Thursday, April 30, 2009

Was Joe Biden's Remark Stupid?

The answer is "yes." An unambiguous, unqualified "yes." In fact, the Vice President's remark was really stupid. So stupid, in fact, that--although I am now responsible for the rearing of young children and am attempting to put on respectable airs given my age and station in life, so I try more often now to avoid vulgarities, but for this situation it fits--his remark deserves an intensifier: it was really fucking stupid.

Why such a big deal?

Well, first we need to review the Veep's reputation with regard to "gaffes." As in: he has a reputation for making them. My personal favorite was his description of then junior Senator Barack Obama, at the time a very very longshot to be the next President of the United States, as "the first mainstream African-American [in national politics] who is articulate and bright and clean and a nice-looking guy." During the campaign, he also looked a little silly when noting that FDR "got on television" after the stock market crash in 1929 to rally the country. A long trail of such howlers have followed him throughout his career. (Although I think he does get a little credit for what was probably the best line of the Presidential primary campaigns, on either side, by having noted in one of the debates that "there's only three things Rudy Giuliani mentions in a sentence: a noun, a verb, and 9/11.")

But these are gaffes. That is, they're awkward and tactless, but in theory they are to be overlooked because, in the grand scheme of things, they don't reveal a great deal about the man's principles and thoughts on the role of government. (Obviously an African-American might find his patronizing and more-than-faintly-racist description of Obama revealing, but if so that's only a reflection on the patronizing views of the socially liberal wing of the Democratic party rather than something specifically damning about Biden himself.) George H.W. Bush and his Vice President, Dan Quayle, were also hounded by the media for similar slip-ups, malapropisms and overall mangling of the English language in ways that, I am certain, caused a high degree of embarrassment for the behind-the-scenes PR folk. Again, though, these were seen more as evidence of goofiness rather than profound stupidity. Admittedly, in Quayle's case this could be debated, but you get the point.

However, Biden's remark today doesn't really fall under the category of gaffe. It was, in fact, quite an articulate statement about actions that he would take in response to the perceived risk of acquisition of the H1N1 variant that has put world public health authorities on their heels (and no doubt has caused the depletion of vast quantities of alcohol in Geneva, for the folks at the World Health Organization must be calming their nerves with scotch late at night as the numbers keep rolling in). He said, in clear terms, that he would not put himself in a situation where he was in an enclosed space with many people, telling the Today show's Matt Lauer that clearly he would not advise any member of his family to take an airplane or a subway for fear of exposing them to the virus.

And this is the crux of the matter, for Biden's statement obliterates all the very careful tip-toeing that the Obama administration, in conjunction with federal US health officials, have been trying to do with respect to the influenza outbreak. The Obama team has gone to great pains to have the public understand that what is going on is cause for concern and may require some dramatic changes in behavior should the worst-case scenarios prove true, but that people shouldn't panic as this could cause all sorts of secondary problems for a viral outbreak whose lethality and susceptibility we have yet to fully understand. Biden's advocacy of essentially abandoning the most important forms of public transportation amounted to calling for panic. Really fucking stupid.

What the Veep appears not to understand is that he is engaging in a risk calculation and has vastly overstated the current risk. Meaning: isn't he really right that avoiding subways and airplanes will reduce one's risk of acquiring this influenza strain? Well, the answer to that is "yes." But that doesn't mean that it's still a good choice. People unconsciously engage in risk calculations every day and still go about their daily activities. We get in our cars fully aware that a very, very small percentage of us, every single day across the US, will never come home in that car because we will be killed in an auto accident; we go to work with others who might be sick of any number of diseases (including psychiatric diseases that lead people to bring in shotguns to kill scores of co-workers) but don't let that trouble us; we mow the lawn but understand that we could get our foot cut off if we catch a piece of rock or wood under the mower. The list of things that could do us lethal bodily harm is endless. I will never forget one quip of an ER doc when I was in medical school, when he said, "Guys, believe me...if you knew all the different ways you could end up dead, you'd sit in the corner of your bedroom with the blankets over your eyes, and you'd never come out for anything." But we don't do that because the likelihood of one of those gruesome outcomes is so low that it doesn't justify the fear.

And, so far anyway, the risk of both acquiring and dying from the new H1N1 influenza by taking public transportation is vanishingly small. That may change; I am not saying that we might not have to take such measures here in the US. These draconian measures are precisely what they are doing in Mexico, and the government there should be praised for its response. Yet the situation in Mexico is far more dire, and so far there's not enough evidence to justify those kinds of actions here. Keep in mind that these aren't trivial decisions--there will be a huge economic impact if we have to take the kinds of steps that they have taken in Mexico, shutting down schools and businesses for days on end. The best we can do is go about our regular business, pay very careful attention to the news and follow the pronouncements of public health officials. But not such a good idea to advise people to let civilization grind to a halt. This is why Joe Biden should be searching his soul in the coming days.

PS--I did want to add some further meditations on my aunt's passing but the flu has occupied my thoughts with respect to this blog. I will have some more to write about hospice care and family involvement with the dying in the coming days, but I did make one unforgivable error in my last entry. In describing the family situation surrounding my dying aunt, I incorrectly described my Aunt Kathy as being a pediatric ICU nurse. As a professional, and one who has long known this fact, it pains me to say that I got that description wrong, for she is a neonatal ICU nurse. This is not a trivial distinction, and she has my deepest apologies.

Wednesday, April 29, 2009

"Swine Flu"--What's In A Name?

Updates Below

Once again the New York Times has written thoughtfully about a subject--but I got there first! (Or at least we seem to have published at about the same time.) On the subject of the very name "swine flu" for this outbreak, see Keith Bradsher's piece "The Naming of Swine Flu, a Curious Matter." In it, he makes most of the same points I made yesterday about choosing to call this human-pig influenza "swine flu," though includes one or two howlers for comic effect. "An Israeli deputy health minister — an ultra-Orthodox Jew — said his country would do the same [i.e. call it "Mexcian Flu"], to keep Jews from having to say the word 'swine,'" he wrote. Then he deadpanned, "however, his call seemed to have been largely ignored." Points for humor, Keith!

Just for review: influenza's habitat--its "breeding grounds," let's call it--are both humans and various birds and mammals. To call this one specifically swine flu may be a somewhat clinically convenient shorthand, but it's not particularly accurate. The virus is coated in two proteins, called "H" and "N." There are sixteen "H" and nine "N" subtypes. Thus, lots and lots of combinations. Not all of these combinations are able to infect humans, much less cause harm or death. Since 1968, the major strains affecting humans have been the H1N1 and H3N2 strains (before that were H1N1 and H2N2 strains, the latter appearing to have dropped from circulation for the time being). These strains change from year to year, so one year's predominant H1N1 strain may be different enough from another year's circulating strain that a previous vaccine may not be protective; this is very different from viruses like measles or polio, which provides essentially lifelong protection with one shot (plus identical boosters). Anyway, some of these strains are more likely to reproduce in the bird population, some in the porcine population, and some in the simian population (that's us). And because of the special quirks of the influenza virus, individual copies can "trade" H and N subtypes, creating recombinant strains that may be more or less transmissible, and more or less lethal than their "parents." Sometimes this is referred to as the "mixing vessel" phenomenon when people talk about the swine, but it's no less likely that humans or birds are mixing vessels; the virus is passed back and forth between species in an continuous cycle of recombination, a constant tinkering with infectiousness. (For the sake of completeness, I am keeping this subject as simple as possible and not discussing Influenza B and C, which are separate types. The subtypes above all refer to Influenza A.)

The all-time biggie is the influenza strain that caused the 1918 pandemic and likely killed tens of millions of people worldwide. This was an H1N1 subtype, and is often called the "Spanish flu" because it supposedly originated in Spain (though this is dubious, but more anon). The "avian influenza" that has kept WHO officials up late at night over the past several years is a more unusual H5N1 subtype, which is quite lethal, killing roughly 50% of those infected, but appears thus far not to be particularly talented at spreading from human to human. For those who don't know much about the 1918 influenza pandemic, for a couple of bucks I highly recommend Gina Kolata's Flu, and though I have not read it I am told that John Barry's thicker tome The Great Influenza is good reading as well. The Cliff's Notes version is that the 1918 flu pandemic was really really bad. At least in my opinion it ranks only second to the bubonic plague outbreak of 1346-9 (the so-called "Black Death") in terms of catastrophic impact on human life, though smallpox was no fun either, especially for the aboriginal populations following contact with European settlers during the 15th-18th centuries.

In terms of nomenclature, scientists in general try to name viruses after their point of origin. Since influenza already has a name (see here for its etymology), the pandemics are named after theoretically originating points: the Spanish Flu of 1918, the "Asian Flu" of 1957, and the "Hong Kong Flu" of 1968 are the most notable. Needless to say, in a fast-moving pandemic--and influenza specializes in creating fast-moving pandemics--the point of origin may not necessarily be where the disease is first detected, so it's an open question as to the reliability of this strategy. Don't believe me? Check out this post which might indicate the virus originated in, yes, Ohio.

In general, locals aren't precisely thrilled when their village or region is used to name a deadly microbe, and that holds particularly true when those places are peopled by groups traditionally marginalized by past European or American governments. No doubt the people in the Yambuku region of Zaire, after enduring centuries of enslavement, famine, and plunder by the west must not have been pleased when scientists chose to name one of the most lethal viruses known to man after the Congo tributary by whose shores many make their home. We are all familiar with that little tributary's name these days, for what more scary virus could there be than Ebola? One of the ironic twists to this practice is that Ebola's close relative, that other filovirus, was not detected until 1967 when there was an outbreak among 31 Germans who worked with African-imported monkeys, and thus the hemorrhagic fever Marburg came to be dubbed.

The practice came to a head in the US just about two decades ago, when a very deadly virus in the Four Corners area of the US infected a small number of people. A new type of hantavirus, the researchers studying it were prepared to give it the place name as per protocol, until a group of local protesters, including many Native Americans, made it clear that this was just a hair shy of engaging in racism and didn't want their community disrespected this way. As a consequence (and a compromise), this virus today literally has No Name: it is known as the Sin Nombre Virus.

Needless to say, Mexicans aren't especially eager to hear about talk of a "Mexico Flu." The potential for pre-existing biases to reinforce themselves is quite strong, particularly given US-Mexican relations over the past century and a half. Consequently it's not much of a surprise to hear the natterings of nativists in the US about closing the border (which is only what is being discussed in the polite circles of those holding such political views; the more fervent adherents, I am certain, are advocating for, um, sterner measures).

The outbreak's current popular name, "Swine Flu," sidesteps the issue of origins, but has its own issues. You may laugh at the complaints of pork producers who fear the loss of revenue from the moniker, but a mostly ignorant populace has no way of being able to sort out that eating pork poses no risk of contracting influenza. For instance: how is a layperson expected to understand that this situation is different from Mad Cow Disease, given that the English culled over four million cattle in the 1990s precisely because consumption might cause disease? So I don't blame the farmers for their distress.

My own preference at the moment is close to HHS Secretary Napolitano's, who calls it "the H1N1 virus." I'm more happy with "the H1N1 influenza strain," "the H1N1 variant," or some such. Call it what you want, until this thing dies down--the topic for my next entry--another good description is that it's one hell of a scary virus.

a. How could I have forgotten syphilis in this discussion?! Though not a virus, syphilis is a good case study in why it's not such a great idea to name diseases after their origin, and why the people from the first identified sites object to such a system. Although syphilis originated centuries ago, and thus didn't involve the modern methods of disease nomenclature, syphilis is especially apt since it is a sexually transmitted disease, and was used by proto-nationalists of every stripe to bash some foreign country. Thus in the 16th and 17th centuries (and long after), syphilis was called the "French disease" in Italy and Germany and England, the "Italian disease" in France, et cetera, with various nationalities being imputed by various other countries (a lot of which had to do with sailors, who were one of the critical amplifiers of disease).

b. Of course, not all viruses are associated with place names. HIV, the Human Immunodeficiency Virus, bears no trace of its geographical origin (else we'd call it the Somewhere In Africa Formerly Chimpanzee-Specific Immunodeficiency Virus), nor do the various Hepatitis viruses which simply bear the letters A, B, C for their designations. Both were named long before political sensibilities were a consideration. One of the viruses equivalent to this current influenza strain in terms of its scariness, the coronavirus that we call SARS (the Severe Acute Respiratory Syndrome virus), was named after its symptoms and not its origin, a province of China. There are others. That said, many viruses bear place names: Crimean-Congo Hemorrhagic Fever virus, Guanarito virus (a small town in Venezuela), Sabia virus (in Brazil), Machupo (in Argentina), Ross River and Hendra viruses (Australia), and the list goes on.

It is possible that one day there will be an international conference that will set up rules on naming of viruses and engage in a complete re-naming of current viruses in a more logical manner. For instance, the Hepatitis C virus is actually more closely related to the West Nile virus than it is to the Hepatitis A virus, and as we have seen above Ebola and Marburg are in the filovirus family, but the names are half a world apart from one another. Theoretically it would be beneficial to pound out a workable system for naming (much like they have in organic chemistry, where literally tens of thousands of molecules need to be named for patent purposes).

c. Anthony Fauci (the director of the NIH branch of infectious diseases) has also come out heavy against the name "swine flu," referring to it in an NPR piece Thursday morning as "the 2009 H1N1 influenza." I still prefer my suggestions above, but I'm in complete agreement with Dr. Fauci on the reasons to emphasize the switch.

Dying Well

My aunt died yesterday morning. I was not particularly close with her, although she had always been pleasant enough to me when growing up (I don't think I have seen her in over 20 years) and I have generally fond memories of family gatherings as a child with my mother's side of the family.

She died of metastatic lung cancer that had been diagnosed just about a year and a half ago. She initially opted for radiation and chemotherapy, but after several months of treatment with typical complications, she had decided not to try to "beat" the disease and focused on getting her affairs in order before she died. (One such complication, typical of the kind experienced by cancer patients, was that the radiation to her tumor at the top of her lung also affected her esophagus, creating ulcers that made it exquisitely painful for her to swallow, requiring her to be fed intravenously. When she understood that "curative" treatment would mean months of IV feeding, or would require "tube feeding" in which a tube would be inserted from her abdominal wall directly into her stomach to provide her with nutrition--and that all of these measures would not necessarily ensure success--that was the final straw for her.) She invited all of the female members of her extended family as well as close friends down to her place just under a year ago for a "celebration of life"; my wife and daughter, who had never met her, flew down and by all accounts it was a wonderful weekend. As the months passed she continued to do relatively well, but by the winter the tumor had metastasized to her brain, and she declined gradually over the past several months, entering into a coma less than a week ago.

During the past few months she was cared for in part by hospice workers, but largely by my other aunt, a pediatric ICU nurse who fortunately is quite familiar with caring for the sick. Other family members provided what support they could by visiting or helping financially. My mother, who had just attended her granddaughter's bat mitzvah ceremony the week before, flew down to be with her sisters until the end and say goodbye.

She died in that comatose state yesterday morning, of what I assume was uremia (kidney failure). Her body had been gradually shutting down, and her descent was peaceful. Yesterday I spoke briefly with my mother, who was not surprisingly upset to have lost her younger sister. With that understanding, I did explain to my mother that my aunt was remarkably fortunate to have died a death, virtually painlessly, surrounded by her family, in her home, and got to say goodbye to those who cared for her. They were all very lucky.

I had another aunt on the other side of the family with whom I was closer, who died about ten years ago from ovarian cancer. Almost to the end she was determined to fight the disease, and consequently suffered unbearably even when, from my point of view, it was clear that she would succumb. In the end she did die at home, but was in considerably more pain because she had not sought hospice weeks or months before when they could have helped her. She died within the same year that another woman, the mother of one of my college roommates and a woman who has come closest in my life to being something approaching a surrogate mother-figure for me, had also died of ovarian cancer. Like this other aunt of mine, she had refused to accept defeat, and the unfortunate consequence was her dying while being coded by total strangers in an ICU, and never having had the chance to say goodbye to her four children or husband.

Their deaths have gnawed at me over the years as I loved them both.

I write this not out of anger but perhaps a certain disappointment in the values that we hold that lead us to such decisions. My mother's sister, by contrast, was in an enviable position considering the hand she was dealt. She died a good death, and though I wasn't much of a nephew to her, as a doctor that is one of the highest compliments I can pay her on her passing.

PS--There is more to be said about The Influenza--much more--and I hope to be back in the next few days with further observations.

Tuesday, April 28, 2009

Various Thoughts on The Flu

The "Swine Flu" situation is so rapidly moving that to provide commentary on the technical aspects of the disease (such as: is this year's vaccine protective against it? why do the cases in the US appear to be not as severe? when should i take Tamiflu? etc.) would be possibly outdated within hours of this post. Moreover, I assume that the limited readership of this blog is familiar with the excellent sources of information whose job it is to keep the public informed, among them the CDC and WHO websites, and in particular the NY Times site has a great page devoted to the outbreak. Thus, what follows is a scattering of thoughts about the portrayal of the outbreak, and my own reaction to what's happening.

a. I first heard about the outbreak Friday morning April 24 at my division's weekly infectious diseases conference. At the end of the meeting one of the senior clinicians informed us that there was a flu outbreak in Mexico City with an apparent new strain, and that up to 60 people were believed dead. That got me to sit up straight. True, Mexico City is (I believe) the most populous city in the world, with a population somewhere in the vicinity of 30 million people, so normally 60 deaths of any cause save Ebola in a city of that size would not seem to be such a big deal. Yet 60 deaths from flu in a short span of time anywhere is at least concerning.

Following the conference I went to my computer and sought info from The Paper Of Record, and was surprised--indeed, stunned--to see a quote from Dr. Anne Schuchat, the head of the respiratory disease division of the CDC, in the first NYT article on the outbreak. "We don't yet know the extent of the problem," she said, "but we don't think this is a time for major concern." [my emphasis] Now it is possible that Schuchat was misquoted, or quoted out of context; I certainly hope so, because this statement seemed to me wildly at odds with my gut impression of the early information coming out of Mexico: hey, this is scary! I am not the world's foremost authority on flu, but I am an infectious diseases doc, and I couldn't fathom how an outbreak of apparently lethal influenza wasn't a cause for "major concern" in a country that borders the outbreak. Within less than 24 hours, the CDC had a much different take on the events in Mexico, and within 48 hours had declared a public health emergency. Which, make no mistake, this is, even if the total number of US cases doesn't rise above 100 and nobody dies. You don't mess with the flu. (Doc Schuchat, it may be time to spruce up that résumé!)

b. There is a fine line between engendering appropriate concern and contributing to hysteria, and while the statements that I have heard from US public health officials have (except for Dr. Schuchat's initial whopper) seemed on the mark, the media sometimes--okay, often--do such a poor job of putting things into context that, when coupled with a largely scientifically illiterate public, you can't help but induce a panic. For the interested reader with 13 bucks I highly recommend Marc Siegel's book "False Alarm," which delves deeply into the mainstream media's dependence on fear-mongering as a means to keep huge segments of the public titillated, distracted, frightened and whatnot.

So far, though, the coverage has seemed reasonably good. I grant that my sources are skewed as I prefer the Times and NPR to Newsweek and "Good Morning America," but the stories have generally put the facts out, supplied the let's-not-go-overboard-but-still-let's-stay-alert quote from public health officials, and then discussed the situation either in Mexico or on the home front with requisite fretting about how this will affect the economy. There's a little obsessing as NPR, for instance, took 10 full minutes this morning to lead with the story, which may have been a bit much, but make no mistake, this is the Number One news story of the week. People do need to know it's out there and that, under worst-case scenario, they may need to be prepared to take the steps that are already well underway in Mexico (see below). Panic isn't useful; concern, however, is, and we should all be concerned about this bug right now.

c. I don't claim to know anything about the machinations of the Mexican government but thus far it appears that their public health officials know what they are doing, and President Calderón has been admirable in his swift response to the events. Given that, it hardly needs pointing out about our own government's failings during Hurricane Katrina. Mexico is experiencing the biological version of Hurricane Katrina right now, and as of now the ferocity and competence of their response has, alas, put our own national emergency response to shame (at least based on recent history, not the current situation, where it's still too early to tell).

d. To expect politicians to be political without being partisan may be expecting too much, but I saw at least one instance this week where a pol was being goofily partisan, and I saw another situation where the pols should have been vociferously partisan but appear to have left the battlefield. In the former instance, one of the Dems (I think Homeland Security Sec'y Janet Napolitano, but please don't quote me) said that the Republican holdup of HHS Sec'y nominee Kathleen Sibelius was putting the country at risk given the situation with the flu. That's just pure overstatement, especially as Napolitano herself appears to have assumed the lead role in terms of crafting a federal government response. I'm not saying that I want the Sibelius nomination held up, only that you don't want to use a real crisis for a political cheap-shot.

On the other hand, President Obama himself should have called a press conference saying that Texas Governor Rick Perry could help himself to all the Tamiflu he wants--per his request that portions of the federal Tamiflu stockpile be dispensed to Texas--if and only if he would stop braying like an ass about seceding from the Union. You wanna secede, Rick? Well, here's your first act as guv of the New Republic Of Texas: find some Tamiflu! Wishing you luck on that front.

e. One other point on the media coverage is that the media has appeared to need to give a moniker to this bug, and thus it is the "Swine Flu" outbreak. And while there is a ring of honesty in the name, it's a touch misleading. Flu biology is quite complicated but one critical point is that the virus's natural habitat is mostly humans, water fowl, and pigs--so nearly all influenza viruses are to greater or lesser degrees "swine flu." The type of virus causing all the fuss is known as H1N1, which is a strain that is "native" to humans; one of the components of the flu vaccine is an H1N1 strain. (Without going too much into detail, there are multiple types of "H" proteins, which combine with multiple types of "N" proteins, and consequently make up dozens of types of influenza, each with strain variants. The vaccine for flu is actually a combination of two of these types, the H1N1 and H3N2 types, and includes a third component of a related virus, Influenza B.)

Those are my thoughts for the moment. I would love to hear anyone else's take in the comments.

Thursday, April 16, 2009

The Autopsy: Still With Surprises, After All These Years

I'm not sure if there is a procedure in medicine more maligned than the autopsy. Early modern European docs, by and large our modern forbears, were peeling recently deceased people apart since the very, very early stages of the renaissance (and, if Roy Porter is to be believed in his seminal-but-goddawfully-boringly-named history of medicine, The Greatest Benefit To Mankind, it may have happened even before then), and my guess is following every major advance in diagnostic medicine, somebody declared the need for the autopsy and research in the gross anatomy lab to be finished. This was followed by defenders of the practice pointing out that our faith in our diagnostics is grounded more in hubris than in reality; fortunately through the magic of the NY Times website I can even produce evidence of such a diatribe--from 1921! The opener: "The need for a change in attitude on the part of the public toward the autopsy and the fact that the very limited number of autopsies performed [in the US] acts as a handicap in the instruction of the [sic] interne and medical students are points which are being earnestly discussed in medical circles." Nearly 80 years later, the same complaints were being made.

Nevertheless, a skeptic of the need for modern autopsies could point to a few key technologies that really have changed the playing field of diagnosis in favor of the physician in the past two decades. When discussing it with patients I refer to this technology as "looking under the hood," and it consists mainly of CT scans, MRIs, and ultrasounds (including echocardiograms, which are just ultrasounds of the heart, yet nobody calls them that, no doubt contributing to the perplexity of laypeople on medical topics). Various maladies that used to be able to hide out in the chest, abdomen and pelvis--such as, for instance, a liver abscess--avoiding detection typically light up on various scans. When coupled with the dozens of biochemical tests we now have at our disposal, it's hard to assert that we don't know what's going on when people die. So the argument goes. "I mean, seriously, back when I was a med student you didn't really know why people were dying, and you wanted to know how good your tests were to see if you got the diagnosis right on someone who died," a very senior physician once told me when dismissing the need for routine autopsies. "But now, I'd say we know better than 95 percent of the time. Anyone who says otherwise is dreaming."

Like many physicians--probably the majority of physicians who harbor any opinions about autopsies--I generally agree with this sentiment, although I heard a presentation the other day that brought me up short. While discussing kidney disease occurring in the midst of HIV infection, a colleague posted some intriguing data that just recently was published in Kidney International. The group, led by Christina Wyatt at Mount Sinai, looked at a subset of HIV-infected patients who were part of a cohort called the Manhattan HIV Brain Bank, and had agreed to undergo autopsy following their deaths. These researchers, not interested in neurological pathology, exclusively looked at microscopic slides of the kidneys of 89 of these patients. And some of their findings struck me: 4 patients had the premortem diagnosis of glomerulonephritis (not a trivial condition), while 8 were found to have evidence of it at autopsy; 1 patient with the premortem diagnosis of interstitial nephritis, but 5 had it at autopsy; no patients were found to have chronic pyelonephritis (kidney infection) prior to autopsy, though 7 cases were discovered under the microscope. Overall, while 75 of the 89 patients were found to have some form of microscopic renal pathology at autopsy, only 27 carried the premortem clinical diagnosis of chronic kidney disease.

It isn't clear to me whether or not these microscopic findings bear relevance on the actual proximal and contributory causes of death for these patients, but it is hard to dismiss the idea that they might be. At the risk of sweeping generalizations, physicians often look for the simplest, most straightforward explanation of a medical event, but this study seems to indicate that, at the cellular level, there may be many pathological events, interacting with one another and creating feedback loops that lead to a medical event (like a heart attack, or abrupt kidney failure, or a blood clot in the lungs, or a stroke, or any number of other things). If so, some, or possibly many of our diagnoses may need to come with asterisks attached.

Two caveats: one is that this study doesn't have any impact on the debate about the gross anatomy autopsy (i.e. looking at a body with the naked eye); with the accuracy of cat scans, it is still almost impossible for abscesses and tumors to "hide." Two is that HIV is a particularly complicated disease, and researchers from bedside docs to bench scientists are still trying to understand how the disease progresses--so this was a patient population most likely to yield surprising findings like this. Would you find hidden kidney pathology in, say, a breast cancer cohort? Not sure. Nevertheless, with studies such as this, the days of autopsy are, I suspect, not yet finished.

Sunday, April 12, 2009

With or Without Bush, the Right Wing War on Science Continues. Is it Working?

President Obama appears to be backing away from strong statements about climate change he made during he made during his campaign for the White House. One key point of the NYT article: in the recently-passed budget resolutions, cap-and-trade provisions for industry were removed from the legislation in both the House and Senate without apparent objections from the Obama administration.

There may be a degree of insider baseball to this story, which the Times goes on to discuss, the gist being that the Obama administration may unilaterally impose dramatic changes to carbon emissions through the EPA rather than having to do it through congress. But more worrisome would be that the administration, trying to pick its fights and expend its political capital carefully, is backing away from a confrontation that they believe they might lose because the public still--after nearly three decades of increasing scientific consensus!--does not quite understand or appreciate the gravity of the situation. And Obama's political opponents appear to be gearing up on this front, threatening a large-scale misdirection and misinformation campaign about global warming. From my point of view, this is part of an ongoing war against the entire process of science; if right wing leaders find the discoveries of science to be incompatible with their political goals, they simply deny it, and go to great lengths to destroy science's credibility. And it hardly goes without saying that this is bad not only for America's present, but its future as well.

Denying global warming is hardly anything new to the right wing, but it has taken a more urgent tone in the past few months. The first and most appalling example came from an op-ed by George Will in the Washington Post on February 15--less than one month into the Obama administration. Entitled "Dark Green Doomsayers," Will lays out the case that climate scientists essentially have no idea what they are doing, that they are quite poor predictors of the future, that in the 1970's scientists actually thought the world was cooling, and as a consequence most if not all of their theories shouldn't be taken very seriously. Three days later, in the midst of several scientific blogs howling about Will's column, Andrew Revkin of the New York Times wrote a "news analysis" entitled "In Climate Debate, Exaggeration is a Pitfall," and among other things included a debunking of Will's column.

It's quite clear that Revkin's column is just that--a semi-opinion column rather than a "pure" news story--but Will counter-punched the following week, getting in a couple of nice jabs at the Times for writing "meretricious journalism in the service of dubious certitudes." This was done while theoretically defending one of his most important claims, which was that "...according to the University of Illinois' Arctic Climate Research Center, global sea ice levels now equal those of 1979." Leaving aside my pedantic instinct to point out that WaPo's copy editor got the possessive of Illinois wrong, Will, in rebutting the rebuttal, screwed the pooch for a second time in less than a week. The full explanation is covered by one of Discover magazine's bloggers Carl Zimmer, and is highly recommended reading, but the short version is that Will managed to cherry pick two points of data apparently supporting his claim, but doing so in a sea of information (an apt simile in this case) casting doubt on that very claim. Moreover, Will, in the second column, never bothered to contact the author of the source information that he cited to make sure he had his facts straight, which he most certainly did not. (And, of course, he didn't even deign to defend the biggest whoppers contained in his first piece, like his claim that most scientists in the 1970's thought the world was cooling, but no matter; as I have linked before, there's a not-very-smart "gosh, why's everybody upset?" comment by the Post's ombudsman.)

By March 21, WaPo ran yet another op-ed, this time improving the discourse: Chris Mooney, a writer whose subject matter is the politicization of science, shredded Will's reasoning (if it can be called that). Since the second column, though, no further words from Will. And as Bob Somersby at The Daily Howler points out, while Mooney's op-ed was welcome news in the editorial pages of the Post, Will's column is picked up by hundreds of outlets and his influence is wide; few probably picked up the Mooney column and thus many readers of Will's two columns haven't heard the reasonable counter-argument, and heard nothing from the people most qualified to discuss the issue (like Zimmer at his Discover blog). All in all, it was not a great month for the Good Guys.

All of this is chewing on old bones, but the Times ran an article on Thursday indicating that the misinformation put out by George Will is just the opening salvo in what might be a coordinated, all-out debunk effort by right wingers before serious attempts are made by the Obama administration to tackle the climate change problem. The piece features Marc Morano, a former spokesman for Oklahoma Senator James Imhofe (for those who don't follow national politics, Imhofe is about the most pure right wing senator there is), and how he is revving up a media campaign to attack any political solutions to the climate change problem. I don't have problems with anyone of whatever political stripe trying to disseminate information on scientific issues; the problem is that Morano appears to be working in the service of a political ideology first and picking the science to suit that view, ignoring or disparaging anything that contradicts that view. Additionally, he is willing to all but lie in support of those views: one of the tastier bits in the article discusses how he posts a list of "more than 700 scientists dissent warming claims" and includes one "meterologist" in the list of scientists who is not only not a meterologist (he's a local TV news weatherman), but one who is opposed to the idea of climate change "because it takes God out of the picture." Well done, Marc! Further explanations of Marc Morano's tactics and those of the global warming-deniers can be found at (that's "De-Smog," if the name didn't make any sense); if interested in yet another example of the corruption of the debate on global ice melt a-la George Will, see here.

I am not a climate scientist and as such do not have the qualifications to say definitively whether climate change is or is not a valid theory. But I can see whether or not there is a consensus (there is one on global warming) and try to understand the science behind it; that's the best any non-specialist can do. Moreover, I can try to understand the motivations of those who might not want the theory to be true, whether it is or isn't. And that has been, unfortunately, the guiding theme of (for the most part) right wingers in the US for at least the last 50 if not 100 years. (Yes, the Scopes trial was prosecuted by noted left winger William Jennings Bryan, but times have changed.) If science doesn't fit in with their short-term goals, they simply deny its truth. If that ain't dangerous, I don't know what is.

PS--I note, to be complete, that the Times ran a piece in its Sunday Magazine two weeks ago about a real scientist who has serious objections to global warming (Nobel laureate Freeman Dyson), though one voice of dissent to me does not suggest that we should ignore the consensus of climatologists and abandon efforts to reverse or halt climate change through public policy. There will almost never be "total" consensus on any given scientific topic (Nobel laureate Peter Duesberg believes that HIV is not the cause of AIDS, for instance; I think he's completely nutz), but in general there are just too many people who know about this stuff that say it is so, and that is good enough for me.

Thursday, April 2, 2009

Two Items, Unrelated (Except for a Big Ten Connection)

a. In a quiet backwater of the news world today, there is a piece about President Obama's nomination for the director of the US Census, which bears significance on this blog's subject matter, though admittedly only in a peripheral way.

Obama's choice is a man named Robert Groves, who served as the associate director of statistical design for the Census from 1990-92. Groves, who is a professor at the University of Michigan, caused a minor kerfuffle during his tenure there for pointing out that the Census's statistical sampling methods were remarkably crude: then as now, the Census works by mailing people forms and counting the replies. This results in dramatic undercounts in areas where people are less likely to have stable, long-term addresses--places that typically vote disproportionately for Democrats. And members of the Republican party have fought against anything other than the 19th-century "head count" method ever since.

The key point here, from my perspective, is not especially about who benefits in the short run from possible changes to how the Census is administered (and there will be no changes for the 2010 census according to the AP story). What is critical is this story represents yet another area in which a war is being waged on scientists simply by virtue of the disinterested information they provide to the government such that the government will make good long-term decisions. For the most part this war has been waged by, and on behalf of, the members of the Republican party, and found its greatest and most effective expression in the machinations of the Bush administration. And though the Republican party may be in something of a retreat at the moment, its far right wing--which clearly dictates the national Party's policies--continues to oppose the entire intellectual structure that allows science to thrive, and does so with great ferocity. That is, the Groves nomination constitutes a threat not only because it might marginally diminish Republican power, but more importantly because it demonstrates a totally different way to arrange government, where non-partisan civil servants provide the best and most accurate data to policy-makers.

Or to put it another way, the reaction against the Groves nomination, which is already quite clear based on the quotes in the AP article, is of a piece with the Republican intimidation of career scientists and policy experts at NASA, the NSF, the FDA and NIH to name but a few, on subjects ranging from global warming, the extinction of endangered species, and the teaching of evolution. To this list we can now add, "how to count a sample of people properly."

b. The Milwaukee Journal Sentinel ran an article over the weekend illustrating in detail the kind of money sloshing around medical schools these days, in which Big Pharma supports the ongoing "education," if it can be called that with a straight face, of physicians. Keep in mind that what goes on at the University of Wiscosin is no different than many or even most other medical schools in the US. I have little to comment on the article other than to say, "read it." Props to the Carlat Blog for the heads-up.