Why death?

But first, a brief digression to note that Her Majesty's Parliament has approved research using cells created by transfer of nuclei from human somatic cells into non-human ova. The media report, as usual, is scientifically inaccurate, calling these "animal-human embryos." They aren't really. As I have discussed previously, the nuclear DNA is 100% human. Only the mitochondria are from other mammals.

The mitochondria -- descendants of ancient archaea that became endosymbionts in eukaryotic cells some billion years ago -- reproduce exclusively asexually, cannot exchange genes with counterparts of other lineages, and live exclusively in the comparatively homogeneous environment of the eukaryotic cell. Hence, while they experience some genetic drift, they do not really evolve. Rabbit mitochondria are very similar to human mitochondria, and it isn't clear that these cells are any different from human cells in any practical way. Nevertheless, as the AP report tells us, "opponents warn that an easing of laws on creating the embryos could lead to the genetic engineering of human beings." As I said before, I really don't see how this is a meaningful step in that direction. This technique is not envisioned for reproductive purposes, but for stem cell research. Conceivably it could be used to produce therapeutic stem cells some day. But it does not contribute to modification of human nuclear DNA, which is what genetic enhancement is all about.

As Kathleen points out in a comment on the previous post, there are enormous practical difficulties with trying to genetically modify humans. The organism is incomprehensibly complex, and pulling on the wrong thread could unravel the whole cloth. Changing genes to try to give someone greater intelligence or some other capability could have unforeseen ill effects; and how could we ever ethically do the experiments to find out? This is a valid observation, certainly, for the present. But we are already doing experiments with animals, to create livestock with commercial advantages; and we are also very close to genetically modifying human embryos in order to correct some of those rare, but real, genetic disorders caused by an identifiable single abnormal gene, such as cystic fibrosis and sickle cell anemia. As this sort of research proceeds, along with research into patterns of genes associated with various characteristics, I would not rule out that we'll learn enough that somebody, somewhere, some day will decide to try enhancing a human genome. But I agree it is not an imminent problem.

So anyway (whoof), let's talk about a non-genetic treatment to delay the aging process, such as a pill. Why do we get old and die in the first place? Because evolution compels it. Evolution is not, as we are often mistaught, driven by "survival of the fittest." This is quite obvious because no organism survives. Natural selection does not concern survival, but reproduction. Genes are preserved that are associated with more successful reproduction, and not just for a single generation but into the future, generation after generation. That requires not only reproduction, but continual evolution, because the environment changes and new challenges arise as other organisms evolve and the earth also changes.

Shorter generations advantageous because they allow an organism to evolve faster, although there is a balance for complex organisms that require time to develop. It may also be advantageous to reproduce multiple times, and then there are mammals and some other creatures that benefit from sticking around to invest in their offspring. So there are factors that may favor a longer lifespan as well. Nevertheless, sooner or later, you have to get out of the way, because you are competing with your offspring for limited resources. In order for them to succeed, and for their offspring to succeed in turn, you must die. You are programmed to do so because evolution has produced that result.

Presumably our lifespan is more or less optimal, from an evolutionary standpoint, for the way our ancestors lived some time ago. That doesn't create any ethical imperative for us to honor it today. We can live longer if we want to, but is that wise? Suppose we could take a pill that would enable us to live to be 120, without necessarily experiencing degenerative diseases, disability, or severe mental decline. What would be the implications for our children and grandchildren? What would our own superannuated lives be like? I don't expect we could draw Social Security for 50 years, we'd have to keep working. And, obviously, this would cost money. Presumably the pills would be patented for the first 15 years or so, and cost thousands of dollars a year. Some people would have access to them, but most would not.

So how would that scenario play out? I doubt that many people who had the chance to take the magic pill would turn it down, but what would be the social consequences? Think about it.

Able to leap tall paradoxes in a single bound . . .

As the comments on the Sunday post demonstrate, there are a whole mess of issues tangled up in this human enhancement problem. People come at it from various directions, although we mostly wind up in the same knot.

So, my first proposal is that it's counterproductive to treat this as a single, general problem. The most prevalent attempt to generalize is a conservative take -- one that we hear not only from religious thinkers but also from a certain strain of environmentalists who have what I would call a quasi-religious or mystical view of nature. This is the claim that there is some entity called "human nature" which has a kind of sacrality. If we set out to make a new kind of human being, or a post-human, we will either be offending God, or destroying ourselves, however you want to look at it.

The liberal view of human nature, in contrast, is as always more reality based. That is, human nature is what we make of it. For as long as we have been capable of the requisite self-reflection, planning, and cultural development, we have been transforming our nature. The invention of writing, for example, produced a revolution in human nature. Literate people are very different from people in pre-literate societies. Command of fire, clothing, agriculture, all of the basics, created new kinds of creatures. Nowadays it is commonplace to change human nature -- it's what we do through education, military basic training, football camp. Cro Magnons couldn't fly, couldn't play saxophones, couldn't make a perspective drawing, and couldn't run a four minute mile. Does that make us no longer human?

Even so, it's fair to ask whether any particular enhancement is for better or for worse. There is even a respectable argument to be made over whether we are in fact better off than our hunter-gatherer ancestors. Disclosure alert: that was the precise subject of my master's thesis and I came down firmly on the side of ambivalence. But if we aren't, it isn't because we have offended God -- who according to all the religions I know about came along through one or another incarnation or prophet no more than 3,000 years ago at the outside, to endorse a social order and human nature that was very far removed from Eden.

We have to look at each of these questions separately, and on their merits. An extended life span is a different issue from enhanced mental capabilities, or physical strength, or whole new functional elements such as wings or X-ray vision. So, I'll take on the longevity thing first, with the next post.

Basic Knowledge

I haven't ranted very much lately about the democratization of science, and mea culpa. So the theme for today is that we can't have a more democratic scientific institution if most people lack the basic knowledge they need to participate.

This is the story of my professional life, actually. My day job is with a community based public health agency, and my academic half is concerned with people's control -- or usually lack thereof -- over their own health and health care. (As I often say, I am a community-academic partnership.) My work concerns all sorts of issues -- mental health, addiction, environmental justice, diabetes, heart disease, you name it -- but HIV is a particularly big piece of it, in part because it has paradigmatic qualities that make it particularly instructive for many of the principal concerns of medical sociology.

Sociologists are interested in the "sick role" and how disease shapes identity, and HIV is a powerful shaper of identity, with particularly strong components of stigma, disability, community and empowerment vs. disempowerment. It's a chronic disease that people have to live with their whole lives. Its treatment is complex and requires intense, ongoing involvement with physicians and the medical institution. Treatment adherence is particularly challenging. People with HIV are a preoccupation of public health authorities, advocates and researchers because they are infectious, but in a way that is fully under their control; and because every person with HIV is a potential incubator of drug resistant virus. These related facts mean that each individual's treatment adherence, as well as their sexual and drug injecting behavior, is of concern to society in general and government agencies in particular.

So, people living with HIV have to navigate all these complexities, for the sake of their own health and autonomy, and for the sake of others. And, people who aren't HIV infected have a responsibility to understand the facts about the virus and engage the problem with both compassion and reason. Unfortunately, the average person has such limited knowledge of biology that it just isn't working very well.

Of course, once people are told that they are HIV infected, they try to learn what they need to know about their condition. But without basic knowledge of cellular biology, and evolution, many people just never really get it. I sat down once to write a basic explanation, in accessible English, of what a virus is, what a retrovirus is specifically, how HIV causes disease, how the antiretroviral drugs work, what drug resistance is and how it comes about. I thought I'd done a pretty good job, so I showed it to an HIV educator. "Oh, this is too technical," she said, "people won't follow this." But I had begun at the beginning, and explained everything, step by step, from cells to DNA and RNA and enzymes and evolution. That was just too much for people, apparently.

So instead, people are given vague and misleading metaphors, often military. HIV is the "enemy soldiers," the drugs are our soldiers, and we need to keep them in the field so the enemy can't advance. The virus "attacks" cells. And the virus is "intelligent," it can "learn" how to get around the drugs. One woman I interviewed personalizes her infection, she refers to HIV as "she." Somebody told her that viral load is a measure of how many baby viruses the mother virus is having.

Many HIV educators and advocates say we should respect these ideas, that they are somehow "indigenous to the community" and represent the points of view of the authentic people, that it's somehow insulting or elitist (yup) to tell people they are inaccurate. I think that's nonsense. People have been told these things by professionals acting as health care providers and HIV educators, who are just too lazy or don't have the time to tell the people the truth and work with them so they can understand it.

I'm not sure what to do about the general ignorance of biology, and that includes far too many high school biology teachers. But it's something we must fix.

Ist ein ubermensch!

Okay, so getting back to Dr. Bashir. Right now there is a rather heated debate going on in some quarters about whether it is ethical to use technology not merely to cure or ameliorate disease, but to enhance human abilities or other desirable characteristics, such as physical attractiveness or personality.

It doesn't take more than a moment's reflection to see that the question, taken at face value, is just silly. People have always looked for ways to make themselves more capable or more beautiful, and we accept it as a matter of course. Just to make this discussion manageable, let's consider athletics.

The big flap these days is obviously over performance enhancing drugs. Yes, they're against the rule -- or rather, some are but not others, as I'll show in a second -- but other than that, is there anything essentially different about steroids and other methods that athletes use all the time? Of course not. Athletes train at high altitude or, if that's inconvenient, in hyperbaric chambers. They consume carefully engineered diets and regimens of supplements. They use elaborate machinery to develop muscular strength, endurance, and flexibility, and to build patterned motions into their motor neurons. Baseball pitchers routinely undergo ulnar collateral ligament reconstruction, "Tommy John Surgery," which actually gives them a superior elbow, and often a faster fastball, than they had before. As for drugs, it's perfectly legal for athletes to take painkillers and anti-inflammatories, undergo, yes, steroid injections to reduce joint and tendon inflammation, and in most sports to consume caffeine and other herbal stimulants. Some people say, well, steroids present long term dangers to health but in fact, professional athletes typically suffer from osteoarthritis, post-concussion syndrome, and other ills after they retire. If the long-term effects on athletes' health really mattered to anyone, we would have to ban most professional sports.

Now consider medicine in general. There is a great deal of handwringing over the prospect that children who are healthy but just shorter than average are being given Human Growth Hormone, and over the possibility of "cosmetic psychopharmacology," in other words that people are taking antidepressants because they are unhappy with aspects of their personality, such as shyness or irritability, that were not considered diseases until the drug companies came along.

But let's consider some treatments that don't seem to bother anyone. When Social Security was established in the U.S., it wasn't very expensive. Most people didn't even make it to age 65, and few lived much past it. Nowadays it's a tragedy if somebody dies before age 70, and most of us fully expect to carry on well into our 80s, simply because of ongoing efforts to prevent and cure disease. That is beyond what used to be considered the normal human life span, of course, but I haven't heard anyone worrying about such a fundamental change in "human nature." Even so, it isn't good enough. Scientists are working on ways to slow or even halt the aging process, and they are already testing the compound resveratrol. If it turns out that it works, and let's us all live to be 120, believe me, there will be very few voices saying it's unethical to take it at all, and many more declaring that it's a human right to take it which needs to be extended to everybody.

What if there were a pill that would make children smarter? (Uh oh. It turns out there just might be one. The word hasn't really gotten around yet, but I'm waiting for the shit to hit the fan.) Assuming it had no dangerous long-term effects, parents would be clamoring for it. People would insist that it be added to school lunches, and I expect I'd be popping it every morning at my desk.*

So there seems to be an arbitrary quality about what sorts of technological "enhancements" do and do not offend people. If you think about it a bit more, it's hard to see how the extension of human intelligence represented by writing, and books, and now by the electronic digital computer, is fundamentally different from sci-fi concepts like getting computer chip implants that enhance memory or processing power. Technology, over time, has made us more capable, longer lived, healthier and yes, better looking. Cosmetic dentistry and wart removal are taken for granted. Face lifts and hair transplants are considered silly by some, but hardly objectionable for those who want them. So why object if parents don't want their children to be short? Why draw the line at some technologies and not others? What's the difference? To me, certainly, it is far from obvious.

So, here's the last step. Suppose we find out that resveratrol works, and everybody starts taking it. What's wrong, then, with inserting a gene into a human embryo so that the person will manufacture the chemical, and won't have to take the pill? The result is the same, only cheaper. And yes, she or he will pass the capability on to her offspring and we'll have a race of people who live to be 120. Why is that unethical, but accomplishing the same thing by taking a pill is not? The same goes for greater intelligence, or physical ability, or even temperament. If we can take pills so we won't be depressed or anxious, why not put happiness and equanimity in our genes. What's the difference?

You tell me.


* Of course intelligence is not a function of a single chemical. Success in school and at all intellectual work or pursuits depends on a combination of memory and information processing capabilities, an inquiring personality, concentration, diligence and hard work, all of which result from a genetic endowment unfolding in a particular environment, and which in turn may be enhanced or suppressed by good or incompetent teaching and mentorship. But a pill might still increase intellectual performance, ceteris paribus.

Ants Taking Over Texas

That was the headline I saw on a fellow traveler's newspaper on the subway this morning. I can only say, it would probably be an improvement over the present administration down there. It got me to thinking I should weigh in here on politics. Lately I've been leaving it to others who specialize in that sort of thing, and I still need to deal with the Man and Superman thing, the rest of Stem Cell Century, and current public health news. However, this will be the most critical election for public health in my lifetime, so it requires attention.

I didn't post yesterday because I was too busy during working hours and too filled with bitter loathing for the malignant dwarf who has fraudulently occupied the office of president to put anything up in the evening. That the toxic slimeball would thrust itself back into the public discourse at this particular moment, to inject more narcissistic sewage, serves to remind us of why we have despaired for the American polity. The Republicans were actually able to build a cult of personality around a sociopath with the mentality of a three-year-old and all the charisma of a leech. The corporate media joyfully joined in the conspiracy, and the voters actually made two successive elections close enough for the conspirators to steal. Hitler and Stalin at least had a certain gravitas, but this clown couldn't be elected president of the fourth grade. Yet there he sits.

And now we're going to have a candidate who is smart, charming, incorruptible, visionary, eloquent; who truly comes from humble beginnings; who is truly a citizen of the world, yet with a life-long record of service to America and proven patriotism; who has inspired a whole new generation of young idealists; who has energized a long-oppressed community to a level of commitment and determination not seen for forty years, since they brought about a great transformation in American society; who has spoken directly and out of complex personal experience about the greatest wound in American society and culture, in a way that every other politician has avoided; whose money comes from millions of small donors, who is storming the ossified Democratic Party establishment and sweeping away the cynical and failing imagemakers and poll parsers in favor of honest discourse and frank confrontation with the hard realities of the day.

And we're afraid he has no chance.

I was a community organizer in my youth, a street organizer, knocking on doors and getting people to sit in at city offices and block streets over trash filled vacant lots and real estate speculators trashing neighborhoods. One of the places I worked was Fishtown, a poor white neighborhood in east Philadelphia on the Delware River. Fishtown was in rough shape, with lousy municipal services, deteriorating schools, unemployment, a bad drug problem, you name it. But the number one issue on most people's minds, as soon as they opened their mouths, was The Niggers. There were two things wrong with The Niggers: they don't like to work and they're all on welfare; and they're taking all the jobs. I usually got this in the same sentence. These people normally voted Democratic, but they liked Republican Mayor Frank Rizzo because he was sending the cops into the black neighborhoods to beat people up -- or, as Rizzo himself put it, Spacco il Capo.

So, the question is, today, are these same people going to vote for the colored guy in November? You know what? I think they just might, or anyway a lot of them will. Partly, it's just because they've gotten more used to the idea. Philadelphia has had two black mayors since then, and Fishtown's white ethnic residents have not been pushed into the river after all. They probably aren't any better off, but they're no worse off either. But more important, they aren't going to be voting for an abstraction, they'll be voting for a candidate, who I absolutely believe will find a way to speak to them.

The Obama presidency will represent a huge historic transformation for this country. The main reason we're so politically and socially backward is that the working class has been divided by race, a fissure that politicians and capitalist have exploited with almost perfect success since they used it to destroy the populist movement of the 1890s. The strategy broke down to some extent during the Great Depression, and again in the Civil Rights era, but it came back with a vengeance thanks to Nixon and Reagan and their clever use of racism. Now we have a chance to really put an end to it.

If we do, Attorney General Edwards will have a chance to put the bastards in jail. Now that will really be sweet.

Paging Dr. Bashir

For those of you who don't know, which I presume is all of you, Dr. Bashir was the genetically enhanced chief medical officer on Deep Space Nine. He was something of a sci-fi cliche: genetically enhancing human beings, in the future, is generally illegal and/or morally repugnant, and the genetically enhanced face discrimination, banishment, imprisonment or termination. Dr. Bashir had to keep his true nature a secret, although as I recall the commander ferreted it out in one episode. The way it works in the Star Trek universe is that his parents were criminals, but he merely faced ostracism and general hatred.

Anyway, today we are confronting mass hysteria over the news that some Top Docs (as the tabloids always call them) in New York inserted a gene into a human zygote. Various moral watchdog groups are viewing with alarm and slippery sloping and demanding public debate and whatnot, on the grounds that this is a step toward making a Dr. Bashir.

So let's take this in two pieces: Is it? And what if it were?

Part one: It isn't. The investigators inserted the gene into a genetically defective zygote that was incapable of normal development. Yes, they could have put it into a normal zygote but either way, the experiment was trivial. Their stated purpose was to demonstrate a way of tracing the ancestry of a clone of Human Embryonic Stem Cells, as a research tool. (Remember from an earlier episode that a clone doesn't necessarily mean an organism which is genetically identical to another, but as in this case, it can simply mean a line of cells of common descent.) This, in turn, is in pursuit of therapeutic uses of HESCs, not reproductive cloning.

I'm sure I don't have to tell you that if somebody is given organs or tissues created from HESCs, the genes of those replacement parts are not passed on to the recipients' offspring, if any.

Now, it is true that if someone were to insert genes into a zygote, and then allow that zygote to develop into a human being, those genes would be included in that person's germ cells, hence in his or her gametes, and could be passed on. But right now nobody is trying to do that, and this little experiment is of no importance in advancing such a project. Of course you can insert genes into a zygote, you can insert genes into any kind of human cell, big whoop.

However, right now, we don't know of any single genes which we could insert into a zygote and bring about any particular desired enhancement of the resulting person. Nor is it clear how such an experiment could be performed, because the whole problem is, you don't actually know what would happen. So it would never be approved. Maybe a mad scientist in a secret laboratory will try it some day, but that has been made no more likely by the experiment at issue. So get a grip, folks.

Part 2: Ahh, now this is a matter of considerable controversy among those who worry about weird stuff that might conceivably happen some day. It's a much more difficult ethical problem than it usually appears to people at first glance, no matter which side they take. Dr. Bashir was engineered to be super smart; he had to conceal his actual intellectual abilities to stay out of trouble. (Hey, so do you and I.) But people also worry about making 8 foot tall people for the NBA superstardom market, or maybe even giving people wings or X-ray vision or something.

Now this is worth talking about, in part because it connects seamlessly with some problems that are not fanciful at all, but are happening right now. So I will discuss it anon. Meanwhile, anybody care to weigh in?

Fool's Paradise

Now, following the Burmese cyclone, we have the Sichuan earthquake. I fear the death toll announced as of this post, 5,000 or so, will turn out to be far lower than the reality. People can't stop earthquakes any more than they can stop cyclones, but are these really "natural" disasters?

The only reason earthquakes are dangerous to humans is because of our built environment. People sitting out in the open will enjoy the ride, that's all. Even living in huts made of sticks and wattle, or teepees, people are perfectly safe from earthquakes. Earthquakes are catastrophes of civilization. They kill and injure us because they make our buildings fall down on top of us.

As I discussed regarding the Kashmiri earthquake two winters ago, the catastrophe was ultimately traceable to deforestation. Buildings in that region used to be wood framed, and would have been at little risk from even the most severe earthquake. But people cut down all the trees, and started to make unframed masonry structures. Then the earthquake came, and they died by the tens of thousands, and the rest were left homeless.

The region in China where the recent earthquake happened is prone to earthquakes and has had catastrophic tremors in living memory. But, as the report linked above indicates, schools, hospitals and factories have collapsed. Officials knew there would be an earthquake sooner or later, but they put up structures that were guaranteed to kill the people inside when that day came. We knew for 15 years or more that a major hurricane would drown New Orleans, but we didn't do anything about it. The Burmese government, such as it is, knew or certainly should have known that the mangrove forests protected the delta against the ocean, but they let them be cut down anyway to develop aquaculture. We know that a serious pandemic of one kind or another -- and it doesn't have to be H5N1 influenza -- will overload the health care system and leave people dying in the hallways and parking lots, but the only response so far is to come up with a list of who should be rescued first.

This is something basic about human nature. We just can't respond adequately to abstract dangers that we don't experience regularly but that somebody has worked out intellectually as being likely to happen. Making a low-cost proposal for that hospital or school building, and bringing it in under budget, is what got local Chinese officials good reviews and promotions. A bureaucrat who argued too strenuously to spend money on making the buildings earthquake proof would be exiled to Inner Mongolia. Americans don't want government telling them they can't build houses on barrier islands or taxing them to make preparations for something that hasn't happened since 1918. We just can't process dangers that have a huge magnitude but a low or unknown probability, or at least they can't compete with immediate and known rewards.

So how are we ever going to take on the problem of global climate change?

When will they ever learn?

(Above image is from Wikimedia commons.)

I've been pondering what lessons there may be in the recent disaster in Burma. (The people from that country who now live in Massachusetts seem to prefer Burma to Myanmar, so I'm going with it.) The "Reverend" John Hagee -- who John McCain has not been called up on to reject, eject, object, subject, deject, project or retroject -- says that God sent Katrina to destroy the Mississippi coast, Plaquemines Parish, and the Lower Ninth Ward of New Orleans because a homosexual parade was planned for a couple of weeks later in the French Quarter, which God was kind enough to spare. Mysterious are the ways of the Lord. I'm pretty certain that no homosexual parades were planned in Burma, however.

Since Burma is a Buddhist country, I expect the people are pondering the impermanence of all things and the wisdom of detachment. Fair enough, but are there any more practical lessons? As the map shows, you could not have designed a more destructive storm path. Nargis moved from west to east across the full width of the Irawaddy delta, at just the distance inland to draw the storm surge as far as possible up the river's many mouths. Hundreds of square miles are now under water. This was an extremely powerful storm, and it retained much of its power as it moved across the delta, now doubt because the land was so flat and the storm had enough water under it to continue to function as a tropical cyclone all the way to Thailand. So was the vast destruction caused by this storm just bad luck?

No, no more so than the destruction caused by Hurricane Katrina. I'll get out of the way quickly the likelihood that global climate change has made such powerful storms more frequent. We'll have to live with that for the foreseeable future. But there are three more points worth considering. In both the Irawaddy and Mississippi deltas, human intervention has destroyed the regions' natural defenses against cyclones. In Louisiana, the Mississipi has been forced into a narrow outlet channel, eliminating the natural process of silt deposition which for thousands of years had built the delta and the vast fringe of wetlands south of New Orleans. As this process was stopped in the 20th century, the wetlands started to erode and disappear, bringing the power of hurricanes and their accompanying storm surge that much closer to the city. In Burma, the mangrove forests which once fringed the delta have been destroyed to make way for aquaculture. Hence the storm surge moved unimpeded up the many mouths of the Irawaddy river.

Second, the Irawaddy delta was very sparsely populated until the British settled people there and developed rice farming in order to feed their south Asian colonies. It is perhaps only in hindsight that we can be so certain that it was foolish for so many people to live in such a vulnerable place, just as we can say about the Mississippi Gulf coast and the Lower Ninth Ward. But in both cases, the possibility of catastrophe was apparent and governments did not prepare adequately. Now that the question arises about whether the devastated areas ought to be repopulated, we have seen in the U.S. a controversy with far more passion than sense. (For the record, I think people need to be moved away from the coast as much as possible, and from areas of New Orleans which are near or below sea level. However, the interests of the affected communities have to be honored in the process. That means a new Lower Ninth Ward, on higher ground. I'm not sure what that might mean in Burma, but it's not for me to say.)

Finally, the atrocious response of the governments in both the U.S. and Burma is likely to be the most impactful legacy of both storms. It signaled the beginning of the end of the rule of the Republican conservative coalition in the U.S., and it may turn out to be the end for the Burmese junta. We can only hope so. If they survive this horror, it can only mean even worse years ahead for the Burmese people.

In broader terms, as a species, we need to find a sustainable coexistence with the rest of nature. Both of these disasters offer clear lessons about our failure to do so.

The Keystone Problem

Erratic posting lately is due to a trip to Brockton yesterday, and another day trip to Portsmouth today. Tomorrow I have to go to Lowell. These excursions all happen mostly over commuter roads, and I can tell you that in spite of the price of gasoline and reports that MBTA ridership is up a bit, the congestion is the same as ever. The state and federal governments just got done spending $16 billion to fix the whole mess by burying the interstate under the center of Boston and adding bridges, tunnels, and service roads all over creation but you already know what happened -- as soon as there was more pavement available, it filled right up. It still takes a half an hour to move a mile and a half from Sullivan Square to the exit to the Callahan Tunnel on I-93 South, all day, every day.

This happens because right now, people don't have much choice. A lot of them live in places that don't offer an easy trip in and out of town on mass transit. Others -- like me much of this week -- need to have their vehicles with them for business. And, if they all decided they couldn't afford the gasoline any more and tried piling into public transit, that wouldn't work either, because getting on an MBTA train is already to know what it's like to be trash in a compactor.

Well, we just won't be able to live this way any more. The Long Emergency has already started, but we've squandered the past couple of decades and it may already be too late. If President Obama is going to pull our asses out of the fire, this is where it will have to begin. Instead of spending that $16 billion on highways, we should have built a mass transit system for the 21st Century, which is what a few of us said back in 1984 but of course, nobody was listening. Now we're going to have to spend that money all over again, but we don't have it any more. And that's just the beginning of what we need to do.

It's a good sign, obviously, that Obama told the truth about his two opponents' disgusting race for the bottom on the gasoline tax, but he's got a lot more truth to tell us. I don't say he has to do it before November 4, but on November 5, he'd better start talking.

Local news, not of general interest

A friend who must remain as anonymous as a Michael Gordon informant sends this along. It seems the Environmental Protection Agency Midwest Regional Administrator has been canned for, you guessed it, trying to protect the environment. More specifically, her malfeasance in office consisted of trying to protect the environment in a way that annoyed a Fortune 500 Corporation.

Gade has been locked in a heated dispute with Dow about long-delayed plans to clean up dioxin-saturated soil and sediment that extends 50 miles beyond its Midland, Mich., plant into Saginaw Bay and Lake Huron. The company dumped the highly toxic and persistent chemical into local rivers for most of the last century.

Many local residents see Dow as a lifeline in region plagued by plant closings and layoffs. But all along the two wide streams that cut through this old industrial town, signs warn people to keep off dioxin-contaminated riverbanks and to avoid eating fish pulled from the fast-moving waters. Officials have taken the swings down in one riverside park to discourage kids from playing there. Men in rubber boots and thick gloves occasionally knock on doors, asking residents whether they can dig up a little soil in the yard.

Gade, appointed by President Bush as regional EPA administrator in September 2006, invoked emergency powers last summer to order the company to remove three hotspots of dioxin near its Midland headquarters.

Now, if she'd done something positive, like using her office to benefit the campaigns of Republican politicians, or to advance the cause of Christian dominion, she'd have good performance reviews. But this is just inexcusable.

The point of my post, however, is that this news has not made it out of Chicago. I haven't heard a peep about it anywhere in the national news media, or for that matter in the blogosphere. In the old days, this probably would have been worth some national attention, but now we just take this sort of thing for granted. With bowling scores and shots of bourbon to worry about, dioxin in the rivers is just too minor of a worry.

Tough luck

A couple of recent reports in the popular press on academic exercises offer considerable food for thought. First, I'll offer my own well-fed cogitations on this effort by a task force of physicians in various powerful positions to decide who gets triaged to the scrap heap in the event of an influenza pandemic or a comparable mass casualty event. Unfortunately, the issue of Chest in which this report appears hasn't made it onto my library's on-line subscription service yet, so I can only go by the news report. Hence I don't know the full composition of the task force. It includes representation from the military and the Department for the Impregnable Defense of the Glorious FatherlandHomeland Security, among other federal agencies, as well as medical societies and prominent academic physicians. I'm sure many will see this as vaguely sinister but I'll give them the benefit of the doubt as to motive.

I've railed against the pathological state of denial in this country often enough that I am obliged to welcome an exercise that seriously contemplates the possibility of bad stuff happening. The idea here is that the need for such resources as mechanical ventilators and intensive nursing care exceeds the supply. The task force members have created guidelines for who gets to breathe and who gets to drown in their own sputum. Those who get shitcanned include those with advanced dementia, people with severe trauma, people with serious chronic diseases such as heart disease and, oh yeah, everybody over age 85.

The news report doesn't spell it out, but my reading is that they have mixed a couple of criteria here, with life expectancy being the most important, but quality of life and the resources required to take care of the person also figuring in the formula. Now, you might just say that this is dirty work, but somebody has to do it. When the people are stacked up like firewood in the ED, you've got to choose somehow and you're better off having a plan.

My first objection ought to be obvious. Who appointed these people God? It's fine to raise the issue but they seem to assume that it stops here. They've pronounced, we're done. In fact, acting on these guidelines would be illegal. You aren't allowed to discriminate in the provision of services -- and particularly publicly funded services such as health care -- on the basis of age or disability. Furthermore, there is a strong correlation between socioeconomic status and the likelihood of having poorly controlled diabetes or heart disease, for example -- among the markers for death in the task force report. That includes education, income, and oh, by the way, race. So these guidelines actually use the consequences of prior lack of access and inferior health care, among other factors, as reasons to deny care to people at the point where they need it the most, while moving the privileged people who enjoy better health thanks to your previous discrmiination to the front of the line.

And yet, and yet. Here you are, overwhelmed by a catastrophe, confronted with hundreds of desperately sick people, and you can't save them all. Doesn't it make sense to try to save the people who have the most life left, and the most left to live for, first?

Well, maybe so, but the 86 list isn't necessarily going to help you very much. You aren't going to have a list of all the people who need care, ordered from top to bottom on the basis of their shitcan score, so you can just work down until you run out of drugs or IV bottles or whatever it may be. Instead, the people are going to come in continually, in more or less random order. They will not be accompanied by detailed information about their cognitive or medical condition. You will not know in advance exactly how much of what resource each person will need -- whether they will need a ventilator, for example, or for how long. If you decide, "I'm not going to bother with this diabetic," and she dies, you may find out later that you did, in fact, have enough resources to take care of her, and they're still sitting on the shelf.

Conversely, in the case of pandemic influenza, it is likely to be the robust young people who are most severely sick and who need the most resources for their care. This was the experience in 1918. The explanation may be that it is an overactive immune response called a "cytokine storm" that caused death in that epidemic. (Here is an attempt to make that concept intelligble to lay people.) So it might well be that a much larger number of people could be saved by concentrating on the older folks.

So I would say this needs much more discussion, and probably legislation of some sort -- which would be almost impossible to pass.

Friday musings

I'll be disconnected from Your Intertubes for a couple of days, so nothing till Sunday at the earliest. Meanwhile, various recent events have brought into focus the role of religion in the political and social spheres.

I wear my atheism on my sleeve, which is supposedly obnoxious, although it's not only perfectly okay but widely encouraged and admired for religious people to do the same. So I pose this for your consideration.

Defenders of religion of late have taken to emphasizing the claim that religion is the source of morality. The Pope in particular is fond of saying that the great threat facing humanity is "moral relativism," from which only religion offers salvation. Evangelical preachers frequently make similar statements.

So let's take a look at the moral values given to us by religion. It is religion which persuades the members of the Fundamentalist Latter Day Saints to force 13 year old girls to have ritual sex with 50 year old men, and start bearing them children.

It is religion which causes Jeremiah Wright to say "God damn America," which is evidently deeply offensive.

It is religion which causes John Hagee to say that God destroyed most of New Orleans, Plaquemines Parish, and the Mississippi coast, killing more than 1,000 people and rendering a million or so people homeless, because some gay people were planning to have a parade a few miles or a hundred miles away. Evidently that is not considered offensive, but it certainly seems ridiculous.

It is religion which causes Pat Robertson to say that God made Mohammed Atta and his friends fly those airplanes into the World Trade Center, killing 2,800 or so bond traders and restaurant workers along with some firefighters and police officers, because there is homosexuality and abortion going on. Again, that's inoffensive but it makes me wonder why God didn't fly some airplanes into office buildings in Paris, London and Berlin. They have homosexuals too, you know.

I'm going to be a contrarian here and say that the principal risk of moral relativism comes from religion. Us atheists are in far greater agreement about morality than are religious people. Atheists never put people on the rack or burned them at the stake because they didn't say the correct mumbo jumbo. I've never heard of an atheist suicide bomber or a war between positivists and critical theorists. So Your Holiness, if you're truly worried about moral relativism, come on over to our side.

From The Prescription Project

Always happy to throw them a link.

Go here to sign the petition.

Drug marketing is out of control. Help send a message to Congress.

Support the Physician Payments Sunshine Act, which will require drug companies to publicly report their gifts and payments to doctors.

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Sign this petition today to ask your members of Congress to support these bills.

'Nuff said. Although personally, I don't think reporting these gifts is sufficient -- they should be banned. As in, you can't do it. And, if that's not possible, doctors should be forbidden to accept them by both medical association codes of ethics, and state licensure requirements. And you should ask your doctor if she or he accepts anything of value from drug companies. If the answer is "yes," go elsewhere.

Denialism

Ana points out that you don't have to be African American to believe in myths about HIV. True enough, but I have been involved in public health work related to HIV for more than 15 years now, and I have never encountered the belief that HIV was created in a secret government laboratory among white people. What I have encountered, however, is the belief, indeed the passionate insistence, that HIV is not the cause of AIDS. This is in some respects essentially the opposite belief -- that the conspiracy has to do with so-called antiretroviral drugs, and suppression of the true causes of the disease, while HIV is actually harmless, or in some versions, does not even exist.

One of the most prominent perpetrators of this claim is Peter Duesberg, an organic chemist at UC Berkeley. Because he holds a tenured position at a prominent research university, HIV denialists have made him their champion. He has no stature within the relevant scientific community and is almost universally regarded as a crank motivated by envy and resentment. You don't have to take my word for it, these people have put together everything you need to know. However, to his supporters, he is the new Galileo, who was also despised for his radical theories. (In case you have any doubts, Avert lays out the proof that HIV is the cause of AIDS in detailed, systematic, and accessible fashion.)

Now, the interesting questions here are why these denialists movements arise, and how we can tell them apart from legitimate scientific dissent. After all, there was a time during which Stanley B. Prusiner was widely ridiculed for his claim that prions -- abnormally folded proteins -- could be agents of infectious disease, specifically Creutzfeldt-Jakob Disease. Prusiner ultimately won the Nobel Prize for his discovery. Could Duesberg be another Prusiner, and why am I so sure he isn't?

First of all, Prusiner was not entirely isolated. The prion hypothesis had been raised earlier. It was a challenge to accepted dogma, and so the initial resistance was not surprising. It is appropriate and healthy for scientists to question new hypotheses and throw up resistance to their acceptance. Claims that step outside of existing frameworks have a high burden of proof. Now, HIV was not entirely a radical idea -- retroviruses were known, as were viruses which cannot be eradicated by the immune system, and viruses which take a long time to produce disease. However, it is certainly novel in preferentially attacking cells of the immune system, and is generally unlike other known viruses that infect humans.

So there was nothing wrong with Duesberg initially raising objections. The problem is that every objection he has raised has been refuted, and yet he continues to insist on his premise, either coming up with new objections, new ever more stringent standards of proof, and ultimately simply ignoring the truth. This is the same way creationism works, and global warming denial. Rather than pursuing the evidence where it leads, the denialists start with the conclusion and reason backward from there. For a time it may be possible to identify gaps in the chain of evidence and reasoning that lead to evolution, or global climate change, or HIV, but ultimately these theories have withstood the test. The evidence is incontrovertible, but the denialists cannot see it.

The essence of the problem is that their stake is not in the truth, but in some other benefit they gain from their belief. The consolations of faith, the opportunity to make billions by burning fossil fuel, or in Duesberg's case the conviction that one is the intellecutal superior of all the other scientists. For his champions, there is the opportunity to con Harper's Magazine into buying your article, or otherwise make money off of snake oil. The cost, however, is people's lives.

It's all a plot

No, HIV was not developed in a secret U.S. government laboratory as a method of wiping out black people and other undesirables. However, the good Reverend is far from alone in thinking so. According to a survey done in 2002-2003 by Laura Bogart and Sheryl Thorburn, 30.5% of African American men and 24.5% of African American women agreed that HIV was produced in a government laboratory; and 21.3% of African American men agreed that it was specifically created to control the black population. This study is in the JAIDS behind the subscription wall, but you can read WaPo summary here. The response rate to this telephone survey was acceptable, but the substantial number of refusals suggests to me, anyway, that the results actually understate the prevalence of belief in these statements.

(These authors also considered it a "conspiracy theory" that "There is a cure for AIDS, but it being witheld from the poor," a proposition with which the majority of both men and women agreed. Although there is no cure, there are effective treatments, and it is absolutely true that poor people, particularly outside of the United States, do not have proportionate access to them, so I can see why many well-informed people might have agreed with that. Since this is the most widely endorsed "conspiracy theory" in their survey, it does tend to undermine their other conclusions. But I digress.)

Since this purports to be a science blog, I should mention that there has been extensive research into the origins of HIV, well summarized for lay readers here. It is pretty well established that the virus first developed in chimpanzees, who acquired two related viruses by eating monkeys. These viruses then swapped genetic material to create HIV. (The process of gene transfer among viruses that co-infect an animal is common. It's one way in which new strains of influenza emerge, for example.) People then acquired it from chimps, probably in the process of butchering them for food. This undoubtedly occurred multiple times, at least as early as the 1950s and likely considerably earlier, although HIV disease was not recognized until the early 1980s.

Barack Obama, obviously, is not responsible for Rev. Wright's beliefs. But it's important to recognize how prevalent they are among African Americans, and to try to understand why this is so. It reveals widespread distrust of government, and of other important institutions in society, notably in this case the medical institution. ("Institution" in this case is a social science term of art that does not refer to a single hospital but to a component of society.) That white people seem to have such a hard time understanding why this is so is just as big a problem. Note my parenthetical paragraph above, about the researchers' idea of what constitutes a "conspiracy theory." Maybe it's not so parenthetical after all.

Update: A few responses to comments.

Yes, there are other infectious diseases which are more prevalent among poor people, and among black people. The death rate from septicemia -- i.e., toxic shock, massive bloodstream infection -- is higher among black Americans, as are STD rates generally. While I suppose people will take the latter as proof that black people are all wildly promiscuous, the truth is that both facts are probably a consequence of lack of access to health care, and inferior care when people do get it. Your risk of STDs depends on their prevalence among the people you are likely to have sex with. Since the main STDs are curable with a shot, people who are part of communities where most people get good quality, regular health care are unlikely to be exposed.

There was indeed a great deal of denial in the early years of the HIV epidemic, particularly in minority communities -- notably African American, Latino and Haitian -- who felt themselves stigmatized by an alleged association with HIV, and which also are characterized by conservative social norms and strong stigmatization of homosexuality. Many preachers in these communities gave counterproductive sermons, and political leaders did not want to confront the reality of the epidemic either. I think the conspiracy theories were in part a response to the feeling that these communities were being blamed and stigmatized, so people reactively turned the blame back on the government scientists who they felt were doing it.

We've come a long way since those years. Nowadays support for nonjudgmental educational and behavioral interventions in African American communities is pretty strong. A lot of clergy have changed their judgments and their approaches. The same is true among Latinos and Haitian-Americans, although stigmatization of homosexuality continues to be a problem in all three communities.

Although HIV is a natural phenomenon, it has functioned as a particularly nasty kind of social experiment. It's revealed a lot about our culture and others, and brought out both the worst and the best in people. The social history of epidemics is usually pretty interesting, but this one is the ultimate. It's probably time for somebody to write the next book.

Blood and Treasure

The takeaway lesson from this meta-analysis published on-line by JAMA is a little bit complicated, and I don't think the general media have succeeded in explaining it very well. (Thanks to C. Corax for tipping me off to the NPR report; I've also read some of the newspaper and news network web site stories.) This isn't quite like those mass murder cases where drug companies knew their products were killing people and kept it a secret. It's more of a structural problem in the way the FDA and the drug companies do research, exacerbated by greed and ass-covering, to be sure, but not primarily about that. Those are a constant that must be allowed for in the way we design our policies for studying and approving drugs and other medical products.

The story begins with concerns about the availability and safety of blood for transfusions back in the '80s, stimulated in part by the HIV epidemic and other blood-borne infections, and the difficulty of making blood available in poor countries and remote places. Various companies developed and tested blood substitutes based on hemoglobin, which as you know if you remember your high school biology is the molecule in red blood cells which carry oxygen from the lungs to the rest of the body. What you might not have learned in school is that the gaseous compound nitric oxide NO is involved in regulating the constriction of blood vessels, specifically it causes them to relax and dilate. (This has to do with the mechanism of action of those erectile dysfunction drugs, BTW.) It also inhibits blood clotting.

Hemoglobin has a strong affinity for NO as well as for oxygen, but NO doesn't cross the membrane of red blood cells, so no problem. However, free hemoglobin in the blood stream soaks up the NO, causing blood vessels to constrict, and raising the risk of blood clots. You have already figured out that this is not good -- we're talking heart attacks.

This problem was understood before anybody even tried experimenting with a hemoglobin based blood substitute. The companies tried some tricks to reduce the risk, but in almost every trial, from the very beginning, whether in trauma or surgical patients, there was an increased risk of heart attacks, and usually of death. The problem is that in any one trial, the numbers were small enough that this risk did not rise to the conventional signicance level of p < .05, in other words there was at least a 5% chance that it was due to chance. This probably doesn't seem very reassuring, and I agree that this is already a problem, but that's how we're supposed to think. If it isn't "statistically significant," it doesn't exist, even though it probably does.

Anyway, the key issue here is that if you put together the results from two or more trials, you would see that the risk was indeed significant, and quite substantial, actually. The pooled results of all the trials the reviewers were able to use show the risk of MI to be 2.77 times as high in people who got the blood substitutes as in controls, who got usual treatment (blood, plasma or saline). The risk for death was 1.27 times as high.

However, and here's the kicker, most of these trials were never published. The FDA knew about most of them, but didn't consider the metanalysis in approving new trials. The information is considered to be a trade secret, so unless the companies chose to publish the data, nobody else could find out about it. (The reviewers who published the JAMA article still couldn't get access to much of the data, or they got it in compromised form. Chances are, the situation is even worse than what they found using the data they could obtain.) This meant that Institutional Review Boards didn't have access to the information. If they had, they never would have approved the studies. So, studies continued, and subjects continued to have heart attacks and to die. There are even studies going on now. Since there is not, in fact, a shortage of blood products, there isn't even a compelling need to be met by these products.

The conclusion is that clinical trials should never be secret. If a company is trying to get a drug or medical device approved, it needs to register all of its trials with the FDA, and the methods, results and raw data need to be publicly available. Congress must change the law in order for this to happen, regardless of the new president's bowling scores.