tag:blogger.com,1999:blog-76554078636607117632024-03-14T11:16:20.202-04:00Billy Rubin's BlogWhere a spiritual descendant of Sir William Osler and Abbie Hoffman holds forth on issues of medicine, media and politics. Mostly.Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.comBlogger190125tag:blogger.com,1999:blog-7655407863660711763.post-63745425076604200622020-11-03T06:35:00.001-05:002020-11-03T06:35:31.021-05:00Requiem For a Democracy (Maybe?): a Brief Meditation on the Day of the Election<div style="text-align: left;"> One of the memes circulating in a small eddy of the internet is the "Fauci scale":<br /><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjFpnFTDtUDktuiHlr8pvgpu33BOp9jIUzpGX51mWBX5ppxc_epIE_qJNE3AgMef5F3ML0qREmXsIKwlpA2WaLAm4TW9Fto7ny7Sp_yxPQqNsxxP_IOlaNjaNcbs5fX9LUWCaWoGwjDniy/s679/fauci+scale+ElmfSlWWMAMppv8.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="383" data-original-width="679" height="267" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjFpnFTDtUDktuiHlr8pvgpu33BOp9jIUzpGX51mWBX5ppxc_epIE_qJNE3AgMef5F3ML0qREmXsIKwlpA2WaLAm4TW9Fto7ny7Sp_yxPQqNsxxP_IOlaNjaNcbs5fX9LUWCaWoGwjDniy/w473-h267/fauci+scale+ElmfSlWWMAMppv8.png" width="473" /></a></div><p style="text-align: left;">Heading into the election, Sam Wang of the Princeton Election Consortium <a href="https://election.princeton.edu/2020/10/31/where-are-you-on-the-fauci-scale/" target="_blank">assesses himself between a two and three</a> (though noting complex feelings such that it's more like 2.5 + √-1).<br /><br />My own personal take is that anything below a Fauci 4.0 is foolhardy. The scale is relativistic, of course: by the standards of the <a href="https://en.wikipedia.org/wiki/1984_Zairean_presidential_election" target="_blank">Zaire Presidential election of 1984</a> (a phenomenally corrupt "election" that defines the term "rigged") the 2020 election could be nothing other than a Fauci 1 (or at least Fauci <2.0). And compared to, say, <a href="https://en.wikipedia.org/wiki/2004_Ukrainian_presidential_election" target="_blank">the Ukranian presidential election of 2004, in which the opposition candidate (and eventual winner) Viktor Yushchenko was poisoned</a>, we're still doing okay, maybe in the Fauci 2 range.<br /><br />But by traditional American standards, I can't see how anyone who has been following US national politics since 2016 can regard tomorrow's election as anything better than a Fauci 4. Personally I'm at a Fauci 4.9 at the moment. Even if we can find our way to a Biden administration in January, democracy in the US has been badly damaged, and in ways that will not quickly abate.<br /><br />The contours of the presidential race have been remarkably consistent for weeks, with Joe Biden showing a commanding lead over Donald Trump, both in the national average and in the Electoral College. If the numbers are even remotely accurate, it would take a statistical miracle for Trump to repeat his narrow 2016 Electoral College victory. </p><div style="text-align: left;">It is here where many people might raise their hands to note that "<a href="https://www.pewresearch.org/fact-tank/2016/11/09/why-2016-election-polls-missed-their-mark/" target="_blank">the polls got it all wrong</a>" in 2016 and to urge extreme caution in interpreting the current poll results. But by and large, the presidential polling <a href="https://fivethirtyeight.com/features/the-polls-are-all-right/" target="_blank">wasn't "all wrong,"</a> and arguably hit the nail on the head for the national overall vote: <a href="https://www.realclearpolitics.com/epolls/2016/president/us/general_election_trump_vs_clinton-5491.html" target="_blank">the Real Clear Politics average of polling showed Clinton ahead by 3.2 points on election day</a>; she went on to <a href="https://en.wikipedia.org/wiki/2016_United_States_presidential_election" target="_blank">win the popular vote by 2.1 points, 48.2 to 46.1 percent</a>, which is well within the error range of the accumulated polling. <br /><br />It's true that at the <i>state</i> level--<a href="https://www.forbes.com/sites/realspin/2016/11/30/in-wisconsin-clintons-pre-election-poll-numbers-were-accurate/?sh=163a87bc7ad1" target="_blank">especially Wisconsin</a>, and to a smaller degree, Michigan and Pennsylvania--there was a lack of sampling. The undersampling, coupled with James Comey's "<a href="https://www.newyorker.com/news/john-cassidy/james-comeys-october-surprise" target="_blank">October Surprise</a>" announcement of the discovery of previously unknown (and ultimately, unimportant) Clinton emails saved to an unsecured location, proved to be enough of a difference in the late-breaking vote that Trump eked out a victory in those three critical states with razor-thin margins of 22,698 votes in Wisconsin, 10,704 votes in Michigan, and 44,292 votes in Pennsylvania. Those three states, with 13 million voters, swung the national election to Trump with fewer than 100,000 votes cast. And even in these states, the polls reflected a tight race, as <a href="https://www.electoral-vote.com/evp2016/Pres/Graphs/wisconsin.html" target="_blank">can be seen here in the Wisconsin polling</a>:</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_DWYCQgd1PmzWCHM4PlgHkAsADXCn_LiTal_EXAePf0lnUsoJBqH4TRkGX0TD3_XkSBcmNoH5ceqNBvYrGSJRYBKv5nBDqVpFiviPYy0hFmitpgIyMcIV1KMaTYa0SQc6dwyH2ypYKNyk/s1060/2016+wisconsin.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="300" data-original-width="1060" height="182" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_DWYCQgd1PmzWCHM4PlgHkAsADXCn_LiTal_EXAePf0lnUsoJBqH4TRkGX0TD3_XkSBcmNoH5ceqNBvYrGSJRYBKv5nBDqVpFiviPYy0hFmitpgIyMcIV1KMaTYa0SQc6dwyH2ypYKNyk/w640-h182/2016+wisconsin.png" width="640" /></a></div><div><br /></div>...while the 2020 Wisconsin polling can be seen here:<br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7nAg4p4MkuXa7lj9PAk35Vo1eBoOrQ47Kdy-5APNz2y7AzE1w3TMtBf1XmBHW9S_0kD1O4oUdwDw4B0GhsuVIf44Rde2CH5g1bgq3ml1qwF05tLR0PVHhs8Rnp8Udxk1rKoiDx90ffrBY/s1060/2020+wisconsin.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="300" data-original-width="1060" height="182" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7nAg4p4MkuXa7lj9PAk35Vo1eBoOrQ47Kdy-5APNz2y7AzE1w3TMtBf1XmBHW9S_0kD1O4oUdwDw4B0GhsuVIf44Rde2CH5g1bgq3ml1qwF05tLR0PVHhs8Rnp8Udxk1rKoiDx90ffrBY/w640-h182/2020+wisconsin.png" width="640" /></a></div><br /><div style="text-align: left;">Michigan and Pennsylvania show similar trends. One can reasonably conclude from this that, under normal circumstances, Biden holds a commanding lead heading into the final hours of the campaign, and is in a significantly stronger position than Hillary Clinton was four years previously.</div><div style="text-align: left;"><br /></div><div style="text-align: left;">We are not operating under normal circumstances, of course. The fact that we are in the midst of the worst infectious disease outbreak since the <a href="https://www.amazon.com/Great-Influenza-Deadliest-Pandemic-History/dp/0143036491" target="_blank">Great Influenza of 1918</a> (yes, that one <i>was</i> worse, and yes, <a href="https://www.amazon.com/Fever-1721-Epidemic-Revolutionized-Medicine-ebook/dp/B010MHA51E/ref=sr_1_1?crid=11PJYVR15KYSN&dchild=1&keywords=the+fever+of+1721&qid=1604358137&s=books&sprefix=the+fever+of+%2Cstripbooks%2C165&sr=1-1" target="_blank">there were other horrible outbreak years as well</a>) is only the beginning of the laundry list of known unknowns that will affect how many people vote, and how many of those votes will count.<br /><br />That laundry list includes Trump whipping up his Brownshirt brigade bent on voter intimidation (though <a href="https://www.propublica.org/article/so-far-trumps-army-of-poll-watchers-looks-more-like-a-small-platoon" target="_blank">perhaps they may be less worrisome than previously thought</a>). It includes the army of forked-tongue lawyers making every possible argument to suppress every vote from Democratic party strongholds (and whose arguments are often so transparently antidemocratic--small "d" there--that as a warm-up exercise, the <a href="https://www.npr.org/2020/11/02/930365888/federal-judge-dismisses-effort-to-throw-out-drive-through-votes-in-houston" target="_blank">Republican-installed Texas Supreme Court refused to toss out more than 100,000 legitimate votes simply because election officials in Houston tried to make it safe and easy to vote by means of using drive-throughs</a>). It includes the <a href="https://www.politico.com/news/2020/10/21/louis-dejoy-usps-changes-430807" target="_blank">sabotaging of the US Postal Service by its own head</a> in an effort to delay mail-in voting so that the will not be eligible for the count.<br /><br />At some level, these kinds of threats to democracy are common fare in American politics: voter suppression is nothing new, everyone is familiar with the Supreme Court's 2000 decision to prevent the recount in Florida, and leading Republican politicians dating back to at least the 1960s have a track record of not merely sanctioning, but leading the efforts to prevent free and fair elections. This group includes such luminaries as <a href="https://old.post-gazette.com/columnists/20001202roddy.asp" target="_blank">William Rehnquist</a>, <a href="Chief Justice of the Supreme Court of the United States" target="_blank">who led an organized effort to intimidate voters in his native Arizona in the 1960s long before becoming Chief Justice of the Supreme Court of the United States</a> (appointed by--this will come as a shock--Richard Nixon), but the list is much longer and runs right up to the present moment, where one <a href="https://www.brennancenter.org/our-work/analysis-opinion/uncovering-kris-kobachs-anti-voting-history" target="_blank">Kris Kobach</a>, the far right former Governor of Kansas who proved even too radical for that extremely conservative state, <a href="https://en.wikipedia.org/wiki/Presidential_Advisory_Commission_on_Election_Integrity" target="_blank">heads the Orwellian "Presidential Advisory Commission on Election Integrity</a>. It may be too rosy an assessment to say the American experiment triumphed over these kinds of borderline fascist tactics that now define the Republican party at virtually all levels (with notable, but unfortunately far too small, pockets of resistance in places like Massachusetts, Vermont, Maryland, and perhaps Utah), but I think it's reasonable to say that, for personal freedoms and having the voice of the people heard, it's still better to be here than, say, China.<br /><br />The absolute dread that is rippling across the United States today, and no doubt in the days to come, is nonetheless very real, and in my opinion, exceedingly well placed. Many <a href="https://www.electoral-vote.com/evp2020/Pres/Maps/Aug05.html#item-5" target="_blank">highly informed people who understand civics at a deep level have gone to great pains to reassure the public that Trump will be unable to "steal" the election</a> via his typical blunt, and not especially clever, tactics. "We cannot say that this is an entirely impossible scenario," noted the authors of electoral-vote.com a seeming lifetime ago on August 5. "What we can do, however, is make clear that it is very, very unlikely." (The link is worth reviewing for those who want to understand the mechanics of how voting for President in the US actually works.)<br /><br />Maybe so, but I fear that Trump's ability to deny obvious realities, and to drag not just millions, but tens of millions of people with him into his madness, has the potential to gum up the works in ways that no expert of the past could possibly predict the future. Electors are chosen by processes that vary from state to state. Many of those states have divided government. Here, for instance, is a map showing the legislative control of each state:</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRx4Eo5Te0zV0hSLjg_ELcLl5GQ2D9BG7pM-j9qAf_U3BjsxlOkdmofuYrOiJEKkTRbfIJRA1GUwAY1MqktuT-nN2YXTzLP7zCuij5I_z-Ve3g7CXN3MCciw1GD2phrcDaMtU0BhRzEvP6/s600/CN2020050701_Map1_600.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="399" data-original-width="600" height="426" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRx4Eo5Te0zV0hSLjg_ELcLl5GQ2D9BG7pM-j9qAf_U3BjsxlOkdmofuYrOiJEKkTRbfIJRA1GUwAY1MqktuT-nN2YXTzLP7zCuij5I_z-Ve3g7CXN3MCciw1GD2phrcDaMtU0BhRzEvP6/w640-h426/CN2020050701_Map1_600.png" width="640" /></a></div><div style="text-align: left;">Note that Donald Trump simply discards reality whenever he finds it inconvenient--which when it comes to political topics, is virtually always. For a moment, just forget legal challenges to the courts to close the polls early, or to have this or that set of votes not count: what is to stop Donald Trump from saying that he won Georgia, Florida, North Carolina, Pennsylvania, Michigan, Iowa, and Wisconsin, regardless of the facts on the ground? (There is <a href="https://www.axios.com/trump-claim-election-victory-ballots-97eb12b9-5e35-402f-9ea3-0ccfb47f613f.html" target="_blank">good evidence to believe that he will declare victory this evening no matter what happens</a>.) As you can see, all of these states have a Republican-controlled legislature (some also have Republican governors). There is a process for certifying the winner of the federal elections in each state. <br /><br />What is to prevent these legislatures from simply declaring, by fiat, that Trump's electors will represent their states? What happens when those electors <a href="https://crsreports.congress.gov/product/pdf/IF/IF11641#:~:text=December%2014%2C%202020%3A%20Electors%20Vote,meeting%20is%20on%20December%2014." target="_blank">get in their cars and drive to Washington on December 14</a>? (Note: <a href="https://en.wikipedia.org/wiki/1876_United_States_presidential_election" target="_blank">this has happened before</a>.) Who is to adjudicate this kind of mess? Do <i>you</i> trust Samuel Alito, Clarence Thomas, John Roberts, Brett Kavanaugh, Neil Gorsuch, and Amy Coney Barrett to be fair judges should legal questions land in their laps? <br /><br />I for one do not. Nor do I trust any Republican office holder at the national political level. All evidence--including an easy opportunity for the Republican leadership to stop Trump via impeachment when evidence of obvious malfeasance surfaced, something that happened only eight months ago--suggests they will follow him no matter where he leads them. Since 2016, the Republican politicians who can see Trump for the dangerous buffoon he is have almost never taken any direct action against him; they express, at most, "<a href="https://www.newyorker.com/humor/borowitz-report/susan-collins-concerned-that-amy-coney-barrett-too-indecisive" target="_blank">concern</a>" about his trampling of democratic norms, or more often, <a href="https://www.cnn.com/2019/10/10/politics/republican-senators-reaction-trump-ukraine/index.html" target="_blank">simply run away from the subject when simple and direct questions are asked of them</a>. And it is worth noting that we're only talking about the rump minority of the Republican party secretly disgusted by Trump; <a href="https://www.npr.org/2019/11/20/781358758/what-rep-jim-jordans-constituents-make-of-his-role-in-the-impeachment-inquiry" target="_blank">the rest are hollering enthusiasts</a>.</div><div style="text-align: left;"><br /></div><div style="text-align: left;">It may come to pass that there will be a happy outcome and the US experiment in governance will dodge this bullet, but I for one remain wary of what lies ahead in the coming hours and days, and while I remain hopeful that the democratic institutions Trump has only <i>partially </i>dismantled will prove up to the task, I do not think it is by any means assured, and I wonder what any sane person will do, individually and collectively, once Trump leads his cult jumping into the abyss.<br /><br />--Billy</div><div style="text-align: left;"><br /></div><div style="text-align: left;"><br /></div>Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-88074634809614144402020-06-04T17:16:00.001-04:002020-06-04T17:21:45.572-04:00The Republican Party Cannot Be Distinguished From President TrumpLet's start with <a href="https://www.nytimes.com/2020/06/03/us/politics/steve-king-iowa-primary.html?campaign_id=60&emc=edit_na_20200603&instance_id=0&nl=breaking-news&ref=cta&regi_id=113404100&segment_id=29929&user_id=ee1c9f240e72e5eebe188b1b7d0d0e59&fbclid=IwAR3yr_sBX5yEJ6QftOE9oZGnwTtjjoyA1mK0Gv7MfM2Ui7lw2Qgo14FGypI">the political demise of Steve King of Iowa</a>. If you don't know who King is, you are the better for it, since King is, put simply, <a href="https://www.nytimes.com/2019/01/10/us/politics/steve-king-trump-immigration-wall.html?module=inline">an unrepentant racist who wondered aloud what was the problem with the phrase "white supremacist,"</a> a comment that, on the heels of dozens of other similar dog whistles to his largely white, rural constituency, <a href="https://www.nytimes.com/2019/01/15/us/politics/steve-king-white-supremacy.html">led him to be stripped of his committee assignments in the House</a>. The loss of influence arguably allowed alternate Republicans to make the case that they should become the Party's standard bearer for the Iowa Fourth Congressional District. A guy <a href="https://en.wikipedia.org/wiki/Randy_Feenstra">named Randy Feenstra</a> won, <a href="https://www.nytimes.com/interactive/2020/06/02/us/elections/results-iowa-primary-elections.html?action=click&module=RelatedLinks&pgtype=Article">beating King handily, 46-36</a>.<br />
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So...this is good news, right?<br />
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Not really. For in truth, Randy Feenstra is no different in substance from Steve King. I don't say this because I have a detailed understanding of Randy Feenstra's policy proposals, and I haven't studied his <a href="https://www.feenstraforcongress.com/">campaign website</a> for hours on end. I haven't looked for any interviews with him on race. I say this because I know <i>one</i> key piece of information about Randy Feenstra, which is that he is a member of the Republican party. And to be a national elected representative of the Republican party, in this day and age, is not merely to be anti-liberal, but simply and forthrightly, to be anti-democratic. That's a small "d," just to be clear, which means we're talking about the institution of democracy, not a political party.<br />
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Now had I written those words twenty or thirty years ago, I would have been dismissed as a crank by an enormous number of people from left, right, and center. <i>Not all Republicans are the same!</i> I would have been told. Such people would have bemoaned my radicalism, my rigidity, my self-righteousness. And to be fair, a good deal of people <i>today </i>would say the same thing; effectively, <a href="https://www.nytimes.com/2017/07/11/opinion/how-we-are-ruining-america.html">David Brooks has been saying this to people</a> on the center-left for nearly two decades.<br />
<br />
Maybe that's right, maybe not. But others share my opinion these days. Take this, for instance:<br />
<blockquote class="tr_bq">
<i>The Republican party, which was founded in 1854, <b>has never been more united. Ninety percent of self-described Republicans support President Trump</b>. I do not believe that Ronald Reagan ever achieved that degree of homogeneity in the Republican party. So, the Republican party today is a Trump party. For that reason, the party has been a) impotent to act as a restraint on the President, and b) <b>thoroughly complicit in his behavior</b>. For that reason, <b>the party itself has to be judged</b>, as well as the President that it nominated and helped reach the White House. </i>[my emphasis]</blockquote>
What about this quote isn't a frothing, rabid, insane rant? It's another of those Antifa people, right?<br />
<br />
Well, no, actually: <a href="https://en.wikipedia.org/wiki/George_Will">it's this guy</a>, George Will, and that clip is from <a href="https://www.npr.org/2020/06/04/869282843/conservative-columnist-george-will-thinks-its-time-for-gop-reboot?t=1591298637321">this interview with Rachel Martin</a> after he wrote this <a href="https://www.washingtonpost.com/opinions/no-one-should-want-four-more-years-of-this-taste-of-ashes/2020/06/01/1a80ecf4-a425-11ea-bb20-ebf0921f3bbd_story.html">op-ed in the <i>Washington Post</i></a>. Anti-Trump op-eds in the <i>Washington Post</i> are about as surprising as dog-bites-man pieces, but this one even <a href="https://www.foxnews.com/media/george-will-donald-trump-takedown">got the attention of Fox News</a>.<br />
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Let's just stop and appreciate that quote for a second, and that it came from <i>George Will</i>. George Will!<br />
<br />
So is it <i>really</i> a victory for decency that we have just replaced an unrepentant racist in a tucked-away corner of Iowa with someone who will support without any change the same program that gave our country Donald Trump? I say no. I say, he's not only just as bad, but in fact he's <i>worse</i>, since he will provide cover for maybe ten or twenty percent of voters to maintain their denial of the bedrock truths that George Will is trying to force them to confront above. The Iowa Fourth is PVI R+11. With King the nominee, that seat is a tossup; without King, <a href="https://cookpolitical.com/index.php/analysis/house/iowa-house/king-primary-defeat-moves-ia-04-solid-republican">it is safely back in the hands of Republicans</a>.<br />
<br />
Could Randy Feenstra be a decent individual? Of course he could. That would put him in company with tens of millions of Germans between 1933 and 1945.<br />
<br />
<i>The Republican party today is a Trump party. </i>It is worth reminding ourselves of this as we look toward the Congo, where <a href="https://www.independent.co.uk/news/world/africa/ebola-congo-outbreak-death-toll-drc-mbandaka-pandemic-outbreak-a9542426.html">another Ebola outbreak has begun</a>. The World Health Organization has, for decades, been critically important in containing and ending Ebola outbreaks. That would be the same WHO <a href="https://www.bbc.com/news/world-us-canada-52857413">that President Trump has stated the US Government will no longer fund</a>, and if he is able to put this into effect, would constitute <a href="https://time.com/5847505/trump-withdrawl-who/">a major budget cut</a> for the group.<br />
<br />
You think a mismanaged federal <i>COVID</i> response is bad? Just try having Ebola out there when the world doesn't have the resources to track it. We are lucky to be living in a time when air travel is significantly limited. But it won't always be so, and you can rest assured that, whatever else Randy Feenstra is as a person, he's not going to be out there fighting hard to rebuild institutions like the WHO after <a href="https://www.theatlantic.com/politics/archive/2019/11/trump-attack-vindman-yovanovitch-hill/602383/">this total assault on expertise that is the Trump administration</a>, and the party that not only enables him now, but <a href="https://www.theatlantic.com/magazine/archive/2018/11/newt-gingrich-says-youre-welcome/570832/">created the kind of politics that led to his rise in the first place</a>.<br />
<br />
At other times, we should support or oppose Randy Feenstra based on his statements, his record in the Iowa State Senate, his debate performance, and so forth. Alas for Randy, it's much more straightforward this year. He is a Republican, which means he is not only part of the problem, he <i>is </i>the problem. <br />
<br />
If that strikes you as the overheated prose of a left-wing fanatic, then let me direct you to one George Will.<br />
<br />
--Billy<br />
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PS. Since we are on the subject of "political people with whom we almost never agree," <a href="https://www.theatlantic.com/politics/archive/2020/06/james-mattis-denounces-trump-protests-militarization/612640/">we cannot let Jim Mattis's astonishingly eloquent essay in <i>The Atlantic</i></a> pass by without a mention. So many writers have written such eloquent denunciations of Trump and Trumpism, and have also written encomia on the better angels of our American nature, even in the dark hours we find ourselves in after the murder of George Floyd. But Mattis's piece is pitch perfect as a clarion call--and like Will's excoriation of the Republican party and its profound moral and intellectual failure in this hour, cannot be so easily dismissed by any but the most intransigent, or unredeemable, of souls.<br />
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<br />Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-55825679258697044502020-05-20T08:34:00.000-04:002020-05-20T08:34:02.893-04:00The Near-Irrelevance of Drs. Birx and FauciNot being a creature of Washington, it's entirely possible that I'm too hopelessly unaware of the insider baseball that regularly gets played at the highest level in the nation's capital, and I'm simply too much a rube to see when someone's outmaneuvering someone else in, say, the corridors of the Rayburn Building. So perhaps I'm just being obtuse when I note <a href="https://www.axios.com/deborah-birx-white-house-coronavirus-trump-79457f04-cab3-425e-9dcc-6ebb77baa4ea.html">how ridiculous I think this political analysis by Jonathan Swan of Axios is</a>. <br /><br />Swan's point is that it is Deborah Birx, and <i>not</i> Anthony Fauci, who is the real wear-the-pants doctor on the coronavirus task force, and therefore is the one who's <i>gotten things done</i>. "Don't be fooled by the grandmotherly demeanor and whimsical scarf collection," Swan crows. "Administration officials say they've been taken aback by Deborah Birx's masterful political skills — including a preternatural ability to get what she wants while telling people what they want to hear." According to Swan, Birx has been "far more adept at influencing the president and shaping the administration's response to the global coronavirus pandemic."<br />
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Well, if that's so, what a bang-up job you've done, Doctor Birx!<br /><br />Amazingly--astonishingly, jaw-droppingly astonishingly--Swan offers recent back-room gossip surrounding discussions about the World Health Organization as evidence of Birx's savvy compared to Fauci's blundering. Weeks ago, Trump asked Birx, Fauci, and CDC Director Robert Redfield their thoughts on WHO. "Birx was very critical of the WHO and its relationship with China. She said the institution badly needed reform," the article notes, while "Fauci was more ambivalent in the Situation Room meeting. He started out by saying the WHO is an imperfect organization...[and the Director General of WHO] has a China problem."<br /><br />Based on that, and presumably other conversations, Dr. Birx can therefore receive credit...for Trump <a href="https://edition.cnn.com/2020/05/18/politics/trump-world-health-organization-coronavirus/index.html">holding WHO hostage in the middle of a pandemic</a>. Or how about her allowing <a href="https://www.nytimes.com/2020/05/18/us/politics/trump-hydroxychloroquine-covid-coronavirus.html?action=click&block=associated_collection_recirc&impression_id=164167814&index=0&pgtype=Article&region=footer">the President to sway tens millions of millions of Americans on the almost-certainly false hope of hydroxychloroquine</a> as a panacea, even as of this late hour in mid-May, weeks after it became clear that this drug's promise was built <a href="https://www.nytimes.com/2020/05/12/magazine/didier-raoult-hydroxychloroquine.html?searchResultPosition=1">on the sale of snake oil from an egomaniacal French doctor</a>. What great public health work! That must be worthy of a marble statue somewhere!<br /><br />The premise upon which this analysis is built is notably described here, <a href="https://www.learnliberty.org/blog/breaking-the-wheel-of-westeros-why-heroes-arent-enough/">in a prescient analysis of Game of Thrones, as "the pop culture fixation on heroic leaders rather than institutions [that] reinforces a dangerous tendency of real-world politics.</a>" The notion of Birx being more adept than Fauci is of a piece with someone admiring a well-played scheme of Tyrion Lannister's. It also contains <i>zero </i>information on the World Health Organization and <a href="https://www.nytimes.com/2020/04/15/health/who-world-health-organization-coronavirus.html">the work that it does in the world</a>. Which, given that we're in this thing called a "pandemic," and "World Health" is in their title, might be something at least as important to explore, right?<br /><br />Nor does this article make even the slightest attempt to explain the <a href="https://www.nytimes.com/2020/04/08/world/asia/trump-who-coronavirus-china.html">complicated relationship that WHO has with China</a> at the very root of the discussion, or even make a nod to past issues with <a href="https://www.nytimes.com/2014/12/30/health/how-ebola-roared-back.html">the structure of WHO and how that has affected prior responses, such as during the West African Ebola Outbreak</a>. <br /><br />No, Jonathan Swan's fixation is on Dr. Birx versus Dr. Fauci and their attempts to get the ear of Nero. Meanwhile, Swan himself seems to be blithely unaware that Rome is burning, and that its leader is trying to hamstring the efforts of the Fire Department by taking away its trucks and hoses, fiddling as he goes.<br /><br />--Billy<br /><br />PS. Disclosure: I have served as a consultant for WHO. Proudly.Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-87562907602295971992020-05-07T10:01:00.001-04:002020-05-07T10:01:36.952-04:00COVID: Trump's Next Target Will Be Organized Medicine ItselfAs has been obvious to anyone paying attention to politics for about the past thirty years, the Republican Party has been escalating a war on science and expertise. In order to keep their evangelical wing on the same page, they've tried to demonstrate hostility to the concept of evolution, at first by <a href="https://www.nytimes.com/2005/12/18/us/evolution-trial-in-hands-of-willing-judge.html">championing the pseudoscientific gobbledygook of intelligent design</a>, and then in more recent years <a href="https://physicstoday.scitation.org/do/10.1063/pt.5.8101/full/">by simply denying the truth of Darwin's insight</a>. Even more importantly, they have <a href="https://www.rollingstone.com/politics/politics-features/why-republicans-still-reject-the-science-of-global-warming-106402/">long tried to obfuscate the truth about global warming</a> once a scientific consensus emerged, initially responding by <a href="https://www.skepticalscience.com/print.php?r=326">evasions </a>and <a href="https://journals.openedition.org/ejas/10305">sophistry</a>, but <a href="https://www.nytimes.com/2017/06/03/us/politics/republican-leaders-climate-change.html">accelerated to outright denial</a> in the <a href="https://environmental-action.org/blog/rnc-platform-goes-off-the-deep-end-of-climate-denial/">past few years</a>. In <a href="https://www.newsweek.com/anti-vaxx-texas-republicans-sorcery-jonathan-stickland-parental-rights-1418960">recent years</a> they've even made <a href="https://www.politico.com/story/2019/05/27/anti-vaccine-republican-mainstream-1344955">tentative inroads toward the antivaccine movement</a>, though that has traditionally been the <a href="https://www.statnews.com/2017/09/22/robert-kennedy-vaccine-safety/comment-page-10/">happy hunting ground for the fringe left</a>. We could list more examples, but we'll assume that these examples will suffice.<br />
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And perhaps before moving forward, it's worth briefly addressing the inevitable harrumphs of <a href="https://www.huffpost.com/entry/david-brooks-satire_b_1176603">those who worship</a> at the <a href="https://krugman.blogs.nytimes.com/2016/09/26/the-falsity-of-false-equivalence/">altar of false equivalence</a> and insist that since the Republican Party has what amounts to an official policy of hostility to science, the same must be true of the Democratic Party. In short: no. Yes, it's true that there are some left wing movements that incorporate a vague kind of disregard for scientific expertise, principally <a href="https://www.realclearscience.com/journal_club/2014/10/20/are_liberals_or_conservatives_more_anti-vaccine_108905.html">the antivaccine movement (although as noted above, this has developed a bipartisan fringe tinge)</a>, and <a href="http://jaysonlusk.com/blog/2014/1/6/politics-of-gmos">the opposition to genetically modified foods</a> is generally rooted in progressivism (and while much of this opposition is based on total nonsense, at the Billy Rubin Blog, we think some aspects GMO skepticism, particularly when it comes to issues regarding biodiversity, is not entirely without scientific merit). <br /><br />But it doesn't take a Kissinger to observe that these groups are relegated to the fringe of the party, and in fact are mostly <i>outside </i>the Democratic tent pissing in, demonstrating how little power they really have. When fringe third-party presidential candidate (and former physician) Jill Stein ran as the nominee of the Green Party in 2016, she <a href="https://www.theguardian.com/us-news/2016/aug/18/jill-stein-anti-vaccination-green-party-ridiculous">sounded some antivax dog whistles</a> to her constituency to mollify them. For her troubles, she got verbally <a href="https://www.huffpost.com/entry/jill-stein-may-not-be-anti-vax-but-shes-pushing-a-dangerous-anti-vax-theory_n_579f885ce4b0693164c1fab4">flayed by the solidly left <i>Huffington Post</i></a> and the <a href="https://www.vox.com/policy-and-politics/2016/10/24/13382998/jill-stein-hillary-clinton-vaccines">center/wonky left <i>Vox</i></a>, among other outlets. And you can't find one US Senator from the Democratic Party who would champion this or other similarly nonsensical beliefs, but demonstrating contempt for the scientific process is worn as a badge of honor by many of the most powerful Republicans.<br />
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As I said, this is no recent innovation within the Republican Party structure, but without any question Trump has turbocharged the activation of the pitchfork brigade. His embrace of climate denial is, like everything else about him, not done by half-measures. Previously, forked-tongued Republicans dealt with the subject by acknowledging that "climate change" is occurring, but would minimize the impact and point to other causes. Not so with Trump, <a href="https://www.bbc.com/news/world-us-canada-46351940">who simply disregards the evidence</a>. Since <i>he</i> lies to advance his personal interests, he assumes that everyone else does, too.<br />
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Which brings us to COVID. We could link you to about a thousand well-written articles now documenting the various missteps of the Trump administration, <a href="https://www.nytimes.com/2020/03/15/opinion/coronavirus-trump-leadership.html">from the early hours of the outbreak</a> up until <a href="https://www.nytimes.com/2020/05/06/us/politics/trump-coronavirus-recovery.html?action=click&module=Spotlight&pgtype=Homepage">five minutes ago</a>; we assume you're already aware of the glaring incompetence <a href="https://www.nytimes.com/2020/05/06/opinion/coronavirus-trump-taskforce.html?searchResultPosition=19">of the man</a> <a href="https://nymag.com/intelligencer/2020/05/jared-kushners-coronavirus-taskforce-is-incompetent.html">and his underlings</a>. Moreover, you're almost certainly equally aware of his <a href="https://www.statnews.com/2020/04/06/trump-hydroxychloroquine-fact-check/">desperate embrace of medications that never looked promising</a>, and his <a href="https://www.youtube.com/watch?v=0wcQYA-ol_A">more unhinged pronouncements on disinfectants and ultraviolet light</a>.<br /><br />Yet the virus marches on, despite Trump's <a href="https://www.bbc.com/news/world-us-canada-52568405?intlink_from_url=https://www.bbc.com/news/coronavirus&link_location=live-reporting-story">attempts to distract and distort</a>. And as the bodies continue to pile up, Trump is likely to become even more unhinged in his public statements, if that's even possible. But supposing it is, one very straightforward way is to capitalize on those decades of the Republican Party program to nurture a hatred for the (liberal), elite, educated classes so smug in their coastal enclaves, is to deny the reality of the situation itself. 70,000 deaths? <i>That's just fake news</i>. You would think that in a sane and prosperous society, this would be an impossible gambit. But there's <a href="https://www.axios.com/trump-coronavirus-death-toll-d8ba60a4-316b-4d1e-8595-74970c15fb34.html">already a whiff in the air that this strategy is coming any day now, if it hasn't already</a>. After all, since disregarding solid evidence is not precisely a new strategy for Trump, and a kind of barely-contained rage at experts is a feature of his administration, why should COVID mortality statistics be sacred?<br /><br />I'll go out on a limb here and make a prediction that that's only the beginning, and denying the reality of the size and scope of the epidemic is only going to be the first move in a more active campaign against the medical establishment itself. Medicare is offering twenty percent bonuses for the care of COVID patients; this is being done so that these hospitals, which are hemorrhaging money both by decreased revenue and by purchasing all the equipment required for COVID care, can stay financially solvent. <br /><br />But don't color me surprised that in Trumpland, this will provide the basis for accusations of fraud. Where it goes from there, we don't know, although it is safe to say that tens of millions of people will continue to buy what he's selling. But the finger's about to get pointed at <i>us</i>, and I would not be surprised to see a local hospital somewhere be on the receiving end of the kinds of <a href="https://www.cnn.com/2020/04/01/politics/anthony-fauci-security-detail/index.html">death threats aimed at Dr. Fauci</a> should Trump whip them up. As Trump himself notes, <a href="https://www.youtube.com/watch?v=wOcY3XlzPzs">he does not take responsibility</a> for anything, especially something like COVID, so with each passing day, a new target is required.<br />
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--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com2tag:blogger.com,1999:blog-7655407863660711763.post-45701996638877809142020-05-03T09:35:00.001-04:002020-05-03T16:19:54.085-04:00COVID: The Dunning-Kruger Effect In Epidemiology<a href="http://www.billyrubinsblog.org/2020/04/covid-and-graphic-representations-of.html#comment-form">My most recent blog entry was</a>, by my assessment, fairly mild in its assertions: I simply attempted to show two graphics to make two specific points about COVID: namely, that the "official" state counts that only include those who were PCR positive for COVID represents an undercount; and that there is now mounting evidence that people spread the disease <i>before</i> their symptoms begin, which makes containment via contact tracing much more difficult. <br />
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Inherent in those two messages is <a href="https://www.amazon.com/Snowball-Blizzard-Physicians-Uncertainty-Medicine/dp/0465050646">a theme I've written about at length previously</a>, namely, that data in medicine has an essential fuzziness to it, and one shouldn't get <i>too</i> caught up in thinking that a number represents a precise, mathematical reality in the same way a physics equation does. Though maybe physicists might indicate that they have the same issues with interpreting data as we do in medicine. Hopefully mechanical engineers are more precise.<br />
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Anyway, I didn't think I was making an especially debatable point, and in the first half of the blog, the part about the relationship between the official count and the true count, I certainly didn't think I made any statements that could be construed as political (the end of the blog tosses in a typically Billy Rubenesque political potshot). Keep in mind I made no confident pronouncement about the exact total: I just pointed out that the real number of deaths from COVID is somewhere <i>between </i>the official count and the total number of deaths in a given county or state. Let me be clear: <i>that's not controversial</i>. Any epidemiologist could tell you this is true. <a href="https://www.cdc.gov/h1n1flu/estimates/April_November_14.htm#UnderCounting">Here, for instance, is a CDC document explaining this very phenomenon for influenza</a>.<br />
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So imagine my surprise when a reader writes back to tell me--politely but forcefully--that I was full of shit:<br />
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<span style="background-color: #fefdfa; color: #333333; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 13px; text-align: justify;"><i>We "know" that's an undercount. </i></span></div>
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<span style="background-color: #fefdfa; color: #333333; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 13px; text-align: justify;"><i>What you "know" ain't exactly "so". Compare 2019 deaths </i></span></div>
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<span style="background-color: #fefdfa; color: #333333; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 13px; text-align: justify;"><i>from 2020 deaths for NY. What we actually know </i></span></div>
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<span style="background-color: #fefdfa; color: #333333; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 13px; text-align: justify;"><i>is that there is a high degree of uncertainty. Sloppy thinking.</i></span></div>
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As I wrote, we <i>do</i> know that the official COVID mortality total is an undercount--though again, nobody knows by how much. Which is to say, there <i>is </i>a degree of uncertainty, and I don't think I ever said that wasn't the case. But I was informed that what I <i>know </i>ain't exactly <i>so</i>, and was told to compare 2019 from 2020 deaths for NY.<br />
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No link was provided so I can't be sure what the reader was referring to, but <a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm">here is the CDC's rolling estimates of total deaths by month in New York dating to 2017</a>:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8hFTjDXDNLC3wYNqncZpvRs2Jrx1cmH5Psi7aacyogi_kKO6Go6z4LcR9YP0pgsXl33ylJAB3GPQnoaYZEdHe9FxG27CZuc-ic2KJ3jhAlYcLvsFjZnvrEmvXgKf5-LmIQ2bPde0iMuhV/s1600/2020+05+03+CDC+excess+deaths+NY.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="587" data-original-width="1057" height="353" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8hFTjDXDNLC3wYNqncZpvRs2Jrx1cmH5Psi7aacyogi_kKO6Go6z4LcR9YP0pgsXl33ylJAB3GPQnoaYZEdHe9FxG27CZuc-ic2KJ3jhAlYcLvsFjZnvrEmvXgKf5-LmIQ2bPde0iMuhV/s640/2020+05+03+CDC+excess+deaths+NY.png" width="640" /></a></div>
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Spot the one part of the graphic that's different? So while there is some uncertainty about the precise number of deaths, there's no debating that COVID mortality is quite substantial. You can also break it down by including known COVID cases, and even including that, you still end up with a huge number of deaths above recent historical averages, <i>which strongly suggests missed COVID diagnoses </i>(you want to look at the lime-green bars above the average):<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjA5Tdfz9WPlq-yuloCAMXkAgb33w8weUPDLsY3pV0PCxpHw_gG0_idAPgjpBHgIpTetGKA02va5ztzuC-pPbtSupK6tQTsvk7y-b7_tsMU7fzbWwaE86yXbtAgQO9B_EsHsn15JAjp-T3l/s1600/2020+05+03+CDC+excess+deaths+NY+2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="593" data-original-width="1057" height="358" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjA5Tdfz9WPlq-yuloCAMXkAgb33w8weUPDLsY3pV0PCxpHw_gG0_idAPgjpBHgIpTetGKA02va5ztzuC-pPbtSupK6tQTsvk7y-b7_tsMU7fzbWwaE86yXbtAgQO9B_EsHsn15JAjp-T3l/s640/2020+05+03+CDC+excess+deaths+NY+2.png" width="640" /></a></div>
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The reader then goes on to imply that epidemiologists must suffer from some kind of rain-is-falling-everywhere bias with what certainly reads like a sneer about the perceived snobbery of coastal elites:<br />
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<span style="background-color: #fefdfa; color: #333333; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 13px; text-align: justify;"><i>People keep saying that covid is coming to my area </i></span></div>
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<span style="background-color: #fefdfa; color: #333333; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 13px; text-align: justify;"><i>of flyover country, but our new infections have been flat </i></span></div>
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<i><span style="background-color: #fefdfa; color: #333333; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 13px; text-align: justify;">for a month and our random swab sample </span><span style="background-color: #fefdfa; color: #333333; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 13px; text-align: justify;">showed almost 4% infections. </span></i></div>
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<span style="background-color: #fefdfa; color: #333333; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 13px; text-align: justify;"><i>I figure we're at 16% who have or have had covid. </i></span></div>
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<span style="background-color: #fefdfa; color: #333333; font-family: "arial" , "tahoma" , "helvetica" , "freesans" , sans-serif; font-size: 13px; text-align: justify;"><i>Herd immunity by end of June.</i></span></div>
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Why and how this reader from "flyover country" <i>figures</i> "we're at 16 percent" is not made fully clear, nor is it clear whether he is qualified to pronounce with confidence that his community, wherever it is in flyover country, will have herd immunity by the end of June. (We'll assume for a second that we're dealing with a <i>he,</i> given the whiff of testosterone ambient in the I'm-splainin'-to-you-you-pointy-headed-professor commentary.) The fact that this reader has previously gravitated toward embracing <a href="http://www.billyrubinsblog.org/2020/04/covid-long-tale-of-hydroxychloroquine.html">what amounts to folk remedies for COVID, touted by people too ignorant to understand their own limitations as they conduct what they mistakenly believe are "clinical trials,"</a> might suggest that they regard assertions made with bravado to have high truth value, regardless of the expertise of the person making those assertions.<br />
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I simply don't know what motivates these declarations, although I am confident that his confidence is overblown, given that <a href="https://www.nytimes.com/2020/05/02/opinion/sunday/coronavirus-prediction-laurie-garrett.html?action=click&module=Opinion&pgtype=Homepage">virtually every qualified epidemiologist thinks we are far from the finish line of this pandemic</a>. What does our reader know that every PhD steeped in epidemiology, virology, and biostatistics does not? Or is this just denial masquerading as swagger? I have an opinion on this; I'll let you guess at it.<br />
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Wherever his section of flyover country might be, it <i>is</i> curious that he might assert everything is hunky and dory in rural or less urban America. Take a look at this graphic from <i>WaPo</i> displaying <a href="https://www.washingtonpost.com/graphics/2020/national/coronavirus-us-cases-deaths/?pwapi_token=eyJ0eXAiOiJKV1QiLCJhbGciOiJIUzI1NiJ9.eyJjb29raWVuYW1lIjoid3BfY3J0aWQiLCJpc3MiOiJDYXJ0YSIsImNvb2tpZXZhbHVlIjoiNWE1ZmVkNWVhZGU0ZTI0NmIxMWMwYmRhIiwidGFnIjoiNWVhZGQ0YzZmZTFmZjY1NGMyY2Y0NjliIiwidXJsIjoiaHR0cHM6Ly93d3cud2FzaGluZ3RvbnBvc3QuY29tL2dyYXBoaWNzLzIwMjAvbmF0aW9uYWwvY29yb25hdmlydXMtdXMtY2FzZXMtZGVhdGhzLz91dG1fY2FtcGFpZ249d3BfdG9feW91cl9oZWFsdGgmdXRtX21lZGl1bT1lbWFpbCZ1dG1fc291cmNlPW5ld3NsZXR0ZXImd3Bpc3JjPW5sX3R5aCZ3cG1rPTEifQ.lXyvxLrwoO2JMilZvVVltWFeVC09OxKkNfihMAOv-AA&utm_campaign=wp_to_your_health&utm_medium=email&utm_source=newsletter&wpisrc=nl_tyh&wpmk=1">the ten counties in the US with the highest rate of deaths, adjusted for population</a>:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrM34CMplPA5U4TruH3Q_8OCIf5Q0RIeLiQWQ3N7B9VN6IyYc8z-XdQPvMDEbuiN49Jb-A1rkeH5fg36ZXtd3ZDefaHOqK736-RDMBgf2u4ci14VTsjdTGeP1mtOvszusEe6xFDUAnUy_3/s1600/2020+05+03+COVID+mortality+by+county.bmp.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="591" data-original-width="791" height="476" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrM34CMplPA5U4TruH3Q_8OCIf5Q0RIeLiQWQ3N7B9VN6IyYc8z-XdQPvMDEbuiN49Jb-A1rkeH5fg36ZXtd3ZDefaHOqK736-RDMBgf2u4ci14VTsjdTGeP1mtOvszusEe6xFDUAnUy_3/s640/2020+05+03+COVID+mortality+by+county.bmp.png" width="640" /></a></div>
In short, <i>half</i> of the ten counties with the highest rate of deaths are in less populated, non-urban settings: four counties in southwest Georgia and a suburbanish community outside of New Orleans. That would strongly suggest that this virus will spare no area, and supposing that it has a predilection strictly for urban centers is wishful thinking.<br />
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Why has our reader's area been spared? <a href="https://www.nytimes.com/2020/05/03/world/asia/coronavirus-spread-where-why.html?action=click&module=Spotlight&pgtype=Homepage">Nobody knows.</a> Japan has the oldest population in the world, and so they should be experiencing a level of misery on par with Italy. So far, they're not. Most countries from warm-weather climates aren't seeing much death; <a href="https://www.npr.org/sections/goatsandsoda/2020/04/20/838746457/covid-19-numbers-are-bad-in-ecuador-the-president-says-the-real-story-is-even-wo">not so for Ecuador</a> and <a href="https://www.nytimes.com/aponline/2020/04/30/world/americas/ap-lt-virus-outbreak-brazils-neighbors.html">Brazil</a>, which are getting hammered. But one reasonable interpretation is that, <a href="https://www.youtube.com/watch?v=__VQX2Xn7tI">in the words of Kim Carpenter, we've only just begun</a>, and over time we're going to see these numbers even out if people return to their normal habits. <a href="https://www.cidrap.umn.edu/news-perspective/2020/05/who-extends-covid-19-emergency-cases-soar-brazil-russia">Russia, for instance, was fine until it wasn't</a>. (Though skepticism of official Russian statistics, given its political structure, is probably warranted, especially as news <a href="https://www.dailymail.co.uk/news/article-8258591/Top-Russian-doctor-falls-5th-floor-window-conference-lack-PPE-medics.html">stories of strange "accidents" befall Russian doctors</a>. Given <a href="https://www.politico.com/story/2019/06/28/trump-putin-relationship-g20-1386490">Trump's warm regard for Putin</a>, Anthony Fauci should watch his back.)<br />
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As with hydroxychloroquine and clinical trials, on the topic of armchair epidemiology, it might be best to follow the simple, but lifesaving, dictum: <a href="https://www.urbandictionary.com/define.php?term=Don%27t%20try%20this%20at%20home">don't try this at home</a>.<br />
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I grew up in flyover country, by the way. I have never forgotten where I have come from.<br />
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--Billy<br />
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(Postscript: we note, with embarrassment, that the great Ms. Carpenter's first name was, of course, Karen and <i>not</i> Kim. <i>Anonymous </i>below in the comments has decided we're not worthy as a consequence, and we find it hard to argue the point, as we'd say the same thing. Some things are not worthy of mercy.)Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com3tag:blogger.com,1999:blog-7655407863660711763.post-53920940016845543042020-04-21T08:19:00.001-04:002020-04-21T08:19:17.936-04:00COVID, and the Graphic Representations of Death, and Transmission<span style="color: #1c1e21; font-family: Helvetica, Arial, sans-serif;"><span style="background-color: white; font-size: 14px; white-space: pre-wrap;">Let's do two curves today: the first is <a href="https://www.nytimes.com/interactive/2020/04/21/world/coronavirus-missing-deaths.html">from the <i>Journal of the New York Times</i>, and shows what is likely to be a more accurate death toll from the COVID outbreak thus far</a>. Counting, it turns out, is a hard business in medicine. What is often the "official" count of COVID mortality in any given country or smaller municipality is a count that a government officer tallies by receiving reports from professionals--usually but not always physicians--who note in a form that so-and-so died, and had a positive COVID test. But that excludes people who <i>never got</i> a COVID test, either because they died outside a hospital, or because testing was woefully inadequate and there simply weren't enough tests to go around, which <a href="https://www.nytimes.com/2020/03/28/us/testing-coronavirus-pandemic.html">might resemble a large, wealthy country located in North America</a>. </span></span><br />
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<span style="color: #1c1e21; font-family: Helvetica, Arial, sans-serif;"><span style="background-color: white; font-size: 14px; white-space: pre-wrap;">Thus, a simple but different way of sizing up the impact of COVID is simply to compare <i>all</i> deaths to the averages in previous years (which are, generally speaking, roughly stable from year to year in most places in the US where there hasn't been mass influx or exodus). If the needle moves above the historical average, then that is a very strong indicator that COVID deaths are being missed. In the <a href="https://www.youtube.com/watch?v=p5L_QkUZ-3s">immortal words of Rasheed Wallace</a>, the <a href="https://www.urbandictionary.com/define.php?term=ball%20don%27t%20lie">ball don't lie</a>.
Anyway, the article looks at 2020 compared to previous years, and each figure, from various parts of the world, all show the impact of the COVID outbreak in stark terms. Because the graphics at <i>NYT </i>can't be pulled and reproduced, a similarish graphic can be found in <a href="https://reason.com/2020/04/09/as-more-death-data-becomes-available-covid-19-looks-less-and-less-like-the-flu/">this piece from Reason</a>:
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSfw2MAda3D4NNGn7OqdxHCLmGvEgUtANL722kDMIbHST-4Iuz7AMOvoZ8AFQCkvQq4im9OrxyTOGWFW7s0g-lw7cSzHn3orsgj6hOpQRsvf4tenbDpkR08TxCxsgmcIXVsU1h2q8f_YJv/s1600/NewYorkStateDeathsFluCovid.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="731" data-original-width="1300" height="179" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSfw2MAda3D4NNGn7OqdxHCLmGvEgUtANL722kDMIbHST-4Iuz7AMOvoZ8AFQCkvQq4im9OrxyTOGWFW7s0g-lw7cSzHn3orsgj6hOpQRsvf4tenbDpkR08TxCxsgmcIXVsU1h2q8f_YJv/s320/NewYorkStateDeathsFluCovid.jpg" width="320" /></a></div>
<span style="color: #1c1e21; font-family: Helvetica, Arial, sans-serif;"><span style="background-color: white;"><span style="font-size: 14px; white-space: pre-wrap;">The upper, flat, gray line, hovering around the number 2000, is the average number of deaths over the preceding seven days in New York City during the years 2015-2019--that is, it's an average of averages. The colored numbers toward the bottom are the seven-day averages of deaths from influenza in New York in any given year from the same period.
Where this departs from the </span><i style="font-size: 14px; white-space: pre-wrap;">NYT </i><span style="font-size: 14px; white-space: pre-wrap;">piece is that these data <i>only </i>look at </span><span style="font-size: 14px; white-space: pre-wrap;">official</span><span style="font-size: 14px; white-space: pre-wrap;"> COVID and flu deaths and compares them to the <i>overall </i>total. For 2020, you would <i>also </i>need to add in everyone else who has died, which now includes a sizable chunk of people, and the red spike would climb even higher. (It's also worth keeping in mind, in an apples-to-apples comparison, that the same issue applies to deaths from influenza, which is at least as hard to diagnose as COVID, so the total deaths from flu in any given year are also higher than the official number. Epidemiologists have various tricks to tease out a reasonably accurate picture of flu mortality in any given year. But as noted before, a very useful way to get a sense of how lethal an epidemic is in a given year, whether from flu or COVID, is to just look at the total number of deaths and compare it to recent years, and if the official number <i>just</i> from the infection exceeds the <i>total</i> mortality in previous years, it's a sure bet that the epidemic is especially severe. The ball don't lie.)
The <i>Times</i> piece includes the observation that "t</span></span><span style="font-size: 14px; white-space: pre-wrap;">he totals include deaths from Covid-19 as well as those from other causes, likely including people who could not be treated as hospitals became overwhelmed," and <a href="https://www.nytimes.com/2020/04/20/health/treatment-delays-coronavirus.html">link to an article explaining this heartbreaking phenomenon</a>. During the Ebola outbreak, for instance, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0150080">pregnant women were unable to receive adequate prenatal care due to hospitals and clinics being closed, and a small percentage of women died from complications of routine problems that would have been handled had such facilities been open</a>. Thus, Ebola killed those who never became infected with the virus, and as the COVID outbreak proceeds, there will be similar effects on overall mortality.
Curve #2 is here:</span></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOmdmxj5uj7XB9fnTeodWFLIKgSL93ZKS1zuV_xv-UdtS749TsRxIT32nLAsMgMF4Y3J-wIL4DyYEl4AkGL4V56FFgk-ZOp3LU_1ooY7j59KylMYHjOcXkpXIu7uoetTC1GTo2i-CzOfoa/s1600/transmissibility+COVID.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="459" data-original-width="556" height="264" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOmdmxj5uj7XB9fnTeodWFLIKgSL93ZKS1zuV_xv-UdtS749TsRxIT32nLAsMgMF4Y3J-wIL4DyYEl4AkGL4V56FFgk-ZOp3LU_1ooY7j59KylMYHjOcXkpXIu7uoetTC1GTo2i-CzOfoa/s320/transmissibility+COVID.png" width="320" /></a></div>
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<span style="color: #1c1e21; font-family: Helvetica, Arial, sans-serif;"><span style="background-color: white; font-size: 14px; white-space: pre-wrap;">It is from <a href="https://www.nature.com/articles/s41591-020-0869-5">this paper</a>, entitled "</span><span style="font-size: 14px; white-space: pre-wrap;">Temporal dynamics in viral shedding and transmissibility of COVID-19." The key here is that the zero of the x-axis is <i>not</i> at the left corner where it is normally found, but rather can be found four ticks in. The gist of this figure--which, to be clear, is like so many other things in COVIDland merely a model based on relatively limited data--is that people with COVID may actually be in their most infectious phase <i>before they even know they might be infected</i>.
And <i>that </i>is one very serious problem as we collectively contemplate, at the local, national, and global levels, about how to resume economic and social activity that resembles something approaching normal. "<i>Significant presymptomatic transmission would probably reduce the effectiveness of control measures</i> that are initiated by symptom onset, such as isolation, contact tracing and enhanced hygiene or use of face masks for symptomatic persons," the authors state in the characteristic understatement of scientific communication (that's my emphasis; journals don't allow for italics). But make no mistake, this makes ongoing policy discussions, which <a href="https://www.nytimes.com/2020/04/19/us/politics/charlie-kirk-conservatives-coronavirus.html">have already become weaponized</a>, not only among the <a href="https://www.nytimes.com/2020/04/21/us/tony-spell-church-assault-coronavirus.html">violent nitwits and infants of the MAGA coalition</a> in the US, but in <a href="https://time.com/5816243/brazil-jair-bolsonaro-coronavirus-governors/">various other locales as well</a>, a good deal more challenging.
The net result will almost certainly be even more graves, and those who will soon reside there.</span></span><br />
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<span style="color: #1c1e21; font-family: Helvetica, Arial, sans-serif;"><span style="font-size: 14px; white-space: pre-wrap;">--Billy</span></span>Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com2tag:blogger.com,1999:blog-7655407863660711763.post-86733235238696103152020-04-19T13:44:00.001-04:002020-04-19T15:09:41.278-04:00COVID, and Delayed GratificationWhile a picture may be worth a thousand words, sometimes one word can stand alone without the assistance of the other nine hundred ninety nine.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiti4q_NWa9YgAOrVRCcrBpb-j5tMjcYM2lpAvd1MrznoL6HBdLRgqXzwELPxE0UzINMdLrVR4CdKx4GxIcXJ4e8fa5FkSACg5hVteOFlYjrh0VfOvF5i8qOTYtj0hLVoelltLJzey-M2iu/s1600/trump+brownshirts.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1067" data-original-width="1600" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiti4q_NWa9YgAOrVRCcrBpb-j5tMjcYM2lpAvd1MrznoL6HBdLRgqXzwELPxE0UzINMdLrVR4CdKx4GxIcXJ4e8fa5FkSACg5hVteOFlYjrh0VfOvF5i8qOTYtj0hLVoelltLJzey-M2iu/s320/trump+brownshirts.jpg" width="320" /></a></div>
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In the case of this picture above, which displays the raw emotions of <a href="https://www.nytimes.com/2020/04/16/us/coronavirus-rules-protests.html?action=click&module=RelatedLinks&pgtype=Article">Midwestern Trumpistas as they literally shout about their states' governments decisions to maintain a lockdown policy</a> in the face of the COVID outbreak, the one-word description can be: Brownshirts.<br />
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In case you aren't familiar with that reference, <a href="https://www.theholocaustexplained.org/the-nazi-rise-to-power/the-nazi-rise-to-power/sa-and-ss/">here's a primer on the Brownshirts</a>. Money quote: "Violent and often disorderly, the SA were primarily responsible for the protection of leading Nazis and disrupting other political opponents’ meetings, although they often had a free rein on their activities." The picture above is from the Statehouse in Columbus, Ohio, but this could just as easily be from Berlin or Munich in 1932.<br />
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At any rate, as I have been thinking about this blood-chilling picture, and of how Trump has (again) whipped up his mob as a means of throwing a temper tantrum when confronted with the reality that <a href="https://www.electoral-vote.com/evp2020/Pres/Maps/Apr14.html#item-1">his power is not, in fact, absolute</a>, it occurred to me that these <a href="https://www.nytimes.com/2020/04/17/us/politics/trump-coronavirus-governors.html">"protests" he has "encouraged"</a> can be likened to one of the most famous experiments of psychology from the 20th century.</div>
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The research is commonly known as <a href="https://en.wikipedia.org/wiki/Stanford_marshmallow_experiment">the marshmallow experiment</a>. In the popular understanding, the experiment was designed to evaluate whether a child could delay the gratification of having one tasty treat (marshmallow, pretzel, cookie, whatever) by holding out a full fifteen minutes, at which point they would be given an <i>additional</i> one. The experimenters tracked the children through time, and what resulted was the surprising finding that <a href="https://psycnet.apa.org/doiLanding?doi=10.1037%2F0012-1649.26.6.978">those who were unable to delay gratification had worse outcomes in what the authors refer to as "cognitive and academic competence and ability to cope with frustration and stress in adolescence</a>." In other words, the inability of some children to restrain themselves predicted a less happy and more troubled life.<br />
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It turns out that, as with many other popular understandings of psychological research (like, say, the <a href="https://www.theatlantic.com/health/archive/2015/01/rethinking-one-of-psychologys-most-infamous-experiments/384913/">infamous Milgram experiment</a>), the story of the marshmallow experiment is not quite as straightforward as is often portrayed. For one, the researcher who designed the experiment, one Walter Mischel, <a href="https://www.npr.org/sections/health-shots/2018/09/21/650015068/remembrance-for-walter-mischel-psychologist-who-devised-the-marshmallow-test">has noted that what people have assumed about the experiment is almost the polar opposite of his philosophy of psychology</a>. The point of the study, he argues, was to demonstrate that children could <i>change</i> their behavior with the proper help--that is, with a few mental tricks helpfully provided by the adult, they could in fact wait as long as their classmates. Moreover, <a href="https://www.theatlantic.com/family/archive/2018/06/marshmallow-test/561779/">other researchers have been unable to replicate Mischel's findings</a>, casting doubt on whether the results, and the conclusions on which they were based, were valid.<br />
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None of which is especially relevant here. What <i>is</i> relevant is that the question of when to re-open the economy in the midst of the COVID outbreak has become, in effect, a giantic, multi trillion-dollar marshmallow experiment, and what we have witnessed, from the President to his thus-far-still-hapless-but-nevertheless-menacing MAGA/Sturmabteilung troops, is the need for instant gratification run amok. The parallels aren't perfect, of course: there will be nothing "tasty" to the one-marshmallow scenario of returning to life too soon, and even the "two marshmallows," for which the waiting is necessary, is merely a best-of-many-bad-options scenario. But it does frame the actions of the President and his horde of thugs as a massive, collective expression of infantilism of the most lethal sort.</div>
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--Billy</div>
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Postscript: a friend writes, brilliantly, "Trump is the most dangerous kind of damaged-child-in-adult-body. He would've just stabbed the researcher, stuffed the whole bag of marshmallows down his pants, and gone home." Ha!</div>
Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com1tag:blogger.com,1999:blog-7655407863660711763.post-10227253290667772452020-04-16T18:57:00.001-04:002020-04-17T08:27:50.349-04:00What an Anti-Chinese Fox Piece Tells You About the Republican Party<a href="https://www.foxnews.com/politics/coronavirus-wuhan-lab-china-compete-us-sources?fbclid=IwAR1vvHmb2y1QALZqMltAQx6QkezrmfSqR94UqUFoy71q4f0pg8HJuUrAwcY">Here's the piece</a>, entitled, "Sources believe coronavirus originated in Wuhan lab as part of China's efforts to compete with US." The Cold War-era editors of <span style="font-size: 20px;">правда</span>--which we in English call <i>Pravda</i>, and was once the Soviet Communist Party's Official Newspaper--would be smiling upon the Fox News Division right now, content to know that the dark arts in which they made their mark, specifically, propaganda, still has a happy home. (Actually, <a href="https://gazeta-pravda.ru/">they're still around</a>, and though the Billy Rubin Blog staff is woefully under-educated about the details of Russian oligarchy, we wouldn't be surprised to learn that there isn't much truth to be found in the Pravda of Putin's Russia, either.)<br />
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Big shock coming: the Fox piece doesn't really tell you much about China, as it is effectively one big Lie wrapped in a cocoon of half-plausible journalistic conventions to provide the scantiest justification for being circulated to millions of rubes who will swallow the story without much fuss, happily scarfing down the news equivalent of canned tuna laden with mercury and PCBs. <br />
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But what such a story <i>does</i> tell you about is the increasing desperation of Donald Trump, the Republican Party, and its various subsidiaries to pin the tail on whatever donkey they can find, so as to distract from their own glaring incompetence in the COVID outbreak, which at this point is most appropriately described as "murderously stupid," the occasional competence of a Republican governor such as Charlie Baker, Mike DeWine, or Larry Hogan notwithstanding.<br />
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Let's start all the way back in early February--in other words, what seems like a lifetime ago--with the <i>original</i> irresponsible speculation about the Chinese origins of COVID to see just how feeble the current attempt at reportage really is. The <a href="https://foreignpolicy.com/2020/02/05/coronavirus-epidemic-wuhan-misinformation-online-social-media/">full details can be found here in a piece by Foreign Policy</a>, but the gist is that some Indian researchers working in a lab circulated a manuscript looking at the protein coat of the COVID virus, and noted some similarities to the outer surface of HIV. An Indian scientist and columnist <a href="https://en.dharmapedia.net/wiki/Anand_Ranganathan">named Anand Ranganathan</a>, in what can only be described as a flight of fancy, wondered aloud in a <a href="https://twitter.com/ARanganathan72/status/1223463647143505920">Tweet</a> on January 31 whether this could mean that Chinese scientists had been mucking about with HIV in a lab and somehow ended up with a version of Frankenvirusstein that got out on the loose. By later in the day, Ranganathan thought better of his armchair speculation, and withdrew the Tweet, which if you click on the link above, you will see. (The scientific paper was withdrawn before submitting to the peer review process, as well.)<br />
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But by that point, like the actual virus itself, the Chinese-bioweapons-lab origin story was on the loose and circulating across the globe, and causing only slightly less mayhem. Conspiracy theorists picked up the ball and ran with it, where it almost immediately found a happy home among Republican Party leaders; <a href="https://www.nytimes.com/2020/02/17/business/media/coronavirus-tom-cotton-china.html">Oklahoma Senator Tom Cotton was so confident in its plausibility that he gave interviews</a> suggesting "we need to at least ask the question" of whether the Chinese government was behind the whole thing. <br />
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That a high-ranking Republican politician would resort to <a href="https://en.wikipedia.org/wiki/Loaded_question">base sophistry and rhetorical gimmickry</a> in 2020 shouldn't have come as a surprise to anyone, given the Red Team's penchant for similar shenanigans in other charged topics where there's a clear scientific consensus, such as <a href="https://books.google.com/books?id=Pr-ZJPcXAvsC">"teaching the controversy" of evolution (hint: there's no controversy)</a> and encouraging denial about the reality of man-made fossil-fuel driven global warming (maybe <a href="https://www.politico.com/agenda/story/2019/09/11/climate-change-conservative-republicans-000955/">the Republican consensus there might be beginning to crack</a>, though no sane person should be holding their breath). Cotton could always claim he wasn't <i>actually </i>alleging this was a fact--since that would require outright lying, something even scalawags like Cotton hesitate to do--but merely noting that since a <i>rumor </i>existed, however ridiculous, it should be considered. Thus, the Senator from Arkansas was able to have his xenophobic cake and eat it too. (Of course, Trump lies without the slightest hesitation; Cotton might demur simply because he isn't sure he can pull it off as well as his master.)<br />
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Since the allegation was built on high-octane paranoia mixed with dark fantasy, it made the rounds for maybe 72 hours before submerging itself into the collective right wing id, and would have evaporated into nothingness. But Fox, along with other right wing media, appears to have regurgitated the story in what seems like a desperate attempt at pointing fingers at anywhere other than where they should be aimed, namely, at a fumbling and laughably inept White House. And it plays like a movie sequel in which a lazy producer simply pops a Roman numeral up, cycles through the same cast, and hopes for further profits to roll in. Since there's no new hard news, Fox News is required to truth-launder its claims by a reliance on "sources." Here's the key graf:<br />
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<span style="background-color: white; color: #222222; font-family: "roboto" , "helvetica neue" , "helvetica" , "arial" , sans-serif; font-size: 18px;"><b>The “increasing confidence” comes from classified and open-source documents and evidence, the sources said. Fox News has requested to see the evidence directly. Sources emphasized -- as is often the case with intelligence -- that it’s not definitive and should not be characterized as such. Some inside the administration and the intelligence and epidemiological communities are more skeptical, and the investigation is continuing.</b></span><br />
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In other words: this stuff is <i>still </i>just made up, but it's made up by people <i>inside</i> the government, and therefore they can be considered "sources" to lend an air of legitimacy to the claims as if this were a well-sourced <i>New York Times</i> story. In reality, it almost certainly means that a Trumpparatchik sent an email to a Fox staffer after reading a feverish post on 4chan repeating the yarn. But now the Fox staffer can pass it along as coming from a secret government official who really knows their stuff. Fox even add the nice buyer-beware touch of noting that this story is <i>not</i> definitive and should <i>not</i> be characterized as such. In the immortal <a href="https://en.wikiquote.org/wiki/Sidney_Morgenbesser">words of Sidney Morgenbesser: yeah, yeah</a>.<br />
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To note that Fox News wants to whip up outrage against an un-American Other (which is to say, not white) like China, and that it considers innuendo to be no less important to their brand of journalism than reporting unassailable facts, is not precisely an earthshaking revelation. So why care at all? Because there are <i>plenty</i> of <i>entirely legitimate</i> reasons to criticize China. So much so that it's like shooting fish in a barrel. And yet, with the ammunition sitting out on the table, practically <i>begging </i>to be used, Fox chooses not only to hold their fire, they don't even lock-and-load.<br />
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If the Federal US response has been an abject embarrassment, China hasn't precisely coated itself in glory, either. When physicians and scientists, all of whom were working <a href="https://www.bbc.com/news/world-asia-china-51409801">at great personal risk</a>, tried to raise the alarm that a frightening new virus appeared to be circulating in Wuhan, <a href="https://www.nytimes.com/2020/02/01/world/asia/china-coronavirus.html">local government leaders used their authority to silence or otherwise intimidate the experts as troublesome worry-warts whose interference might have negative effects on the economy</a>. (Sound familiar?)<br />
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As the epidemic worsened, the US Government, along with the World Health Organization, offered help by sending leading virologists, physicians, and epidemiologists. <a href="https://www.latimes.com/science/story/2020-01-28/coronavirus-china-accepts-who-help">China refused the offers until finally relenting and allowing in experts by the end of January</a>.<br />
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As January progressed, the outbreak became out of control and could no longer be swept under the rug by local leaders. So the damage control response was to erase the evidence, as <a href="https://www.ft.com/content/aa5f37ab-4d67-494c-9434-3b044524c4fe">the "wet market" where the virus almost certainly originated was wiped clean</a>, preventing any opportunity to fully understand the circumstances of the virus's jump into humans. (Side note: <a href="https://www.latimes.com/food/story/2020-03-11/coronavirus-china-wet-markets">"wet market" is, at least according to one reporter, akin to the American concept of the Farmer's Market</a>, and as such isn't particularly exotic; <i>some</i> wet markets, such as the Huanan Wholesale Market in Wuhan, do substantial traffic in exotic animals, and one of those animals, <a href="https://www.cell.com/current-biology/pdfExtended/S0960-9822(20)30360-2">perhaps a pangolin</a>, is highly likely to be the original host. All the early epidemiology points to the Huanan Market as Ground Zero, but the trail has been forever lost due to the local government's eagerness to cover it up.)<br />
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After reeling in January and early February, the national Chinese government responded in full force, and with a level of competence that has thus far put the Americans to shame. They famously <a href="https://www.nytimes.com/2020/02/03/world/asia/coronavirus-wuhan-hospital.html">built a large hospital for those with the virus in less than two weeks</a>, shut down travel in Hubei Province, did <a href="https://www.bbc.com/news/business-51305566">reasonably well at feeding a locked-down population the size of New York</a>, and, to use the parlance commonplace today, flattened its epidemic curve. But what pride it could have taken in a job well done was eclipsed by the Chinese government's worst authoritarian tendencies: they have <a href="https://www.nytimes.com/2020/03/14/business/media/coronavirus-china-journalists.html">prevented honest reporting of the outbreak</a>, <a href="https://www.nytimes.com/2020/04/07/world/asia/china-tycoon-coronavirus.html">"investigated" critics of President Xi</a> to the point <a href="https://www.nytimes.com/2020/03/14/world/asia/china-ren-zhiqiang.html">where they simply disappear</a>, and <a href="https://www.nytimes.com/2020/04/02/us/politics/cia-coronavirus-china.html">publish data about their epidemic that has increasingly strained credulity</a>, suggesting that they are <a href="https://www.nytimes.com/2020/04/03/world/asia/coronavirus-china-grief-deaths.html">finding ways by which they are juking their stats to look more impressive than they really are</a>.<br />
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So with all these easy targets out there in broad daylight, wagging their tails, why would Fox pick the tin-foil hat, kooky theory to promote? And to promote it in a way that anyone other than a total doofus could see was a con?<br />
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The answer, of course, is that Donald Trump <i>approves</i> of ignoring experts, silencing journalists, destroying evidence, intimidating opponents, protecting personal interests above those of the public good, and sidelining the civil servants who protect that public good. <a href="https://www.theatlantic.com/international/archive/2018/03/trump-xi-jinping-dictators/554810/">Trump's admiration of President Xi's worst dictatorial tendencies</a> couldn't be more plain. These things <i>constitute</i> his political program, so of course Fox wasn't going to criticize China for <i>that</i> stuff.<br />
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--Billy<br />
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postscript: Since the precise origins of COVID are not firmly established, <i>could</i> there be some kind of a link to a lab researcher who got infected doing research and then spread it? Perhaps it doesn't involve the fanciful bioweapon component, but could COVID have originated from a lab tech making a mistake simply in a scientific research institute? <a href="https://www.nytimes.com/2005/01/24/us/exposure-at-germ-lab-reignites-a-public-health-debate.html">Similar accidents have occurred in the United States</a>, so why not assume it could have happened there?<br />
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Two answers. The first is: yes, it's possible; <a href="https://thebulletin.org/2020/03/experts-know-the-new-coronavirus-is-not-a-bioweapon-they-disagree-on-whether-it-could-have-leaked-from-a-research-lab/#">some scientists acknowledge that possibility here</a>. But if so, a lab accident simply becomes a different version of the wet market origin, which is to say, there may be human error at bedrock, but not the kind of nefarious Chinese world domination scheme that is driving episodes of nocturnal emissions among the Fox staff. One doesn't need to resort to science fiction to see evidence of China's imperial ambitions: <a href="https://www.latimes.com/world-nation/story/2020-04-10/coronavirus-doesnt-deter-chinas-aggression-in-south-china-sea">they're making it perfectly obvious for anyone to see</a>. And yet <i>that</i>, which is a legitimately concerning development years in the making, remains a relatively quiet story in American politics.<br />
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The second answer is, simply, that extraordinary claims require extraordinary evidence. After being fed a daily diet of Whoppers by the Republican party, not only in the form of Donald Trump although he is their most enthusiastic practitioner, the policy with respect to any of their pronouncements should be: <a href="https://www.youtube.com/watch?v=Ug75diEyiA0">where's the beef</a>?<br />
<a href="https://en.wiktionary.org/wiki/%D0%BF%D1%80%D0%B0%D0%B2%D0%B4%D0%B0" ping="/url?sa=t&source=web&rct=j&url=https://en.wiktionary.org/wiki/%25D0%25BF%25D1%2580%25D0%25B0%25D0%25B2%25D0%25B4%25D0%25B0&ved=2ahUKEwj0_cWM6-zoAhXil3IEHQ-UDDIQFjAEegQIAxAB" style="background-color: white; color: #660099; cursor: pointer; font-family: Roboto, arial, sans-serif; font-size: small;"></a>Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com1tag:blogger.com,1999:blog-7655407863660711763.post-7665619731438583372020-04-13T21:56:00.004-04:002020-04-14T08:23:42.935-04:00COVID: Randoms at the Easter/Passover Mark<b>I</b>. Christianity has Easter. Islam has Eid al-Fitr, which is coming in a little late this year at the end of May, but for the purposes of this discussion we'll count it as their "spring" holiday. And Billy Rubin's people have Passover to celebrate, which like Easter we are in the midst of as this is written.<br />
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I note this simply to say that I belong to a people whose spring holiday commemorates a plague--ten of them, in fact--so this year I think we've got the inside track for Western religion with the most appropriately-themed holiday.<br />
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<b>II</b>. If I have to see another vent setting with a fucking PEEP of 10 or more, I'm going to break something.<br />
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<b>III</b>. Along those lines, it remains clear to me that COVID is a disease of inadequate oxygenation. Ebola, I came to realize, was a disease of fluid loss. Technically we call the COVID complication "ARDS," which stands for "Acute Respiratory Distress Syndrome," which is a very fancy, doctory-sounding way of effectively saying that people have inadequate oxygenation. Now, the term "inadequate oxygenation" is <i>itself </i>a complicated phrase, but you can only simplify so far, as understanding what oxygen does in the human body takes <i>just</i> a bit longer to explain.<br /><i><br />Why</i> the oxygenation is inadequate--that is, what <i>leads</i> to ARDS--is, quite literally, a trillion-dollar question at this point. The oft-invoked explanation you hear in my circles is that it is the result of a "cytokine storm." What, you may ask, is a cytokine storm? There are two separate explanations. The first is that it is a complicated chain of biochemical signaling that results in edema (fluid going where it shouldn't be, like into the lungs) and the initiation of "the inflammatory cascade" (roughly, the process by which the body reacts to trauma and does its best attempt to heal itself, like when a person accidentally whacks their thumb with a hammer when trying to nail something to the wall). The thumb gets hot, red, and swollen, and in a cytokine storm, this thumb-swelling molecular process happens throughout the body, and in COVID, it seems to happen especially in the lungs.<br />
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The second explanation, which doctors are loath to admit, is that "cytokine storm" is a phrase designed to make us sound like we know what we're talking about when, to a large degree, we don't. It's akin to saying something like "the kinetic energy of air molecules as measured by kilojoules increases substantially in weather patterns, when increased levels of solar radiation reach the atmosphere due to the axis tilt of the earth." <i>That </i>is a fancier, dressed-up way of saying "it gets hot in the summer." To use the 25-cent words isn't being inaccurate, and it does express a <i>general</i> understanding of the process from a distance. But likewise it does not do an exceptionally good job of describing the mechanics of the process, and doesn't contribute much beyond the more pedestrian observation. It's just verbal strutting.<br />
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This is where we're at with COVID. To think of this disease in the blunt instrument, Mickey Mouse language of "inflammation activation" or "cytokine storm" is merely to say that Bad Shit Is Happening, but people who didn't go to medical school could have told you that. I don't mean to imply that my colleagues are <i>wrong</i> in using language like this, for the cytokine storm does, indeed, appear to be a useful general concept (not worth going into here, but there is much circumstantial evidence that this disease is associated with elevations of all kinds of "inflammatory markers" such as ferritin, ESR, CRP, IL-6 among others). It's what we know, give or take. That means we understand the <i>phenotypic</i> response, the end product of the molecular dysharmony, but we do not yet have a deep grasp of the <i>genotypic</i> mechanism of the disease: the actual, step-by-step process by which a tiny piece of nucleic acid wrapped in a protein coat kills a thing one trillion times its size.<br />
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No, my objection to the hand waving prevarications of "cytokine storms" and "inflammatory cascades" and "hyperactivation of the immune system" is that we portray ourselves as more knowledgeable about this than we are. Which means that, when we put forward some hopelessly simple hypothesis about what <i>might</i> make a difference for the better, we portray medicine, and the process by which it works, in a false light. It's a setup for heightened expectations, and since we don't <i>really</i> understand the mechanics of this virus at this point, it's a setup for failure, for having people lose faith in our ability to solve the problem.<br />
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And <i>that</i> is a pity, because our profession really <i>is</i> collectively competent enough to figure this out. It took more than two or three centuries of hard-won victories in creating the proper <i>system</i> by which we can solve the processes that drive disease, and the knowledge that we have gained in those two centuries have put the accomplishments of the preceding ten <i>millenia</i> to shame. But we don't know everything, and we're still figuring out this virus that we only just met three months ago. We're smart, and accomplished, but we shouldn't act smarter than we are.<br />
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This is the <a href="http://www.billyrubinsblog.org/2020/04/covid-long-tale-of-hydroxychloroquine.html">hydroxychloroquine story in a nutshell</a>. But it could just as easily be the ACE-inhibitor story. Haven't heard of the speculation about the relationship between <a href="https://www.nejm.org/doi/full/10.1056/NEJMsr2005760">ACE inhibitors and COVID</a>? That's because Donald Trump hasn't heard of it--and more importantly, because he has focused the public's attention on hydroxychloroquine by pouring so much kerosene on what was a slowly-burning dumpster fire about that drug that nobody outside of narrow medical circles has paid much attention to other investigations like this. <br /><br />But in my opinion it's a similar story. Like hydroxychloroquine, it's built on seemingly reasonable observations: ACE inhibition <i>might</i> upregulate the expression of the ACE-2 receptor; ACE-2 happens to (apparently) be <i>the</i> receptor by which COVID gains entry into the body; thus people using ACE inhibitors <i>might</i> be at risk for more severe disease because they have so many more ACE-2 receptors, leading to increased susceptibility to infection. <br />
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It's speculation built on an untested hypothesis built on a highly simplified model. It might be right, but likewise it could be wrong in one, or more than one, step along the path. Thus, someone taking ACE inhibitors might be at increased risk of a poor outcome if infected with COVID...<i>or</i> they might actually be <i>protected</i> by taking the medication. (The authors in the link argue for the latter.) So who is right? Nobody knows. So until this is studied properly--and <i>that</i> is the gift of two centuries of hard work, the idea that proper study is the only good way to know what works and what doesn't--we shouldn't jump on or off any pharmaceutical bandwagons in the way that an oafishly dull politician might endorse some Highly Iffy medication.<br />
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And keep in mind hydroxychloroquine and ACE inhibitors are just the beginning. Should we be using low molecular-weight heparin to interfere with "microangiopathic thrombosis"? Should we be giving steroids for "inflammation activation" during the "cytokine storm" during the "second phase" of illness? Should we give the antiviral remdesivir early in the disease, or late? And so on. To my mind, the answer is that we can't know if we don't study them properly, and that requires not being emotionally invested in the outcomes of one or more of these medications. Narrow your eyes, and steel your emotions. Otherwise there may be <i>more</i> bodies in the ground at the end of the day.<br />
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<b>IV</b>. There's so much good journalism being done that this entry isn't going to even bother with finding appropriate links, something we normally take quite seriously at the Billy Rubin Blog. (Of course, one does need to make sure to find the <i>good</i> journalism, since there's so much shit circulating on the interwebs, too. This is a topic for a different day: the need for a Good Housekeeping Seal of Approval, although the short version of it is, when in doubt, look to the <i>New York Times</i> or the <i>Washington Post</i> in the US; the BBC or Al Jazeera are pretty good sources, too.) But with that said, one story that we <i>haven't </i>seen--yet--involves that quintessentially American penchant for violence. Here's the basics.<br />
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The President has decided, against increasing piles of evidence, to go all in and promoted the healing properties of the above-mentioned drug hydroxychloroquine. As regular readers of this blog know, <a href="http://www.billyrubinsblog.org/2020/04/covid-long-tale-of-hydroxychloroquine.html">we weren't fans of it ten days ago</a>, which in COVIDland is equivalent to a few lifetimes, and several stories from the professional media were published in the days that followed that blog entry providing much-needed pushback against the anti-scientific boosterism that has accompanied hydroxychloroquine's star turn on the medical stage. But so far as I know, the President hasn't backed down, and there is no real reason to suppose that he will, since there is no downside to adding yet one more outrage into his catalog of misrepresentations, exaggerations, and overt falsehoods. Indeed, there is now strong evidence that <a href="https://www.washingtonpost.com/nation/2020/04/13/trump-fire-fauci-coronavirus/">Anthony Fauci will pay the price for telling truth to power</a>, and specifically on the subject of hydroxychloroquine.<br />
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Why is the continued mention of hydroxychloroquine important, besides this being another instance of how thoroughly appalling Donald Trump and his enablers and supporters are? And what does this have to do with violence? Because there is a slowly emerging consensus that the drug really does do more <i>harm</i> than good--which is to say, it quite likely <i>kills more people than it saves, if it saves anyone at all, which it probably doesn't</i>. The reason is that in order for hydroxychloroquine to work, it has to be dosed in such a way that <a href="https://www.dicardiology.com/article/covid-19-hydroxychloroquine-treatment-brings-prolonged-qt-arrhythmia-issues">the side effects, which includes potentially lethal damage to the electrical system of the heart</a>, prove more dangerous than any potential benefits. Many doctors clued into the medication, and who were appropriately skeptical of the phenomenon of bandwagon-jumping, were aware of this weeks ago, but now <a href="https://www.livescience.com/coronavirus-chloroquine-study-stopped-early.html">some hard evidence is trickling in</a> to support the notion that it's a genuinely dangerous drug in COVID infection. The data is by no means definitive, but likewise there's been <i>zero</i> legitimate evidence, in well-designed trials, that it has any lifesaving benefit. So on balance, it strongly suggests that it's bad medicine to give this drug unless it's part of a study. I have never felt otherwise.<br />
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And thus, Trump has not only taken on Fauci in touting what may well be a worthless drug to stressed and frightened Americans terrified of losing a loved one to COVID, but he may well be taking on the entire medical establishment should the evidence become increasingly clear--as the Billy Rubin Staff believe it will--that there ain't no there there with this drug. I've already been hearing stories, in blue blue Massachusetts, which is not exactly Trump Country, of people asking doctors about "Trump's drug" to help with their mothers and fathers. How many of them will accept an explanation from one of those pointy-headed infectious disease doctors that there's no value and more than a little risk in the drug, when their main source of news--which is to say, a nightly diet of <i>Donald Trump </i>talking from a lectern--continues to insist that it's a miracle drug, and that there's a Deep State conspiracy against him? And when will there be one of his followers who decides to make his or her (though probably his) views known at the end of a shotgun barrel? We are as a nation armed to the teeth, and the stress of this event, and the dead that continue to mount, increases the chance that doctors <i>as a group</i> become a target of hatred and fear in the mind of a psychopath who finds himself at the Resolute Desk.<br />
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<b>V</b>. Not to depress you more, but this thing won't be over in May, <a href="https://www.nytimes.com/2020/04/11/us/politics/coronavirus-trump-response.html">no matter what Donald Trump and his not-so-lovable Republican scamps say to the contrary</a>. I haven't a clue what the country, or the world, is going to look like after the various lockdowns and shelter-in-place orders are lifted, but what I can say with confidence is that <a href="http://www.billyrubinsblog.org/2020/03/a-covid-19-analogy-snowstorm.html">my analogy to a snowstorm was an unfortunate choice</a>, for the simple reason that snowstorms <i>end</i>. Eventually this will end, so perhaps in some sense it wasn't a total debacle to call it as such. But it's better to think in terms of a year rather than a few more weeks. We can't stayed locked down that long, and that means we are going to have to confront the question of just how many dead we can tolerate at the expense of worse instability.<br />
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<b>VI</b>. I saw a patient with COVID yesterday morning. He didn't look too bad. He shook his head at one point, noting, "It's crazy. I'm lying here in bed because <i>one guy</i> wanted to have bat soup." His joke wasn't literal, as it was clear from conversation that he understood <a href="https://www.theguardian.com/world/2020/apr/13/how-did-the-coronavirus-start-where-did-it-come-from-how-did-it-spread-humans-was-it-really-bats-pangolins-wuhan-animal-market">the exact origins of COVID are murky</a>, even if we are certain that the epidemic began in Wuhan. The point, he was trying to make--and making quite well--is that the only reason why he was in the hospital was because of an event that began on the other side of the world to <i>one</i> person, and that a chain of you-can't-believe-this failures ensued to land him where he was. We both laughed at the absurdity of the situation, an ice-breaking moment of black humor in the midst of the doctor-patient interaction.<br />
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I went home, slept, and came back this morning to discover that he was intubated hours before after the bottom fell out of his respiratory status, as it were. And the PEEP on his vent is set at ten.<br />
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--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com10tag:blogger.com,1999:blog-7655407863660711763.post-53560804668427962652020-04-04T14:21:00.000-04:002020-04-04T14:21:55.505-04:00COVID: A Long Tale of the Hydroxychloroquine MessOriginally this was going to be a multi-subject entry, but trying to explain hydroxchloroquine took a <i>lot</i> more words than I had anticipated, so for today I'm just going to try to tackle this one topic. Tomorrow, other randoms as we wrap up one hell of a week in COVID land.<br /><br />The Billy Rubin blog staff had a bit of a temper tantrum earlier in the week on the subject of hydroxychloroquine, puzzling some of Billy's Facebook friends as they tried to understand why the innocent question of "why does this not work?" was met with replies that, to put it bluntly, <a href="http://content.time.com/time/specials/packages/article/0,28804,1843506_1843505_1843496,00.html">were raving</a>. The outbreak is bringing out the best and worst in Dr. Rubin, and among his worst traits is a lack of patience with what he would describe as "bad medicine." In professional circles, for the most part, he works very hard not to lose patience. On Facebook, though, he ranted a little without explaining himself properly. As a consequence, he's now a little embarrassed, and consequently is referring to himself in third person to make it look like it's someone else entirely.<br />
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Here is a more sober explanation of the problem. It's a <i>long</i> explanation. But let me note that absolutely nothing has changed my conviction that what has transpired on the subject of hydroxychloroquine is, from a professional standpoint, shameful. "Shame" is a strong word to use in the realm of medicine; we don't like throwing feces balls at each other like enraged chimpanzees. But it's unfortunately the right word, and unmasks a collective philosophical problem in medicine that irks all members of the Billy Rubin Blog staff.<br />
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Let's start at the beginning, all the way back to just over two whole months ago, in Wuhan, China, in the early days of the outbreak. As <a href="https://abc7ny.com/nyc-hospital-queens-coronavirus-news/6070475">we now see in New York</a>, the healthcare system in Wuhan was overwhelmed, and the doctors there lacked any known, specific therapy for an unknown virus that looked one hell of a lot like its genetic cousin SARS (what we know now but didn't then is that COVID is significantly less lethal than SARS, and for which the world should be breathing a deep sigh of relief). The doctors there, in a valiant but ultimately uncoordinated attempt at doing <i>something</i>, started trying out whatever they had in their arsenal that could be reasonably justified on biological grounds, and this included a variety of drugs used in treating <i>other</i> viral infections. (Side note: I'm no expert on the subject of the infrastructure of Chinese medicine, but based on reading years of medical papers out of China, and doing a brief sojourn to Beijing, Xi'an, and Luoyang a few years back, I'm reasonably confident that Chinese medicine in the urban areas is effectively indistinguishable from the West. The idea that China is third- or second-world in its living standards is well out of date at this point.)<br />
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The <a href="https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf">discussion of these drugs got a glancing mention in the report on the early outbreak</a> issued by the WHO and Chinese CDC (see bottom of page 32 if interested). Because everyone was trying to play nice together, the language is careful to avoid judgement, and basically says, "well, doctors tried this stuff." The drugs included the following:<br />
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<b>chloroquine</b>: an antimalarial--<i>not</i> an antiviral, more on that in a second;<br />
<b>lopinavir/ritonavir</b>: a drug used in treating HIV known as a <i>protease inhibitor</i>, more on that in a second, too;<br />
<b>alpha interferon</b>: an old drug used mainly for treating Hep C until new drugs came along, now almost never used in the US;<br />
<b>ribavirin</b>: an old drug used now mainly for two very different viruses, a respiratory virus called RSV, and a hemorrhagic fever virus called Lassa Fever<br />
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The paragraph ends with a nod to traditional Chinese medicines, where it was noted "the effects [of which] must be fully evaluated." No snark about Chinese medicines coming from me on this; the problem isn't the medicine itself, <b>only how such compounds get evaluated so that we can know what works and what doesn't</b>. And the same could be said of these "well, we tried this stuff" drugs. But the rationale behind using some of these drugs is, in my opinion, very thin.<br />
<br />Let's take the lopinavir/ritonavir example before getting to chloroquine and hydroxychloroquine. As I said, lopinavir is an HIV protease <i>inhibitor</i>. What's a protease? Well, when HIV reproduces, it starts out as this long strand of nucleic acid; the HIV strand then uses the body's own cellular machinery to "translate" that strand into one huge combination of <i>all</i> the proteins used in making an HIV particle. It would look like an Ikea set <i>with every single piece of the furniture, from the big pieces to the individual screws, taped together</i>. The function of the protease is to <i>cut </i>those pieces of tape to allow for assembly. Thus a protease <i>inhibitor </i>keeps everything glommed up together so that it can't be assembled. Protease inhibitors remain one of the mainstay drugs in treating HIV, though lopinavir is now a third-line drug in the US and Europe owing to very real and unpleasant side effects--side effects that could be lethal in a sick person.<br />
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Anyway, coronaviruses like COVID <a href="https://www.ncbi.nlm.nih.gov/pubmed/32198291">have their own proteases</a>, so the basic reasoning was, "well, since both viruses have proteases, maybe it'll work." It wasn't that shot-in-the-dark, though: despite the fact that HIV is a <i>very</i> different virus and is far away from COVID on the evolutionary tree, the reasoning <i>was </i>based in scientific research, as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081067/pdf/EXCLI-19-400.pdf">this paper notes that lopinavir appeared promising as an anti-SARS drug as long ago as 2005</a>. Every drug used by the doctors in Wuhan follows a similar rationale. They did their homework, for sure--and that they did so in the midst of being overrun by a plague that felled members of their own ranks, including a number of <a href="https://www.nytimes.com/2020/02/06/world/asia/chinese-doctor-Li-Wenliang-coronavirus.html">people who not only braved the virus but also told truth to power</a>, should earn our eternal thanks, regardless of where we find ourselves on the ideological divide with respect to our governments.<br /><br />Chloroquine <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2495604/pdf/postmedj00320-0056.pdf">is a drug whose formal development goes <i>way</i> back 1945</a>, but its roots date much further back to the <i>early</i> <i>seventeenth</i> <i>century</i>, when European empires began their systematic program for extracting resources from the tropics in earnest. The <a href="https://archive.org/details/b2982381x/page/418/mode/2up">earliest Western observations came from observing the medicinal properties</a> of preparations from the bark of the <a href="https://en.wikipedia.org/wiki/Cinchona">Cinchona tree in the Andean region of South America</a>. The Cinchona gave us quinine, the critical ingredient in the original Gin & Tonic, which in addition to being a delight to drink, provided legitimate protection against malaria. From there, the massively oversimplified story of chloroquine requires a fast forward to the early 19th century, when the foundations of modern medicine were being laid by the development, of all things, of the modern dye industry, because they eventually begat German biochemical and pharmaceutical companies like IG Farben. (If you're puzzled by seeing a reference to dye makers, the link is that 19th-century scientists discovered that some dyes like methylene blue had antimalarial properties, which led to further research. In fact, the story of the link between the dye industry and infectious disease is a pretty fascinating one, as <a href="https://www.amazon.com/Demon-Under-Microscope-Battlefield-Hospitals-ebook/dp/B000JMKR2A">the story of the development of Bactrim</a>--still ubiquitous in modern medicine--cannot be told without explaining its origins in dye research and development. But we're getting far afield, and we still haven't gotten to the meat of this post.)<br /><br />Anyway, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2495604/pdf/postmedj00320-0056.pdf">chloroquine was the most promising of the antimalarials that came out of the mid-20th century research</a>, and its mass production led to the first reliable industrial treatment of the disease. At the same time, physicians who were trying to understand the biological process of inflammation (which, one hundred years later, we're <i>still</i> trying to understand) noted that part of chloroquine's effectiveness seemed to reside not only in how it killed the malaria parasite, but also that it seemed to tamp down the human (or "host," in sciencespeak) inflammatory response. That is, it appeared that part of malaria's lethality was not only directly from the parasite, but also from the exaggerated host immune/inflammatory response, and chloroquine seemed in part to work by pulling the reins on inflammation. Which made people wonder whether it might be useful in <i>other</i> diseases where the body had an exaggerated immune response, but not in the setting of malaria. (Spoiler alert: <a href="https://watermark.silverchair.com/360799.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAm8wggJrBgkqhkiG9w0BBwagggJcMIICWAIBADCCAlEGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMR9EQP3ii7DhqoHQFAgEQgIICIuHVWKVg4KZY8TLzOXJUuPL-6Nz07Uo19ZZaE7iBEaOQJSYd_ExGhIupxwDbqOqqvpMJwqpepR4b2RNkcA5Sqh3K_PmwQR9hDEJmtBXWGjSaJbgm5MkDSOfsIc0cdxSlMxSKXqr1kzkylwrXJEXLr24rRXBIKjyeWhrQQGmI4_x144UZ_QEXyaYaMPDxbDtVZNvM4W_V4VDg_kncC2cW4WtFIpztfQsbi0btSq_yrQCCNT_C-nJvDMRsa93Xsmfv1tKfkZxiHIOgLRR0irLAxCgLXPv2LdV2mdMSaV9PcULTsW56u8HQPD3LAnIXtm4uruF7kQP0eR2E8HzPsK7a5CU0ZVRljBdCF3zVD0L87zQ2bJrUECA-VIC5PhrTo-OOdGO4i9loz1jK2BHS5c7KvRAnDjyXja92EfgXRC-y9Pl-t9b4XqW8t2S42VuSD_p4YwCy3IotBIu1JeWrXstLlabS-txYr0y3um9IEYOTogkE8vtHt4Ux4Vlm8vt5HVFdH6c4yaoNCCVd8jDxlDjfMS-P2dzp3E0je6cV8mSYfvdJC-UBfHjOT0Jw6uAQ24kxorkui3Msnadm1ehbkld8yTg45vbJwyT62S0vOPyB3XhAKJDazVwGVUhuxIczv1nE0vonZDHxPUngxLhaZKPKQblELumYZcyAzmaQmpxaHLGdYBjKSmX9u-Uud_8zGPgblFFi0T8etkT_3yiIwYfO7HphDg">it was</a>.)<br />
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The upside was that chloroquine could save you from malaria; the downside was that it wasn't an entirely benign drug in its own right. Tinkering with the drug, chemists added a "hydroxyl" group onto chloroquine (which is to say, an oxygen atom attached to a hydrogen atom), and thus was born hydroxychloroquine. It was one of many different variants that was studied at the time and was found to be as effective against malaria as chloroquine, but with a much more favorable safety profile. This is the bread and butter of what drug companies do, and it's worth noting that chemists in these companies create <i>hundreds</i> of compounds, all slightly different, and run preliminary tests to identify the most promising compounds that might make it to a human trial. Hydroxychloroquine was just one of these hundreds of compounds at the start of the process, and many more drugs fail to get to a drug trial than those that don't--<i>and</i> most of those that make it <i>to</i> a drug trial end up failing as well.<br /><br />Malaria falls out of this drama by the late 20th century owing to the fact that malaria got wise and developed resistance to chloroquine and hydroxychloroquine, such that <a href="https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/malaria">there are now few malaria-endemic areas on earth where the drugs still work</a>. Thus, by the time we arrive in the pre-COVID world of early December 2019, hydroxychloroquine's use mainly resided in its anti-inflammatory properties. And the principal diseases of inflammation where they have been found to be most effective have been in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6310637/">lupus</a> and (to a more limited extent) in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7091063/">rheumatoid arthritis</a>. <a href="https://www.karger.com/Article/PDF/165777">Newer agents</a> have begun to replace hydroxychloroquine, but particularly in lupus, hydroxychloroquine is still commonly used. Which means lupus patients need those drugs to be stockpiled for their use.<br />
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The use of chloroquine and hydroxychloroquine in the treatment of <i>viral</i> infections <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC319619/pdf/pnas00657-0343.pdf">dates back to at least the early 1980s</a>, again as virologists tinkered around labs seeing what drugs worked and what didn't against some pet virus. And chloroquine/hydroxychloroquine's record against viruses in the laboratory is pretty good. Poke around Pubmed for awhile and you can see promising results against <a href="https://www.ncbi.nlm.nih.gov/pubmed/6842189?dopt=Abstract">influenza</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27183377">Hepatitis C</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/8427717">HIV</a>, and, of course, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1232869/">SARS</a>--a virus that can be thought of as the raging beast relative of COVID, the Trump to COVID's George W Bush, as both are deadly, but one significantly more so. Since January, <a href="https://www.nature.com/articles/s41421-020-0156-0">virologists were able to see the same antiviral effect against COVID</a>, as well. But this is all "in vitro" data, which is to say, those experiments just looked at what the drug did with the virus on the battlefield of a few cells in a petri dish.<br /><br /><i>That </i>was the background behind hydroxychloroquine's star turn on the COVID stage. But did it work? The most intellectually pure scientific answer is "we don't know." The most <i>likely</i> answer, in the opinion of the Billy Rubin Blog Editorial Staff, is "nope."<br /><br />The original <i>clinical</i> evidence supporting hydroxychloroquine came from a study <a href="https://www.mediterranee-infection.com/wp-content/uploads/2020/03/Hydroxychloroquine_final_DOI_IJAA.pdf">found here</a> in the International Journal of Antimicrobial Agents. (Note: this study may be amended, or even withdrawn, but the point is where it moved the needle with respect to how it influenced the medical community, and ultimately, Donald Trump, in March 2020. Thus, post-hoc changes to the article matter little.) The study evaluated 42 patients: 26 got hydroxychloroquine, and 16 did not.<br />
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Before we get to just how bad a study it is, let's ponder that sample size for a second. And to get context for that, there needs to be a discussion about case fatality rates.<br />
<br />There is <a href="https://www.newscientist.com/article/2239497-why-we-still-dont-know-what-the-death-rate-is-for-covid-19/">now spirited debate</a> about just how lethal COVID is--is it one percent, or four, or zero-point-five? For my part, I'm going with two general numbers: the <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30243-7/fulltext"><i>overall</i> case fatality of <i>everyone </i>who gets infected is about one in two hundred</a> (or 0.66 percent)--but this is only a rough estimate because we don't know how many people there who have very mild symptoms, or no symptoms at all, since they don't get tested. By contrast, the case fatality rate of people who develop obvious symptoms of illness is somewhere around <i><a href="https://wwwnc.cdc.gov/eid/article/26/6/20-0320_article">four</a> </i>or maybe <i><a href="https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820%2930195-X">five</a> </i>in one hundred. Overall I think this is a sideshow except for the epidemiologists who need to figure out things like herd immunity in their modeling of just how bad this epidemic is going to get. <br /><br />But from a <i>clinician's</i> standpoint, the latter number (ie CFR of 4-5%) is far more important, because what we really want to know when using a drug is: if I use this on someone, how likely am I to save a life? And to do that you have to know how many people would die from doing nothing at all. Hopefully everyone out there can see that, if you have a disease in which four people out of one hundred die, then recruiting 42 patients is not going to tell you what you need with any confidence, as all 42 could simply survive by chance. So that's strike one against the study--and it's a <i>big</i> strike, so kinda worth strike two as well.<br /><br />But there can be clever ways to use a small sample size and get <i>surrogate</i> data to tell you whether doing a full, count-em-up clinical trial to look directly at mortality is worth it. In this case, the surrogate marker is the amount of virus people have in their bodies. This was the finding that got everyone's attention, and it was mainly due to this picture:<br />
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It <i>purports </i>to show that those who got hydroxychloroquine (the red line) had a much faster decline in their viral loads than those who didn't--and from that, the conclusion was that we should try this out clinically. The problem, or at least one among many, <a href="https://sciencebasedmedicine.org/are-hydroxychloroquine-and-azithromycin-an-effective-treatment-for-covid-19/?fbclid=IwAR1MBnSqAVjXl4PaBJBRGoSFNva-YmUVWGcaP6X9TvUiyuTrM_A5WnP7Ibw">as extensively outlined in this extremely well-written blog by David Gorski</a>, a surgical oncologist with a PhD and who writes often on clinical trials and the statistics that underlie the work, is that even this scant data is cherry-picked, as (for starters) patients who were moved to the Intensive Care Unit--which is to say, <i>the sickest ones</i>--got left <i>out</i> of the hydroxychloroquine group. This borders on scientific malpractice, and is a rookie error of clinical trial design. In fact, we don't even expect rookies to make mistakes like this.<br /><br />But what happened in the medical world, even before Donald Trump came along and made everything much worse, was that only the punch line got repeated (hydroxychloroquine works!), and nobody took a direct look at the data to see just how shoddy it was. That's understandable in the layperson world, but for doctors who are trying out untested and potentially dangerous medications in critically ill people, it's the worst kind of laziness. Doctors were prescribing this drug (or, appallingly, <a href="https://twitter.com/ml_barnett/status/1242525351160528897">hoarding it for their own use</a>) because they read somewhere or heard from someone who spoke to someone who read something that "maybe this works." Well, <i>maybe</i> it does work. But <a href="https://www.acam.org/page/RowenEbolaNews">maybe ozone therapy works for Ebola, too</a>. (Hint: it doesn't, really.)<br />
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Hydroxychloroquine thus became the great hearsay drug in the early hours of the COVID epidemic. It had no proof, a vaguely plausible justification for its use, and ready availability. But by mid-March, there was still very much no there, there.<br /><br />Then Trump's tweet came on March 21. I won't say much about this chapter of the saga other than to note that it should be self-evident that there is a high inverse correlation between <i>any</i> pronouncement Donald Trump makes and its truth value. Thus, the fact that he touted the drug (along with a second drug we don't have time to go into, azithromycin) could be reasonably regarded <i>a priori</i> as clinically useless, or at least wildly overblown, simply by dint of the fact that Trump endorsed it.<br />
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Meanwhile, in <a href="https://www.amazon.com/Fantasyland-America-Haywire-500-Year-History-ebook/dp/B004J4WNJE">Fantasyland</a>, tales <a href="https://www.nytimes.com/2020/04/02/technology/doctor-zelenko-coronavirus-drugs.html">from a "simple, country doctor"</a> were filling the airwaves of the magical hydroxychloroquine elixir. The doctor in question is one Vladimir Zelenko, who noted that he was "seeing tremendous results" in patients using hydroxychloroquine, azithromycin, and zinc. How could such a simple country doctor outwit such heavyweights as <a href="https://thehill.com/homenews/media/491008-fauci-warns-theres-no-strong-evidence-anti-malaria-drug-works-on-coronavirus">Anthony Fauci, who seemed to remain stubbornly skeptical of hydroxychloroquine</a> when doctors like Zelenko could see its obvious promise? Was Fauci secretly part of the Deep State trying to take down Trump by making things <i>worse</i> and <i>withholding </i>lifesaving, and readily available, drugs?<br /><br />The answer to these questions are simple: <i>Zelenko's </i>simple. He is, like his President who took to the Twitterverse in enthusiastic endorsement, a living, breathing, <a href="https://www.youtube.com/watch?v=pOLmD_WVY-E">perfect example of the Dunning-Kruger effect</a>. He is so hopelessly in over his head that he has no mental tools to understand just how in over his head he really is. Maybe--<i>maybe</i>--if COVID were as lethal as Ebola, simple country doctors could see for themselves if a drug worked without having to resort to clinical trials, or troublesome issues like placebo controls and informed consent, or confidence intervals and power calculations. But with this virus? Not so much. You need the machinery of modern medicine, and the research tools that took two centuries to develop, to really know whether you're making an impact. But he has no clue <i>that</i> he has no clue. And so can be said for the followers of Donald Trump, who have been remarkably resistant to grasp his obvious buffoonery, despite it being on daily display over the past month. It's quite impressive, really. Denial is a powerful thing.<br />
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But let's end not on the cartoonish stupidity of the President and his Republican enablers, let's turn back to what under normal circumstances would a be solid place to find information, for even they can make the occasional slip-up. And this week, <a href="https://www.nytimes.com/2020/04/01/health/hydroxychloroquine-coronavirus-malaria.html?searchResultPosition=1">a piece in the <i>New York Times</i></a> described a <i>new </i>trial on hydroxychloroquine <a href="https://www.medrxiv.org/content/10.1101/2020.03.22.20040758v2.full.pdf">in which the results were favorable</a>. It's certainly a better study than the one mentioned above, though that's a pretty low hurdle. But it's not <i>substantially </i>better: it once again enrolled too small a cohort to look directly at mortality, so it relies on surrogate data that make it hard to know whether the benefit is real or an optical illusion; the patient population studied never got very sick, making its relevance in saving lives of unclear significance; and people did suspiciously well in this cohort, potentially suggesting some unseen bias that shaped the numbers. Everyone in my division took a look at the paper: the reaction was swift, and it wasn't anywhere near as favorable as the warm coverage in the article.<br /><br />The study hasn't been peer reviewed, where these and other troubling issues would be addressed. Perhaps upon peer review, the study might not even be published because it is found to be wanting. The question, then, is why did <i>NYT</i> pick it up? At the Billy Rubin Blog, we're scratching our heads on that one, because the publication of this article just made it harder for every ID doctor everywhere to try to do their jobs, in no small part because we have to continuously explain to stressed and worried families at length why these studies aren't really very good, and that these drugs come with side effects that might actually <i>end</i> their loved ones life, not save it. This blog entry, despite running to thousands of words, hasn't even taken a shot at explaining a heart-stopping effect called the <i>long QT syndrome</i>, which is almost certainly hydroxychloroquine's most deadly acute effect, and is even worse when used in conjunction with azithromycin, and which I've seen once already in a COVID patient.<br />
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Ultimately, there's an old saying in medicine that encapsulates the skepticism that we should be applying toward hydroxychloroquine's boosters, whether those boosters are motivated by naked partisan political considerations (which is to say, Trump, who wants this to go away for narrowly selfish reasons), or by a look-we're-trying-to-do-everything-we-can motivation (doctors who feel they just can't stand around and do <i>nothing</i>). The saying is <i>really</i> old, so old that it comes from a different language, and a different epoch, entirely. The language is Latin, and the saying is <i>primum non nocere</i>. It means, "first, do no harm," and is a caution to physicians who panic in the midst of an outbreak by trying to throw everything at the wall and seeing what sticks. <i>With a four percent case fatal virus, you cannot see what sticks unless you do a clinical trial</i>. With a drug like hydroxychloroquine, off-the-shelf use is a recipe for killing not only <i>one</i> patient--the COVID patient receiving the drug--but possibly a <i>second</i> as well. That person is the lupus patient who has been denied their drug. Because soon, stockpiles of hydroxychloroquine, like the ventilators that are crucial to the survival of the sickest COVID patients, will have dried up.<br /><br />Among the many lessons that the West African Ebola outbreak had to teach was that physicians shouldn't lose their collective clinical head in a disaster. We should take a page from Douglas Adams, and conduct ourselves by the motto <i><a href="https://www.amazon.com/Dont-Panic-Official-Hitchhikers-Companion/dp/0671664263">don't panic</a></i>. We should treat patients by what we <i>know</i> works, not what we <i>hope </i>works, because we're probably going to <i>kill</i> somebody if we practice medicine that way, and we're no better than the <a href="https://www.amazon.com/Quacks-Old-London-C-Thompson/dp/0766136094">Quacks of Old London</a> in the 1600s. We do what we can, and in the meantime, we (urgently) do well-designed, adequately-powered clinical trials to learn what works and what doesn't. That includes a trial of hydroxychloroquine! But without doing good science, we're <a href="https://www.nationalgeographic.com/history/reference/european-history/plague-doctors-beaked-masks-coronavirus/">the same as doctors during the bubonic plague</a>, or at least not as good as we could and should be.<br />
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There were no good clinical trials that came out of the West African Ebola outbreak. <i>That</i> failure was enough to get a group of experts together to work with US, European, and African countries so that they were more prepared to do quality clinical trials when the next Ebola outbreak came. Thus, it came to pass, that good clinical trials were conducted in a much more challenging Ebola outbreak in the Congo, so that <a href="https://www.nih.gov/news-events/news-releases/investigational-drugs-reduce-risk-death-ebola-virus-disease">now we have two therapies that dramatically reduce the mortality from Ebola</a>. <br /><br />There is no reason why we cannot do such research right now, and adjust our practices as fast as humanly possible, in the midst of <i>this </i>outbreak, especially as it may not be over anytime soon.<br />
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--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com9tag:blogger.com,1999:blog-7655407863660711763.post-80727443677219984282020-03-31T22:13:00.004-04:002020-03-31T22:13:40.908-04:00COVID: Ninety FiveA <a href="https://www.nytimes.com/2020/03/30/nyregion/ny-coronavirus-doctors-sick.html">thoroughly scary, sobering piece</a> in the Metro Section of the <i>New York Times</i> 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.<br />
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Yet it is the opening <i>picture</i> 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.<br />
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Except for one thing: that assumption is not, largely speaking, true.<br />
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What <i>is</i> 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 <a href="https://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respsars.html">that it filters out 95 percent of airborne particles</a>. (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.)<br /><br />The N95 mask is used in medicine for what is known as <i>airborne</i> 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 <i>cough</i> to infect another person, all they have to do is <i>breathe</i> and have someone in their vicinity. Once they breathe, the virus can remain in the air for hours. (Coughing, though, <i>really</i> 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.)<br /><br />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 <i>droplets</i>. 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 <i>some kind </i>(like a surgical mask), you stand almost no chance of getting infected--and we'll get to the "almost" in a second.<br /><br />The question then becomes: is COVID an airborne, or a droplet/contact-spread, virus?<br /><br />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 <i>many</i> 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 <a href="https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf">the epidemiologists in China looked at what was happening in the <i>homes</i> of the health care workers, and in a substantial number, they found that workers didn't get infected <i>at work</i> where they adhered to proper precautions, but they got the virus at home, when they reverted to less vigilant practices</a>. (See page 11 of the report.) Thus, it wasn't at all clear whether N95 provided adequate protection or not.<br /><br />Based on previous experience and study with coronaviruses, the <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection-prevention-and-control">World Health Organization felt that airborne precautions (that is, the use of N95 masks) were not necessary in caring for COVID patients <i>unless</i> they were generating aerosols</a>. 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.)<br /><br />But <a href="https://www.nejm.org/doi/10.1056/NEJMc2004973">a brief letter to the <i>New England Journal of Medicine</i></a> 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:<br />
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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 <a href="https://www.medscape.com/viewarticle/926929">immediately generated headlines</a> suggesting that WHO had gotten it wrong (and, sort of by extension, the CDC, <a href="https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html">whose guidelines are subtly different but basically concur with WHO on the notion that there's no strong evidence for airborne spread</a>).<br />
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But here's the relevant description from the article of how they designed the study. The authors state that "aerosols...were generated <i>with the use of a three-jet Collison nebulizer and fed into a Goldberg drum to create an aerosolized environment</i>" [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.<br /><br />Which is to say, this doesn't look <i>anything</i> 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. <br /><br />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: <a href="https://www.darkdaily.com/clinical-laboratories-should-be-aware-of-potential-airborne-transmission-of-sars-cov-2-the-coronavirus-that-causes-covid-19/">“Important: we experimentally generated [COVID-19] aerosols and kept them afloat in a drum. This is not evidence of aerosol transmission.”</a><br />
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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 <i>smart</i>!) <a href="https://nypost.com/2020/03/31/coronavirus-could-travel-27-feet-stay-in-air-for-hours-mit-researcher/">is quoted in the <i>New York Post </i>as saying that COVID "can travel 27 feet and linger for hours</a>." The "research" done to prove this? Turns out <a href="https://jamanetwork.com/journals/jama/fullarticle/2763852?resultClick=1">it's little more than a commentary</a>, 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 href="https://edhub.ama-assn.org/jn-learning/video-player/18357411">a video of someone sneezing</a>. And what is its biggest citation? The very <i>NEJM </i>study described above. Which is to say, there's no there, there.<br /><br />At the Billy Rubin Blog, we don't consider that to be the kind of science to merit headlines. <a href="https://www.statnews.com/2020/03/16/coronavirus-can-become-aerosol-doesnt-mean-doomed/?fbclid=IwAR3Hy4BTxulbgxV2_YYRGgaharNMwa5Gm3Q-gtIvk-4ZgHhYNYzHy7fVvl0">We like articles like this, instead, that provide a whole lotta context about the question of airborne versus droplet spread</a>. Good reading! And a lot less anxiety-provoking than the <i>New York Post</i> story.<br /><br />Indeed, in this environment, when fingers are being angrily pointed, this seems to just pour kerosene on the flames. There are <i>real</i> 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.<br /><br />The outbreak is moving fast, and that <i>could</i> change, but as of yet, the science isn't even close to being definitive that the N95 is required in all COVID situations.<br /><br />--Billy<br />
<br />Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-87039619210819699572020-03-30T22:05:00.000-04:002020-03-30T22:05:07.243-04:00COVID: As AdvertisedScattered thoughts:<br />
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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 <i>precisely</i> its subtlety among most infected people that makes it so difficult to contain. <br /><br />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 <i>New England Journal</i> images so amply demonstrate:<br />
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I have now seen three or four such CTs on patients I'm following; I expect to see more in the days to come.<br />
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II. The notion that this was some piddling, trivial virus should have all but evaporated once <a href="https://en.wikipedia.org/wiki/2020_coronavirus_pandemic_in_Italy">Italy</a> <i>and </i><a href="https://en.wikipedia.org/wiki/2020_coronavirus_pandemic_in_Iran#Timeline">Iran</a> exploded at the end of February, although even <a href="https://www.motherjones.com/kevin-drum/2020/03/republicans-are-not-very-concerned-about-thbe-coronavirus-pandemic/">as recently as two weeks ago a majority of Republicans still found it untroubling</a>. 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 <i>lot </i>of people equals <i>a lot of people</i>. 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.<br />
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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, <a href="https://www.who.int/news-room/fact-sheets/detail/measles">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</a>.<br />
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COVID's not <i>that</i> 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.<br />
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III. There are at present <i>three</i> countries left in the world that do not have documented cases of COVID, and <a href="https://www.rnz.co.nz/international/pacific-news/412761/covid-19-micronesia-shuts-border-to-inbound-travellers">last week I was on one of the last planes out from one of them</a>. Sometimes I do question my own sanity.<br />
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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 <i>more</i> 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.<br />
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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.<br />
<br />This thing? It's not so much that I'm <i>scared</i>, but I am definitely <i>tense, </i>and in a way that I never was in the Ebola Treatment Unit. The whole damn hospital is Hot--indeed, the <i>entire state is Hot</i>. And there is something grim and menacing about that.<br />
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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 <i>The Great Influenza</i>. It is impossible to read this book now without feeling a sense of <i>deja vu</i>. 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.<br />
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More soon.<br />
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--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-29858301188127921742020-03-04T15:03:00.000-05:002020-03-04T15:03:27.404-05:00A COVID-19 Analogy: SnowstormHere at the Billy Rubin blog we're fond of <a href="https://www.amazon.com/Snowball-Blizzard-Physicians-Uncertainty-Medicine/dp/0465050646">medical analogies to blizzards</a>, 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.<br />
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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, <a href="https://www.thestreet.com/opinion/the-economics-of-snow-blizzard-impact-will-be-temporary-13022675">the economic impacts are real, but temporary</a>, and mostly remain confined to cold-weather areas and don't ripple all the way through the economy.<br />
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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 <i>lot</i> 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.<br />
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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.<br /><br />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.<br />
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Just as with snowstorms, there are protective measures that reduce risk, and the most important of these is <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public">handwashing</a>.as well as "<a href="https://www.cdc.gov/coronavirus/2019-ncov/community/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fpreparing-individuals-communities.html">social distancing</a>"--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.<br />
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Analogies are tricky, but hopefully this one helps give a little context to the numbers.<br />
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--Billy<br /><br />Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-69343306427880216312020-02-26T21:32:00.002-05:002020-02-26T21:33:41.801-05:00COVID-19 *Is* Coming: Should You Panic?In a word: no. Panicking is never good, gets you nowhere, and invariably makes things worse.<br />
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But COVID-19 <i>is </i>coming to the United States. And by that, I mean coming <i>everywhere</i>, as common as the cold or flu. Am I <i>certain</i> that it's going to be widespread? No, but I'm confident at this point that this is a virus that <i>might</i> 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 <i>lot</i> of people. Containing its spread is highly, highly unlikely.<br />
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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.<br />
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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. <a href="http://www.cidrap.umn.edu/news-perspective/2020/02/study-72000-covid-19-patients-finds-23-death-rate">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</a>. The typical influenza case fatality rate <a href="https://www.nytimes.com/interactive/2020/world/asia/china-coronavirus-contain.html?action=click&module=Top+Stories&pgtype=Homepage&fbclid=IwAR1vQQprYoy6Z87KuoVI149OL9TJC_O7l9JCf5Y8w9N1LGtALbREZUg8kA4">is a little less than one per one thousand, somewhere between <i>ten and twenty times less deadly</i> than COVID</a>.<br />
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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, <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200226-sitrep-37-covid-19.pdf?sfvrsn=6126c0a4_2">the number stands at 1261</a>; one <i><b><u>week</u> </b>ago, <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200219-sitrep-30-covid-19.pdf?sfvrsn=3346b04f_2">that number was 51</a></i>. That is breathtakingly fast. By comparison, <a href="https://apps.who.int/iris/bitstream/handle/10665/131974/roadmapsitrep1_eng.pdf;jsessionid=8D7D2BE766D891D8BCA32F3FCBCB9D58?sequence=1">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</a> (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.<br />
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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. <a href="https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html">Others may be spreading the virus <i>before </i>they have symptoms</a>, 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.)<br />
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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 <a href="https://www.bbc.com/news/health-30632453">back to Patient Zero, the original source of the outbreak</a>. 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 <a href="https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College---COVID-19---Relative-Sensitivity-International-Cases.pdf">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</a>. This is why the virus has popped up in unexpected places, and will continue to do so.<br />
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Which includes the United States--and as if to prove the point, just <i><a href="https://www.nytimes.com/2020/02/26/health/coronavirus-cdc-usa.html?action=click&module=Top%20Stories&pgtype=Homepage">during the time I've been writing this, it appears a new case has arisen in California</a></i>. 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.<br />
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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 <a href="https://www.rushlimbaugh.com/daily/2020/02/26/im-the-only-guy-getting-the-coronavirus-right/">Rush Limbaugh, that purveyor of well-reasoned political analysis, has opined recently, likening COVID to the common cold</a>?<br />
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Similarly: no. Two percent of a <i>lot </i>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. <a href="http://www.cidrap.umn.edu/news-perspective/2020/02/covid-19-sickens-over-1700-health-workers-china-killing-6">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</a>. 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 <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0150080">people died as a result, without ever having contracted the virus</a>.<br />
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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 <a href="https://en.wikipedia.org/wiki/Keep_Calm_and_Carry_On">Keep Calm, and Carry On</a>.<br />
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--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-22012480564429085662018-10-27T18:42:00.001-04:002018-10-27T18:42:07.933-04:00"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.<br />
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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.<br />
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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 <a href="https://www.hias.org/mission-and-values">HIAS</a>, 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 <a href="https://www.nytimes.com/2018/10/27/us/active-shooter-pittsburgh-synagogue-shooting.html">may have been one of the critical factors spurring on the shooter to act</a>. 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.<br />
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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 <a href="https://www.washingtonpost.com/world/national-security/charleston-church-shooter-i-would-like-to-make-it-crystal-clear-i-do-not-regret-what-i-did/2017/01/04/05b0061e-d1da-11e6-a783-cd3fa950f2fd_story.html?noredirect=on&utm_term=.79dcd670a6be">one of the members of the Emanuel African Methodist Episcopal Church in Charleston</a>, 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 <a href="https://www.nytimes.com/2017/11/06/us/shooting-victims-texas.html">the First Baptist Church in Sutherland Springs, Texas</a>, 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.<br />
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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.<br />
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The past few days I have been listening to <i>The Death of Expertise</i>, 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 <a href="https://en.wikipedia.org/wiki/Godwin%27s_law">Godwin's law</a>--the adage that "As an online discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches 1."<br />
<br />
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. <br /><br />Just curious, but when Jews and African Americans are being mowed down by people SS-style as they scream "All Jews Must Die," and <a href="https://www.nytimes.com/2018/10/15/opinion/fascists-leaders-america-trump.html">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</a>?<br />
<i>--Billy</i><br />
<br />Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com1tag:blogger.com,1999:blog-7655407863660711763.post-66355324888264372882017-10-28T18:29:00.000-04:002017-10-28T19:34:18.185-04:00Simple Questions--or Not--At Harvard Medical SchoolThe 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 <i><a href="https://www.amazon.com/Snowball-Blizzard-Physicians-Uncertainty-Medicine/dp/0465050646">Snowball</a> </i>seemed to the organizers to be a perfect fit. Hopefully it was enough of a match that I didn't embarrass myself completely.<br />
<br />
The talk is here: <a href="https://soundcloud.com/user-713665386/hms-med-ed-day-oct-24-2017">https://soundcloud.com/user-713665386/hms-med-ed-day-oct-24-2017</a>. 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.<br />
<br />
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.<br />
<br />
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):<br />
<br />
<b>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?</b><br />
<b><br /></b>
<b>Me: When they </b>[patients]<b> ask, "What would you do if you were me?"</b><br />
<b><br /></b>
<b>MD: Yes.</b><br />
<b><br /></b>
<b>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, "<i>Well</i>, I'm <i>not </i>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."</b><br />
<b><br /></b>
<b>MD: I think they're asking, very specifically, that question. </b>[Audience laughter.]<br />
<b><br /></b>
<b>Me: I don't...I don't agree. I actually think that question is a <i>good deal</i> <i>more complicated</i> than it looks on the surface.</b><br />
<br />
What's fascinating to me about this exchange, <i>in a talk on uncertainty</i>, 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.<br />
<br />
My reply in the moment was not perhaps as quick-witted as I would have liked, but I'd add here that medical decisions <i>aren't </i>the same as car repair decisions. I <i>trust</i> 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.<br />
<br />
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>I'd</i> hold on to it, but there's a risk," or alternately say, "<i>I'd </i>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.<br />
<br />
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?<br />
<br />
Don't <i>these</i> questions seem rather more important than, "Well, doctor, what would <i>you</i> do?" as if the subject could be so easily compressed to a singularity of physician wisdom?<br />
<br />
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?<br />
<br />
--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com1tag:blogger.com,1999:blog-7655407863660711763.post-1631140745645430562017-04-22T17:22:00.001-04:002017-04-22T17:23:57.997-04:00Why It's Not OK for Docs to Participate in ExecutionsSandeep Jauhar's <i><a href="https://www.nytimes.com/2017/04/21/opinion/why-its-ok-for-doctors-to-participate-in-executions.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-left-region&region=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region&_r=0">op-ed in the New York Times today</a></i> poses precisely the opposite formulation, theoretically offering his musing on ethics <a href="http://www.cbsnews.com/news/arkansas-rushes-to-execute-seven-inmates-before-lethal-drug-expires/">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</a>, for which there have been a flurry of legal challenges, <a href="https://www.washingtonpost.com/news/post-nation/wp/2017/04/21/arkansas-executed-one-death-row-inmate-three-more-executions-are-planned-this-month/?utm_term=.f763283094c3">although they have succeeded with one thus far</a>. 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.<br />
<br />
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 <i>doesn't</i> violate the dictum, "do no harm." (Often dressed up in the fancier Latin phrase <i>primum non nocere</i>, 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, <i>relieving the patient's suffering</i>. It is hard to write this with a straight face. <br />
<br />
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.<br />
<br />
"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 <i>Times'</i> 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.<br />
<br />
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, <a href="https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html?ref=opinion&_r=0">he had used similarly questionable logic while he advocated for the return of the old model of Doctor Knows Best</a>, which <a href="http://www.billyrubinsblog.org/2014/02/paternalism-no-rilly-its-bad-idea.html">led me to harrumph about it at the time</a>. I haven't read his writing systematically or exhaustively, and now I'm beginning to worry what I might find if I do.<br />
<br />
--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-1957302795788265732017-01-30T08:42:00.001-05:002017-01-30T08:42:04.735-05:00Quick Take on Trump Ban, MD Training EditionI 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. <br />
<br /><br />
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.<br />
<br /><br />
The cause of the alarm is that a <em>lot </em>of resident trainees are going to be affected by this--see here for <a href="https://www.propublica.org/article/cleveland-clinic-doctor-forced-to-leave-country-after-trump-order">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</a>. 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 <em>half</em> 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. <br />
<br /><br />
But the ban's impact is going to affect much more than the physicians coming just from <em>these</em> 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 <a href="http://www.nrmp.org/press-release-results-of-2016-nrmp-main-residency-match-largest-on-record-as-match-continues-to-grow/">about 28,000 first-year spots open</a>, of which <a href="http://www.ecfmg.org/news/2016/03/30/img-performance-2016-match/">nearly a quarter are filled by IMGs</a>. 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.<br />
<br /><br />
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 <em>eight days</em> 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.<br />
<br /><br />
--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-31331041209090542912017-01-21T10:12:00.001-05:002017-01-21T10:12:20.181-05:00Inauguration Special: Flags & HypocrisyThis 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 <i>white </i>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...<i>him</i>. 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.<br />
<br />
As I said, there isn't much to say. Basically, <a href="http://nymag.com/daily/intelligencer/2017/01/the-system-has-failed-and-a-con-artist-has-won.html">I would say this</a>, if I could. <br />
<br />
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.<br />
<br />
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: <a href="http://www.wweek.com/news/city/2017/01/20/protesters-burn-american-flag-in-pioneer-courthouse-square-as-portland-braces-for-anti-trump-marches/">US protesters engaged in the burning of the American flag</a> 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, <a href="http://www.politico.com/story/2016/11/trump-flag-burning-231920">along with Trump himself</a> 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 <i>draining </i>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--<i>sticking it to elites</i>....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.<br />
<br />
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 <i>actually</i> fight for the small guys against the <i>real</i> elites will make any difference. <br />
<br />
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. <br />
<br />
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 <i>he</i> 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. <br />
<br />
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.<br />
<br />
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.)<br />
<br />
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 <i>dissolved</i> 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.<br />
<br />
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.<br />
<br />
--Billy<br />
<br />
(**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 <i>shot to death</i> 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.)<br />
<br />Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-31976270622924027772016-10-30T12:34:00.002-04:002016-10-30T12:34:43.531-04:00Billy Rubin Storage Vault: 1995 Edition, Cleveland Indians Chief Wahoo SpecialLong 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.<br />
<br />
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 <a href="https://en.wikipedia.org/wiki/Cleveland_Indians#1960.E2.80.9393:_The_33-year_slump">midst of a three-decade slump</a> (affectionately known by fans wanting to imitate a Red Sox tradition by referring to it as the "<a href="https://www.amazon.com/Curse-Rocky-Colavito-Loving-Thirty-Year/dp/1598510355">Curse of Rocky Colavito</a>" 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 <i>lot</i> better--in the mid-1990s, and finally got a crack at winning a World Series, but <a href="http://www.baseball-reference.com/postseason/1995_WS.shtml">lost to a great Braves team in 1995</a>. (They lost again, to the Marlins, in 1997, but that tragedy is a story for another day.)<br />
<br />
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.<br /><br />One small point of explanation: the greed of the players and owners mentioned below is in reference to the <a href="https://en.wikipedia.org/wiki/1994%E2%80%9395_Major_League_Baseball_strike">baseball strike of 1994 and 1995</a>, which led for the first cancellation of a World Series since 1904 and significantly depressed fan interest when the playing resumed.<br />
<br />
<br />
<div style="margin: 0px; text-indent: 0.5in;">
<span style="font-family: Calibri; font-size: large;"><b>Cleveland Plain Dealer</b></span></div>
<div style="margin: 0px; text-indent: 0.5in;">
<span style="font-family: Calibri; font-size: large;"><b>July 10, 1995</b></span></div>
<br />
<div style="margin: 0px; text-indent: 0.5in;">
<span style="font-family: Calibri; font-size: large;"><b>To the Editor,</b></span></div>
<div style="margin: 0px; text-indent: 0.5in;">
<span style="font-family: Calibri; font-size: large;"><b>As I near the end of my 25</b></span><sup><span style="font-family: Calibri; font-size: large;"><b>th</b></span></sup><span style="font-family: Calibri; font-size: large;"><b>
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 </b></span><i style="mso-bidi-font-style: normal;"><span style="font-family: Calibri; font-size: large;"><b>the best team in baseball</b></span></i><span style="font-family: Calibri; font-size: large;"><b> 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.</b></span></div>
<div style="margin: 0px; text-indent: 0.5in;">
<span style="font-family: Calibri; font-size: large;"><b>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.</b></span></div>
<div style="margin: 0px; text-indent: 0.5in;">
<span style="font-family: Calibri; font-size: large;"><b>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 </b></span><i style="mso-bidi-font-style: normal;"><span style="font-family: Calibri; font-size: large;"><b>is </b></span></i><span style="font-family: Calibri; font-size: large;"><b>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.</b></span></div>
<div style="margin: 0px; text-indent: 0.5in;">
<span style="font-family: Calibri; font-size: large;"><b>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 </b></span><i style="mso-bidi-font-style: normal;"><span style="font-family: Calibri; font-size: large;"><b>love</b></span></i><span style="font-family: Calibri; font-size: large;"><b> 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.</b></span></div>
<div style="margin: 0px; text-indent: 0.5in;">
<span style="font-family: Calibri; font-size: large;"><b>The suggestion that Cleveland’s
mascot </b></span><i style="mso-bidi-font-style: normal;"><span style="font-family: Calibri; font-size: large;"><b>might</b></span></i><span style="font-family: Calibri; font-size: large;"><b> 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.</b></span></div>
<div style="margin: 0px; text-indent: 0.5in;">
<span style="font-family: Calibri; font-size: large;"><b>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 </b></span><i style="mso-bidi-font-style: normal;"><span style="font-family: Calibri; font-size: large;"><b>Cleveland Dagos</b></span></i><span style="font-family: Calibri; font-size: large;"><b> or the </b></span><i style="mso-bidi-font-style: normal;"><span style="font-family: Calibri; font-size: large;"><b>Cleveland
Wops</b></span></i><span style="font-family: Calibri; font-size: large;"><b> 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?</b></span></div>
<div style="margin: 0px; text-indent: 0.5in;">
<span style="font-family: Calibri; font-size: large;"><b>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.</b></span></div>
<div style="margin: 0px; text-indent: 0.5in;">
<span style="font-family: Calibri; font-size: large;"><b>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 3,000</b></span><sup><span style="font-family: Calibri; font-size: large;"><b>th</b></span></sup><span style="font-family: Calibri; font-size: large;"><b> hit, and hopefully his eventual 500</b></span><sup><span style="font-family: Calibri; font-size: large;"><b>th</b></span></sup><span style="font-family: Calibri; font-size: large;"><b>
home run, or the pennant that is within their reach. The debate has to do with
understanding that symbols sometimes </b></span><i style="mso-bidi-font-style: normal;"><span style="font-family: Calibri; font-size: large;"><b>do</b></span></i><span style="font-family: Calibri; font-size: large;"><b>
represent things, and that they </b></span><i style="mso-bidi-font-style: normal;"><span style="font-family: Calibri; font-size: large;"><b>can</b></span></i><span style="font-family: Calibri; font-size: large;"><b>
be used to perpetuate stereotypes that are inaccurate and harmful. Surely we as
a citizenry </b></span><i style="mso-bidi-font-style: normal;"><span style="font-family: Calibri; font-size: large;"><b>must</b></span></i><span style="font-family: Calibri; font-size: large;"><b> 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.</b></span></div>
<br />
--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-48988631917356491472016-09-27T18:47:00.002-04:002016-09-27T20:31:56.101-04:00The non-republicanism of Trump vs. the republicanism of Clinton, and Why That Should Matter to Republicans (and Democrats)If one wanted to be appalled by Donald Trump's performance in the first (perhaps only) presidential debate, one would have had a virtual cornucopia of comments or mannerisms, each one a subtly different flavor from the next in terms of belligerence, complete lack of knowledge or understanding of public affairs, and just general indecency. But as is often the case with placing Trump in perspective, the truly meaningful moments--where the menace he represents to American democracy in a way heretofore never seen is laid bare--can get lost in the dust cloud of nattering about whether "stop & frisk" was unconstitutional, or whether he really <i>did </i>say that China invented the concept of global warning (<a href="https://twitter.com/realdonaldtrump/status/265895292191248385?lang=en">he did</a>), or why he hates Rosie O'Donnell so, or who on earth Sydney Blumenthal might be, and so forth. All that noise, in which people who sympathize with either Republican or Democratic views can disagree or at least emphasize different ways of looking at a contentious topic, can obscure the statements that should, to any sane individual, show that this is <i>not</i> a Republican running for president, but a man who has no apparent regard for the democratic process at all.<br />
<br />
For Trump may be running as a Republican candidate, but there is no republicanism--small "r"--in his governing philosophy whatsoever. For over a year, his overt bullying indicated to tens of millions of Americans that this was probably true, but last night, in front of more than 80 million people, he stated in no uncertain terms what he really thinks about the purpose of the US government, and especially the US military: they're a moneymaking machine. <a href="http://www.vox.com/2016/9/27/13068420/trump-debate-foreign-policy-hofstra">Trump said that "we defend countries. <i>They do not pay us what they should be paying us</i>."</a> There's very little need to reach for elaborate explanations to grasp the unsubtle nature of his view that <a href="http://www.nationalreview.com/article/440458/donald-trump-debate-foreign-policy-nato-allies-treaties-vladimir-putin">the purpose of the US military should be an elaborate protection racket</a>, in the words of the <i>National Review </i>(!). One pictures Trump envisioning small NATO countries the same way a mafioso might wander through a neighborhood of weak individuals, taking a casual stroll through, say, Estonia, as he drops a little hint to its leader, "Nice houses you got here. Pity if something bad should happen to them."<br />
<br />
And what might have gotten missed in the literal he-said-she-said was that Hillary Clinton's reply was <i>not</i> the articulation of the philosophy of the Democratic party. Instead, it was the articulation of the philosophy of <i>the United States of America</i>--one shared, in almost absolute unanimity, by every member of <i>both</i> political parties, and is a philosophy that dates back to when Donald Trump was in swaddling clothes. The level of contempt that he has shown not simply for Hillary Clinton, or the Democratic party, or Jeb Bush, or Marco Rubio, or a former Miss Universe, or nearly anyone who speaks Spanish, or any number of people on a seemingly endless list--not these individuals, but the level of contempt for America as a democracy was undeniable in his NATO remarks, and this was not a spontaneous riff, for <a href="http://www.nytimes.com/2016/07/22/world/europe/donald-trumps-remarks-rattle-nato-allies-and-stoke-debate-on-cost-sharing.html?_r=0">he has articulated this view before</a>. It wasn't a mistake; it's the centerpiece of how he thinks.<br />
<br />
I am aware of the difficulties that Trump's candidacy has created for lifelong Republicans who do believe in basic ideals of democracy and republicanism as part of the American project. But from where I stand, after today, now that he has gone before tens of millions of people and explained in clear terms what he really thinks about the meaning of US military force around the world, only someone who has taken complete leave of their senses could defend this man as being the standard bearer for what previously constituted Republican party philosophy. This undoubtedly leaves many Republicans having to deal with the unpleasant question of what, in fact, <i>does</i> currently constitute Republican party philosophy, since a clear majority of Republican primary voters prefer Trump to what has been peddled before. But either way, I think such voters will have to make the decision as to whether they are willing to throw their lot in with a man who thinks that, with respect to our military commitments, extremism in the defense of wealth is no vice.<br />
<br />
--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com1tag:blogger.com,1999:blog-7655407863660711763.post-58875115015400783442016-07-09T08:53:00.000-04:002016-07-09T08:54:05.553-04:00Today in Zika HyperboleIn the aftermath<i> </i>of one of the more appalling weeks in our nation's history<i>, Slate's </i>lead headlines for July 9, 2016 include a news item about Zika<i> </i>to provide a further dollop of anxiety and dread. The headline notes that someone has <i>actually died </i>of Zika--right here, in the United States!--and then asks the question: <i>now</i> should we panic?<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiH6o8dOA_wZogUKZfch7aNH4G4hJelZASM-mQQtW_8l-fE0MfOnKTGW2vvHxahFwBdel21w5Dq1SG21Ih1LcOuoqUVJ2O7DW3QGCo5ue3PWxmjglemA_YJ6jEq2QHH04siRxFDDavYM-Nt/s1600/Zika+Slate+2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="188" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiH6o8dOA_wZogUKZfch7aNH4G4hJelZASM-mQQtW_8l-fE0MfOnKTGW2vvHxahFwBdel21w5Dq1SG21Ih1LcOuoqUVJ2O7DW3QGCo5ue3PWxmjglemA_YJ6jEq2QHH04siRxFDDavYM-Nt/s640/Zika+Slate+2.png" width="640" /></a></div>
<br />
The answer is "no," but what's amazing about this is that <i>the article itself makes clear the degree to which the headline is overblown</i>. "The individual was elderly and 'had an underlying health condition,'" author Matt Miller notes in quoting a press release from the Utah Department of Public Health. Citing WHO statistics, Miller later reveals that the total number of Zika infections in 2015 was estimated to be between 400,000 and 1.3 million people, of which <i>three </i>can be supposed to have died from the virus (and five infants born with microcephaly--yes, that number is <i>five</i>, not five <i>million</i>, or even five <i>thousand</i>). "Zika is still a situation that warrants better public health communication, more extensive research, and certainly <a href="http://www.slate.com/articles/health_and_science/medical_examiner/2016/04/a_zika_outbreak_in_the_u_s_is_not_anything_to_panic_about.html">more funding</a>. But this death is no <a href="http://www.slate.com/articles/health_and_science/medical_examiner/2016/05/rio_should_still_host_the_summer_olympics_the_risk_of_zika_is_not_high_enough.html">reason to panic</a>," the article concludes.<br />
<br />
If that is so, then why run the article at all, unless the headline was to suggest precisely the opposite of what it did say?<br />
<br />
--Billy<br />
Billy Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-29008208137391883892016-03-29T18:34:00.000-04:002017-03-04T17:43:15.828-05:00Politics & Consistency: Presidential Primary EditionI'm okay in general with people who feel the Bern. There's a lot of his critique that resonates with me, especially his sense of outrage about the injustice of a wildly inequitable system. But without getting too far into a debate about whether or candidate Bernie Sanders and his policy prescriptions are superior to that of Hillary Clinton--<i><b>this post is not about advocating for one or the other</b></i>--it is worth looking at one argument the Sanders' supporters consistently cite as evidence of the Fix that the Democratic Party and its mainstream media enablers have for Bernie and the Revolution: the undemocratic nature of the superdelegates.<br />
<br />
As of March 29 following this weekend's contests, the current "pledged" delegate count stands at Clinton's 1243 to Sanders's 945 according to both <a href="http://www.realclearpolitics.com/epolls/2016/president/democratic_delegate_count.html">RealClearPolitics</a> and <a href="http://www.bloomberg.com/politics/graphics/2016-delegate-tracker/">Bloomberg</a>. The total number needed for the nomination is 2,382 delegates. So you say, aha! It's close! But then there are the superdelegates--effectively freelancers who are Party apparatchiks and, although still part of specific state delegations, can pledge themselves to whomever they see fit. Clinton is, at present, thumping the Vermont Senator in this category, 469 to 29. That means that Clinton has a sizeable advantage heading into the homestretch for the nomination.<br />
<br />
<i>Foul!</i> Cry the Sanders people. <i>This isn't democracy! This is a sham! </i><br />
<br />
Maybe yes, maybe no. I'm not sure how I come down on the question of superdelegates, and so this post isn't trying to defend that. What this post <i>is</i> trying to do, however, is point out that if you think democracy involves opening the doors to as many voters as possible, you can't trumpet big delegate pickups as evidence of the Will of the Voters if the process by which those delegates were earned is equally undemocratic. You can't have it both ways.<br />
<br />
Sanders won the Alaska, Hawaii, and most importantly the Washington State caucuses this weekend. He won big, and that led to a haul of delegates, closing the gap by about 70. He crushed Clinton in Washington 73 to 27 percent. That's about as lopsided a win as you're going to get this cycle. And Sanders supporters have been reminding everyone of this huge win, saying it's every bit as important as all those Southern states that Clinton racked up, even though (the argument goes) the media plays up every Clinton victory, and downplays every Sanders victory.<br />
<br />
But here's the thing: Clinton's southern victories really <i>were</i> bigger. Take a look at North Carolina: Clinton got about 55 percent of the vote to Sanders's 45. Less impressive than the Washington rout, right? Depends on how you count these things. In NC, 616,000 voted for Clinton to 460,000 for Sanders. In Washington, 19,159 <i>caucused</i> for Sanders, while 7,140 did so for Clinton.<br />
<br />
Basically, Sanders has done exceptionally well in states that choose their delegates by holding caucuses--where the diehards have disproportionate impact on a contest. With the exception of Iowa, Nevada, and the American Samoa, Sanders has won every single caucus event (and Iowa was very close). By contrast, he has won the primaries in his own home state of VT and its neighbor in NH, the "Democrats Abroad" caucus, and the one big surprise, the close win in Michigan. But if you look at the total number of people who have actually cast their votes for the two, Clinton's lead is, as the Senator would say, <i>yuge</i>.<br />
<br />
Effectively, caucuses are contests by which someone like Sanders with his dedicated following can win his own version of superdelegates. We can never know what would have happened in an open Washington primary, but I can only appeal to reason by saying that, even if Sanders had won the state, there was no way he would have won 73 to 27.<br />
<br />
Just to be clear again: I am not saying that it's not fair that Sanders picked up his delegates that way. I don't have much of a dog in the fight for the Dem nomination one way or the other. But what I find off-putting about the righteous screeds that the Sanders supporters is their deep belief that everyone has stacked the cards against them...unless the cards happen to fall in their favor. If you say that superdelegates are undemocratic, well, then you're committed to saying that caucuses are as well.<br />
<br />
--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-39681746811461742662016-02-29T19:34:00.002-05:002016-02-29T19:34:22.465-05:00Getting Back Into the GrooveIt's been awhile since I've been in blogging mode owing to <a href="http://www.amazon.com/gp/product/0465050646/ref=s9_simh_gw_g14_i1_r?ie=UTF8&fpl=fresh&pf_rd_m=ATVPDKIKX0DER&pf_rd_s=desktop-1&pf_rd_r=0JQ6RD2WQ7D5BW057H2P&pf_rd_t=36701&pf_rd_p=2079475242&pf_rd_i=desktop">the completion of one manuscript</a> and the simultaneous generation of another (stay tuned), to say nothing of fairly heavy clinical duties. I even let Zika pass along without any grumpy commentary, which is a shame, all things considered. And even though we are on the eve of Super Tuesday, which includes a primary in MA, I'm just going to throw out <a href="http://www.theatlantic.com/health/archive/2016/02/when-doctors-should-say-i-dont-know/471222/">this little link to the Atlantic</a> as a way to ease back in to the blog.<br />
<br />
Who knows what kind of time I'll have in the months to come, but will try to squeeze something in.<br />
--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com0tag:blogger.com,1999:blog-7655407863660711763.post-62812701192993822532015-07-18T18:51:00.000-04:002015-07-18T18:51:01.638-04:00Late Night Thoughts on Pluto & MonroviaI have been drinking a fair amount of alcohol tonight here in Monrovia, enjoying the company of some remarkable people at a dinner in the city center. We drove from there to our flat in Congo Town, about five miles away, where I sit and write this now.<br />
<br />
The ride back along Tubman Boulevard was quiet as we listened to an extended BBC news report of the Pluto fly by of NASA's <em>New Horizons </em>spacecraft. I haven't actually seen many of the new pictures of Pluto given limited bandwidth here; mainly I check my email, and splurge on <em>New York Times</em> headlines every second or third day, but generally avoid the stories with high-resolution graphics as my internet access cuts out during the download. <br />
<br />
Nevertheless, even listening to the radio program, it is hard not to feel a sense of wonderment at the magnificence of the event. This icy piece of rock, that circles the sun at an unimaginably long distance from our home, has become linked to us in a new and profound way; we are just a little more a part of a bigger and more amazing environment as a result of some electronic signals emanating from a piece of metal about to leave the Solar System. It is humbling. It is wonderful. It inspires awe.<br />
<br />
Earlier today I stopped by the John F. Kennedy Hospital to check in on my resident. I didn't actually find him, but instead saw a 17 year-old who had been in terrible respiratory distress two days ago. She has an enlarged heart and had retained fluid around her lungs. I couldn't tell you the cause, though I have a few guesses--but without the resources to order the proper tests, they will remain only guesses. One of the residents--a true star, every bit as good and frankly better than many of even my high-quality residents back home--had taken the fluid off her lungs the previous two days, so that when I happened to wander in this afternoon, she had smiled for the first time I had seen her. <br />
<br />
Her future remains tenuous, but for the moment, she thrives, and that has filled me with a certain hope, not merely for her, but somehow for Liberia, a country that has gone through much over the past year and yet moves ahead with hope and ambition. Along Tubman Boulevard, going from Congo Town to the JFK Hospital, there's a Coca-Cola billboard advertisement that wasn't there during the outbreak. It is simple. It merely shows a man, maybe my age, emerging from a car door, looking straight into the camera with a content appearance. "I'm confident of better days ahead," reads the caption. <br />
<br />
I tend to brood, but perhaps tonight I am as well.<br />
<br />
--BillyBilly Rubinhttp://www.blogger.com/profile/04850166742797443954noreply@blogger.com1