dying in a very short span of time is going to tax the healthcare system to its maximum. There are only so many ventilators in a given area, and areas in an outbreak may not have enough ventilators to go around. We have already seen in China that the people on the front lines taking care of patients become infected and sick, taking them away from non-COVID patient care duties. Who will be able to do the emergency appendectomy when the one surgeon in town is down and out themselves? Will women get needed urgent C-sections if anesthetists aren't available for emergency procedures? The list goes on. This happened during the Ebola outbreak, and people died as a result, without ever having contracted the virus.

That's where I'll stop for the moment, other than to note that, if one can't panic, and one still has to take this with the gravity it deserves, then perhaps the proper mentality can be found in our British cousins--that we should steel ourselves for the coming storm, and simultaneously Keep Calm, and Carry On.

--Billy

Saturday, October 27, 2018

"All Jews Must Die"

Six years ago I interviewed for a job at the University of Pittsburgh Medical Center. The work was to be based out of Mozambique, where I was planning on living and doing research, but the idea was to spend a year or two there, and thereafter return to Pitt.

They flew me out for an initial interview; I gave a talk about my work at the time on dengue. A few weeks later, they invited me to come back to meet some of the people who would need to sign off on the budget lines required to offer me a job. Miriam came along, and we spent a few days driving around the area, taking a careful look at the housing market in the event that we ever did move. I fell in love with the city in short order. We looked at the Jewish stronghold of Mount Lebanon, the inner-city neighborhood of Shadyside, and some new downtown lofts along the river. Driving around the city, which I was seeing with new, adult eyes since I had last visited in high school, I knew that I was more than willing to move there after a stint in Mozambique. And I knew that I wanted to live in Squirrel Hill.

Had I accepted that job, there is a strong likelihood that Tree of Life would have become my synagogue. Here in Boston, I attend a synagogue with what sounds like a similar moral aesthetic. Our synagogue has a social action committee involved with aiding refugees, and sounds nearly identical to HIAS, the Jewish organization whose purpose is to "protect the most vulnerable refugees, helping them build new lives and reuniting them with their families in safety and freedom." HIAS is based in Maryland, but its local Pittsburgh partner is Tree of Life, and this shared sense of mission may have been one of the critical factors spurring on the shooter to act. It's well within the plausible to think that I could have been there today, maybe cradling one of my children as I watched their lives seep out of them, or them doing the same for me.

That, however, is probably not the most important point to be made in this hour as we collectively process yet another mass murder, and one associated with peaceful worship. I could not have been one of the members of the Emanuel African Methodist Episcopal Church in Charleston, though I mourn those lost lives no less and feel the horror of that violation with equal force; I definitely wouldn't have been at the First Baptist Church in Sutherland Springs, Texas, but that provides ice cold comfort, and as I scrolled through the Pittsburgh updates at the hospital, my mind turned once again to  Pastor Frank Pomeroy, who was attending a class in Oklahoma the day of the shooting. His daughter was there and she was killed, as was the visiting pastor Bryan Holcombe and seven of his family members, including a pregnant daughter in law. I assume this quirk of fate must weigh heavily on Pastor Pomeroy.

On Facebook, an acquaintance posts a dirge about the Pittsburgh shooting. At the end, he writes, "please, no political comments"--an entirely reasonable request. It was followed by, "This has nothing to do with right or left, red or blue," which is almost certainly the funniest line I've read all day, although I can't quite say that it brought levity.

The past few days I have been listening to The Death of Expertise, a book by Tom Nichols, a professor at the Naval War College. Though I have occasionally serious quibbles with some of his analysis about the loss of deference to experts, it is a compelling read. At one point he bemoans the loss of reasoned exchange, giving a nod to Godwin's law--the adage that "As an online discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches 1."

Today, as I drove home listening to Nichols's careful reasoning, I wondered what he might think of the discussions today, in which my people are sitting around thinking about how we Jews--and as the African American victims of the Emanuel African Methodist Episcopal Church demonstrate, other minority groups as well--could be the victim of an act of unspeakable violence specifically directed at them. And, moreover, that these acts would be happening just when the President of the United States repeatedly encourages such people with the praise of brutality, the hymns of resentment, and the encomia to aggression.

Just curious, but when Jews and African Americans are being mowed down by people SS-style as they scream "All Jews Must Die," and that should happen when the worst reprobate to hold the highest office in the land spews forth excrement on a daily basis directed at this-or-that minority group, is invoking the name of Hitler and Naziism still worthy of a condescending tut?
--Billy

Saturday, October 28, 2017

Simple Questions--or Not--At Harvard Medical School

The Billy Rubin Blog went mobile this week, as I gave a talk at the Harvard Medical School Academy's annual Medical Education Day. The theme of the day was medical uncertainty, which given my work in Snowball seemed to the organizers to be a perfect fit. Hopefully it was enough of a match that I didn't embarrass myself completely.

The talk is here: https://soundcloud.com/user-713665386/hms-med-ed-day-oct-24-2017. The talk proper starts at 30 seconds. Apologies for the stops and starts; it felt much more fluid in the moment than the slightly herky-jerky quality the address has on playback.

One exchange at the end is worth meditating on--and I include it here as a meditation, a sidenote, for I don't mean for it to indicate that this was anything approaching the most important moment of the hour. But it does allow a second for a departure on the philosophy of medicine.

When I was taking questions at the end, at about the 51:30 mark, a senior clinician wondered about the process of advice from doctors. Here's the exchange (in raw transcript form--the dead-ends make a little more sense as you hear it in the moment):

MD: There's a very specific prime question that I think is legitimate for patients to ask: "Well, what you you do if you were in my shoes?" And this is a very different question from an erudite but simple discussion of a problem, and they are asking for a very specific answer. And I wondered if you give this, believe in it, and if you do, what do you tell your students about answering such questions?

Me: When they [patients] ask, "What would you do if you were me?"

MD: Yes.

Me: So, I know we have one of my former students here who's a psychiatry resident; I would bounce the question right back and say, "Well, I'm not you...so, um, I'm different. I come with certain, you know, fears, hopes...and then you open up a discussion about, really--because when they ask you that question, they're not asking you that question. They're trying to figure out how to prioritize things. That's my sense."

MD: I think they're asking, very specifically, that question. [Audience laughter.]

Me: I don't...I don't agree. I actually think that question is a good deal more complicated than it looks on the surface.

What's fascinating to me about this exchange, in a talk on uncertainty, was the unequivocal confidence this physician had that patients just want to know what their docs would do in the same situation, no further question asked.

My reply in the moment was not perhaps as quick-witted as I would have liked, but I'd add here that medical decisions aren't the same as car repair decisions. I trust what my mechanic tells me, because a car is an expensive but not priceless piece of machinery, important to my life, worth something but something finite. Thus, I can have a straightforward discussion about whether it makes sense to rebuild the engine for $3000 in a twelve-year old Toyota that has 180,000 miles on it and has a reasonable chance of breaking down in other ways, or just trade it in for a new model. Maybe it's more expensive in the short run to get another car, but that comes at the benefit of fewer headaches induced by repeated trips back to the garage.

A good mechanic can lay out the risks versus benefits in a clear way, and based on what they've seen over the years (the number of 12 year-old Toyotas that make it to 15 without constant servicing, for instance), they can say, "it's a good car, I'd hold on to it, but there's a risk," or alternately say, "I'd be rid of the headache." That kind of advice in that kind of situation is genuinely helpful, and more importantly, the terms being discussed are reasonably clear and equivalent to both parties.

But a doctor just casually dropping advice to a patient's family asking a similar question about a loved one struggling for life on the vent in the ICU, and whether the doctor would request to have all lifesaving measures stopped, presupposes any number of areas of understanding that may not be so. What value does the family place upon religion and ethical precepts about the value of life no matter the struggle? Have they had good or bad experiences with the medical system? Are there life events on the horizon that might make a patient or family try to subjugate themselves to the frequently tortuous procedures and treatments medicine can provide, in order to reach such moments? Does the patient or family have regrets about saying goodbye, of having fights years ago in which no reconciliation has ever been broached?

Don't these questions seem rather more important than, "Well, doctor, what would you do?" as if the subject could be so easily compressed to a singularity of physician wisdom?

And if those questions are explored between doctor and patient, or doctor and family, then what need of such an absurd and possibly dangerously oversimplified question?

--Billy

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