This is Stayin' Alive, and of all the blogs, web sites, regular columns, and street corner ranters in all the world, this is the one place where you are guaranteed to have it driven relentlessly like a spike into your brain, that the United States spends too much on medical services and that much of that is for useless or counterproductive procedures and pills and devices. That includes a lot of services that are labeled as preventive. I have even bored my readers half to death with endless mathematical wonkery to support my assault on preventive medicine. Check out the URL for this blog. What do you think it means? Read the mission statement at the top.
So we get the problem, we definitely do. Now Republicans, including the formerly mavericky John McCain, say that the reason we spend too much on stuff we don't really need is that we have insurance. If people had to pay out of pocket, they'd spend less. Voila! Oh sorry, that's in the language of the enemy.
Anyway, here's what you need to do. Remove your head from the anus of Milton Friedman to look around you. What do you see? That wonderful, wacky world called reality, which Dr. Friedman's theories, however wonderful and wacky they may also be, do not describe.
It turns out that in this world, unlike the world of Dr. Friedman's imagination, the United States spends more, far more on medical services than every country which is comparable in terms of wealth. And yet, and yet -- in all those other countries, everybody has health insurance, whereas here, around 45 million do not. And here, of those people who do have insurance, most already pay quite a bit out of pocket, for copays, deductibles, uncovered services, and a share of the premiums; whereas in all those other countries, the people have good, comprehensive insurance and they pay little or nothing out of pocket. And the country which is most like the U.S., where the people do pay substantial co-pays and deductibles -- that would be the land of the yodel and the holey cheese -- has the second highest spending, after the U.S.
Okay, you're a Republican, so I know what your response is already: my ideology doesn't predict that, so to hell with reality, I'm going with my ideology. But for those of you willing to be swayed by facts and logic, read on.
One of the most common fallacies is the ecological fallacy, in essence that means deducing the part from the whole. On the whole, we spend too much. But that doesn't mean that we should just spend less. In fact, some of what we spend is wasted, some is well spent, and on some things, we should probably spend more. But simply throwing costs onto consumers does not achieve wiser spending, in fact it does the opposite. Rationing by cost is not "rationing" at all, it's totally irrational. People who just can't afford it may not get some services that would be wasteful, but they also won't get the ones they need; whereas people will still end up digging deep into their pockets and giving up fresh vegetables to pay for stuff they'd be better off without, because they don't know any better.
This is a huge subject, and I haven't written the book yet. But consider the case of prostate cancer screening. I believe that it is not in the best interest of society to routinely screen all men over a certain age for prostate cancer. That does not mean that no man should ever have examinations or tests for prostate cancer, it means that doctors should not routinely, during office visits for other purposes, do DREs and PSA tests on men who do not have particular risk factors.
And yet many of them do. My doctor is one of them, but I refuse to be screened - which by the way makes him quite unhappy and it's a continual struggle. As it happens, I have a co-pay for an office visit but not for prostate cancer screening specifically. However, I'm quite sure that most men, if their doctor told them they should get a prostate cancer screening because it might save their life (which is true, BTW, but that's insufficient reason), would go ahead and cough up ten or fifteen bucks. I'm very highly unusual in having more and better information about this than my doctor does, and in making what is a highly unusual decision.
The reason my doctor wants to do something that is probably not a good idea is not because "I'm not paying for it, so what the hell." It's because his interests are not aligned with mine. The recommendation for screening was developed by a committee of oncologists -- doctors who make their living treating cancer. My doctor works for a community health center which is owned by a big, fat famous teaching hospital that has all kinds of equipment for treating prostate cancer that cost 8 figures and they need to pay for it. Once somebody is diagnosed with prostate cancer and they get into that labyrinth, even their high deductible, high co-pay insurance will be fully engaged. And guess what - if it wasn't, there would be a howl from the middle class that would make the Chinese revolution look like the College Republicans withholding their student activity fees.
So y'all have the wrong diagnosis. More to come.
Saturday, August 30, 2008
This is Stayin' Alive, and of all the blogs, web sites, regular columns, and street corner ranters in all the world, this is the one place where you are guaranteed to have it driven relentlessly like a spike into your brain, that the United States spends too much on medical services and that much of that is for useless or counterproductive procedures and pills and devices. That includes a lot of services that are labeled as preventive. I have even bored my readers half to death with endless mathematical wonkery to support my assault on preventive medicine. Check out the URL for this blog. What do you think it means? Read the mission statement at the top.
Friday, August 29, 2008
Just had the dental surgery I've been needing for a few months. Had to get it over with but the next couple of days I will not be at my best. On the other hand I hope this will end what has been a subtle drain on my batteries for who knows how long. Having a guy drill into your jawbone is unpleasant even if you can't feel it, however, and one less tooth will take some getting used to as well.
He was good enough to give me 20 Vicodin -- which by the way only cost me six bucks. I could make a tidy profit were I so inclined. I hope this won't cause too big of a hole in the blogging but if I stay woozy you may not hear from me for a couple of days. As for people without dental insurance -- in my home town, the local auto mechanic once pulled out his own teeth with a pair of pliers. At least he had the tools and the hand strength. Had I been unable to afford this, it literally could have ruined my life. Think about it.
Thursday, August 28, 2008
Unfortunately, most of the comments I attract here are from people who basically agree with me, which is not all that much fun. I had a brief burst of creationists at one time -- now that was hot -- but other than that, the only recurring challenges come from libertarian perspectives. Glad to have them, who wants to preach to the choir all the time?
I once tried to capture the difference between liberalism and libertarianism in a nutshell with an aphorism to the effect that liberals believe society must establish liberty, while libertarians believe that liberty just happens. I believe the former, and I also believe that health and health care provide a felicitous occasion for the demonstration.
Libertarianism is founded largely on principles that liberals share, notably a high value placed on personal autonomy, but they part on considerations of reality. It should be obvious that the scope of our freedom depends on our resources, which include natural endowments (over which we have no control, for which we have no desert, and the fruits of which are inherently unjust, in my view, and be careful if you want to object to that, you may not like where it leads); the resources society bestows upon us by virtue of our birth, such as George W. Bush's political career and Cindy McCain's many mansions; and what comes to us by luck, be it the rain that nourishes one farmer's crop and the drought that destroys another's, or the disease that deprives one person of vigor and not the next. After all that, if you wish to argue that some of our power to enjoy our liberty comes from what we have earned by enterprise, you will have to notice that said enterprise is frequently unethical and rapacious. The most ruthless and unprincipled often -- I would say usually -- become the most powerful, and then what happens to the liberty of the rest of us?
A person who is wealthy, healthy and socially powerful obviously enjoys more liberty than one is is poor, sick and marginalized. But these conditions have little to do with desert.
Libertarians presume a fundamental right to use and enjoy one's property as one wishes. If pecuniary differences are not deserved, this is already suspect, but then it founders on an inescapable self-contradiction: what if you want to use your property to deprive me of my liberty? Fine, say the libertarians, we will pass the most limited set of laws necessary to restrict that sort of behavior: robbery, kidnapping, rape, will be illegal, but leave it at that.
But it is not only those extremes which are at issue. There is almost nothing you can do that does not affect the liberty of others. Your liberty and my liberty are always a problem of balancing. They must be negotiated. Liberty does not consist of you always getting your way, as libertarians often seem to think. After all, I can just turn that around.
Liberals and libertarians, therefore, tend to agree on the easy cases, where laws or institutions try to restrict behavior that has limited impact on others but is merely morally disapproved, such as private sexual or drug using behavior. They have major disagreements, however, on situations in which people interact willy nilly, notably the design of economic institutions. The libertarian position, as it turns out, depends on premises about the economic system which are simply false.
Consider the health care industry. This industry is unusual in many ways, though not so fundamentally unusual as many people seem to think. One unusual feature is that people's basic need for its output varies so hugely. Our daily caloric requirement varies somewhat depending on metabolism, age and body size, but within a fairly constrained range. But some people, in a given year, don't actually need any health care at all, while others might need hundreds of thousands of dollars worth to remain alive. Some people need to consume high levels their entire lives, others episodically or only toward the end, others need comparatively little for a lifetime.
What percentage of this variation is deserved or "just" may be argued. Some proportion of sickness may be attributed to irresponsibility, but it is certainly much less than half. And even people whose personal behavior may have contributed to their sickness aren't 100% responsible. For example, tobacco companies spent hundreds of billions of dollars promoting and marketing cigarettes, creating doubt about whether they were really dangerous, and creating a popular culture in which they were not only accepted, but symbols of sexiness and sophistication. Many people are in ill health because they were born into poverty, or breathed polluted air, or happened to catch an infectious disease, or were physically assaulted, or in a car crash, and so on. And, of course, our health just tends to get worse as we get older, which all of us hope to do.
Second, the maintenance of one person's health is not important only to that one person. People have dependents and loved ones who care what happens to them regardless of the degree to which their affliction may be "deserved." Their contribution to society as workers, parents, volunteers, neighbors, friends, etc. is affected by their state of health, so we may all be harmed by a less healthy population. People may carry infectious diseases. And, whether because of empathy or mere aesthetics, everyone's quality of life is compromised if there are a lot of sick, impoverished people sleeping in the doorways. In other words, there are externalities associated with our utilization of health care, whether determined by our choices or our resources. When people don't get enough, others suffer.
Third, health care is an expert service. I can determine my own preferences in many matters, from what foods to eat (assuming I have an adequate budget), to whether to spend my surplus on theater tickets or a sailboat, if I'm that lucky. But contrary to the (truly preposterous, in this case) arguments of libertarians, I don't consume health care because I feel like it, or enjoy it, or get intrinsic rewards from undergoing a mammogram or a colonoscopy. I consume health care because my doctor recommends it. If I have to pay more, I may well get less of it, but what I forego will be services that my physician would have recommended, since there are no others that I would even consider buying in the first place. (There are people who are exceptions, but they are eligible for a DSM-IV diagnosis.) Whether the physician is always right is another question, but that is not determined by the amount of money I have to pay.
Any argument about the proper way to structure the health care and health insurance systems must begin by acknowledging these underlying realities. Arguments for "consumer driven" or "free market" health care do not, and are therefore fundamentally invalid.
Wednesday, August 27, 2008
Since the election is all about who is elitist and out of touch, who is more pious, who is the Antichrist, and who is white, I thought somebody, somewhere, might have an interest in public policy. Nobody seems to know it, but here's what John McCain wants to do to you.
First, he will eliminate the tax exclusion for employer-provided health insurance.
Many working adults will immediately lose their current health insurance, as small businesses that are already struggling to provide it will have little reason to continue.
Everybody else will immediately face a large tax increase, unless they decide to drop their employer-provided coverage.
McCain will use the new taxes (in other words, don't read his lips) to give people a $2,500 refundable tax credit for individuals, or $5,000 for families, to buy health insurance on the open market, as an individual.
Even with the tax credit, low income people still won't be able to afford insurance, so they'll just stay uninsured.
Moderate income people may find insurance they can afford, but it will have high co-payments and deductibles, which means that if they are injured or get sick, they will have to pay more out of pocket.
As health care costs continue to increase, if Congress doesn't increase the tax credit, health insurance will become less and less affordable and more and more people will be uninsured.
Insurance companies will be allowed to use medical underwriting. Consequences:
People who are older, or in poorer health, will have to pay more, or may not be able to buy insurance at all.
People will not be able to get coverage for "pre-existing conditions."
Insurance companies will be able to sell policies across state lines, meaning that state regulation of insurance will become meaningless. Consequences:
State mandates to cover preventive services such as cancer screenings, disease management, smoking cessation, etc., will become ineffective. Insurance companies will stop offering these benefits, because even though they save money in the long run, you as an individual probably won't still be their customer by the time the savings are realized -- either because you'll be on Medicare by then, you won't be able to afford insurance at all any more, or they threw you off the plan because, yup, you got sick.
McCain proposes to create a plan of last resort for people who can't buy insurance on the market, but it won't actually offer any help: it will have high costs, limited benefits, and exclusions for pre-existing conditions.
The Republicans argue that "competition" among insurance companies, and consumer choice, will lower costs, but it isn't true. Insurance companies compete by trying to skim healthier customers and charging sicker people more; and consumers don't choose to get medical procedures or take prescription drugs just because somebody else is paying for them, they get those services and goods because they actually need them. If they can't afford them, they won't get preventive services and treatment.
My friends, The McCain health care "reform plan" will mean:
- Higher taxes.
- More uninsured people.
- Higher costs for health insurance.
- Less preventive care, and a sicker population.
- Higher health care costs in the long run.
- Injustice -- sick people won't be able to get health care.
- Bigger profits for insurance companies.
I'm Cervantes, and I approved this message.
Tuesday, August 26, 2008
I've been meaning to ask Pastor Hagee why God flooded out all those folks in north Florida. I'm pretty sure they weren't planning to have a homosexual parade. But here I'm seeing all these retired people on my teevee, with pleasingly fair complexions, slogging out the mud and remnants of their destroyed lives from their sagging houses. And these good folks can be relied upon to vote for the God's Own Party, too. It's hard to figure.
Now we've got another hurricane starting up. It's going to hit Haiti, which doesn't have an obvious explanation but those Haitians are poor and no account so God just keeps messing with them, I guess. Then it's heading on to Cuba, which doesn't have any homosexuals but they're Godless Commies so that makes sense. What happens after that, I'm sure Pastor Hagee will explain to us.
But what I really don't understand is why we aren't getting any hurricanes up here in the Sodomite Republic of Massachusetts. We've got homosexual marriage, a homosexual congressman, homosexual anchor on the nightly news, homosexual Commissioner of Public Health, homosexual chaplain at the World's Greatest University™. We've even got the Congregational Church, which started out as the Puritans and used to have the decent moral values to hang witches and Quakers and put the scarlet letter on adulterers, marrying homosexuals left and right. They even had ads bragging about it on teevee for a couple of weeks, but then they remembered that only right wing Christians get to say anything in public, so they stopped. Pastor Hagee comes on my teevee every night, but the UCC knows better than to inflict their abominating and gomorrahfying on the teevee watching public.
Anyway, we haven't had a hurricane here since as long as I can remember. Okay, I looked it up, it was 1991, long before all this homosexual stuff started happening. About the worst that was going on here back then was Daniel Dennet and a few Unitarians. But lately we've just had Absolutely Fabulous weather. I can't figure it out.
Monday, August 25, 2008
As long-time readers know, I'm fortunate enough to own some land in rural Connecticut. It's essentially a peninsula into state forest. There are a few houses around along the roads, cornfields and dairy farms within shouting distance, the Shettucket River, and woods. That's about it. No subdivisions, no downtown except for a general store and a post office. I mow about 2 1/2 acres, three times a year or so, otherwise my place is embedded in deep oak and hemlock forest, with an old pine plantation running within 200 feet of the road.
There's a lot of wildlife around, but the one category that is by far the most obvious, impressive and extensive is the phylum arthropoda. When you walk through the field, the grasshoppers fly up ahead of you in a great cloud -- I mean dozens or who knows, hundreds of different kinds, all different sizes and color schemes. Sometimes Mark (the carpenter I'm working with to build the house) and I leave the door open to the sun porch to bring in material or cool it down, and three or four butterflies will come right in. Yesterday we were removing some vegetation in order to do some outside work and Mark was stung by a saddleback caterpillar -- a very weird critter which neither of us had ever seen before:
If you see one of these, don't touch it!
At night, the fields are so full of fireflies you can just about see your way by them. Where the soil is sandy, there's hardly any space between the anthills. Walk through the brush, and the spiderwebs are all over your face. They're back in minutes. I'm knocking down wasp nests from the eves and door frames of the house and barn every week. The trees are filled with continuous trilling, there are mantids sitting on the rocks and along the borders of the grassy areas, ladybugs form great masses of boiling orange --
I could go on but you get the idea. I'm very lucky by the way -- the white-tailed hornets are a real problem but there are almost no mosquitoes or biting flies around. I don't really know why -- there's a vernal pool on my property and plenty of wetland associated with the Shettucket and its tributaries, but for some reason we're spared.
The city and the suburbs, and even most farmland and other rural areas I know, are nothing like this. Oh yes, there are plenty of insects and a lot more than you realize if you know how to look for them. But this place is really noticeably different. The bugs are everywhere, in clouds and congregations, stirring and flitting and jumping and crawling, turning the air and soil into constant motion, making the planet vibrate and thrill with life.
For one thing, I expect the complete absence of any pesticides has a lot to do with it -- the farm closest to me is organic, and while I don't expect the cornfields are managed completely organically, I haven't seen any pesticide application and I expect the farmer is at least using IPM. Anyway, corn doesn't need a lot of chemical assistance. The homeowners aren't into perfect artificial lawns, all they do is mow.
My own garden has never had a problem from insects. Deer, I would happily poison, but I have not had insect damage. I'm sure I will soon enough if I keep at it, but the fact is, in the middle of an insect metropolis, I can live with them quite happily. Well, the hornets are an annoyance, but they actually aren't very difficult to deal with by mechanical extirpation. Just use a long stick, and do it at night.
The insects have their own home page, well worth checking out.
Friday, August 22, 2008
Well, I might have something, but I don't feel like working. As I head for CT for a couple of days, please read this by finance columnist Paul B. Farrell. Or as Country Joe put it, "Come on wall street don't be slow, why man this war is a go-go, there's plenty good money to be made by supplying the army with the tools of its trade."
In public health news, there's been a bit of a spike in measles cases in the U.S. -- still just 131 so far this year but that's a big jump. The reason is that parents are refusing to have their kids vaccinated. A big part of the responsibility goes to execrable upper class twit Robert Kennedy Jr., who traded on his dead father's reputation to make a name for himself by accusing hundreds of physicians, biomedical researchers and public servants throughout the world of engaging in a conspiracy to make children autistic, because, because - oh, just because they could. That this charlatan continues to be accepted as some sort of spokesperson for progressive ideals is just another blot on our shallow, celebrity obsessed culture. Oh yeah, NRDC -- you need to fire this clown, your own reputation is at stake.
Finally, yeah, I admit it, I own two houses, or at least I'm borrowing them from the bank. But at least I know the number.
Thursday, August 21, 2008
I'm feeling a certain amount of peer pressure here to ramp up the politicalness of the blog, so here goes. I have heard rumors that Christians are not necessarily far right delusional puritans, that there are actually liberal Christians out there who believe that life on earth evolved over billions of years, aren't waiting for the rapture, marry gay people and think that the question of when human life begins is essentially imponderable and support women's right to control their own bodies and reproduction.
Okay, folks, if you're out there, how about sticking your heads out of the foxhole long enough for us to hear a peep out of you? If there's dialogue or debate within Christendom, we sure aren't hearing it. Where are your radio and TV shows, your books, your press conferences, your candidate forums? Why is there only one definition of Christian belief known to political discourse?
Let me get specific here. Warren asked, "When does life begin?" McCain said, "At the moment of conception," and got applause. Obama said it was above his pay grade, and left it at that. But nobody, as far as I can tell, no politician, no commentator, no pastor, no theologian, ever publicly debates this issue. I'm not asking Barack Obama to do it, but here's what I would have said.
In the first place, why do you think that it's somehow a Christian belief that "human life begins at the moment of conception?" You certainly don't get that from Christ -- there is not one word about abortion anywhere in the Bible, New Testament or Old, no definition of human life, and no reference to the sanctity of fetuses or even, for that matter, the sanctity of human life in any form. God commands the Hebrews, at multiple times and in multiple books of the Old Testament, to kill people under various circumstances, including innocent people who happen to be in their way.
Christians didn't start to argue that abortion was even sinful, let alone tantamount to murder, until the late 19th Century. So how did they make this discovery? Do you believe that it suddenly occurred to God that he'd forgotten to mention it while he happened to be incarnated almost two millennia earlier, so he quickly provided the Pope and some Evangelical preachers with a new revelation? Or, if it's merely a conclusion you come to based on your overall understanding of ethics, then why aren't other people free to come to different conclusions?
Now let's consider the consequences if you really mean what you say, that a zygote, a single cell, is the moral equivalent of a breathing, feeling, suckling and squealing human child. In the first place, Almight God is by far, by many orders of magnitude, the most prolific abortionist, and therefore murderer, who has ever existed or ever could exist. Approximately 2/3 of all zygotes never become babies, not because the mother has an abortion, but because they fail to implant in the womb in the first place or are miscarried shortly thereafter; in most of these cases, the woman never even knew that conception had occurred. (Whether or not she was even "pregnant" is a semantic quibble.)
Now, you can decide that God is off the hook for this, that God cannot be held morally responsible for the depredations of nature, and of course you have to believe this or God is a murderer thanks to pestilence, famine, hurricane and earthquake. But then you also have to conclude that humans are as morally responsible for trying to stop it as they are for saving their neighbors from every other form of disaster, which is to say that this is by far, by orders of magnitude, the most profound public health problem that we confront, in terms of total deaths and Quality Adjusted Life Years Lost. Therefore, NIH should redirect all of its resources away from cancer and heart disease and HIV and everything else it's studying and launch a massive project to solve the holocaust of non-implantation of the blastocyst. If you believe that human life begins at conception, and you don't believe that, you are a hypocrite and you don't really care about saving babies after all.
How about a common sense answer to the question of what constitutes human life, which is that it's not the possession of two sets of human chromosomes, rather it's human consciousness? We aren't sure when that first appears but it cannot be until the development of the cerebral cortex fairly late in pregnancy. If human self awareness is also essential to our humanity, that does not appear until some time in infancy. We acquire our moral status as humans gradually, not in a mystical instant but through a process that continues to unfold throughout our lives. While I agree with Barack Obama that defining when human life begins is above my pay grade, it surely does not pertain to a microscopic ball of cells or even a two inch embryo.
I'm going to give Pastor Warren, at least, some credit. Unlike most of his allies among the "Christian" leadership, he at least purports to care about the millions of born, living, breathing, feeling children who suffer and die around the world every year. But is he really serious about this "life begins at conception" nonsense? Of course not. It isn't about human life, it's about sex. It's about the repression of sexuality and the oppression of women. "Life" has nothing to do with it.
Now why can't somebody with a public platform stand up and say that? There isn't any debate about it, we're just supposed to say, well, people have different beliefs. But in fact, one set of beliefs makes sense, and the other makes no sense at all. Let's have this out, and let's have some Christians who aren't too cowardly to stand up and say so.
Wednesday, August 20, 2008
My mother once scolded me for telling my younger sister that she had millions of microscopic animals living on her skin. But of course I was just telling the truth, more or less -- technically the term "animals" is currently reserved for one of the two kingdoms of the eukaryotes, and my sister's inhabitants are mostly (though not exclusively) prokaryotes, but still . . .
In fact, inside and outside, we have about 10 bacteria and archaea for every one of our own 50 trillion human cells. So we aren't just organisms, we are each of us entire ecosystems. Recent analyses -- discussed by Robert Dorit in American Scientist (I'm starting you on page three so you can skip the mystical BS at the beginning) -- find that each of our body parts, from the crook of the elbow to the crack of the ass, the stomach to the nostril, constitutes a unique habitat with its own, specific ecosystem and particular complex of microorganisms.
The fact is that 99.99% of the microbes on and in our bodies, and in our environments, are not just harmless, not just beneficial, but essential. In innumerable ways, they make our own lives possible. That's why I am more and more annoyed -- nay outraged -- by the ever growing barrage of advertising for products intended to sterilize our homes, our clothing, and our children. Spraying bactericides all over your bathroom and your kitchen will not, repeat not, protect you from disease.
If anything, such practices will increase your chances of getting sick. One of the most common adverse effects of taking antibiotics is, get this, opportunistic infection. Take amoxycillin for your earache,wipe out the natural flora in your throat, and you get thrush. I'm inclined to think that something comparable can happen with topical bactericides on your skin or in your house. Pathogenic organisms are continually reintroduced from contaminated food, and infected people (whether or not they have a clinically observable illness). A healthy microbiotic environment crowds them out. We control them specifically by the way we handle food -- washing the knife and cutting board, and our hands, after handling raw meat, for example. If we try sterilize the rest of the environment, we just give them room to move in.
I wish we could put a stop to the shameless promotion of these useless and even harmful products, but you know, it's a free country. Anyway, you read it here: wash with soap and water, and leave it at that. Germs are your friends.
Tuesday, August 19, 2008
Every two years, with the winter and summer Olympics, we get a spate of stories about athletes being disqualified for so-called "doping," or superior performances being questioned because the athlete may have "cheated" by using performance enhancing drugs. As you probably know, there is even a World Anti-Doping Agency, an international body which is accorded legitimacy by virtually all nations, to enforce a world-wide prohibition on the use of proscribed drugs by athletes.
Kayser and Smith in a recent BMJ discuss this new prohibition. (Subscription only but you can read the extract and read the responses.) I generally agree with their critique.
The main rationale for prohibition of performance enhancing drugs is based on two propositions:
1) To promote a "level playing field," to eliminate "cheating," and
2) To protect the health of athletes, both the elite athletes who are subject to drug testing and disqualification, and aspiring youngsters who might be inclined to imitate them.
With respect to rationale number 1, it is simply illogical. There is no level playing field in sport, all sport is inherently unfair. First of all, obviously, some people happen to be born with genetic endowments that give them exceptional physical capacities. The rest of us, the vast majority, can never be elite athletes no matter how hard we work at it -- or how lucky we are in other ways. And that's really the point. Many children are malnourished, chronically sick from parasites and microbial diseases. Even if you're lucky enough to have a health childhood, the nurturing of athletic talent requires all sorts of resources that are invested in some people and not in others.
By the time athletes get close to the elite level, they may have all sorts of technological advantages: carefully designed diets, high altitude training or time in hypobaric chambers, specialized machinery for training, etc. Some are lucky enough to have better coaching than others, and of course avoiding injury is largely a matter of luck as well. It is difficult -- I would say impossible -- to explain why using a steroid or EPO is fundamentally different from dietary approaches to manipulating hormone levels or high altitude training to stimulate red blood cell formation. In fact, allowing these measures makes the playing field more level, not less so, since they are more accessible and less expensive.
Finally, the prohibition makes the playing field less level because athletes with the most money, who live in technologically advanced countries, have the best chance of beating the drug tests -- and we know that many of them do so. That's why suspicion continues to fall on the winners. The ones who get caught have lesser advantages, or are just unlucky. If use of performance enhancing drugs were allowed, these inequities would be eliminated.
As for protecting health, like most drug prohibitions, this one has the precise opposite effect. The long-term health effects of using anabolic steroids and other PEDs are actually unknown, but appear to have been greatly exaggerated by anti-"doping" propaganda. Even so, the fact is that people do use them, but since they are illegal, they do so without medical supervision in most cases and in a manner which does not optimally protect their health. Problems include non-sterile injection, excessive dosing, and failure to monitor possible side effects. An open, legal regime would make harm reduction possible.
Remember that we do not worry over much about protecting athletes' health in general. Contrary to what you might think, high level athletic competition is not a healthful endeavor. Professional athletes, once their careers are over, are almost universally plagued by osteoarthritis and other orthopedic problems, and they often suffer from permanent and progressive effects of repeated concussions. They face difficult psychological challenges from having to retire from their chosen field at an age when most people are just entering their prime. Depression, substance abuse disorders, bankruptcy and suicide are not infrequent fates of retired athletes. Of course many of them do manage to get a rewarding second life, whether in coaching or by investing their earnings in business or finding another profession, but there are too many tragic outcomes.
So this is a much more complicated question than it is often made out to be. What would an effective harm reduction approach to performance enhancing technology in athletics look like? Think about elite and professional athletes, and society as a whole. What's your answer?
Monday, August 18, 2008
1) Here in the eastern time zone, NBC's Olympics coverage has consisted of a relentless, endless diet of beach volleyball. Early last week, they threw in a bit of the largely meaningless gymnastics qualifying and the world's most popular sport, synchronized platform diving, but from Wednesday on NBC has been the Beach Volleyball Channel, interrupted only for trips by Mary Carillo to the Great Wall or to the local restaurant to try the civet cat.
Saturday I had to go build my house, and Sunday I had some chores to do, but I figured Sunday evening they would have to cover something else but no, I switched on the teevee at 5:00 and there was yet another beach volleyball match. I know that other stuff has been going on because I read about it in the papers, but that's because sportswriters get to stay up till 3:00 am and are also allowed to watch TV during the day. For those of us on the east coast with jobs, the Olympics is from 8:00 pm to 10:00 pm, and NBC has decided that what we want to see, everything we want to see, and the only thing we want to see, is beach volleyball.
DEAR MR. COSTAS: I DO NOT GIVE A SHIT ABOUT BEACH VOLLEYBALL! I DO NOT WANT TO SEE OR HEAR ONE MORE THING ABOUT IT, NOT FOR ONE SINGLE SECOND. MAKE IT GO AWAY. MAKE IT NOT EXIST. That is all. The players can't even wear proper clothing. It's indecent.
As I say, I know other stuff has been going on because I read about, although I haven't actually been permitted to see any of it.
2) Naturally, the world's fastest human is named Usain Bolt. He's the world's fastest human even when he sticks his arms out like a little kid pretending to be an airplane. If he ran normally, he would break the speed of light barrier and go into the past, where he might accidentally kill his own grandfather, thereby destroying the future, which is our present. So he's careful not to do it.
3) As the World's Greatest Athlete, Michael Phelps could be -- well, you know what he could be doing. Instead, he just wants to hang out with mother and sisters. Entirely too wholesome, if you ask me.
4) Female -- you can't say woman -- gymnasts used to be tiny pixieish waifs. Now, they're still short of stature but they're built like tanks, except for the Chinese, who are 12 years old. Buzzy Bissinger, who I went to school with for two years but who wouldn't remember me because I was a nerd, but I get to call him Buzzy anyway, thinks that female gymnastics is child abuse. I have had no personal contact with girls' gymnastics, but the ones who make it to the top seem to like being there, and I don't see how any of Buzzy's complaints are unique to that sport. Only one in a million (figuratively, exact numbers vary) of kids who take up any sport make it to the highest levels of competition, and there is always a trail of broken dreams and injuries among those left behind.
Buzzy also thinks there is unhealthy erotic interest in the performers, but whose responsibility is that? Bob Costas certainly isn't promoting it, he's too busy slavering over beach volleyball.
5) Performance enhancing drugs -- the subject of my next post.
Friday, August 15, 2008
Actually I've made it before, but it's now clearer than ever -- in 2009, the Massachusetts attempt to provide universal health insurance coverage to its citizens [sic -- undocumented residents are screwed] is going to blow up like an unarmored humvee hitting a buried artillery shell.
Steffi and David, with colleague Benjamin Day, review the long sad history of failure of state level reform efforts, and they predict that Massachusetts is going to hit the wall because a) the so-called "affordable plan" that people with too much income to qualify for the subsidy have to buy is already unaffordable, and b) Massachusetts is going to lose the federal subsidy next year. Let me add to that:
1) The private insurance companies that provide the "affordable" plans underbid and they are losing money. They're going to come back with an even higher price next year;
2) The recession means lower state tax revenues even as --
3) Employers are covering fewer and fewer of their workers and people are losing jobs or being downgraded to part time and lower pay
4) The state already faces a huge budget deficit and
5) The cost of health care continues its inexorable rise.
Bottom line: the numbers don't add up -- they never did -- the money isn't there, the mandate will be repealed, and we will have more, not fewer people uninsured one year from now than we do today.
The reason this doesn't work is because it isn't true reform. It takes the existing system of fragmented, largely private health care insurance as a given and tries one way or another to stretch it to cover more people. But it does nothing to bring down costs, doesn't have sufficiently progressive financing, and doesn't get rid of the waste. States cannot fundamentally reform the system because health care is part of a national market and a national system. Pharmaceuticals, devices, labor, capital are all traded and regulated nationally. Massachusetts can't force insurers or drug companies or doctors or anybody else to accept its terms. And the politicians are much too timid and much too bought to undertake, or even talk about real reform anyway, because it means getting rid of the insurance companies entirely, which we cannot do even though they provide no socially useful function whatsoever; and it means limiting the profits of drug companies and the incomes of highly paid medical specialists. (Primary care docs should be making more than they are now, and there should be more of them, by the way. Doctors can be winners with real reform, but not all of them.)
The smash up of the Massachusetts experiment may finally convince the wimps in the reform movement that we need to stop farting around with half-assed measures and go for the real thing; or it may set us back 20 years. I don't know. But I do know this:
We need universal, comprehensive, single payer national health care.
Say it again!
Thursday, August 14, 2008
Or is you?
I am a bit of a skeptic about some organ transplantation on essentially cost-benefit grounds, but putting that aside for now, there is the question of when it's okay to "harvest" (as they say) the organs from the unfortunate donor. (Living donors are an entirely different story, with its own ethical twists and turns.)
As usual, the New England Journal of Medicine drives a media feeding frenzy, this week on some envelope pushing that's been happening on the question of death, in pursuit of fresh, rosy-cheeked human hearts. There are a couple of free access pieces in the new Journal, but since I know you're busy, you may find Robert Veatch's contribution sufficient to give you the gist.
The question of when a person is dead didn't perplex people very much until the late 20th Century. No pulse was an adequate criterion. Once we could restart stopped hearts, and keep hearts beating indefinitely that wouldn't beat on their own, that didn't work any more. Occasionally that becomes a problem when family members don't want to turn off the switch for somebody who has no hope of recovery, but you don't actually have to be dead for current ethical principles - including principles endorsed by the Catholic Church, by the way - to endorse allowing death to happen by ending mechanical intervention.
It's a different problem, however, when doctors are hovering over the mortal clay hoping to grab the heart and other used parts for the use of somebody else. Currently, the person has to be officially dead before they can open up the chop shop. The criterion of brain death is one that the public seems not to find problematic. That means that the entire brain is not producing electrical signals, basically. If you're brain dead, you're already in the junk yard.
The difficulty is that not everybody whose organs are potentially usable is brain dead, in fact most such people are not. They may even have enough brain stem left that they would keep breathing on their own. But their higher functions -- the cortical activity that makes us human -- are gone, and the family is ready to cut the switch. Those people aren't officially dead until their hearts have stopped - yes, cardiac death still counts as death. But since we can restart stopped hearts, mere cardiac arrest does not count as death either. The heart has to be stopped long enough that it can't be restarted. But, but, but . . .
If you waited that long, it wouldn't be any good to the next person. So, the new concept is that the cardiac arrest is irreversible because nobody has any intention of restarting the heart, at least not in the body of person A. But of course they do intend to restart it in person B, and they follow through on that intention. So could person A truly have been dead at the time his or her heart was removed, given that said heart could indeed be restarted and person A was not brain dead?
The bioethicists writing in the journal propose two different solutions:
1) Decide that it's okay to harvest organs from people who are alive, provided that they are in the process of being allowed to die -- which, BTW, implies that the act of harvesting the heart is what kills the person; or
2) Redefine death to include the condition of having a stopped heart which nobody intends to restart until it ends up in person B.
Practically, these amount to the same thing: they endorse the identical actions. Veatch things (1) cannot possibly be ethical however, since we aren't allowed to kill people for the benefit of somebody else, so he's going with (2). Seems like nothing but bullshitting around with words to me. The fact is, we've crossed a line, and now we need to figure out exactly how to draw the new one.
Tuesday, August 12, 2008
As I said yesterday, if a race of technologically superior extraterrestrials had wanted to test our scientific talents, they couldn't have come up with a better experiment than starting the HIV pandemic. HIV has taught us a lot about the immune system and about viruses, but we still haven't come up with a way to prevent or cure it.
It's also been an extremely revealing sociological experiment. As everybody knows, it was first noticed among gay men in the United States. For many years, it was absolutely devastating -- men have told me heartbreaking tales of seeing their networks of friends almost entirely wiped out by a brutal, lingering form of disability and death. But it also had a galvanizing effect on gay activism and community organization, and it is fair to say that the epidemic converted thousands of gay men into activists, who stepped out of the shadows to demand, first of all, an adequate investment in HIV-related research and treatment, and ultimately created the modern gay rights movement which is transforming U.S. society and inspiring change around the world.
Don't get me wrong, though -- the initial response to the AIDS epidemic in the society as a whole was intensified discrimination and homophobia, and that hasn't gone away either. The essential problem of the public health response to HIV when it was still perceived as the Gay Plague was to combat stigma and discrimination. And then it was noticed that HIV existed among another marginalized group, injection drug users, and finally that it was an affliction of poor people generally in the poorest countries, initially principally in Africa and Haiti, and that it was showing up among men who have sex with men, female sex workers, and injection drug users all over the planet. And of course it doesn't stop there -- it passes to the babies of infected women, and to the female partners of infected men (less likely in the other direction, which is a less likely situation in the first place), particularly in cultures in which they have no way of protecting themselves.
So the ETs have given us an incurable disease which preferentially seeks out the wretched and despised. How we respond to this situation is an exacting test of our moral nature as a species. One thing it has taught me already is that religious leaders -- the people who claim official standing as proponents and judges of morality -- are for the most part notably immoral. The Catholic hierarchy and the evangelical leaders who campaign for "moral values" are the most egregious offenders. Their beliefs are the precise opposite of moral beliefs, and are radically offensive to the Jesus of the Gospels.
It has also taught me that there is, after all, a great reservoir of moral commitment among humans, and that the ethical basis of medicine and public health is sound. Impressive moral leadership has come from within the medical profession, from the schools of public health, and from ordinary people from all over the world who have dedicated their lives to fighting the HIV pandemic -- and that means standing forcefully against "morality," as understood by the preachers, and standing up for human dignity, human rights, and the worth of every individual. In other words, some good may come of this.
Monday, August 11, 2008
Whew. As always, my flight was late and I got into Boston at 2:00 am. It's okay, I expected that. Had time to digest everything now so I'm going to do some overall takes on the conference. This the first installment, on the state of the science of HIV.
I'm sorry to say that in spite of the cheerleading and optimistic spin, it's pretty grim.
First, Anthony Fauci (Director of NIAIDS, the NIH unit that funds HIV research) made it absolutely clear that in his opinion, there is no effective preventive vaccine anywhere in the foreseeable future. Reading between the lines, I would venture that he believes it to be ultimately impossible. He said the best we can hope for in the next 25 years is a vaccine that would be partially protective for people who happen to have the right genetic makeup. That, in my view, would be useless. You could never market it because all it would accomplish is to give people a false sense of security. Fauci said, unequivocally, that he will not approve funding for any HIV vaccine trials at this time.
The difficulties in creating an HIV vaccine are already well known. (The most important obstacle is that the protein that forms the envelop of the HIV virion hides from the immune system behind a screen of sugar molecules, but there are further difficulties as well.) The news is that the strategies people hoped might get around them have unequivocally failed. That's all folks: the HIV vaccine story is over for the time being.
Equally discouraging is the prospect for a cure. A cure for HIV would mean that the infected individual could live disease free and without risk of infecting others, without needing continual treatment. The reason HIV is incurable is a bit complicated if you don't already know the basics, but let me try to make it simple.
As you know, the genetic instructions that control the cell are contained in DNA in the chromosomes. RNA in the cell ordinarily carries those instructions from the nuclear DNA out into the cytoplasm, where proteins are synthesized, and also does the work of protein synthesis. Most viruses contain DNA, and when they enter the cell, their own DNA hijacks the cell's machinery. But HIV is different, it's a retrovirus. It does not contain any DNA, but rather RNA. When HIV enters a cell, it's own RNA first produces an enzyme called reverse transcriptase, which then causes HIV's genetic code to be written into the nuclear DNA of the host. The viral DNA residing in the host's DNA is called a provirus.
We are usually told that HIV disease is all about the infection of CD4+ cells, which are turned into factories for producing virus particles, called virions, which constitute the "viral load" in the blood plasma. Antiretroviral drugs control this process. However, they do nothing about the reservoir of proviruses, which exists in non-active CD4+ cells, but also in other cells of the body including the meninges (the membrane surrounding the central nervous system), macrophages (cells that go around scouring up debris) and now, it appears, just possibly lymphatic stem cells. These latter cells continually renew themselves and also produce new lines of infected T cells. That is why, no matter how long you have been taking anti-retrovirals, and no matter how long you have had undetectable viral load, if you stop taking the ARVs, the virus will reappear.
So, the advances are incremental: better understanding of exactly how to use antiretroviral drugs, the possibility of topical "microbicides" (really a misnomer) that women could use in vaginal inserts to prevent becoming infected, better post-exposure prophylaxis. That's about it. Oh, they're also talking about pre-exposure prophylaxis, basically meaning that people expecting to be exposed could take ARVs, but that strikes me as a very bad idea, frankly.
If extraterrestrials had engineered this little particle to maximally mess with us, they could not have done a better job. As we confront the future of the HIV pandemic, it is essential to get this absolutely clear, whether you like it or not:
No vaccine. No cure. Not next year. Not next decade. Never say never, but best to plan for never because nobody knows when, or how. That's where it's at.
Friday, August 08, 2008
It's a travel day for me, so I have to throw this out early.
-- Demonstration of the week: It was a close call, and the die-in at Bristol-Myers-Squibb almost took it, but I'll give the nod to the takeover of the U.S. booth by a group protesting the strings attached to the U.S. AIDS relief program (called PEPFAR, for those who don't know, the President's Emergency Program for AIDS Relief). Yeah, it's money that's done some real good, but to get it, countries have to take an oath to condemn sex work (which can be counterproductive), to emphasize abstinence-only sexuality education (which does not work), not to use the money for HIV prevention counseling, treatment or care in family planning settings, and to abide by the so-called global gag rule, which prevents organizations that receive funding from providing abortion, consultation or referral to abortion services. Designing programs based on ideology and self-righteous concepts that are inconsistent with reality does not constitute "moral values" when it kills people.
-- Sad and disturbing observation of the week: The U.S. embassy is surrounded by concrete barricades, a welded steel fence with bars 4 inches thick, and guards wearing body armor and carrying automatic rifles. Signs warn against taking photographs and the lane of Paseo de la Reforma in front of the embassy is closed off by a steel fence and occupied by police cars. To permit entry, an armed guard swings open a door that belongs on a bank vault. This is in the country which is our immediate neighbor, with which we have close and friendly relations. Think about it.
Hope to have time to post tomorrow after I've had a chance to digest all this a bit more. The perspective of Americans is narrow, parochial, and self-centered. I've always known that, but this week really drives it home.
Thursday, August 07, 2008
With so much going on, I haven't gotten around to what is probably the biggest thing going on here, which is that there is an official quasi-commitment on the part of UNAIDS, the Global Fund, B&M Gates, the WHO, and the rest of the gang, to provide global access to HIV treatment by 2010. I say quasi because UNAIDS is being weaselly about it, and also because I'm not sure that even the most impassioned advocates really believe it is possible.
First a word about antiretroviral drugs. On the one hand, they are miraculous. It used to be a legitimate position that doctors tended to overtreat and that what with the side effects and the expense and all, it would be best to wait until people were manifestly sick before prescribing them. It's becoming clear now that people do better in the long term if they start earlier, based on CD4+ cell counts, with the latest guidelines calling for starting at 350 cells/ml. Unfortunately, in most of the world, people don't have access to these tests. In fact, few people present for treatment who aren't already sick, and have T-cell counts that are much lower than that. The point of all this is that there are different ways of looking at the global need.
Right now, about 3 million people worldwide are on ARV treatment, which means that 40million people with HIV are not. However, they don't all qualify for immediate treatment. If we use current criteria, we'd need to get 7 million more people on treatment today to meet the official need. If we use the guidelines in place in the wealthy countries, we'd need to treat 10 million more. But all of those 40 million+ will need treatment eventually, and meanwhile, there are 2 to 3 new infections for every additional person who receives treatment, in other words, we're falling further and further behind.
What happens when people don't get treatment? They die a horrible, slow death. What happens when they do get treatment? Most people can live an almost normal, healthy life. You need a little bit of luck. There are side effects which are worse for some people than for others, and treatment interruptions can produce resistant virus and treatment failure. Nevertheless, it has been proved beyond doubt that even in the poorest places on earth, it is possible to successfully maintain people on ARV therapy and that they can then resume productive lives. So there is an obvious moral imperative.
The cost of regimens used currently is about $95/year per person, but second line regimens for people who fail their initial treatment are more expensive. Some people argue that providing universal AIDS treatment takes money away from building comprehensive health care systems and combatting other diseases, but there is another way to look at it. The effort to provide universal HIV treatment has stimulated the development of health care systems where no other need or cause has done so before. The challenge is to integrate all the essential efforts that have to be made to address the severe public health needs of the poor. These needs are not in competition with each other, they are a single problem.
Right now there's a demonstration going by -- in fact they're stepping over my legs as I sit against the wall -- against extending drug patents for second line drugs. That's a key part of the challenge, getting drug costs down so that the scale up of universal treatment is feasible. Drug companies want to make their billions from consumers in the wealthy countries and they're afraid that selling drugs more cheaply to poor countries will interfere with that noble objective.
There are many other political and technical complexities to this problem, but I think I've given you the pistachio shell summary. The stories of near death and resurrection when people get access to these agents are as moving as any human stories can be. They really are a triumph of biomedical science, for all their shortcomings. And their existence sharply delineates the ethical quandary of our planet.
Well, of course, where I am now, I'm from north of the border, but what the heck, the whole point of these posts is that I'm being an idiot tourist.
-- The police here drive around with their blue and red lights flashing at all times, so the crooks will know they're coming. What they do if they want to pull you over, I don't know, but since there is no such thing as a traffic violation in Mexico City, it probably doesn't come up very often.
-- There are magnificent monuments in the middle of the traffic circles in El Paseo de la Reforma. The one near my hotel is called Angel de la Independencia. In principle, you could climb the steps to the base of the monument, but you could never get there alive. The cars go around the circle in both directions simultaneously. There must be a system to prevent head on collisions, but I could not decode it in the time I had for observation.
-- There are no clocks in this city. Not on the walls, not on the public edifices. When I got to my hotel, there was no clock in the room. I went down to the desk to report it, and they looked at me like I was nuts. There is no clock anywhere in the Banamex Center. There are no clocks behind the bars. If you're interested in the time, you're on your own. But why would you want to know that?
-- I have a friend who lives in town, and she took my colleague and me out to dinner last night. Indeed, as I observed previously, there aren't any good, authentic Mexican restaurants in my neighborhood, so we took a short drive. They brought my margarita in what I can only describe as a soup tureen with a stem. How they expect people to walk out of there is a mystery, but people do it. I managed to, but they actually asked me if I wanted a second one. The food was good, and plenty. The tortillas are completely different from anything I've had in the U.S. (I'll have to ask Alfredo how they do it when I get back.) However, they don't believe in vegetables here. We're talking 100 million people with vitamin deficiencies.
Next post will be another substantive one about the conference. There's still too much to say but I might as well keep trying.
Wednesday, August 06, 2008
Now we hear from Anthony Fauci, head of the National Insitute for Allergy and Infectious Diseases (NIAID) -- and by the way Tony, thanks for the dough, he's never heard of me but he's paying for this trip -- and Peter Piot, head of UNAIDS. For those of you who aren't AIDSologists, these are the big guys. Fauci sets the agenda for biomedical research on HIV, and Piot is probably the single most influential individual when it comes to the organized social and political response, or at least he sits at the hub of the international response.
Their mission was to lay out the projected course for the next 25 years. Piot is retiring this year, so all he had to offer was his thinking, but Fauci's talk was the hard stuff. He actually does control the money, and he was telling us how he intends to spend it. And by the way, what he says is for real because it's at least 100 to 1 President Obama will leave him right where he is.
I could say a great deal about the presentations of each of them, but I'll just take a bit sized chunk for now. Fauci does not intend to fund any vaccine trials in the foreseeable future. He has decided that research needs to get back to basic biology that can support development of a vaccine, but even so, he does not foresee any vaccine that will offer full protection or a cure. Indeed, the most he's hoping for is a vaccine that offers partial protection to people who happen to have a favorable genetic inheritance. He didn't say so, but it's not clear to me that such a vaccine would have any practical use whatsoever.
He also doesn't see any hope for a cure, at least not in a meaningful sense. He believes it's possible that if intervention could start within a few days of infection, a cure might be possible, but he doesn't point out that hardly anybody will be aware that they have been infected within such a short interval and this is again, a meaningless concept of "cure."
Weirdly, he described his outlook as "optimistic." He has some other, serious blind spots, which I will discuss in an upcoming post. But, bottom line, HIV will be with us, and probably as a growing problem, for the rest of my life and probably considerably longer. Get used to it.
I'm not a real scientist, I'm a sociologist. But I'll try not to be too distracted by the demonstration against Abbot pharmaceuticals going in one direction, and the sex workers demonstration going in the other, and tell you what's going on these days in the hard science of HIV.
First of all, I'm not sure what practical value this may have, but it's becoming clear that the infection event, in most cases, consists of a single virion. This discovery comes from a study of sero-discordant couples (heterosexual, by the way) and mother to child transmission. In a person with established infection, the virus is extremely genetically diverse, but in newly infected people, they are usually all identical, or at most there may be two or three varieties. Think about that: there might be millions of copies in semen or genital secretions, but exactly one of them manages to infect a cell of the host and start the process of HIV disease.
Second, and here is the part that is probably much more important, the story we have all heard, which is all about CD4+ cells, is highly incomplete. The most important way HIV causes disease is by selectively infecting and destroying these key cells of the immune system. And the essential process of HIV viremia is replication of the virus inside this type of cell. Furthermore, it is this extraordinarily prolific replication that supports the rapid evolution of the virus and its ability to escape pharmaceutical control.
So why don't the anti-retroviral drugs cure HIV? Scientists have had a vague understanding for a long time, but now they're starting to tighten the focus, and the answers may be discouraging. Some people simply think that the ARVs don't completely suppress viral replication, but it turns out that regimens including protease inhibitors can indeed drive it down to zero.
But remember that HIV is a retrovirus -- it inserts the viral genome into the nuclear DNA of an infected cell. Activated CD4+ cells turn into virus factories, fill up with virus, and eventually burst and die, releasing the virions into the blood. But the viral genes in an infected cell can also just sit there and do nothing, or perhaps produce small amounts of virus without necessarily harming the cell. It has long been known that some infected CD4+ cells remain latent, and so form a reservoir for the virus even when replication is suppressed. These undergo very slow attrition, and so can provide a life-long reservoir.
One approach to actually curing HIV would then be to somehow stimulate all these latent cells to become active. They would then die, and the ARVs would eliminate the virus. Lamentably, HIV also infects the meninges -- the membrane surrounding the brain -- and macrophages -- blood cells that scour up foreign matter and detritus -- in this way. Infected macrophages from the meninges can enter the brain, and call in others of their kind. Over a long period of time, this process can cause brain damage, so even people with perfectly suppressed viral loads can still suffer AIDS-related dementia.
An even more discouraging finding is that HIV may infect hematic stem cells, the precursors of lymphocytes (including CD4+ cells and macrophages), and these cells constantly reproduce, creating new copies of the so-called provirus in their DNA, and ultimately sending infected lymphocytes into the blood stream. Somehow finding and eradicating these cells would probably be impossible.
So maybe there can never truly be a cure for HIV disease, even in principle. A vaccine that could lead to effective lifelong suppression of the virus by the immune system would do the job for all practical purposes, but that might be impossible also. On the odds of that rests the great current controversy in HIV research priorities, but this post is already too long.
Demonstrations aside, this conference has its particular culture and traditions, obviously built up over many years, but I don't know much about that since this is the first time I've attended. I've been involved in HIV/AIDS research and services in the U.S. for a long time One thing I noticed right away is that HIV-related conferences in the U.S. tend to be a lot, well gayer (NTTAWWT). There is plenty of gay representation here, to be sure, but my informal observation is that the majority of participants are actually women.
HIV disease was first noticed in the U.S., and it was formally called Gay Related Immunodeficiency Disorder, or GRID. It took a while for people to figure out that this disease actually existed elsewhere, particularly in Africa, where it had no particular association with homosexuality, and that anybody could get it. It is pretty sobering to realize that AIDS was killing people in Africa by the tens of thousands before anybody even noticed it, and that it had to start killing Americans to be officially discovered.
I said before that the conference is as much politics as science but I want to amend that remark. It's a false dichotomy. There's plenty of science here, this is where the cutting edge gets mainstreamed, and I'll tell you about that anon. The story of HIV disease is not exactly what we've been told. But the science drives the politics, and politics drives the kind of science we need to do.
What I mean by that is evident in the culture of this unique association. It is a scientific fact, demonstrated by difficult, complicated research under hard circumstances, that oppression, marginalization and stigma are principal causes of HIV infection and AIDS. Yes, biologically, anybody can get it; but your risk is dramatically increased if you are of low social status, forced to live in shame and hiding, poor, oppressed, and despised. It's easier to see that if you do get it, being poor and outcaste means you are much less likely to get adequate treatment, but it's the disease risk itself that's the key.
In the U.S. we are always talking about personal responsibility. But let's consider a woman in a conservative muslim society, such as Nigeria, where one of our speakers yesterday works. She enters an arranged marriage at 14, then her husband leaves her. She has no option but to become a sex worker. The Imams won't even recognize the existence of prostitution in their society, but insist that if they did discove it, the women would be killed. Of course they know it goes on but they can't really kill the women or the men wouldn't have anhy prostitutes to visit. The women can't insist that their customers use condoms because the customers can always go elsewhere and the women are desperately poor.
Think about men who have sex with men in societies around the world where we can't call them "gay" because that's an identity that doesn't even exist. They may be invisible, or they may occupy recognized but largely despised social roles. Think about migrant workers, forced to live apart from their families for months or years at a time. Drug addicts, prisoners, and women in societies where they are the property of their husbands -- these are people who cannot protect themselves against HIV unless they are given material and social resources and are allowed to step into the light.
This is both the science and the politics of AIDS. As an epidemiologist, you can't separate them. They're a single entity.
One of the most popular things to do here is to have yourself photographed with the giant anthropomorphized condoms. These amusing characters are the creation of Jose Saavedra, Director of the National AIDS Programme of Mexico. Dr. Saavedra has been notably successful among his international peers, and Mexico has a low rate of HIV. That's to the credit of the national government, as I said before, but Saavedra is definitely pushing the envelope here. Listening to an earlier speaker talk about the oppression that comes from not being allowed to marry, I remarked to my colleague, "Don't blame me, I'm from Massachusetts." (That was a famous bumper sticker that appeared after only Massachusetts gave its electoral votes to George McGovern over Richard Nixon.) Then when Dr. Saavedra spoke, he referred to his husband, and showed off his wedding ring, to thunderous applause. He and is partner had traveled to Massachusetts to get married. So I'm very proud of our state.
As Clinton said yesterday, gender equality is essential in this battle, and it's essential to the conquest of poverty and many of the other ills that afflict our kind. To be in a place where everybody from an Indian (i.e. Hindu) drag queen to gay activists from San Francisco to religious leaders from Indonesia to Nuns from Budapest and Doctors from Harvard to recovering addicts from Russia to former prostitutes to the former President of the United States are together and have equal stature is unique. This has got to be the only place it can happen.
Tuesday, August 05, 2008
I should write about the conference, but it's almost too much and I need to digest. Meanwhile, here's more of my letter home from camp.
The climate here is very equable -- contrary to what you might think, it doesn't get hot, because we're up in the mountains. It can be a touch humid, and air conditioning is uncommon, but you don't miss it much.
The traffic in this city is beyond description, the drivers beyond belief, and the street vendors, who stand in the middle of it all, beyond comprehension. How it is they don't have a massacre of the innocents every day is inexplicable.
The peso has gained quite a bit against the dollar recently and it actually priceds aren't all that cheap here. In fact, the lead story in the business section today was that Mexicans are busy gobbling up foreclosed properties in the U.S. Don't tell Lou Dobbs or his head will explode.
The stereotypes are true, if a bit exaggerated: they're into bureaucracy and elaborate paperwork. For example, I tried to make a local call last night to a friend here and I couldn't get an outside line -- instead I got the hotel operator, who by the way does not speak a word of English. She told me I had to go down to the front desk and make a deposit. At the desk I handed the young woman a 200 peso bill, and she then filled out an elaborate form, which we both had to sign. Then I could go upstairs and get an outside line. Of course there were no instructions about this in the room. Of course, they already have my credit card, so the point of all this is hard to discern. I could tell similar stories.
As for comments on the previous post:
They do have Mexican food, obviously, just not at the Banamex Center. It's mostly in the street stands and neighborhood joints, however. The fine restaurants, including the hotel restaurants, don't really serve much Mexican food. They seem to be ashamed of it. Of course, I'm sure there are many restaurants that serve Mexican haute cuisine, but not right around here, and this is the tourist district. So it's sort of odd.
I have indeed had some tequila. They definitely aren't ashamed of that, and the margaritas are good and they don't skimp either.
Since I'm attending the AIDS conference, the only way I'd be aloud to visit a brothel would be to make sociological investigations. I'd have no problem finding people at the conference who could tell me where to find them, however, and which ones are safe to visit. Not that I would do that anyway.
So, more on the conference tomorrow, WiFi willing. Access at the center was very spotty today and became impossible in the afternoon. I'm not sure what's going on, but if you don't hear from me for a while that's why. Hoping to have luck though, I do want to blog more from the conference.
Hoping I can get this post done before the jodido wireless networks here kick me off. I've got more to say than I can tell you about the conference, but first let me give you my gringo turista view of Mexico City.
I'm staying in the upscale, touristy, and heavily policed Zona Rosa; and the route to the Banamex Center takes us along the Paseo de la Reforma, through gorgeously maintained parks, past the botanical garden, and the zoo, modern high-rise office buildings, and an extravagant display of public sculpture. The conference center is next to the hippodrome and a theme park. Somehow, I have the feeling I'm not getting a totally unbiased impression of the city.
Mexico City is one of the world's largest cities in population, and in fact the largest in geographic extent. Most of it, of course, is quite impoverished and some of it consists of miserable slums without proper sewage or electricity. A tourist visting Boston, of course, wouldn't be likely to see our poor neighborhoods either; and in contrast, would not see anything as magnificent as the Paseo de la Reforma, although I suppose Washington D.C. offers comparable grandeur (along with worse poverty and slums than Boston.) Mexico truly is a developing country, not an undeveloped one. It has a middle class, effective government, and a growing economy, but it has a long way to go.
The Banamex Center is municipally owned, and it appears to be part of a strategy to soak up unemployment that reminds me of the old Soviet hot dog stands, where one guy would put the hot dog in the bun, one guy would put on the mustard, another guy would hand you the napkin and the fourth would take your money. Getting anything to eat here is a half hour ordeal of waiting in line, and at the end of it the food is all prefab and pretty dull. (Not even Mexican, by the way -- it's tuna sandwiches and chef's salads.) Once you get to the front, one person hands you the beverage, another takes your order, a third consolidates the drink with the sandwich, another one aggregates the chips or cookie, and then there's the cashier. But she doesn't take your money. A guy standing in front of the counter in a suit takes the money and hands it to the cashier, then hands you the change. He seems to be in charge, although he has nothing particularly to supervise.
The buses that bring us from our hotels are waved through to the infield of the hippodrome by a small army of functionaries, even though the bus drivers already know where they're going. The way they mow the lawn is to have two guys meticulously sweeping weed wackers while two other guys with brooms carefully remove the clippings.
I expect that private industry here is as efficient as it is anywhere else, but there's a lot of unemployment and the government is obviously trying to do something about all the people who graduate from college and have no work waiting for them. It obviously isn't enough and social stability here is a bit fragile. There is also a terrible problem with crime, much of it commited by the police, as today's copy of Reforma informs us at length. In fact, the Mexico City police harbor a kidnapping ring.
You may have heard that tourists can expect everyone to speak English, but that is not true. Even the hotel bartenders and bellmen may be far from fluent. Mexico is holding onto its language fiercely, but it is also reforming its culture. The government for some years has been running an anti-machismo and anti-homophobia campaign, and you can see the billboards around the city. Women are far from achieving equality here, but there are more and more female professionals and public officials, and violence against women is less and less acceptable.
Mexico would be unequivocally on the way up except for two major problems. One is crime, and the profound corruption of law enforcement. That's really tough to solve. What are you gonna do, have the police arrest themselves? The second is that oil depletion. Mexico's economic development has been built on petroleum but they're running out. Once they don't have enough to export, they're going to be in trouble unless they can diversify their export industries, fast and big time. They're trying - one of the front page stories in Reforma is about a new foundry. (Bill Clinton's visit and this conference are also big news, of course.)
Economic opportunity in Mexico is the answer to our own bitter struggles over immigration, of course. Most Estadounidensias seem to have no understanding that the fates of our countries are closely linked. What's good for Mexico is good for the U.S. The leadership here seems to understand its challenges but whether they can beat them remains to be seen. It's going to be close.
So, viva Mexico. Let's pull with them.
Monday, August 04, 2008
I'm sitting up against a wall outside the hall where Bill Clinton just spoke, demonstrators to the right of me and to the left of me, huge throngs stepping over my legs. The conference organizers didn't do much to play up Clinton's talk -- you actually had to read the fine print in the program to find out when it was happening. Never fear, the big hall was packed, and rapt.
His words would have fallen harder on the world if he were President of the United States, of course, instead of just president of a foundation. But he's enormously respected around the world and as a matter of fact, I think most of the audience still thinks of him as PUSA.
For all his faults in his former job, he reminds of us what we are missing. His talk was substantive, erudite, passionate and, oh yeah, morally right. That the political culture in the United States has come to regard being intelligent and well informed as a disqualification to be president is one of the strangest, and most dangerous things that has happened to us.
"The dragon of AIDS does not ravage the world alone," he said. "It's partners are inequality of income, health care, and education." Silent demonstrators carrying signs on behalf of homeless people with HIV paraded in front of him at one point (which the ubiquitous security guards allowed them to do) and he connected with him. He used the occasion to say that poverty was not only the partner of AIDS in the poor countries where his foundation works, but in the United States as well, and he feared that economic hard times in the U.S. would mean better times for HIV.
The key to his address, in my view anyway, was that he tried to move beyond HIV exceptionalism. (A demonstration is marching by me right now, but I'm trying to stay on point.) It is not possible to combat HIV in the poor countries without building health care infrastructure generally, including self-sufficient decentralized services in rural regions, and integrated care management services. Right now, for example, funding for TB and AIDS comes through separate pipelines and people often end up with two doctors and two nurses. It is not possible to combat HIV without universal access to health care and affordable drugs. It is not possible to combat HIV without gender equality and an end to gender violence, adequate housing, food and access to education for all the world.
Clinton wasn't just reading a speech, he was speaking from the heart. I don't know what will happen in November, but I do know this: John McCain will never give such a speech, or even care about these matters.
I'm sitting on the floor in the Banamex Center -- Mexico City's conference center -- because it's the only place to sit. There are one quadrillion people at this conference and the place was only designed for 500 trillion. The official language of the conference is English, but you hear every language extant and some that are extinct. Before I get to the conference however. . .
I was waiting to change planes in Dallas when I noticed that my return flight was booked for September 8, not August 8. American Airlines said they couldn't do anything about it, because of the conference, they got nuthin' on that date, actually less than nothing. (There were 19 standbys trying to get on my flight here, BTW.) I envisioned spending a pleasant month in La Ciudad de Mexico but I really can't afford a hotel room for that long.
When I got to Benito Juarez Airport, it turns out the airline had lost my poster. Of course I had to wait in line for 45 minutes to talk to them about it because of all the people with lost luggage ahead of me. They couldn't find it. When I got to the hotel, it turns out my computer was jodido in some way and I couldn't get Internet access. Windows knew it was connected, but the browser wouldn't recognize that fact. So no way to get to Expedia, no way to get to the file with my poster so I could have it reprinted here (it's on my e-mail server) and no way to contact my colleagues. Nobody at the hotel or the Banamex Center could help me with the Internet problem or anything else.
Finally, for no apparent reason, the computer started working, Delta had a flight that day, and if I don't have the poster, what will be will be.
Now, as for the conference, indeed it is about politics more than science. Not that there's anything wrong with that. HIV is as much a political problem as a scientific problem, obviously. And that's politics very broadly defined -- how do we do sex ed, what is the status of women, is homosexuality a sin, should we respond to addiction with harm reduction -- social and moral issues like that, not just how we allocate resources and who has money and who doesn't.
On the downside, even the science gets politicized, vaccine research being a current example. More on that anon. For now, I just need to recover from a stressful 18 hours.
Sunday, August 03, 2008
As I pack to go to the International AIDS Conference, it occurs to me that I have written rather little about HIV here. Not that I've never mentioned it, but it's been a rare subject. Now that I think about it, that is a bit surprising because HIV is in fact a major focus of my work. It has also killed some friends of mine, most notably Wayne Wright. If not for Wayne, I would not today do what I do and I would not be writing Stayin' Alive.
I think the main reason I have not particularly emphasized HIV here is that I study it not because it's more important than other diseases, but because it is such a compelling example for a medical sociologist. HIV highlights many issues which are important in medical sociology generally.
One is stigma. Disease has been associated with stigma at least since the Diagnostic and Statistical Manual of Skin Diseases in Leviticus 13:
44 He is a leprous man, he is unclean: the priest shall pronounce him utterly unclean; his plague is in his head.
45 And the leper in whom the plague is, his clothes shall be rent, and his head bare, and he shall put a covering upon his upper lip, and shall cry, Unclean, unclean.
46 All the days wherein the plague shall be in him he shall be defiled; he is unclean: he shall dwell alone; without the camp shall his habitation be.
There is a stigma associated with being HIV infected which in many cultures, including for many people in the U.S., is so powerful that people with HIV are forced to hide their condition from friends and family, even household members. HIV also disproportionately infects people who carry social stigma in the first place, here in the U.S. -- male homosexuals -- and everywhere it is associated with poverty and low social status, although of course it knows no boundaries and the wealthy and powerful are not immune.
Now that HIV disease is treatable, it is paradigmatic of chronic, complex diseases in other ways. Management of HIV requires very strict adherence to often complex drug regimens that have unpleasant side effects, which can put great strain on the therapeutic relationship between physician and patient. Yet the diagnosis of HIV usually occurs when there are no symptoms. It is the act of labeling, not any physical manifestation, that creates the Person Living With HIV, who immediately embarks upon a new social status. The biomedical concepts underlying HIV disease and disease care are rather difficult to understand, but they matter to the person with HIV because they explain the problem of viral drug resistance, and the importance of avoiding unsafe practices even with infected partners. (Not all HIV is the same; you don't want to give or receive a strain which is resistant to one or more drugs.)
The disease is expensive, both to treat, and in lost productivity. In some parts of the world, it is a major economic burden. It has proven very frustrating to biomedical scientists, eluding technical means of prevention, eluding cure, and constantly evolving to evade treatment. HIV has destroyed innumerable lives but, paradoxically, it has renewed the lives of some people for whom the diagnosis was a kind of epiphany. It has destroyed communities and ravaged entire nations, but it has also created communities and energized constructive social change.
If extraterrestrials had wanted to perform a revealing social experiment on humans, throwing HIV at us would have been a pretty smart trick. It will be a great day when we finally beat this thing, but meanwhile, we have to learn from it.
Friday, August 01, 2008
I have occasionally written about mental health parity here -- insurers generally offer very limited benefits for mental health and substance abuse treatment, and they often throw up obnoxious obstacles such as requiring you to call a third-party contractor and spill your strife and woe to some clerk in Bangalore in order to get the services approved. (Okay, I don't know about the Bangalore part, but it could be.)
For some reason, however, all services ending in "ental" get short shrift. The reason I didn't post yesterday is because I had a toothache. Long story short, unlike most people, I do have dental insurance, provided my employer, but guess what? There's a $1,200 annual limit. That means I got the root canal, the insurance was used up, so I put off the crown. Bad idea, as it turns out. Fortunately, however, although I'll be out of pocket for a couple of G notes by the time this is all over, I won't end up like 12 year old Deamonte Driver, who died for lack of dental insurance. Unfortunately it's like that all over -- in most states, poor kids on Medicaid get little, if any, dental care. Medicaid may cover some services, but the reimbursement rates are so low that few dentists will accept it.
We think of dental and mental health care as luxuries, apparently. And insurers are afraid, on no evidence, that people will abuse them -- that if they give decent mental health coverage, everybody will become Woody Allen, spending their lifetimes in therapy; and that if they give dental coverage, everybody will get their teeth capped like a starlet. These hazards can be controlled without killing people. Good dental care is actually extremely important, not just so we can eat solid food, look acceptable, and live without pain, but also, believe it or not, because chronic inflammation of the gums is linked to heart disease.
Like the man keeps saying, we need universal, comprehensive, single payer national health care. And note that word comprehensive. It will, yes, save money.