Who Was That Masked Man?

Flashback: Autumn 1980

I was a medical student at the University of Pittsburgh, on a clinical rotation in head & neck surgery.  I was in the operating room with a nationally admired surgical specialist named Eugene Myers, the editor of a major textbook in this discipline.

Many of the patients had cancers of the mouth or throat.  Surgery for them typically involved removal of cancerous tissue and reconstruction to make it possible to retain essential functions, such as speech and swallowing.

It was also common to explore the neck to identify and remove lymph nodes to which cancer may have spread.  This is called a radical neck dissection.

Such surgery requires great skill and precision.  It is very laborious, tedious, and time-consuming.  I recall one operation that took 16 hours.  For a medical student the experience might be torture, except that Dr. Myers was an engaging teacher, and he played recordings of classical music in the operating room.

For the entire 16 hours I was wearing surgical scrubs, over which was a surgical gown.  I wore sterile surgical gloves.

And guess what else?  Yes!  A surgical mask.

These days I am working in a medical facility in which protocol calls for me to wear an N95 mask from the beginning of my workday to the end.  In this setting I get to take the mask off to eat or drink during my breaks.  This means that each day I am wearing an N95 for at least 7 hours.

If you know me, you know that I can be a complainer.  I complain about policies I don't like, rules with which I disagree, directives that seem nonsensical or misguided.

Guess what has never made the list of things I complain about?

That's right: wearing a mask.

What's the big deal?  I have found it no more difficult to get used to wearing a mask than it was to get used to wearing a seatbelt in an automobile more than half a century ago.

If you think wearing a mask is a burden, a nuisance, an imposition, wait until you see what it's like being sick enough with COVID-19 to be a patient in the hospital, or to be in the ICU, or to have a plastic tube in your trachea, connected to a mechanical ventilator.  Or maybe these things won't happen to you, but to someone you care about.  Chances are you won't be able to visit that person in the hospital.  You won't get to hold your loved one's hand.  If you get to say goodbye, it will be because some young doctor or nurse has a smartphone or tablet to connect you with your mother, your sister, your grandfather, or your best friend for a virtual farewell.

I assure you, that's just not the same.

Please think about all this when you want to grouse about wearing a mask.  Life is full of inconveniences.  Some of them are really a bother.  Others are trivial.  This one is trivial, and it serves the purpose of controlling the spread of a disease that kills.  If you are looking at benefit versus burden, this is an easy one to calculate.

Be smart.  Be a good person.  Do the right thing.  Wear a mask.

Juneteenth Appropriated?

President Trump will hold a campaign rally in Tulsa, Oklahoma next Friday, June 19th.  The choice of date and location has drawn harsh criticism of a president whose words have done so much to validate the endemic racism that has afflicted this nation for over four centuries.

The date is the one on which the long-delayed implementation of the Emancipation of enslaved Africans was initiated in Texas in 1865, commemorated by celebrations of "Juneteenth."

The location - Tulsa - was the site of a massacre of Black residents of the city's Greenwood district.  Hundreds of Black Americans were killed, and the district - home to a thriving business community - was largely destroyed, beginning over Memorial Day weekend in 1921.

While racial killings - including massacres - have been many in US history, the destruction of Greenwood and the number of murders committed there hold an especially ignominious place.

It is impossible to know whether Mr. Trump had any idea, when this rally was planned, that either the date or the location was of any special significance.  After all, this is the same fellow who said, during Black History Month in 2017, that "Frederick Douglass is an example of somebody who’s done an amazing job and is getting recognized more and more" - as though Douglass is alive today and doing important things in the service of his country.  [One can imagine that Trump was really talking about the legacy of Douglass, but it is difficult to credit that notion.]

A solution to this quandary immediately leaps to mind.

President Trump could select the occasion of this campaign rally to tell the American people he is working on a comprehensive plan of reparations to African Americans for more than four centuries of slavery and brutal oppression, details to be made public over the next several months.  He could mention a dollar figure: there is quite a range possible, as estimates of the total amount required in the cause of racial justice range from $1.4 trillion to $17 trillion.  Anything remotely approaching the latter number would have to be spread out over a decade.

The president could thereby transform his public image - from that of a leader of a cult of personality, lacking any admirers outside of his loyal following, and devoid of any but the dimmest perceptions of our nation's annals - to a transformative and heroic torchbearer of freedom, establishing a legacy in US history to be esteemed for many generations to come.

Yes, I know.  Given Trump's denial, in the aftermath of the killing of George Floyd, that there is systemic racism in America, emphasized this week by his sending messengers from his Administration - including Attorney General William Barr and Director of the National Economic Council Lawrence Kudlow - to reinforce that claim, it seems most improbable.

But to quote one of my heroes:

Defund the Police: What's in a Word?

Many Americans who are not decidedly left of center politically are criticizing the choice of "defund" to capture what should be done about police departments that have strayed so far from "To Protect and to Serve."

Of course it is an obvious case of the turning of tables.

It has long been a favorite tactic of conservatives, combining their social conservatism with their professed fiscal conservatism (that never applies to their pets, such as defense contractors and the military budget) to withhold or withdraw funding from anything they don't like.  So they want to defund Planned Parenthood, public broadcasting (PBS and NPR), the National Endowments for the Arts and the Humanities, public health research on gun violence, and "failing" public schools.

Indeed, this is the way they approach government agencies they dislike.  They want to defund the Department of Education to the point of abolishing it.  Likewise for the EPA.

This is their overall approach to government.  Steadfastly denying the role of government as a proper agent of the people, doing our bidding for the benefit of American society (recall the phrase "promote the general Welfare" from the preamble to the Constitution), they want to shrink it.

How?  "Starve the beast."

Nothing, perhaps, captures the sentiment underlying "defund the police" better than "starve the beast" - because so many of us are currently seeing that American policing is a great beast, or at the very least employs far too many officers whose behavior is beastly, working in departments that do little or nothing to prevent or restrain such behavior.

Defund the police.  Starve the beast.

Don't like the word?  Does it conjure up a lawless America?  How can we be a nation of laws if there is no one to enforce those laws?

Do you prefer "reform?"  Fine.  Maybe that is correct in concept, but what about in execution?  Reformers - in this nation so much given to holding tightly to the status quo - are consistently frustrated in their efforts, forced to settle for the most modest incremental changes.

This simple fact leads to "defund" and even "abolish."

So let us return to the question: how can we be a nation of laws if there is no one to enforce them?

But before we ponder the answer to that question, we must examine the premise.  Should this be a nation of laws?  Or must this be a nation of justice?

We must focus on becoming a nation of justice.  And then we can decide what laws promote justice, and how the enforcement of laws must be conducted so that it, too promotes justice.

We are so very far away from that.  Incremental reforms of policing in America are not the answer.  When you are wrestling with a beast, you cannot settle for trimming its whiskers to make it look less threatening and think you have accomplished something.

Petrochemicals and the Pandemic

An article published by Reuters yesterday on the effects of the pandemic on petrochemicals took me back half a century.

From the 1967 film "The Graduate" --

Mr. Maguire: I want to say one word to you, Benjamin. Just one word.

Benjamin Braddock: Yes, sir.

Mr. Maguire: Are you listening?

Benjamin Braddock: Yes, I am.

Mr. Maguire: Plastics.

**********

The processing of petroleum into plastics via polymer technology has fascinated me for decades, since I first learned of it as a college student in organic chemistry.

The environmental impact of our use of plastics - especially when they are disposable and not recycled or recyclable - was unknown to me then.

I was, however, keenly aware of the environmental consequences of petroleum combustion for energy.  And so, far more times than I can count, I expressed the opinion that future generations would take a very dim view of our burning up all the petroleum as fuel instead of saving it to make synthetic polymers.

Occasionally the subject came up in the context of my stitching up a patient.  "Is that catgut?" the patient might ask.  "It's nylon," would be my reply.  And then, if I thought the patient would like being distracted from what I was doing by some conversation, I would offer a brief overview of the origins of nylon in the pioneering polymer technology research done at DuPont, beginning in 1927, sometimes mentioning other familiar substances produced in the early years, including rayon and neoprene.

These days my thinking has been transformed by an awareness that we are dumping single-use plastics into our oceans and landfills far more than we are recycling them.

As our reliance on petroleum for energy declines, while the supply of oil and natural gas remains relatively abundant, the cost of producing virgin plastics will continue to compare favorably to that of recycled plastic.  Only a substantial increase in the monetary cost of extracting petroleum via offshore drilling and fracking will change this calculus.  We have shown that we care far too little about the effects of drilling and fracking on our oceans, the air quality near refineries, power plants, and petrochemical installations, or contamination of ground water.

This unfortunate tendency to focus on monetary rather than environmental cost will slow the replacement of plastics with biodegradable polymers, such as those made from hemp.

If you live in a region like mine, where fracking and the petrochemical industry are major economic players, discussion of these issues is viewed by policymakers and elected officials as unwelcome at best.  Expect to be branded a job-killing environmental extremist.

This kind of thinking is an unending source of frustration for me.  In recent years I have had some unsuccessful forays into politics, and in the occasional candidate forum I was asked my views on fracking.  Sometimes the question was extremely pointed: would I support a moratorium on fracking pending additional regulations requiring more transparency from the industry - related to their extraction processes, the danger to groundwater, and monitoring of the air and water quality near drilling sites and petrochemical plants?  Would I support more taxes on all this activity?  Would I support a permanent ban on fracking?

In southwestern Pennsylvania such questions are as challenging to a political candidate as any related to gun control or abortion.  Any answer risks alienating a sizable segment of the electorate.  A response that is non-committal or evasive, on the other hand, instantly labels one as a "typical politician" who won't reply to a direct question with a straight answer.

I do not expect to be seeking public office again, but my answers to these questions now are unchanged from what they were on the campaign trail: I support many proposals to reduce the environmental impact of our use of petroleum, including strict regulation of fracking and petrochemical plants, and I would not stop short of bans if the data tell us the environmental impact cannot be reduced to the point of no longer representing a significant threat to the planet and the living creatures inhabiting it.

To accompany such statements, I have also explained that we are often presented with a false choice between jobs and the environment, explaining how many ways there are to pursue economic growth and environmental protection simultaneously.

Today I would be dismissed by the right as a "green new-dealer."

It is exactly this kind of dismissive attitude that stands in the way of moving the nation and the planet in the right direction to protect the environment.

Oh, and one more thing: climate change is not a hoax. 

Thinking of John Quincy Adams and Abolition

Recently I wrote a post for a Facebook group of doctors in my specialty relating some of my thoughts on racism as a public health problem in the US, and more broadly on the subject of racial justice.

The reaction by - well, the reactionaries in the group - was predictable. My post was denounced as political. It was declared that half of emergency physicians hold views diametrically opposed to mine. I was taken to task for crafting an argument in terms that made it seem morally wrong to disagree with me. (I'm still trying to figure out how that is a legitimate point of criticism, when it is actually evidence of rhetorical cogency.) I was advised that I am much in need of psychiatric help. And, of course, I was spewing "liberal bullshit."

One participant in the thread suggested it is the thinking of people like me that is the real reason for the sorry state of race relations in this country.

This last point brought to mind John Quincy Adams (our sixth president, 1825-1829). The younger Adams served in the United States House of Representatives for many years after his presidency: from 1831 until his death in 1848 at the age of 80. In that phase of his political career he was one of the leaders of the Northern abolitionists.

Abolition of slavery would require amending the Constitution, and a Civil War en route to that. Congress by itself did not have the power to put an end to America's "original sin." But Congress did have jurisdiction over the District of Columbia, for which it served as governing authority. Resolutions to end slavery in the District were introduced in the House of Representatives, repeatedly, by Adams and others.

The First Amendment - that familiar repository of guarantees against infringement by Congress of the rights of free expression, free exercise of religion, and peaceable assembly - also guarantees the right "to petition the government for a redress of grievances."

During the few decades preceding the Civil War, petitions, from the people, demanding an end to slavery were brought before Congress by Adams and other northerners.

Such petitions provoked the ire of southerners in Congress, as did the resolutions to end slavery in the District of Columbia. Every resolution and every petition resulted in the parliamentary maneuver to table, meaning there would be no debate.

Southerners denounced these resolutions and petitions as divisive and declared that it was these, and not the institution of slavery, that constituted the real threat to the Union.

So, when I read the comments denouncing my post - and especially the one saying people who think the way I do are the real cause of America's troubles with racism - I could not help thinking of Congressman Adams.

[For those who love to read history, I recommend the scholarly and beautifully written biography of John Quincy Adams by Samuel Flagg Bemis.]

Racism as a Public Health Issue

Coronavirus-induced anxiety, fear, and frustration; unemployment rising to levels not seen since the Great Depression; and the boiling over of outrage at police officers who are brutal thugs with badges and blue uniforms have given us quite the incendiary concoction.

Mayors and governors must act swiftly, decisively, and meaningfully if we are to keep our cities from erupting in wildfires again and again in the coming weeks and months.

There will be no leadership from the top. We have a president whose delusions have risen to heights that are stunning, even for him: telling a reporter yesterday, on camera, that MAGA loves African Americans. While uttering this astounding lie, Trump simultaneously pours gasoline on every fire in sight, tweeting: "When the looting starts, the shooting starts.”

No, Mr. President, the shooting has been going on for quite some time. A decade ago Amnesty International reported that police in the US were killing people in numbers approaching one thousand per year. The British newspaper The Guardian is tracking the numbers and reported 1,136 in 2015. The statistics-monitoring website Statista reported that 1,004 people were shot to death by police in the US last year: 37% white, 23% black, 16% Hispanic, 24% other or unknown. The sheer numbers of us being shot and killed by police each year are horrifying. The disproportionate killing of people of color is unmistakable.

There are millions of people in the US who think they are not racists, who say they don't discriminate, that they are "color blind," but whose lack of depth of understanding of the history of the problem makes them comfortable sitting on the sidelines and shaking their heads at the overt racists but never doing anything to be part of the solution.  They think we have anti-discrimination laws, and that's all we need.  They think those laws are enough to allow blacks to pull themselves up by their own bootstraps and solve their own socioeconomic problems.  They think the obstacles to that have been removed, and nothing more needs to be done - and both of those notions are false.  They also think the police officers who have been involved in the murders of men like George Floyd are just a few bad apples.  They have no idea how many white police officers have deeply ingrained racism when they join the force, how many have pathologically authoritarian personalities, or how pervasive is the practice of "over-policing" of communities of color.

We are told that "blue lives matter." Of course they do. Yet we cannot ignore the grim statistics. The lives of Americans killed by police matter, too. We must pay attention to these - and ask how many of these killings were genuinely justified, truly unavoidable.

I have long thought this nation could erupt in bloody revolution over economic inequality. I still think that is so, and I am starting to believe that our stubborn refusal to seek racial justice earnestly, with determination and seriousness of purpose, could be the match that sets America aflame.

What do Vladimir Putin, Kim Jon-un, Recep Tayyip Erdoğan, and Xi Jinping have in common?

All are admired by Trump - for their authoritarian style.  He describes this as being "a strong leader.”

Trump's idea of being a strong leader is becoming clearer lately.  He encourages law enforcement to treat subjects roughly.  He is inclined toward having the Secret Service use "vicious dogs" and "ominous weapons" in dealing with protestors.  He calls governors weak who search for ways to replace violence and looting with conciliation.  And he appears eager to use the US military to quell civil unrest, using the Insurrection Act of 1807 - which has most recently been invoked in response to the Los Angeles riots after the acquittal of police officers who had participated in the videotaped beating of Rodney King, and before that during rioting that occurred in 1968 following the assassination of the Reverend Dr. Martin Luther King, Jr.

Unlike the governors he scorns, Trump has no interest in conciliation, or in addressing the institutionalized racism of American society, or in making the fundamental changes we need in the way police interact with communities of color.

This is not the presidential leadership America needs.  No, instead Donald Trump offers a response to a nation gripped by racial violence - that predictably erupts when an oppressed minority is brutalized yet again as it has been in this country for four centuries - that is authoritarian in character and fascist in ideology.

We need mayors, county officials, and governors throughout the USA to reject Trump's dark vision and find positive ways to meet the demands being made in these protests.  The refrain we hear echoing throughout the land is "No justice, no peace."  We must not allow the president to respond to that cri de cœur with yet more brutal force.

We must press the cause of justice so that genuine peace is attainable.

Thomas Jefferson's "fire bell in the night" is ringing.

Black Lives Matter: A White Man's Interpretation

Last year we marked the fourth centennial of the arrival of the first Africans brought to Virginia in the transatlantic slave trade.

The history of humans enslaving other humans goes back thousands of years.  The basis for this has varied: some have been enslaved after being captured in wars; others in a form of permanent indentured servitude because of debt; and still others in extreme versions of class or caste systems in which some people spent their lives in a condition of servitude to others because the relation of one group (we might call them peasants or serfs) to another (nobility or aristocracy) was one of being treated as property: that some humans owned other humans was a feature of a society or culture.

Enslaved Africans brought to the New World were not, however, simply humans owned by other humans.  They were regarded as less than human, more a distinct species than a race.  They were mostly employed as beasts of burden and were bought and sold like livestock.

In the British colonies of North America there developed exceptions to this treatment of enslaved Africans as less than human.  A slave might serve as a household servant, a nanny, or a wet nurse.  On a plantation a slave might be a foreman or overseer of other slaves, responsible for managing their labor and maximizing their output, a sort of surrogate master who might employ such tools of enforcement as the whip.  Having such a relatively elevated status could mean a lower likelihood of being sold as chattel.  A slaveholder might come to regard such a slave almost as a member of the family and decide to render the servitude impermanent by providing for the slave to be freed after many years, sometimes upon the death of the owner.

But these were exceptions to the rule of having a sub-human status.  In general slaves continued to be bought and sold as beasts of burden.  When they reproduced, offspring were viewed as the products of breeding farm animals.  Little or no thought was given to the notion that an adult male, an adult female, and the children produced by their sexual intercourse constituted a family, and such thinking did not enter into decisions about selling them when doing so would permanently separate them.

************************

In the 1970s I attended an academically selective public high school that drew students from all over the city.  There were black classmates I held in high esteem because they were intellectually gifted, or talented musicians, or accomplished athletes who led my school's teams to championships.  A few I had the good fortune to get to know well, forming deep friendships.

When I was in college and spent a summer driving a taxi - my first blue collar job - I was exposed to - in fact immersed in - the society of white working class fellow employees.

In general the city in which I was born and raised was extremely segregated.  Nearly all of Philadelphia's neighborhoods were overwhelmingly white or black, typically virtually 100% one way or the other.  My cab-driving coworkers came primarily from a working class neighborhood that was 100% white.

While I was by no means unfamiliar with racism, the content of some conversations astonished me, because it was not until that summer that I understood how some Whites regarded Blacks as less than human, a distinct species, referring to them as "animals" or even "things," statements about them often dripping with contempt.

At the age of 18 I had no idea how to respond to this - and so I didn't, except internally, where my response was to be shocked, appalled, horrified.  Perhaps I sensed that nothing I might say could influence such thinking.  And I was certainly too timid to try.  Although I didn't know it at the time, I was an enabler.

The city's political milieu was hardly encouraging.  The mayor was Frank Rizzo, police commissioner turned law-and-order politician, an unabashed racist whose treatment of the residents of black neighborhoods was disgraceful.  Few black officers were added to the force when he was commissioner, and his tenure as mayor was marked by incidents of racist brutality and oppression.

The Black Lives Matter movement was formed nearly seven years ago.  Only gradually did I come to realize that the movement was truly needed.  My initial reaction was, "Of course black lives matter."  It was not clear to me what, exactly, was the point of this statement.

Gradually I realized that there was good reason for making the statement, through the name of the movement and its myriad actions.  News reports of incidents told the same story again and again: city police departments, both leaders and rank-and-file officers, conducted themselves as though black lives do not matter.  City government officials' responses to such incidents ranged from indifferent to ineffectual.

When Black Americans are subjected to police brutality, the consequences span a gamut of effects, from injury, both emotional and physical, to death.  It is all unmistakably dehumanizing.  Yet rather than taking away the humanity of its victims, it flatly denies their humanity's very existence.

Black lives matter.  They do not matter more than the lives of other members of our society.  Black lives do not matter more than "blue lives."  Black lives do not matter to the exclusion of the importance of others' lives.  This insistence that black lives matter matter is necessary because they are in constant danger in the USA in a way that others are not, the result of a long history of seeing Blacks as less than human.  Indeed, "structural racism" and "institutional racism" are mere euphemisms for the attitude that Blacks are less than human.

The statement made by the name of the movement conveys one simple and important truth: Black Lives Matter, and all of what we countenance in American society that denies that statement's verity must stop.

Responsible Citizenship in a Pandemic

As restrictions on various activities are eased this month, it will be very important for all of us to adhere to measures recommended to mitigate contagion: wearing masks, social distancing, and meticulous attention to personal hygienic practices such as hand washing.

It is being emphasized that these are necessary to prevent a steep rise in COVID-19 cases - and, ultimately, deaths.

It may be instructive to look a bit further at the practical consequences of doing - versus not doing - what is recommended.  Let us call the recommendations - masks, social distancing, hygienic measures - the "triad."

Scrupulously implementing the triad - or failure to do so - has predictable results.

Of those who get infected with the virus, some will have minimal or no symptoms - referred to as "subclinical" infection.  Many others, however, will feel ill enough to experience definite effects on their ability to engage in all their usual activities.  Some will get sick enough to be hospitalized, and some of those will require intensive care.

Some who get infected will transmit the infection to others, for a "multiplier" effect.

Here are some things that will happen as a direct consequence of not adhering to the triad:

1.  You will be more likely to get sick enough to miss work.  This affects workplace productivity.  It may place an additional burden on co-workers who must pick up the slack.  It is harmful to the employer's bottom line - which is likely, ultimately, to be bad for you and your co-workers.

2.  You will be more likely to get sick enough to require hospitalization, thereby consuming healthcare resources that could otherwise have been devoted to caring for others and driving up society's overall healthcare costs.

3.  You will be more likely to become critically ill, thus requiring intensive care - the most costly utilization of healthcare resources.

4.  You will be more likely to transmit the infection to others, thereby multiplying the effects enumerated as 1, 2, and 3 above.

5.  Among those you may infect will be healthcare workers, despite their best efforts to keep from catching it from their patients.  This may cause them to miss work, placing additional burdens related to cost and productivity on the healthcare system.  (Sickness among employees is costly for hospitals, which must pay premium wages to those working overtime to cover.)  It also increases the risk that healthcare workers will then transmit the infection to others, including their co-workers and their families - and other patients who are in the hospital for unrelated reasons.

In sum, when you fail to adhere to the triad, the risk you are taking goes far beyond misery and expense for yourself.  Responsible citizenship - in other words, behaving as a member of a society, with obligations to act in the best interests of not only yourself but of all members of our society - requires that you do the right things.

Socialism and the Pandemic

The right wing of US politics takes every opportunity to condemn socialism, often citing Venezuela and Cuba as countries where socialism has been associated with economic dysfunction and poor decision making, not merely ignoring the role of authoritarianism but claiming that socialism requires an authoritarian regime to govern.

Conspicuous by its absence is mention of Denmark - you know, that country where McDonald's workers earn a living wage rather than being regarded as kids in their first jobs doing it for pocket money while in reality still financial dependents of their parents.  No, Denmark is not considered a socialist nation, as it has many features of a market economy side-by-side with high taxes and an extensive array of social welfare programs.  And it certainly does not satisfy the classic definition of socialism in which the means of production are controlled by the State.  But there is a great deal about the way Danish society works that Americans - especially those on the right - regard as socialist.

What did Denmark's government do about shutting down its economy for the pandemic?  It told everyone there would be a freeze.  Companies not in essential businesses would simply stop doing business.  They would not terminate or furlough any employees, but instead keep them on the payroll.  Those businesses would receive government assistance sufficient to cover their residual expenses, while employees would receive their paychecks from the government, essentially keeping pace with what they were earning.

Denmark has a strong economy.  Not strong like President Trump says the US economy is, but strong in reality.  The national treasury was brimming with budget surpluses, so there was enough money to cover the financing of the freeze for several months without incurring debt.

And now the Danish economy is reopening, as broadly and widely as any in the West - more so than most - with population-adjusted numbers of COVID-19 cases and COVID-19 deaths comparing favorably with the rest of Europe - and with the US.  Population-adjusted cases for Denmark are 45% of the US number; deaths, 39%.

When the Danish government first announced how it was going to manage the economic shutdown, it was estimated that for the USA to do the same thing, it would cost between $2T and $2.5T.  Perhaps you've noticed that we have already appropriated more money than that, yet the unemployment rate has soared, and other economic indicators are calamitous, with widespread effects on Americans that have people desperate to put an end to restrictions despite statistics that portend disastrous increases in cases and deaths.

Maybe there is no way we could have done what Denmark did.  It would have been so alien to the way our economy operates that a proposal to do such a thing would have been regarded as preposterous in the halls of Congress.

But let us be honest: the approach taken by Denmark is undeniably socialist, and the strength of the Danish economy that made it so easy to decide to do it exists despite the many aspects of that nation's economy that are socialist in character.

Let's broaden our view of socialism beyond Castro's Cuba and Venezuela under Chavez - the "socialism" America's right wing loves to hate - and acknowledge that it can work very well, indeed.

Truth in Science

For my entire adult life I have been a student of the philosophy of science with a keen interest in the subject of truth in science.

In the midst of this pandemic, it has struck me how many people - with no training in scientific disciplines - set forth assertions of what they believe to be facts.

In the Second Century the Greek mathematician and astronomer Ptolemy developed a mathematical model of an Earth-centric universe. Such a model, to gain acceptance as scientific theory, must be consistent with all known observations. To retain its status, it must then predict future observations: as they are made, the model must be consistent with them, too.

Ptolemy's model was complex, but it fit so well that a heliocentric model of our solar system posited a few centuries earlier by Aristarchus was superseded.

The Earth-centric model was very comfortable for humanity, which had long thought of our position in the universe as being at the center, as we believed its Creator had made us in His image.

It was not until the Sixteenth Century that mathematician and astronomer Copernicus developed a compelling heliocentric model. In the following century Kepler set forth a model of elliptical orbits, and Galileo made detailed observations with increasingly powerful telescopes that were consistent with the model of Copernicus, and not of Ptolemy - essentially proving Ptolemy wrong after fifteen centuries.

We have known that certain diseases are caused by infectious agents only since the 19th Century, thanks to the work of men like Pasteur and Koch.

Virology is relatively young. While Jenner (smallpox) and Pasteur (rabies) developed vaccines against diseases now known to be caused by viruses, the infectious agents responsible were poorly understood. The first virus to be studied by electron microscopy - essential because viruses are too small to be viewed with a light microscope - was the tobacco mosaic virus, in the 1930s.
The great influenza pandemic of 1918, then, occurred when virology was in its infancy. We have learned a great deal about viruses in the last century: indeed, we have arrived at a point at which we are able to isolate viruses, study their structure with electron microscopy, and characterize the proteins and genetic material (DNA or RNA) of which they are made. We can even sequence the genome of a virus.

Yet there are still secrets to be elucidated about what makes some viruses use humans as hosts, what factors enable viruses to cross from one host species to another, why some viruses are more lethal than other related strains, and why some are more readily transmitted from one human to another.
Then there is the fascinating subject of how viruses change over time, with genetic mutations and minor modifications of their protein structures.

Now that you have some sense of just how much we know about viruses - and, more important, how much remains to be learned - perhaps you can understand why sometimes expert opinions on specific points may diverge. When you layer over this the complexities of human behavior that influence the interactions between viruses and the host species, you get some sense of the extremely challenging field of the epidemiology of viral diseases.

All of this is what scientists are up against when they try to figure out the best ways of facing a pandemic.

Now imagine that you are an elected official or a government regulator trying to make decisions about protecting the public, completely dependent on advice from experts who are, in turn, frantically gathering and interpreting a constant stream of new data.

In a situation like this it is critically important to recognize what we don't know. Yes, we still have to make decisions. But when the people trying to make the decisions - relying on the best advice available from those who know the most in a discipline full of unknowns - make decisions you don't like, just say you don't like those decisions. Don't imagine you have the knowledge to support a coherent argument that the decisions are wrong - if those decisions are made after careful consideration of the best advice to be had.

And if you believe you know the truth of the science, please remember Ptolemy.

Remdesivir: First Glimpse of the ACTT

The National Institute of Allergy and Infectious Disease (NIAID) has issued a press release about the results of the Adaptive COVID-19 Treatment Trial (ACTT).

As described on the website <www.clinicaltrials.gov>, this is a randomized, placebo-controlled trial of the anti-viral drug remdesivir, administered intravenously for ten days.

No data from the study have been released for public scrutiny thus far.  It is unclear whether this will be done before a formal manuscript is prepared and submitted for publication in a peer-reviewed medical journal.

The primary endpoint was time to recovery.  This was defined as no longer requiring in-hospital care (including oxygen therapy) - or, for non-hospitalized patients, no longer requiring home oxygen and having no limitations on activities.  [As the drug was administered in hospital, the latter description presumably was intended to include patients discharged while still requiring oxygen at home.]

The study failed to show a statistically significant difference in mortality.  The NIAID press release says the results "suggest" a mortality benefit.  In the language of medicine it is said there was a "trend" toward a certain outcome.  That means if the study had enrolled a larger number of subjects, the difference might have achieved statistical significance, but we don't know that.

The statistically significant difference that did emerge was in the primary endpoint, time to recovery.  For the placebo group, the median time was 15 days, while it was 11 days for the remdesivir group.  (Median means half the subjects took less time, half took longer.  One might imagine that using "mean," the arithmetic average, could tell a different story, depending on the time distribution of recovery, but only the raw data could tell us that.)

How can we put these results in context as we await more details?

Consider that patients with seasonal influenza are commonly prescribed oseltamivir (Tamiflu), for which the time-to-recovery data are less impressive: when initiated within 24-48 hours of onset of symptoms, oseltamivir makes a difference of about one day.

So remdesivir looks better than that, and if it shortens hospitalizations, and isn't terribly expensive (which we don't know yet), it will also prove cost-effective.

NIAID Director Dr. Anthony Fauci is being quoted as saying remdesivir is now the "standard of care."  This is both premature and imprecise.  The term "standard of care" refers to what a reasonable and prudent physician would do, and it is hard to say that the US population of reasonable and prudent physicians would order this drug when they haven't even been able to get a good look at the results of the clinical trial.  More appropriate would be to say that the drug should become standard treatment, because it actually appears to do something useful, and that is superior to not giving a drug with potential benefit.

It is anticipated that the FDA will promptly issue an emergency use authorization, which is a preliminary step that may be followed by formal approval after an FDA panel has been able to review the raw data from the trial.

As you might imagine, it is unclear how soon Gilead, the manufacturer, will have the capacity to produce hundreds of thousands (or even millions) of doses to treat all the patients hospitalized with COVID-19 now and in the coming months.

Gilead CEO John O'Day was quoted yesterday as saying the company has enough remdesivir for "more than 50,000 treatment courses" and will have 140,000 by July - and could then ramp up from there.

O'Day also said that "from July on, we’re going to work very closely with the government and with health care systems to make sure that it’s accessible, that it’s affordable to governments. We’re going to make sure that access is not an issue with this medicine."

Universal Health Care - a Personal Perspective

The latest figure I've seen for the USA is that about 11% of Americans don't have health insurance. Tens of millions more have coverage with premiums, co-pays, and deductibles that either wreak havoc on the family budget or make them effectively uninsured, because they never seek medical care unless they are quite certain they have something very serious. I'm not one of those. (I do tend to seek medical attention only if I think I have something very serious, but that's unrelated to health insurance; it's just the way I am.) I'm one of the very fortunate ones. I have excellent health insurance through my wife's employment, and her job (knock on wood) seems to be very stable.

A few years ago I developed an unusual heart condition, the evaluation and treatment of which has been costly.

Today I needed to gather up statements of what I paid in calendar 2019, to submit for reimbursement from a health savings account (HSA) - that device that enables us to pay for our out-of-pocket expenses with untaxed dollars, at least to the extent that we are able to forecast them. (It's like the old TV show "The Price is Right," in that you want to get as close as possible without going over your expenses, because if you don't use it, you lose it.)

After some time-consuming and irksome phone calls, I was able to get the information I needed online, as I hadn't saved all those tree-killing paper statements.

I believe we have a family deductible of "only" $1,000 a year, so I knew I would cover the amount that we put in the HSA, which was less than that.

I looked at the charges billed for all of the medical evaluation and treatment I received in calendar 2019.

I did not have major surgery. (Most of us know how expensive that is just from the information we get from stories in the news.)

Yet my total charges for the year were just shy of $450,000.

Without health insurance, I would be bankrupt or dead (or both, in that order, I suppose).

My cardiac condition is not the kind you get because of advanced age or unfortunate lifestyle choices (smoking, dietary over-indulgence, being sedentary). We so often think of America's health problems as being self-inflicted, and many of them are, to some degree. Not this one. Nope, nobody's fault. Just bad luck.

If this bad luck had been coupled with the kind of bad luck that afflicts thirty-some million Americans - being uninsured - my life would be a financial calamity, to put it very mildly.

What is the moral of this story?

Every American who lacks health insurance is just one unlucky roll of the dice from financial disaster. It is completely unacceptable that people facing dire threats to their health must simultaneously spend time with lawyers navigating bankruptcy proceedings.

I happen to like doctors better than lawyers, but that's just me. Nevertheless, I think people who are seriously ill or injured should focus on their health - not on the fact that everything they've worked for their whole lives is now gone.

COVID-19: What's the Big Deal?

The proteins on the surface look like a crown, as in coronation

As is true for influenza, illness caused by COVID-19 can range from very mild to severe.  So why are we more worried about it than we are about seasonal flu?

The answer lies in part of the original name - before COVID-19 was adopted.  It was called "novel" coronavirus. Novel doesn't mean the virus likes to read fiction, any more than the "corona" part of the name means it's connected to Corona beer.

Novel means new. Not new in the big scheme of things. New to humans, after making the leap from an animal species.

How can that cause so much trouble?

It means that it is new to our immune systems.

Let's say we take a group of 100 people who are well, put them in a room, and then add a person with seasonal influenza. That person can spread the flu virus to the others in the room. But not so easily. Each time a person who comes into contact - of the sort that lends itself to transmission - with the infected "index case," either of two things can happen. The new contact gets infected, and experiences illness.

Alternatively, if the new contact has some immunity, through vaccination against, or previous infection with, the same or closely related flu strains, the new contact will most likely not get sick, and will not be a source of contagion that - like the index case - threatens everyone else in the room.

The presence of immunity among people in the room means person-to-person spread will be limited. Thus, what epidemiologists call the "attack rate" will be reduced. (This is what epidemiologists sometimes call "herd immunity.")

Now, take the same group of 100 well people and add a person sick (even very mildly) with COVID-19. Nobody else in the room has any immunity, because this is a "novel" virus. So person-to-person transmission happens much more readily, and thus the "attack rate" will be much higher.

So we can see that even if COVID-19 is no worse than seasonal flu in the average person, the "novel" attribute enables it to spread quickly to a large number of people. And that really matters, because a certain percentage of people who get infected will die. That is called the "case fatality" rate. No matter what the case fatality rate is, the more people who get infected, the more will die.

Right now we aren't really sure how the case fatality rate compares with seasonal influenza. We just don't have enough population data yet, and that makes it a moving target.

But there is reason to be concerned that it will be significantly higher than for seasonal flu. Again, this is because of the "novel" attribute.

It is believed that one of the reasons the Spanish Flu of a century ago, a novel strain, killed so many people - and especially so many young and previously healthy people - has to do with the immune response. If you have been exposed to other viruses that are similar, you will have a little bit of immunity. This helps in two ways. First, your immune system is at least a little "primed" to respond. Second, some of the immune system's response will be to produce partially-matching antibodies that can act as "blocking" antibodies that lessen the intensity of the overall immune response. And this is actually a good thing.

Why? Because a good bit of the effect of the virus on your body - especially on the respiratory tract - is the result not so much of the virus itself but the inflammatory aspects of the immune response. The "blocking antibody" effect can lessen the severity of the inflammation. You don't get that when you're infected by a novel virus. Since young, healthy people typically have the most intense immune response to any infectious agent, the lack of a "blocking antibody" effect means they can get very sick very quickly. Paradoxically, then, their risk of becoming seriously ill or dying may not be that much lower than it is for the elderly and infirm.

What does all this mean? If we start to see evidence of rapid "community spread" - and there is reason to think we will - the attack rate will be high, the number of cases will be high, and the number of deaths will be high.

So pay attention to all the advice you're getting from reliable sources on how to limit contagion.

For my entire career I have been telling patients and families who ask me how to avoid spreading an infectious disease from the "index case" in the family: "Lots of hand washing." This applies to everything from "pinkeye" to the common cold to influenza. And now to COVID-19.

Wash your hands!